Respecting upper facial anatomy for treating the glabella with neuromodulators to avoid medial brow ptosis—A refined 3‐point injection technique

Abstract

Background: Current injection algorithms for treating the glabella rely on a five-or seven-point injection technique with possible medial eyebrow ptosis and lateral eyebrow elevation as undesirable outcomes.Objective: The objective of this study was to investigate the efficacy and safety profile of a refined 3-point injection technique targeting horizontal and vertical glabellar lines.Methods: A total of n=105 patients (27 males and 78 females) with a mean age of 40.90 ± 9.2 years were investigated. The injection technique relied on targeting the muscular origin of the procerus and the corrugator supercilii muscles exclusively. The time of effect onset and the injection-related outcome 120 days after the treatment was evaluated using the 5-point glabellar line severity scale. Results:The onset of the neuromodulator effect was on average 3.5 ± 1.5 days. There was no statistically significant difference in the amplitude of movement before or 14 days after the treatment with 2.99 ± 4.4 mm vs. 3.39 ± 3.6 mm (p = 0.149) for the medial head of the eyebrow and with 3.18 ± 4.7 mm vs. 3.33 ± 4.3 mm (p = 0.510) for the lateral head of the eyebrow, respectively. Conclusion:Incorporating anatomic concepts into clinical practice for glabellar frown line neuromodulator treatments with the investigated 3-point injection technique resulted in the absence of adverse events like eyebrow ptosis, upper eyelid ptosis, medial eyebrow ptosis, and lateral frontalis hyperactivity. This technique demonstrated efficacy throughout the 4-month study period. K E Y W O R D S abobotulinum toxin, corrugator supercilii muscle, glabellar frown lines, incobotulinum toxin, onabotulinum toxin, procerus muscle How to cite this article: Cotofana S, Pedraza AP, Kaufman J, et al. Respecting upper facial anatomy for treating the glabella with neuromodulators to avoid medial brow ptosis-A refined 3-point injection technique.

Injection technique of the upper face with onabotulinumtoxinA in chronic migraine

“…The muscle courses laterally and cranially to insert in the middle of the skin of the eyebrow with two slips of muscle, one vertical and one transverse, which pass through fibers of the frontalis to reach the dermis. 23 The corrugator muscle is partially blended with the orbicularis oculi. It depresses the brow and pulls it medially and inferiorly, which can cause vertical wrinkle lines in the skin between the brows.…”

“…Recent facial anatomic research findings accurately estimate the underlying muscular anatomy from skin surface landmarks. These findings 23,[27][28][29] shape onabotulinumtoxinA treatment algorithms in the following ways: The procerus muscle is targeted with one single injection in the midline at the level of the line connecting left and right medial canthal ligaments. This injection is performed perpendicular to the surface of the nasal bone.…”

“…No lateral injection points are performed according to this paradigm. 23 This unique technique relies exclusively on targeting the origins of the muscles responsible for glabellar frown lines with a limited risk of medial brow ptosis.…”

“…This originates from the superciliary arch of the frontal bone ~0.5 cm lateral to the midline. The muscle courses laterally and cranially to insert in the middle of the skin of the eyebrow with two slips of muscle, one vertical and one transverse, which pass through fibers of the frontalis to reach the dermis 23 . The corrugator muscle is partially blended with the orbicularis oculi.…”

“…The bony origin of the procerus muscle is in the midline of the nasal bone. Its insertion is the dermis at the level of the upper margin of the medial heads of the eyebrows 23 . The muscle determines the position of the medial eyebrows and balances the action of the eyebrow‐elevating frontalis muscle 23 .…”