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Plastic Surgeon Dr. Dean Kane of Baltimore Answers Question Regarding Botox Forehead Injection Technique

Q. Was my Botox injected in the right places? 3 days ago I had botox injected to my forehead for the first time. I told the nurse (who did the injections) that I was worried about lowering of the eyebrows. She put four injections along my horizontal lines, and then she put two injections to the hairline “to prevent eyebrow lowering”. After the appointment I searched the Internet about this, and I think the hairline injections are just going to make it worse. What do you think, is my botox nurse right, or have I just read wrong information?

A. Thanks for sharing your photos. There are many variations of the “right” technique. The FDA approves sale of a drug or device and its marketing based on the safety and efficacy of what the FDA was presented. In the case of Botox, the “on-label use is 20 units in 5 lower central forehead injections. See this in Diagram 1.

Diagram 1

A physician is allowed to deviate from this technique, called “off-label” use if the risk of complications is reasonable.  Therefore it is used to weaken the pull of the forehead muscle creating horizontal “lines”.

Careful dissection of the forehead finds 2 flat muscles (frontalis) over each brow attached to a fibrous band called the Galea Aponeurotica on top of the scalp which is attached to 2 flat muscles along the posterior scalp (occipitalis) causing upward forehead and occipital elevation and therefore folding or wrinkling of the skin.  I have found there are wisps of muscle fibers central to the frontalis as well. They create wrinkling but not necessarily the same creases as the frontalis lines. Generally, Botox in the central forehead to reduce these lines works well. Botox within the region of the frontalis will weaken the upward elevation (and lines) and allow the brow to droop. See Diagram 2.

Diagram 2

There has been a recent article in the Plastic Surgery literature describing the use of Botox along the hairline to reduce brow descent. This has not been my experience and I find the technique unintuitive.

  1. The hairline is very variable or none-at-all.
  2. The attachment of the frontalis to the galea is also variable and the galea without muscle fibers does not respond to Botox. Any Botox to the frontalis muscle fibers should weaken them and allow the overlying skin attachment to sag. This again, is my experience.

I would expect that you will weaken the horizontal lines in the mid-forehead probably causing some ptosis of the brows and similar sagging from the hairline injections. Please let us know what happens! I wish you well!

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This information is not meant as medical advice. It is provided solely for education. Our practice would be pleased to discuss your unique circumstances and needs as they relate to these topics.

Give us a call at  410.602.3322  or email Lauri@DrDeanKane.com and make an appointment soon. We’re located on Reservoir Circle just a block off the Baltimore beltway, convenient to greater Baltimore, Annapolis, the Eastern Shore, Southern Pennsylvania, Delaware and Carroll County.

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