The Impact of Botulinum Toxin on Brow Height and Morphology: A Randomized Controlled Trial

Neuromodulator Assessment and Treatment for the Upper Face: An Update

Neuromodulator treatment of the upper face has been extensively studied and serves as an excellent tool to enhance facial appearance, non-verbal communication, and social functioning. Optimal outcomes are best achieved when health care providers take an individualized approach, based on knowledge of structural and functional anatomy, thorough facial assessment, and customized injection techniques and patterns.

Impact of Glabellar Injection Technique With DaxibotulinumtoxinA for Injection on Brow Position

BACKGROUND

Precise injection technique is vital for avoiding suboptimal eyebrow position when treating glabellar lines with botulinum toxin type A.

OBJECTIVES

The aim of this study was to evaluate the impact of glabellar injection technique on eyebrow position in patients treated with DaxibotulinumtoxinA for Injection (DAXI).

METHODS

This retrospective post hoc analysis involved 60 adults who received a single treatment with DAXI 40 U to the glabella and had standardized facial photography. Median vertical and horizontal displacement of the brows (at rest) at baseline and 2 weeks after glabellar injection were measured. Brow position outcomes were evaluated by an oculoplastic surgeon and expert anatomist. Investigators were interviewed to ascertain individual injection techniques.

RESULTS

Precise injection location and depth, and median resting brow position following treatment varied between investigators. Positive brow outcomes were achieved with deep DAXI injections into the medial corrugator, superficial lateral corrugator injections placed between the midpupil and lateral limbus, and deep midline procerus injections. Glabellar injection technique that more precisely targeted the corrugator muscles resulted in longer glabellar line treatment duration compared to a less targeted technique. Medial corrugator injections above the medial brow; lateral corrugator injections administered deeply or more medially, toward the medial third of the brow; and procerus injections superior to the inferomedial brow tended to be associated with suboptimal outcomes that were more apparent during dynamic expression.

CONCLUSIONS

Aesthetically pleasing brow outcomes and greater duration of efficacy can be achieved with an injection pattern that precisely treats the anatomic location of the corrugator supercilii and procerus muscles, avoiding the frontalis.

LEVEL OF EVIDENCE: 4

Impact of DaxibotulinumtoxinA for Injection on Brow Position and Frontalis Muscle Activity Following Treatment of Glabellar Lines

BACKGROUND

Botulinum toxin type A (BoNTA) injections for the treatment of facial lines may lead to pleasant or undesirable changes in eyebrow height and position.

OBJECTIVES

The aim of this study was to evaluate the impact of glabellar injection of DaxibotulinumtoxinA for Injection (DAXI), a novel BoNTA formulation, on eyebrow position and frontalis activity.

METHODS

This study involved the post hoc analysis of adult patients from the Phase 2a forehead lines (FHL, N = 60) and open-label safety (OLS, N = 175) studies who received a single dose of DAXI 40 U to the glabella and for whom facial photographs were taken at rest and at maximum eyebrow elevation. Median vertical and horizontal displacement of the brows and median forehead strain (an objective quantitative assessment of frontalis activity) from baseline to 2 weeks after glabellar DAXI injection were measured.

RESULTS

Two weeks after glabellar DAXI injection, vertical eyebrow movement (at rest) of the lateral brow was observed. In both studies, vertical movement was greatest in the lateral (0.6-0.9 mm) and mid (0.5-0.7 mm) brow regions; movement in the medial brow was negligible (0-0.23 mm). In both studies, a graded reduction in forehead strain was observed 2 weeks post glabellar DAXI injection, with the greatest reduction being in the lower segment (FHL, -73%; OLS, -82%). Treatment with DAXI showed improvements in FHL wrinkle severity.

CONCLUSIONS

Glabellar injection of DAXI showed a positive reduction in dynamic frontalis activity that maintained or had a positive effect on eyebrow position. Vertical movement of the brow was suggestive of an improved eyebrow shape with a mild lateral arch.

LEVEL OF EVIDENCE: 4

Eyebrow Shape Preference Across Age, Gender, and Self-reported Ethnic Group

BACKGROUND

Preference in eyebrow shape has been studied in young women, but less so in older adults, men, and a wide variety of ethnic groups.

