Upper face treatments with Botox often revolve around the mitigation of frown lines, commonly referred to as glabellar or “11” lines, which form due to the hyperactivity of specific muscles, primarily the corrugator supercilii and procerus muscles, which are responsible for pulling the eyebrows together.
While Botox injections in the upper face can result in remarkable aesthetic improvements, the potential for side effects necessitates a meticulous and individualized patient approach to prevent Botox upper face complications. This article is dedicated to informing healthcare providers about the solutions for minimizing the risks connected to this treatment.
Common Complications With Upper Face Botox Treatment
Botulinum toxin type A (Botox-A) injections in the upper face can result in transformative aesthetic outcomes; however, they have some potential complications. The main ones related to Botox injections in the upper face area are the following:
- Ptosis, the drooping of the upper eyelid or eyebrow, occurs when the neurotoxin spreads to unintended areas, affecting the levator palpebrae superioris or frontalis muscles.
- Eyebrow asymmetry may arise due to variations in muscle response, facial anatomy, or injection technique. Patients may express dissatisfaction if their eyebrows appear uneven.
- Diplopia (double vision) can occur when Botox diffuses to the extraocular muscles, affecting their function.
- Lagophthalmos is the inability to close the eyelids fully. This complication can result from the diffusion of Botox into the orbicularis oculi muscle, which is responsible for closing the eyelids.
- Palpebral ectropion refers to the outward turning of the lower eyelid. It can occur if Botox inadvertently affects the lower eyelid muscles.
- The prominence of palpebral bags may occur due to Botox treatments in the upper face, particularly in the forehead.
- Allergic reactions to the components of the drug.
- Headaches and flu-like symptoms.
- Bruising, swelling, and discomfort in the area of Botox application.
Below, we will explore the methods and techniques that can help doctors prevent Botox upper face complications.
A thorough patient selection process is essential before starting any Botox procedure in the upper face area. It should entail a detailed medical history review, including any prior cosmetic procedures or underlying medical conditions. Doctors should explore patient expectations and motivations to ensure that their goals align with the potential outcomes achievable through Botox treatment.
There are also several contraindications for patients regarding these types of treatments:
- A history of neuromuscular disorders, such as myasthenia gravis or Lambert-Eaton syndrome;
- Kelodial scarring;
- Allergies to the components of the drug;
- Pregnancy and lactation period;
- Body dysmorphic disorder.
Dosage Selection and Injection Techniques
Determining the appropriate dosage of Botox is an essential aspect of upper face treatments. It depends on factors such as:
- Patient’s age;
- Muscle strength;
- The severity of the patient’s frown lines.
Generally, a total dosage of 20-30 units of the drug is distributed across the procerus and corrugator muscles to minimize the risk of Botox upper face side effects and achieve optimal results.
A deep knowledge of facial anatomy is vital for accurate injection site selection. The procerus muscle, for instance, is a small, triangular muscle that pulls the eyebrows down and contributes to the formation of frown lines. Injection points for this muscle are typically situated at the midline of the forehead, slightly above the bridge of the nose.
The corrugator muscles, responsible for the vertical furrows between the eyebrows, are targeted with injections slightly above the lateral aspect of the eyebrows.
Good injection technique helps avoid Botox side effects. The fine-gauge needles (typically 30-gauge) are recommended for precise and controlled injections. A microdroplet technique involving multiple small injections in the target muscle is commonly employed to ensure uniform distribution of Botox and reduce the risk of ptosis.
Maintaining sterile conditions throughout the procedure is essential in preventing infection and other Botox complications. Properly disinfecting the patient’s skin and using aseptic techniques during injection are non-negotiable practices.
There are also specific regions that demand extreme caution. The periocular region, which encompasses the eyelids and surrounding areas, is particularly delicate and requires a meticulous approach. Doctors must take extreme caution to avoid injecting Botox too close to the upper eyelid margin, as diffusion into the levator palpebrae superioris can lead to ptosis.
Other areas requiring special caution are the frontalis muscles and the glabella region on the forehead. Precise drug dosage and placement in this region are critical to achieving a natural and aesthetically pleasing outcome.
Post-Treatment Care Instructions
Effective post-treatment care instructions are crucial in preventing complications and ensuring patient satisfaction. Patients should be advised to remain upright for a few hours after the procedure to minimize the risk of Botox migration. They should also avoid strenuous physical activities for at least 24 hours and refrain from touching or massaging the treated area.
