How to treat the Glabellar frown lines using Botox

How to treat the Glabellar frown lines using Botox

Medically Reviewed by Mohsen Talani, MD on November 27, 2023 | Written by CBAM Author

The area between the two eyebrows is called glabella or frown area. Three important muscles, corrugator supercilii (CSM), procerus (PM) and depressor supercilii (DSM) are located in this area. Their contraction causes vertical or horizontal lines known as frown lines.

Statistics have shown that most of the side effects caused by Botox injection are technical and generally due to incorrect dosage or misplaced injection. Under-correction or over-correction of folds leads to adverse effects such as eyelid ptosis, eyebrow ptosis, lip corner ptosis, smile asymmetry and mask appearance. Although these complications are not serious, they are very uncomfortable for patients because they may last for weeks or months.

Therefore, it is essential that treating professionals have the highest level of understanding of facial muscle anatomy, accurate injection technique, and understanding of the patient’s desired aesthetics. Variables that must be considered prior to treatment include the anatomical area to be treated, gender, muscle mass, ethnicity, skin thickness, and signs of aging. In each chapter, the anatomy of the desired area is explained first. Then we discuss the method of determining injection points, injection technique, complications related to injection in that area and important points in increasing injection skills in that area.

An overview of the muscles of the upper third of the face

It can be said that more than 70% of the use of cosmetic Botox is in the upper third of the face. In this area, Botox is used to treat forehead wrinkles, frown lines, and crow’s feet wrinkles near the eyes. Five important muscles are located in this area. Knowing their location and function is the basis of correct Botox injection in this area. These muscles include:

  • frontalis muscle
  • corrugator supercilii
  • Procerus
  • Depressor supercilii
  • orbicularis oculi

These five muscles are classified into three parts in terms of location and use:

A- Muscles of the frown complex:

  • supercilii corrugator
  • processor
  • supercilii depressor

B – forehead muscle or frontalis muscle

C- Orbicularis oculi muscle

These muscles are all connected to the eyebrow from one end and their contraction causes the eyebrow to move up or down. Of the five muscles, the contraction of the frontalis raises the eyebrow and the other four muscles lower the eyebrow. Knowing this point is an important key in Botox injection for eyebrow changes, which will be mentioned in detail in the following sections.

Anatomy of the glabella muscles

Procerus muscle

This small muscle is placed vertically between the two eyebrows. It originates from the periosteum of the nasal bone and ends in the middle membrane of the forehead and eyebrow skin. The contraction of that medial part (crown) brings the eyebrows down. In people where this muscle is bigger, its contraction causes a horizontal crease on the top of the bridge of the nose.

Corrugator supercilii muscle

This muscle originates from the supraorbital edge of the frontal bone and goes upwards and outwards. The inner head of this muscle is deep, and as it extends outward, it becomes more superficial and connects to the frontalis muscle and enters the skin of the middle part of the eyebrow. Due to the contraction of this muscle, two states are created:

First- vertical and oblique furrows are formed in the area between the two eyebrows (glabella), which is known as “vertical frown line”.

Second- the crown of the eyebrow (the inner head of the eyebrow) is pulled down.

This muscle is larger in men than women and exists in two patterns:

The first pattern: the long and almost vertical corrigator muscle above the middle of the eyebrow is V-shaped, and its contraction creates long, vertical lines. This pattern is more common.

The second pattern: the corrector muscle is wide and transverse and is located a little higher than the rim of the pupil. Its contraction causes shorter and more angular vertical lines.

These different patterns are easily observed clinically. When the patient contracts the frown muscle complex, the frown depression is visible in the skin. Botox injection should be in the path of muscle anatomy. To treat vertical lines between the eyebrows, Botox injection should be done in the thickest part of the corrector muscle.

Depressor supercilii muscle

The superciliary depressor muscle is very small and is located near the eye. It originates near the tear ducts and enters the interdermal membrane under the inner head of the eyebrow. The fibers of some of its parts are attached to the fibers of the inner part of the orbicularis oris muscle and some of its parts are attached to the corrector muscle. To the extent that some anatomists consider it a part of these muscles. In any case, this muscle, along with the corrector muscle and the inner part of the orbicularis oris muscle, creates vertical frown lines between the two eyebrows and pulls down the medial head (crown) of the eyebrow.

The corrugator and superciliary depressor muscles play a role in creating vertical wrinkles, and the procerus muscle plays a role in creating horizontal frown lines.

Contraction of all three muscles lowers the inner head (crown) of the eyebrows.

