Jeuveau Certification & Jeuveau Training Course

Cosmetic Medical Training provides you with our FREE Jeuveau Certification Training Manual. Please contact us for your hands-on Jeuveau training.

How to Inject Jeuveau®: a Beginner’s Guide to Jeuveau Certification

What is Jeuveau®?

Jeuveau® is a purified botulinum toxin made by a company called Evolus that temporarily relaxes the muscles that cause wrinkles on the face. Jeuveau® works on the neuromuscular junction by blocking the release of acetylcholine which prevents the contraction of the muscle. Jeuveau® enters the nerve terminal and cleaves a protein called SNAP-25, which is essential to the release of acetylcholine in the nerve endings. Jeuveau® reduces muscle activity through this partial chemical denervation.

Jeuveau® was FDA-approved in 2019 “for the temporary improvement in the appearance of moderate to severe glabellar lines associated with corrugator and/or procerus muscle activity in adults”. Injection of other areas besides the glabellar lines by Jeuveau® is off-label.

Much like Botox®, Jeuveau® takes up to 7 days for full results. The relaxation of the muscle may last 3 to 4 months. The main difference between Jeuveau® and Botox® is that Jeuveau® has a different purification process in preparation. The efficacy was tested in a head-to-head clinical trial which concluded that “20 U prabotulinumtoxinA was safe and effective and noninferior to 20 U onabotulinumtoxinA for the treatment of moderate to severe glabellar lines”.

Contraindication

Jeuveau® is contraindicated in the following:

Known Hypersensitivity to Botulinum Toxin
Infection at the Injection Site

Warnings

Jeuveau® is observed to spread beyond the site of the injection. Symptoms such as asthenia, generalized muscle weakness, diplopia, ptosis, dysphagia, dysphonia, dysarthria, urinary incontinence, blurred vision, and breathing difficulties have been observed to occur within hours to weeks. There have also been reports of deaths related to the spread of toxin. These symptoms have been reported hours to weeks after injection. Swallowing and breathing difficulties can be life-threatening and there have been reports of death related to the spread of toxin effects, including excessive weakness, dysphagia, and aspiration pneumonia

Reconstitution and Handling

Jeuveau® (prabotulinumtoxinA-xvfs) is supplied as 100 units in a vial with vacuum-dried powder. Jeuveau® should be stored in a refrigerator between 2° to 8°C (36° to 46° F). Evolus recommends that you reconstitute the vial with only sterile, preservative-free 0.9% Sodium Chloride Injection. This will give you a reconstituted solution at a concentration of 4 Units/0.1 mL or a total treatment dose of 20 Units in 0.5 mL. When you use 0.9% preservative-free 0.9% Sodium Chloride, you should use the newly reconstituted Jeuveau® within 24 hours. The vial should be kept in the refrigerator and not frozen. The package insert states “after reconstitution, Jeuveau® should be used for only one injection session and for only one patient. Discard any remaining solution after administration.” This implies that the entire vial of Jeuveau® should be used for one injection session for one patient. This is not what typically happens in the real world as most injectors use it as a multi-use vial.

100 units per 2.5cc

20 units per 0.5cc

4 units per 0.1cc

Although the manufacturer, Evolus, recommends using non-preserved 0.9% Sodium Chloride, most practitioners use preserved 0.9% Sodium Chloride. Preserved (Bacteriostatic) 0.9% Sodium Chloride has shown to increase the activity of the botulinum toxin protein for up to 6 weeks when stored at 4°C (As recommended by Consensus Recommendations on the Use of Botulinum Toxin Type A in Facial Aesthetics).

Additional dilution options will be discussed during your hands-on Jeuveau certification and Jeuveau Training class.

Patient Consultation

Prior to your injection, you must obtain a detailed medical history from your patient. This includes pertinent history about prior use and experience with any other botulinum toxin. Your patient should be given the complete information regarding Jeuveau® and a consent form should be signed detailing the risks and benefits of the treatment. Take a good before photo under good light to record the patient’s face prior to the treatment. Discuss with your patient any asymmetry of the face prior to the injection.

