April 6, 2023

Dr Tim eye injection anatomy

Treating older patients – those over 55 – with Botox® or botulinum toxin for wrinkle reduction and upper face lifting procedures requires a different approach than when treating a younger cohort, given factors like reduced skin elasticity, volume loss, and weaker muscles.

In this blog, Dr Tim Pearce will share his valuable insights on how to achieve optimal results from botulinum toxin treatments in older patients, including practical advice and tips.

Do you feel anxious about causing complications? Many clinicians feel so overwhelmed with the thought of causing a vascular occlusion that it stops them growing their aesthetics business. Dr Tim is currently hosting a webinar series to help you overcome your fear of complications so that you can uplevel your knowledge, and increase your CPD-certified learning to build a successful aesthetics business. Sign up here >>

Why is treating older patients with botulinum toxin so difficult?

There are several reasons why treating older patients is much trickier, particularly when it comes to lifting eyebrows. As we age, multiple variables change in the face, and everyone is different.

botox-spock-brow-largeSome patients, for example, have hyperactive eyebrows, with lots of movement. Thus, if you carry out a brow lifting procedure with botulinum toxin, they can easily become exaggerated with hyper elevation, resulting in Spock brows or eyebrows like The Joker from Batman. The reason being a lack of fat pads that normally cushion the muscle, leaving it unopposed. As you increase the resting tone of the muscle, without any fat to resist it, it can result in a much more arched eyebrow. However, the real problem with these patients, explains Dr Tim, is if you then try to soften this undesirable look. It can easily result in another problem when you cause a brow drop. Hence, why carrying out eyebrow lifts with botulinum toxin in those classed as older (over 55) is more difficult, but not impossible.

Dr Tim explains that he has had many great results in older patients, but they do become harder to treat. As an aesthetic clinician, you need to learn and understand the variations in anatomy with this cohort and the differences that occur with ageing and volumetric changes in the face.

Some people will have excess fat pads as they get older, others get much thinner, and both are very different to treat. He believes that it is probably easier to treat patients who have excess fat pads because this will simply manifest as a slightly disappointing result, whereas with patients with very little fat in their face, you can cause quite shocking results that will have others talking about them negatively!

How to approach treating older patients with botulinum toxin

In an older patient where you do not believe you can achieve much of an eyebrow lift; honesty is usually the best policy. You may not get a great eyebrow lift, but you can use the injection patterns that should cause an eyebrow lift, and it will likely soften some of the lines whilst creating a very small lift. The good news being that there is no real risk of causing too much eyebrow arching.

The other type of patient is trickier as it presents a balancing act between too much lift, with very elevated brows, or their brows collapsing, appearing heavy and sad. Both outcomes make patients very unhappy.

As an aesthetic injector, you must learn how to grade eyebrow lifts, and with practice, know that you are leaving a certain amount of the frontalis untreated, to vary the amount of lift, and fade in the impact of the botulinum toxin, particularly around the top of the arches – varying the depth or the strength of the injection relative to the muscle that you want to leave untreated to achieve variations in eyebrow softening. Dr Tim’s SkinViva Training Academy  teaches his delegates on Foundation Botulinum Toxin training courses to use a ‘cat ears’ template when treating the area.

If you have a patient with a larger forehead, making their eyebrows easier to lift, you can draw the ‘cat ears’ all the way to the top of the hairline and place one unit of botulinum toxin (Botox®) lower down in that section. If they still have a very strong muscle, and they have very low facial volume, they might still get too much activity. This is where you learn the little adjustments, for example, you could put two lots of one unit dose injections lower down in the ‘cat ears’ and one at the top to achieve a fading effect, or you could put two units right in the middle of the ‘cat ear’ and allow the spread of the botulinum toxin to change slightly as you get lower down towards the eye.

Dr Tim explains that it comes down to finessing your technique and experience with that area of muscle, taking away just enough so you get a little bit of brow lift, but not so strong that you get the ladder lines.

