• Dr. Carin Litani

The Skinny on Injectables, Part I

What are they? What are they made of? Do I need them? When should I start? What goes where?

I get questions about injectables all the time. I realize most of you know what they are and/or have already experienced their magic. Yet I still get questions from experienced patients about which filler or toxin goes where so I’d like to review what injectables are and what they do.


Okay, let’s divide injectables into two categories: Neuromodulator Toxins (commonly known by one brand name (of 4) in the category, Botox) and Fillers.


In this blog post, we’ll look at NMTs (Neuromodulator Toxins).


What Are Neuromodulator Toxins and How Do They Work?


Neuromodulator Toxins is a mouthful but it’s actually pretty simple. Let’s break it down. Neuromodulator means it’s doing something to modulate (or affect the function of) the neurons (or nerves) and toxin … well … basically means poison. Sounds pretty scary when you put it like that, but, as with any pharmaceutical, it is meant to be administered by a board certified medical professional (I do hope you are only seeing a dermatologist or plastic surgeon for this!) and, when used properly, is effective in getting the outcome you want. The original toxin came from the bacteria that causes botulism; we use a commercially available, medical-grade protein which, when appropriately injected through the skin and into facial muscles, causes them to relax for a more youthful appearance.



Here’s how they work. When you want to flex a muscle, your brain sends a signal down the nerve to that muscle. At the neuromuscular junction between the nerve and the muscle, the nerve releases a chemical signal (a neurotransmitter called acetylcholine) which floats across the junction to signal the muscle to “contract.” This happens when you want to lift your arm, or take a step … or when you want to furrow or raise your brow. Basically, what Botox® and other Neuromodulator Toxins do, is put up a wall at that junction so the signal cannot be received and the muscle does not contract … and the lines in your brow get a chance to relax.


Ok, so what goes where?


Back in the day when I was a resident and Botox® was relatively new, it was injected in the same grid-like pattern in everyone. Unfortunately, this meant that all patients ended with the same, frozen countenance.


This has changed dramatically over the last 15 years. Not only do we have four brands of Neuromodulator Toxin on the market in the US: Botox®, Dysport®, Xeomin®, Jeveau®, we simply know more. Board certified dermatologists and plastic surgeons have advanced their knowledge of how to use the products discretely on specific physiological locations at various strengths to effect desired outcomes.



In other words, today we have a better understanding of not only where we inject but also of ways to manipulate the strength of the product to achieve certain outcomes. The toxin comes as a powder that has to be diluted with saline. Depending on how concentrated we want the solution, we use more or less saline. Around the eyes, where I want to inject less volume, I will use a more highly concentrated solution, while on the forehead, where I want fewer units of toxin so that it spreads more evenly over the large frontalis muscle and avoids dropping the eyebrows, I use a more diluted solution.


So where DO we put it?

  • Bunny lines – minimize the diagonal lines on the sides of the bridge of the nose

  • Smokers lines – erase these lines that form when your mouth makes a “kissy” face

  • Dimpling of the chin - just your lower lip put and watch that chin dimple Just ??? your lip?

  • Minimize a gummy smile (my favorite!!!) – relax the ?????? what to do what?

  • Masseters* - to relieve TMJ, teeth grinding, and to slim a wide face, relax thes muscles that you feel when you clench your teeth

  • Beneath the lower lashes - help open up the eye and make it appear bigger

  • Depressor anguli oris – lift up the corners of the mouth by relaxing these muscles we used to frown

  • Neck lines and bands (make a face where your lower teeth show and watch those bands pull your face down)

  • Armpits, hands, and feet and even scalp (blowtox) - relieve excess sweating

  • Correct smile asymmetry – relax the side that’s pulling too much

As you can see this toxin is quite amazing. I recommend planning two (2) visits for your treatment two (2) weeks apart so you can get a “touchup” at the second treatment to correct any asymmetry. We all have one side of our face that is stronger and so that side may need a touchup. Two visits allow us to proceed with care; we can always add more but we can’t take it away if too much was injected.


Once dynamic lines of movement like the “11’s” or forehead lines get etched in the skin (which means they are obvious even when the skin is stretched) , it will take several cycles of treatment to iron it out. It is always better to treat these dynamic lines before they get etched in!


Contact me for your appointment today!