OBJECTIVE

To identify preference in eyebrow shape across age groups, genders, and ethnic groups for both the survey responder and the observed subject.

METHODS

Digital images of subjects from 3 age groups (18-39, 40-59, and 60+ years), 2 genders (female and male), and 4 self-identified ethnic backgrounds were edited to correspond to 5 brow shapes (Anastasia, head-up, horizontal, rounded, and tail-up). Panels of images representing the same subject with different brow shapes were displayed and responders ranked them in order of attractiveness via an online survey.

RESULTS

Six hundred fifty-two responders answered the survey. Survey responders generally preferred the Anastasia shape, but not in all subgroups. Strength of preference in eyebrow shape was more marked when observing images of women and less marked when observing men.

CONCLUSION

An arched brow, such as the Anastasia shape, was the preferred eyebrow shape. This study is limited by its survey nature, underrepresentation of self-identified Black study responders, and categorization of data. Despite these findings, the authors advocate determining eyebrow shape preference individually with patients during cosmetic consultations.

Forehead Movement Discrepancies After Botulinum Toxin Injections: A Review of Etiology, Correction, and Prevention

BACKGROUND

Forehead rhytides are a popular target for botulinum toxin injections, but neuromodulation of the frontalis can be fraught with complications because of its anatomic complexity and integral role in brow position and expressivity.

OBJECTIVE

This article explores common forehead movement discrepancies that can occur after neuromodulation of the frontalis, as well as how to correct and prevent them.

METHODS

A review of the literature was conducted and combined with clinical experience to examine underlying forehead anatomy, etiology and correction of forehead movement discrepancies, and important factors to consider before injecting the frontalis with botulinum toxin.

RESULTS AND CONCLUSION

Variable anatomy from person to person necessitates an individualized treatment approach to achieve the best cosmetic results and prevent the occurrence of forehead movement discrepancies.

The Effect of Zero Gravity on Eyelid and Brow Position

PURPOSE

To describe the effect of spaceflight on upper eyelid and brow position.

MATERIALS AND METHODS

Images of astronauts on earth and in space were collected from a National Aeronautics and Space Administration image library. For each astronaut, front facing portraits captured within a 5-year period were obtained. At least 6 photos were collected per astronaut, 3 taken on earth, and 3 in zero gravity. Measurements from the center of the pupil to the upper eyelid margin (MRD1) and center of the pupil to the inferior eyebrow margin [pupil-to-brow (PTB)] were performed digitally for each image and averaged for each condition and each individual. Differences in mean MRD1 and PTB were assessed to illustrate the effects of zero gravity on eyelid and eyebrow position respectively. Linear-mixed effects modeling, analysis of variance and post hoc power analysis were performed.

RESULTS

One hundred and twelve photographs (55 earth, 57 space) from 18 astronauts (4 women, 14 men; mean age 45.9 years) were retrieved. Zero gravity resulted in a mean PTB increase of 3.7 mm (p < 0.01) but did not result in significant change in MRD1 (p = 0.21). Post hoc power analysis of the measured MRD1 difference was performed by simulation. At an MRD1 difference of 0.5 mm, the probability of a type II error is 2.6%, equivalent to a beta power of 97.4%. Thus, we can be 97.4% confident that a difference in MRD of 0.5 mm or greater would be detected.

CONCLUSIONS

While spaceflight led to significant elevation of PTB, it did not consistently alter MRD1. As such, the brow and eyelid appear to be independently regulated with respect to gravitational changes.

Current Use of Cosmetic Toxins to Improve Facial Aesthetics

LEARNING OBJECTIVES

After studying this article, the participant should be able to: 1. Compare and contrast the various types of botulinum toxin on the market. 2. Appropriately select patients for treatment with cosmetic botulinum toxin. 3. Understand the common injection patterns for treating various regions of the face with cosmetic botulinum toxin. 4. List the complications associated with treating various regions of the face with cosmetic botulinum toxin.

SUMMARY

Nonsurgical rejuvenation of the face with botulinum toxin is one of the most commonly performed procedures in the United States. This article reviews the current evidence in treating different regions of the face: upper face, lower face, masseter, and platysma. Dosing and complications associated with different facial regions are reviewed.

