How Safe is It to Use Restylane Between the Eyebrows?

Dysport and Botox are the first part of the treatment plan in relaxing the underlying condition (muscle contraction) that is leading to the lines, wrinkles, and furrows.  

If the lines are still present after two weeks, the lines may be considered "static" or permanent regardless of the muscles being put to rest.  At that point, using smooth HA fillers ( Juvederm/Restylane) may be a good option to soften and fill these areas.

Many injectors agree that a combination treatment approach is sometimes best but to make best use of your time and finances, fillers should only be secondary if the Botox or Dysport did not meet your goals.  

Although using the filler in this area is "off label", it is an accepted standard of practice.  As with all techniques, an experienced injector will be able to approach this with safety and efficacy.

 

It's safe,  but you have to be careful.  That is because the risk of embolizing (getting filler into a vessel)  one of the small arteries that supplies the skin between the eyebrows seems to be higher in this area.  If one of these vessels gets occluded by intravascular injection of restylane or any filler, an area of skin between the eyebrows will die, leaving a wound that has to be dealt with, obviously not a desirable situation.

Many patients want that crease between the eyes to go away, and if is well-formed, long-standing and deep, Botox alone will not take care of it. All Botox can do is stop the creasing over time and maybe the crease will improve or not get worse as a result.

When filler is used between the eyebrows, care should be taken to inject very slowly and smoothly and inject while withdrawing the needle. This technique lessens the chance that some filler will get injected into a vessel. Another precaution I take is to put a finger over the orbital rim to put pressure on the vessels. That will prevent any filler from going back toward the eye and collapse the vessels in the area to be injected, lessening the chance that filler will get into them.

Frown line injections are not uncomon and complications related to those injections are extremely rare.

Filler products, just like botox receive FDA approval for particular sites of treatment. Restylane is approved for volume enhancement in the folds.

Injecting into other areas is common medical practice but is, by the book, off label use of the product.

With that being said, typical complications are essentially the same as filling other areas of the face - irregularity of fill, erythema reactions, and skin injury. One specific concern for glabellar frown filling is injection into an artery or vein, which is very difficult to do. An experienced injector would stay superficial to those vessels when filling that area. Occular complications can only theoretically occur with inadvertent intravascular injections.

I use filler products in the frown area to assist in smoothing after botox in many situations and patients tend to be very happy with their results.

Find an experienced injector and chances are you will be too.

All the best

 

The glabella or central brow area has relatively superficial vessels which can be occluded (and cause skin necrosis) by injection with any filler. Therefore, great care is exercised whenever this area is treated with fillers.  Generally speaking, the first line of therapy for such glabellar lines is Botox or Dysport, which minimize muscle activity and the ensuing vertical lines.  Fillers can be applied only if Botox results are insufficient

Hyaluronic acid fillers such as Restylane and Juvederm are safe for use in many areas of the face, including between the eyebrows.  Combining this with Botox or Dysport for relaxation of the muscles is a great way to treat deeper lines in the glabella (the area between the nose and forehead).

With an experienced provider, Restylane and Juvederm are very safe in the glabellar area (the area between the eyebrows) to reduce the furrows some patients have between the eyebrows from repeated frowning or furrowing of the brow. Often, botulinum toxin (Botox or Dysport) is used to soften the lines as well.

Most practitioners, including myself, will recommend that Botox or Dysport be performed first to treat the frown lines between the eyebrows (known as the glabella area), as these are dynamic or movement wrinkles. Once the movement of this area has been treated, then restylane or another hyaluronic acid filler (juvederm) can be used to fill in any remaining wrinkle that is still there. In regards to the safety of filler in this area, injector technique is very important as there is a superficial artery that lies below the frown lines and it must be avoided or complications can occur such as bleeding, bruising, or rarely necrosis of the skin. Thus, you should only have it done by someone who has experience in treating this area with filler.

Agree with Stephen Prendiville, MD, but make sure you fully understand the risks before having the injection done. 

Dynamic (absent at rest, present during contration of muscles of facial expression) glabellar lines are best treated with Botox.  When the lines become static, meaning the wrinkles are present when the face is at rest, they will not be smoothed out by just Botox alone.  Here a combination of Botox and filler is best.  In fact, when this combination is used the results tend to be more long lasting because Botox is preventing the muscle contraction that would eventually decrease the amount of filler in the lines.

However, there are blood vessels in the glabella that are at some risk when filler injections are done in the area.  These complications include compression of the blood vessels with a decrease of blood supply to the skin and potentially injecting filler into a blood vessel which can potentially travel to the eye and cause visual defects or blindness.  This happens very rarely. In an article in Dermatologic Surgery 2009 Oct;35  "The spectrum of adverse reactions after treatment with injectable fillers in the glabellar region: results from the Injectable Filler Safety Study." the incidence of adverse events in the glabella after injection of various fillers was seen in 40 out of 139 patients.  With hyaluronic acid fillers, serious adverse effects were seen in only 2 of 139 patients.  Authors concluded that "adverse reactions seen in the glabella are overwhelmingly product associated and to a lesser extent location associated. Vascular complications with necrosis and ulceration were rare."

Since this is considered a high risk area for injection of fillers, please make sure that the procedure is done by a board certified dermatologist or plastic surgeon with training and experience in this procedure.  Technique and a thorough knowledge of anatomy go a long way towards decreasing the risk of complications.

Botox is truly the treatment of choice for that area.  Once the effects of Botox are seen, sometimes it is necessary to add filler to achieve the desired result.  Restylane is fine to use, but there is always a risk of getting material in a blood vessel or compressing a blood vessel leading to an unsightly bruise or ulceration.  These are uncommon side effects though.