CATEGORY 46 AUSTRALASIAN DENTIST SALADS: A simple framework for reducing botulinum toxin complications Six practical principles that every injector should remember before picking up the syringe CLINICAL Dr Giulia D’Anna By Dr Giulia D’Anna Founder, Dermal Distinction Academy. Aesthetic Medical Emergency Team (AMET) Complications Expert I recently had the opportunity to present a lecture on reducing botulinum toxin complications at Australia's largest aesthetic conference, the Non-Surgical Symposium. The same principles were reinforced during a cadaver workshop where I was cofaculty, reminding me that regardless of experience, preventing complications always begins with understanding anatomy and refining technique. Botulinum toxin is one of the most predictable treatments in aesthetic medicine, yet complications still occur. Fortunately, most are not the result of the product itself, but of treatment planning, anatomical variation or injection technique. Eyebrow heaviness, eyelid ptosis, asymmetry and unwanted weakness often develop because the toxin reaches a muscle that was never intended to be treated. While no single approach can eliminate complications entirely, adopting a systematic injection technique can significantly reduce risk. Over the years, I have found the acronym SALADS provides a simple way to remember six key factors that should be considered before every injection. Like any good clinical checklist, it encourages practitioners to pause, assess and inject with intention rather than habit. S – Speed of injection The rate at which botulinum toxin is injected is often overlooked. Rapid injection creates greater tissue pressure, increasing the likelihood of the solution tracking along tissue planes. A slow, controlled injection allows the product to be deposited more precisely within the target muscle while reducing discomfort for the patient. Although botulinum toxin diffusion is influenced by multiple factors, gentle injection technique remains one of the simplest ways to improve accuracy. Slowing down also gives the clinician time to appreciate tissue resistance and needle position before completing the injection. Sometimes the best way to inject is simply to inject more slowly. appear anatomically similar in textbooks demonstrate substantial variation in clinical practice. Before every treatment, practitioners should ask themselves: u Which muscle am I trying to affect? u What neighbouring muscles must I avoid? u Is this patient's anatomy typical or are there variations? Understanding the relationship between agonist and antagonist muscles is equally important. Weakening the frontalis without considering the depressor complex, for example, may produce brow heaviness. Similarly, treating the depressor anguli oris without appreciating the position of the depressor labii inferioris may increase the risk of lower lip asymmetry. Knowledge of anatomy remains the single most effective strategy for reducing complications. L – Layer (Depth) Injection depth matters. Facial muscles vary considerably in their thickness and anatomical position beneath the skin. Some lie immediately within the superficial musculoaponeurotic system (SMAS), while others are deeper or overlap adjacent muscles. Depositing toxin too superficially may reduce efficacy or increase spread into neighbouring muscles. Conversely, injecting too deeply may place the product beneath the target muscle, reducing the desired clinical effect. Successful treatment requires an appreciation of threeA – Anatomy Every face is different. Muscle size, orientation, strength and recruitment vary considerably between patients. Even muscles that
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