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Dr Tim Pearce
The glabella is a commonly injected area for patients in medical aesthetics, used to address the frown or eleven lines in between the brows, but it is not as easy as it seems to get consistent results without causing undesirable side effects.
In this blog, Dr Tim Pearce answers the many questions he gets sent and discusses safety tips, the variations in injection patterns, including male versus female patients, and his top tips for achieving consistently great results in this area.
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The anatomy of the glabella
The anatomy of the glabella for facial aesthetic treatments is about understanding the origin and insertion points of the core muscles being treated with botulinum toxin.
The main muscle is the corrugator supercilii; this muscle runs medially from the nasion (bridge of the nose) all the way up to the insertion point just lateral to the mid pupillary line above the eyebrow. The corrugator (for short) is the muscle pulling inwards, creating the classic eleven creases or frown lines.
Then we must consider the procerus; this muscle pulls the brow down and has its origin on the nasion, running up into the dermis of the forehead.
These two muscles – corrugator supercilii and procerus – are responsible for most of the activity in the glabellar area, but they are not alone, with a third, often debated muscle also playing a role – the depressor supercilii. The depressor supercilii is often described as part of the orbicularis oculi muscle but is sometimes regarded as a separate muscle in itself. For the purposes of botulinum toxin injection placement, it matters little because the depressor supercilii overlaps so closely with where we inject the corrugator supercilii.
Dr Tim notes that all these muscles change plane, starting on the bone and going into the dermis; this is a crucial piece of information for injecting accurately. As aesthetic clinicians, he advises that you do the same with our injections – where the muscle is intermediate, inject at an intermediate depth, and where it is superficial, inject superficially. This also improves your safety.
What are the potential complications when injecting the glabella?
The most important complication you should be aware of is causing an eyelid ptosis. If you affect the levator palpabrae muscle within the eyelid, it is likely to result in a droopy eyelid. This only happens when the injection has been deep, and deep enough for the botulinum toxin to make its way into the orbit of the eye.
The orbit is shielded by multiple structures, the orbital membrane, preseptal fat pads, and muscles, but the depth of injection is key. If you know your anatomy, and you are injecting at the right depth, it should be very rare to get a droopy eyelid.
Read more on this complication, including the eye anatomy to prevent eyelid ptosis from Botox® and learn how to identify and fix eyelid ptosis caused by Botox injections
Another more common complication is treating the frontalis muscle by mistake. The corrugator and the frontalis muscle are intertwined. If you look at the anatomy of the corrugator muscle, as it becomes more superficial, it passes through the frontalis muscle, which means that at the point of insertion – which you can usually see when a patient frowns – above the muscle is frontalis and lateral to the muscle is also frontalis, making it the most sensitive area for a misplaced injection.
If you place botulinum toxin into the frontalis at these crucial points, it is likely to result in an asymmetrical eyebrow – perhaps one side will lift more than the other, or worse, there will be a droopy eyebrow or eyebrow ptosis where the eyebrow slumps downwards and causes an asymmetry at rest, giving a tired appearance which can either be unilateral or bilateral depending on where the frontalis was affected.
Dr Tim warns that other things can go wrong when injectors are ‘aiming for’ the corrugator because you can still affect the frontalis muscle all the way along the path of the corrugator muscle simply because the frontalis is above it. He notes this tends to happen to extremely cautious, newer injectors. When aesthetic clinicians are new to the specialty, they tend to be very wary and want to leave a bit of extra safety margin when injecting, compared with how they were taught in their training. They are usually very afraid of being near the eye, hence, they move a little bit superiorly with their injections, perhaps only by 5mm, but this is enough to mean they will completely miss the corrugator muscle and directly inject the frontalis muscle instead, causing a medial brow drop, often with a lateral brow lift or classic Spock brow complication.
Understand what causes brow ptosis and learn the best Botox brow lift injection patterns to avoid ptosis and Spock brow.
Why do we treat the glabella with botulinum toxin?
The most common reason for patients requesting botulinum toxin treatment in the glabella is because they believe that they look cross when they are not.
