October 23, 2023

foundation aesthetics courses

Older patients are more likely to experience side effects from botulinum toxin treatment than younger patients, including brow drop or ptosis, or ‘Spock’ brow, usually caused by error or mistake on the part of the aesthetic clinician who may follow a one-size-fits-all approach.

In this blog, Dr Tim Pearce reviews the common mistakes that are made when treating older patients with Botox, and how you can avoid them to achieve great results for your more mature patients.

For a quick recap, learn facial muscle anatomy for Botox in 10 minutes with another great blog from Dr Tim.

Facial anatomy affects how you treat older and younger patients with Botox

It is vital to understand the important differences in the anatomy when treating older patients to highlight what underpins the different approaches and outcomes between treating older and younger patients with botulinum toxin or Botox.

The biggest difference between the anatomy in older patients versus younger patients is the decrease in fat distribution. Older people tend to lose fat in certain areas of the face, while increasing fat in others, creating different dynamics for muscle movement; combine that with a decrease in collagen and elastin, and it results in problems with support. Effectively, there is a decrease in the natural support of the skin, both underneath in terms of the fat pad, and of the skin itself.

Mistake 1: Not thinking about what happens in the upper face with volume changes as we age

brow muscles anatomyIf you examine the forehead of an older patient, even if they are a little more overweight than average, they often have very little fat in the area so you can see the contour of the forehead. This means that the muscle underneath is unopposed by the fat pad whilst the elasticity of the skin is lower due to ageing.

This presentation will make many of your treatments have a greater effect than you might anticipate, warns Dr Tim, although not necessarily in terms of reducing wrinkles, but rather what happens to the muscle after the treatment.

You can think of this as making the muscle more sensitive to botulinum toxin, even though the skin might be less sensitive to the result.

Mistake 2: Not assessing the wrinkles properly

Dr Tim notes that when healthcare professionals first start in aesthetic practice, they often fall into thinking that botulinum toxin can solve any cosmetic problem, and that might well be somewhat true if you are treating the average patient, which in Dr Tim’s clinic has always been defined a 43-year-old female.

With a woman aged 43, you can usually soften most of their lines and wrinkles within 2 to 4 weeks of treatment. But, if the same patient were to attend your clinic when they were 65 years old, they would have a different result, simply because the lines would be deeper and they may have glycation on the skin or other things causing a change in skin texture that will diminish the result of the Botox.

To decrease the risk of over-promising to your older patients, it is vital that you properly assess and physically check the wrinkles, lines, and creases that concern them. Try and pull apart the line, simply with your fingers, and see how well the skin unfolds. By doing this, you can usually get a good indication of how well the skin will recover when the muscle is relaxed with botulinum toxin, notes Dr Tim. Typically, if the line remains, and particularly if there is a three-dimensional component to it, i.e., you can feel the line even though you are separating it apart with your fingers, you should be very pessimistic (and honest with your patient) in your prediction for botulinum toxin outcomes.

Mistake 3: Not understanding how much more commonplace brow ptosis becomes the older a patient gets

Experiencing a brow drop as a side effect becomes exponentially more common as you get older because of the lack of other tissue supporting the skin.

In a younger patient, you can use a higher dose of botulinum toxin. They usually have much more volume in the upper face, with stronger muscles, and more skin elasticity which means you do not notice a drop or ptosis as easily. Once a patient has lost perhaps bone, muscle, fat, and muscle strength altogether, you may compensate and attempt a lower dose treatment, but you can still find that the brows slump down much more easily than on a younger patient. Learn more about what causes brow ptosis.

Therefore, aesthetic injectors must be much more careful when treating older patients, using smaller doses, more evenly distributed, and avoiding applying licensed doses, which Dr Tim believes would be quite heavy-handed in this cohort and probably explains why there is no license for cosmetic treatment with botulinum toxin in those over the age of 65. Licensing and clinical trials tend to focus on defining a patient cohort who will get the most benefit from treatment. As you move away from this common age group, there is more variability in the results, and often disappointing results or side effects are more likely. This does not mean that you cannot get great results with older patients, it simply gets less likely the older they get.

