ORIGINAL ARTICLE
Modifications of Eyebrow Position
With Botulinum Exotoxin A
Mimi S. Kokoska, MD; Jason B. Amato, MD; Christopher S. Hollenbeak, PhD; Dee Anna Glaser, MD
Objective: To determine if clinically used botulinum Results: In 29 patients at rest, we found no significant
exotoxin A (Botox) injections to the forehead and gla- (P value range, .17 to .97) change in eyebrow position,
bellar and crow s-feet regions result in modifications of except for a point depression at the right lateral eye-
eyebrow position. brow. The 15 patients who received injections into the
forehead and glabella, with or without treatment of the
Design: Prospective study. crow s-feet, had no significant (P value range, .11 to .84)
change in eyebrow position, except for a point of depres-
Setting: Academic medical center in St Louis, Mo. sion at the left medial eyebrow. Both groups exhibited
eyebrow depression in the active state (eyebrow maxi-
Subjects: Twenty-nine adult patients treated with botu- mally elevated).
linum exotoxin A injections for rhytids.
Conclusions: Botulinum exotoxin A injections into the
Intervention: The eyebrow position at 13 different sites forehead and glabellar, and crow s-feet regions did not
was measured before injection and 2 weeks after treat- significantly change the resting eyebrow position. How-
ment. The areas injected were based on patient prefer- ever, forehead injections contributed to eyebrow depres-
ence and physician assessment. Of the 29 patients, 14 re- sion in the active state.
ceived injections into the glabella only and 15 received
injections into the glabella and forehead, with or with-
out treatment of the crow s-feet. Arch Facial Plast Surg. 2002;4:244-247
SE OF botulinum exo- of the face were enrolled into our study, and
informed consent was obtained. There were 2
toxin A (Botox; Allergan,
male and 27 female patients (age range, 28-73
Inc, Irvine, Calif) has been
years). Fourteen of these patients received
well described for the cos-
injections into the glabella only, and 15 re-
Umetic treatment of hyper-
ceived injections into the glabella and the fore-
functional facial rhytids.1-3 For the upper
head, with or without injection into the crow s-
third of the face, the drug is commonly used
feet region. Selection of treated areas was based
to paralyze muscles causing glabellar frown
on patient preference, along with physician rec-
lines, horizontal forehead furrows, and lat-
ommendations. Measurements were taken be-
eral orbital crow s-feet. Reversing the age- fore injection and 2 weeks after injection.
associated ptosis of the eyebrow, tradition- Thirteen measurements were taken with
the eyelids closed and the eyebrow relaxed, and
ally done using a surgical approach, gives
again in the active state, with the eyebrow maxi-
a youthful result that is cosmetically desir-
mally elevated (Figure 1). Vertical measure-
able. Other articles4-6 that have examined the
ments A, B, and C were taken from the upper
effects ofbotulinumexotoxin Aon eyebrow
eyelid margin to the upper eyebrow margin at
position imply that it is possible to create a
the lateral canthus, the mid eyelid line, and the
chemical eyebrow-lift with selective use of
medial canthus, respectively. Vertical measure-
From the Department of
the medication. Some of the injections in
ments D, E, and F were taken from the upper
Otolaryngology Head and
these previous studies were purposefully
eyebrow margin to the hairline at the lateral
Neck Surgery, Indiana
placedtoproduceeyebrowelevation.Inthis
canthus, the mid pupillary line, and the me-
University School of Medicine,
study,ourobjectivewastodetermineifmodi-
dial canthus, respectively. The intereyebrow
Indianapolis (Dr Kokoska); the
ficationsineyebrowpositionoccurwithclini- distance was also measured. Subscripts R and
Department of Dermatology,
Saint Louis University Health cally used botulinum exotoxin A injections L denote the right and left sides of the face, re-
Sciences Center, St Louis, Mo
forhyperfunctionalfacialrhytidsofthefore- spectively.
