Agree to Disagree

Problem Area: Forehead Lines

Unfortunately for my patients that hate their horizontal forehead lines, this is one area that I am consistently conservative.   The muscle causing these horizontal lines across your forehead is called the frontalis muscle.  I get it that people don't like thick, deep lines spanning the width of their face.  Let's agree to disagree because I don't think having some expression lines across your forehead is a bad thing.  I will agree to treat this area on a patient if they have the anatomy to support it, which we will discuss here shortly, and if they agree to entertain other avenues of improving skin quality.   This is one area where ya'll want your cake and to eat it too...if you want an overall lift in your eyebrows...treating this area will give you little assistance in lifting the brow.

The Fix: Neurotoxin, Microneedling, Skincare

To treat this we would use a neurotoxin to temporarily weaken the muscle contraction.  Botox or Dysport are good choices for this treatment area.  An average dose for females for the frontalis muscle is 6-10 units of Botox or 15-25 units of Dysport.

The result is not seen immediately.  It takes 2-3 days for the neurotoxin to uptake into the muscle.  The product is completely active at 2 weeks out.  On average, the result lasts for 3-4 months.  I tell my patients to budget for their treatment 3-4 times a year, if they want to keep the results up.  Some patients are able to stretch their appointments out and others have to come in sooner.  Metabolism, skin quality and condition, under-dosing, and overall desired result can have an impact on how often you will have a treatment.

Microneedling, which is a skin care treatment, can dramatically improve fine lines and wrinkles in dynamic areas like the forehead.  Doing this in combination with a good skin care routine at home can help stimulate new collagen formation and buff out the static lines on your forehead.  We will definitely talk about skin care in more depth in another post but always think ABCs and Sunscreen.

Anatomy Lesson: Frontalis

Your frontalis is a wide banded muscle that starts at your brows and goes back up into your hairline.  You have the ability to express portions of the muscle more than others.  This is why you might be able to lift one eyebrow up and not the other.  Your frontalis muscle splits or bifurcates.   For some, this split takes place below the hairline on the forehead, but for others this split takes place further back on your scalp.   This muscle is responsible for lifting or elevating your eyebrows.  Sometimes there is an asymmetry of the eyebrows, meaning one sits lower or higher than the other.  When appropriate, we can help balance this by adding an extra unit or two to the side that sits higher or we can recruit other muscles to help out in lifting.

Treatment Pattern: Two to Five Pokes

To successfully treat the frontalis, plan for two to five pokes from the injection needle.  The treatment dose and pattern is identified during animation of the muscle.  If you have a hooded upper eyelid to start with, I strongly encourage you have a glabella treatment first, let that settle in and then at your two week follow up visit have your frontalis treated.  You will be so excited with the improvement of your upper eyelids that you will appreciate my caution in treating your forehead lines.  The weakened ability to elevate your eyebrows would cancel out the lift that was created from your glabella treatment.  I don't want it to appear that I never treat the frontalis muscle because I certainly do.  If a patient is looking for more of an arch to their eyebrows, I would treat the frontalis medially and leave the lateral aspects of the frontalis alone.  Or if they have stubborn lines laterally, we could treat the lateral points conservatively.  I would much rather be in the position that we need to add a little more product at the two week follow up rather than being aggressive and my patient feel heavy in the brow for the next month.  General rule of thumb for the treatment provider is to aim high and treat lightly.