Dr. Niamtu’s Weblog

….on cosmetic facial surgery

Botox Customization and the Droopy Brow

The discovery of neuromodulators to treat hyperfunctional lines was the cosmetic shot heard around the world and ushered in the most popular cosmetic procedure in the world.  When I began injecting Botox in 1996, it was a pretty much unheard of cosmetic therapy and the “pretty poison” was only used by those early adapters.  Back in the day, patients wanted paralysis, plain and simple.  If I injected a patient and they had even minimal muscle movement, they considered it a failure and wanted a refund.  It was not hard (still isn’t) to pick out those patients with mask-like expressions from total upper facial paralysis.

Things have changed greatly in the past decade.  Botox (and now Dysport, and soon to be others) has become an everyday procedure and the fear from “the toxin” has diminished.  What has also diminished is the desire for patients to look “done”.  Contemporary cosmetic surgery patients desire the ability to retain positive animation while stopping negative animation such as scowling.  After being injected for years, most patients now have an appreciation for exactly what they want their Botox to do.  Whereas in the past, they came in for injection and said “do what you think I need”, now they come in with their own tailor made request of units and injection patterns.  Although this bothers some surgeons, I welcome this “Botox customization”; after all, we are here to please the patient.

It is now common for patients to stretch or disperse their Botox units to achieve what they want.  I also feel that the sour economy we have seen over the last several have added to this where patients are trying to get more for their buck.

The most common customizations I see are in the glabella and frontalis.  Whereas the traditional 5 point glabellar injection is still the most common treatment, numerous patients present and request a more central glabellar treatment because fear of “lowering their eyelids”.  The same thing has occurred in my practice with the frontalis.  First of all the frontalis was the second most requested treatment in my office for over a decade, but has fallen to number three with the lateral canthal regions (crow’s feet) now being second.  The main reason for backing off of the frontalis is the fact that when coupled with glabellar treatment, a significant loss of animation can occur.  Again “my eyelids get droopy” (the real truth about this later) is a complaint from aggressively treating both glabella and frontalis.  This trend has led to my frequently injecting the glabella and using “half the units” on the frontalis.

Cosmetic surgery patients are finicky, but when patients feel that they have “droopy lids” from Botox, they can become livid and rebellious.  Proportionately, it seems patients can get madder about this condition than most other “real” cosmetic surgery complications.

Patients must understand the pathology of the “droopy Botox brow”.  Botox cannot make extra skin, but it can prevent patients from elevating their brow.  Many females, especially those with excess lid skin, perpetually elevate their brows.  It is subconscious and they cannot help or control it, they simply spend their waking hours with their brows elevated.  Ask any surgeon who performs brow lifts and they will confirm that it is impossible to take a before picture on many women with their brows relaxed.  Herein lies the problem.  When patients with excess upper eyelid skin raise their brow (via the frontalis muscle) they have the appearance of having less excess upper eyelid skin because the skin is stretched.  In some cases, they can also see better as the obstructing skin is elevated, hence improving vision.  If these patients are aggressively treated with a neuromodulator and cannot elevate their brow, they notice the extra eyelid skin (usually about 3 days after injection while applying eye makeup) and can become quite upset.  They think that the Botox gave them extra skin (impossible) or that they have true upper eyelid muscular ptosis (extremely rare).  What they frequently fail to understand is that they are chronic brow elevators and now they cannot elevate to their preinjection level.  The picture below is of your truly.  Admittedly, I need blepharoplasty or a brow lift.  I am bald, so the brow lift is out the window and I am simply too busy fixing everyone else to have my own blepharoplasty.  In the top picture, I am raising my brow and I look better that the bottom picture with my brow relaxed.  This picture tells the story!

It is imperative (especially for novice injectors) to recognize patients (usually older females with excess upper lid skin) who may be at risk for the “low brow”.  In these patients, especially those who are getting Botox for the first time, it is best not to inject the glabella and frontalis at the same time.  If the patient has a low hairline, the glabellar injection can deactivate a good portion of the frontalis.  If the frontalis and the glabella are to be simultaneously injected, it is better to use only 10 units of Botox (or 30 units of Dysport) over the entire frontalis to lessen the effect.  Also a good idea on any person is to taper off the Botox units and injections over the lateral brow.  Having a good central effect with a lateral tapering effect will still allow brow elevation.

Unfortunately, we cannot reverse neuromodulators so an unhappy patient may be unhappy for several months.  Fortunately, the lateral brow elevations seems to return before all the toxin is worn off.   The inventor of a botulinum toxin reversal agent will be a wealthy man or woman!

My advice to novice injectors is to include discussion of the above in the consent and to treat lightly with the frontalis.  My advice to patients is to be conservative as more Botox can always be added and to realize they may be in need of a browlift or blepharoplasty.

To find out more about cosmetic facial surgery by Dr. Joe Niamtu in Richmond, Virginia, visit


Joe Niamtu, III DMD

Cosmetic Facial Surgery

Richmond, Virginia

April 25, 2010 Posted by | Botox, Brow Lift Surgery, Minimally Invasive Cosmetic Facial Surgery, Risks of Cosmetic Surgery, Uncategorized | , , | Leave a comment

Eyelid Surgery Vs Browlift: What’s it all about?

