Eyebrows, Foreheads & Toxin: An Advanced Trouble-shooting Guide

That’s me and my forehead whilst raising my eyebrows. I’m Dr Michael Aicken, a ‘Botox’ Doctor from Belfast. I’ve been practicing for 7 years now. Although I thankfully haven’t seen many disasters, I have seen most possible outcomes of ‘Botox’ injected slightly in the wrong place either by myself or a colleague.

I thought it would be useful for others, and cathartic for me to share my experiences and some of the questions I have answered for colleagues as I have toiled and struggled to achieve the perfect technique. My first blog post was entitled “Holy Shit, it’s Filler Blindness“. It was frightening and covered extremely rare and catastrophic complications of filler; conversely this post covers extremely common and minor complications of Botulinum Toxin. So relax!

From here on I will use the term “toxin” to collectively refer to “Botox”, “Boucouture” and “Azzalure” unless referring to a specific brand of toxin.

As mentioned above, you’ll note that I’ve included a picture of my own forehead and eyebrows for reference, although you probably have both of these items yourself. Interestingly, there are three theories as to why humans have eyebrows. One theory is to help protect the eyes from small debris and water1. Another theory is that humans evolved to have eyebrows so that whilst sleeping, the shape of the eyebrows along with the eyelashes in low lighting would resemble open eyes and deter predators from attacking during sleep1. The third theory relates to communication1 and so, I thought it would be useful to watch this short video demonstrating the importance of having correctly functioning eyebrows during normal social interactions. Video embedded from the BBC Youtube channel; from Jimeoin live on Michael McIntyre’s Comedy Roadshow.

Frontalis Muscles. These create forehead lines on elevation of the eyebrows. Image from Wikipedia.

Basic Knowledge

Did you know that as part of the “normal” ageing process, you can expect to gain one additional forehead (horizontal) line for every decade of your life? So I don’t need to tell you my age – you can just calculate it from the photo above.

The frontalis muscle is the primary elevator of the eyebrows. It comes in a variety of shapes and sizes with varying degrees of separation in the middle by an aponeurosis.

Procerus muscles. Part of the glabellar frown complex. Image from Wikipedia.
Corrugator Supercilli of the glabellar frown complex. Image from Wikipedia.

Depression of the eyebrows is mostly performed by the procerus and corrugator supercilli muscles.

Dosing depends on the product used- for “Botox/Boucouture” the “industry standard” starting dose for is 5-7 x 2.5 units for frontalis and 5 x 4 units for glabella whereas with Azzalure/Dysport it is typically 5-7 x 6 units for frontalis and 5 x 10 units for the glabella. Note that the manufacturers will make recommendations for glabella only as forehead line injections are not (yet) licensed. Note too that Galderma (manufacturers of Azzalure) recommend using double these doses for male patients although I generally use 1.5x these doses rather than double as it’s easier to give a top-up than to remove toxin once it has been injected! Here is a link to Hamilton Fraser’s advice on reconstitution and delivery of Azzalure.

Typical location of forehead injections with toxin. Image taken from the demo version of the Cosmetic Clinic App, Flourish.
Typical location of forehead injections with toxin. Image taken from the demo version of the Cosmetic Clinic App, Flourish.
Typical location of glabellar frown line injections with toxin. Image taken from the demo version of the Cosmetic Clinic App, Flourish.

Forehead and glabellar frown line injections are typically given as shown in the attached diagrams, taken from the demo version of the Cosmetic Clinic App, Flourish.

Note that additional lateral forehead injections are given for some patients whose forehead lines extend laterally beyond the mid-pupillary lines, but injecting here can increase the risk of upper eyelid and eyebrow ptosis (covered later).

Now let’s look at some common side effects of forehead and/or glabellar frown line treatment with toxin.

Highbrow (Eyebrows up)

When the eyebrows go up we get either “spocking”,

"Frightened rabbit"; a side-effect of toxin used in the upper face.
“Spocking”; a side-effect of toxin used in the upper face.

“frightened rabbit”

A side-effect of toxin used in the upper face.
“Frightened rabbit”. A side-effect of toxin used in the upper face.

or a “vague sense of looking more awake and alert”

A "vague sense of looking more awake and alert".
A “vague sense of looking more awake and alert”.

