105
Shaping of the Eyebrows with Botox
David F. Horne and Thomas E. Rohrer
By rebalancing the forehead and periocular muscles, Botox injections can improve the shape and position of the eyebrows. It is even possible to induce a modest “chemical brow lift” and help correct intrinsic or iatrogenic asymmetry of the eyebrows. Reports by Carruthers1 as well as Frankel and Kamer2 have shown that the majority of patients experience a modest elevation of the brow.
A thorough understanding of the functional anatomy of the upper face is essential to obtain optimal cosmetic outcomes and to avoid undesirable side effects. The muscles involved in modifying the eyebrows may be functionally divided into the elevator (the frontalis), the medial depressors (the medial portion of the orbicularis oculi, the corrugator supercilii, and the procerus), and the lateral depressors (the lateral portion of the orbicularis oculi).
Modifying the Position of the Medial Eyebrows
Treatment of the medial depressors can result in cosmetic improvement of the glabella by elevating the medial aspect of the eyebrow and diminishing dynamic and static “scowl lines” created by contraction of the corrugator supercilii and the procerus. Many patients contract or maintain resting tone in these muscles, causing the medial eyebrows to move inferomedially. This creates vertical rhytides in the glabella, resulting in a tired or angry expression. Chemical paralysis of these muscles results in a decrease in their resting tone, maintenance of the medial eyebrows in a more superolateral position, and an “opening of the glabella” that is cosmetically desirable.
Modifying the Position of the Lateral Eyebrows
The isolated treatment of the medial depressors consistently results in elevation of the lateral eyebrows as well. This may be the result of diffusion of Botox from the medial depressors into the inferomedial portion
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of the frontalis. Partial paralysis of the medial frontalis triggers a compensatory increase in the resting tone of the lateral frontalis, resulting in an elevation of the lateral and central eyebrow. This effect may be exaggerated in cases where only the medial frontalis is injected with Botox, resulting in marked ptasis of the medial portions of the eyebrows and superolateral movement of the lateral portions. A characteristic and usually undesirable appearance described as a “Jack Nicholson,” “Spock,” or “quizzical” effect may result. This side effect is treated or prevented by injecting a small amount of Botox into the lateral frontalis muscle. Caution should be taken not to inject too inferior in this area or a ototic lateral eyebrow may ensue. Small injections laterally near the temporal fusion lines above the midway point of the eyebrow and hairline will release the compensatory increase in tone of the frontalis muscle and lower the corresponding lateral eyebrow.
Arching and Lifting the Eyebrows
If the inferomedial and lateral aspects of the frontalis are treated as described above, the compensatory increase in tone of the untreated frontalis overlying the midpupillary area can result in an aesthetically desirable arching of the central portion of the eyebrow. This lifting of the brow can be further supplemented by treating the lateral depressors of the eyebrows, the lateral portions of the orbicularis oculi. In properly selected patients, 1–3 mm of elevation of the eyebrows can be obtained with this technique. Cosmetically unacceptable lifting or arching can be corrected by injecting small amounts of Botox into the portion of the frontalis that has increased in tone. It is important to keep these correcting doses small and located relatively superior to avoid overcorrection and brow ptosis. This chemical brow lift is eliminated if the bulk of the frontalis is treated for dynamic forehead rhytides.
Lowering and Flattening the Eyebrows
An eyebrow that is too high or too arched may be lowered by focally weakening the frontalis that lies superior to it. To avoid overcorrection and ptosis, it is prudent to start with small doses relatively superior ( 3 cm above the orbital rim). Reassessment after 10–14 days, with supplemental injections as needed, will minimize the risk of brow ptosis.
Treating Eyebrow Asymmetry
The experienced clinician can use the above principles to improve intrinsic or iatrogenic brow asymmetry in a variety of situations. The patient should be warned that while asymmetric treatment may result in improvement of eyebrow symmetry at rest, dynamic rhytides and functional expression with the eyebrows may be uneven.
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Pitfalls
As with any cutaneous injection, pain and small areas of bruising are usually minimal, but sometimes unavoidable. Injecting superificially into thin periorbital skin, using high gauge needles, avoiding obvious underlying blood vessels, and applying pressure for several minutes after injection will minimize these complications.
