Counteracting Ptosis with Simultaneous Forehead and Eyebrow Botox Injections?

I had Botox in the horizontal forehead lines. Even though my plastic surgeon limited the injections to the upper part of forehead (I wanted him to go lower, but he said no it might drop the brows too much), the brows dropped a bit anyway. My question is this: when I have the horizontal forehead lines done again, can I ask him to do a simultaneous Botox brow lift to counteract the brow ptosis from the Botox in the horizontal lines?

Doctor Answers 12

Botox and lines

You certainly can have Botox injected in the lateral aspects of the eyebrow itself to help elevate the eyebrow.  However, there is a slightly increased risk of causing eyelid ptosis.  The Botox can migrate a bit and when injecting the area of the eyebrow it can seep into the orbicularis

New York Plastic Surgeon
4.1 out of 5 stars 29 reviews

Botox in the forehead weakens the brow lifting muscles

Dear Huntress

It is impossible to make forehead go up and down at the same time.

Where the eyebrow sits is a tug of war between the frontalis, the lifter muscle in the forehead, and the orbicularis oculi muscle just below the eyebrow and extending into the crowsfeet area, and the muscles at the top of the nose that squeeze the brows together. Increasing lines in the forehead are an indication that the forehead is fighting the pull of the eyebrow depressors. We do this for a variety of reasons. The main signal is when the eyelid fold crowds the upper eyelid and eyelashes. The brain sends a signal to the frontalis muscle to work harder, making for forehead lines.

Now lets think about what happens with various types of BOTOX treatments. The single FDA approved application of BOTOX for cosmetic treatment is 5 to 7 injections in the area between the eyebrows. This effectively treats the worry line, what Allergan, the maker of BOTOX, calls the 11 line. All other BOTOX treatments are "off label," not FDA approved but doctors are legally permitted to use medication, including, BOTOX for off label purposes. Treatment of the crows feet lines with BOTOX permits the brow to lift and the combination of treating the crows feet with treatment of the worry line area is sometimes referred to as a BOTOX forehead lift. And indeed it does create some elevation of the brows. Another common treatment is to take BOTOX and essentailly use it to paralyze the forehead. While this does create a glass smooth forehead, the aesthetic price is high. The frontalis muscle is the forehead lifter. So guess what this type of treatment causes the forehead to crash down (think Marcia Cross or Nichole Kidman to are thought to get hefty BOTOX treatments to the forehead).

A treatment variation that is considered by some doctors to produce a forehead lift, is a treatment that places BOTOX in the crows feet area, the worry line area and instead of treating the entire forehead, the treatment is placed in the central forehead but not on the sides of the forehead. This treatment pattern causes the eyebrows to lift up on the outsides. Beacuse the frontalis muscle on the sides of the forehead is not treated, the brain attempts to compensate for the portion of the frontalis muscle centerally that is not working. There is over action of this residual working frontalis muscle cause muscular recruitment lines. The heaping forehead lines that are produced on each side are sometimes referred to as a Klingon forehead. Not a super desirable result.

I have a patent pending microdroplet BOTOX method that actually leaves the forehead alone and treats a large portion of the orbicularis oculi musle under the eyebrow. This creates a profound brow lift by treating a large portion of the orbicularis oculi muscle that pulls the eyebrow down. The forehead lines are diminished because the frontalis muscle has less work to do. To get this benefit, one has to really understand the muscular anatomy of the face and how these muscles interact. Encourage your doctor to look at my website:, which describes how microdroplet BOTOX is done.

Kenneth D. Steinsapir, MD
Beverly Hills Oculoplastic Surgeon
4.9 out of 5 stars 26 reviews

Botox Brow Lift is possible


The short answer is yes. This is a technique that a good plastic surgeon uses all the time. The frontalis and obicularis oculi muscles are "antagonistic muscle pairs" for eyebrow position - when one contracts the other relaxes - changing the eyebrow position. The skill part of injecting botox is understanding the anatomy of the antagonistic muscle pairs in the face and injecting the right amount of botox in the right places to control the position of the eyebrows. I also use this concept to elevate the corners of the mouth by injecting the DAO muscle.

