Geometric Wrinkle Injections

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Geometric Wrinkle Injections

Botox Tape Measurement

Prof. Hussein Ghanem

Geometric botox injections is an accurate botox injection technique developed by Prof. Hussein Ghanem.  The technique was presented in the International Masters Congress on Aging Skin, Paris, Jan 2011 (Lectures 901 & 913) January 9, 2011

The presentations were well received & generated a lot of interest among the audience due to its accuracy, simplicity, effectiveness & most importantly lack of complications and symmetry.


Even the most experienced eye can not act as an accurate measurement device that would place injections at exactly symmetrical positions on both sides of the face.  Unsatisfactory results are frequently related to asymmetry of Botox injection sites. Geometric Botox injection is a simplified approach to achieve accurate reproducible results.

Botox Female Forehead

Botox Marionette lines and chin

PATIENTS & METHODS This case series includes 120 patients who underwent botulinum toxin injections for face rejuvenation.  Injections sites were predetermined by tape measurements and distances based on the anatomical landmarks & special needs of the patient e.g. required position of eye brows. Forehead injections (Fig 1 & 2):Forehead injections included 5 points, 1 point in Midline, and 2 points on either side.  All points placed at equidistance, from the eyebrows as well as the midline, measured by tape and marked.  Generally, the injections were placed 3 cm above the eyebrows (2.5 for small foreheads).  The lateral forehead injection points were 4 cm from the midline (for narrow foreheads), while for broad foreheads, the lateral forehead injection points were up to 6 cm from midline (about 1 to 2.5 cm outside midpupilary line).  The remaining injections were placed at the middle point between the midline and lateral forehead injections.  Injections were high outside the midpupilary lines to avoid eyebrow elevation by the compensatory action of the lateral frontalis fibers.Glabellar injections (Fig 3):Glabellar injections included 3 points. Point 1 the Procerus muscle (5 units) in the point of the intersection of 2 imaginary lines between the inner canthus of the eye and the medial eyebrow.    Points 2 and 3 (5 units each) are placed medially just above the eye brows in line with the medial canthus.  The needle is directed upwards and laterally.Injections for Crows feet (Fig 4):The patient is asked to smile maximally. Points are marked at least 2 cm from the lateral canthus or 1.5 cm from the lateral orbital margin.  Injections did not go medial to a line drown vertically down from the lateral canthus.  Five to 15 units of Botulinum toxin are injected at 2 to 3 points.Injections for Marionette lines (Fig 5,6) & Dimpled chin:The Depressor Anguli Oris (DEO) is injected at a point just medial to the Massetter muscle.  That point is marked on either side as well as the midline of the chin.  The distance from midline is measured to ensure symmetric injection of the DEO. Three units are injected on either side. Five units of Botox are injected in the Mentalis muscle to treat the dimpled chin (peau d’orange)

Botox Tape Measurement

RESULTS No complications occurred.  Retouching was needed in 8 patients; 3 to lower the lateral eyebrows and 5 to deal with remaining lines.  The degree of muscular response is variable from one patient to another. The doses and locations of injections erred to the side of safety.  Though no complications occurred, retouching was needed in 8 patients.  Most of the patients didn’t wish to elevate the lateral eyebrows so in 3 cases retouching of the lateral frontalis was needed to lower the eyebrows.  In 5 patients the dose injected was not sufficient to relax the frontalis muscle satisfactorily so retouching was needed.

DISCUSSION Placing Botulinum toxin at exactly the same position (vertically and horizontally) on either side of the forehead (measured from the midline and the eyebrows) would decrease the possibility of brow position asymmetry (e.g. one brow higher than the other). Measuring the distance of Botulinum toxin injection from established landmarks is easy-to-learn, safe, effective & yields reproducible results.

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