How to avoid causing a fishhook eyebrow from Botox treatment

Continuing our series of blogs on unwanted dynamic side effects caused by undertreatment or overtreatment of the upper face with botulinum toxin or Botox®, Dr Tim Pearce moves on the fishhook brow. This presentation, caused by undertreatment, is similar to the Spock brow and the S-shaped eyebrow. Despite not being a serious complication, it can significantly impact patient satisfaction due to its shocking appearance.

In this blog, Dr Tim will discuss the anatomy of the fishhook eyebrow and the specific cause of the outcome when treating the forehead with botulinum toxin. He will guide you on patient selection and injection techniques to avoid it so you can steer clear of upsetting your patients.

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What is a fishhook brow?

Unlike the unwanted Spock brow effect, the fishhook brow tends to occur more readily in older patients. Often, slim-framed, with a low BMI, they have very little resistance to muscle movement.

You may treat the frontalis muscle, as normal, to address forehead lines, leaving adequate room to create a small eyebrow lift. However, the muscle is unresisted due to a lack of fat in the skin and pulls up sharply on the brow, creating the effect of being caught by a fishhook, pulling the eyebrow up at the mid-point creating a very unnatural appearance.

The cause of this dynamic effect can be explained as a frontalis gradient problem, referring to the difference between treated and untreated muscle which is too significant for the supporting structures to maintain, and the transition becomes very clearly visible as an upward pull. A resolution will require action to dampen the transition.

How to avoid causing a fishhook brow

There are several different options we can use to address or resolve a fishhook brow presentation, but the most important strategy is to understand the anatomy so you can identify if it might occur in your patient before it does; in other words, prevention is better than cure, and patient selection and assessment are paramount to avoid it.

For example, you might consider learning the skill of adding dermal filler to the forehead to provide the necessary additional ‘dampening’ for your at-risk patients. It becomes more and more difficult to treat older patients because of their decreased skin resistance; therefore, choosing to add volume before botulinum toxin treatment can create a much softer transition in the upper face, and allow for less worry when you follow it with a Botox treatment.

The cause of the fishhook is the hypertonic (overactive) lateral frontalis muscle in the context of the rest of the brow being relaxed. To avoid this problem, when reviewing your patient, it is vital to note if their muscle is relatively active or hyperdynamic at rest, (always contracting) because this will dictate how you choose to treat it. Although we should be rightly concerned to avoid causing a brow drop, it may be prudent to use a very small dose of botulinum toxin, in the middle of the muscle where it is most likely overactive and may pull up. Using half to one unit of Botox can be just enough to ‘blur’ the transition between the treated and untreated muscle.

The other option is to treat less in the medial frontalis, but the compromise with this option is that it will preserve lines, and the patient may not be keen to compromise, even if the risk is reduced for the fishhook.

Depending on the patient’s age and presentation, you may have to consider recommending completely different treatments like dermal fillers and other skin rejuvenation treatments, or only adding tiny amounts of botulinum toxin to just reduce the risk of a stark upward pull of a fishhook.

Get more insight from Dr Tim on how to get a great result with Botox in older patients.

How to resolve a fishhook brow

Fishhook brow resolution can be moderately tricky because you risk causing an eyebrow drop and swapping one problem for another; however, it is possible if approached as a combination treatment.

The key comes back to anatomical understanding and considering the difference between the brow depressor and brow elevator muscles.

A combined treatment aims for a small adjustment in the frontalis muscle – no more than one Botox unit at the point where it is pulling on the eyebrow – alongside treatment of the brow depressors to mitigate a brow drop – one Botox unit injection to orbicularis oculi, underneath the eyebrow. This combination may release the muscles just enough to cause a slight eyebrow lift without a visible pull.

If you are too concerned about the risk of swapping the fishhook for a brow drop, you always have the option of waiting and providing reassurance to your patient that it will fully resolve in time as the effects of the botulinum toxin naturally wear off.

Here are additional blogs from Dr Tim, exploring potential unwanted dynamic side effects related to Botox treatments in the upper face.

• How to avoid causing eyelid ptosis with botulinum toxin treatments
• How to avoid lateral rectus palsy and double vision from Botox treatment
• How to avoid lacrimal gland compromise and dry eye from Botox treatment
• How to avoid unwanted dynamic effects (new lines) from Botox treatment
• How to avoid causing an S-shaped eyebrow from Botox treatment

If you have any questions or topics for discussion, you can find Dr Tim Pearce on Instagram.

Botox® is a registered trademark of Allergan Aesthetics plc.

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