| |

Received: 22 January 2021    Revised: 15 March 2021    Accepted: 30 March 2021

DOI: 10.1111/jocd.14133

ORIGINAL CONTRIBUTION

Respecting upper facial anatomy for treating the glabella

with neuromodulators to avoid medial brow ptosis—­A refined
3-­point injection technique

Sebastian Cotofana MD, PhD1  | Angela P. Pedraza MD2 | Joely Kaufman MD3 |

Luiz E.T. Avelar MD4 | Diana L. Gavril MD5 | Claudia A. Hernandez MD6 |
Emy C. Onishi MD7 | Andreas Nikolis MD8,9  | Thais Sakuma MD10  |
Konstantin Frank MD11
1
Department of Clinical Anatomy, Mayo
Clinic College of Medicine and Science, Abstract
Rochester, MN, USA
Background: Current injection algorithms for treating the glabella rely on a five-­ or
2
Private Practice, Bogota, Colombia
3
seven-­point injection technique with possible medial eyebrow ptosis and lateral eye-
Skin Associates of South Florida and Skin
Research Institute, Coral Gables, FL, USA brow elevation as undesirable outcomes.
4
Private Practice, Belo Horizonte, Brazil Objective: The objective of this study was to investigate the efficacy and safety profile
5
Private Practice, Cluj-­Napoca, Romania of a refined 3-­point injection technique targeting horizontal and vertical glabellar lines.
6
CH Dermatologia, Medellin, Colombia
Methods: A total of n=105 patients (27 males and 78 females) with a mean age of
7
Private Practice, Manila, Philippines
8
40.90 ± 9.2 years were investigated. The injection technique relied on targeting the
Clinical Research Unit, Erevna
Innovations Inc, Montreal, Quebec, muscular origin of the procerus and the corrugator supercilii muscles exclusively. The
Canada time of effect onset and the injection-­related outcome 120 days after the treatment
9
Division of Plastic Surgery, McGill
was evaluated using the 5-­point glabellar line severity scale.
University, Montreal, Quebec, Canada
10
Private Practice, Campo Grande, Brazil Results: The onset of the neuromodulator effect was on average 3.5 ± 1.5 days. There
11
Department for Hand, Plastic and was no statistically significant difference in the amplitude of movement before or
Aesthetic Surgery, Ludwig–­Maximilian
14 days after the treatment with 2.99 ± 4.4 mm vs. 3.39 ± 3.6 mm (p = 0.149) for the
University Munich, Munich, Germany
medial head of the eyebrow and with 3.18 ± 4.7 mm vs. 3.33 ± 4.3 mm (p = 0.510) for
Correspondence
the lateral head of the eyebrow, respectively.
Sebastian Cotofana, Department of
Clinical Anatomy, Mayo Clinic College of Conclusion: Incorporating anatomic concepts into clinical practice for glabellar frown
Medicine and Science, Mayo Clinic, Stabile
line neuromodulator treatments with the investigated 3-­point injection technique re-
Building 9-­38, 200 First Street, Rochester,
MN, 55905, USA. sulted in the absence of adverse events like eyebrow ptosis, upper eyelid ptosis, me-
Email: cotofana.sebastian@mayo.edu
dial eyebrow ptosis, and lateral frontalis hyperactivity. This technique demonstrated
efficacy throughout the 4-­month study period.

KEYWORDS
abobotulinum toxin, corrugator supercilii muscle, glabellar frown lines, incobotulinum toxin,
onabotulinum toxin, procerus muscle

J Cosmet Dermatol. 2021;00:1–9. wileyonlinelibrary.com/journal/jocd© 2021 Wiley Periodicals LLC.     1 |

