How Botox is done: the real step-by-step, from the mirror to the needle

The part everyone pictures — the needle going into the skin — is the shortest and the least important. It takes a few minutes. What decides the result happens before it, with the patient sitting in the chair making faces in front of a mirror.

This is not rhetoric. Botulinum toxin does not treat skin: it treats muscle in motion. So the information that matters is which muscle in that face pulls hardest, which one pulls against it, and what happens to the whole face if one of them is weakened. Two people with the same forehead line can need completely different injection maps, which is why "how many units for the forehead" is a question with no generic answer.

The step-by-step, in the order it happens

1. Talk before looking. What bothers you, for how long, what has been done before and what you expect to see. A poorly calibrated previous treatment changes the plan — the muscle may still be partially inhibited, and injecting on top of that is adding in the dark.

2. Assessing the face in motion. This is where the faces come in: raise the eyebrows, frown, squeeze the eyes shut, smile hard, push the chin forward. This is the stage where you see the asymmetry that was already there (almost every face has one) and the hierarchy of strength between the muscles.

3. Assessing the whole face, not just the complaint. The patient arrives talking about the forehead; what gets assessed is the whole picture. The complaint points to the symptom, and the plan starts from the structure. A forehead that wrinkles a lot is sometimes a forehead compensating for a heavy eyelid — and switching off that compensation without understanding why leaves the eyes looking droopy.

4. Marking. With a surgical skin marker, point by point, while the patient contracts. Marking is done on the active muscle, not on skin at rest.

5. Antisepsis. Cleaning the area, always without makeup.

6. Injection. A very fine needle, small injections that are superficial or intramuscular depending on the area. Each point takes seconds. The whole thing usually takes ten to twenty minutes.

7. Instructions and follow-up. The precautions for the first few hours and scheduling the reassessment — which is where the result is actually judged.

Door to door, a routine session fits into a lunch break. The initial assessment, the first time, is much longer than the injection itself.

How injection points are chosen

The map of points does not come from a textbook diagram pasted onto the patient's face. It comes from reading that person's musculature.

• A strong muscle calls for more distributed points, so one area is not left motionless while another stays active, creating that "wave" effect on the forehead.
• The opposing muscle has to be factored in. The frontalis raises the eyebrow; the group around and between the eyes pulls it down. Weakening only one side of that tug-of-war changes the position of the brow — for the better when it is intentional, for the worse when it is an accident.
• Pre-existing asymmetry gets documented beforehand. If the left eyebrow was already higher, it will stay higher, and that needs to be said before, not after.
• The edge matters more than the center. The peripheral points are the ones that decide whether the result looks natural or whether a step shows up between the treated area and the untreated one.

A rule I use as a criterion: when I am torn between two doses, the lower one. Too little effect is fixed with a top-up at the reassessment. Too much cannot be fixed — it only fades with time.

Does it hurt? Is anesthesia needed?

It hurts a little, and the little lasts the instant of the prick. The needle is among the finest available and the volume injected at each point is minimal. The most common description is a quick sting, more uncomfortable in the glabella — the area between the eyebrows, where the skin is thicker.

Topical numbing cream is an option for people who are afraid of needles, with a wait of a few minutes beforehand. Ice beforehand also helps, and lowers the chance of bruising. A nerve block is not used: it would be more invasive than the procedure.

What gets in the way more than pain is tension. A tense face changes how the muscles contract and makes them harder to read during marking.

What to do beforehand

• Avoid anti-inflammatories and aspirin in the preceding days, unless a doctor has prescribed them — they reduce clotting and increase bruising. Never stop an ongoing medication on your own.
• No alcohol the day before, for the same reason.
• Arrive without makeup or ready to remove it.
• Mention any neuromuscular disease, pregnancy, breastfeeding and current medications. Some antibiotics interfere with how the toxin works.

What not to do afterward

• Don't lie down or bend your head down for about four hours. This is where the so-called four-hour rule comes from: keeping the product from spreading to neighboring muscles before it settles.
• Don't massage, rub or have a facial on the area that same day.
• No intense exercise, sauna or strong heat for the first 24 hours.
• No alcohol that day, because of the bruising risk.

None of these restrictions lasts long. They are short-window precautions, and the next day is back to normal life.

The day-by-day progression, what you can see at each point and how to judge a results photo are covered in the article on Botox before and after — here the subject is the procedure itself.

