Pearls and Pitfalls of Botox and Filler Substances in the Upper Third of the Face

  • Seth L. Matarasso


The three aesthetic units that comprise the upper third of the face are the midline glabellar complex, the forehead, and the peri-ocular areas. Unlike rhytids in the lower half of the face, which are static and primarily due to cumulative photodamage and gravitational changes, wrinkles above the zygomatic arch are dynamic and are in large part a result of hypertrophy of the underlying musculature. The deep vertical lines in between the eyebrows are from chronic movement of the brow depressor muscles: the procerus, the bilateral corrugator supercilii, and the medial fibers of the orbicularis oculi (depressor supercilii). The horizontal creases of the forehead are the result of the brow elevator, the frontalis muscle, and the arciform perioribital lines (the crow’s feet) are due to the lateral fibers of the orbicularis oculi muscle. There are many treatment options available to improve these lines, including surgery as well as the ever-expanding list of new filler agents and lasers. However, as with any intervention, the treatment should be aimed at the underlying pathology, and as such the treatment of choice for rhytids in the upper third of the face is chemodenervation with botulinum toxin. A small amount of botulinum toxin injected precisely into facial muscles renders them immobile and releases the superimposed cutaneous defect and rhytid (Table 123.1) Currently the sole FDA-approved neurotoxin is Botox (Allergan Inc., Irvine, CA) and the only cosmetic indication is “for the temporary improvement in appearance of moderate to severe glabellar lines associated with corrugator and/or procerus muscle activity in adult patients 65 years of age or younger.” All other uses are considered off-label.1,2
Table 123.1.

General Dosing Guidelines for the Treatment of the Upper Third of the Face with Botox


Botulinum Toxin Zygomatic Arch Orbicularis Oculus Corrugator Supercilii Brow Lift 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


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Copyright information

© Springer Science+Business Media, LLC 2008

Authors and Affiliations

  • Seth L. Matarasso
    • 1
  1. 1.Department of DermatologyUniversity of California, San FranciscoSan FranciscoUSA

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