An unanticipated increase in the resting tone of untreated frontalis is relatively easily treated, as discussed. Overtreatment of the frontalis with resulting brow ptosis is much less acceptable and may persist for weeks to months. Particular caution should be used if treating large portions of the frontalis for reduction of horizontal forehead rhytides at the same time as the glabellar or periocular regions. Using small doses in relatively superior locations in the frontalis or treating the forehead 10–14 days after treating the glabella may avoid this complication.
Inadvertent introduction of Botox into the levator palpebrae superioris will result in eyelid ptosis. Ptosis of the brow or eyelid is cosmetically unacceptable and may partially obstruct the visual field. Fortunately, this is extremely rare. Injections should be placed at least 1 cm above the bony rim of the orbit to reduce the likelihood of this complication. Apraclonidine 0.5% drops three times daily will cause contraction of Müller’s muscle. This will partially correct the ptosis until the effect of the Botox has resolved.
Conclusion
With proper technique and understanding of underlying anatomy, intramuscular Botox is a safe and effective way to temporarily modify the shape and position of the eyebrows.
Chapter 105 Shaping of the Eyebrows with Botox 325
A
B
Figure 105.1. (A) Prebrow and (B) Postbrow shaping with Botox.
References
1.Carruthers A, Carruthers J. Botulinum Toxin. Philadelphia: Elsevier, 2005.
2.Frankel AS, Kamer FM. Chemical browlift. Arch Otolaryngol Head Neck Surg 1998;124:312–323.
106
Botox Injection Techniques:
Crow’s Feet
Jemshed A. Khan
Crow’s feet injection is one of the simplest and most satisfying applications of Botox.
The radiating dermal crow’s feet lines result from the concentric constriction of the underlying orbital and preseptal orbicularis oculi muscle. Orbicularis oculi injections of Botox diminshes both active and static crow’s feet rhytids, may prophylactically delay the onset and progression of such wrinkles, and improves final outcome following ablative periocular resurfacing (Figure 106.1). Since the thin periocular skin is prone to visible bruising, injection should be in the subdermal plane while avoiding actual intramuscular injection. The loose periocular subdermal plane in the area of crow’s feet rhytids should visibly balloon up when the injection is delivered at the proper depth. Following injection, the patient may apply pressure for 1–2 minutes over the injection sites to minimize bruising.
Crow’s Feet Treatment Keys
•Avoid visible vessels
•Insulin syringe with integrated 30-gauge needle
•Injection sites 1–2 cm lateral to lateral canthal angle
•10–15 units total dose per side divided into 2–5 injections per side
•Injections 1–5 cm apart
•Apply pressure after each injection
Originally published in: Chen WPD, Khan JA, McCord, Jr. CD. Color Atlas of Cosmetic Oculofacial Sugery. Philadelphia: Butterworth Heinemann/Elsevier.
2004.
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Chapter 106 Botox Injection Techniques: Crow’s Feet 327
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Fig 106.1. (A) Crow’s-feet rhytids. (B) Typical injection sites for radiating crow’s-feet rhytids. (C) Location of underlying concentric orbicularis oculi muscle fi bers. (D) Improvement in rhytids following Botox injection. (Images courtesy of Joan Kaestner, MD.)
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D
107
Orbicularis Oculi Treatment with Botox
Samuel M. Lam
Ecchymosis occurs most readily around the eyes and should be minimized to the best of a physician’s ability. Avoidance of any anticoagulant is crucial as well as close scrutiny of the skin surface for any major vessels after makeup has been thoroughly removed. Other techniques to avoid ecchymosis involve liberal use of icing and only superficial injection of
Botox.
The physician should study the patient’s surrounding anatomy. A malar protuberance could represent a malar bag or an orbicularis festoon.
A malar bag is a descended and visible malar fat pad; a festoon is a weakened and prolapsed orbicularis-oculi muscle. If the prominence is partially or completely effaced with smiling, an orbicularis festoon is present and the physician should not inject the area as the orbicularis might prolapse further. Preexisting lower eyelid laxity may be exacerbated with Botox, and snap and lid distraction tests are informative. Patients who have wrinkles that extend all the way down the face when smiling are not great candidates for Botox therapy. Chasing these wrinkles down the face may paralyze the zygomaticus musculature and cause unwanted facial droop and loss of normal facial animation. In order to establish realistic expectations for what Botox can achieve in this area, the physician can lift the cheek up manually to evaluate what component of wrinkling is attributed to cheek movement (which cannot be safely addressed with Botox) versus what is caused by orbicularis activity by then having the patient smile. This is shown to the patient in a mirror.