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2      COTOFANA et al.
1  |  I NTRO D U C TI O N
Neuromodulator treatments of the face account for 48.2% of
all non-­surgical aesthetic procedures worldwide with more than
6 million injections performed in 2018, according to the global
survey of the International Society of Aesthetic Plastic Surgery
(ISAPS).1 Toxin injection techniques vary depending on facial re-
gion treated and manufacturer guidelines which offer predefined
injection points to guide experts and novices toward predictable
2-­4
outcomes.
Recent facial anatomic research findings provide for a more
accurate estimation of the underlying muscular anatomy from skin
surface landmarks, thus influencing neuromodulator treatment al-
5-­7
gorithms. In 2017, a cadaveric study related the shape of the hor-
izontal forehead lines to the underlying muscle fascicle angle of the
frontalis muscle and formed a fundament for skin surface relation-
ships.5 These results were confirmed in 2019 in a clinical study utiliz-
ing skin vector displacement technology and revealed that the shape
of horizontal forehead lines are statistically significantly related to
the direction of forehead skin movement.6 Utilizing the same tech-
nology, in 2020 the bi-­directional movement of the frontalis muscle
was described and an explanatory model for eyebrow ptosis after
neuromodulator application in the lower part of the forehead was
proposed.7 The authors introduced the “Line of Convergence” which
separated the frontalis muscle into an eyebrow-­elevation segment
(=lower forehead) and into a hairline-­depression segment (=upper
7
forehead). This segmentation of the frontalis muscle provides a
mechanism by why neuromodulators injections into the lower fore-
head may result in eyebrow ptosis.
Current injection algorithms for treating the glabella rely on a 5-­
or 7-­point injection technique, 2,8 which target the procerus and the
medial and the lateral aspects of the corrugator supercilii muscles;
the latter is injected above the eyebrow. The reported incidence
9
rates for eyebrow ptosis were reported to be at 3.1% and to be
independent of the product administered.10 The explanatory model
for this adverse event is that the eyebrow elevation segment of the
frontalis muscle is affected, which results in an inability to elevate
the eyebrow and to act as an antagonist for the eyebrow depressors
at rest. Although eyebrow ptosis is not long-­lasting, it can cause sig-
nificant patient dissatisfaction and should be avoided. However, cur-
rent injection algorithms target the lower forehead despite its close
proximity to the upper margin of the eyebrow. A deeper understand-
ing of the underlying anatomy may suggest an injection algorithm
which would not administer neuromodulators cranial to the level of
the hairy eyebrows.
Therefore, it is the aim of this study to present a refined 3-­point
injection algorithm which is based exclusively on the anatomy of
the procerus and corrugator supercilii muscles. The investigated
injection algorithm targets the bony origin of those two muscles
without additional product administration above the level of the
hairy eyebrow. The time to onset of neuromodulator effect and the
injection-­related outcome 120 days after the treatment is evaluated
using the 5-­point glabellar line severity scale.11
2  |  M ATE R I A L S A N D M E TH O DS
2.1  |  Study participants
This clinical interventional study investigated the effects on the gla-
bellar frown line severity of a neuromodulator injection technique
in a total of n = 105 patients (27 males and 78 females) with a mean
age of 40.90 ± 9.2 years [range: 22–­59]. Of those were n = 1 (1.0%)
Fitzpatrick type I, n = 19 (18.1%) type II, n = 55 (52.4%) type III, n = 27
(25.7%) type IV and n = 3 type V (2.9%).
Inclusion criteria were age 21 –­60 years, glabellar line severity
with a score at baseline of 1 –­4 (mild to very severe) at maximum
frowning on the validated 5-­p oint (Flynn-­) scale 11
(0 –­ 4; best to
worst), no glabellar or frontal neuromodulator treatment 1  year
prior to the start of the study and the willingness to participate
and to adhere to the scopes of the study which included comple-
tion of the follow-­up period (120  days) and no additional facial
neuromodulator or facial soft tissue filler treatments during the
study follow-­up period.
This study was performed in adherence to the Declaration
of Helsinki (1996), and in accordance with regional laws and good
clinical practice for studies in human subjects.12 IRB Approval was
obtained from Biomedical Research Institute of America (Protocol
Number: SITES01). Written and informed consent was obtained by
all participants prior to the inclusion into the study for the use of
their images and data for research purposes.
2.2  |  Clinical centers
Inclusion and exclusion criteria as well as a precise injection de-
scription were established in a central protocol and distributed to
the participating clinical centers. Participating centers were free to
choose the amount of neuromodulator units injected and the type of
