Optimizing Outcomes When Treating Glabellar Lines

Practitioners have been utilizing botulinum toxin type A (BoNTA) to treat glabellar lines for more than 20 years. Treatment typically entails a traditional 5-point injection pattern that is intended to target the glabellar muscles (procerus and corrugator supercilii) responsible for wrinkle formation. Historically, practitioners have been taught to place the corrugator supercilii injections 1 cm or more above the eyebrow, presumably to avoid the levator palpebrae superioris and adverse outcomes such as eyelid ptosis. Although aesthetically pleasing eyebrow outcomes can be achieved when the depressor complex is weakened with BoNTA, injection sites above the eyebrows that do not target the precise location of the corrugator supercilii may in fact unintentionally expose the frontalis to BoNTA.1 As the only levator of the eyebrows, inadvertent weakening of the frontalis by exposure to BoNTA may cause unwanted or adverse eyebrow outcomes. Each of the participants in this panel has had many years of experience employing botulinum toxins to treat patients with facial lines. In this roundtable discussion, the participants discuss how recent advances in the understanding of facial anatomy have led to improvements in injection technique, and how individual variation in facial musculature can affect aesthetic outcomes for patients with glabellar lines (Video). Watch now at http://academic.oup.com/asjopenforum/article-lookup/doi/10.1093/asj/sjad087 The panel starts by discussing the current understanding of facial anatomy and the importance of the interplay between the frontalis and the procerus and corrugator supercilii muscles when treating the glabellar region. The key takeaways are that the lower region of the frontalis muscle interdigitates with the upper region of the procerus and that the corrugator supercilii originate far lower than has been taught historically, below the superciliary arch, deep on the orbital rim, and extend laterally up toward the underside of the dermis, rarely above the upper margin of the eyebrow.2,3 Because no 2 patients are the same and because muscle location is not symmetrical, it is important to be able to identify and accurately target the procerus and corrugator supercilii to avoid unintentionally exposing the lower frontalis to BoNTA. Recent experience with the use of the traditional 5-point glabellar lines injection pattern in clinical trials for daxibotulinumtoxinA-lanm for injection (DAXXIFY; Revance Therapeutics, Inc., Nashville, TN) revealed subtle differences in each investigator's injection technique that had an impact on aesthetic outcomes and on duration of efficacy.4 This analysis showed that injection sites that targeted the precise locations of the procerus and corrugator supercilii muscles (ie, that were placed deep into the lower region of the procerus, deep into the inferomedial region of the corrugator supercilii, and placed superficially just above the lateral extent of the corrugator supercilii in the midpupillary line or slightly lateral from the midpupillary line) resulted in optimal aesthetic brow outcomes. In contrast, injection sites that were more aligned with the traditional 5-point pattern (ie, placed superior to the medial and lateral corrugators or superior to the procerus) and therefore inadvertently targeted the frontalis were more likely to result in less optimal aesthetic outcomes. These suboptimal outcomes included a drop in the medial eyebrow and an unbalanced elevation of the lateral eyebrow and were not observed with the more precise injection technique. Although glabellar line treatment may appear simple, there is now an anatomical justification for a careful and detailed integrated assessment that includes the upper facial muscles and eyebrow position before treatment.5 The frontalis muscle is a major contributor to aesthetic outcomes during glabellar line treatment, and it varies substantially among individuals in depth, shape, and muscle fiber orientation. Patients with a nonbifurcated frontalis have an uninterrupted frontalis muscle sheet that produces straight horizontal lines across the forehead on eyebrow elevation. Patients with a bifurcated frontalis typically have a central aponeurosis, which on eyebrow elevation produces wavy-shaped or few to no lines in the central forehead. These patients are thought to be at higher risk of adverse outcomes with glabellar line treatment because they have little to no central frontalis muscle activity to oppose the downward force of the depressor complex. BoNTA injections that are placed too high above the procerus or the medial region of the corrugator supercilii are likely to insufficiently weaken the depressor complex and further weaken the little frontalis activity that is available, resulting in medial eyebrow ptosis.5 Other key factors that place patients at greater risk of adverse outcomes with glabellar line treatment include the presence of preexisting eyelid or eyebrow ptosis, which can be exacerbated by inadvertent weakening of the frontalis by exposure to BoNTA, or preexisting eyelid ptosis that is compensated for by involuntary frontalis activity causing the eyebrow to lift (ie, pseudoptosis). In patients with pseudoptosis, exposure of the frontalis to even small amounts of BoNTA can cause a loss in frontalis compensation, which then releases the upward force on the eyebrow, causing the eyebrow and consequently the eyelid to drop. The panel discusses in detail how to distinguish between patients with true ptosis and pseudoptosis. However, in both cases (true ptosis and pseudoptosis), the risk of adverse aesthetic outcomes can be minimized by a precise injection technique that avoids the frontalis and accurately targets the bulk of the procerus and corrugator supercilii muscles. Finally, the panel discusses injection technique for treatment of upper forehead lines and individual patient factors, including the presence of eyebrow ptosis, that can affect aesthetic outcomes in these patients. This article contains supplemental material located online at www.aestheticsurgeryjournal.com. The authors thank Dr Nowell Solish for moderating the video roundtable. Dr Solish is a clinical investigator and consultant for Allergan Aesthetics, an AbbVie Company (Irvine, CA), Galderma (Lausanne, Switzerland), Merz Aesthetics (Frankfurt, Germany), Croma-Pharma (Leobendorf, Austria), and Revance Therapeutics, Inc. (Nashville, TN); and is a speaker for Allergan Aesthetics and Galderma. Dr Bertucci has been an investigator and consultant for Evolus, Inc. (Newport Beach, CA) and a speaker, investigator, and consultant for Allergan Aesthetics, Galderma, Merz Aesthetics, and Revance Therapeutics, Inc. Dr Green has served as clinical trial investigator for Revance Therapeutics, Allergan Aesthetics, Galderma, and Merz Aesthetics and as a consultant for Revance Therapeutics, Inc., Allergan Aesthetics, Galderma, and Merz Aesthetics. Dr Kane has been a consultant and investigator for Galderma, Merz Aesthetics, and Revance Therapeutics. He is a consultant for Allergan Aesthetics, Alphaeon (Irvine, CA), Teoxane (Geneva, Switzerland), Valeant (Laval, Quebec, Canada), and Premier Pharm (Moscow, Russia). This video roundtable was sponsored by Revance Therapeutics, Inc. (Nashville, TN), manufacturers of DAXXIFY (daxibotulinumtoxinA-lanm for injection). Writing and editorial assistance was provided to the participants by Evidence Scientific Solutions (Philadelphia, PA) and was funded by Revance Therapeutics, Inc. The participants did not receive honoraria or payments from Revance or any third party (including Oxford University Press) for taking part in this activity.

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