Lifting effect of onabotulinumtoxinA in patients treated for glabellar and crow's feet rhytids

OnabotulinumtoxinA injection can enhance the appearance of the eyes. This study evaluated the lifting effect of onabotulinumtoxinA treatment of the eye area. A retrospective, single-center audit of patients treated for glabellar and crow's feet rhytids was undertaken. Standardized photographs taken before and 2-4 weeks after treatment were assessed. Computer-based measurements were made of the height of the visible superior tarsal plate (STP) and brow (measured from upper eyelid lash edge to eyebrow base) at rest and maximum frown. One hundred patients were included (96 females; mean age: 46.2 ± 8.8 years). Mean onabotulinumtoxinA doses were 14.95 ± 0.61 units (glabella) and 17.83 ± 2.74 units (crow's feet). There were significant post-treatment increases in mean STP height at rest (left side, 0.76 ± 0.99 mm, p = .02; right side, 0.79 ± 0.94 mm, p = .01) and maximum frown (left, 2.25 ± 1.52 mm, p < .0001; right, 1.87 ± 1.34 mm, p < .0001), and mean brow height at rest (left side, 1.54 ± 1.49 mm, p = .0006; right side, 1.47 ± 1.84 mm, p = .0009) and maximum frown (left, 4.37 ± 2.29 mm, p < .0001; right, 4.16 ± 1.88 mm, p < .0001). OnabotulinumtoxinA injection is effective for elevating brow position and increasing STP show.

A 3D Morphometrical Evaluation of Brow Position After Standardized Botulinum Toxin A Treatment of the Forehead and Glabella

BACKGROUND

Botulinum toxin treatment for forehead wrinkles has been extensively studied and found to be a safe and reproducible procedure. However, the effect on the position of the eyebrows, which relies on the dynamic positioning of the treated muscles, has received less attention and has not been studied with 3-dimensional (3D) technology.

OBJECTIVES

The authors sought to evaluate the changes of eyebrow position after standardized botulinum toxin treatment of glabella or glabella and frontalis muscles with 3D imaging.

METHODS

In a prospective study, 2 groups of adult females were treated with botulinum toxin A at the glabella only (G) or at the glabella and the frontalis muscle (F/G). The brow position was measured at 5 positions with 3D photography before injection and 2 weeks, 3 months, and 6 months after injection. Results were statistically analyzed and related to patient age.

RESULTS

In the F/G group, the brow descended significantly almost across the whole brow length after 2 weeks. The descent lessened after 3 months and moved medially. No clear trend was evident in the G group. There was no significant change attributed to patient age in both groups.

CONCLUSIONS

Botulinum toxin treatment of the glabella and frontalis muscle impacts the position and configuration of the eyebrow. The degree of change is affected by the amount of frontalis weakening rather than by treatment of the glabella. While age in general is not a reliable predictor, individual factors play the major role in how pronounced a change of the brow can be expected.

LEVEL OF EVIDENCE: 2

"The Evolution of Eyebrow Morphology: The Westmore Model Revisited"

BACKGROUND

The most widely recognized eyebrow model was described by Westmore in 1974. With the rapidly changing concept of beauty, an accurate up-to-date model is needed.

METHODS

The Westmore model was tested on fashion models that were randomly selected from the covers of the 1965-1975 (group 1) and 2006-2016 (group 2) Vogue magazine. The eyebrows of fashion models, which represent the beauty ideals of these decades, were objectively measured and compared. We proposed a modified eyebrow model more adapted to the modern standards of beauty, applied it to group 2, and objectively compared it to the Westmore model. This new model was validated on a group of randomly selected Caucasian women.

RESULTS

Thirty women were included in each group. The medial edge of the eyebrow was better defined by the Westmore model in group 1 compared to group 2. The lateral edge of the eyebrow was better defined by the Westmore model in group 2. The peak of the eyebrow was not well defined by the Westmore model in both groups. The new model was more adapted than the Westmore model for both the medial edge and the peak of the eyebrow in group 2. It was also accurate in non-model Caucasian women.

CONCLUSION

Eyebrow morphology has evolved since the description of the Westmore model. Our model represents a simple way to accurately predict the eyebrow landmarks according to the modern ideals of beauty.