Will 20 units of Botox along the hairline cause eyebrow dropping?

Question

Hi I got 32 units of Botox in my forehead today 20 along my hairline and 4/4 in brows and 4 in my frown. My question is about the 20 in my hairline - I went for an eyebrow lift today and my injector insisted that the 20 along my hairline will help pull my eyebrows higher (since my forehead is on the bigger side) I don’t know if this is true. Is it?

Luis Villar, MD, FACS · Answer

Botox/Xeomin neurotoxins do not "lift" anything.  This is urban legend propagated by the vast number of  injectors who do not know the anatomy or how neurotoxins work.  Neurotoxins work by paralyzing  the muscles of expression.  Forehead muscles lift the brows, so if you paralyze them, the brow may drop to varying degrees. You can affect brow position by paralyzing antagonistic muscles (muscle that act against each other). Weaken one, the other dominates. If you weaken the muscles in the crows feet area, you may achieve some lift of the lateral brow as the foreheads muscles now dominate.  But if you also paralyze the forehead, the effect is neutralized.  If you only paralyze the frown lines,  the mid brows can sometimes drop slightly, giving the illusion that the lateral brows have been lifted. This is the theory of relativity, but not Einstein's theory of relativity :)

Philip Solomon, MD, FRCS · Answer

Botox works by relaxing the musles it is injected into, and therefore preventing creasing of the skin. It is important that injectors understand the mechanisms of the facial muscles.For example- the forehead muscles, called the frontalis, work to elevate and raise your brows upwards. By injecting 20units into the forehead, the opposite effect occurs and your brows will not raise. When clients request a brow lift, an injector should treat the “depressor” muscles of the upper/mid face. These muscles are activated when making a frowning face or squeezing your eyes together tightly. Injections would occur between the eyebrows and at the tail of the eyebrows.

Michael I. Echavez, MD · Answer

Normally, when Botox is used to help lift the brows, the injection is placed just below the brows.  This weakens the muscle that pulls the eyebrows down and thus causes them to raise a bit.  Injecting Botox anywhere above the brows, including along the hairline, should not cause the brows to raise.

Nirmal Nathan, MD · Answer

Dear Yolanda00,Thank you for your question. What your injector is describing does not anatomically make sense. The frontalis muscle along the hairline pulls your eyebrows up. Inactivating any part of it will decrease upward pull on the eyebrows.Good luck,Nirmal R. Nathan, M.D.
Certified, American Board of Plastic Surgery
Member, American Society of Plastic Surgeons

Scott Loessin, MD · Answer

When injecting Botox in the Forehead by your hairline it will not cause the eyebrows to raise. When patients come to see me for Botox and are wanting a chemical eyebrow lift I inject slightly under the outer brow. By doing this it paralyzes that muscle that pulls the eyebrow down and thus causes the eyebrow to raise.  I hope this helps and be sure to see a Doctor who is Board Certified to get the best care.

Victor M. Perez, MD, FACS · Answer

your injector needs to know the anatomy of your period oral muscles, hence why a surgeon is the best option for you, in summary you have groups of muscles that will pull down your brow and muscles that will pull up your brows, the muscles that pull up your brows create the forehead horizontal lines, treatment of this muscles will help you with those lines, but treatment of the muscles pulling down your brows are absolutely necessary. If you only treat the forehead muscles (pulling up) with out treating all the muscles that pull down the brows, then the effect will be the opposite of what you want.

Jesse E. Smith, MD, FACS · Answer

Botox in the hairline injects a muscle called the frontalis.  The frontalis actually lifts the brow.  So, it is unlikely that placing Botox in this region will actually produce a brow lifting effect.

