Chapter 1. Glabella

Glabella Anatomy

The glabella is the most common and popular facial area treated with BoNT-A and the most studied aesthetic application.

In aesthetic cosmetic treatment, experienced clinicians are guided by each patient's individual facial anatomy, pattern of muscle activity, muscle mass and treatment.

Glabella lines are created by the action of 3 muscles:

the corrugator supercilli;
the procerus;
and the depressor superciliis.

The muscles are shaded in yellow in the illustration. The blue ovals represent the approximate appropriate injection area for neurotoxin treatment of the glabella.

(Adapted with permission from Ipsen)

Contracting the corrugator supercilii leads to vertical lines between the eyebrows. Contracting the depressor supercilii will draw the eyebrows down and give a person a menacing expression. Contracting the procerus will induce a horizontal line between the eyebrows.

This video is a 3-dimensional animation demonstrating the muscle action of the glabella region.

(Video courtesy of Sergio Talarico, MD, Dermatologist, Sao Paulo, Brazil.)

For optimal results, aesthetic clinicians individualize dosing and the treatment approach and assess patient musculature. It is important for clinicians to review patient desire. Some patients prefer to have a "softened" not "frozen" look. This is the core basis of static versus dynamic enhancement. Younger patients typically require less aggressive treatment and are looking for prophylaxis instead of correction of deep wrinkles.

Kinetic and hyperkinetic patients are best to treat. Kinetic patients produce glabella wrinkles in their expression of anger or concentration. The lines are usually superficial. Hyperkinetic patients present glabellar lines independently of a willingness to express anger or concentration. The lines are seen in dynamic situations and are deeper.

The illustration represents a "typical" or common approach to neurotoxin treatment consisting of injections into the corrugator and procerus muscles.

(Adapted with permission from de Maio M, Rzany B. Botulinum Toxin in Aesthetic Medicine. Berlin, Springer-Verlag; 2007. )

The aim of treatment is to reduce the vertical as well as the horizontal lines of the glabella.

This approach may not be appropriate for all patients, therefore practitioners should use their best judgment based on their experience and patient assessment.

The typical approach consists of injections into the corrugator (red and blue circles) and procerus (green circle) muscles:

Procerus => 1 injection point
Corrugator => 1 injection point, .5 to 1 cm above the medial orbital rim (total of 2 injections)
Corrugator =>1 lateral injection point, 1 cm above the orbital rim (total of 2 injections).

For the corrugator injections, the patient receives a total of 40 to 60 DYSPORT Units. For the procerus injection, the patient receives 5 to 20 DYSPORT Units. BOTOX Cosmetic and DYSPORT dosing are not interchangeable and unit measurements are unique to each product.

The total dose is distributed over 3 to 5 injection points in the glabella area covering all 3 muscles involved in the formation of the glabellar lines.

In most patients, the first injection point is used to treat the procerus. The 2 most important points for treating the glabella are the injection points in the corrugator muscles, which are located medially about 0.5 to 1.5 cm above the edge of the orbital bone. Two further possible injection points are located laterally following the course of the corrugator over the first 2 points. The injection is done perpendicularly.

Case 1

Glabella Treatment Approach

A thorough patient assessment is an essential step in the development of an individualized treatment plan.

The patient is a 52-year-old female Caucasian, neurotoxin-naïve. Her treatment goal is to achieve a more relaxed appearance and a less angry look. Her practitioner's goal of treatment is to reduce the vertical lines of the glabella. The video shows the patient before treatment, as she alternates from rest to expression. The patient's muscle mass is evaluated as medium-to-large and she has moderate glabellar lines at rest.

The photo illustrates the injection points and suggested dosage during this patient's treatment. The patient is to receive 5 injections of 10 DYSPORT Units each (at blue circles), for a total of 50 DYSPORT Units.

Glabella Injection Demonstration

The treating physician injected this patient while her muscles were relaxed.

A 52-year-old female patient being treated for glabellar lines receives 5 injections of 10 DYSPORT Units each, for total of 50 DYSPORT Units.

The 52-year-old female patient, frowning in both photos, as she looked before and 32 days after treatment of the glabella with DYSPORT.

Glabella Results

The patient received a total of 50 DYSPORT Units. Her glabellar complex is fairly effaced, though she could have used a little more neurotoxin in the right corrugator.

In the photo, the patient is seen from the oblique angle, again frowning in both photos taken 32 days after treatment with DYSPORT.

No longer able to frown very well, and her muscle mass is well effaced. The video presentation shows the patient before and 32 days after treatment alternating expression from rest to frowning.

The photo shows the patient before treatment and 32 days after DYSPORT treatment in the glabella. The patient's muscles are at rest.

Case 2

Glabella Treatment Approach

Achieving a more "relaxed" look in a 33-year-old female. The practitioner's goal for this patient is to reduce the vertical lines of the glabella.

The goal of treatment for this 33-year-old Caucasian female, experienced with aesthetic neurotoxin treatment but not with DYSPORT, is a more relaxed - but not "frozen" - appearance with limited aging in the glabellar area. Her muscle mass is small to medium and she has moderate glabellar lines when she frowns.

Glabella Injection Technique

Once the needle is in the muscle, the product can be delivered to the target very specifically.

The patient received 7.5 DYSPORT Units at each injection site in her other corrugator, plus 10 Units in the procerus. Only 1 injection was done on the left side due to muscle mass needs. The skin puncture is simply a vehicle to place the needle.

At the same visit, the patient received treatment to the frontalis (25 DYSPORT Units total) and bilateral crow's feet (20 DYSPORT Units total).

Holding the skin between fingers for injection reduces pain and allows for exact placement of neurotoxin into the muscle because the injector can feel the exact location of the active muscle.

Glabella Results

The same patient, before and 29 days after treatment with DYSPORT, 25 DYSPORT Units to the frontalis and 20 DYSPORT Units per side for bilateral crow's feet.

Case 3

Neurotoxin-naïve 30-year-old Caucasian female with small muscle mass and a mild frown wants to limit the future signs of aging.

Treatment Approach

The goal of treatment is to gain dynamic relaxation of the glabella and to reduce vertical lines of glabella. The patient required only 3 injection points (blue circles), totaling 10 DYSPORT Units, due to small musculature.

Injection Demonstration

The injector can feel the exact location of the active muscle by holding the skin between the fingers.

Glabella Results

Neurotoxin-naïve 30-year-old patient before and 28 days after glabellar treatment with DYSPORT.

Holding the skin between fingers for injection reduces pain and allows for exact placement of neurotoxin into the muscle because the injector can feel the exact location of the active muscle. Needle is pointed upwards to prevent migration into the eye area.

Glabella Treatment Summary

Younger patients typically require a less aggressive treatment approach and are often looking for prophylaxis instead of correction of deep wrinkles.

In summary, patients should be assessed individually to determine muscle mass, optimal injection sites and variable dosages. Static versus dynamic enhancement is the basis for patient goals and injection technique is linked to clinical outcome.

For each patient, there are different ways to approach rejuvenation. The commonly stated 4 Rs of cosmetic surgery provide an overview of rejuvenation strategies and tactics. The 4 Rs are relax, refill, resurface, and redrape. The goal of using BoNT-A is the first R, to relax muscles.