To prevent the most common side effects such as eyelid swelling, heaviness and discomfort in opening the eyes, avoid injecting up to 2-2.5 cm above the eyebrow or, the area below the lowest forehead wrinkle. Pay particular attention in patients who habitually lift eyebrows, have ptosis, or have thick and protruding eyelids to avoid side effects.

 

Injecting deep into the muscle may cause severe paralysis and side effects without any desired benefits. It is advisable to avoid an aggressive approach in the beginning and make additional correction in the follow-up after observing initial response and symmetry.

 

Figure 4. Lines of glabellar and nasal root area.

 

Glabellar Frown Lines and Nasal Root Horizontal Lines (horizontal lines in the glabella and around the nose bridge)

Shallow or deep wrinkles that form due to contraction of the corrugator muscle in the glabella generally form vertically. They may form symmetrically or asymmetrically with one of the vertical lines being more pronounced than others.

 

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These vertical wrinkles are often accompanied with horizontal wrinkles that form due to the contraction of the procerus muscle. Removal of shallow wrinkles that form from dermal atrophy is relatively easy but if the subcutaneous fat caves due to long-term muscle contraction causing deep grooves, botulinum toxin may not be sufficient for correction and may need to be combined with dermal filler. It is important to clearly communicate to the patient in advance about the severity of wrinkles and the need to combine dermal filler (Figure 4).

 

Major muscles around the glabella include the frontalis, corrugator and depressor supercilli, and procerus. Among these, the corrugator muscle, the main culprit of deep glabella wrinkles, lies the deepest from the skin surface. It is involved in lowering and furrowing the eyebrows. Bilateral corrugator muscles originate from the bone about 1 cm above the nasion and 3mm lateral to the midline. They each run superolatearlly and ascends superficially to attach to the eyebrow area. It attaches to the skin at the center point of the eyebrows where grooves form in a frown.  (Figure 5). 

 

-To be continued