Alex Eshaghian, MD, PhD · Answer

Thank you for your question Yolanda00. I understand your concern. Botox is a purified protein used to address wrinkles associated with facial expression. When injected into the skin Botox will relax the muscles and smoothen out the overlying wrinkles. The most common areas of treatment are in the upper face. These include the horizontal lines seen on the upper forehead when one raises the brows, the vertical lines seen between the brows when one frowns (frown lines), and the crow's feet seen around the eyes when one smiles.
It is difficult to make an assessment without a formal exam in the office where I can view the skin in multiple angles and observe wrinkles formed with facial expression. However, I hope the information provided here is useful.The pivotal studies used 20 units of Botox in the forehead area above the brows to address the horizontal lines seen when one raises the brows. These studies demonstrated that the peak results are seen 14 days after the treatment and most people enjoy their results for 3-4 months. At that point, a maintenance treatment is recommended. While some people start to see results as early as the next day, it can take two weeks for full results so patience is important. We have our patients return two weeks after their treatment to assess their results via photographs. At that time additional units may be added if necessary. 
The pivotal studies for the horizontal lines on the upper forehead were published many years after doctors had been using Botox. In these studies, 20 units of Botox were used to treat this area. However, in my experience I find that anywhere from 10 to 20 units works well in this area. For patients with narrow foreheads a lower dose may be used and those with a broad forehead generally require higher doses. I have also found that the full results in this area are seen by two weeks. Therefore, we have our patients return two weeks after their treatment to assess the results via photographs. At that point additional units may be used if further enhancement is desired.
When patients present with concerns about specific wrinkles in the upper face such as the frown lines, I always assess and usually treat the other wrinkles in the upper face including the horizontal forehead wrinkles and crow’s feet. The reason is to maintain a harmonious and natural balance to the appearance of the upper face. The muscles in the glabella which are responsible for the formation of the frown lines serve to pull down on the inner brows when a person frowns. Similarly, the muscles around the eyes which are responsible for the formation of the crow’s feet seen when smiling (orbicularis oculi) are also responsible for pulling down on the brows, but in this case the outer brows. On the other hand, the muscle in the upper forehead which is responsible for the formation of the horizontal forehead wrinkles when a person raises the brows (frontalis) serves to pull the brows upward. If one of these muscles is relaxed with Botox and the others are not, the other muscles will still be active. This will lead to an unbalanced and unnatural appearance of the upper face where the brow can be elevated, depressed, or uneven in shape or position. Therefore, I recommend that my patients take a global approach to the upper face when receiving Botox treatments and treat all three of these areas. Sometimes bunny lines on the bridge of the nose are also treated.
In addition to addressing various wrinkles, Botox can also be used to adjust the position and shape of the eyebrows. It works the same way as it does when addressing wrinkles, namely by relaxing muscles. In the upper forehead, there are muscles that move the eyebrows up and other muscles that move the eyebrows down. The muscle that moves the eyebrows up is on the upper forehead; this is called the frontalis muscle. It is responsible for the horizontal lines seen on the upper forehead when one raises the eyebrows. The muscles that pull down on the eyebrows are located between the eyebrows and at the corners of the eyebrows. The muscle group between the eyebrows is called the glabellar complex. There is another muscle that goes around the entire eye called the orbicularis oculi muscle. The portion of this muscle under the tail of the eyebrow is responsible for pulling down on the tail of the eyebrow. When any of these muscles is relaxes with Botox the position of the eyebrow can be adjusted. When treating the horizontal lines on the upper forehead seen when one raises the eyebrows, if the dose is too high or if the placement of the product is too low it can lead to the feeling of a heavy eyebrow, difficulty raising the eyebrow, or downward movement of the eyebrow. This can also lead to downward movement of the eyelids, making a person appear tired. It also can make it difficult to apply eye makeup. To correct this Botox is placed in the antagonistic muscles, those in the glabella and orbicularis oculi which pull down on the eyebrows. This will raise the position of the eyebrows. These two areas can be treated with Botox to provide a brow lift. To do so 4-20 units of Botox are used in the glabella between the eyebrows and 2-12 units of Botox per side are used at the tail of the brow and/or the entire crow’s feet region.
It is impossible to make an assessment without seeing a patient in person or at least via photographs. However, as described above treating the upper forehead in the hairline will relax the muscle that pulls the brows up. This may lead to a heavy feeling if other muscles are not treated. However in this case the glabella and crow's feet were treated with a low dose. For those with a broad forehead such a dose may work well. If I had a patient with the concern described here I would say that the treatment described here would more likely lower the brows than raise the brows, depending on the individual.With any injection, there are risks such as pain, bleeding, bruising, redness, swelling, tenderness, and infection. We take special precautions to minimize these risks such as using a painless technique. We also treat bruises with a laser as early as the next day. Bruises usually resolve within two weeks if untreated. After a laser treatment bruises usually resolve in 1-3 days, but may still take two weeks for full resolution. In addition to these risks, with Botox there is also a risk that the product spreads or diffuses to nearby structures. Spread to nearby muscles can lead to side effects such as the temporary appearance of droopy eyelids or a temporary asymmetric smile.
  
After a Botox treatment, I recommend that my patients avoid heat exposure, alcohol consumption, and strenuous exercise for 24 hours and not lie down flat for four hours. This is because all of these activities may possibly lead to the movement of the product and consequent side effects such as droopy eyelids. Although there have been no definitive studies shown that these actually occur and some physicians do not provide such aftercare instructions, in the absence of data I err on the side of caution and recommend that my patients avoid such activities.
  
Please consult with a doctor for specific recommendations. Good luck!

Melvin Elson, MD · Answer

Botox injected at the hairline will not lift the eyebrows and may actually have the reverse effect

Center for Aesthetics and Plastic Surgery - Grand Rapids · Answer

Hello there! Typically to maximize the lift created by Botox, I will avoid treating any part of the frontalis (forehead) muscle. This muscle lifts the brow, so eliminating any of its strength will decrease the lift you achieve from treatment. That being said, injecting high on the forehead will decrease the lift less than treatment lower on the forehead. I would see how things look for you in two weeks, when everything has taken affect. At that time you can discuss your concerns with your injector if needed.  Good luck! Sarah RN BSN

Will 20 units of Botox along the hairline cause eyebrow dropping?

Answers (12)

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