Glabella (Frown Lines) Jeuveau Certification

Muscles Involved

The procerus muscle and the corrugator muscles make up the two main muscles that you will inject into the glabellar complex. The procerus originates from the nasal bone and attaches to the medial forehead & skin of the brow. The action of the procerus draws the medial brow down inferiorly. The corrugator originates from the medial superciliary arch and inserts into the skin of the medial forehead.

Injection Technique

Glabellar injections are deep intramuscular injections where the needlepoint depth should be near the periosteum. Since the frontalis muscle overlaps the glabellar complex superficially, a superficial injection can paralyze the frontalis muscle and cause the patient’s eyebrow to feel heavy. Conversely, a deep injection can cause you to dull your needle tip by hitting the periosteum.

Landmarks:

Medial corrugator injection = 1 cm above the bony orbital rim and vertical to the medial canthus

Lateral corrugator injections = 1 cm above the bony orbital rim and around 0.5cm medial to the vertical mid-pupillary line

Procerus injection = immediately above the crossing point of the X formed by drawing a line from the medial eyebrow to the contralateral medial canthus.

20 units are the standard FDA approved injection for the Glabellar lines as found in the Jeuveau® package insert.

Complication

According to Evolus, Jeuveau® was used on 654 patients and the complication rates are as follows:

Headache (12%)
Upper Respiratory Tract Infection (3%)
Eyelid ptosis (2%)
White Blood Cell count increase (1%)

Please note that injection lateral to the mid-pupillary line may cause brow ptosis. Also, injection too close to the orbital rim can cause lid ptosis by paralyzing the levator palpebrae superioris muscle. Usually, complications will be seen in 48 hours to 7 days. The effects of the complication may last up to 4 – 8 weeks.

Frontalis (Horizontal Forehead Lines) Jeuveau Training

Muscle involved

The frontalis muscle is a superficial muscle that varies in shape and size. Rather than relying on the surface landmarks of visible wrinkles, you must use your fingers to palpate the muscle to identify the proper outline. The muscle may be tall or short, narrow or broad, and v-shaped or square-shaped. We will go over the methods to correctly identify the shape of the frontalis muscle during your hands-on Jeuveau training session.

Injection Technique

All injections are intramuscular. However, since the skin is thin and there is no other major structure on the forehead, you can angle your needle at a 45-degree angle like a subcutaneous injection. All injections should be at least 2 cm apart. The lower 3 – 4 cm of the frontalis muscle plays a large role in elevating the eyebrow; therefore, injections here should be avoided.

Complication

Since injection of the frontalis is an off-label indication for Jeuveau, there is no research data. According to Allergan, Jeuveau® was used on 665 patients and the complication rates are as follows:

Headache (9%)
Eyelid ptosis (2%)
Brow ptosis (2%)
Skin tightness (2%)

Brow ptosis may happen for many reasons. Commonly, an injection too low on the frontalis may cause this. Also, a person who has a hyperfunctional frontalis (a person who always uses the frontalis when opening their eyes) will feel that their eyebrows will feel heavy. Finally, this can happen if your patient requests that you inject only the frontalis without glabellar treatment. This will cause unopposed glabellar activity which will depress the eyebrows.

Orbicularis Oculi (Crow’s Feet) Jeuveau Certification

Muscles Involved

The orbicularis oculi is a single circumferential muscle. It originates from the medial palpebral ligament and inserts into the lateral palpebral raphe, corrugator, frontalis, and depressor supercili. The action is to pull the skin of the forehead, temple, and cheek towards the medial angle of the orbit.

Injection Technique

The skin around the lateral edge of the eyes is thin and there are no other structures in this area. Therefore, you can angle your needle at 45 degrees and inject it like a subcutaneous injection. However, this injection is still intramuscular. Place your injection at least 2 cm apart in a triangle shape. Inject at least 1 cm outside of the bony rim to avoid the spread of Jeuveau® into the lateral rectus muscle.

Complication

Since injection of the crow’s feet is an off-label indication for Jeuveau, there is no research data. According to Allergan, Botox® was used on 526 patients and the complication rates are as follows:

Eyelid edema (1%)

Other rare side effects are asymmetrical smile or diplopia due to migration. You can help avoid this by injecting at least 1 cm outside of the bony rim, but not close to the zygomatic arch.