How Botox for migraine is done

It is a different procedure, with a different protocol and a different purpose. For chronic migraine, injections are spread across multiple points on the head, neck and shoulder area, in a much larger quantity than an aesthetic treatment, and the goal is to reduce how often attacks happen, not expression lines.

It is a medical indication, handled by a neurologist, with its own diagnostic criteria — the migraine has to qualify as chronic. It is not something we do at RUV, and no aesthetic forehead treatment should be sold as a headache treatment.

The same goes for the other questions that tend to come up alongside it in searches: injections for overactive bladder, spasticity and lower back pain are medical uses, done in specific settings by specific specialties. The molecule is the same; everything else is not.

Are Sculptra and toxin the same thing?

No, and the question comes up a lot because both are often done by the same person, in the same office.

A collagen biostimulator works on the skin and on volume, stimulating collagen production over months. Toxin works on the muscle, reducing contraction. Neither replaces the other, and neither is a prerequisite for the other. They can belong to the same plan when it makes sense — laxity and dynamic lines are different problems on the same face.

Anyone who says you "need to do both" without explaining why is selling a package, not treating a complaint.

What makes one treatment cost more than another

Without talking numbers: what goes into the cost of a treatment is the amount of product used, the brand registered with Anvisa, the number of areas treated and the time spent on consultation and reassessment. A cheaper treatment almost always means one of three things: less product, a different product, or less assessment time.

The third is the one that costs the most later. The assessment is what decides the map of points, and a wrong map is not fixed with a better product.

Safety: what gets checked

Botulinum toxin is not the procedure with the highest vascular risk in the office — that title belongs to filler. Even so, injecting the face requires knowing what lies beneath the needle.

At RUV, Doppler ultrasound assessment is part of the procedure: beforehand, to understand the structure of that face — including filler material from previous treatments, which changes the injection plan; and afterward, when the case calls for it, to confirm there is no compression of a vessel. That is what turns "it's safe" from a promise into a verification.

And it is worth saying the obvious that is sometimes missing: the product has to be registered with Anvisa, opened in front of the patient and reconstituted on the spot. A vial that is already open, unlabeled, or injected outside a clinical setting is the red line.

Who can inject it

In Brazil, injecting botulinum toxin for aesthetic purposes is restricted to qualified professionals — physicians, dental surgeons within the scope of practice allowed by the CFO (Brazil's Federal Council of Dentistry), and biomedical scientists with the specific certification. At RUV, the injections are done by Dr. Najla Vicentini Toledo, a dental surgeon specializing in Facial Harmonization.

When we advise against it

• Pregnancy and breastfeeding. An elective procedure waits, no exceptions.
• Neuromuscular disease — myasthenia gravis and related conditions.
• Active infection or a skin lesion in the area to be treated.
• Less than three months since the previous session, because of the risk of resistance to the product.
• When the request is "I want a completely smooth forehead". Immobility is not the goal, and the expectation usually comes from edited images.
• When the complaint is a deep static wrinkle or sagging. Toxin acts on muscle in motion; a line already etched at rest and loose skin call for a different approach, and promising otherwise is dishonest.

Frequently asked questions

How long does the injection take?

The injection itself, ten to twenty minutes. The full appointment is longer because of the assessment, and the first time it is much longer.

How do you inject Botox in the face without looking artificial?

By lowering the dose, respecting the opposing muscles and resisting the urge to treat every area in the same session. An artificial look almost never comes from some exotic technique: it comes from high doses in many areas at once.

Do I need tests beforehand?

Routine lab tests, no. What is needed is a complete medical history — current medications, conditions, previous treatments. At RUV, Doppler ultrasound assessment comes in when there is a history of filler or a poorly documented previous procedure.

Can I go back to work afterward?

Yes, as long as the work does not require lying down or bending your head down in the first few hours. The small red needle marks fade within minutes to a few hours; a bruise, when it appears, lasts a few days and can be covered with makeup the next day.

What is the four-hour rule?

Not lying down or bending your head down for the first four hours after the injection, so the product settles in the target muscle before any spread.

How many sessions will I need?

One at a time. The effect is temporary, and maintenance is decided at the reassessment, not in a package locked in ahead of time. People with a history of regular treatments tend to space them further apart, because a muscle treated consistently weakens its habitual contraction.

Can I get toxin and filler on the same day?

In many cases yes, and sometimes it is the best plan, because each one sharpens the read on the other. But the order and the combination depend on the areas, and that is an assessment decision — not a scheduling one.