Injecting Botox into the frontalis muscle, safety advice

The frontalis muscle is one of the most difficult areas to treat effectively and successfully in the upper face with botulinum toxin (Botox®); but do you know why?

In this blog, Dr Tim Pearce will share his top tips for injecting the frontalis, including the correct injection points, why treating men and women requires a different approach, and how to adjust your dosing for different foreheads.

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Why is the frontalis muscle so difficult to treat with Botox?

The primary reason, according to Dr Tim is that frontalis is one of the few areas where we are constantly trying to balance relaxed and unrelaxed muscle.

This means that there is a requirement to leave the lower area of frontalis active, (more active in females if the aim includes an eyebrow lift), whilst the upper area needs to be treated to achieve some results in reducing the forehead lines – a constant balancing act.

Over treating and under treating can become a real problem for newly qualified aesthetic injectors:

• If you treat too heavily in the middle, and too little at the sides, it can result in a Spock brow.
• If you over treat all the way across, it results in a heaviness across the brow, and you can drop eyebrows very easily.
• If you under treat, it can result in strange movements or spasms to the eyebrows, as well as eyebrow asymmetries, where one eyebrow might lift a centimetre higher than the other.

Other helpful blogs from Dr Tim include the best Botox brow lift injection patterns to avoid ptosis and Spock brow.

The accuracy of your injections in therefore vital – understanding boundaries within the tissue and knowing exactly how much botulinum toxin you can inject for different types of patients to achieve the desired aesthetic result. A significant difference is present between men and women – here we can inject different patterns because men are generally not worried about their inability to move their eyebrows quite as much as women who seek the arched eyebrow as a sign of feminine beauty.

The anatomy of the frontalis muscle

The frontalis muscle is sometimes connected (to the bone) all the way back to the occiput (at the back of the head) and is called the occipital frontalis muscle.

Occasionally, you may see patients who when asked to raise their eyebrows, their scalp also moves. However, in most cases there are enough adhesions that it moves separately to the scalp, thus, such patients are in the minority, but it presents interesting anatomy when we consider that it is one structure that arcs over the back of the head.

If we look at the tissue layers, we can see that it is relatively simple compared to other areas of the face. Starting with the skin on the forehead, there is a thin layer of hypodermic fat, followed by the fascia, the muscle, and the loose areola tissue underneath the muscle.

In some textbooks and clinical papers, the illustrations will also mention the deep frontal fat pads. Dr Tim highlights that sometimes the changes in the fat pads (with ageing) compounds the effect of the muscle and the loss of support which can cause a descent of the eyebrows. Although, in some older patient, the fat pads can cause an elevation of the eyebrows, as they become more dynamic and lift more easily due to the changing fat pads.

There are wide variations between different people’s foreheads (their frontalis muscle) and you see variations both within males and females, but also between the different sexes.

Characteristically male foreheads are larger and have stronger muscles. In particular, the lateral aspect of the frontalis muscles often goes much higher up, towards the scalp, or even into the hairline with men.

This can become a pitfall if, like most aesthetic clinicians, you are more used to treating female faces because they make up most of your patient database. You can get caught out if you do not remember the difference when presented with a male patient. If you only inject the midsection, just as you would a female (but without elevating the eyebrows) and forget that the muscle goes up into the hairline, they will usually return at the two-week review with small extra lines, sometimes called ‘horns’ because you have not treated high enough on the forehead.

For more helpful tips, check out Dr Tim’s male Botox injection patterns: forehead, frown lines and crow’s feet.

The variation in forehead sizes can have an impact on dosing for botulinum toxin. Dr Tim notes that he has male patients where the treatment to the frontalis is probably the equivalent of the doses marketed as two or three areas of botulinum toxin, in terms of units used. This can be very costly and significantly affect your bottom line depending on your pricing model if you do not charge for the extra required. He recommends having this discussion with your patients before embarking on treatment. His approach means that if he needs to use more than 20 units of Botox in the frontalis, this would be charged as a second area and the patient made aware and in agreement.

