‘Tall’ Foreheads and Botox – by Dr. Aicken – Visage Academy

I am often asked questions in regards to Botox treatments. Recently questions around how to treat a “tall” forehead.

Q: 

  1. How do you mark someone with a long forehead?
  2. How do you inject people with wrinkles on the sides of their forehead above their eyebrows? 

A: 

  1. Some practitioners will use two rows of injections for the forehead (frontalis) if the forehead is long/tall. I normally just use one row, as we do on the course.

I start by marking off the frown line injection sites. Note that botox will spread approximately 1-1.5cm from each injection point.

Then I ask the patient to raise their eyebrows. I have found that the vast majority of patients, even those with long foreheads, have their wrinkles take up, in the vertical dimension, a similar 3-5cm in distance. It is normally therefore possible, if placing the forehead injections into the frontalis at the correct height, to use just one row of injections. Whilst my default vertical height for these injections is ‘the top third of the lines when eyebrows are raised, another important consideration is how far the botox will spread from the injection site. A common mistake is giving the injections too high and ‘wasting’ the benefits, as then too much of the potential benefit has gone higher up where the fascia, between the two bellies of the frontalis muscle, is, and botox there has no benefit. A second common mistake is to miss the fact that sometimes, the two bellies of the frontalis may join in such a pattern as to cause a central ‘V’ formation between them. If this is the case, you may get better results by approximating the ‘V’ pattern with your 5-7 forehead injections, rather than sticking to a straight line formation, as works of the majority of my patients. 

2. Regarding the lateral frontalis injections, I have been asked about. My advice is to first assess that the patient does not have natural eyelid ptosis, or at least the eyelid ptosis is not so bad as to risk the slightest bit of worsening of the ptosis to cause temporary blindness to the patient.

Assess the patient with them sitting up and looking straight ahead, with a neutral facial expression. I like to see at least 3mm between their pupil and their upper eyelid in this position because typically, eyelid ptosis with botox doesn’t come down more than 2mm. If the eyelid obscures the pupil(s), of course, their vision will be affected. If this distance is less than 3mm, consider using fine dermal filler injected linearly along the forehead lines, rather than botox to the forehead or frown.

Once you have satisfied yourself regarding that risk, you should consider whether or not lateral forehead injections are required (7, rather than the typical 5 injections). As above, consider that each injection will spread approximately 1-1.5cm from the injection point. If your 4th and 5th forehead injections will ‘cover’ the horizontal forehead lines, then additional lateral injections are not needed and carry an unnecessary extra risk of eyebrows and subsequent eyelid ptosis. If the 4th and 5th injections will not cover those sites fully, then consider the extra lateral injections. I give the same dose as with the other forehead injections. Roughly, the position is at the apex of the curve of the wrinkles or, equidistant along the horizontal place, following on the same pattern from the other 5 injections, depending on the pattern. Typically these points will also coincide with the lateral canthus of each eye in the vertical plane. Often you’ll find yourself in a situation where there is some natural lid ptosis but the patient really wants their lateral forehead lines shifted. If that’s the case, consider a compromise where you give a lower dose and/or inject higher up on the forehead to help mitigate the ptosis risk. In that case, also document carefully, the conversation you have had with the patient where you consent them fully to this risk.

It’s a balance where you aim to soften their lateral frontalis wrinkles without causing noticeable eyelid ptosis. It’s not easy. Remember that consent involves you passing on the risk of the procedure from you to the patient via explanation. It’s their choice, but you need to explain it to them well enough for them to be able to make an informed choice.

Thanks for reading,

Dr. Michael Aicken

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