Note that if the “Frightened Rabbit” outcome is seen as desirable by the patient, it is commonly referred to as a “chemical eyebrow lift” by the practitioner.

Advanced Knowledge

Like I tell all of my patients, when you are treated with toxin, there is a risk that your eyebrows can go up or down. Most patients and most practitioners know this part, at least superficially. You can take a look at how I document this here (scroll down and select the ‘Botulinum Toxin’ drop-down consent box). However, there are times whenever understanding a subject superficially can lead to worse outcomes than not knowing anything at all; and this is one such subject. Let’s consider the patient who says,

“I don’t want my frown treated [with toxin] because last time it made my eyebrows droop”

We’ll come back to this common misconception after a little more discussion about the underlying problem.

Bear in mind that a patient can be particularly unhappy with a side effect that most patients wouldn’t even mention to their practitioner. In fact, upper face toxin results are often interpreted depending on how happy the patient is with the outcome, how competent the practitioner feels in correcting the problem (if it is a problem) and also, the shape of the eyebrows. Short, flat eyebrows for example, are easily “spocked” whereas people with natural ptosis can achieve the “vague sense of looking more awake and alert” whenever eyebrow elevation is achieved. As alluded to above, one patient’s “Frightened Rabbit” is another’s ‘Chemical Eyebrow Lift’.

Theoretically the eyebrows/eyelids could droop so much that a patient is unable to open their eyes but the classic presentation is the female patient who mentions in passing,

“I noticed that I had difficulty applying my eyeliner”.

This hints that there was a slight loss of ability to elevate the lid – but not enough to complain about per sae.

Patients and practitioners can get confused about why these side effects occur, so-much-so that I am often asked by patients to specifically do the OPPOSITE of what would reduce this risk so, in fact, they are asking me to INCREASE the risk of something they are concerned about. In this case, the customer is not always right.

My children, playing tug-of-war (to help daddy illustrate a point about toxin on his blog).
My children, playing tug-of-war (to help daddy illustrate a point about toxin on his blog).

EyeBROW ptosis/ elevation

Imagine the eyebrows are like the knot in a rope in a game of tug-of-war, played by two primary school children. Don’t worry; these are my daughters and neither was harmed during this demonstration.

One daughter represents the frontalis and lifts the eyebrows. The other daughter has two layers of muscle, one being the bulky, central procerus and the other being the longer, thinner, strap-like corrugator supercilli.

Imagine you inject one of the children with toxin. I should reassure you now that I HAVE NOT yet done this. What will happen? You might expect the one who had been weakened by toxin to become weaker and so, the other child would tend to win at tug-of-war. The same is true of the eyebrows- weaken either the frontalis or the glabellar frown complex of muscles and the other group will win the eyebrow ‘tug-of-war’. This is essentially how you get the eyebrows going up or down.

Upper EyeLID ptosis

However, there’s also eyelid ptosis. I’m referring to upper lid ptosis in this example. When caused by toxin, this is an entirely different entity from eyebrow ptosis. This occurs when the toxin injected into the glabellar muscles migrates superficially downwards into the small palpebral muscles. I say superficially because the suspensory ligament stops the toxin from migrating downwards on a deep level, provided the injections are given high enough above the supraorbital rim. I’ve seen a patient with one eyebrow raised following toxin treatment AND on the same side, ptosis of the eyelid- that was the moment I realised that eyebrow and eyelid ptosis were not the same thing. Matters are complicated further when you consider this: a patient presenting with apparent eyelid ptosis might have this effect secondary to eyebrow ptosis. How does that happen? It’s easy- it’s because the eyebrow is connected to the eyelid. This happens if patients have natural lid ptosis to start with. This is familial- I have it, my mum had it but got it fixed (upper eyelid blepharoplasty) and her father had it but also got it fixed. Where does that leave us? How do we know the cause of a given case of eyelid ptosis? This is one of the reasons we take notes! If a patient has had their forehead treated but not their frown lines, then the dropping in the eyebrow and consequent eyelids must have come from overtreating the frontalis. Even if standard doses have been used. If the patient has had only frown lines treated and not forehead/frontalis, then it’s another “no-brainer’; it had to be the frown line injections that are the culprit. If they had both treatments and have eyelid ptosis, look at the before and after photos and ask yourself- have the eyebrows drooped or just the eyelids?

