Common anti-wrinkle problems and how to fix them | Cityskin

Anti-wrinkle injections are the most commonly performed treatment at Cityskin Melbourne with over 5000 treatments performed per year across our clinics. This guide explains what to do if you have had a recent anti-wrinkle treatment that you are not 100% happy with – often the solution is quick and easy to resolve. We also discuss what to do next time to avoid the problem recurring.

If you need a review of your anti-wrinkle treatment we recommend coming back within 3 weeks of treatment unless you have had your masseter muscle treated (4-6 weeks review).

At Cityskin we love to help. Consultations are free of charge and you can book an appointment here.

1. Frown lines

Frown line injections are one of the most popular anti-wrinkle treatments performed in Australia. Below are some of the most common issues that arise after treatment.

i) Problem – “I’m still able to frown after my anti-wrinkle treatment”

If it feels as though your frown lines have worn off quicker than expected we have to look at the units used and when you had your previous treatment. As Practitioners we want to predict how many units you need to treat your frown to reduce the frown muscle.

If you look at the image below you can see that these two patients have very different frown strengths. The patient at the top has very strong frown muscles and this may need 30 – 35 units to stop the muscle frowning. The patient below has a much weaker frown and may need only 15 units to stop her from frowning. Using less units that recommended means that we don’t fully reduce your frown muscle (meaning you can still cause lines) or the treatment wears off quicker than ideal

Solution – Let us guide you on how many units you might need to treat your frown. If you have very strong frown muscles you may need as high as 35 units and if you have very weak muscles you may use as little as 10 or 12 units. If you are still able to frown 2 weeks after your treatment then we recommend coming in for us to use a little more anti-wrinkle product.

frown-line-anti-wrinkle-worn-off-too-quick
A comparison of frown lines – the patient at the top may need up to 35 units to reduce the frown whereas the patient below may only need 15 units

ii) Problem – “I can still see my frown line after treatment”

Not all frown lines are equal! If you look at the patient below this is an example of a patient who has established frown lines at rest. She is frowning slightly in the photo but on relaxing the muscle the lines will still be present.

If it has been a long time since your last anti-wrinkle treatment or if it is your first treatment, and you have established or deep frown lines at rest then they may only soften on this treatment rather than going away fully. What we need to do as injectors is to stop the frown muscle contracting entirely for as long as possible to reduce the lines. Think of the treatment like ironing a cotton shirt on silk setting – you only have one pass with the iron which will reduce the creases but not fully. In 3 months time, or when you are able to move the frown muscle well again, treat the frown again.

If you are still able to move the frown muscle 2 weeks after treatment then you will need more units in the frown.

Solution – To treat deep, established lines we recommend using enough units to stop the frown muscle contracting entirely. Repeat the treatment when you are able to move the frown muscle easily again or 3 months later, whichever comes sooner.

It may take up to 12 months of repeated treatment (every 3 months) to eradicate the line at rest.

anti-wrinkle-frown-lines-at-rest
Deep frown lines at rest may take 12 months of repeated treatment to fade

iii) Problem – “The outer part of my frown still moves after treatment”

Most patients, when they frown, have lines above the inner part of the eyebrown rather than above the outer brow. Some patients have one solitary line, some have ’11’ lines but some patients have ‘11111’ lines. To reduce frown lines we tend to use 7 injection points starting inbetween the eyebrows and going out to the mid-pupillary line as shown in the picture below. Most frown line movement occurs inside the ‘mid pupillary line’ – the imaginary line going up vertically from the centre of the pupil upwards. Outside the mid pupillary line is a danger zone for injectors. We have to be very careful when treating in this area because too much product or too deep an injection could cause a heavy brow or heavy lid.

Some patients are able to move the outer part of the frown after treatment but this can be ok as the outer part of the frown doesn’t contribute to the main lines that occur inbetween the eyebrows.

