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These markings form aseries of contiguous trian-gles. Inject 3 units of Botoxin each of the areas of thecorrugator and procerusmuscles in the glabellarregion and at the “M spot”if a chemical brow lift isdesired. Three units may beinjected at the frontalis mus-cle markings. Alternatively,using our extended pattern,stagger injections of 1.5units (per injection) aroundthe markings in the frontalisterritory (Figure 3).

Results

We have corrected glabellar and forehead wrinklesusing this pattern and have not noted any cases of browand upper lid ptosis. Rarely will patients perceive theirdeformity as having been undercorrected and requireadditional Botox treatments.

Discussion

Unlike traditional surgical treatments for forehead andbrow rhytids, Botox achieves results by altering the dynam-ic muscular forces that act on the upper third of the face.1

Complications of Botox administration may include ecchy-mosis; diplopia; incomplete eyelid closure; brow, eyelid andlip ptosis; and decreased tear expression.2,3 Anecdotalreports of eyelid spasm have also been documented.4 Theefficacy of forehead rejuvenation using Botox has been wellstudied and reported in the literature.4-6

Given the benefits of Botox, more and more healthcare providers from different areas of specialization areusing it to treat aesthetic concerns. Because of providers’varied training backgrounds, there is a need for standard-ized and systematic treatment methods.7 The triangularand extended triangular pattern of Botox administrationrepresents a standardized method for forehead rejuvena-tion. Our techniques rely on the identification of clear

A Triangular Pattern for Botox ForeheadRejuvenation

Michael Bain, MD, MMS,Newport Beach, CA, is aplastic surgeon. Co-authors:Richard Shih, MD; JohnnyChung, MD; and Robert X.Murphy, Jr., MD, MS.

The authors contend that their triangular pattern ofBotox administration provides reproducible correctionof both static and dynamic forehead wrinkles with min-imal risk of brow and upper lid ptosis. Further, byvarying dosage and injection technique, mimetic func-tion may be preserved or obliterated. (Aesthetic Surg J2006;26:617–619.)

Facial rejuvenation using botulinum toxin type A(Botox, Allergan, Inc., Irvine, CA) is currently themost sought-after aesthetic procedure in the

United States. Ease of administration, lack of downtime,and relative efficiency in reducing facial rhytids accountfor its popularity. Complications are rare. However,patients may express dissatisfaction when treatment doesnot completely ablate wrinkles, or when brow or upperlid ptosis occurs. Further, some patients complain thatthe resulting total paralysis of the forehead and glabellarregion does not allow for expressive facial movements.Here, we present patterns for Botox injection that pro-vide facial rejuvenation, minimize the possibility of pto-sis, and preserve some mimetic function, if desired.

Method

Reconstitute Botox in the standard fashion, so thatyou have a dilution of 3 units per 0.1 mL. Mark thepatient anatomically (Figures 1 and 2):

• Place the first pair of marks, the “M” spot, 0.5 cmbelow the lateral brow on each side.

• Place the second pair of marks in the midpupillaryline, halfway between the eyebrow and the frontalscalp on each side.

• Place the fifth mark at the vertex of the forehead. • Place the sixth mark in the midline, just below the

meeting of the eyebrows. • Place the seventh mark in the midline of the fore-

head, halfway between the nasal radix and thevertex of the scalp.

• Finally, place a pair of marks over the corruga-tors, approximately 1 cm above the medial por-tion of each eyebrow.

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anatomical landmarks, can be easily taught, minimizethe possibility of complications, and yield pleasing,reproducible results.

Efficacy and low complication risk associated withany successful method of Botox administration are deter-mined by relevant facial anatomy. The “M” spot (0.5 cmbelow the lateral brow on each side) corresponds withthe underlying lateral and superior fibers of the orbicu-laris oculi muscles, which act as brow depressors.4

Injections superior to this point inactivate the inferiorfibers of the frontalis muscle, yielding brow ptosis.Injections inferior to this point risk inactivation of thelevator palpebrae muscle, causing eyelid ptosis.Injections 1 cm above the medial eyebrows, and midlineinjections just below the meeting of the eyebrows andmidway between the nasal radix and the vertex of thescalp, paralyze the underlying corrugators and procerusmuscle. It is important to note that traditional drawings

Figure 1. Triangular pattern of injection.

Figure 2. Anatomic reference.

Figure 3. Extended triangular pattern of injection.

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of the corrugator muscles do not adequately define theextent and the width of the corrugator muscle. Our pat-terns address this concern, thereby eliminating the asso-ciated vertical glabellar and horizontal radix rhytids.5

The remaining injections in the frontalis muscle distribu-tion eliminate the contribution of the frontalis muscle toforehead rhytids. All of the injection sites in the triangu-lar pattern avoid the orbital rim where injections havebeen associated with eyelid ptosis, decreased tear expres-sion, lateral rectus paralysis, and diplopia.4,6-8

Maas and Kim6 reported in 2003 that they decreased theamount of Botox injection into the frontalis distribution(from 16 to 24 units down to 12 to 16 units) and increasedthe injection-free zone above the brow to 2 cm. This result-ed in a decreased risk of brow ptosis with a concurrentincrease in persistent rhytids. Our technique uses injectionsgreater than 1 cm above the medial eyebrows, and we havenot observed brow ptosis in any of our patients.

By adjusting dosing (3.0 units vs 1.5 units) and injec-tion patterns (triangular vs extended technique), varyingdegrees of facial animation can be preserved. We havefound that use of between 30 and 40 units is adequatefor retention of mimetic function with decrease in staticand dynamic rhytids; use of 50 units or more is necessaryfor complete obliteration of mimetic function. Many ofour patients have found this flexibility to be a particular-ly appealing characteristic of our approach. ■

References1. Koch RJ, Troell RJ, Goode RL. Contemporary management of the

aging brow and forehead. Laryngoscope 1997;107:710-715.

2. Matarasso SL. Decreased tear expression with an abnormalSchirmer’s test following botulinum toxin type A for the treatment oflateral canthal rhytides. Dermatolog Surg 2002;28:149-152.

3. Matarasso SL. Complications of botulinum A exotoxin for hyperfunc-tional lines. Dermatolog Surg 1998;24:1249-1254.

4. Matarasso SL, Matarasso A. “M” marks the spot: update on treat-ment guidelines for botulinum toxin type A for the periocular area.Plast Reconstr Surg 2003;112:1470-1472.

5. Ahn MS, Catten M, Maas C. Temporal brow lift using botulinum toxinA. Plast Reconstr Surg 2000;105:1129-1135; disc. p. 1136-1139.

6. Maas CS, Kim EJ. Temporal brow lift using botulinum toxin A: anupdate. Plast Reconstr Surg 2003;112:109S-112S; disc. 113S-114S.

7. Carruthers J, Fagien S, Matarasso SL. The Botox Consensus Group.Consensus recommendations on the use of botulinum toxin type A infacial aesthetics. Plast Reconstr Surg 2004;114:1S-22S.

8. Parsa FD. How to avoid eyelid ptosis when injecting botulinum toxininto the corrugators. Plast Reconstr Surg 2000;105:1564-1565.

Reprint requests: Michael Bain, MD, Lehigh Valley Hospital, Department ofSurgery, PO Box 689, Allentown, PA 18105.

Copyright 2006 by The American Society for Aesthetic Plastic Surgery, Inc.

1090-820X/$32.00

doi:10.1016/j.asj.2006.07.005

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