One of the most common points of confusion in cosmetic facial surgery is  understanding the diagnosis and treatment options between eyelid surgery and brow and forehead lift surgery.

Put plain and simple, the brow and forehead are intimately related to the eyelids in youth and aging.  If you look at your picture in your 40’s or 50’s and compare them to your high school picture, the chances are that your brow has drooped, your forehead has wrinkled and your eyelids have excessive skin, muscle and fat.

Although cosmetic eyelid surgery is one of the most popular procedures worldwide, many times people have skin removed from their upper eyelids when in fact they should have a brow and forehead lift.  The problem with misdiagnosing the need for browlift surgery is that if a patient has excessive skin removed from his or her eyelids then it may be impossible in the future to have a brow lift as there will not be enough skin left  to close the eye.  Likewise, even if conservative skin removal is performed and then repeated later a brow lift may be impossible.  Finally, if a patient already has low brows and more skin is removed, the brow can be lowered even more. So, what do you do?

Basically, when you seek a consult for upper eyelid rejuvenation, if the doctor does not mention the word “brow” in the first several sentences, you should seek another opinion.  This is because many surgeons do not understand the extreme importance of upper facial aesthetics.  In female patients, the brow normally sits above the upper bony rim of the eye socket (superior orbital rim).  If you ( as a female) reach up and feel your brow and it sits at or below the rim, you may be a candidate for a brow lift.  In males, the brow usually sits at the orbital rim.

Not every patient is a candidate for brow and forehead lifting, but many patients are.  If you look in a mirror and relax your brow and forehead and they gently elevate your brow on the middle and lateral portions regions you can see a preview of what a brow and forehead lift may do.  In the average patient a brow lift of 5-8 millimeters (less than ½ inch) will produce a more youthful, alert, awake and open eyed look.  When I manually elevate a patient’s brow they either love it and say “that is how I used to look years ago” or they feel that it is excessive or unnatural.  Obviously, browlift is not an option unless one likes the look.  In my experience about 60% of patients like the look and the other 40% don’t like the look.  There is no doubt that an excessively elevated brow looks very fake, so conservative surgery is imperative for a natural look.

For those that do like the elevate brow appearance, they will notice that it elevates the most lateral (side) region of the brow.  As this area gets saggy, it causes a “sad puppy” appearance which doctors call lateral hooding.  Elevating this hooding makes most patients look younger.  You will also notice when you elevate the brow that the excess eyelid skin significantly improves.  This is because elevating the brow lifts the saggy tissues and fat and repositions them to a more youthful position.  Many times, patients present to the office asking for blepharoplasty (cosmetic eyelid surgery) and after education them, they opt for brow and forehead lift which corrects the upper eyelid aging as well as the sagging brow and forehead.  Patients with significant excess skin or fat may need eyelid surgery and browlift at the same time.  Another benefit of brow and forehead lift surgery is the ability to improve forehead wrinkles by tightening the forehead skin.

Obviously, not all patients need brow and forehead lift as many patients do not want or need their brows elevated.  In these patients, removal of skin, muscle and fat on the upper eyelids is all that is necessary.  A brow lift is a more comprehensive procedure and is a bigger surgery with a longer recovery when compared to blepharoplasty.  When I perform blepharoplasty I don’t use scissors or scalpels, but rather high tech devices such as CO2 laser and radiowave surgery.  These modalities prohibit bleeding and blood loss is several drops.  Less bleeding means, less bruising, less swelling, less pain and faster healing.  Normally surgery on all four eyelids take about an hour and is usually performed with light sedation.  The recovery is generally one week, although most patients are up and around in less time.

Most old fashioned brow lifts were performed by a very aggressive incision at the top of the head to reflect the entire front scalp during the procedure (coronal brow lift).  Contemporary brow and forehead lift is frequently performed with endoscopic surgery through small, button hole incisions hidden in the hairline.  Another very popular contemporary method of brow and forehead lift is the mini open brow technique.  In this technique, a small incision is made just behind the hairline in a very specialized manner to allow the hair to regrow through the scar, making it extremely cosmetic.  One big advantage of the mini open procedure is that it does not raise the hairline.  All other brow lift procedures will raise the hairline to some extent.  This is not a problem for patients with low hairlines, but many females already have elevated hairlines and would not look good with an even higher hairline.   There are pluses and minuses of both of these procedures and each patient is different.  A competent surgeon will offer multiple means of performing brow and forehead lift to tailor a custom procedure for that specific patient. 

The take home message here is that if you think you need your upper eyelids improved, success may lie in eyelid tuck, brow and forehead lift or both.  If your surgeon does not offer both options or discuss the importance of either, a second opinion may be in order.


Joe Niamtu, III DMD

Cosmetic Facial Surger

Richmond, Virginia


March 6, 2008 Posted by | Brow Lift Surgery, Eyelid Surgery | , , , , | Leave a comment