toxin utilized (onabotulinum toxin type A, Allergan, Dublin, Ireland,
n = 16; incobotulinum toxin type A, Merz Pharma, Frankfurt/Main,
Germany, n = 23; abobotulinum toxin type A, Galderma, Lausanne,
Switzerland, n  =  66). The treating physician could choose freely
based on their experience and based on each individual patient's
needs. Standardization across clinical centers occurred only for the
injection technique, that is, the injection location (2-­dimensions) and
injection depth (3-­dimensions) applied. Patients were not included in
this analysis if they had neuromodulator treatment of their glabellar
region or forehead within the last six months prior to the initiation in
this study. Additionally, any soft-­tissue filler, biostimulator, or energy
device-­based treatments were also regarded as exclusion criteria for
this study.
COTOFANA et al.
Patients were treated according to the central protocol in six dif-
ferent clinical centers.
2.3  |  Injection technique
The applied injection technique is a modified version of the pre-
viously described 3-­p oint technique. 8 The modification included
the inferior re-­p osition of all 3 injection points to match precisely
the anatomic origin of the procerus and the corrugator supercilii
muscles.
In detail: the procerus muscle was targeted with one single in-
jection point in the midline at the level of a connecting line between
the left and right medial canthal ligaments; this injection was per-
formed at an perpendicular angle to the nasal bone surface and in
constant and direct contact with the bone. The corrugator muscles
were targeted at the medial and inferior margin of the eyebrows
with a 45-­degree injection angle in relation to the midline and to
the underlying frontal bone with bone contact during the injection
procedure. No additional (lateral) injection points were utilized
(Figures 1, 2).
2.4  |  Outcome assessment
2.4.1  |  Glabellar line severity
Glabellar line severity was assessed before the treatment (=day 0),
14  days after the treatment, 30  days after the treatment, 60  days
after the treatment, 90 days after the treatment, and 120 days after
the treatment. The assessment of the glabellar line severity was
conducted in person at day 0, day 14, and at day 30; further evalu-
ation was performed either in person or via online assessment (tel-
emedicine) for days 90 and 120. Glabellar line severity was assessed
by the treating physician only based on a previously published and
validated 5-­point scale: grade 0 = No glabellar lines, grade 1 = Mild
glabellar lines, grade 2 = Moderate glabellar lines, grade 3 = Severe
11
glabellar lines, and grade 4 = Very severe glabellar lines.
F I G U R E 1  Bar graph showing the
median values for the glabella line severity
scale at each follow-­up assessment
throughout the study period. Whiskers
represent 95% confidence interval
|
      3
2.4.2  |  Time of onset
The time of onset was defined as the decrease by one grade in the
glabellar line severity scale from baseline when assessed by the
treating physician. This assessment was conducted online via tel-
emedicine or via transmitted videos. Those videos were sent by the
patient on a daily basis after the treatment to the treating physician
who documented at what day after the treatment a decrease in one
grade in the glabellar severity scale was first observed.
2.4.3  |  Eyebrow position
The position of the medial and the lateral head of the eyebrows was
measured with a standard—­flexible ruler and results were docu-
mented before the treatment and at day 14 by measuring the dis-
tance (in mm) from the medial and the lateral canthus to the inferior
margin of the hairy eyebrow, respectively. The same measurements
were conducted while asking the patient to maximally contract their
forehead (frontalis muscle).
2.4.4  |  Dosage
The dosage (measured in international units and in Speywood units)
injected into the procerus and into the left/right corrugator supercilii
muscles were documented. Speywood units were converted with
1:1 for onabotulinum toxin type A, 1:1 for incobotulinum toxin type
A and 1:2.5 for abobotulinum toxin type A.13
2.5  |  Statistical analysis
Differences between measurements (male vs. female) were calcu-
lated using independent Student's t test and between baseline and
follow-­up parameters using paired Student's t test. Differences
with ordinal variables (glabellar line severity scale) were com-
puted using Mann-­W hitney U test and Wilcoxon signed-­r ank test.
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4      COTOFANA et al.
Multivariate analyses were run utilizing generalized linear models
with robust estimator and adjustment for age, gender, and total
amount of neuromodulator dosage injected. Analyses were per-
formed using SPSS Statistics 23 (IBM), and differences were con-
sidered statistically significant at a probability level of ≤0.05 to
guide conclusions.
F I G U R E 2  Three injection points demonstrated on a 42-­year-­old
male patient
3  |  R E S U LT S
3.1  |  Dosage
The mean dose for treating the procerus muscle was 5.23 ± 2.5 I.U.
