Best Botox brow lift injection patterns to avoid ptosis and Spock brow

Dr Tim Pearce

March 31, 2022

Have you been wondering how you can upgrade your eyebrow lifting skills?

In this blog, Dr Tim Pearce will share the anatomical principles behind injecting botulinum toxin into the forehead, and the Botox injection patterns that he uses to achieve great eyebrow lifts with beautiful arched eyebrows for his female patients. He will also cover how to achieve that without any of the nasty side effects like ptosis or a Spock brow.

Dr Tim will be discussing more medical aesthetic training tips as part of his upcoming webinar series, so if you’re looking to increase your CPD-certified learning and want to learn more skills to make you a better clinician, then step one is to register for the free webinars by Dr Tim.

Eyebrow lift Botox injection patterns

The above image shows the injection patterns that can be used to create an eyebrow lift with Botox® (botulinum toxin). If you follow these injection points for all your patients, you will achieve a decent brow lift for most of them, however, you will sometimes get bad results – you may lift eyebrows too much in some patients and drop them in others. The reason for this is that every face is different, and Dr Tim reminds us that the Holy Grail of a one-size-fits-all approach just isn’t out there. A patient’s age, sex, muscle strength, eyebrow shape, and desired lifting all play a part in the nuances of their individual face and the treatment plan you must design, just for them.

To do this we must understand the principles or building blocks from which you can appropriately design a treatment plan for any face, and any patient.

The impact of the shape of the female eyebrow on a Botox brow lift

The shape of the ideal female eyebrow is a guiding principle for this treatment as it is mostly performed on women; Botox eyebrows lifts in men are less common as they tend to feminise the face.

The female eyebrow has been well described by artists and should be in harmony with the rest of the facial features. The medial border should be on a line linking the alar base of the nose, the inner canthus, and the head of the brow. The tail of the eyebrow should be on a line from the alar base of the nose, through the lateral canthus and to the end of the tail of the eyebrow. The arch of the eyebrow will typically be on a line running from the alar base of the nose, through the pupil and up to the arch of the brow.

Knowing the position of the arch of the eyebrow is key to knowing which parts of the muscles must be left with movement and strength to lift the eyebrow when you are carrying out an eyebrow lift with botulinum toxin.

Which facial muscles affect eyebrow positioning?

You can divide the upper face into eyebrow elevators and eyebrow depressors. The eyebrow is elevated by the frontalis muscle, upwards and laterally. It is pulled downwards and medially by the corrugator supercilii, and the procerus muscle and the depressor supercilii pull the medial head of the brow down. The orbicularis oculi pull the eyebrow inferior and medially, laterally, and inferior, laterally, medially. The most important being the lateral component.

Understanding the muscles and the different directions of pull over the eyebrow makes it more intuitive to understand how relaxing different muscles, or affecting their resting tone, can affect the balance of forces across the eyebrow and its relative position.

When using botulinum toxin, there are two ways that it can affect the position of the eyebrow. It has been observed that if you relax half of a muscle, the other half increases its resting tone; this is very useful when treating the medial frontalis as it makes the lateral frontalis more active in some cases and is typically where we want to lift the eyebrows. The second is by altering the vector across the eyebrows. Vectors are simply a force with a particular direction and the eyebrow is held in a balanced position by the forces from all the muscles, much like a game of tug-of-war between the elevators and the depressors. As injectors, you have control over how strong the elevators remain and how weak the depressors become, to achieve variations in the degree of lift achievable.

How to perform a Botox eyebrow lift

If we consider the weakest possible eyebrow lift, we can look at a muscle that is involved in restraining the eyebrow and pulling it down, seeking to relax it slightly – the orbicularis oculi. By injecting this muscle, just at the area it pulls the eyebrow down, we can treat the lateral brow. A 4-unit (Botox) injection into the tail of the eyebrow will affect the orbicularis oculi muscle superior and laterally and create a little lift with minimal risk and side effects possible.

This lift could be increased by treating more of the orbicularis oculi muscle, which can be achieved by injecting medially, underneath the eyebrow, typically a 1-unit dose, always very superficially, and underneath the lateral third of the eyebrow. This will enable more lift whilst still creating a natural-looking result.

For more information on why this is low risk when it comes to eyelid ptosis, check out Dr Tim’s video from SkinViva Training where he gave a lecture on eyelid and brow ptosis.

To lift the eyebrow even more, we can utilise the other effect of botulinum toxin to increase the resting tone of the lateral frontalis muscle, by treating the medial frontalis. Dr Tim finds this to be one of the most powerful ways to lift an eyebrow.

Avoiding a Spock brow

A word of caution – typically it is not advisable to treat the frontalis muscle without also treating the glabellar complex because in most patients, although not all, the corrugator and the procerus are sufficiently able to depress the brows, so when you treat the elevator (frontalis) on its own, and the depressors are no longer opposed, a heavy frown may develop, alongside a lateral brow lift, otherwise known as the ‘Spock brow’. Your patient may still end up looking angry, when they are not, even if the brow spocking is avoided. This also occurs if the medial frontalis is over treated, even if the glabellar complex is treated. It all stems from an overall loss of medial support to the brow.

Perform a Botox eyebrow lift with the frontalis muscle

Take the line from the alar base of the nose, through the mid-pupil and the eyebrow arch, and extend it out to the hairline. The frontalis muscle along this line is the area that should be more active for the arch of the eyebrow to be lifted.

