Background: Frown lines are a major concern for many people as they make them look like they are scowling and angry. The frown lines are one of the major undesired facial features that have accounted for the meteoric rise in Botox sales and for making it a household name. Unknown to most, frown lines are actually the only FDA-approved cosmetic indication for Botox, even though it is widely off-label for other facial areas.
Despite the success of Botox in reducing the undesired actions on the skin between the eyebrows (aka glabella) of the corrugator and procerus muscles, one’s frown lines may not go completely away. Once the long-term actions of the muscles have permanently etched lines or grooves into the skin, muscle weakening along will reduce but not eliminate them. Botox is successful for the treatment of dynamic wrinkling (lines that appear when the face moves), static wrinkling (even when one is not moving muscles) requires a different or companion approach.
Case Study: This is a case of a 50 year-old female who was bothered by her scowling and the unhappy expression that the lines into between her eyebrows gave. She has received Botox injections and, while it was better, still had some obvious vertical furrows in the glabellar area. She desired further efforts on reduction of these lines.
Adding some form of soft tissue filling is the next treatment strategy. Most commonly this is done with injectable fillers which are widely used. She did undergo Radiesse filler injections and was pleased with the results but wanted something that would last longer.
Other forms of soft tissue filling of facial lines and furrows are non-injectable and require a more invasive approach. (although not that much more invasive) Graft or filling options include one’s own fat, allograft dermal grafts (off-the-shelf) and a synthetic implant. (Advanta, also known as PTFE or Gore-Tex)
She desired a collagen-based implant over that of a synthetic one. Through two small nick incisions, above and below the vertical glabellar lines, the soft rehydrated dermal grafts were cut and threaded underneath. This was done as a simple in-office procedure under local anesthesia that took about 15 minutes to do. This provided her with a result that was equal to that of injectable fillers but which would last much longer. She remains with good results one year after procedure.
Adding an injectable filler or a dermal graft to glabellar furrows does not mean that one no longer needs muscle-reducing Botox injections. Deep glabellar furrows requires a double approach in some cases to get the best result, treating both the muscular hyperactivity and the skin
etching.
Case Highlights:
1) Deep glabellar furrows or wrinkles may be reduced by controlling the muscle action with Botox but will not be completely gone. In long-established frowning, the skin becomes permanently indented which is not responsive to reducing muscle action alone.
2) Soft tissue filling is a companion treatment to Botox for deep glabellar lines. Treatment options include temporary injectable fillers or longer-lasting implants.
3) While Botox and soft tissue fillers can be done at the same time, it is usually best to do Botox first and see what the results are. Management of the grooved skin can always be done later if further improvement is desired.
Dr. Barry Eppley
Indianapolis, Indiana