(12.90 ± 6.30 S.U.), whereas the mean dose for treating each corru-
gator supercilii muscle was 13.27 ± 5.7 I.U. (33.17 ± 14.2 S.U.).
3.2  |  Glabellar line severity scale
The median glabellar wrinkle score before treatment was 3 (=severe
glabellar lines) with an IQR (=interquartile range) of 1 [range: 1–­4]. At
14 days after the treatment, the median score was 0 (=no glabellar
lines) with an IQR of 1 [range: 0–­2] representing a statistically sig-
nificant improvement with p < 0.001. At 30 days, the median score
was 0 with an IQR of 1 [range: 0–­3] with p < 0.001 (when compared
to the pre-­treatment score); at 60 days, the median score was 1 with
an IQR of 1 [range: 0 –­3] with p < 0.001 (when compared to the pre-­
treatment score); at 90 days, the median score was 2 with an IQR of
1 [range: 0 –­4] with p < 0.001 (when compared to the pre-­treatment
score); and at 120  days, the median score was 2 with an IQR of 1
[range: 0–­4] with p < 0.001 (when compared to the pre-­treatment
score). Results are shown in Figure 1.
3.3  |  Time of onset
The mean time of onset as defined by the interval in days between the
treatment and the first observed decrease in one grade of the glabellar
F I G U R E 3  Image of a 46-­year-­old
female patient with illustration of the
measurements conducted at rest before
the treatment and 14 days after the
treatment
COTOFANA et al.
line severity scale was on average 3.5  ±  1.5  days [range: 1–­8]. No
statistically significant difference in onset between genders was ob-
served with males 3.44 ± 1.42 days and females 3.56 ± 1.60 days with
p  =  0.731. Stratification by neuromodulator type revealed that on-
abotulinum toxin type A had a mean time of onset of 2.31 ± 0.79 days,
incobotulinum toxin type A 2.74  ±  1.4  day, and abobotulinum toxin
type A 4.11 ± 1.5 days with p < 0.000 across groups.
3.4  |  Eyebrow position
The medial eyebrow increased in height 14 days after treatment (=in-
crease in distance between the medial canthus and the inferior margin of
the medial head of the eyebrow) by 1.21 ± 2.8 mm (p < 0.001), whereas
the lateral head of the eyebrow increased in height by 1.06 ± 2.8 mm
(p  <  0.001). When additionally asking the patient to maximally con-
tract their frontalis muscle the change between baseline and day 14
in eyebrow position was 1.61 ± 2.6 mm for the medial (p < 0.001) and
1.21 ± 1.8 mm (p < 0.001) for the lateral heads of the eyebrow.
There was no statistically significant difference in the amplitude
of movement (=difference in eyebrow position between frontalis
muscle contraction and at rest) before or 14 days after the treatment
with 2.99 ± 4.4 mm vs. 3.39 ± 3.6 mm (p = 0.149) for the medial head
of the eyebrow and with 3.18 ± 4.7 mm vs. 3.33 ± 4.3 mm (p = 0.510)
for the lateral head of the eyebrow, respectively (Figures 3 and 4).
3.5  |  Adverse events and additional observations
No ptosis of the medial or total eyebrow and no ptosis of the upper
eyelid were observed in any of the treated patients during the
F I G U R E 4  Image of a 46-­year-­old
female patient with illustration of the
measurements conducted upon maximal
eyebrow elevation before the treatment
and 14 days after the treatment
|
      5
4-­month follow-­up period of the study. No hyperactive lateral eye-
brow elevation was observed when asking the patients to contract
their frontalis muscle leading clinically to the “Spock” or “Mephisto”
eyebrow shape at any follow-­up assessment (Figures 5 and 6).
4  |  D I S C U S S I O N
The objective of this study was to investigate the efficacy and safety
profile of a refined 3-­point injection technique targeting horizontal
and vertical glabellar lines. The fundament for this injection tech-
nique is the muscular origin of the procerus and the corrugator su-
percilii muscles which is specifically targeted by the applied injection
algorithm.
One strength of the present study is the innovative approach to
determine the 2-­ and 3-­dimensional location of the injection points
purely on anatomy and on the muscular origin of the targeted mus-
cles. Despite the plethora of currently available injection points and
2,8,14
algorithms, the presented injection technique is unique as it
relies exclusively on targeting the origins of the muscles responsi-
ble for glabellar frown lines. Another strength of this study is the
long follow-­up period with 120 days (=4 months), which allows for
evaluation of onset, duration, and the reduction in effectiveness of
the administered neuromodulators. The presentation of this cycle is
important to reveal the true effectiveness of the applied technique
as it accounts for the limited durability of the injected drug. This may
account for the confounding variables of differing drug efficacy and
injection techniques: a longer durability of the effect could be due
to the selected product rather than due to the performed injection
technique. Another strength of the study is the coordination across
the six participating clinical centers via a central study protocol to
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6      COTOFANA et al.

