Reducing Brow Ptosis Risk with The 3-Point Glabella Technique

Understanding the New Approach to Glabella Treatment

The glabella region—that area between your eyebrows where frown lines form—has traditionally been treated with a standard 5-point or 7-point Botox injection pattern. This approach has been the industry norm for years, largely because it aligns with licensed dosing guidelines and has been taught in countless training programs worldwide.

However, a paper by renowned anatomist Sebastian Cotofana has sparked significant discussion among aesthetic practitioners. The paper proposes a modified 3-point injection pattern that may deliver comparable results with potentially fewer side effects. This has left many injectors questioning their fundamental techniques and wondering: Have we been doing it wrong all this time?

As an aesthetic practitioner, you’ve likely experienced that moment of doubt when confronted with new information that challenges your established methods. It’s a natural response—one that Dr. Tim Pearce addresses directly in his analysis of this innovative approach.

The 3-Point Glabella Pattern: What’s Different?

The traditional approach typically involves five injection points distributed across the glabella region, targeting both the procerus and corrugator muscles throughout their length. The new technique proposed by Cotofana reduces this to just three points, focusing on injecting near the origin of the muscles rather than following the muscle along its entire length.

The most significant difference is the elimination of the lateral corrugator injection points. Instead of treating the corrugator muscle throughout its length, this technique concentrates on the bottom third of the muscle near its origin. This represents a fundamental shift in thinking about how we approach muscle relaxation in the glabella.

The study, which included 105 patients treated by clinicians using this specific technique, reported no instances of brow or eyelid ptosis—a promising finding for practitioners concerned about these common complications. While the sample size isn’t large enough to definitively prove superiority (as Dr. Tim notes, you’d ideally want thousands of patients for that level of certainty), the results are certainly encouraging enough to warrant consideration.

The Anatomical Rationale: Why It Works

The effectiveness of this modified technique is rooted in solid anatomical understanding. By injecting near the origin of the muscles (procerus and corrugator), you can achieve muscle relaxation while potentially reducing the risk of affecting adjacent muscles that could lead to unwanted effects.

A key technical element highlighted in the video is the angle of injection. The technique employs a 90-degree angle to the surface of the bone, directing the needle upward toward the brow rather than toward the orbit. This approach places the neurotoxin precisely at the muscle origin, making it difficult to miss the target.

This injection angle serves two important purposes:

1. It directs the toxin away from the orbit, reducing risk of migration
2. It ensures placement directly at the muscle origin for optimal effect

The precision of this approach reflects a deeper understanding of the three-dimensional anatomy of the glabella region—something that flat diagrams in training manuals often fail to convey adequately.

Brow Ptosis vs. Eyelid Ptosis: Understanding the Critical Difference

One of the most valuable insights from Dr. Tim’s analysis is the clear distinction between brow ptosis and eyelid ptosis—complications that are often confused by newer injectors, leading to repeated mistakes and suboptimal outcomes.

Brow Ptosis occurs when the frontalis muscle (which elevates the eyebrows) is over-treated or over-relaxed, causing the eyebrows to slip downward. This commonly happens when injectors, in an attempt to stay “safe” by moving away from the eye, inadvertently inject the frontalis muscle. Ironically, this safety measure can create the very problem they’re trying to avoid.

The lower third of the frontalis is particularly important for brow elevation, so treating this area can result in the characteristic drooping of the brow. Sometimes this presents as a medial brow ptosis, while other times it manifests as the infamous “Spock brow” where the medial brow drops while the lateral portion lifts.

Eyelid Ptosis, by contrast, occurs when toxin affects the muscles that control the eyelid (levator palpebrae and tarsal muscles). This is anatomically distinct from brow ptosis and requires different prevention strategies and treatments (such as apraclonidine drops, which stimulate the tarsal muscle to elevate the eyelid).

Understanding this distinction is crucial for proper technique adjustment and complication management. Many practitioners mistakenly attribute all “drooping” to the same mechanism, when in fact they represent entirely different anatomical issues requiring different approaches.

Benefits and Limitations of the 3-Point Technique

The study demonstrated several benefits of this modified approach:

1. Reduced risk of brow ptosis by avoiding areas where frontalis could be affected
2. Potential for fewer side effects due to more targeted placement
3. Evidence of medial brow lift (a few millimeters) as a positive side effect
4. Efficiency with fewer injection points
5. Potentially less product usage while maintaining efficacy

However, Dr. Tim notes an important limitation based on his clinical experience: in patients with strong muscles, you may still see lateral corrugator movement. This means:

• Patients seeking complete immobilization might not be satisfied
• Some patients may require additional lateral corrugator treatment
• The technique may need to be modified based on individual patient goals and expectations

This highlights the importance of thorough consultation and setting realistic expectations with patients about the degree of movement that will remain after treatment.

Practical Implementation: Injecting Anatomy, Not Points

Perhaps the most valuable takeaway from this analysis is the emphasis on “injecting anatomy, not points.” Many newer injectors make the mistake of memorizing surface landmarks without truly understanding the underlying muscular structure—a recipe for complications and suboptimal results.

To implement this or any technique effectively, practitioners should:

1. Visualize the origin and insertion of the muscles being treated
2. Understand that injection points are merely where the needle enters the skin—the needle tip placement is what matters
3. Consider the angle and depth of injection relative to the target muscle
4. Recognize that moving further from the eye isn’t necessarily safer if it means injecting the frontalis
5. Adapt techniques based on individual patient anatomy, which can vary significantly

This approach requires a deeper level of anatomical understanding but results in more consistent outcomes and fewer complications over time.

Is This the New Gold Standard?

While the 3-point technique shows promise, Dr. Tim emphasizes that there is no “golden tool” in aesthetic medicine—no single technique that works perfectly for every patient. This is a crucial mindset shift for practitioners who may be searching for the one “perfect” way to perform treatments.

Instead, skilled practitioners should:

• Understand the anatomical basis of each technique
• Recognize the strengths and limitations of different approaches
• Apply techniques selectively based on individual patient needs
• Be willing to combine or modify techniques as appropriate
• View each new technique as an addition to their toolkit, not a replacement

The 3-point glabella pattern isn’t necessarily better than traditional approaches for all patients, but it represents another valuable tool in the aesthetic practitioner’s arsenal—one that may be particularly useful for patients concerned about brow ptosis.

Conclusion: Adding to Your Toolbox, Not Replacing It

The emergence of this modified glabella technique shouldn’t cause practitioners to question everything they’ve learned. Rather, it should encourage a deeper understanding of facial anatomy and how different injection techniques interact with underlying structures.

As Dr. Tim notes, the psychological response of “My whole career is built on a lie!” when encountering new techniques is common but unnecessary. Every technique has its place, and mastery comes from understanding when and how to apply each one.

By adding this 3-point glabella pattern to your repertoire—while understanding its anatomical basis and limitations—you can offer more personalized treatment options and potentially reduce complication rates for appropriate patients.

Remember: inject the anatomy, not just the points, and you’ll be well on your way to consistently excellent results with fewer complications and more satisfied patients.

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