“Lock this sucker down!”

Dec 11, 2020

With so much talk about lockdowns and quarantine, it would be forgiven if anyone mistook the title for being related to the pandemic. It may be however casually related, so please allow me to explain:

This blog post is actually about Botox. Over the past 20 years, having performed thousands and thousands of Botox treatments, I’ve been able to discern patterns of response and fine tune my ability to assess individual needs and anticipate the dosage and precise placement of treatment points in order to achieve optimal results.


One of the more challenging areas in this regard, is the forehead. The reason being that the same muscle (frontalis) that lifts the brow and causes horizontal lines, is also responsible for the function of holding up the eyebrow and simultaneously creating eyebrow shape. To relax the muscle overall and obtain a wrinkle free forehead in return is the easy part, one just has to use a sizeable dosage of Botox and distribute it evenly across the area. To reduce wrinkling AND create a nice brow shape, while retaining the ability and function of suspending and elevating the brow is the more challenging aspect.

Younger patients with firm, elastic skin and inherently higher brow position at rest are less prone to their brow drooping and tend to be the easier candidates for forehead treatment. Unfortunately with age comes hormonal decline and with that a decline in tissue repair. Tissues shrink (atrophy) and proteins like collagen that keep our skin elastic and firm, deteriorate and are lost without being replaced. Unless proactive steps are taken, even the most optimally healthy lifestyle cannot prevent the inevitable march of time and the ravages of the aging process that come along with it.

The bottom line is that the brow becomes heavier with age and we become increasingly dependent on the frontalis muscle to elevate the brow and eyelid complex until a critical point is reached when even the smallest amount of Botox placed in the forehead will cause the brow to droop. That means the end of Botox treatment and increasing forehead wrinkles become inevitable, unless more drastic intervention is to be considered.

Fortunately, in addition to sunscreen and good skin care, there are a few more preventive measures that can be taken, provided they are introduced early enough, and I would recommend as early as age 35. Skin tightening procedures, platelet rich plasma and fraxional laser treatments have all been shown to improve skin quality and elasticity, amongst other things, increasing the quality and quantity of collagen within the skin layers and adjacent tissues. If done regularly and in conjunction with Botox, great skin quality as well as silky smooth skin can be maintained for decades to come. This is true for all areas of the face and also of the body.

This means that investing in ones appearance and skin quality from a younger age, pays big dividends in later life. Some things can unfortunately not be reversed once a certain threshold is reached. As one of the tools in our cosmetic medical armament, Botox certainly has become one of the most amazing preventive interventions we could ever have anticipated. Not only allowing the skin to rest and recover when little muscles of expression are relaxed, but also diminishing negative expression and helping the eyes look brighter and the mouth area happier.

And this brings me back to the reason for the title. At a recent appointment, although the patient’s risk is presently low, I revisited the discussion with her about the reason for being conservative with treating the forehead. Perhaps because of being a bit more reluctant to make unnecessary trips during the pandemic and the restrictions around it, as most of us are, she was ready, willing and able to proceed there and then with treating her forehead with an adequate dosage, so that it would be silky smooth & she was not too concerned about the brow position per sé.

Quite to my surprize and delight she proceeded to make the statement, while indicating in a circular motion over her forehead: “Let’s lock this sucker down!”, something I have to admit has come to mind a few times since, when the topic of forehead treatment comes up, along with a good o’l chuckle to brighten up the day as I bite my tongue. 

*Disclaimer: the word “Botox” is used as a general term to describe the spectrum of neuromodulator products which include Botox Cosmetic(R), Xeomin(R), Nuceivia(R) and Dysport(R)

Dr Renier van Aardt MD