Does Botox eyebrow peaking go away on its own, or does it always need touch up?

Question

I've had forehead botox many times, and the result is always the same: within 3 days, everything freezes except the outer brows, giving me Jack Nicholson brows when I lift them. But when not lifting, my brows look great. After 7 days I've always gone back to correct it, but then I'm left with a slightly lower brow overall. Is it a normal part of the process for the outer brows to freeze last? Im wondering if I should just wait longer this time instead of getting the touch up.

Stephen T. Greenberg, MD, FACS · Answer

Thank you nyc455 for your question.  Botox can take up to 2 weeks to see the full effect.  Typically within the first 5 days should you start seeing some improvement.  I recommend to patients to wait a full 2 weeks before doing a touch up. Follow up with your provider with your questions and concerns.

Aldo Guerra, MD · Answer

Yes this can happen, but can be improved with better planning and technique. You might have had your touch up a bit soon. I recommend 14 days for Botox full effect. Be sure to see an expert injector.Best wishes. Dr. Aldo

Robert M. Tornambe, MD · Answer

nyc455.    I agree that Jack Nicholson brow peaks are a dead giveaway for Botox treatment. I try to achieve a gentle lateral brow lift when treating forehead wrinkles. This technique slightly raises the lateral brows without the harsh peaks.  Be sure to consult with a board-certified plastic surgeon or dermatologist

Gary Linkov, MD · Answer

A few thoughts:
All the muscles should "freeze" at the same time, it is not that one is delayedThe injection should likely be more lateral for you on the forehead to get the area over the lateral browIf you over inject the lateral, or medial forehead you will see the brow drop overall since the frontalis muscle is the only brow elevatorAlso, to counteract the lowering of the brow, especially laterally, an injection into the orbicularis oculi muscle should be considered. 
Good luck!

Benjamin J. Cousins, MD · Answer

Thank you for your questions. Botox kicks in after about 7 -10 days and lasts ~3months. Adjustment in the doses and placement should be able to get you the best result with just the right amount of brow elevation. Hope this helps. Sincerely,Dr Benjamin J. Cousins MD Board Certified Plastic Surgeon Miami Beach, FL

Shaun Patel, MD · Answer

Since we know that your lateral frontalis is strong enough to cause an excessive eyebrow raise after Botox treatment, a little more Botox can be injected above the lateral eyebrow to prevent this from happening. The injector should adjust the dosing with your next treatment to prevent this from happening.

Michael H. Gold, MD · Answer

Thanks for your question and we always recommend that you have these injections performed in the offices of board certified dermatologists or plastic surgeons.  If this happens once, and know that it is can be corrected, then that happens.  If this happens each time, then someone is not planning the procedure correctly, not injecting the right areas, and this needs to be addressed.  Find the right provider and get things done correctly the first time