However, we do not want ladder lines running all the way up into the forehead which is a side effects of under treatment of the frontalis, thus we need to shape this area of untreated muscle so that it lifts without causing lines.

The line drawn up to the hairline helps with this as you can see the direction of the vector you are trying to increase. Next draw a line from the endpoint to the position of the tail of the eyebrow and a second line from the hairline to a point equidistant to the tail of the brow. This triangular shape is an area where you do not want botulinum toxin to reduce the strength of the lateral frontalis muscle.

There are other areas of the frontalis muscle that we do not want to treat, so they must also be ruled out before treatment planning. To prevent a medial brow ptosis, it is a good idea to leave a good portion of the frontalis muscle active in the lower third. Dr Tim uses a rule of two centimetres from the orbital ridge, drawing a line to create a safety zone of untreated frontalis. Conveniently, very few patients have lines in the lower third of their forehead, so the area can happily be left untreated to provide support to the medial brow.

To ‘save’ and be more efficient with your botulinum toxin usage, it is worth marking out the areas where there is no frontalis muscle within the forehead, so you know you are targeting active muscle, this avoids wasting product on the aponeurosis, for example.

Taking all this into consideration, you should be left with a small area of the frontalis muscle, medially, that is ready for you to treat with Botox, with the areas required to support the medial brow and lift the lateral brow having been excluded from relaxation.

Injection points should be spaced evenly within the target zone, for efficiency, and to optimise the spread of botulinum toxin – with a dose of 1-2 units of Botox, Dr Tim estimates a circumferential spread or effect on the muscle of 1.5cm, about the size of a marble, so spread your injection points accordingly, and maintain symmetry. It is vitally important that your injections are symmetrical laterally, if the face is symmetrical; small changes in the placement of your lateral injections can lead to large changes in the relative size of the untreated muscle meaning that the relative size of lift will be impacted, resulting in asymmetrical eyebrows which are very noticeable.

Upon reviewing your patient after two weeks, if the degree of lift is too much, you can add 1 unit of Botox into the tip of the triangle you created, at the hairline, to soften the look. Similarly, if you only treated the glabella and frontalis at the first appointment, and are looking for additional lift, you can treat the orbicularis oculi at the follow-up. Treating a patient for the first time is a journey for you both, and adjustments are normal as you build up a pattern for their personal eyebrow lift and understand their face, ready for next time.

Be sure to download Dr Tim Pearce’s 26 essential patterns for Botox for more specific information on product placement when treating the forehead and other areas with botulinum toxins, including licensed cosmetic dosing and off-label use for eyebrow lifts.

Learn more about how to manage and avoid Botox complications with Dr Tim’s eLearning courses on botulinum toxin complications mastery.

Aesthetics Mastery Show

Best Botox Eyebrow Lift Injection Patterns, Avoiding Spock Brow & Ptosis

This blog accompanies a popular Aesthetics Mastery Show, where Dr Tim Pearce covers the injection patterns he uses to achieve beautiful arched brows for his patients, without the nasty side effects. He also explains the anatomical principles behind why we should choose certain Botox brow lift injection patterns over others.

Watch the full Aesthetic Mastery Show episode here:

The show has had around over 16k views already and over 50 comments, including:

“Absolutely love the video it is extremely informative and right to the point Dr Tim you are a master injector and explaining things extremely eloquently love love your videos.” – Jennifer  Craig

“Hi Tim! This is a great explanation! For patients wanting a brow lift that have wrinkles above brow arch or were to return with wrinkles above the brow arch, would you hope that 1u at the peak of the cats ear near the hairline would be enough to soften this? Or do they sort of have to choose between lift or wrinkles? Hope that makes sense. I want to be able to lift but of course if everywhere else stops moving their dynamic movement laterally can become more obvious and then they find that a problem.” – Anna H

“What an absolutely brilliant video! Full of information and explained so well Thanks Dr Pearce” – Claire Campbell

We also had some interesting questions such as this:

“Informative as usual, thank you Dr. Pearce! I have had patients come in asking for a brow lift, their previous injector injects higher on the lateral frontalis to “Spock” it a bit. I get concerned that I will inject too high and “Spock” it too much! Have you found a sweet spot that lifts the lateral brow but not a huge spock brow? I know everyone is different, but just wondering if maybe 2cm above the lateral brow is a place to start and then fine tune during follow up?” – Swing Tsang

Dr Tim’s Clinical Advisor replied:

“https://drtimpearce.com/2020/08/18/the-best-tried-and-tested-botox-injection-patterns-and-mistakes-to-avoid/ I have attached a link that may help but in our experience every patient is different. Skin thickness, age of patient etc. We recommend leaving the ‘cats ears’ out and as you have suggested, fine tune in 2 weeks time. What you find for one patient won’t be the same for the next until you really get to know your patient. In time you will learn these little variables and guesstimate it better.”

Visit our YouTube channel to read more and join in the debate!

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Dr Tim Pearce eLearning

Dr Tim Pearce MBChB BSc (Hons) MRCGP founded his eLearning concept in 2016 in order to provide readily accessible BOTOX® and dermal filler online courses for fellow Medical Aesthetics practitioners. His objective was to raise standards within the industry – a principle which remains just as relevant today.

Our exclusive video-led courses are designed to build confidence, knowledge and technique at every stage, working from foundation level to advanced treatments and management of complications.

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