(Drs Amato and Glaser); and Botulinum exotoxin A was prepared by di-
head and glabellar, and crow s-feet regions.
the Department of Surgery, luting a 100-U vial with 2.0 mL of sterile pre-
Graduate Health servative-free isotonic sodium chloride solu-
METHODS
Administration Program, tion for a final concentration of 5 U/0.1 mL. A
The Pennsylvania State Twenty-nine adult patients who presented to 1.0-mL tuberculin syringe and a 30-gauge
University College of Medicine, Saint Louis University Hospital for botuli- needle were used for percutaneous injections
Hershey, Pa (Dr Hollenbeak). num exotoxin A injections into the upper third into the muscular layer.
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DR ER FR FL EL DL
AR BR CR CL BL AL
Figure 1. Measurements taken in the relaxed position and then with maximal Figure 3. All 29 patients at rest, showing no change except for a right lateral
eyebrow elevation. Vertical measurements A, B, and C were taken from the eyebrow elevation (arrow).
upper eyelid margin to the upper eyebrow margin at the lateral canthus, the
mid eyelid line, and the medial canthus, respectively. Vertical measurements
D, E, and F were taken from the upper eyebrow margin to the hairline at the
lateral canthus, the mid pupillary line, and the medial canthus, respectively.
Subscripts R and L denote the right and left sides of the face, respectively.
Figure 4. The 15 patients who received injections into the forehead and
glabella had only a left medial eyebrow depression (arrow).
RESULTS
Figure 2. Standardized injection sites (diamonds).
We first tested whether modifications in eyebrow posi-
Botulinum exotoxin A injection doses and sites were se-
tion could be detected for resting positions. In all 29 pa-
lected based on the typical injections used for treatment of the
tients at rest, only the right lateral eyebrow elevation (po-
upper third of the face in our practice (Figure 2). For treat-
sition AR in Figure 1) was significant (mean, -1.34 mm;
ment of the forehead, 5 injection sites were used, with4Uper
P=.006) (Figure 3). There was no significant (P value
injection, for a total of 20 U. Three 5-U injections were used
range, .17 to .97) change in intereyebrow or other eye-
to treat the glabella, for a total of 15 U. Each lateral orbital re-
brow distances. In the subsample of 15 patients who re-
gion was injected at 2 sites, with 4 U each, for a total of 16 U to
treat the bilateral crow s-feet regions. ceived injections into the forehead and glabella, with or with-
Statistical analyses were performed using SAS statistical soft- out treatment of the crow s-feet, the left medial eyebrow
ware, version 6.12 (SAS Institute Inc, Cary, NC). Observations
(position FL in Figure 1) was significantly depressed (mean,
were paired measurements of the distance before and after treat-
-1.87 mm; P=.03) (Figure 4). No other significant (P value
ment with botulinum exotoxin A; therefore, we used a paired t
range, .11 to .84) changes were found in other eyebrow po-
test in our statistical analysis.7 Posttreatment measurements were
sitions or in the intereyebrow distance. A separate analy-
subtracted from pretreatment measurements, and the average dif-
sis of the 14 patients who received glabellar injections with-
ference was tested using a null hypothesis that the average dif-
out forehead injections produced no significant (P value
ference was 0. We performed one statistical test for each of the
range, .18 to .73) changes in eyebrow position.
13 sites for the entire sample and for the subsample of 15 pa-
We did find significant (P value range, .001 to .01)
tients who received injections into the forehead and the glabella.