Mistake 4: Chasing the line rather than understanding the anatomy

Grumpy Face Wrinkles Ageing TreatmentOlder patients naturally have more lines, which means they will come back to see you and ask for top-up treatments in areas where a younger patient would not be asking because they simply do not have the same lines.

For example, a patient may complain about lines that run into the cheek, particularly the inferior part of the cheek. This does not mean that you should treat those lines because they probably do not come from the orbicularis oculi muscle, more likely, they come from the zygomatic muscle. By treating, you will either waste product or worse, end up treating the zygomaticus major and cause a slump in the cheek. Similarly, even if you choose to treat more laterally and inferiorly, and thus not hit the zygomaticus major muscle, it will still affect the SMAS (Superficial Muscular Aponeurotic System) in that area and can create a saggy appearance, warns Dr Tim. You simply must be very careful chasing lines in older patients, he warns because even if you improve the line, it often results in another side effect because muscles support the whole structure of the face.

Another example to illustrate the potential for adverse effects from line chasing is when treating the orbicularis oculi. This is an accessory muscle to cheek elevation. If you look at a person making a broad smile, you will see that the orbicularis oculi muscle is pulling up their cheek. It also smooths over the transition between the cheek and the lower lid junction, creating a smoother contour. As soon as you completely relax that muscle with botulinum toxin, a ‘ledge’ forms but it can also create a rather sad-looking smile because the cheek is no longer being pulled up in the way that it would normally.

Mistake 5: Forgetting that the volume of the muscle is part of what makes people look a certain age

If you shrink the volume of muscle, you can make people look older. Probably the worst illustration of this is if you were to shrink the masseter muscles in an older person. For example, if you perform a masseter reduction procedure with botulinum toxin in a 55-year-old with a slight jowl, unfortunately, what can happen is that the loss of volume allows the whole of the jowl to slip forward causing a new crease or melolabial fold. It is vital to take this into consideration if you are thinking about treating an older patient for bruxism with botulinum toxin.

Dr Tim concludes with a tip to think about the face, as you get older, as a balancing act that gets more and more difficult; the older someone gets the bigger the difference a single unit of Botox can make. As an aesthetic injector, you must create treatment plans more carefully to ensure they have greater variability between patients, allowing for smaller doses, spread out evenly across an area. Start with lower doses when treating older patients, even if the patient believes they need more because they have deeper lines. As the practitioner, you are the expert who knows that underneath the area is a muscle that, if overtreated, can cause a drop, heaviness, or sagginess, but if undertreated, at least you can add more later. Take your time, be more careful, and learn each patient’s face before you build up to your normal doses, advises Dr Tim.

For more insight from Dr Tim, read how to get a great result with Botox in older patients.

For additional guidance on botulinum toxin treatments, download:

If you have any additional questions for him, you can find Dr Tim Pearce on Instagram.

Botox® is a registered trademark of Allergan Aesthetics plc.

Aesthetics Mastery Show

5 Botox Mistakes you’re making on older patients.

Dr Tim says:

“I see many clinicians making the same mistakes when injecting Botox on their older patients. Older patients are more likely to suffer from a spock brow or brow drop, so in this episode I discuss the most common Botox mistakes I see injectors making on older patients AND what to do instead for great patient results”

Watch the full Aesthetics Mastery Show here.

The show has had over 7k views in less than 2 days. It has also generated a number of comments from viewers, including:


“This is great! It would be really helpful to see your mapping technique to match the concepts discussed here when treating older patients”


“My concern with older patients is treating tail of corrugators! I always have them activate prior to injecting, but it still fills me with dread in case it diffuses into frontalis Great video”


“This is great! It would be really helpful to see your mapping technique to match the concepts discussed here when treating older patients

Read more comments and join in the debate on our YouTube channel.

Subscribe to our YouTube channel for really useful regular tips and advice.  YouTube

BOTOX (Botulinum Toxin) eLearning Courses

If you want to increase your confidence in botulinum toxin injections, or learn how to avoid and handle complications, Dr Tim Pearce offers two comprehensive courses that are highly rated by our delegates:

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.

Comment (1)

  1. Patrice Stewart

    Oct 25, 2023

    Great article! Less is more in older patients.

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