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Technique Tips To Avoid Neurotoxin Droopy Brow
As all experienced neurotoxin practitioners are aware, you should expect two types of nerves during a procedure: the nerves related to muscle relaxation, and the nerves that come with your patient’s anxiety. With botched results plastered on the internet, even the most seasoned neurotoxin recipients might sit on your chair afraid they’ll end up with, say, a droopy brow – one of the most common injection errors seen on Google.
Medically called ptosis, droopy brow is when the eyebrows or eyelids look “weighed down,” as if the person has trouble opening their eyes. Although there are other (albeit rare) causes of ptosis, such as injury or congenital/medical muscle conditions, ptosis is an unquestionable reality of neurotoxin treatment—one that can be avoided with an overabundance of precaution, deep knowledge of facial muscles, and emphatic patient education.
First, a brief overview of neurotoxin and facial muscles
Neurotoxin is a neurotoxic protein called onobotulinumtoxinA produced by a microbe, the bacterium Clostridium botulinum. When neurotoxin is injected into a muscle, it blocks certain nerve signals that make those muscles contract, thus relaxing the muscles and improving fine lines and wrinkles.
When it comes to ptosis, it’s critical to form a deep understanding of three major muscles in the eye area: the levator palpebrae superioris muscle, frontalis muscle, and glabellar complex. The levator is mostly responsible for keeping eyelids in place, the frontalis muscle helps raise the eyebrows (elevator muscle), and the glabellar complex is the muscle under the frontalis that moves eyebrows downward (depressor muscle).
Although each patient has the same set of muscles, the placement of them varies from person to person depending on their facial structure, how they regularly move their face, their age, and other individual factors (like if they’ve had a facelift procedure before).
The key is to intelligently assess where to inject based on the patient’s unique anatomy. Getting deeply familiar with these three eye-area muscles (as well as all surrounding muscles) will help you determine how to target only the intended muscles depending on the goals of the client, whether that’s smoothing out horizontal lines on the forehead or removing vertical lines (a.k.a. eleven lines) between the brows.
The top causes of droopy brow
Droopy brow specifically caused by neurotoxins are mostly caused by unintended migration of the toxin.
Neurotoxin bleeding into the levator muscle from between the brows (in an attempt to treat eleven lines) is one of the main reasons why droopy brow occurs.
Another cause of droopy brow is when neurotoxin is injected to remove forehead wrinkles and the frontalis muscle is left frozen and therefore unable to lift.
Also, it’s essential to consider the glabellar complex prior to treating the frontalis. If the glabellar complex is active, thus pulling the eyebrows down, while the frontalis forehead muscles are unable to move, you can see why ptosis is more likely to happen.
Our top tips to prevent ptosis
Preventing ptosis on your patient has much to do with the location of injection, the depth of the injection, and proper dosage in order to control migration of the neurotoxin into other areas. Proper dosing to the glabella also supports the frontalis when they’re treated together so that the frontalis isn’t heavy. However, there are other preventative actions you can take before and after treatment.
Be OK with turning down certain patients
It might be tempting to accept every patient who’s willing to pay, but it will save you some trouble if you refuse service for higher-risk individuals. For instance, skin with a high number of wrinkles and looseness might make it more difficult to properly locate the correct spots for injection.
If a patient has a lot of upper eyelid skin laxity, and a naturally heavy brow, it is recommended to avoid injecting frontalis in those patients as they are at a higher risk for ptosis. Most likely a lot of those patients are a good candidate for an upper blepharoplasty. If you’re confident you can treat these patients, that’s your decision. However, if you’re just starting out and haven’t had enough firsthand experience, you should first perform injections under direct supervision and study other credentialed experts conducting the procedure.
Properly dilute the solution
Neurotoxin bleeding into the levator muscle from between the brows (in an attempt to treat eleven lines) is one of the main reasons why droopy brow occurs. Therefore, it’s best to keep your dilution tight in this muscle so you get less spread. Think 1:1 or 1:5 dilution in the glabella complex.
Document everything
Mark each injection site. Make sure you take photographs (in good lighting, including the marks) at all angles both prior to and after treatment. Take before photos at rest, and photos of each muscle animating (you may consider taking video). A follow up in 2 weeks is recommended to assess treatment results and to see if the patient requires a dose adjustment.
Make intradermical injections into the frontalis
For the frontalis muscle, make sure the injection is inserted into the dermis.
Be mindful of glabella injection depths
Deep injections to medial corrugators and procerus, and superficial injections to lateral corrugators (tail end of muscle) will help prevent ptosis.
Educate the patient
Do not simply hand your patient aftercare instructions, especially if they appear they might be at higher risk for ptosis. Take your time to emphasize the importance of the following tips:
- Do not rub or massage the face for at least 48 hours.
- Avoid facials and other beauty treatments involving the face for a week.
- Do not wear a tight hat for at least 24 hours.
- Avoid lying down for at least 4 hours and do not sleep on the face.
- Avoid strenuous physical activity for 24 hours.
Encourage your patient to contact you with any questions or concerns
Making yourself available to your patients—and communicating clearly that you’re happy to speak to them with any post-treatment concerns—will go a long way. Give them a card with your phone number and email, opening days and hours, and if you’re willing, emergency contact information. Schedule a follow up appointment in 2 weeks to assess treatment results.
Have a droopy brow plan in place
Don’t be surprised if your patient asks what steps you’ll take if they do indeed get droopy brows! If ptosis does occur, assess the patient for muscle movement, and add additional units where you see any muscular pulling (glabella, orbicularis oculi to help open and lift). Avoid any more injections to the frontalis muscle if that muscle has been injected. Consider Upneeq drops of 1-2 units of neurotoxin, 1:1 reconstitution to the upper eyelid by the last line.
Lastly, prevention is key. Learn who is not a candidate for frontalis injections (the culprit to a droopy brow) and avoid injecting those clients in that muscle.
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