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On 01



| By

Ricky Sayal, DO

Whether you are aware of it or not, your face is constantly expressing your emotions on a daily basis. The features of your upper face can tell a story: Did you have a good day at work? Are you well rested? How stressed are you? The process of aging holds the power to sometimes hide your true feelings and convey a message that isn’t really you. 

Do you sometimes feel like the outside does not reflect what is truly on the inside? If so, you may want to continue reading this article!

Understanding the Signs: The Keys to Forehead Aging

Forehead aging presents itself as a combination of two things: frown lines and forehead skin drooping. 

Furrows and frown lines form from repetitive movement of the underlying muscles in the forehead. There are three muscles that have their own unique function, creating wrinkles in specific locations. The frontalis muscle helps pull the eyebrows up which, in turn, leads to horizontal wrinkling across the entire forehead. The central forehead frown lines are due to the procerus muscle, the corrugator muscle, and the depressor supercilii muscle, producing the two deep vertical parallel lines often known as the “elevens.”. 

The second sign of forehead aging is sagging of the forehead skin and eyebrows. As we grow older, the skin starts to thin and the forehead loses volume. The skin loses elasticity which causes the eyebrows to drop down to the upper eyelid region, creating excess skin and unwanted soft tissue there. To compensate for this, the forehead begins to contract the frontalis muscle to try to lift the eyebrows back into their normal position. This adds to the horizontal lines and creases of the forehead. Unfortunately, a “skeletonizing” appearance can result from the combination of forehead volume loss and skin thinning that accentuates the brow bone. 

For many years, forehead rejuvenation consisted of only invasive surgical procedures such as a brow lift. With evolving techniques and technology, we have diversified our treatments and can now rejuvenate forehead frown lines with less invasive procedures, anesthesia, and downtime.

Understanding the Anatomy: The Key to Successful Treatment

Whether your surgeon is providing invasive or noninvasive treatment, mastery of forehead anatomy is critical for success. There are two important arteries along the forehead that emerge from under the eyebrow bone. Additionally, a branch of the facial nerve arises from near the temples. This nerve is responsible for the strength and movement of the frontalis muscle—the muscle that keeps your eyebrows elevated. Your surgeon must be aware of these structures and avoid harming them during treatment. 

The scalp is divided into multiple layers. Each layer contains various anatomic elements including specific muscles, nerves, and blood vessels that animate the forehead. The galea, for example, is a dense fibrous layer that divides the fat compartments of the forehead. Creating a youthful appearance requires the provider to know and understand which compartment is linked to which muscle and how to specifically treat that area. The provider should feel comfortable with this anatomy to avoid any potential complications. A facial plastic surgery specialist will have extensive knowledge of facial anatomy and how to perform your rejuvenation procedure safely and effectively.  

Understanding the Patient: The Key to a Successful Consultation

During the consultation, I always take into consideration a combination of the patient’s age, gender, skin texture, and facial features. I like to systematically evaluate patients’ foreheads from the top down, including an assessment of the following elements: 

  • I examine the hairline thoroughly. The position of the hairline is important if a surgical approach is being considered, because certain brow lift techniques are recommended depending on the patient’s hairline. 
  • I evaluate the forehead characteristics. I pay attention to the height of the forehead and, at the same time, the shape and curvature. I assess the wrinkles, both horizontal and vertical, and determine how deep they are. Are there more wrinkles on one side than the other? 
  • I look at the eyebrows in relation to the patient’s gender, race, and age. What is the shape of the eyebrows? Are they a straight line or arched laterally? Are the eyebrows symmetric, or is one side higher than the other? 
  • I observe the upper eyelid area to determine whether the issue stems from the eyebrow drooping or is a result of isolated aged eyelid skin that can be corrected with an eyelid procedure (blepharoplasty) instead. 

I listen to everything the patient has to say and take all their priorities into consideration. This is the most important step. What I feel may be different from what is concerning the patient. It is my duty to help educate my patients but not make the decision for them. 

Understanding Your Options: The Key to the Right Decision

Forehead rejuvenation can be divided into noninvasive and invasive treatment. Noninvasive treatment consists of neuromodulators, injectable fillers, and skin resurfacing, such as laser therapy. Each of these addresses the furrows and frown lines distinctly, depending on the individual case. Invasive procedures consist of a forehead lift and brow lift surgery.  


