Posted by Jennifer Stanford, MD on Aug 15th 2015
Neurotoxins are commonly used to treat the vertical lines between the brows.
The vertical lines of the glabella result from the contraction of the paired corrugator supercilii muscles, and the horizontal lines are caused by contraction of the central procerus muscle. The corrugators originate on the upper eye socket ridge of the frontal bone and insert on the skin above the middle third of the eyebrow. The procerus muscle originates on the nose bone and inserts onto the mid-forehead skin.
There are two patterns of corrugator positioning: either horizontally along the brow, or more vertically in a V shape. The injector should "look through" the skin to imagine the location of the muscles and their contribution to the wrinkles produced during movement.
This injection usually can be tolerated without anesthesia.
Have the patient frown his brow before inject, and look through the skin to determine the size, strength, and location of the procerus and corrugator muscles.
Usual doses for frown lines are 20 to 30 BU (Botulinum tox units); however, some patients can do well with as little as 10 units, and men may need 40 BUs.
Injections should be placed 1 cm above the upper eye socket rim to reduce the risk of upper eyelid droop. Injections should be placed in the muscle belly. The periosteum should not be touched with the needle because periosteal contact can cause a post-injection headache.
Injection in the brow area can result in upper lid droopiness, which can up to two weeks after an injection and may last for 2 to 4 weeks.
Neurotoxins should be reconstituted with preserved saline (0.9% sodium chloride) because preserved saline causes less patient discomfort.
Botox Cosmetic-100 BU may be reconstituted with:
1 mL preserved saline, which produces a solution of 10 BU per 0.1 mL
2 mL preserved saline, which produces a solution of 5 BU per 0.1 mL
2.5 mL preserved saline, which produces a solution of 4 BU per 0.1 mL
4 mL preserved saline, which produces a solution of 2.5 BU per 0.1 mL
Botulinum toxin should be stored in a freezer until reconstituted. After reconstitution, botulinum toxin should be kept in a refrigerator.
After reconstitution, botulinum toxin A can be withdrawn from the vial with a 1-mL syringe and a 20-gauge needle, and a 30-gauge needle can then be used for injection.
Patients should not to bend over, push on the injection sites, or lie down for 4 hours after the injection. The patient should not exercise that day or actively move the injected muscles for 90 minutes.
Diffusion of Bo toxin into the eyelid may paralyze the levator palpebrae superioris muscle and result in a transient droop.
The patient should frown to demonstrate the size and shape of the muscles. Filler injections may be necessary for deep wrinkles in the brow region. Application of pressure with a thumb along the eye socket rim during injection may prevent diffusion of Botox toward the levator palpebrae superioris muscle.
a) More horizontal muscles. (b) More vertical V-like muscles.
Fig. Patterns of injection for more horizontal corrugator supercilii muscles.
Fig. Suggested patterns of injection for V-like corrugator muscles.
Fig. Injection sites for horizontal glabellar wrinkles with more contribution from the procerus muscle and less contribution from the corrugator muscles.
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