How to treat an older patient who has hooded eyelids

It is very important to distinguish between actual eyelids versus a brow that is pressing on the same area, says Dr Tim. If they have skin that is connected all the way down to the eyelashes, in one continuous sheet, without a periorbital sulcus, then they will end up with skin that rests on the eyelids linked to the frontalis muscle. In these patients, you might be able to create some brow lift, but they are also particularly prone to experiencing a drop which will make the problem worse, even if only by a millimetre.

There is a cohort of patients with a genuine eyelid drop; with ageing, some patients’ eyelids get heavier. As an aesthetic clinician, you are unlikely to affect that by treating the frontalis, the corrugators, or the orbicularis oculi. There is a chance that you can cause a small lift by treating the orbicularis oculi that is on the eyelid, as you might treat a botulinum toxin-induced eyelid ptosis (some experienced clinicians now perform this – learn more on how to identify and fix eyelid ptosis caused by Botox injections). However, Dr Tim notes that he has never seem this technique used for an age-related eyelid ptosis, although it should work in theory.

Do you need to change the dosage when injecting older patients with botulinum toxin?

Despite ageing, many areas of the face will have a very similar muscle strength, but with different levels of supporting tissue, compared to a younger patient.

Therefore, Dr Tim does not believe that age always make a difference in terms of dosage of botulinum toxin, especially when treating the glabella of a 68-year-old patient compared to a 25-year-old; they will require similar dosages depending on the desired resultant movement.

However, there is a difference when treating the frontalis muscle and potentially the orbicularis oculi because there is less support for the tissues in an older patient.

When you are treating crow’s feet in an older patient, it is very easy to relax the muscle and improve the lines; yet the problem with ageing means the degree of support provided by the muscle relative to other structures, such as the cheek, is higher. The orbicularis oculi muscle supports the cheek in its resting position; thus, if you were to use the same dose in a younger patient, it would make them look older because the tissue in the cheek would descend and sag through lack of support.

This is an important consideration with older patients, warns Dr Tim. There is a point at which the muscle is so much more important for supporting other structures – eyebrows and the cheek – such that you would not want to treat it at all, because despite addressing superficial lines and wrinkles, it will result in a ptosis or drop in other tissue, even with low doses of botulinum toxin. He concludes, if there is no support from other tissue, it is better not to treat, particularly with frontalis and orbicularis oculi.

For more on treating older patients, why not have a read of 10 negative expressions caused by facial ageing, where Dr Tim reviews frown lines, the Omega sign, tear troughs, hypertonic inferomedial orbicularis oculi muscle, the naso-labial snarl, pursed lips, down turned mouth, chin crease and jowls.

You can also download Dr Tim Pearce’s free guide to 26 essential patterns for Botox® for more specific information on product placement when treating with botulinum toxin.

Dr Tim always loves to hear from his followers, so why not drop him a comment on social media if you have further questions on treating an older patient cohort, you can find Dr Tim Pearce on Instagram.


Botox® is a registered trademark of Allergan Aesthetics plc.

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Aesthetics Mastery Show

Botox on older patients – how to get a great result

In this episode, Dr Tim shares valuable insights on achieving optimal Botox results in older patients. He explains how factors like reduced skin elasticity, volume loss, and weaker muscles require a different approach. Dr. Tim offers practical advice on how to successfully achieve a brow lift. Watch the full Aesthetics Mastery Show here.

The show has had great interaction from practitioners and patients with over 27k views since it was released on 16th March. Read their comments, questions and answers on our YouTube channel. You’re welcome to or join in the debate!

BOTOX® / Botulinum Toxin eLearning

One way in which practitioners can improve their skills is to invest in training. If you’re a medically qualified aesthetic clinician, then eLearning courses could be a great way to support your learning. Dr Tim Pearce has created a pair of courses which provide foundation knowledge and complications training for botulinum toxin. Find out more about the courses together with a list of modules at:

Both give CPD and certificates on completion.

In addition, browse our FREE downloadable resources on complications.

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.

Thousands of delegates have benefited from the courses and we’re highly rated on Trustpilot. For more information or to discuss which course is right for you, please get in touch with our friendly team.

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