A common question I get asked on our training courses is this: “Should we not just inject higher than 1.5cm above the supraorbital rim to ‘be on the safe side’ or to ‘make sure’ we are avoiding the risk of lid ptosis?” Hopefully now you will know the answer to this question, which is this: if you inject higher than 1.5cm above the supraorbital rim you’ll reduce the risk of lid ptosis but increase your risk of brow ptosis.

Lower eyelid ptosis

This doesn’t really fit in very well in this post but for completion I’m mentioning it. There is such a thing as lower lid ptosis. This can occur when using toxin below the eye. The only situation where I do this is in treating under eye fine lines with toxin. Here is how I minimise this risk of lower lid ptosis:

  • Use a low dose (maximum 4 units Azzalure or 2 of Botox bilaterally)
  • Before injecting, carry out the “snap test” as shown here:

This is performed by gently pulling down on the lower lip and watching that the normally instantaneous return to position on letting go, is not prolonged. If this “snap” back to position was prolonged, and you use toxin thus making it worse, the cornea could be at increased risk of dryness, irritation and abrasion.

One of our first patients, using Hollywood Eye Magic. Before and after photo taken 10 minutes apart.
One of our first patients, using Hollywood Eye Magic. Before and after photo taken 10 minutes apart.

In addition to these measures to reduce the risk of lower lid ptosis I also assess first that there is no bagginess of the lower lids. Avoid treating with toxin if eye bags are present – it is likely to make these bags worse. Instead, consider using something like Hollywood Eye Magic which gives immediate results but has to be reapplied daily. We no longer sell this as although the effect at rest is impressive, it can make lines more pronounced on movement. Here are before and after photos from when I used it on my dad.

Another risk with under-eye toxin, is double vision. This is extremely rare if you inject superficially and laterally to the pupil but theoretically could arise if toxin were to reach the inferior oblique where it’s anterior attachment to the eye is very superficial.

Treatment of eyebrow & upper eyelid ptosis

If eyelid or eyebrow ptosis occurs there is good news. Usually this resolves within 2 weeks of onset. I don’t know why; possibly due to the number of times we use our upper lids to blink in a day compared how much we use other muscles commonly treated with toxin. It is fortunate for us as toxin users and, of course, for our patients. It’s hard to give an exact incidence of ptosis as I’d say patients don’t report most cases as they merely notice a difficulty putting on eyeliner. But I’d say my rate of ptosis where a patient actually complains to me that they have noticed it and finds that it is an issue for them, is approximately 0.5% of treatments although I’ll admit that I haven’t properly audited this. But, what is better than treating drooped eyelids, is avoiding them in the first place. If someone has natural ptosis I recommend fully counselling them as follows: (1) they are at an increased risk of noticeable eyelid ptosis when treating either their forehead or frown lines. (2) Neither one is completely risk free but treating just the forehead puts the patient at greatest risk. (3) If they are happy to compromise some of the anti-wrinkle affect on the lower forehead, you can reduce their risk of ptosis by treating their forehead lines higher up than you normally would. Note that the frown line injections must stay in exactly the correct position as raising them will increase the risk of eyebrow ptosis and lowering them will increase the risk of eyelid ptosis (see above). This correct distance is 1.5cm above the supraorbital rim – and by supraorbital rim I mean the point where your finger catches on their supraorbital rim as you draw your finger up over their cornea and attempt to ‘hook’ it onto their supraorbital rim. A simple treatment protocol might be: 1) Conservative approach (reassure, should resolve within 2-3 weeks of onset). 2) Consider eyebrow raise with toxin or a top-up of frown lines if already treated. 3) Lapraclonidine 0.5% – consult the BNF).

Applied Advanced Knowledge & some Additional Considerations

Me & my forehead during an eyebrow raise.
Me & my forehead during an eyebrow raise.

 

Me and My Forehead

Back to the photograph of my forehead.What can you tell about me from this one image, apart from my age? You can tell that I am male, you can tell that I’m Caucasian and you can also tell that I have natural eyelid ptosis. You are probably looking at the photo and thinking- “I need to google what ptosis means because I don’t see any’. Let me save you the trouble. True, there is very little ptosis in my photo- it’s best seen in a photo taken at rest. However, you will note that my forehead lines above my eyebrows are in a similar shape to my eyebrows. This suggests that subconsciously I have been compensating for eyelid ptosis by raising my eyebrows and hence creating deeper lines in this area. If I was to treat someone with this pattern of facial anatomy, I’d use dermal filler for the fine lines and use some cross-hatching to prevent these lines above the eyebrows from buckling during movement. I have done this and have seen excellent results.