Solution – If you have some movement in the frown outside the mid-pupillary line after treatment please come in for us to assess the area. If the movement is subtle it may be best to leave the area alone as treating it could cause more harm than good. As injectors we do treat outside the mid pupillary line at times but we tread very cautiously. If you’re 90% happy – leave it alone!

frown-line-movement-after-anti-wrinkle-injections
Be careful when reducing movement in the outer frown

iv) Problem – “My eyelids are heavy and hooded after treatment”

When treating the frown area patients are often worried about a ‘lazy eye’ after treatment. Thankfully the lazy eye that people worry about (also known as ptosis) is really uncommon. Dr Brown says he sees it once every 10 years in his anti-wrinkle patients. The image below shows a patient with eyelid heaviness (top photo) vs eyelid ptosis (bottom photo). More commonly patients experience heaviness of the eyelid rather than ptosis.

eyelid-heaviness-vs-ptosis-after-anti-wrinkle-injections
The difference between eyelid heaviness and eyelid ptosis. Note – not Cityskin patients

Eyebrow heaviness can occur in patients who have pre-existing heavy upper eyelids and then have forehead anti-wrinkle treatment. The forehead muscle is the only muscle that lifts the eyebrows and reducing forehead movement can cause the lids to drop.

The rule of thumb is if you have have less than 3mm between the eyelashes and the eyelid skin be very, very careful when trying to reduce forehead lines. Sometimes patients with heavy lids cannot have forehead anti-wrinkle treatment for this reason.

Solution – If you have heavy upper eyelid skin after anti-wrinkle injections there are three options available:

  1. The first is to try and lift the brow by placing anti-wrinkle treatment in the frown and outer part of the eyebrow. This can provide a subtle lift to the brow.
  2. The second option is to wait until the treatment has worn off and next time treat the forehead more lightly. This does mean that if you have heavy lids and strong forehead lines you cannot reduce the forehead lines as much as you would like without heaviness. You may have to accept that your forehead lines will not reduce as much as you may want them to
  3. The third option is to have surgery to the eyelid skin – known as a ‘blepharoplasty’ before treating the forehead again. Some patients that undergo a blepharoplasty notice that their forehead lines reduce over time. This can be because before surgery they were constantly lifting their eyebrows to improve their visual window. After surgery the eyelids are no longer hooded and there is less need to lift the eyebrows hence the forehead lines reduce

v) Problem – “I have a lazy eye after anti-wrinkle treatment” (ptosis)

A true heavy eyelid after anti-wrinkle treatment is known as a lid ptosis, shown in the image below. Dr Ben Burt, Oculoplastic Surgeon, says a good way to assess lid ptosis is to look at the distance between the eyelid and the reflection of light on the eye. When you take a photo the light reflection is usually in the same position in both eyes. In the image below you can see a light reflection in one eye no light reflection in the other.

What causes a lid ptosis? It is thought that in rare cases – when the frown with anti-wrinkle injections some of the product can inadvertantly spread to the eyelid muscle known as levator palpabrae superioris. This muscle is responsible for opening the eyelids. Inadvertant spread into the levator muscle can make the eyelid heavy.

how-to-assess-for-lid-ptosis-after-anti-wrinkle-injections
A patient with a lid ptosis. Note – not a Cityskin patient

Solution – Thankfully eyelid ptosis resolves as the anti-wrinkle product wears off. The length of time that it takes for a ptosis to improve depends on how much product affected the muscle and this is difficult to know. Some mild casdes of ptosis last as little as 2 weeks whereas others can last as long as 2 months. To help improve the appearance of ptosis your Doctor can prescribe an eyedrop called Apraclonidine which, when used, stimulates the levator muscle and open the eyelid. The drops tend to be used up to four times per day. Temporary side effects of the eye drops can include itchiness around the eye and light sensitivity.


2. Forehead lines

Forehead lines are the second most common anti-wrinkle injection that we perform at Cityskin. It is also the most technically difficult as forehead lines vary greatly and each patient needs a different treatment to achieve the best results.

care-when-treating-forehead-lines-anti-wrinkle-injections

Forehead line treatment is like climbing a mountain – we want to get as close to the top without going over the edge. In our case – over the edge could mean heaviness or a shiny forehead. The skill of the injector is getting as close to the edge of the cliff as possible without going over and this can be the difference of a couple of units in some patients.