Results were considered significant if P .05. changes in eyebrow position for the active state, with the
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This results in an improved cosmetic appearance.8 The pri-
mary functional upper facial rhytids include the glabellar
frown lines, the horizontal forehead furrows, and the crow s-
feet. The medial frontalis, the procerus, the corrugator su-
percilii, and the medial orbicularis oculi muscles contrib-
ute to the glabellar frown lines. Contraction of the frontalis
muscle causes the horizontal forehead furrows, and con-
traction of the lateral orbital portion of the orbicularis oculi
muscles results in the crow s-feet rhytids.9
Eyebrow position is determined by underlying skel-
etal shape, resting muscular tone, and overlying skin
tone. It is generally accepted that the eyebrow is elevated
by the frontalis muscle and depressed by the procerus,
the corrugator supercilii, and the orbicularis oculi
muscles.1
In their retrospective study of 29 patients injected
with 20 U of botulinum exotoxin A into the procerus and
corrugator supercilii muscles, Frankel and Kamer5 found
Figure 5. All 29 patients with maximal elevation, showing a depression of
that 8 (32%) of 25 patients had an elevation of the me-
the medial two thirds of the eyebrow (arrows).
dial eyebrow, 12 (48%) of 25 patients had an elevation
at the mid pupillary eyebrow, and 17 (59%) of the 29 pa-
tients had an increase in intereyebrow distance with mea-
surements from standardized photographs. A subjec-
tive comparison of the photographs by blinded observers
found that 18 (62%) of the 29 patients have a higher me-
dial eyebrow. Although this is not stated in their article,
further interpretation of their results suggests that 17
(68%) of their 25 patients had either a depression or no
change in medial eyebrow position, 13 (52%) of the 25
patients had either a depression or no change in mid pu-
pillary eyebrow position, and 12 (41%) of the 29 pa-
tients had either a depression or no change in intereye-
brow distance. Huilgol et al4 reported that 5 of 7 women
showed an eyebrow elevation of 1 to 3 mm with selec-
tive botulinum exotoxin A treatment of the eyebrow de-
pressors. They injected a total of 10 to 14 U into the gla-
bellar region and the supralateral eyebrow, and measured
from the mid pupillary line to the lowest portion of
the eyebrow to make this determination. One difference
Figure 6. The 15 patients who received injections into the forehead and
from the present study is that the subjects in the study
glabella in the active position had a depression of the entire eyebrow
by Huilgol et al received lateral eyebrow injections. No
(arrows), except at the right lateral eyebrow position.
statistical analysis was performed in either of these stud-
ies; therefore, the results should be interpreted with this
eyebrow maximally elevated. For the 29 patients in the in mind.
active position, the medial two thirds of the eyebrow (po- Ahn et al6 examined subjects with only injections
sitions B, C, E, and F in Figure 1) were depressed to the supralateral eyebrow. The purpose of the injec-
(Figure 5). The numbers were bilaterally consistent, with tions was to produce an eyebrow-lift, not to treat rhytids.
absolute means ranging from 1.93 to 7.86 and P values No injections were performed in the crow s-feet area in-
ranging from .01 to .001. The subsample of 15 pa- ferior to the lateral canthus. There was significant lat-
tients also had a depression of the entire eyebrow in the eral and mid eyebrow elevation after supralateral eye-
active position at all sites shown in Figure 1, except site brow injection. The injection sites differ significantly from
AR (Figure 6). Again, the effects were bilaterally con- those in the present study; therefore, no direct compari-
sistent, with absolute means ranging from 2.93 to 11.53 sons can be made.
mm (P value range, .001 to .01). In our study, eyebrow position was assessed after
injections of botulinum exotoxin A for cosmetic treat-
ment of hyperfunctional facial rhytids on the upper third
COMMENT
of the face. The 29 patients at rest had no statistically sig-
Functional facial rhytids result from tension of the under- nificant change in eyebrow position after injection, ex-
lying mimetic facial musculature on the overlying skin. cept in the right lateral eyebrow measurement. These same
Botulinum exotoxin A acts as a peripheral neuromuscular patients had a depression of the medial two thirds of the
blockade and, thus, weakens the underlying muscles of fa- eyebrow in the active position. This change can be ex-
cial expression, causing a flattening of the overlying skin. plained by the toxin s effect on the frontalis muscle, the
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only eyebrow elevator. In patients who received injec- feet (lateral orbicularis oculi), injections did not
tions into the forehead and the glabella, with or without significantly change resting eyebrow positions. Fore-
crow s-feet injections, there was no significant change in head injections resulted in depression of the eyebrow in
eyebrow position at rest, except for the left medial eye- the active state. This translates into a decreased ability
brow measurement. These patients also had a depres- for upward excursion of the eyebrow after injection into
sion of the eyebrow in the active eyebrow-raising posi- the forehead.