Educate patients about the potential onset of action, which typically occurs within 3 to 5 days but can take up to two weeks to reach full effect.
In cases where patients experience minor bruising or swelling, reassure them that these effects are typically transient and will resolve on their own, but emphasize the importance of seeking medical help if they notice any severe or persistent side effects, such as ptosis, significant swelling, asymmetry, or allergic reactions.
Botulinum toxin injections in the upper face are a medical procedure with associated risks. An understanding of possible complications, along with strategies for prevention, is essential for healthcare providers specializing in aesthetic medicine.
By adhering to the recommendations from this article and demonstrating expertise in the administration of Botox, doctors can minimize the likelihood of Botox upper face risks and increase patient satisfaction and procedure safety. If complications do arise, doctors must evaluate and manage them promptly.
What are the most common complications of upper face Botox?
Here are some of the most common complications associated with upper-face Botox injections:
- Pain, discomfort, or a feeling of tightness at the injection site;
- Headaches, particularly in the forehead area;
- Drooping eyelids (ptosis);
- Slight asymmetry in facial expressions;
- Allergic reaction to Botox (itching, rash, hives, swelling, dizziness, and difficulty breathing);
- Infection at the injection site;
- Temporary numbness or tingling at or around the injection site.
The majority of these complications are temporary and resolve on their own.
How can complications be avoided when injecting Botox?
Here are recommendations for healthcare providers on how to avoid Botox upper face complications:
- Conduct a comprehensive consultation with the patient to understand their goals and medical history.
- Calculate and administer the appropriate dosage of Botox based on the patient’s needs and desired outcomes. Avoid overuse or excessive dosing to prevent unnatural results.
- Possess a thorough knowledge of facial anatomy to accurately identify and target the specific muscles responsible for the wrinkles that need to be treated.
- Use precise injection techniques to ensure accurate placement.
- Use the appropriate needle size and gauge for the procedure.
- Ensure the injection site and its surroundings are clean and maintained under sterile conditions to prevent infection.
- Provide patients with clear post-injection care instructions, including recommendations such as avoiding strenuous physical activities, refraining from touching or massaging the treated area, and remaining upright for a specified period post-treatment.
Where should you avoid injecting Botox?
There are specific zones on the upper face where botulinum toxin injections should be avoided or used with extreme caution to prevent undesirable effects or complications from Botox:
- Periocular area – the muscles around the eyes are delicate, and improper injections can lead to complications like ptosis or an unnatural appearance.
- Injecting Botox too close to the eyebrows and in the glabella region can lead to changes in eyebrow shape or position, resulting in a “droopy” or “hooded” appearance.
- While the forehead is a common area for Botox injections to reduce horizontal forehead lines, it’s important not to over-inject, which could lead to a frozen or unnatural look. Also, when Botox injections are administered too close to frontalis muscles, it can affect the blood vessels and cause complications.
Borba A, Matayoshi S, Rodrigues M. Avoiding Complications on the Upper Face Treatment With Botulinum Toxin: A Practical Guide. Aesthetic Plast Surg. 2022;46(1):385-394. doi:10.1007/s00266-021-02483-1.
Jia Z, Lu H, Yang X, et al. Adverse Events of Botulinum Toxin Type A in Facial Rejuvenation: A Systematic Review and Meta-Analysis. Aesthetic Plast Surg. 2016;40(5):769-777. doi:10.1007/s00266-016-0682-1.
Zargaran D, Zoller F, Zargaran A, et al. Complications of Cosmetic Botulinum Toxin A Injections to the Upper Face: A Systematic Review and Meta-Analysis. Aesthet Surg J. 2022;42(5):NP327-NP336. doi:10.1093/asj/sjac036.
Klein AW. Contraindications and complications with the use of botulinum toxin. Clin Dermatol. 2004;22(1):66-75. doi:10.1016/j.clindermatol.2003.12.026.
Sethi N, Singh S, DeBoulle K, Rahman E. A Review of Complications Due to the Use of Botulinum Toxin A for Cosmetic Indications. Aesthetic Plastic Surgery. 2020;45(3):1210-1220. doi:10.1007/s00266-020-01983-w.
Lowe NJ, Shah A, Lowe PL, Patnaik R. Dosing, efficacy, and safety plus the use of computerized photography for botulinum toxins type A for upper facial lines. J Cosmet Laser Ther. 2010;12:106–111. doi: 10.3109/14764170903480013.