A new look at the correction of the intereyebrow in patients over 40 years old

A good result  of the blockade of the interbrow area is obtained, of course, when the patient is young, the eyebrows do not fall down, and there are no ptotic phenomena. Then the correction between the eyebrows gives a beautiful aesthetic result: blocking the interbrow area, we inject the drug with 3-4 divisions of an insulin syringe into  each head m.corrugator supercilii - this turns out to be about 24 units of Dysport at each point (when diluting a bottle of Dysport on 1.5 ml saline).

With this introduction, we get a very good blockade of the forehead and  we have the opportunity to avoid such complications as drooping, sagging forehead, windage of the upper eyelid. But this is possible only at a young age – at 30-35 years old.

At an older age, due to age-related changes, it is dangerous to carry out such a blockade of the forehead with botulinum toxin. At an older age, patients may present unpleasant "surprises" to doctors. 

What should be feared in older patients? 

When  correction of vertical forehead wrinkles is carried out, usually blockage is started from the head of the corugator. During the blockade the fiber of the frontal muscle (m.occipitofrontalis) remains movable, but it is correct to turn off the frontal muscle slightly medial to the main vector. As a result of such a blockade of the forehead with botulinum toxin, we will see a rise in the tail of the eyebrow, and a thickening of the corugator itself will definitely appear. The thickening of the corugator is due to the fact that the resistance from the frontalis muscle is turned off, and it was this muscle that stretched the tail of the corugator.

With this blockade of the forehead with botulinum toxin, the tail of the corugator gets complete freedom and shortens. It is this contraction that gives the shortening, which visually we will observe in the form of a strand (it can sometimes be located at an angle). Neither the patient nor the doctor will be satisfied with such a correction. The aesthetic effect will be negative.

How can I fix this?  Do we need additional correction points for this?

 The new approach is that the head of the corugator should not be turned off directly (by injection into the corugator muscle), but at the upper-inner border of the corugator. It is with such a chosen correction point that you can correctly block the formation of vertical wrinkles on the one hand and avoid the drooping of the eyebrows on the other. It is necessary to correctly block the tail of the corugator. This requires an additional correction point.  

How to find the right points for blockade of the tail of the corugator 

In order to correctly assess the size, strength and boundaries of m.corrugator supercilii, we ask the patient to actively frown and  start to palpate the corugator, paying attention to all the subtleties. When we run our finger   over the corugator and rest against the ledge, then this place must be fixed.

This slight rise we feel under our finger cannot be an injection point. However, it will be the starting point from which it is necessary to step back 3 mm more medially and enter 0.5 divisions of the insulin syringe - this is 4 units.

Remember that you can only inject intradermally! Because we are in a square where intramuscular injections are banned.  

In order to avoid negative consequences and complications, it must be remembered that below and lateral to the internal canthus, we make injections only intradermally!

How do we know if turning off the head of the corugator's tail will cause the upper eyelid to droop? 

Such a complication is indeed possible, this should be remembered when choosing the point of blockade and with an adequate selection of the dose of the drug at the injection point. It is always worthwhile to carefully examine the patient and use additional tests. For example, to eliminate such troubles, there is a very simple test - ask the patient to close his eyes and look at the condition of his upper eyelid.

If you find these two signs with your eyes closed, then you should think about it: 

1. Overhang, that is, a small internal hernia with excess skin to the inner edge of the upper eyelid. 
2. An extra crease on the upper eyelid when eyes are closed. 

It is this skin fold with closed eyes that will not only be a relative indication for upper eyelid surgery, but  and a sure sign that with adequate blockade of the head and tail of the corugator, even when you keep the movement of the tail of the eyebrow, the windage of the upper eyelid can be preserved . In other words, in such patients, we should expect a temporary weighting of the upper eyelid.

 We must remember and explain to our patients that such a visual weighting of the upper eyelid is not terrible and is temporary. Even with all our knowledge, it is impossible to accurately predict many moments, but it is always necessary to tell the patient that temporary complications occur. After 2-3 weeks, this temporary complication will pass, and the patient will be satisfied with the aesthetic result of the correction. Particular care must be taken on this issue with patients who have swelling of the face.

We remind you that only highly qualified doctors who have undergone appropriate training can use this technique.

Author: Elena Stoyanova, PhD, scientific supervisor of the project estet-portal.com