First time Botox. Was 30 units between eyes and 20 units in frontalis muscles too much? Inner eyebrow drop, looking angry.

Question

My frontalis muscles in forehead are completely frozen except for the lateral areas giving me a Spock look when I make expressions. Shouldn't a doctor start out with less units for first time botox?

Jack Kolenda, MD, FRCS (C) · Answer

Thank you for your question. It sounds like there were too many units injected but you should clarify with the injector what areas were treated. In my office 21-30 units is standard for treating a frown area (depending on the patient). As for the forehead there are many areas that can be treated to alleviate lines and lift the brows. Unfortunately these effects will need time to wear off on their own.
Best of luck,
Dr.Kolenda

Ron Shelton, MD · Answer

If you had Dysport the units are fine. Botox can droop the forehead if too many units are used or if the placement is too low on the forehead or if glabellar units migrate to beyond the inner eyebrows extending to middle eyebrows. 30 units of Botox for the first visit of a woman is rather high although I have injected these doses myself, but usually after a few treatments working up in unit dosage as tolerated.        The information provided in Dr. Shelton's answer is for educational purposes only and is not intended to constitute medical advice.  The information provided should not be relied upon as a substitute for consultations with a qualified health professional who may be familiar with your individual medical needs.

Mark Kearns, MBChB, BSc, FRACGP · Answer

Hey there  - thanks for the question. 
I'd probably clarify with your injector about which brand they used. 20 units for the forehead is a huge dose if they used botox - but if the brand was dysport (a different type of botulinum toxin) it would have been a modest dose - and 'spocking' could be corrected with a little bit more in either side.

Michelle Ellern, DO · Answer

It is hard say without a photo or an exam what you would or would not need.  I would return to your injecting physician to correct any Spocking that is occurring. Also discuss what you didn't like so you have a plan for the next treatment. Good luck.

Carmen A. Traywick, MD, FAAD · Answer

Not nesecarilly. The amounts that you have recieved are pretty average numbers. Follow up with your injector at 2 weeks to discuss any questions or concerns that you may have. Botox locks the release of a chemical called acetylcholine, which triggers the muscle contractions that create wrinkles. Botox essentially paralyzes the muscles and stops them from contracting. Results from these treatments are visible within 3-7 days with results that can last anywhere from 3-4 months. Hope this helps.

Camille Cash, MD · Answer

Each person must be evaluated for the appropriate dosing for Botox.  Often it is better to err on the side of conservatism as you can always return for a touch up two weeks after injection.  Unfortunately there is no reversal agent for Botox.  It is considered in full effect after two weeks and will gradually wear off over 3 to 4 months.

Alex Eshaghian, MD, PhD · Answer

Thank you for your question joannne. 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 in the absence of consistent photographs before and after in the same lighting and angles for comparison. However, I hope the information provided here is useful.The appearance of frown lines is variable from person to person. Usually they are in a vertical orientation but sometimes they can be oblique and sometimes a horizontal line is seen across the upper portion of the nasal bridge. The most common variation is to have two parallel lines, hence the common term "11's" to describe them. But some people have one, three, or more lines. Some people also will see a bulge in the area when contracting the muscle. This bulge is smoothened out after a Botox treatment.The pivotal studies used 20 units of Botox in the glabella area between the brow to address the frown lines and 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.Although 20 units is a good standard dose to start with, some people require a higher dose because of higher muscle volume. This is common in mature patients, in those with large bulges from expressive faces, and in men. I find that Botox still works in these cases, just a higher dose is required. I have used up to 40 units in the glabella.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 patients present with concerns about specific wrinkles in the upper face such as the frown lines, I always assess and usually treat the other wrinkles in the upper face including the horizontal forehead wrinkles and crow’s feet. The reason is to maintain a harmonious and natural balance to the appearance of the upper face. The muscles in the glabella which are responsible for the formation of the frown lines serve to pull down on the inner brows when a person frowns. Similarly, the muscles around the eyes which are responsible for the formation of the crow’s feet seen when smiling (orbicularis oculi) are also responsible for pulling down on the brows, but in this case the outer brows. On the other hand, the muscle in the upper forehead which is responsible for the formation of the horizontal forehead wrinkles when a person raises the brows (frontalis) serves to pull the brows upward. If one of these muscles is relaxed with Botox and the others are not, the other muscles will still be active. This will lead to an unbalanced and unnatural appearance of the upper face where the brow can be elevated, depressed, or uneven in shape or position. Therefore, I recommend that my patients take a global approach to the upper face when receiving Botox treatments and treat all three of these areas. Sometimes bunny lines on the bridge of the nose are also treated.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.
If I had a patient with the concern described here I would first want to look at the before and after pictures. She would likely be a good candidate for the correction described above.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. 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!

Vilma Di Maria, MBBS · Answer

Thankyou for your question. You are correct in saying that less is more. the forehead can look over done if frozen so I usually  start with a small dose and slowly build it up. Unfortunately you just need wait for the movement to come back.
If however you have spocking you can go back to settle this.
FYI 25 units in a forehead is a very high dose.
Good luck

Jo Herzog, MD · Answer

I start with smaller doses then patient might need and tell them that if does not do the trick, come for touch up in two weeks and if does not last three months dose too low. It is much better to start with less as some people need less and you can always add but can't take it back.

Steven F. Weiner, MD · Answer

The FDA approved doses are 20 for the glabella and 20 in the forehead. My standard dosing in glabella is 20-25 but can go up to 35 or 40 in very strong men. In the forehead, I'm usually about 6-8 units, but go up to 15 -20 in some cases. The forehead is trickier because too much will lead to dropping of the brow especially in patients with low brows already. In men, low brows is fairly common, so care must be taken to not overly inject foreheads in men 50 or older. Spock can usually be resolved with a small dose placed above the brows. Sometimes, Botox injected along the crows and brows will help raise a lowered brow, but if the frontalis is completely frozen, this usually won't work. Injection in the depressor supracilii can raise the medial brow sometimes as well.

First time Botox. Was 30 units between eyes and 20 units in frontalis muscles too much? Inner eyebrow drop, looking angry.

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