As a trainer, I get asked quite a bit about the anatomy of the forehead as it pertains to injections. Injectors want to lift the brows without dropping them (as do patients). For more information about this topic you can see my post on the Botox Browlift: http://facialplasticsurgeryinstitute.com/2017/11/17/the-botox-browlift/
So how do the muscles of the brow play together? The larger muscle of the forehead, the Frontalis muscle is actually the only muscle responsible for lifting the brow. If this is injected, then there simply is no other muscle that can elevate the brow. The muscle starts at the top of the head in a layer between the skin and the bone (skull), known as the Galea (Or Galea Aponeurotica)
To know the layers of the scalp, we often use the acronym: SCALP. Skin, Connective tissue and fat, Galeal Aponeurotica, Loose Alveolar Tissue, Pericranium. The Frontalis muscle is continous with the Galeal Aponeurotica and sits above the loose connective tissue. This allows a smooth movement of the muscle. (We see this muscles very clearly when performing brow lifts in the operating room.)
Understanding these origins and insertions allows us to understand how the frontalis muscle works to lift the skin of the brow and create expressions. The muscle starts at the back of the scalp, continuous with the galea and travels forward to insert at the skin of the brow. These fingerlike insertions are spread across nearly the entire brow and sit just below the skin at that level.
Let’s now discuss the corrugator muscle. The corrugator muscle starts on the bone just underneath the middle brow along the rim of the eye socket. This muscle pulls the eyebrow down and inward. Where does it insert? Again (simply) in the skin at the level of the brow, typically around the midpoint of the brow.
So how does one inject the entire corrugator without injecting the frontalis muscle? Quite simply, you can’t! There are so many intermingling fibers that the two all meet in one point at the skin. So what are my tips for injecting as much corrugator as possible without much frontalis muscle? (Which I think is the better question since we are playing a tug of war with the brow and we simply want to weaken the corrugator MORE than the frontalis. There is no way to only weaken one.)
Tips for injecting the corrugators (and procerus) muscles:
- Look at the patient and see them move their muscles. By injecting into the body of the muscle you avoid a lot of the pitfalls of guessing where the muscle is and your injections will be more effective. See where the muscle belly is located, pinch it, then inject it.
- Use more botox or dysport at the origin of the muscle along the bone and less towards the tail of the corrugator. These are the injections towards the midline which are the origins of the muscle along the bone (So deeper injections at this point, usually 5-7mm deep).
- For your superficial injections along the tail of the corrugator, stay superficial and target right where the muscle is pulling maximally. Keep this injection slightly less than the other injections to minimize spread to the surrounding frontalis muscle. I perform this injection at a shallow angle to only catch superficial fibers and try to minimize my volume.
Hope that helps some of you to conceptualize this relationship. Check out some of the botox and surgery before and after photos for examples. Happy injecting and email me if you have any questions – jordan@rihanimd.com
Thanks!
Dr. Jordan Rihani is a national trainer and lecturer on both surgical and injectable treatments and is considered one of the top injectors in Dallas Fort Worth. In addition to his practice, he is a clinical assistant professor at UT Southwestern Medical Center. He performs deep plane facelift, browlift, rhinoplasty, eyelid lifts as well as injectables in both Fort Worth and Southlake Texas. If you are interested in seeing Dr. Rihani for a treatment please give us a call to schedule.