Alex Eshaghian, MD, PhD · Answer

Thank you for your question nyc455. I understand your concern. Botox is a purified protein used to address wrinkles associated with facial expression. When injected into the skin Botox will relax the muscles and smoothen out the overlying wrinkles. The most common areas of treatment are in the upper face. These include the horizontal lines seen on the upper forehead when one raises the brows, the vertical lines seen between the brows when one frowns (frown lines), and the crow's feet seen around the eyes when one smiles.It is difficult to make an assessment without a formal exam in the office where I can view the skin in multiple angles and observe wrinkles formed with facial expression. However, I hope the information provided here is useful.The pivotal studies used 20 units of Botox in the forehead area above the brows to address the horizontal lines seen when one raises the brows. These studies demonstrated that the peak results are seen 14 days after the treatment and most people enjoy their results for 3-4 months. At that point, a maintenance treatment is recommended. While some people start to see results as early as the next day, it can take two weeks for full results so patience is important. We have our patients return two weeks after their treatment to assess their results via photographs. At that time additional units may be added if necessary.The pivotal studies for the horizontal lines on the upper forehead were published many years after doctors had been using Botox. In these studies, 20 units of Botox were used to treat this area. However, in my experience I find that anywhere from 10 to 20 units works well in this area. For patients with narrow foreheads a lower dose may be used and those with a broad forehead generally require higher doses. I have also found that the full results in this area are seen by two weeks. Therefore, we have our patients return two weeks after their treatment to assess the results via photographs. At that point additional units may be used if further enhancement is desired.When Botox is used in the upper forehead, if the dose is too high or the placement is too low it can result in the feeling of heaviness in the eyebrow or even lower the position of the brow. In order to reduce the risk of this possibility, I use a conservative dose in the area and place the product high on the forehead, sometimes near the hair line. Additionally, I recommend that my patients simultaneously receive a small amount Botox between the brows and at the corners of the brows. This will relax the muscles that pull down on the brows to counteract this effect and provide a harmonious balance to the position of the brow. The results are assessed two weeks after the treatment. If there is any asymmetry a small amount of Botox can be placed in the upper face for correction.Sometimes after a Botox treatment a peaked appearance of the eyebrow is seen. This is sometimes called the Spock or Mephisto look, which makes a person appear surprised or sinister. It is also called the Jack Nicholson look, after the appearance of his eyebrows. This can occur if the muscles that pull the eyebrow down are relaxed with Botox. It can also occur if the upper forehead only is treated. In this case the inner portions of the muscles are relaxed preferentially over the outer portions of the muscle. This allows the outer portions of the muscle to pull up on the tail of the eyebrow. While some people desire this appearance, others do not. This effect can be corrected by placing a small amount (1-2 units) of Botox in the upper forehead approximately midway between the eyebrow and the hair line at the peak of the brow. This relaxes the muscle that pulls up on the tail of the eyebrow, thereby restoring a natural appearance.With any injection, there are risks such as pain, bleeding, bruising, redness, swelling, tenderness, and infection. We take special precautions to minimize these risks such as using a painless technique. We also treat bruises with a laser as early as the next day. Bruises usually resolve within two weeks if untreated. After a laser treatment bruises usually resolve in 1-3 days, but may still take two weeks for full resolution. In addition to these risks, with Botox there is also a risk that the product spreads or diffuses to nearby structures. Spread to nearby muscles can lead to side effects such as the temporary appearance of droopy eyelids or a temporary asymmetric smile.After a Botox treatment, I recommend that my patients avoid heat exposure, alcohol consumption, and strenuous exercise for 24 hours and not lie down flat for four hours. This is because all of these activities may possibly lead to the movement of the product and consequent side effects such as droopy eyelids as described above. Although there have been no definitive studies shown that these actually occur and some physicians do not provide such aftercare instructions, in the absence of data I err on the side of caution and recommend that my patients avoid such activities.Please consult with a doctor for specific recommendations. Good luck!

Sheryl D. Clark, MD, FAAD · Answer

Dear nyc455:People who get the lifted lateral brows with Botox treatment have a strong lateral frontalis muscle segment; it does not happen to all patients. Since you know this is an issue with you, you can have the  “quizzical brow” area treated before it happens. Also, the brow drooping can be prevented by keeping the injections high in the forehead, and/or treating the glabellar complex and lateral brows as well as the forehead. See an expert, board-certified advanced injector with many years of experience for the best results. If you want to understand more, you might watch this video. All the best,   Dr. Clark

Nicholas Gentry, MD · Answer

I won't typically touch up or add botox until at least day 10-12 as it usually takes this long for peak action. (some say 14 days). It depends on where/how much botox you are getting. The lateral eyebrow is typically viewed more attractive if it elevates slightly with an arch. This can be difficult even for experienced providers for the following reasons (and likely more than I am listing)
1) Many providers do an eyebrow lift where we inject a small amount (2-3 units) at the lateral edge of the eyebrow trying to lift it slightly. 
2) If your forehead is untreated it can exacerbate the lift because the forehead muscles pull up and if only the down pulling muscles are treated it will leave the forehead unopposed for the eyebrow- I judge each person based on their anatomy and goals and discuss the options. If I am treating the forehead, I usually do the eyebrow lift above for women (maybe 80-90% +/-) unless their eyebrows arch naturally already quite a bit. 
You can treat forehead toward the lateral (outside) slightly to help with this or if they are doing an eyebrow lift consider less botox at that location. For some this is a tradeoff. You said you like how it looks at rest but not when you lift your eyebrows. I will sometimes not treat the outside of the forehead (or minimally treat) to avoid giving a woman a heavy brow/angry look.

I know this is a complicated answer but it isn't a straight forward issue for everyone. I choose the treatment plan based on individual anatomy and patient preference. Hope this helps!

Does Botox eyebrow peaking go away on its own, or does it always need touch up?

Answers (13)

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