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Dr Tim Pearce
Let’s face it, there is nothing more awkward than sitting in a room with a patient who is complaining about the horrendous Spock brow that you have just given them.
Sadly, this situation is occasionally going to happen to all aesthetic clinicians. It is impossible to know for certain the result of a botulinum toxin or Botox® treatment until two weeks later because it takes that much time for the neurotoxin to relax the targeted muscles. Every patient is different, and there are many ways of injecting patients with Botox to achieve differing desired outcomes; throw in age and anatomy that will not be the same for everyone and you are bound to get different, sometimes undesirable results, especially when you are starting in aesthetic practice.
In this blog, Dr Tim Pearce shares his knowledge on what causes the so-called Spock brow complication, what you can do to improve the situation if you create one, and how best to avoid doing it again in future.
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What causes a Spock brow?
The ‘Spock brow’ look, named of course after the eyebrow presentation of the famous Star Trek TV show character is often caused because many aesthetic clinicians are afraid of causing a brow drop when treating patients with botulinum toxin. The result is that they leave a lot of untreated muscle, above the eyebrows, to avoid dropping the eyebrows, their main fear. The downside, however, is that it can cause the opposite problem – too much lift in the eyebrows due to increased activity of the lateral frontalis muscle. In a small cohort of patients, this will cause a significantly larger brow lift than you might expect; often also presenting with Wi-Fi or ladder lines at the sides of the temples.
Interestingly, notes Dr Tim, this is not a true Spock brow (we will get to that in a moment). This one is predominantly caused by undertreatment when a patient asks for a brow lift or when you are afraid of causing a brow drop. This is a better outcome or complication, than a side effect from overtreating, because you could always add more botulinum toxin to correct it.
What can you do to improve a ‘non-true’ Spock brow?
Because the non-true Spock brow is a result of undertreatment, you can simply adjust the strength of the frontalis muscle in a way that is safe to do so.
If you have over-lifted and need to decrease the strength of the lateral frontalis, Dr Tim advises targeting one to two injection points, edging down the forehead. The lower you get, the more sensitive it is for the patient. When you first start, you may divide the active muscle in half and treat the upper half with one unit. If that is not enough, you can treat lower down, but you might use a slightly lower dose. If you get down, close to where the eyebrow is located, Dr Tim has used a dose of 0.5 units to soften the activity of this muscle, but this takes experience.
He concludes that this confuses practitioners because he often talks about it as a safety area, but the truth is it is only a relative risk in treating the lateral frontalis. You must do it cautiously, and in many patients, you will not get a drop, even if you use significant doses, but it is sensible to start with less, putting more in as time goes on and if you need it, as you learn what works for your patient.
What is a true Spock brow?
A true Spock brow is a combination of an overtreated medial frontalis and an undertreated lateral frontalis, explains Dr Tim. This occurs most commonly with inexperienced aesthetic clinicians because they are usually trying to be extra safe.
If we consider the risks associated with botulinum toxin treatment, eyelid ptosis often evokes the most worry. One way to mitigate the risk of eyelid ptosis is to stay away from the orbit. Therefore, instead of injecting directly into the corrugator, cautious injectors, believing they are being safer, will inject slightly above it. This means that a good dose of the neurotoxin hits the medial frontalis causing a medial brow drop.
Similarly. if they have also attempted to be extra safe laterally, to avoid a lateral brow drop, it results in the opposite result – a lateral brow lift – because the frontalis has been heavily treated in the middle, hardly treated at all laterally, and the result is the true Spock brow.
What can you do to improve a ‘true’ Spock brow?
Your first consideration, enlightens Dr Tim, must be with the muscles that are undertreated which are pulling the eyebrow down. If you have treated too high up and hit the frontalis, it is quite simple to see what you need to do next, i.e., treat the brow depressors so that the elevators have a chance of winning in the tug of war.
Find the corrugator and the procerus muscles and relax them because this action should assist in elevating the medial brow. At the very least, your patient will look better when they are cross or angered. An angered face, even mild anger with frowning can look a lot worse if combined with a Spock brow presentation because it causes a very deep frown line due to unopposed corrugator activity and a frontalis muscle that is doing nothing. You must treat the glabellar complex properly.
Then move on to address things laterally, using low dosing to balance the seesaw effect. The original treatment dropped the middle and lifted at the top and side, the remedy is to elevate the middle and soften the lateral lift to harmonise the face.
Here is a simple formula used by Dr Tim to soften an overly arched eyebrow. If he is 2 centimetres from the periorbital ridge, he will place 0.5 to 1 unit of Botox. If he is 3+ centimetres away, he will place 1 to 2 units because it is safer to increase the dose when there is extra space. Consider how much muscle you have that is still untreated, and how much you feel happy to take away. The core principle is that botulinum toxin will treat approximately 1 to 1.5 centimetres of muscle around the area of the injection point due to spread. This helps to gauge how much muscle you are still leaving untreated that will provide some eyebrow support, vital in female patients.
This can be more difficult with older patients. For more insight, read:
- How to get a great result with Botox in older patients
- 5 Botox mistakes you are making when treating older patients
How to manage a patient complaining of a Spock brow
Communication is key; if you have made a mistake, it is better to explain this to your patient, telling them what caused it, and how you are remedying it so that it will never happen again.
Dr Tim urges you to avoid communicating that it is “just a side effect that happens to everyone” because it will make the patient feel out of control. You both need to learn from what happened, ensuring they will never go to a different clinic/practitioner, instead trusting you and your skills in the future. The alternative is that they have a negative opinion of botulinum toxin treatment or you and avoid one or both in future. Better to be honest and transparent and come up with a plan to avoid it happening to them again so you can maintain the relationship.
For some patients, if the experience is bad enough and they are very upset by it, it may be better to resist trying it again and consider alternative treatment options to avoid a future negative result. This may be the case with older patients.
For additional guidance on botulinum toxin treatments:
- Download our free guide – Dr Tim Pearce’s 26 essential injection patterns for botulinum toxin
- Dor more insight – Best Botox brow lift injection patterns to avoid ptosis and Spock brow
- Also check out – Botox injections: common mistakes aesthetic clinicians make!
Dr Tim is always keen to hear about the experiences of his followers. So, if you have any questions, case studies, or discussion points for him, you can find Dr Tim Pearce on Instagram.
Aesthetics Mastery Show
How do you fix a Spock brow after a Botox procedure and how do you stop it happening again next time?
Dr Tim says:
“In this episode I discuss why Spock brow happens, the injection techniques and injection points you can do to fix it and how to discuss why this has happened to patients without freaking them out.”
Watch the full Aesthetics Mastery Show here.
The show has had thousands of views already and been well received by practitioners all over the world.
@timrai2100 said:
“Great video… I always learn at least 1 or 2 things with each video of yours”
@dianefrancessanchez916 added:
“Great presentation Dr Tim !!”
@patriciawatson1065 said:
“Wonderful explanation Dr thank you so much!”
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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.
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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.
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