Alternatives to botox for the "11" wrinkles between eyebrows?

Question

I'm 28 and now have a wrinkle from frowning between the eyebrows. I know that with time it will become deeper. I have read botox is FDA approved for this area, but the serious side effects and even the possible eyelids drooping really worries me. What is the best treatment to prevent and/or treat the "11" wrinkles?

John L. Burns Jr., MD · Answer

A neuromodulator such as Botox, Xeomin or Dysport is your best option at age 28.  For very deep wrinkles a filler may be necessary as well.

Michael Horn, MD · Answer

Although botox works extremely well for the "11" frown lines between the eyebrows, you can alternatively use fillers or laser for the area. Hylaform gel can be injected into the area to improve wrinkles. Also if the wrinkles are present at rest, laser can be used to help smooth the lines.

Rebecca Fitzgerald, MD · Answer

Certainly Botox has the longest history for erasing those mid brow frown lines. Proper injection makes a big difference and most experienced injectors seldom see any lid drooping (used to be more common before the injection techniques were changed).But it IS a toxin and if the idea of that is disturbing, then your options are reduced. But, before Botox there was - and still is - a little product called Frownies that theoretically trains you not to frown. The stiff paper is glued to the skin and makes muscle contraction more difficult while wearing it. Obviously best used at home alone or when you sleep but it's usually day events that have your frown going. Does that take the place of Botox? Certainly not, but it's something you could try if you want to go the completely noninvasive route.Other options might be to consciously relax - place a mirror at your desk to check your frown activity and every so often stop what you are doing and close your eyes. Literally TELL yourself to relax and to stop frowning.There is a topical product in FDA trials that is developed for the crows feet. That would eliminate injections in that area but won't address the glabellar muscle that gives you the 11's.Fillers alone probably won't be the best option since you'd still be contracting muscles and creating the lines.Frowning is a habit and like any habit, requires some conscious effort to change.

David Hansen, MD · Answer

The frown lines between the eyebrows often need both botox and fillers for the best results. Permanent implants do good in this area as well as temp. fillers. Sincerely, David Hansen,MD

Laura Schilling, MD · Answer

Botox, or other neuromodulators (such as Dysport or Xeomin), is your best option for treating the "11" lines.  Botox is a very well tolerated, and relatively low risk, procedure that provides extremely satisfying results. Serious side effects would be very rare, especially when being treated by a well-trained and experienced injector.  Even if you were to have the rare and unfortunate side effect of eyelid drooping, this is only temporary (and there are ways to make it less apparent in the meantime, if necessary). I would recommend having a consult with your provider to review the treatment, discuss expectations, and address any more specific concerns you have regarding the risks (to hopefully ease your mind!).
Other options would include injecting hyaluronic acid fillers into the area. However, this is a high-risk area for filler injections, and you would definitely need to see an experienced injector with in depth knowledge of facial anatomy. In my opinion, Botox is a much superior option (especially in younger patients with likely less severe wrinkles) than filler for this area due to its lower risk, high satisfaction, and preventative benefits. Fillers would only treat, not prevent, these lines. Less common options for the "11" lines would be resurfacing lasers or microneedling - but, again, I say neuromodulators such as Botox remain the gold standard for this area. good luck!

Monika Soni, MD · Answer

Thank you for your question! Although botox works extremely well for the "11" frown lines between the eyebrows, you can alternatively use fillers or laser for the area. Hylaform gel can be injected into the area to improve wrinkles. Also if the wrinkles are present at rest, laser can be used to help smooth the lines. Best of luck!