F I G U R E 5  Clinical image series of a 38-­year-­old female patient. The upper row images are facial expressions before treatment and
the lower row 14 days after the treatment. The facial expressions evaluated were at rest (left column), at maximal glabellar frown (middle
column), and at maximal eyebrow elevation (right column)

limit the injector bias on the study outcome. This central protocol
was designed independently and in absence of the individual pref-
erences of the participating injecting physicians to increase objec-
tivity when assessing the performed injection technique, that is, a
difference in effectiveness could be due to variability in injection
technique performed at each study center. Another strength of the
study is the freedom of choice of the participating clinical centers for
neuromodulator type and the amount of toxin injected per patient.
A study protocol providing regulations for product choice or amount
of neuromodulator injected per injection location would limit the
ability of the treating physician to use their experience to customize
the treatment for each patient. In the present study, this freedom of
choice was opted in to account for each patient's individuals needs
to exclude the influence of the “patient factor,” that is, variation in
muscular anatomy, soft tissue thickness, patients age, gender, and
ethnic background on the study outcome by allowing the treating
physician to best adjust the treatment. In this way, it is hoped to
exclude the bias of the “patient factor” on the study outcome and
to emphasize exclusively the effectiveness of the applied injection
technique: a difference in effectiveness could be due to anatomic
variation of each patient which can be observed and adjusted for
by the treating physician but would be disregarded by a rigid study
protocol.
A limitation of the study is that glabellar line severity was semi-­
quantitatively assessed by the treating physician only and not by
blinded and independent additional observers. This setup was spe-
cifically chosen to best capture the nuances in change in glabellar
line formation which would be potentially limited by non-­involved
experts. This could however also result in a bias toward a more pos-
itive outcome which has to be acknowledged here. Another limita-
tion of the study is relatively small sample size with n  =  105. This
sample size results from the study design where patients were en-
rolled during continuous clinical routine and products were donated
by the participating clinical centers and not by funding sources from
industry.
Understanding and targeting precisely the underlying anatomy;
this concept was utilized in the present study to eliminate the poten-
tial of eyebrow ptosis after neuromodulator treatment. No injections
were performed at the upper margin or above the hairy eyebrow;
only inside or inferior to the eyebrow the product was administered.
The results of the performed analyses confirm the validity of previ-
ously published anatomic concepts as no eyebrow ptosis (0%) and no
COTOFANA et al.
F I G U R E 6  Clinical image series of a 42-­year-­old male patient. The upper row images are facial expressions before treatment and the
lower row 14 days after the treatment. The facial expressions evaluated were at rest (left column), at maximal glabellar frown (middle
column), and at maximal eyebrow elevation (right column)
upper eyelid ptosis (0%) were observed in any of the treated individ-
uals during the study follow-­up period.
The bony origin of the procerus muscle is located in the midline
of the nasal bone whereas its insertion is the dermis and the fron-
talis muscle at the level of the upper margin of the medial heads of
the eyebrows. The muscle majorly determines the position of the
medial eyebrows and is at a muscular balance with the eyebrow el-
evating frontalis muscle. Injections cranial to the superior margin of
the eyebrows can therefore affect the eyebrow elevation segment
of the frontalis muscle and result in medial eyebrow ptosis. This is a
relatively frequent adverse event after forehead and glabella neuro-
modulator treatments and can also be seen with a hyper-­elevation of
the lateral eyebrow. 9,10 Targeting the origin of the procerus muscle
exclusively at its bony insertion eliminates the possibility of medial
eyebrow ptosis as no frontalis muscles will be affected. This was
confirmed by the measurements conducted; the amplitude of me-
dial eyebrow elevation exerted by the eyebrow elevation segment
of the frontalis muscle remained unaffected. The amplitude of the
medial eyebrows was 3.0 mm at baseline and was 3.4 mm at 14-­day
|
      7
follow-­up (p = 0.149); this provides numerical evidence for the unaf-
fected mobility of the medial eyebrow. The increase in amplitude by
0.4 mm can be explained by the reduction of the inferior-­pull of the