tion 2 weeks after injection, also explained by the Our findings are important for patient counseling
botulinum exotoxin A effect on the frontalis muscle. before injection with botulinum exotoxin A. While it may
These results can be correlated with facial anatomi- be possible to modify the eyebrow with botulinum exo-
cal features. The corrugator supercilii muscle is situated toxin A injections, the resultant modification of the eye-
in a horizontal or diagonal plane. The procerus is a ver- brow position in the relaxed state is not consistently pre-
tical muscle, and the orbicularis oculi is a circumferen- dictable. When treating the forehead for rhytids, the
tial muscle. These eyebrow depressors, however, are rela- physician should modify the injections in a patient with
tively smaller in muscle mass than the frontalis muscle a ptotic eyebrow to avoid further lowering of the eye-
and, therefore, in most patients, contribute less to eye- brow in the extended position. In other words, patients
brow elevation or depression than the frontalis muscle. who constantly and actively raise their eyebrows will likely
The frontalis muscle inserts into the skin of the eye- be perceived as having eyebrow ptosis after botulinum
brows and the nasal root.10 Therefore, botulinum exo- exotoxin A injections to the frontalis muscle, because their
toxin A injections at the eyebrow level will likely affect eyebrows will be relatively depressed. It is helpful in the
the most inferior portion of the frontalis muscle, in ad- pretreatment patient consultation to manually lift or de-
dition to the corrugator supercilii muscles. This relation- press the patient s eyebrows to demonstrate the possible
ship may explain the lack of eyebrow elevation with in- modification in eyebrow position and the varying de-
jections into the medial eyebrow area. The horizontal or grees of resultant upper eyelid skin redundancy. This pro-
oblique orientation of the corrugator supercilii muscle vides the patient with a better understanding of the pos-
explains its dominant role in eyebrow medialization and sible aesthetic changes in the upper third of the face after
its more minor role as an eyebrow depressor, creating the botulinum exotoxin A injection.
vertical wrinkles at the glabella. The 2 sites that showed This study suggests that botulinum exotoxin A in-
a statistically significant change at rest, the right lateral jections to the upper third of the face do not universally
eyebrow and the left medial eyebrow, may change with lift the eyebrows. Based on this study and our review of
a larger sample size. the literature, botulinum exotoxin A may result in eye-
We found that it was more difficult to measure from brow depression, eyebrow elevation, or no change in eye-
the eyebrow to the hairline than from the eyebrow to the brow position. The resultant effect on the eyebrows is
closed eyelid margin. The exact margin of the hairline likely multifactorial, including the site(s) and dosage of
was sometimes ambiguous and more difficult to repro- injections, the extent of muscular paralysis, the state of
duce at the 2-week follow-up. Despite this, the eyebrow- muscle activity, and individual anatomical variations.
to-hairline measurements were generally confirmatory
with respect to eyebrow position.
Accepted for publication January 8, 2002.
A subpopulation of subjects in this study (n=10) who
Corresponding author: Mimi S. Kokoska, MD, Depart-
were classified as hypertonic (defined in the pretreat- ment of Otolaryngology Head and Neck Surgery, Indiana
ment consultation as having clinically constant corru- University School of Medicine, 550 N University Blvd, Room
gator and/or frontalis muscle contraction) were not sig- 3170, Indianapolis, IN 46202.
nificantly different from the general population. This may
be secondary to the small numbers in the subpopula-
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