Alex Eshaghian, MD, PhD · Answer

Thank you for your question MsKate28. 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 in the
absence of photographs. However I hope the information provided here is helpful.The appearance of frown lines is variable from
person to person. Usually they are in a vertical orientation but sometimes they
can be oblique and sometimes a horizontal line is seen across the upper portion
of the nasal bridge. The most common variation is to have two parallel lines,
hence the common term "11's" to describe them. But some people have
one, three, or more lines. Some people also will see a bulge in the area when
contracting the muscle. This bulge is smoothened out after a Botox treatment.The pivotal studies used 20 units of Botox in
the glabella area between the brow to address the frown lines. 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.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. Most
importantly are muscles required to perform various functions. The muscles that are treated with Botox around
the eyes are close to the muscle that lifts the upper eyelid. If this muscle is
affected it can lead to a temporary droopy eyelid (blepharoptosis) as you described. The
duration depends on the placement of the product and the dose used. Usually it
resolves in 2 weeks, but it can last up to 4 months. Blepharoptosis can be
treated with apraclonidine 0.5% ophthalmic solution (also known as iopidine)
and various other medications. The incidence of blepharoptosis is reported
to be approximately 1% but in my experience, I find it to be about 0.1%. This
is likely due to the fact that when these studies were initially performed
injectors may have not been as aware of this adverse effect nor been taking
extra precautions to avoid it. Therefore it is not a concern for many patients at all, especially since it is temporary and treatable. Diffusion into this
area may also be caused by other preventable things. For this reason, I
recommend that my patients to carefully follow the aftercare instructions described below. This may be a reason for the low incidence of side effects in
my practice.There are some alternatives to Botox to address the frown lines. For example, some physicians use fillers in this area. However when fillers are placed in this area, in addition to the risks described above from injections there is also the risk for permanent and irreversible blindness. Although this is very rare, it is the primary reason why I avoid fillers in this area. Treatments such as fractional CO2 laser resurfacing can tighten the skin in the area and help with wrinkles. However the underlying cause of these wrinkles is muscle movement and if the muscles are not relaxed with a product such as Botox the wrinkles will return.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 as described above. 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.Botox is what we call a neuromodulator. This
means that it controls nerves to relax the muscles by preventing them from contracting.
Botox is the most popular neuromodulator available, has been the most studied,
and is cleared for the most number of indications. Other neuromodulators
available in the United States include Dysport, Xeomin, and Mybloc. Overseas
many others are also available. Each product has slight differences, but all of
them work. The majority of our patients find that they like the results of
Botox the best. Additionally, Allergan, the maker of Botox, offers the
Brilliant Distinctions Program. This is a rewards program where patients
receive points from their Botox treatments which can be used toward discounts
at subsequent treatments. Points are also received when patients purchase other
treatments in the Allergan portfolio including Juvederm Ultra, Juvederm Ultra
Plus, Voluma, Volbella, Vollure, and Kybella or products such as Latisse or
Skin Medica products.I find that combining Botox with other
treatments or skin care regimens enhances the results and allows patients to
enjoy their results for longer. One specific topical product our patients have
found to be outstanding in conjunction with a Botox (and filler) treatment is
our Hydrating Serum, which contains hyaluronic acid. Hyaluronic acid draws water
into the skin and helps to fill in fine lines and wrinkles.Please consult with a doctor for specific
recommendations. Good luck!

Steven F. Weiner, MD · Answer

There are 2 alternatives to neurotoxins for the frown lines.  The first is using radiofrequency to ablate the nerves that cause the muscles to contract.  This is promoted by the company ThermiRase.  It gives a long term correction (a few years) but will cost you in the $1500 range.  The other technology uses a freezing solution to cause injury to the nerves and this has been dubbed "Frotox".  I don't think this is available yet in the states.  I think it also isn't giving as long a result - months.  I wouldn't worry about dropping brows if just injecting the 11's and you go to an experienced injector.  There are millions of people who have had Botox treatments.

F. Victor Rueckl, MD (in memoriam) · Answer

The two alternatives that Dr. Weiner notes are indeed those I would discuss as well. ThermiRase I have concerns with at this point only because it's NOT as temporary as Botox so any issues could be longer-term should you have any. Frotox is still not used in the states, but is in studies for approval. Most issues with Botox have to do with people selecting non-qualified injectors or looking for a "deal" rather than experience. Millions of people have been treated safely with Botox, for over a decade. If you seek a good, experienced injector, any issues should be negligible. "This answer has been solicited without seeing this patient and cannot 
be held as true medical advice, but only opinion. Seek in-person 
treatment with a trained medical professional for appropriate care."

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