Trends, pitfalls and the balanced approach to Botox Cosmetic®, Xeomin® and Dysport®

It’s no secret: Botox Cosmetic® is an extraordinarily successful product for smoothing facial wrinkles. Botox Cosmetic® belongs to a group of products known as neuromodulators; this group also includes relative newcomers Xeomin® and Dysport®. All neuromodulators work by relaxing muscles, which in turn smooths the overlying skin and rejuvenates the face. We use neuromodulators in several different facial zones. The zone between the eyebrows, called the glabella, was the first zone to receive approval when Botox Cosmetic® was introduced in 2003. In this zone, we use neuromodulators to improve the vertical wrinkles, or “11” lines, that form between the eyebrows. Botox Cosmetic® has since gained approval for the wrinkles around the corners of the eyes; we also commonly use neuromodulators “off-label” in a third zone, the forehead, in order to smooth the wrinkles that run above the eyebrows.

Since neuromodulators first appeared on the aesthetic scene, we’ve seen trends emerge, become aware of pitfalls and learned how to better tailor our treatments to our patient goals.

Tends: One trend we are seeing in the aesthetic medicine community is to be less aggressive when we treat wrinkles on the forehead, a trend that makes good sense for several reasons. Previously, we frequently had patients requesting aggressive treatments of their foreheads. This achieved the desired effect of a smooth forehead, but it came with the potential cost of a nearly expressionless upper face and the risk of drooping eyebrows, something we’ll discuss in more detail below. As a results, we find ourselves recommending a subtler approach to the forehead. We are also seeing another trend emerge, which is an increase in the number of patients requesting treatment to the wrinkles that form on the outer corners of the eyes.

Pitfalls: With the trend towards a less aggressive approach in the forehead, we are moving in a direction that lowers the risk of one of the major pitfalls of neuromodulators: temporary eyebrow drooping. Eyebrow drooping is caused by excessive relaxation of the muscle in the forehead.

Our foreheads have a single muscle beneath the skin: the frontalis muscle. This muscles works to lift our eyebrows, allowing us to express surprise and emotion. When we weaken this muscle with Botox Cosmetic®, or other neuromodulators, we are weakening the only muscle that lifts our eyebrows. As this muscle weakens, forehead wrinkles will smooth, but the muscle may no longer be strong enough to support the brow in its normal position, leading to the risk of drooping eyebrows. For this reason, I support the current tend towards a subtle approach to treating the wrinkles of the forehead with Botox Cosmetic® or other neuromodulators. This approach has the added advantage of avoiding a frozen appearance, and preserving facial expression.

The balanced approach: If I think a patient is at risk of having their eyebrows droop, I will typically recommend that if we are treating the forehead, we also need to treat the muscles that pull the eyebrows downward. By relaxing the muscles that pull the eyebrows downward, we are promoting the eyebrows to rise. There are two major muscle groups that pull the eyebrows downward, and between the two of them, these groups are also responsible for the “11” lines between the eyebrows and the “crows feet” at the corners of the eyes. Treatment of both of these areas has its own cosmetic benefit beyond allowing the eyebrows to rise.

Think of this approach like a tug of war. In this tug of war, we are simultaneously using our neuromodulators to relax the muscles that are pulling the eyebrows in opposite directions. If we do this well, we stand a better chance of maintaining eyebrow position. If we only relax one side of the tug war, the other side will pull the eyebrows out of harmony.

When used with these pitfalls in mind, the neuromodulators are incredibly powerful options for rejuvenation. If you would like more information on Botox Cosmetic®, Xeomin® or Dysport®, please stop in and visit our office. Or, call us today at 563.213.5080 to schedule a consultation with Dr. Repp. We’re right here in Davenport, serving the Quad Cities. You can also watch Dr. Repp discuss this topic in the video associated with this post.