Is it normal to only give Botox to the top half of a forehead? (photo)

Thank you for your question. You submitted a single photo asking if it is normal to place Botox® only at the upper part of the forehead. You describe in your question a recounting of the dialogue you had with your doctor who stated they would leave about 2 inches above your brow in the areas that were injected to avoid losing full facial expression, and to avoid downward drop of the brows that would cause the eyelids to be heavy. It seems you’re still dissatisfied, and you feel “defeated” after all the money you spent.
I can share with you how I discuss this with my patients with similar situations like yourself, which are actually fairly common. A little background: I’m a Board-certified cosmetic surgeon and Fellowship-trained oculofacial plastic and reconstructive surgeon. I have been in practice in Manhattan and Long Island for over 20 years. And I have been treating patients with Botox® since 1993.
One of the challenges we have to deal with up to this day has been patients who got over treated. When I say over treated, I mean well-meaning doctors who want to treat the wrinkles across the forehead. By doing so, they eliminate the mechanism by which the eyebrows can be elevated, which is used to help reduce the heaviness of the upper eyelids in the eyelid itself.
When we look at horizontal lines on the forehead, the question that first comes to mind is why are those lines relatively deep? Very commonly, beyond a certain age, it’s because unconsciously, people are raising their eyebrows because of the soft tissue and amount of skin descent of their eyebrows weighing down on their eyelids. They’re unconsciously keeping their brows up so they can see better. When they look at the mirror and see those lines, they’re distressed by them. Doctors will typically, or as I would do in my practice, I will have them look straight and relax their forehead. When their forehead is relaxed and I take their pictures, I’ll show them there’s so much extra skin over their eyes. We discuss other options in addition to Botox®. The Botox® can be done in a variety of ways to maintain some degree of tone so you maintain the ability to raise your eyebrows for natural expression and to prevent the full cascading of the skin over your eyelids.
Very often, once people realize they have all this extra skin over their eyes, we have a discussion of different brow lifting options and upper eyelid cosmetic surgery. What’s really nice is when people are aware of the fullness and heaviness of the skin over their eyes, a procedure like cosmetic upper eyelid blepharoplasty, which we do pretty much every day in our practice under local anesthesia with LITE™ sedation in our office Joint Commission approved facility, we’re able to reduce the amount of wrinkles on their forehead by diminishing or extinguishing the habit because they don’t have the weight over their eyes.
Interestingly, it still does take some Botox® to extinguish a habit. Very often, people still raise their eyebrows even after eyelid surgery, so it’s not a 100% immediate. Once they’re able to relax their forehead and don’t have to work so hard, then the schedule for Botox® can change, so they often don’t need as much. Maybe they need a little just to maintain a nice, natural look, but not as much to avoid the deep wrinkling of the forehead which comes from continuous contraction. Not to mention they also get fatigued from raising their eyebrows consistently. It’s like holding a weight up with any muscle - you can only do it for so long before you get fatigued.
As far as your doctor’s approach, I would say that’s a valid approach, and I think your doctor was certainly thoughtful in explaining what the basis was to help you achieve a natural result. There are pluses and minuses to being aggressive. I would say that once somebody is unable to move their forehead, or feels like their eyebrows are too low, and their eyelids are heavy, they’ll describe feeling trapped, and they’re very distressed and unhappy. Life is about compromise, and I do have to figure out with your doctor what you are willing to tolerate. Often in clinical medicine, it’s treat, then observe so you can see what kind of result you’ll have.
You can also compare your before and after photos. I always take pictures of muscles under activity, then relaxed, and show my patients how they look even after something as minor as Botox®. It’s very important to understand the activity of the muscles and how they would diminish. I always explain to my patients the definition of success is improvement. We can’t eliminate everything with just a needle, you have to decide what you’re comfortable with, and what you are ready to do now or later on. My patients tend to stay with me for a long time, and we may do Botox® for an important event, but later on like a year or 6 months later, we’ll do some surgery to address the underlying issue such as a hooding over the eyelids causing a reflex of raising the eyebrows which leads to wrinkles. Treat the underlying cause, and you can diminish the wrinkling in a long-term way with a strategy in mind. I hope that was helpful, I wish you the best of luck, and thank you for your question.This personalized video answer to your question is posted on RealSelf and on YouTube. To provide you with a personal and expert response, we use the image(s) you submitted on RealSelf in the video, but with respect to your privacy, we only show the body feature in question so you are not personally identifiable. If you prefer not to have your video question visible on YouTube, please contact us.

When I use Botox/Dysport in the forehead area, I tend to be fairly conservative until I get to know the patient and see how much they need in order to get the right effect.  I would rather they came back in a week for a little bit more than have them call me later and tell me they have heavy eyebrows.  That is the big risk with Botox/Dysport in the forehead.  Still, two inches above the eyebrows is too high.  You can get closer than that without running into any problems.  

Your injector is not incorrect in saying that one has to be careful injecting the lower half of the forehead as it increases the risk of a droopy eyebrow. That said, the lower half of the forehead can be injected with low doses of Botox to soften the creases, especially when the crows feet and 11-lines were injected in conjunction as well to help elevate the eyebrow and counteract and potential droopy ayebrow. You can discuss this with your injector and if you are not satisfied with him or her, it never hurts to seek a second opinion. Best wishes!