Your Questions

Q: Dr. Eppley, you have done some Botox for me in the past. We discussed that I was one of the few people who didn't respond very well to the Botox. You said maybe because my forehead muscles are too strong or some other reason. Whatever the case may be, I would like to know what option I have to get rid of the deep “angry eyebrow” wrinkle. Is the only option to go under the knife?? Thanks.

A: To review your forehead/glabellar furrow issue, it is not that  Botox didn't work. Botox always works but its mechanism of action (muscle weakening) was unlikely to correct what is now the main problem with your furrow, it is so deeply indented from years of muscle overactiivty that the skin is now permanently etched or grooved. This is beyond being ideally treated by muscle weakening (although it was worth seeing how much of a difference that could make) but now requires some form of skin management for improvement. For patients with these very deep grooves or furrows in which Botox fails to provide any significant improvement, the furrow can be treated by a variety of options. The simplest and most common is an injectable filler (e.g., Juvederm) to plump it out and soften its depth. This is often done either after Botox has 'failed' or in combination with it. (the filler lasts longer if it is not pounded on by the muscle movement that caused the problem in the first place) All current injectible fillers are temporary and do not create a permanent filling result.  Another filler approach is to place a small tubed implant under the skin to create a permanent filler. The tubed implant, Permalip, is the same type of permanent implant that is used in the lips, nasolabial or labiomental folds. Another permanent option is to excise the furrow and treat it like a geometric scar revision. By cutting it out and putting the skin back together in an irregular fashion, the furrow is made smooth. All of these treatment options can be done in the office under local anesthesia.

Dr. Barry Eppley

Indianapolis, Indiana

Q: I have a deep vertical line in between my eyebrows that is still noticeable despite having Botox injections. I was wondering if endoscopic browlift could correct this. Im only 27 years old. Please help.

A: The development of vertical wrinkles between your eyebrows, known as the glabellar area, is common and is the result of excessive muscle activity. There are a set of six paired muscles that affect the glabella area and create what has been described as a number system of galbellar wrinkles or furrows. As the popular ad goes, are you a 1, 11 or 111? These numbers describe whether one has one, two or three vertical glabellar wrinkles.

The first approach for glabellar wrinkles is Botox which will be highly effective for most people. For many the wrinkling is completely or nearly completely gone by this temporary muscle paralyzing treatment. For those with more deeply etched glabellar furrows, Botox will soften it to some degree but may not reduce it enough for the person’s satisfaction. This is the result of the skin being ‘etched’ or having a permanent v-shaped change in the skin. Muscle paralysis will not change permanent deformation of the skin.

An endoscopic browlift will not create a better effect than that of Botox because it works on the muscle only. It may help decrease the long-term need for Botox and, rarely, the need for Botox at all.

A companion treatment for the deep glabellar furrow is some type of soft tissue fill.  Usually this is an injectable filler but its effect will only be temporary. More permanent options include the threading of an allograft collagen dermis material or actual synthetic implant. (e.g., Advanta)

Dr. Barry Eppley

Indianapolis, Indiana