Thank you for your question.
You submitted a single photo and you’re asking is it normal to place Botox® only
to the upper part of the forehead. And you describe in your question a recounting of
the dialogue that you had with your doctor who stated that they would leave about 2 inches
above your brow with the areas that were injected to avoid you losing full expression as well
as to avoid downward drop of the brows which would then cause the eyelids to be heavy.
And it seems that you’re still dissatisfied and you feel “defeated” after spending
all the money you spent.
Well, I can certainly share with you how I have this discussion with my patients about
similar situations like yourself which are actually fairly common. A little bit of background,
I’m a Board-certified cosmetic surgeon and Fellowship-trained oculofacial plastic and
reconstructive surgeon. I have been in practice in Manhattan and Long Island for over 20 years.
And I have been treating patients with Botox® since 1993.
So I think that one of the challenges that we have to deal with up to this day has been
dealing with patients who got over treated. And when I say over treated, I mean basically
well-meaning doctors who want to treat the wrinkles across the forehead. And by doing
so, eliminate the mechanism by which the eyebrows can be elevated which is used to help reduce
the heaviness of the upper eyelids in the eyelid itself.
You see, when we look at horizontal lines on the forehead, there’s a question that
first comes to mind is why are those lines relatively deep? Very commonly, beyond a certain
age, it’s because unconsciously, people are raising their eyebrows because of the
soft tissue descent of their eyebrows, the amount of skin that is weighing down on their
eyelids. So they’re unconsciously keeping their brows up so that they can actually see
better. And of course, when they look at the mirror and they see those lines, they’re
distressed by those lines. So doctors will typically or as I would do in my practice
is I will have them look straight and relax their forehead. And when their forehead is
relaxed and I take their pictures, I’ll show them that there’s so much extra skin
over their eyes. And so then we discuss other options in addition to the Botox®. The Botox®
can be done in a variety of manners to maintain some degree of tone so that you maintain the
ability to raise your eyebrows both for the sake of a natural expression as well as for
the ability to prevent the full cascading of the skin over your eyelids.
Now very often, once people realize that they have all this extra skin over their eyes then
we have a discussion of different brow lifting options as well as upper eyelid cosmetic surgery.
What’s really nice is that when people are aware of the fullness and heaviness of the
skin over their eyes, well a procedure like cosmetic upper eyelid blepharoplasty which
we do pretty much do every day in our practice under local anesthesia with LITE™ sedation
in our office Joint Commission approved facility, we’re able to actually reduce the amount
of wrinkles on their forehead by diminishing the habit or actually eventually extinguishing
the habit because they don’t have the weight over their eyes.
Now interestingly, it still does take some Botox® to extinguish a habit. Very often,
people still raise their eyebrows even after eyelid surgery so it’s not a 100% immediate.
But once they’re able to relax their forehead and they don’t have to work so hard then
the schedule for Botox® can change and they don’t often need as much. Maybe they need
a little bit just to kind of maintain a nice natural look but not as much to avoid the
deep wrinkling of the forehead which comes from continuous constant contraction. Not
to mention that they also get fatigued from raising their eyebrows consistently. It’s
like holding a weight up with any muscle. You can only do it for so long before you
get fatigued.
As far as your doctor’s approach, I certainly would say that’s a valid approach and I
think your doctor was certainly being thoughtful in explaining what the basis was to help you
achieve a natural result. Now there is certainly pluses and minuses to being aggressive. But
I would say that once somebody is unable to move their forehead or feels like their eyebrows
are too low and their eyelids are heavy, they’ll describe like feeling trapped and they’re
very distressed and very unhappy. So life is about compromise and I do have to kind
of figure out with your doctor what you are willing to tolerate. But a lot of times in
clinical medicine, it’s treat and observe so you can see what kind of result you’ll
have.
Now you can also compare your before and after. I always take pictures of muscles under activity
and then relaxed and I show my patients how they look even after something as minor as
getting Botox® done. It’s very important to understand the activity of the muscles
and how they would diminish. And I always explain to my patients that the definition
of success is improvement. You know, we can’t eliminate everything with just a needle and
you have to decide what you’re comfortable with and what you are ready to do whether
it’s now or later on. My patients tend to stay with me for a long time and we may do
Botox® for the important event but then later on, a year later, 6 months later, whatever,
we’ll do some surgery to help address the underlying issue such as a scenario like this
where hooding over the eyelids causes a reflex of raising the eyebrows which therefore leads
to wrinkles. So you treat the underlying cause, you can diminish the wrinkling in a long-term
way with a strategy in mind.
So I hope that was helpful, I wish you the best of luck and thank you for your question.