Worsening glabellar shadow for 2 years, what is this and how can I treat it? (Photos)

Question

I have this progressively worsening shadow in the center of my forehead/glabellar area. It’s much more noticeable in person and is now even visible through makeup. It’s become one of my biggest insecurities, since it’s quite aging and right in the center of my face. Before suggesting Botox, I’d appreciate your thoughts on whether Botox could actually be what’s causing this? I’ve been getting it for about 9 years, but only semi-regularly (generally no more than twice a year, often with more than 6 months between treatments). A top NYC injector said it looks like atrophy. This doesn’t seem to be pigmentation. I’ve tried hydroquinone and multiple lightening agents without improvement. It started about 2-3 years ago, as faint shadows above both brows, but it has progressively darkened into this central shadow. What do you think this most likely is? If Botox-related atrophy, is it reversible? If not, what else could cause this? I’m willing to travel for treatment, but I understand glabellar filler carries extreme risks like occlusion and blindness, so I’m extremely hesitant unless it’s truly the best/only option. Are there safer treatments (strategic Botox, fat grafting, biostimulatory fillers, laser, RF microneedling, etc.) that could help? Finally, what specialist should I see for this (dermatologist, facial plastic surgeon, or oculoplastic surgeon)? I don’t even know where to start. Thank you, I’d greatly appreciate any guidance. It has become very distressing.

Anna Chacon, MD, FAAD · Answer

I can understand why this has become so distressing, especially since it's right in the center of your face and you've noticed it gradually worsening over the last few years. Based on your description, I don't think you're overreacting, this is worth evaluating carefully.

The first thing that stands out is that you've already ruled out one of the more common causes. If hydroquinone and other pigment-lightening treatments haven't helped, this makes true hyperpigmentation less likely. A "shadow" can actually be caused by changes in contour rather than changes in skin color.

One possibility is volume loss or soft tissue atrophy in the glabellar region. Long-term Botox has been associated with some degree of muscle thinning in certain patients, although clinically significant atrophy is relatively uncommon and usually subtle. Since you've only been treated about twice a year on average, Botox alone may not fully explain the progression, but it could potentially contribute in someone who is particularly susceptible.

Other possibilities include:

Age-related loss of fat or collagen in the central forehead.
Changes in the underlying frontalis or corrugator muscles.
Normal facial anatomy becoming more noticeable as surrounding tissues lose volume.
Less commonly, a structural issue beneath the skin that deserves evaluation.

The reassuring part is that if Botox-related muscle thinning is contributing, some improvement can occur over time if treatments are paused or spaced further apart, although recovery varies from person to person.

Regarding treatment, I agree with your caution about glabellar filler. The glabella is one of the highest-risk areas for vascular complications, including skin injury and vision loss, so filler there should only be performed by someone with extensive experience and a detailed understanding of facial vascular anatomy. Even then, it isn't always the first or best option.

Depending on the exact cause, other treatments may actually be more appropriate:

Microfat grafting can restore volume if true tissue loss is present.
Biostimulatory treatments that stimulate collagen production may improve subtle contour changes over time in carefully selected patients.
Radiofrequency microneedling may help if skin laxity is contributing, although it won't replace lost volume.
In some cases, adjusting future Botox injection patterns can improve balance rather than worsening the appearance.

Because this appears to be more of a structural contour issue than a skin pigmentation problem, I would recommend evaluation by a facial plastic surgeon or an oculoplastic surgeon with expertise in facial aging and facial volume restoration. A cosmetic dermatologist with extensive experience in advanced injectables and facial anatomy would also be an excellent choice, particularly if they routinely manage complex filler cases and can distinguish between volume loss, muscle atrophy, and skin changes.

The most important step is establishing the correct diagnosis before choosing a treatment. In situations like yours, careful examination, and sometimes even high-frequency ultrasound imaging of the soft tissues, can help determine whether the shadow is due to volume loss, muscle changes, or another structural issue. Once the underlying cause is identified, the treatment options become much clearer and can be tailored to minimize risk while achieving the most natural result.

Worsening glabellar shadow for 2 years, what is this and how can I treat it? (Photos)

Answers (1)

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