What is this vertical ridge in the center of my forehead? After Botox I still can't get rid of it. (photo)

I had botox in my corrugator muscles. After great results from that, I noticed this vertical ridge in the center of my forehead was still there but looked worse. Maybe because everything else smoothed out except for that ridge. When I try to frown it seems the muscles on either side of the ridge cause it to look deeper. Is it my frontalis muscle that needs botox to smooth it out? Will filling it with a Hyaluronic acid filler be the best bet? My injector doesn't want to do anything about it.

Doctor Answers 13

Ridge in Frontalis

This question brings up a great point about assessing a patient's anatomy when performing botox and filler injections. The effects of the botox in your corrugator complex look wonderful, and your eyebrows appear to have a gentle feminine arch following the injection.

The forehead ridge you are seeing is a product of your natural frontalis anatomy. There are several anatomical variations to the frontalis muscle  - the ridge you are seeing is secondary to a space between the fibers of your frontalis muscle or from a deficiency in the fat or bone in the area. I strongly advice against any filler injections to this area - you have lots of blood vessels here and injecting a filler can lead to blindness should any filler be inadvertently injected into a vessel. 

Thanks for your question!
- Dr. Krishnan

San Francisco Dermatologist
5.0 out of 5 stars 2 reviews

Vertical ridge in the center of my forehead -- Botox and filler

The depression seems to worsen with movement suggesting that more Botox may be needed in the area surrounding this depression.  Since it is also present at rest, a small amount of filler could be placed to help volumize and lift this area to the level of the surrounding tissue.  Filler injection in this area should only be performed by "core" cosmetic injectable physicians (facial plastic surgeons, plastic surgeons, dermatologists, or occuloplastic surgeons). This is because we all have a keen understanding of facial anatomy and the effects of injecting Botox/ Xeomin/ Dysport and fillers in different regions of the face. Be sure you are seeing one of us, and I wish you well!

Parker A. Velargo, MD
New Orleans Facial Plastic Surgeon
5.0 out of 5 stars 47 reviews

It appears as though the indentation is worse when frowning.

It appears as though the indentation is worse when frowning, indicating Botox is required to either side of the ridge. Botox should smooth your forehead. If 2 weeks following treatment you still notice an indentation schedule a consultation for a small amount of filler. 

An expert injector should be able to give you an accurate treatment plan. 

Martin Jugenburg, MD
Toronto Plastic Surgeon
4.9 out of 5 stars 457 reviews

Ridge in forehead after corrugator Botox

Then photo suggests that muscles are forming the ridge and you need Botox on either side of the ridge.
But you need an exam to be sure. 
If your injector is not a physician, consult a Board Certified Plastic Surgeon to determine the cause and do Botox and/or fillers as indicated by the exam.

Elizabeth Morgan, MD, PhD
Atlanta Plastic Surgeon
4.6 out of 5 stars 43 reviews

More botox and/or an HA filler

You may need more Botox injection if the ridge looks deeper with frowning movement. In addition, you will need a filler. You can start with an HA filler (hylauronic acid filler) since this type lasts 6 months to a year and can be reversed if you do not like the results.

Lenore Sikorski, MD
Orange County Dermatologist
4.3 out of 5 stars 24 reviews

Dermal fillers

Botox did relax the muscle well. A filler is needed to address the anatomical dent. Fat or dermal fillers could be the answer. 

Hisham Seify, MD, PhD, FACS
Orange County Plastic Surgeon
5.0 out of 5 stars 19 reviews

Soft filler would be good option for forehead dent

I think that your wrinkles have been eliminated with Botox and this "dent" is part of your natural facial structure. A soft filler like Belotero, Restylane or Juvederm would help. This should be injected carefully by an experienced injector.

Jo Herzog, MD
Birmingham Dermatologist
5.0 out of 5 stars 18 reviews

Ridge on Forehead

This would require fillers to treat and there are many options.  I suggest going to a good surgeon for this as there is risk of complications if not performed meticulously.  Best, Dr. Emer.

Jason Emer, MD
Los Angeles Dermatologic Surgeon
4.8 out of 5 stars 190 reviews

Dermal Fillers In The Forehead.

Generally, I only place dermal fillers in the forehead for vertical lines (not the horizontal ones).  You may have unusual muscular anatomy that is causing the vertical depressions that concern you following botox.  Retrograde injection and use of a blunt-tip cannula are especially important in the forehead area to avoid intravascular injection complications (necrosis of the skin, visual blindness etc.).  The hyaluronic acid fillers can be reversed with enzyme if necessary, but I also have had good success with more semi-permanent fillers (e.g. Radiesse)  in many patients.  If your forehead skin is thin then I would go with the hyaluronic fillers, and would probably wait to do anything until after your botox has worn off.  You have your pictures that you can show an experienced injector so they can know what has happened  in the past.  Best regards.

John R. Burroughs, MD
Colorado Springs Oculoplastic Surgeon
5.0 out of 5 stars 14 reviews

Dermal Fillers in the forehead

Hi LFW.  There are many injectors that are averse to injecting dermal fillers in the forehead, but in your case, we believe it's a good option.  There are a few key issues that you or any injector should consider when going down this road.  

First all injections into this area (and others) should use a "retrograde" technique.  If you ask your injector if they use this technique and they don't know what to say, that's a bad sign.  Injecting as you remove a needle from the skin helps to avoid injecting the product into blood vessels.  In most cases, occlusion (blockage of blood vessels) occurs when pushing the product out of the needle at the same time that the needle is being moved forward into the skin.

Second, only soft Hyaluronic acid products should be used in the forehead and we prefer Restylane.  Finally, for anyone injecting into this area, they should have a healthy supply of Hyaluronidase (Vitrase) on hand.  It's a good idea to have Vitrase around at all times anyway, but particularly important when injecting into the forehead.  Find an injector that's comfortable with this area and ask the right questions during the consultation.  

To view an example of before and after pictures for a patient that we treated with Botox and Restylane for deep forehead lines, check the link below.

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