This can present as a crease or frown line at rest, or in someone who is a habitual frowner, whether they are angry or not, often noted in younger patients who simply make that expression regularly. Such an expression creates a negative aura on the face, making them appear less approachable in work and social situations and is the underlying driver for seeking treatment. As aesthetic clinicians, we know that once they appear happier, they will be able to collaborate better with others.
What are the typical injection points for treating the glabella with botulinum toxin?
The licensed dose
The licensed dose is usually a spread of equally sized injections of four units – based on Allergan’s Botox® product and those of a similar characteristic. Four units across five injection points – one in the procerus and two into each corrugator. This is a very effective way of completely neutralising the glabella, explains Dr Tim, but notes that you can often get a very similar result, for some patients an even better result, by leaving a little bit of movement with fewer injections.
3-point injection
With a 3-point injection approach, we can inject the procerus with four units and then one injection into the corrugator on either side, usually also four units, but sometimes a bit more. This leaves a bit of lateral movement, which can be a good thing because it looks more natural. Of course, it also means you need less botulinum toxin to create a good result.
Frozen look
For patients who want a completely still (frozen) result with no movement, you can separate the final four-unit injection into a three- and a one-unit dose. In practice, you inject the procerus with four units, then the bulk of the corrugator with four units, followed by a three-unit injection at an intermediate point, and a one-unit injection into the insertion point, or just before the insertion point of the muscle This approach should preclude the patient from returning for a follow-up or top-up treatment because it will achieve the frozen look from the start.
What are the differences between treating the glabella with botulinum toxin in men and women?
In general, there are a lot of similarities and crossovers in approach when treating the glabella with botulinum toxin in male and female patients. However, there are extremes where we see much smaller and weaker glabellas in females and stronger, more muscular glabellas in males.
Dr Tim believes that there is often a difference in the direction of pull with the glabella between the sexes. Many females are more neutral in terms of the angle of the corrugator, whereas more males will pull heavily downwards which may simply be a consequence of the strength of the muscle.
However, overall, the biggest difference from a clinical perspective between treating men and women is the dose of the botulinum toxin required.
There are very few females who are not adequately treated with a 20-unit dose, explains Dr Tim, but you will meet a fair number of men who need 30-40 units to make their muscles completely still. This is particularly true if the male is very muscular and works out in the gym because the growth hormone associated with such activity means they have bulkier muscles that require higher doses.
In practice, and in the UK, where it is commonplace to charge for botulinum toxin treatments by area, you may consider charging men more for treatment because they will likely require more than a 20-unit dose or the equivalent of one area.
Learn more about male Botox injection patterns: forehead, frown lines and crow’s feet.
For additional guidance on botulinum toxin treatments, download Dr Tim Pearce’s 26 essential injection patterns for botulinum toxin and learn more about how to manage and avoid Botox® complications with Dr Tim’s eLearning course for aesthetic practitioners.
Dr Tim is always keen to hear about the experiences of his followers. So, if you have any tips for others or questions for him on botulinum toxin treatments, you can find Dr Tim Pearce on Instagram.
Botox® is a registered trademark of Allergan Aesthetics plc.
Aesthetics Mastery Show
Injecting the glabella. Injection Points & Safety Advice
Dr Tim says:
“The Glabella is a commonly injected area for patients.In this episode I discuss the variations in injection patterns for patients, male vs female injection patterns and my top tips to get a great result in this area.”
Watch the full Aesthetics Mastery Show here.
The show has had nearly 10k views in the first few days. It has also generated some interesting feedback, queries and debate.
@andrevictorrios70
“Thank you for your insights Dr Tim! I often like to leave some movement at the glabella aiming for a more natural result. But sometimes, patients tend to think that i left that movement in order to not spend more toxin. Most dont understand the benefits of leaving that tiny lateral movement.”
@gigicoogler
“I agree in reference to the three point injection points versus the five. I began implementing that following a previous video you did. (At least I’m 99 percent sure it was you). Definitely made a difference and saved a little $ which always helps. oh and much appreciation”
@MissP7197
“Super interesting. Would love to know if you need filler if the ‘elevenses’ are quite deep or can Botox deal with that alone?”
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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.
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