Dermatologist Debriefs

Important tips for having botox on your forehead

• Stefanie Williams

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Dermatologist Debriefs is back with another fast-paced, myth-busting session. In this episode, consultant dermatologist Dr Stefanie focuses on the deceptively tricky forehead and explains why treating it with botulinum toxin demands much more than a steady hand. 

She starts by mapping the frontalis muscle—from hairline to brow—and shows how habitual “brow lifting” carves horizontal lines into the skin. You will learn why relaxing that muscle can leave some patients feeling unexpectedly heavy-eyed, why true eyelid ptosis is rare, and how thoughtful dose adjustments—or even skipping the forehead entirely—avoid the problem. Dr Stefanie also unpacks the two-centimetre safety zone, dissects the dreaded “Mephisto” eyebrow, and reminds listeners that botulinum toxin is a prescription-only drug in the UK. 

Dr Stefanie also looks at some of the alternatives such as collagen-stimulating injectables and energy-based devices such as high-intensity focused ultrasound, explaining where they fit into a personalised plan. Whether you are new to cosmetic treatments or refining an existing routine, invest eight crisp minutes with Dr Stefanie before anyone comes near your forehead.

Speaker 1:

Dermatologist debriefs. Join no-nonsense dermatologist Dr Stephanie Williams as she debunks myths and shares her professional insights, separating facts from fiction, in just a few minutes.

Speaker 2:

Hello, this is Dr Stephanie. Today I'm going to share important information about what to look out for if you are having Botox in the forehead area. And just to be clear, for a simple ease of speaking, I shall continue calling it Botox in this post, although of course, there are many other brands with the same active ingredient, ie botulinum toxin A, including, for example, bocoture, which I use in clinic. So this is not specific to the brand Botox and I'm only using the word because it's easy to pronounce and this is what people have heard about. This is the brand people know, but this is the same for whichever brand of botulinum toxin you are using.

Speaker 2:

Okay, so let's get started. Firstly, you will need to know a little bit about the anatomy of our muscles on the forehead, otherwise all of this won't make sense on the forehead. Otherwise, all of this won't make sense. So the main muscle on our forehead is called the frontalis muscle. It stretches from the hairline down to the brows and this muscle is responsible for lifting the eyebrows, creating that classic surprised look. And with that same action, the frontalis muscle is also responsible for horizontal lines and wrinkles seen on the forehead, and these horizontal lines are, of course, a very common reason that people come to see us in clinic and they want those lines to be softened. The problem is, though, that many people unconsciously use their frontalis muscle as a crutch, so to say, to keep their eyebrows lifted, especially if their natural brow position feels maybe a little heavy or there may be some excess skin above the eyes. So this habitual lifting of the brows via the frontalis muscle leads to persistent and, over time, deep horizontal forehead lines, and when we inject Botox as a cosmetic treatment into the frontalis muscle, it relaxes the muscle and reduces its ability to lift the brows to some extent anyway. It all depends on the dose, of course, and we don't freeze people's foreheads, but it just reduces the ease of lifting the brows. But for those of us who rely on this muscle to keep their brows elevated, this can result in a sensation of heaviness or even visible brow descent. So this feeling of heavy brows is often mistaken by patients for eyelid drooping ptosis in medical speak, but it's actually not that. The heavy brow sensation is simply due to the loss of compensatory lifting from the frontalis muscle, rather than an actual eyelid muscle weakness, muscle weakness, true eyelid ptosis after Botox is thankfully rare, while the feeling of heavy brows after Botox treatment is unfortunately rather common.

Speaker 2:

But to avoid the unwanted brow heaviness it's really crucial to individualize the Botox dosing and placement. So some patients might benefit from an ultra low dose sprinkling technique that softens those lines without fully incapacitating the muscle, preserving some lifting action. In other cases it may be best to avoid treating the forehead altogether and instead maybe focusing on the frown lines, which is called the glabella area, and maybe the area around the eyes, which can also lift the brows further, which is lovely if you have a naturally heavy brow position. And this low sitting brows in men may look intriguing, even as they may give off a kind of mysterious, confident vibe that some people might find even charismatic. Heavy brows in women sadly hardly ever look attractive. So we have to be extra careful with this topic when we are treating the forehead in our female patients. So here it's all about knowing how much can I inject and where exactly to inject it, and this is very individual.

Speaker 2:

And another trick is the so-called two centimeter rule, which means that Botox injections shouldn't be, or should be, placed at least two or three centimeters above the upper bony eye socket margin to minimize the risk of heavy brows. However, on the other hand, we have to be careful not to stay too high, because this may cause an unusual eyebrow shape that we call the Mephisto sign. So this is kind of like an exaggerated arc at the tail of the eyebrow and that's due to uneven muscle weakening on the forehead, with exaggerated wrinkles at the border between the treated and the untreated sections of the frontalis. And this Mephistocine is a dead giveaway of a badly done Botox. But thankfully it's easy to fix. So if you observe that after your own treatment, make sure to go back to the doctor rather than just soldering through it. This is very easy to correct.

Speaker 2:

But overall, the forehead in particular is a minefield with regards to Botox treatments and should only be done by very experienced practitioners, and that goes very much against what is commonly thought to be the fact, as, sadly, new practitioners often think that the forehead is an easy area to start treating. So it's kind of like a starter area, but it's far from it. And, by the way, botox is a prescription medication in the UK, so anybody who is not a doctor or a nurse with prescribing license is not legally allowed to inject Botox Again, something that not many people are aware of. There are, of course, alternatives for treating the forehead, apart from Botox, in those where the Botox might not be a good option, including a variety of collagen stimulating skin boosters, such as Sunicose, and non-invasive energy-based treatments like high-frequency focused ultrasound.

Speaker 2:

Ultherapy is one of the devices you may have heard about, and these can improve skin quality and firmness without directly affecting the muscle movement. So really important to see a reputable medical professional who understands the intricacies of facial anatomy and is confident in assessing your unique muscle pattern. And if it's not the right thing to just say no, botulinum toxin is highly effective, but it is not suitable for everybody. Butulinum toxin is highly effective, but it is not suitable for everybody, and a personal approach is key to natural looking results Because, remember, it's better to look old than to look weird. Bye.