Treating glabellar lines with botox

Treating Glabellar Lines with Botox

Treating glabellar lines was the first FDA-approved nonmedical indication for Botox, and it is where most patients begin their cosmetic journey. Lines in the glabellar region (between the eyebrows) convey emotions that do not reflect the patient’s true frame of mind. It can easily make someone appear sad, tired, stressed out, or angry. Most patients complain of dynamic and static wrinkles in this region more than any other areas of the face.

In the Unites States, glabellar Botox injection is the most common entry procedure for physicians aiming to incorporate cosmetic treatments into their practice.1 The ever-increasing demand for anti-aging solutions using minimally invasive cosmetic methods propels the popularity of Botox worldwide.

Who would be interested in this treatment?

The ideal candidates for glabellar correction with Botox are patients with dynamic wrinkles at the central brow. Patients with frown lines visible at rest may also be treated with botulinum toxin, but results are slower and 2 to 3 consecutive injections are needed for optimum results. Deep static lines require combination treatment with dermal fillers to experience significant improvement.1 The following conditions are contraindicated to botulinum toxin injection:

  • Allergy to any components of Botox products;
  • Keloid scarring;
  • Neuromuscular disorders;
  • Body dysmorphic disorder;
  • Unrealistic expectations;
  • Pregnancy and breastfeeding.

According to American Society for Aesthetic Plastic Surgery, the average physician or surgeon fee per Botox procedure is $376.2 The per unit cost is between $9 to $20 in the US and Australia. In the UK, 1 session starts at £250 and above for board-certified injectors.

Botox treatment for glabellar lines

Botox products contain botulinum toxin A, a potent neurotoxin protein derived from the paralysis-inducing bacterium, Clostridium botulinum. The aim of the therapy is to reduce frown lines by causing temporary relaxation or weakening of the glabellar muscles.

Frown lines are formed by repetitive contraction of underlying facial musculature. Correction of glabellar lines with Botox therapy requires targeting the corrugator supercilii, depressor supercilii, and procerus muscle using the standard 5-point injection.

Injecting small quantities of neurotoxin in these muscles causes localized muscle relaxation by inhibiting the release of acetylcholine, a chemical neurotransmitter that signals the muscles to contract. Relaxation of the targeted muscles smooths the outer skin and reduces wrinkles.3 The effects of Botox is reversible and muscle contraction will be restored in 4–6 months.

Tips for treatment

How to inject

Glabellar frown lines are caused by 4 depressor muscles of the brow. The corrugator supercilii and depressor supercilii muscles produce the vertical lines of the glabella. Differences in glabellar wrinkle patterns depend on the size and strength of each of the 4 muscles; their response to Botox denervation is also different in every individual. It’s important to observe the pattern, location of wrinkles, and the musculature of the patient at rest to identify the injection points. The use of anesthesia is not necessary for Botox injections.

  • To activate the depressors, ask the patient to scowl or frown using a hand mirror. Evaluate the size and location of individual muscles and the intensity or strength of muscle contraction by palpating the central brow using the fingertips of the non-dominant hand.
  • The standardized technique for treating frown lines is to inject 4 to 10 units of Botox superficially for each of the 5 injection points. A total dose of 20–30 units can provide significant results for women and approximately 40–80 units for men.4
  • Patients with stronger and more hyperkinetic corrugators and procerus muscle may require higher doses in the 7-point injection pattern.
  • When injecting into the corrugators, take note of the danger zone, which is the 1cm area above the superior orbital rim. Injecting into this area will cause migration of toxin to the levator palpebral muscle, resulting in eyelid ptosis.
  • After injection, the patient must be advised to avoid lying supine for at least 4 hours.

Minimize side effects

  • Bruising – This can be minimized by asking the patient to discontinue taking aspirin and other medications and dietary supplements with anti-coagulant effects.
  • Localized burning or stinging sensation – This usually resolves within a few minutes and should not be a cause for alarm
  • Brow ptosis – This can be avoided by performing superficial injections to avoid weakening of the frontalis and orbicularis muscle fibers.
  • Blepharoptosis – This can be avoided by injecting at least 3–4cm above the bony orbital rim.
  • Sharp pain during injection – This can occur when the needle impinge on the bone. Always inject within the muscle while avoiding the frontal bone.

When should my patient return?

The effects of botulinum toxin typically last for 3 to 6 months, although a unique case has been reported lasting for 12 months.5 Successful clinical therapies yield consistently high patient satisfaction through the years.

Before and after treatment

Gradual reduction in function of the underlying glabellar complex muscles is experienced by the third day. Maximal reduction is noticeable within 14 days, and dynamic frown lines are greatly reduced after a month. Muscle function slowly returns 3 to 4 months post-injection. Patients can avoid returning to their pretreatment appearance by getting repeat injection when muscle contraction resumes or facial fine lines become visible. After years of having subsequent multiple injections, treatment intervals can be prolonged beyond 3 to 4 months.