I also recommend that you seek a Board Certified Plastic Surgeon for all plastic surgery on soft tissues around the eye. This includes Botox, Juvederm, Restylane, Eyelid surgery, Browlift and other surgical procedures. Board Certified Plastic Surgeons have 2 to 3 years of comprehensive formal plastic surgery training on the aesthetics, anatomy and function of the soft tissue, muscles and bone around the eye.

Daniel Reichner, MD
Newport Beach Plastic Surgeon
4.9 out of 5 stars 45 reviews



You have identified the fine balance that defines the facial musculature. Just as your bicep and tricep muscles act antagonistically (against each other), so too do your brow raising and depressing muscles. So, if you also paralyze your brow depressors at the same time you paralyze your brow elevators, you may be able to avoid the brow dropping or ptosis. The next time you go in for a treatment tell your plastic surgeon about the brow ptosis and ask if he can treat your depressors as well. Be prepared to pay more, as this would constitute another area of treatment. Good luck!

Kenneth R. Francis, MD, FACS
Manhattan Plastic Surgeon
4.6 out of 5 stars 47 reviews

The Art of Balancing Botox

Botox placement and dosage is definitely an art. Even though your plastic surgeon only placed the Botox in the upper forehead, you still felt heaviness on your brow. Optimal Botox is not only goverened by location, but also by amounts used. Too much Botox in the forehead, even high up, can still produce undesired effects.

Balancing the actions of opposing muscles (Botox brow lift with forehead line softening) is definitely an art and takes practice. It is worth pursuing. As you did, I recommend seeing a board-certified dermatologist or plastic surgeon.

Jessica J. Krant, MD, MPH
New York Dermatologic Surgeon
4.7 out of 5 stars 41 reviews

A fine balance

Well put by all panel members. There is definitely an art and technique to bring a balance in finding the correct dosing to meet both goals. Patient education is a must when helping one understand how to reach their goals. Take the time to find a practitioner that accomplishes both.

Harold J. Kaplan, MD
Los Angeles Facial Plastic Surgeon
4.3 out of 5 stars 6 reviews

Very common to treat lower forehead with Botox

Yes, it is very common to treat the lower forehead (the area between the eyebrows) with Botox to decrease the pulling-down effect of these muscles when treating the upper forehead to minimize the drooping that does occasionally occur.

Ronald Shelton, MD
Manhattan Dermatologic Surgeon
4.9 out of 5 stars 37 reviews

Yes, brow elevation with Botox can be done

Thank you for your question.

Getting brow elevation, or preventing/counteracting brow ptosis, can sometimes be an art. To accomplish this, simply speaking, I would inject Botox into the central areas of the forehead and avoid the outer areas. In addition, I may choose to do the area between the eyebrows and a spot underneath the outer eyebrow.

If you do the entire forehead, then yes, your physician may actually cause a brow ptosis if he injects too low. Try asking to see if your physician can try this technique. Remember, even if the results aren't perfect initially, they can usually be adjusted with a touch-up; and, of course, one of the best things about Botox is that it isn't permanent.

Hope this helps, and good luck!

Don Mehrabi, MD
Beverly Hills Dermatologist
5.0 out of 5 stars 1 review

Brow elevation with Botox is possible

Hi Huntress,

Yes, by treating the depressor muscles of the brow (the corrugators and procerus), the brows should lift a bit.  The injections in the forehead (frontalis) muscle should be minimal to avoid that completely frozen look of Marcia Cross or Nicole Kidman.

Good luck and be well.

Dr. P

Michael A. Persky, MD
Encino Facial Plastic Surgeon
4.8 out of 5 stars 36 reviews

The vertical lines between the eyebrows should be injected at the same time.

The horizontal lines on the forehead are produced by the forehead muscles contracting. These muscles lift the brow in an upward direction. When Botox weakens the forehead muscles, the muscles between the brows, called the procerus and corrugators, will have an unopposed downward pull on the forehead. So you should definitely have these muscles injected at the same time. That will keep the brows from drooping and give you a nice natural improvement in brow position and wrinkles. Good luck.

Dr. Miller

Andrew Miller, MD
Edison Facial Plastic Surgeon
4.8 out of 5 stars 205 reviews

These answers are for educational purposes and should not be relied upon as a substitute for medical advice you may receive from your physician. If you have a medical emergency, please call 911. These answers do not constitute or initiate a patient/doctor relationship.