Botox activity guides applications

"Many men may require higher doses of Botox, up to 80 units in the glabellar area," says Derek H. Jones, M.D., clinical assistant professor of dermatology, University of California Los Angeles.

Determining how much to add after initial treatments is "where the art of Botox comes in," he says. "Many times, depending on the thickness of the muscle, I'll go up in the glabella to the 40 unit range. If I'm not seeing much result, maybe next time I'll use 60. Very rarely does a patient require 80 units."

Esthetic gender differences

One must also keep in mind that male patients have a different ideal esthetic than females.

"In women," Dr. Jones explains, "we like to arch the lateral brow, but not in men. So when I'm treating the glabella alone, I often use three units of Botox in the lateral frontalis muscle to prevent overarching of the brow in men."

Glynis Ablon, M.D., adds, "If you have one happy patient with botulinum toxin, the patient will tell a few friends. But if you have an unhappy patient, they'll tell a lot of friends. And even more friends will notice that they look funny. So you really want to be cautious in placing the botulinum toxin." She is clinical assistant professor of dermatology at UCLA and director of the Ablon Skin Institute, Manhattan Beach, Calif.

Less is always more, she says. And only Jack Nicholson wears the Jack Nicholson look well.

"If you have a very young patient who doesn't have a significant superior browline or crease, you can get away with (treating) the superior frontalis muscle for a browlift. But if you have a patient with a prominent line above their
brow and you try to treat the superior frontalis muscle or forehead specifically, you can either create that quizzical look or flatten their forehead so much that they drop their brow," she says.

Langer skin tension lines, which show where creases naturally fall on the face, can help physicians select appropriate injection sites. If one blocks an elevator muscle from lifting, these lines will be accentuated.

"The corrugator muscles, the procerus and the orbicularis oculi all act to depress the brow," adds Fredric S. Brandt, M.D., a private practitioner with offices in Miami and New York City. "So when you're treating the forehead area, you want to make sure you're treating these muscles very adequately so you can get an elevation of the brow. And one must balance that with the treatment of the frontalis muscles so you're not overtreating the frontalis and getting a brow droop."

One also must realize that whatever muscle is being treated, botulinum toxin A achieves a 3 cm diffusion rate.

"Even though you may be treating one muscle, you'll be affecting other muscles on the forehead," Dr. Brandt explains.