Below we have listed the common problems that we see after forehead anti-wrinkle treatment and what can be done to address them.

i) Problem – “My forehead treatment wears off quickly”

This is one of the most difficult dilemmas when treating forehead lines with anti-wrinkle injections. As injectors we try and accurately predict how many units you need to reduce your lines. Forehead line treatment is a very delicate balance between using too much product and using a frozen look or a heavy feeling vs not using enough product.

The two patients below have very different forehead lines – the patient at the top has very faint lines at rest and on moving whereas the patient below has very strong muscles and deep furrows. The patient at the bottom needs at least twice as much product as the patient at the top to last for the same time.

fine-vs-deep-lines-on-forehead
A patient with faint forehead lines (above) vs a patient with deep furrows (below)

We tend to start seeing movement in the forehead about 7-8 weeks after treatment. The lines are still reduced at rest but on moving there may be faint forehead lines. Full movement in the forehead is usually seen after 3-4 months.

Solution – If the treatment has worn off quicker than you would have liked we need to use more units next time. Anti-wrinkle injections in the forehead, however, are a balancing act – the more product you use the longer it lasts but the increased chance you have of the brow feeling heavy. Less product allows more movement and wears off quicker but there is less chance of heaviness in the brow. Sometimes you can’t have both and you have to pick which you would prefer

Cityskin
The anti-wrinkle balance between longevity and heaviness


ii) Problem – “My treatment didn’t last as long this time”

Often when you have anti-wrinkle treatment for the first time you are blown away by the results. It is amazing how the treatment can effectively airbrush lines for a few months with no downtime. Often we are so happy with the change that we don’t notice a few lines creeping back after 7-8 weeks – something that is absolutely normal.

Something we have to be clear about is what does someone mean by a treatment not lasting as long? Is this the time when you noticed full movement in the forehead? Is it when there was the faintest hint of movement? Is it when the lines had fully returned? How many units were used? Were the units the same as with previous treatments?

Results means different things to different people and whilst some patients are happy to have a reduction in the lines at rest (this typically lasts 3-4 months with the correct units) some patients will say that the treatment has worn off when there is some movement in the forehead (normal 6+ weeks after treatment).

how-long-do-anti-wrinkle-injections-last
Dose / response curves showing results that last longer with regular treatments rather than letting the treatment wear off fully. Arrows = treatments

The graphs above show typical dose:response curves after anti-wrinkle injections. The arrows represent anti-wrinkle treatments. In each case the maximal line reduction is 2 weeks after treatment with the results slowly wearing off over time.

If you have treatment every 5-6 months (as shown by the arrows in the top graph)- you are likely to get the same results each time. If, however, you repeat the treatment every 3-4 months (before the lines have fully gone back to how they were before) you get an additive effect with the lines reducing more than the time before and the results lasting longer.

What we saw after COVID lockdowns was that patients who were used to having regular anti-wrinkle treatment (every 3-4 months) found their treatment didn’t last as long. This is likely to be because they were used to cumulative effect of repeated treatment (bottom graph) but having a prolonged gap between treatments reset things back to the top graph.

Solution – This problem is an easy one to resolve. Firstly we have to decide what we both mean by the treatment outcome and when we expect to see movement and reduction of lines. If there has been a long gap since the last treatment (5-6 months) then we should expect the results to last about the same, provided the same units and product are used.

To make the treatment last longer we can use more units each treatment and make sure that we treat as regular intervals, ideally before the lines form at rest again or every 3-4 months whichever is sooner. Always bear in mind that treating the forehead with more units can make the eyebrows feel heavy!


iii) Problem – “My forehead feels heavy after anti-wrinkle injections”

At Cityskin we always recommend treating the frown if you are having the forehead treated. If you have the forehead alone treated with anti-wrinkle injections it can make the forehead feel very heavy and flatten the eyebrows – as shown in the picture below.

