Are neuromodulators enough for this deep gabullar crease? What would be the best option? (Photos)

Question

I have a treatment plan for my acne scarring and linear scar but I don’t know what to do with this gabbullar crease neuromodulators haven’t really worked

Anna Chacon, MD, FAAD · Answer

Thank you for sharing your concern. This is actually a very common situation, and it can be frustrating when you've been told that neuromodulators such as Botox, Dysport, Xeomin, or Daxxify should help, but the crease remains visible.

The reason is that there are two components to glabellar lines. The first is the muscle activity that causes the frown lines to form. Neuromodulators work very well on this dynamic component by relaxing the muscles that repeatedly fold the skin. The second component is the static crease, which is the line that remains etched into the skin even when the muscles are relaxed.

From your description and photos, it sounds like your glabellar crease has developed into more of a static line. Once a crease becomes deeply etched, relaxing the muscles alone may prevent it from worsening, but it may not completely erase the line.

In these cases, combination treatment often produces the best results. Depending on the depth and characteristics of the crease, options may include:

Continued neuromodulator treatments to prevent further folding of the skin.
Small amounts of hyaluronic acid filler placed strategically to support the crease.
Microneedling or radiofrequency microneedling to stimulate collagen remodeling.
Fractional laser resurfacing to improve texture and soften the etched line.
Chemical peels or other collagen-stimulating procedures for mild improvement in skin quality.

It is also important to be realistic about expectations. Deep glabellar creases that have been present for years rarely disappear completely with any single treatment. However, they can often be softened significantly and become much less noticeable.

Since you are already pursuing treatment for acne scarring and a linear scar, there may be an opportunity to address the glabellar crease as part of a broader collagen-remodeling strategy. Procedures that improve skin texture and stimulate new collagen can sometimes benefit multiple concerns simultaneously.

Overall, if neuromodulators have not provided the improvement you hoped for, it does not necessarily mean the treatment failed. It may simply mean that the line has progressed from being primarily muscle-related to being a structural crease within the skin itself. In that situation, a combination approach is usually more effective than neuromodulators alone.

Erik Peterson, MD · Answer

Hi, I’m Dr. Erik Peterson, a cosmetic dermatologist. Glabellar creases can be particularly stubborn because there are a few different components that contribute to them. Neuromodulators such as Botox, Dysport, or Xeomin work best on dynamic lines caused by muscle movement, but once a crease becomes etched into the skin at rest, relaxing the muscle alone often is not enough to fully correct it.
In those cases, treatment usually shifts toward improving the actual dermal scar or fold within the skin. Depending on the depth and character of the crease, options can include soft hyaluronic acid filler placed very conservatively, collagen-stimulating treatments such as RF microneedling or fractional resurfacing, subcision if there is tethering, or occasionally a combination approach. Acne scarring and linear scars can sometimes be treated in parallel with similar collagen-remodeling procedures, which may allow for a more comprehensive treatment plan overall.
One important point with the glabella specifically is safety. This is an anatomically high-risk area for filler because of the blood vessel anatomy, so it is an area where injector experience matters tremendously.
If neuromodulators have provided little improvement, that usually suggests the crease is now more static than dynamic, meaning you likely need a treatment aimed at remodeling or physically lifting the etched line itself rather than simply weakening the underlying muscles.

Nelson Lee Novick, MD · Answer

This is a very, very common problem and one that when properly treated requires BOTH calming the underlying muscular movements responsible for creating the creases with a neuromodulator, and, afterwards using an appropriate HA Filler to elevate and smooth the creases that have already been etched into the fabric of the overlying skin after years of untreated muscular movement. 
Think of the overlying skin as a  "fabric" that has been folded and refolded thousands of times over the years. Even if stop folding it the creases will still show. Well that's really what happened to your skin., except the constant folding resulting from the underlying muscles has deeply etched itself in the skin.
So, in order to achieve optimal results, you must first address the muscular activity below with neuromodulators, like Botox or Xeomen, and then, AFTERWARD, address the residual creasing by elevating and smoothing them with the use of an appropirately chosen and injected HA Filler. 
Repeatedly injecting with Botox by itself, not surprisingly, would not not be expected to produce a successful aesthetic outcome. 
You would be wise to make sure consult with an experienced, board certified cosmetic dermatologist injection expert and best of luck.

Are neuromodulators enough for this deep gabullar crease? What would be the best option? (Photos)

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