The presence of brow asymmetry may also be partially or entirely corrected with Botox into the upper tail of the eyebrow on the ptotic side. The orbicularis on the contralateral side should not be injected this far supero-laterally for fear that the brow will also elevate on that side, eliminating the symmetrizing benefit. The unopposed frontalis must adequately elevate the brow, which becomes less likely with ongoing age.
Botox should not be aggressively injected into the lateral outer frontalis on the descended side so that the frontalis can still act to elevate the brow after injection of the orbicularis depressor.
Compared with other upper facial areas, treatment of the orbicularis oculi tends to last a bit shorter (less than 3 months) compared with 3–4
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Chapter 107 Orbicularis Oculi Treatment with Botox 329
months on average for other anatomic zones. If the Botox is lasting 2 months or less, higher dosages are warranted. Using less than 10 units of BTX per side typically is insufficient, and I have used as much as 15 units per side to achieve the desired aesthetic result.
The application of ice is very important to shrink periocular vessels as well as limit discomfort. Injection is very superficial to raise a dermal wheal, as the vascular orbicularis muscle resides immediately below the skin surface. The objective is not to inject the muscle but the subcutaneous plane, which will in turn diffuse directly into the muscle. I usually inject about four sites (with 2.5 units per site) around the eyes that correlate with where wrinkles are distributed as observed during animation
(Figure 107.1). With any evidence of bleeding from the injection site, the physician applies immediate pressure with gauze for 3 minutes without removing the gauze to observe the area. Unfortunately, even if a small trickle of bleeding is observed from any injection point, there will most likely be at least some ecchymosis there. Unlike in the glabellar region, where pressure application is unsafe, it is mandatory in the orbicularisoculi region when any bleeding is noted.
Figure 107.1. The Xs mark the areas for Botox therapy of the orbicularis oculi. Each X is treated with 2.5 units.
108
Perioral Botox Injections
Jemshed A. Khan
The perioral area responds less predictably than other treatment areas because the dynamic muscle actions associated with eating, drinking, speaking, and smiling may be impaired. A cautious approach to this area is warranted.
Only 50% of patients are satisfied with perioral Botox because of lack of perceived benefit or side effects of drooling, difficulty in puckering and whistling, impaired enunciation, or drooling.
Perioral Botox therapy may focus on the orbicularis oris muscle to relax perioral rhytids, the depressor anguli oris muscle to produce an upturn in the lateral oral commissure, or the mentalis muscle to relax a peau d’orange chin.
Orbicularis Oris Therapy
The orbicularis oris muscle must be treated cautiously with very small doses on Botox. Singers and woodwind instrumentalists must be avoided (Figure 108.1).
Depressor Anguli Therapy
The depressor anguli oris is treated cautiously to give a subtle, but pleasing, upturn to the lateral oral commissure (Figure 108.2). Caution must be exercised to avoid injecting too medially and weakening the depressor labii inferioris, which will produce a stroke-like appearance.
Originally published in: Chen WPD, Khan JA, McCord, Jr. CD. Color Atlas of Cosmetic Oculofacial Sugery. Philadelphia: Butterworth Heinemann/Elsevier. 2004.
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Figure 108.1. Typical treatment sites for vertical lip lines. Minute doses, i.e., 1–1.5 units per site, are delivered. Dose and number of injection sites may be gradually increased if the response is inadequate.
A B
D
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Figure 108.2. (A) Preoperative appearance of patient with depressed lateral oral commissures. Note the slight downward angulation of the lateral oral commissures prior to injection. (B) Injection sites for treatment of depressed lateral oral commisures. Generally, 3–8 units per site is delivered. Injection is inferior to lateral commisure and two thirds of distance to chin border. (C) Overlay of perioral muscles. Red lines represent depressor anguli oris. Green lines represent depressor labii inferioris. Both muscles may be targeted for Botox-A treatment. (D) Note subtle improvement in wrinkles and slight elevation of the lateral oral commisures 2 weeks following injection.