Neuromodulators, such as Botox, are the most requested cosmetic treatment nationwide. The forehead is a very common site to place this product. These neuromodulators help soften the transverse and vertical lines of the forehead. Neuromodulators work by temporarily blocking a neurotransmitter pathway that stimulates muscle contraction. The muscle then relaxes, preventing wrinkle formation. The surgeon should tailor neuromodulator treatment to the specific patient, depending on the strength and shape of the muscles. 

My injection patterns are different for every patient because I take into consideration their age, brow height, and area-specific wrinkles. Also, there is a tradeoff with injecting the frontalis muscle to treat the long horizontal forehead wrinkles. Too much can drop the eyebrow height, which can cause a result some patients find displeasing. Too little will not relax the muscles to the patient’s satisfaction. As surgeons, we are always balancing the patient’s cosmetic concerns with our own medical knowledge and evaluation. 


Soft tissue fillers restore volume loss from aging. Not only do they help lift areas such as “sunken in” foreheads and temples, but they can also be used to conceal wrinkles. 

Treatment of forehead aging with fillers requires mastery of the forehead anatomy. Injecting the forehead must be done carefully because of an abundance of blood vessels that, if compromised, could lead to serious complications, such as blindness. Therefore, when injecting the forehead, it is important for your provider to stay in the correct plane, avoiding the risk of an intravascular injection. One should strongly consider using hyaluronic acid, a filler that is reversible, in the slight chance an inadvertent intravascular injection occurs. 

Your provider should go over the other risks involved, which include swelling, asymmetry, bumpiness, bruising, and tenderness. Additionally, it is important for the patient to provide a thorough health history during the consultation. For example, previous surgery or trauma can create scarring and aberrant vessel anatomy which can increase the chances for an intravascular injection. 

Laser Skin Resurfacing

Neuromodulators help soften the transverse and vertical wrinkles of the forehead, mitigating exaggerated facial expressions, but not so much when the face is at rest. Additionally, fillers will not help with the actual quality of your skin. 

As the forehead ages, the outer skin layer (the epidermis) begins to thin and lose elasticity. Lasers are one form of technology that helps with skin resurfacing. The layers of sun-damaged and wrinkled skin are precisely targeted with the laser and replaced with new collagen and elastic fibers. This helps with fine lines while tightening the skin. There are various lasers with different energy levels designed to treat wrinkles, dyspigmentation, and prominent blood vessels. 

I often use a combination of treatments with neuromodulators, fillers, and laser skin resurfacing in forehead rejuvenation. It is important that your surgeon has multiple tools in his or her armamentarium to achieve a complete result.  

Surgical Treatment

If the patient’s forehead furrows and frown lines are not able to be corrected to their satisfaction with noninvasive methods, surgery is an option. This is also a choice for patients who express a desire for a longer-lasting treatment for their deep lines. 

To perform this kind of surgery, an incision is created within the hairline, and the skin and soft tissue are elevated down the forehead until the eyebrow bone is reached. The surgeon is like an artist, analyzing where the wrinkles are more prominent on the outer skin and correlating it to muscles under the skin in direct visualization. Again, for your safety, it is essential that your surgeon is a specialist who is experienced with facial anatomy because critical arteries and nerve structures are found close to the eyebrow bone. 

Understanding Your Goals: A Plan Fit for You

Forehead rejuvenation requires an intricate, tailored approach for each individual. If the wrinkles that bother you the most are involved with your facial expression, then neuromodulators will help soften them. If you feel you have deep forehead lines which are static, then fillers may help, but they should be performed by an expert. If fine lines, dyspigmentation, or skin laxity are your main concerns, then laser skin resurfacing is an excellent option. 

In reality, it is not simply one of these things, but rather a combination of aging characteristics that affect us. Therefore, most of the time we treat patients with a combination therapy of neuromodulators, fillers, and laser skin resurfacing. If  you want a longer-lasting result after these noninvasive methods, you may be a candidate for facial plastic surgery. 

Our role as your chosen surgeon is to help you look and feel your best. If you are interested in getting rid of the furrows and frown lines of the forehead, please contact Clevens Face and Body Specialists, and let our team of trusted facial plastic surgery experts be your guide... For more information on facial rejuvenation procedures, check out our free on-demand webinar.


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