procerus muscle which acts as an eyebrow depressor. The analysis
of the amplitude additionally provides evidence that the function of
the frontalis muscle remained intact as it was not affected by the
neuromodulator.
The corrugator supercilii muscle originates from the supercil-
iary arch of the frontal bone around 0.5  cm lateral to the midline
slightly medial and inferior to the most common location of the su-
pratrochlear notch/foramen. From this location, the muscle courses
laterally and cranially to insert in the middle and/or lateral third of
the skin of the eyebrow. Its cranial boundary is formed by the infe-
rior frontal septum which corresponds to the upper margin of the
hairy eyebrow.15 At its dermal insertion, orbicularis oculi and fron-
talis muscle fibers merge and connect additionally to the overly-
ing skin comparable to the perioral subcutaneous architecture.15-­17
Most commonly performed injection techniques target this mus-
cle in two or three locations of which the medial injection is aimed
 |
8      COTOFANA et al.
at the muscle belly and the lateral injection at its dermal insertion
2
above the eyebrow or even further lateral and cranial. The lateral
injections have the potential to drop the eyebrow as the eyebrow-­
elevating segment of the frontalis muscle can be affected resulting
in an unbalance favoring the inferior-­pull of the eyebrow depres-
sors. The performed injection technique targeted exclusively the
bony origin of the corrugator supercilii muscle without a lateral in-
jection component. This resulted in an elevation of the lateral head
of the eyebrow in the resting position of 1.06 mm between baseline
and 14 days after the treatment (p < 0.001). This can be explained
by the reduction of the medial and inferior-­pull of the corrugator su-
percilii muscle which favored the increase in eyebrow height after
the onset of the neuromodulator effect. The eyebrow-­elevation
segment of the frontalis muscle was not affected by the treatment
(medial injection only); this was confirmed by the similar amplitude
in eyebrow elevation upon frontalis contraction with 3.18 ± 4.7 mm
before the treatment and with 3.33  ±  4.3  mm 14  days after the
treatment (p = 0.510).
The performed 3-­p oint injection technique targeted specif-
ically the bony origin of the procerus and corrugator supercilii
muscles resulting in predictable and long-­lasting effects up to
4 months. Due to the specific administration of toxin at the bony
origin exclusively, no collateral (adverse) effects were observed
during the duration of the study. No eyebrow or upper eyelid pto-
sis occurred as the eyebrow-­e levation segment of the frontalis
muscle was not affected; no injections cranial to the upper mar-
gin of the hairy eyebrow were conducted. The central portion of
the frontalis muscle was not affected which could have resulted
in a hyper-­a ctive contraction state of the lateral frontalis muscle
fibers presenting clinically as a “Spock” or “Mephisto” eyebrow
shape. This was avoided by the injection at the bony origin of the
procerus muscle which left the medial frontalis muscle activity
unaffected.
5  |  CO N C LU S I O N
Incorporating anatomic concepts into current clinical practice has
been revealed in the present study to result in the absence of ad-
verse events like eyebrow ptosis, upper eyelid ptosis, medial eye-
brow ptosis and lateral frontalis hyperactivity. The presented 3-­point
injection technique showed effectiveness throughout the 4-­month
study period. A natural and unaffected forehead movement was ap-
preciated by the treated patients.
C O N FL I C T O F I N T E R E S T
The authors declared no potential conflicts of interest with respect
to the research, authorship, and publication of this article.
E T H I C A L S TAT E M E N T
IRB Approval was obtained from Biomedical Research Institute of
America (Protocol Number: SITES01).
AU T H O R C O N T R I B U T I O N S
S.C., A.P, J.K, L.A, D.G., C.H., E.O, A.N., T.S., and KF contributed sub-
stantially to the conception, the acquisition, analysis, and interpreta-
tion of data for the work. The work was drafted and revised critically
by all authors.
DATA AVA I L A B I L I T Y S TAT E M E N T
The data that support the findings of this study are available from
the corresponding author upon reasonable request.
ORCID
Sebastian Cotofana  https://orcid.org/0000-0001-7210-6566
Andreas Nikolis  https://orcid.org/0000-0002-2927-5564
Thais Sakuma  https://orcid.org/0000-0002-6390-1223
Konstantin Frank  https://orcid.org/0000-0001-6994-8877
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How to cite this article: Cotofana S, Pedraza AP, Kaufman J,
et al. Respecting upper facial anatomy for treating the
glabella with neuromodulators to avoid medial brow
ptosis—­A refined 3-­point injection technique. J Cosmet
Dermatol. 2021;00:1–9. https://doi.org/10.1111/jocd.14133