For many people considering botox© injections, the most common area of concern is the vertical lines between the eyebrows (the glabella complex). These lines form from overuse of the muscles which allow us to frown and tend to develop in people who are very expressive with their facial expressions, people who subconsciously contract these muscles when concentrating or reading or people with generally strong facial muscles. With constant contraction of these muscles eventually the vertical lines become permanent even when the facial muscles are rested. Botox© is effective in relaxing these muscles making people look less angry or serious and also giving a slight lifting effect to the lower central forehead. These muscles are generally quite strong and so higher doses of the Botox© neuromodulator are required than when treating other areas of the face. Men in general require higher doses than women as their muscle volume is larger.
As these muscles naturally pull down there is a low risk of developing a heavy forehead if higher doses are used, and completely blocking these muscles does not give a frozen look as long as eyebrow movement is still possible. No one really notices if you are unable to frown unless you are a dramatic artist or stern parent.
If vertical lines are present when at rest then the aim of treatment would be to keep the glabella complex permanently inactivated to allow the skin to repair itself through preventing the repeated creasing of the skin allowing the lines to soften or disappear completely. For these cases we recommend repeating injections as soon as movement is noted to allow the skin to continue to recover. If the vertical lines are very deep then complete effacement of the wrinkles may not always be possible and so at some stage in the future hyaluronic acid injections (dermal filler) may also be required to reduce the wrinkles. The combination of the two treatments can work extremely well. Using hyaluronic acid injections alone on the vertical frown lines is less beneficial as it does not address the underlying mechanism causing the creases.
A knowledge of the underlying facial anatomy is essential when treating the glabella complex. Knowing how far laterally to inject the lower forehead is important as there is a risk with this treatment of hooking or a ’Spock’ effect with an unnatural lifting of the lateral. This can be easily corrected by additional injections to the lateral eyebrow. The main risk from treatment in this area is a droopy eyelid. This occurs when an injection is placed too low on the forehead above the midline of the eye or where there is abnormal migration of the Botox© and the neuromodulator paralyses one of the muscles responsible for elevating the eyelid, the levator palpebrae superioris. In experienced hands this side effect hardly ever occurs and if it does the effect is temporary lasting only a few weeks. Fortunately, there is treatment for this problem which is to use eye drops to the affected side which contain an adrenergic agonist, apraclonidine, on a regular basis until the negative effects of the neuromodulator wears off. These drops stimulate retraction of the affected eyelid.
Treating the vertical frown lines on the forehead is a very safe procedure in experienced hands and is a good starting point for the people who may wish to soften these lines, particularly for men. Friends and family are usually unaware that the treatment has been done but may comment that the face looks fresher or that the person appears well rested. You can find out more about Botox(c) treatments for the face here.
Dr Martin Wade, Dermatologist at London Real Skin.