Where are the right places to inject Botox to avoid eyebrow droop?

Question

I keep reading Dr's comments saying that eyebrow droop avoidance is down to a skilled dr who knows where to place the injections. As a patient, can you please tell me where those correct areas are so that I know if the person doing it is doing it right? I have mild/moderate horizontal forehead lines and still want to keep movement in my forehead but get rid of the lines.

Vito C. Quatela, MD · Answer

I encourage you to seek the evalution of a board certified surgeon in your area for your Botox® injections. With their training, plastic surgeons have an understanding of the relationship between facial muscles. This allows them to understand which areas of the face to inject to avoid causing the eyebrow to droop.

Rod J. Rohrich, MD · Answer

The
key element in avoiding an eyebrow drop is to
choose a Board Certified Plastic Surgeon or Dermatologist with Expertise in
performing Botox
and understands the underlying basic anatomy. This should be done in an
accurate manner.
In these cases this should be a very infrequent occurrence.

Brian S. Biesman, MD · Answer

And experienced Physician who understands the anatomy of the forehead will be able to choose a product and place it correctly so as to minimize the risk of eyebrow drooping.  If you have horizontal forehead lines because your eyebrows or eyelids are heavy,You may not be a candidate for neuromodulator injections at all.  This is why it is important to see an experienced physician for administration of Botox dysport or Xeomin

Naveen Somia, MBBS, PhD, FRACS · Answer

This is a common concern.It is more to do with understanding anatomy and the basis of the forehead wrinkles than the skill of the injector. I guess a skilled injector will understand the anatomy well.The forehead muscle ( frontalis) is mainly responsible for lifting the eyebrows. It also has small connections between the muscle and the forehead skin. When the Frontalis lifts the eyebrow the connections between the muscle and the forehead skin create the forehead wrinkles. So the skill here is to inject between the skin and the frontalis muscle  rather than to inject INTO the frontalis muscle. People refer to this as 'droplet' or 'micro botox'. If you inject into the Frontalis muscle you will weaken the ability of the frontalis to LIFT the eyebrow.All the best

Estee Williams, MD · Answer

Great question. In the forehead the injections should be kept high, and a certain distance above the brow should be left untouched. The precise amount depends on your anatomy and brow position. Second, by injecting the glabella (region between eyebrows above the nose) one can actually open up the mid forehead, thus this second region is usually injected at the same time as the forehead. Best-

Jacquelyn Dosal, MD · Answer

A centimeter or two above the brow should be safe, and in general you want to treat the forehead (frontalis) lightly.  It is the main muscle keeping your eyebrows elevated.  An over-treated forehead looks frozen and brows can look heavy.  Many women can achieve a natural look with only 8-10 units of Botox (depending on anatomy).

Richard Ort, MD · Answer

In general, it is best to stay above the brows a certain distance with injections to maintain some actvity of the frontalis muscle which keeps the brows elevated.  I usually don't inject the forehead within a centimeter or more from the brows.  I also use a conservative amount of total Botox dose in the forehead.Once you find an experienced injector, you need to have a certain amount of trust in that person.  You should have a discussion before your treatment about your goals and expectations from the treatment.  Usually what I strive for on the forehead is not the frozen look or complete elimination of all lines but rather a more natural, relaxed look with softer lines.

Mats Hagstrom, MD (license on probation) · Answer

The muscles around your eyes have opposing forces.This is how we are able to bring our eyebrows both up and down to help give emotional expression.Muscles that bring the eyebrows down are referred to as depressors.Muscles that bring the brows up are referred to as levators. For example, the frown lines are caused by a combination of three muscles. The main one is the corrugator. This muscle causes the brows to be pulled inwards and slightly downwards.Another depressor is the procerus muscle. This muscle causes the central glabellar or frown area to be pulled straight down, often giving a horizontal line at the top of the nose.Some people have a strong procerus, and some don't.This differentiates how treatments should be designed.A third muscle pulling the brow down is called the depressor supercilii. This muscle also causes the central brow to be pulled straight down.The muscle around our upper and lower eyelids that is injected to control crow's feet can also be a depressor muscle.This muscle is called the orbicularis oculi muscle. It is a large, wide, pancake-looking muscle whose function is to close our eyes.It is a functional muscle as opposed to the previously named muscles which are referred to as muscles of facial expression.The only purpose of muscles of facial expression is to convey our emotional state.Placing Botox in any depressor muscle will cause a gentle lifting of the brow.Treating the outer upper aspect of the orbicularis oculi muscle has the potential of raising the corner of the eyebrow and creating a more peaked or feminine look.Over-treating or incorrectly treating this part of this muscle also puts patients at risk for a droopy eyelid, a highly undesirable complication of Botox treatments.The main levator muscle of the eyebrows is called the frontalis. This is a large, flat muscle that sits over the central part of the forehead.Anytime an attempt is made to treat the horizontal forehead lines, a patient is at risk for at least a partial dropping of the eyebrows. Great care and experience is required in treating this muscle to not cause drooping of the eyebrows, which can give an aged and masculine look.Treating only the central part of the forehead or the frontalis muscle while leaving the outer edges to still move can create a very undesirable "Mephisto" or "Mr. Spock" look.It is possible to partially treat the frontalis muscle in order to get a balance between softening the forehead lines with a minimal drop of the eyebrows.This is perhaps the most difficult part of high-quality Botox treatments.More than anything else, please seek an experienced and talented provider. This type of treatment requires great knowledge skill and experience.Best of luck,Mats Hagstrom, M.D.

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