Would you consider a chemical eyebrow lift to improve eyelid ptosis?

Someone who, like myself, has some natural eyelid ptosis is already at increased risk of further eyelid ptosis but, conversely, may really benefit from a chemical eyebrow lift. In this circumstance I would be reluctant to attempt this without having built up a rapport with the patient first and explaining to them the risk vs. benefits of attempting the procedure i.e. you are trying to raise the eyelids but there is a risk that the lids could droop further, albeit, normally only for a few weeks. When attempting the chemical eyebrow lift, as well as giving the standard 5 injections to the glabella region you might also consider giving an additional injection 1.5 cm above the most lateral part of the supraorbital rim (2.5 units Botox/Boucouture or 5 units Azzalure/Dysport).

How much [toxin] should I give at a follow-up appointment?

The key is to look at your before photos and compare to the patient in front of you. Do this with the patient. The questions are- ‘can we see any difference here?’ and ‘are we likely to get a better result if we use more toxin?’. Ideally you will have explained beforehand that toxin reduces lines present or made worse by movement. It won’t treat lines present at rest- usually. If you see no difference between the before photos and the patient at follow-up and the lines are made worse or are present only with movement then repeat the same dose- again taking care to check for risks of side-effects (drooping and bruising). If some improvement, decide whether to use 1/2 original or 2/3 original dose.

Regarding the extra (celebrity) lateral forehead injections for forehead lines to avoid ‘spocking’; are these usually inline with the outer edge of orbital ridge?

Yes.

What if someone wants just their forehead treated and not their frown lines?

Firstly, advise them that they are more likely to get an overall better result and a reduced risk of side effects if they get both their forehead and glabella treated together with toxin. However, if they insist upon just having the forehead treated I recommend that you give them one extra injection, free of charge, into the procerus. This reduces the risk of them developing procerus hypertrophy, also known in the industry as “planet of the apes’.

Does it matter how I make up the [toxin]?

For Azzalure the manufacturers specify how to reconstitute- 0.63ml normal saline. They also provide specialized syringes to make it easier to do this. When I use Botox, I make it up with 2.5ml for a 100 units vial but I know that others use different volumes of saline. I recommend using Bacteriostatic normal saline as the addition of benzyl alcohol really reduces the sting of the injection.

The simplest answer to the question is yes. It is due to diffusion physics. Imagine the tide on a beach (saline) and how it carries seaweed (toxin). High tide will carry the seaweed further than low tide. So consider whether diffusion of the toxin over a greater area is something that you would like to happen or not. Hint: you probably don’t want more diffusion as it increases the risk of upper face toxin side effects.

I have had two patients experiencing the ‘spock’ look; both have received lateral forehead injections as they had described raised eyebrows with previous [toxin] injections. Where might I be going wrong?

If they are prone to eyebrow raising and they told you that and you treated the lateral forehead you have probably done what I would have done in the first instance. It’s easier to fix spocking than ptosis. I would use the same dose again to the lateral forehead at follow-up. Occasionally patients just really need a larger dose in this area and you can give a larger dose the next time in the first instance. But be wary of patients who raise their eyebrows subconsciously to compensate for natural lid ptosis, as overtreating the lateral forehead in these patients will lead to their inability to continue this compensation (see the photo of my forehead for reference).

How should I adjust my injection sites if a patient has shaped their eyebrows?

You shouldn’t. Eyebrows are not an anatomical marker for the muscles of the glabella. Muscles attach to bone so use bone for your landmarks. Ignore whether eyebrows are threaded, plucked, tattooed or drawn on and stick to the bony landmarks.

Thanks for reading and/or sharing. If you would like to ask me or any advice or you take issue with anything I’ve said, please let me know on visageacademy@gmail.com

Dr Michael David Aicken

Ask Dr Michael Aicken for some professional advice about either Botulinum Toxin OR Dermal filler, either as a patient or a practitioner.