Determination of injection points in the glabella for the treatment of frown lines

The following care needs to be observed:

  • Patient should be examined first.
  • Determine the depth and degree of frown lines.
  • During the examination and injection, patient should be sitting and his chin should be down.
  • The patient’s head should be lower than the therapist’s head.
  • Each person has their own examination and unique conditions.

In the authoritative articles and books, depending on the experiences of the professors, different models have been suggested for teaching frown Botox injections. We will first mention the most commonly defined pattern of injection in the frown area and then go on to review other patterns. Five standard points are defined in the glabella area for Botox and Dysport injections, which are two world famous brands.

One point is in the ventricle of the procerus muscle and two points are in both ends of the corrector muscle. We need a landmark to determine the injection points. Anatomically, a landmark is a fixed location or area that can be used to mark a distance. There are four suitable landmarks for determining injection points in the frown area, including:

  • The inner head of the eyebrows
  • Inner canthus (inner corner of the eye)
  • pupil hole
  • Rim or the upper edge of the pupil

The first point – injection in the procerus muscle:

Injection at this point paralyzes the procerus muscle, and as a result, the inner part (crown) of the eyebrows rises and the eyes become more open. Also, in those who have a horizontal frown line on the nose, this line disappears. (red dot shape)

Injection point: the area between the two eyebrows exactly in the middle line and slightly above the root of the nose (blue dot shape)

The second point – injection in the inner head of the corrector muscle:

In this place, there is a supratrochlear groove, from which the supratrochlear nerve, artery and vein come out and travel upwards, and there is a high possibility of getting damaged and creating a hematoma. For accurate injection and to reduce the said complication, we must use two landmarks. The first landmark is the inner canthus of the eye and the second landmark is the rim or the upper edge of the pupil. The injection point is considered to be one centimeter higher than the upper rim of the pupil in alignment with the vertical line that passes through the inner canthus. (yellow dot shape)

The third point – injection in the external head of the corrector muscle:

In this place, there is a supraorbital hole, through which the supraorbital nerve, artery, and vein come out and travel upwards, and the possibility of damage and hematoma formation is high. For accurate injection and to reduce the said complication, we must use two landmarks. The first landmark is the pupil and the second landmark is the rim or the upper edge of the pupil. The injection point is considered to be one and a half centimeters higher than the upper rim of the pupil in alignment with the vertical line that passes through the pupil. (green dot shape)

The above picture shows the Botox injection point in the glabella, Procerus (blue), inner head of the corrector (yellow), outer head of the corrector (green).

The total injection volume is 20 units of Botox or 50 units of Dysport.

Eyelid drooping (ptosis) is an important technical complication of the frown area

Ptosis or drooping of the eyelid is a state where the upper eyelid covers part of the pupil. Normally, when the eye is open, the upper eyelid should be far from the upper edge of the pupil. This problem can be congenital or iatrogenic, such as paralysis of the levator palpebrae muscle due to Botox leakage. According to the statistics of reliable articles, in the best conditions and following the correct technique, there is a 2-3% chance of this complication.

Improper technique and low accuracy may increase the incidence of this complication. The levator palpebrae muscle is a muscle that starts from the roof of the orbit and goes down and attaches to the fibers of the edge of the upper eyelid in front. Its contraction raises the eyelid and opens the eye. The main cause of Botox leakage to this muscle is the injection in the external head region of the corrector muscle (green dot shape).

Among the causes that increase the possibility of Botox leakage and ptosis complications, the following can be mentioned:

  • Failure to maintain a distance of one and a half centimeters from the upper rim of the pupil during injection
  • A higher than standard dose of toxin
  • Excessive dilution of the toxin
  • Failure to teach the patient about post-injection care (not lying down and bending the head for 4 hours, not massaging the area, etc.)

Eyelid ptosis may not always be typically severe drooping of the eyelid. The feeling of heaviness of the eyelid, the feeling of swelling and puffiness and sleepiness, especially after waking up until the middle of the day, the feeling of tightness and tightness in the eyes, etc. are other interpretations that patients express about ptosis. It disappears by itself four weeks after the injection. But if the dose of injection was high, it may take several months until the end of the effect of the toxin. Although methods and drugs such as apraclonidine drops have been suggested to treat and shorten the length of this complication, it can almost be said that there is no 100% sure method except waiting until the effect of Botox wears off.

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Management of the complication of ptosis caused by Botox injection

The best way to manage this complication is to help the Patient to accept the problem and be patient. Explain to the patient that this complication is not permanent and will disappear in less than two weeks. If the problem still persists after two weeks, Patient can be invited to be patient and wait for another two weeks, and of course, medicinal methods, massage and heat.

Apraclonidine eye drops can be effective up to 50% in cases of severe ptosis.

It has been said that heat, massage, HIFU have been helpful in reducing the duration of ptosis.