Male Botox injection patterns: forehead, frown lines and crow’s feet
Many men now visit clinics for medical aesthetic procedures, including anti-wrinkle treatments with botulinum toxins or Botox®, but can you treat men and women the same when it comes to achieving great results with these neurotoxins? The short answer is no, keep reading to find out why.
In this blog, Dr Tim Pearce will discuss the injection patterns required for treating the male forehead with botulinum toxin, including treating frown lines and crow’s feet, and how to inject men successfully without feminising their faces.
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How to treat the male forehead with Botox
Treating the frontalis is the trickiest muscle in men – in masculine faces, it often goes higher up, more superiorly and laterally into the hairline, and is stronger than in females. This can become a problem if you treat a male patient with a feminine injection pattern because you will get additional movement, high up, near the hairline, and they will return to your clinic wanting a follow-up and retreatment.
When marking your patient and approaching the treatment, from a safety perspective, it is worth marking out the areas where you do not want to inject, such as the inferior margin of the area where you will inject, leaving approximately a two-centimetre margin from the eyebrows. Similarly, it is helpful to consider and mark where the lines and wrinkles appear on animation, and the aponeurosis, where there is minimal movement, as you would be wasting valuable botulinum toxin placing it in the aponeurosis.
This leaves you with a smaller area on which to focus your attention, to decide where to inject, whilst considering how far botulinum toxin diffuses from the injection point. The rule of thumb for this is approximately 1.5cm – the diameter of a marble – thus you can space out your injection points to fill the frontalis with marble-sized areas of diffusion. To make it easier to space them out, choose your first medial injection point and then your most lateral injection point, bearing in mind this spread of the toxin. This will make it easier and clearer to decide where to place the rest of your injection points between those two extremes. If in doubt, place one more superiorly as it is a very safe place to treat.
Men who get lines and wrinkles higher up after a procedure will often refer to them as ‘horns’. This manifestation is why we need to treat effectively on the first pass with the botulinum toxin, and this is true even if the muscle is not that strong to begin with because it tends to increase in activity after a procedure during which it has not been treated.
Treating the forehead, although technically the most difficult area to plan, is the simplest area to inject. This is because there is only the frontalis muscle nearby – were have skin, hypodermis, fascia, muscle (which we want to target), loose areolar connective tissue, and bone. The botulinum toxin injections are effective in all these layers, although probably most effective when placed directly into the muscle or underneath it. Dr Tim aims to inject into the muscle because he does not like touching on bone with the needle tip due to the blunting effect this will have on the needle for subsequent injections, causing additional pain for patients. Injecting into the dermis is also more painful and less effective.
With experience, you become more familiar with estimating the depth of the muscle as the needle penetrates through the skin and hypodermis and into the muscle itself.
For a man wanting a relatively natural result, two units of Botox in all these areas is sufficient, although Dr Tim notes that some licenses for botulinum toxin brands now include much higher doses of four units per injection point.
How to treat crow’s feet in men with Botox
When assessing the orbicularis oculi muscle, Dr Tim starts by looking for the thickest part of the muscle which tends to follow the trajectory of the eyebrow. The orbicularis oculi is an accessory muscle for cheek elevation, thus this is not a muscle that you should completely neutralise to remove wrinkles around the eyes or the face will look heavy or sad when the man is not smiling, i.e. having a drawn look.
For this reason, Dr Tim makes a small adjustment when marking the muscles and uses lower doses of botulinum toxin lower down. The key to injecting the orbicularis oculi muscle, to avoid potential side effects, including bruising, is to stay superficial. The skin is very thin, so injections need only go 1-2mm beneath to pass through the skin and fat until resting just above the orbicularis oculi muscle.
It is particularly important to be accurate when injecting in the inferior part where the risk of affecting zygomaticus major is at its highest.
How to treat frown lines in men with Botox
With male patients, Dr Tim uses a seven-point injection strategy for the glabellar area, this is designed to minimise movement. It is acceptable to use a five-point or even a three-point option if you do not mind a little bit of lateral movement. The downside of using fewer injection points is this lateral pull which some patients do not like, so you must discuss it with them, and choose the best treatment plan together.
The goal when injecting the glabellar complex is to reduce the risk of botulinum toxin making its way into the orbit and affecting the levator palpebrae muscle (which maintains the eyelid positioning), and to avoid treating the frontalis which overlaps with the corrugator.
Dr Tim avoids these concerns by injecting at the correct depth, plus applying compression during injection is a simple way of reducing the risk – place your finger inferior to the eyebrow compressing on the superior aspect of the orbit and angle the needle so that it is pointing away from the orbit. Aim for a deep point underneath the mark placed on the forehead, do not penetrate through the mark left by the pencil as this can cause accidental tattooing.
The corrugator muscle is deep medially, intermediate at the intermediate injection point, and superficial laterally as you work across with your injections (three on each side and one in procerus for the seven-point strategy). Injections should be deep medially, in this case depositing four units of Botox, although Dr Tim would commonly use six units in a man if he knew they required a higher dose. As you move more laterally, the muscle becomes more superficial as it traverses, thus the final injection point is the most lateral and requires one to two units.
It is important to be accurate and understand that staying medial to the mid-pupillary line when injecting the corrugators may decrease the chance of affecting the frontalis muscle which is vulnerable to causing eyebrow asymmetry, heaviness, or eyebrow ptosis. Treating the procerus is the easiest and safest injection in this sequence.
For more guidance on the best botulinum toxin injection patterns for treating men with strong muscles, why not get your hands on Dr Tim Pearce’s 26 Essential Injection Patterns for Botulinum Toxin, a handy electronic guide to keep in your clinic. His eLearning Foundation course for Botulinum Toxin in Aesthetic Medicine also includes a bonus module on treating the male forehead.
You can find Dr Tim Pearce on Instagram if you have a question on Botox treatments that you want him to answer, or if you have any other burning questions or comments about aesthetic practice..
Aesthetics Mastery Show
Botox Tutorial For Men | Botox Injection Patterns | Forehead, Corrugators & Crows Feet
To find out more, watch the Aesthetics Mastery Show, where Dr Tim shares a full tutorial on how he injects male patients to achieve great results.
BOTOX® & Dermal Fillers Foundation Courses
One way in which practitioners can improve their skills and confidence is to invest in further training resources. If you’re a medically qualified aesthetic clinician, then eLearning courses could be a great way to support your learning. Dr Tim Pearce’s foundation courses provide essential knowledge which you can refer to again and again. Find out more about the courses together with a list of modules at:
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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.
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