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Chapter 2. Forehead Anatomy

Forehead Anatomy

The forehead muscle is an elevator. Overtreating will result in brow ptosis. The frontalis forms the frontal "belly" of the occipitofrontal muscle.

The frontalis antagonists are the corrugators, procerus, and the orbicularis oculi. Action of the frontalis forms horizontal forehead lines. Classic anatomy typically illustrates the frontalis, shaded in yellow, as 2 distinct muscle bands, separated centrally. However, a common clinical presentation is a broad muscular band with no central separation.

(Adapted with permission from Ipsen.)

The blue oval represents the approximate appropriate injection zone for neurotoxin in this muscle. The red circle labeled "Mephisto treatment" indicates the approximate injection point for correction of cocked eyebrow.

BoNT-A is an effective treatment for horizontal forehead lines and the forehead is often treated in conjunction with the glabella. Injecting BoNT-A into the frontalis can also be used to compensate for brow ptosis. Before initiating the treatment, the practitioner should evaluate the patient's anatomy for expressivity, muscle mass, symmetry, lateral versus medial movement, compensation for brow ptosis, and a narrow or wide brow.

(Video courtesy of Sergio Talarico, MD, Dermatologist, Sao Paulo, Brazil.)
This video is a 3-dimensional animation demonstrating the muscle action of the forehead region.

Forehead Treatment Approach

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

In the illustration, specific injection points, representing a common approach to treatment, are noted as blue circles and optional red Xs. This approach may not be appropriate for all patients and practitioners should use their best judgment based on their experience and patient assessment. Injections restricted to the area between the midpupillary lines may result in the Mephisto sign.

Forehead Case

The treatment goal is to achieve a balance between brow elevation with forehead smoothing.

A Caucasian female in her late 40s has been treated with neurotoxins for years, her last treatment 2 years prior. Previous to her last neurotoxin treatment, she had received filler treatment with hyaluronic acid. Her primary treatment goal is to balance brow elevation with forehead smoothing. She has full upper eyelids and naturally low brows, resulting in deep forehead grooves. She also had a previous episode of brow ptosis due to her crowded upper eyelids. In the video, the patient is seen pre-injection alternating from rest to expression. She has full upper eyelids and naturally low brows, resulting in deep forehead grooves. She also had a previous episode of brow ptosis due to her crowded upper eyelids.

The practitioner's treatment goal was to reduce appearance of horizontal forehead lines in balance with maintaining brow elevation.

Patient was injected at points indicated on the photo by the 2 blue and 4 green circles. Red Xs indicate optional injection points that some practitioners may choose to add to treatment plan. Blue circles represent injections of 5 DYSPORT Units each and green circles represent injections of 2.5 DYSPORT Units each. The total dose was 20 DYSPORT Units. Patient also received concomitant treatment for bilateral crow's feet and glabella at same visit.

Forehead Injection Demonstration

Forehead Results

The patient is seen in the video at rest before and 33 days after DYSPORT treatment (20 DYSPORT Units in total) of the forehead. Patient received DYSPORT treatment for bilateral crow's feet and glabellar lines at the same visit.

The patient's forehead lines are fairly effaced and she now has decent brow position.

In this video, the same patient is shown with raised eyebrows before and 33 days after treatment with DYSPORT. The patient received a total of 20 DYSPORT Units. The patient has relatively normal brow position, and softening of rhytids without dropping of the brows.

Same patient shown alternating her expression from rest to raising her eyebrows, 33 days after treatment with DYSPORT.

Neurotoxin treatment of frontalis can yield very satisfying results, but patients require very careful evaluation to identify any muscle variation, pre-existing brow ptosis, or pre-existing asymmetry. Potential adverse events from neurotoxin treatment of the frontalis includes asymmetry, bruising, swelling, unmasked eyelid ptosis, unwanted elevation of lateral brow.

Forehead Treatment Summary

BoNT-A in the frontalis reduces horizontal forehead lines and can yield very satisfying results. Careful evaluation is required when injecting the frontalis. The practitioner must pay attention to assessment of muscle variation, pre-existing brow ptosis, and pre-existing asymmetry.