Variations between patients can be quite significant, and not just between men and women, with some men not requiring a higher dose, which may rule out the need for a blanket levy on all male patients, as is commonplace within the aesthetic sector.

Dr Tim concludes that typically he uses approximately 12 units of Botox, which is on the low end of the scale, most licensed doses for foreheads for both men and women are now approximately 20 units. However, he does not find it necessary to use that much in most of his patients, but it is relevant for a smaller subset who

You must pay attention to the strength of the muscle and the area that is being treated, with each injection being between one and four units, depending on the dose that you are following. Consider the spread of the toxin and mark out your area and dosing before you start. This also allows you to negotiate with your patient depending on their budget and your pricing model once you have marked up the dosing need.

Dr Tim’s top tip if you are unsure is to inject fewer units than you think – a lower dose, such a 1 unit per point in females – and follow up the patient after two weeks. This avoids over treatment which cannot be adjusted and must wear off, an unhappy patient. Take a picture of your injection points to allow you to reflect when your patient comes back – you can see exactly what each injection point achieved and adjust accordingly. This will speed up your learning cycle much faster than using before and after photographs as your only guide. It is critical to make good notes, this will ensure that their next visit it is likely to be a single appo

Do not forget to have a read of Dr Tim’s best tried and tested BOTOX® injection patterns and mistakes to avoid.

If you have any questions or comments about treating the frontalis or the upper face with botulinum toxin, you can find Dr Tim Pearce on Instagram.

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Aesthetics Mastery Show

Injecting the Frontalis | Botox Injection Points & Safety Advice

In this Aesthetics Mastery Show, Dr. Tim shares his tips for injecting the frontalis; including the correct injection points and how to adjust treatment for males and females and also based on forehead size. Watch the full Aesthetics Mastery Show here.

The show has had over 11k views in under a week and of views and a number of comments of appreciation from fellow practitioners plus some queries from patients themselves.

Anna Fantastic 111 said:

“@Dr Tim Pearce , @0:11 , when u injected the botox there is that bump that forms then goes away … I used to get those bumps, but now I do not anymore … I am 55 years old , is it cus of my age , or maybe the “Botox Dilution” is not correct ..”

To which Mary (Dr Tim’s Clinical Advisor) Replied:

“It’s just the product amount within the tissues they either crest a bump if they’re in the more superficial plane or if you find you don’t have a bump it’s been injected a bit deeper. Plus more dehydrated skin will like the hydration. Kind regards Mary. Clinical advisor for Dr Tim”

Saxophonist Br@dley asked:

“my doc charges 12 USD/unit and and doesn’t ever inject less than 50 at a time (always felt this was a bit… strange) BUT he’s the only person I’ve found (out of 3) that will inject my left nasalabial (or trail it, rather) because from years of playing saxaphone my embouchure its overdeveloped and without the trailing it looks very asymmetrical (to me) but I both cannot afford/don’t want to risk getting filler in this area, at least at this point in my life (im 36). The only thing he does that confuses me is he always says he wants to maintain expression (which i understand) but leaves me with two upside down rainbow shapes above and to the side of my brow that i notice after a couple days and I see them disappear within 3 months, but they’re never all that symmetrical and I would rather just have those “wiped out” if thats what he considers expression. I can see how with the nasalabial forehead combo that this could add up to 50 but what’s the best way to explain to him that I don’t want these “expression” arches? I like everything in the results except these two arches because to me they look fake, i’d rather just have it all smoothed out what should I suggest that I want to change?”

Dr Tim himself replied to this, advising:

“Some clinicians worry about causing brow heaviness by treating the arches I think you are describing. I think in most men it’s better to treat- just 1-2 units in the apex of the rainbow I think you are describing is what I would do- but I am not seeing your face, so I cannot give real advice. Just principles you could discuss.”

Read more or join in the debate on our YouTube channel.

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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