ABSTRACT

Forehead Over-treatment with botulinum toxin results in reduced ability to contract the affected muscle, leading to varying effects, depending on the site of treatment. When the forehead is treated excessively, frontalis muscle activity is diminished, leading to reduced elevator activity, possibly leading to brow ptosis. Thus, although transverse forehead rhytides will be diminished, the overall effect may be to give an appearance of fatigue as the brows rest lower on the face, possibly giving rise to upper eyelid “hooding.” This complication may be avoided by reducing forehead dosing and/or injecting higher up on the forehead with advancing age and in those individuals who have evidence of preexisting brow ptosis. In some cases of prominent pre-existing brow ptosis, it may be best to avoid frontalis treatment altogether. Concomitant treatment of the brow depressors (i.e., the procerus, corrugators, depressor supercilii, and orbicularis oculi lateral to the temporal fusion line) helps to minimize this complication by diminishing the downward pull of the depressors, thus permitting further upward mobility of the brow (3).