How Low Should Botox Be Injected in my Forehead?

Question

I've had a series of unfortunate events with botox; my eyebrows drop dramatically from botox injected into my forehead. Like a trooper (or fool) i let my doc inject high on my forehead my last visit. It actually had the affect of lifting my brows, BUT also left me looking like a klingon; a smooth patch high on my forehead, with a band of horizontal wrinkles in the middle of it. What area would you recommend injecting to remedy this? Keeping in mind that anything near my brows drops them.

Mark K. Markarian, MD, MSPH, FACS · Answer

Short answer -- you should try to inject at least 1-2cm above the brow to reduce the likelihood of brow drooping.  Note however, that I said to "reduce the likelihood" and did not say to "prevent" brow drooping.  Reason being, with someone with low-set brows, or those of increasing age, one is more likely to develop a brow droop as their brow raising muscle, the Frontalis, is paralyzed with the Botox.It all depends on the examination by your physician injector.  He/she would carefully examine you to assess, at the very least, your brow position, the location of your forehead wrinkles, and the vector of pull of your Frontalis muscle.  Over-treating some areas can give you a brow droop, while under-treating some areas can give you a "Spock-like" or "Klingon" result -- whichever Star Trek reference you prefer :)  These are just a few of the complications that can happen...My overall recommendations are to seek the services of an experienced physician injector. I think the key with Botox lies in truly understanding the anatomy of the injected area, and more importantly the variability in the anatomy between patients -- for brows, the forehead, and anywhere else you plan on receiving a Botox injection. This includes having a firm understanding of the origin, insertion, and action of each muscle that will be injected, the thickness of each muscle targeted, how deep beneath the skin the actual muscle resides, and the patient variability therein. As an aesthetic-trained plastic surgeon, I am intrinsically biased since I operate in the area for browlifts and facelifts, and have a unique perspective to the muscle anatomy since I commonly dissect under the skin, see the actual muscles themselves, and learn "first-hand" the incredible variability between patients -- live, "on the OR table" -- as opposed to via lectures or a cadaver dissection. For me, this helps guide where to inject and where not to. However, with that said, I know many non-aesthetic trained plastic surgeons and other physicians who know the anatomy well despite not operating in that area, and get good results.Good luck.Dr Markarian

Asif Pirani, MD, FRCS(C) · Answer

Hi Jen,You need to see an experienced injector.  If you're in BC, I'd recommend the offices of Peter Lennox, Kevin Bush, Alex Seal, or Rob Thompson just off the top of my head.  There are many fantastic injectors in BC.Best,

Ron Shelton, MD · Answer

Unfortunately, as we age, our forehead droops and we use the forehead muscle actively and subconsciously, to contract and pull up the eyebrows and eyelids with them.  This causes more mid forehead horizontal lines. If we were to treat those lines with Botox, then the forehead muscle would relax and not be able to keep up the eyebrow/eyelid complex and the drooping of the lower forehead would be inevitable. Even if the person has had botox done for years without problems, they may find as they reach the early to late 40s that their botox regimen will have to be different to accomodate the aging effect of the forehead.

	If a doctor were to try to give very few units in the mid forehead, it probably wouldn't help reduce the lines signficantly and it would still run the risk of dropping the eyebrows.

	Occasionally fillers can help smoothen this area but swelling and bruising temporarily (more than a week) could be a factor and there is a risk of lumpiness and even some filler moving by gravity or expressive muscular force to a lower area on the forehead depending on the technique used to inject the filler (volume, placement at which depth, rate and force of injection, etc.).

	Many patients eventually realize they can only continue having botox injecitons in the glabella between the eyebrows and no longer can treat their forehead.

Matthew Bridges, MD, FACS · Answer

My 2 cents in this case is as follows: Horizontal lines in the forehead are most commonly caused by subconscious activation of the frontalis muscle, which is the muscle that elevates the brow. People with heavy brows tend to do this without knowing it. The key to addressing this is to inject the "fronwner muscles" between the eyebrows, staying low over the brows. Also, the orbicularis muscle, the one that closes the eye is injected just above the brows (in minute amounts), and also in the crow's feet. This allows the brow to elevate and takes away the subconscious need to hold the brows up with the frontalis. If there are still horizontal lines, very small amounts (usually diluted) of Botox can be added to the frontalis itself.

James M. Ridgway, MD, FACS · Answer

The question you ask is a very good one. It is important to receive your injections (Botox or fillers) by a physician who specializes in the treatment of the face. This is the most important, and understated, element of a successful result. Indicators that help are: Specialization in the face, certification by an accredited American board, fellowship training, strong community reputation, fellowship training and even academic affiliation.

Be healthy and be well,

James M. Ridgway, MD, FACS

Be healthy and be well,

James M. Ridgway, MD, FACS

Benjamin Barankin, MD, FRCPC · Answer

Generally speaking, Botox when used for the forehead is injected in the top 1/3 of the forehead. More importantly, you need to ensure that for the best results, that you seek a highly trained professional such as a dermatologist or plastic surgeon. Best to see your physician to fix up the problem you're describing. Be aware that some people need their forehead muscle (frontalis) to keep their eyebrows up, and are not good candidates at all for Botox treatments.

Michael H. Gold, MD · Answer

As with any procedure, please make sure the "injector" knows what they are doing and knows the facial anatomy extremely well. Injecting botox by many out there is done through the use of a cook book system instead of actually studying the muscles and insertions of those muscles to make sure that the toxin is placed in the most useful places to assure the best possible results. So the injector is key – make sure they are well skilled – board certified dermatologists, plastic surgeons, oculoplastic surgeons, and facial plastic surgeons and their staffs is where you should be getting the injections done. There are lots of alternatives – and then you are risking skills and proper training in most instances. For you I would find the best of the best in your area and let them do their magic in trying to make you not look like a Klingon or Mr. Spock.

Martie Gidon, MD, FRCPC, FAAD · Answer

Ensure you are treated by an experienced specialist. The amount and placement of the Botox injections depend on the individual patient. You may be raising your forehead unknowingly because of saggy eyelids. In this case, you probably should not have any Botox injected into your forehead but may be a candidate for a Botox brow lift to raise your eyebrows to help your eyelids. Fillers can be injected into your forehead lines to soften them and not cause a forehead droop.

Mark Taylor, MD · Answer

There is an art to cosmetic medicine. Make sure you are going to an experience medical artist who knows where the muscles are and how to get the Botox results that you want. Botox and Dysport are not idiot proof.

George J. Hruza, MD · Answer

If you have significant horizontal forehead wrinkles, they may be there because you are contracting your forehead muscles to keep your eyebrows elevated as eyebrows tend to droop with age. For forehead injections small unit quantities, and injecting the eyebrow depressors to elevate the inner and outer eyebrows are important. This allows a balancing out of the central drooping with medial and lateral elevation. In patients that rely on their forehead muscles to keep the eyebrows elevated it may be advisable to not inject the forehead.

How Low Should Botox Be Injected in my Forehead?

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