This can look ok for men but should be avoided in women at all costs. Dr Brown says that treating the forehead alone in men makes them look more like Chris Hemsworth but treating the forehead alone in women makes them look more like Chris Hemsworth.

why-forehead-anti-wrinkle-treatment-can-make-the-brow-heavy
Why the forehead can feel heavy after anti-wrinkle injections

We always recommend treating your frown if you are having your forehead treated. This can reduce the chance of flattening the brow shape. If you have had your frown and forehead treated it is normal for the first couple of weeks for the forehead to feel slightly heavy. This usually settles after about 2 weeks.

Solution – If you have had your forehead treated but not your frown (we sometimes have patients attend from other clinics where this has happened) we can try and reduce the flattened brow by treating the frown muscle and under the outer part of the eyebrow to try and create a lifting effect.

how-to-correct-a-heavy-brow-after-anti-wrinkle-injections
How to treat a heavy forehead after anti-wrinkle injections

If a large amount of units have been used on the forehead to treat the lines then it may be a case of waiting for the forehead treatment to wear off and going lighter next time.

If you have had your frown and forehead treated and the forehead still feels heavy after 2 weeks we may need to use less product in your forehead next time. It is a delicate balancing act- the less product we use the quicker it wears off but the less heavy it feels. If you have deep forehead lines you may not be able to reduce them fully without experiencing a heavy forehead.


iv) Problem – “My forehead moves at the side and my eyebrows look different” (a.k.a ‘Spocking’)

Movement at the sides of the forehead causing the brow to lift is known as ‘Spocking’ (named so because it looks like Mr Spock’s brows). The image below shows a patient in her 60s who has had anti-wrinkle injections (note – not one of our patients). You can see that she has expressive lines on her forehead which extend into the temples. After anti-wrinkle injections you can see how the outer part of the forehead is still moving causing a lift to the brow.

Spocking occurs for one of two reasons:

  1. The frown has been treated with anti-wrinkle injections but not the forehead
  2. There is strong muscle movement at the outer frown and not enough product was used in this area
spocking-after-anti-wrinkle-injections
‘Spocking’ after anti-wrinkle treatment. Note – not a Cityskin patient

Solution – Thankfully Spocking is easy to correct. Spocking is corrected by placing 0.5 – 1 units of anti-wrinkle product into the area in the forehead that is still moving to reduce the movement.

To prevent Spocking happening again we have to be mindful to treat the outer forehead area – sometimes as far out as the temples – to reduce movement across the forehead.


v) Problem – “I have patchy areas of movement in my forehead after anti-wrinkle injections”

As mentioned earlier – not all foreheads are the same. Some patients need as little as 5 units of anti-wrinkle product to reduce forehead movement whereas some men need 20+ units to smooth forehead lines.

We tend to see patients with drier, crepey skin have finer lines scattered in a larger area across the forehead. When we inject we try and scatter the treatment across the areas that move, as shown in the image below

forehead-line-anti-wrinkle-injection-guide
Forehead lines in a large area across a male forehead

Patients that have a large area of movement on the forehead can sometime experience patches of movement, as shown in the image below. Sometimes patients can also develop new lines in the hairline even if there were no lines there initially

patchy-forehead-movement-after-anti-wrinkle-injections
Patchy forehead movement after anti-wrinkle injections

Solution – If there is patchy movement in the forehead 2-3 weeks after treatment we recommend coming in for a couple of extra units to soften the movement. Next time you have a full treatment we need to use slightly more units across the forehead and scatter the product across a wider area


vi) Problem – “My forehead looks shiny and frozen after anti-wrinkle injections”

The injector has used too many units on the forehead causing a flat surface which reflects light. This is especially a problem for patients with oily skin.

how to prevent the frozen forehead look
Over treating the forehead can lead to a shiny look. The treatment, however, will last longer

Solution: Use less units next time! A shiny forehead may be ok on American TV but in the real world it can look over-done and un-natural.


3. Crows feet

Crows feet are the third most commonly performed anti-wrinkle treatment in Australia. Patients with easy crows feet to treat include patients under 30 and patients with upper and mid crows only. Difficult crows feet to treat are in patients over 40, those with loose / crepey skin under the eyes and patients with lower / diaganol crows feet.

i) Problem – “I have lines under my eyes after crows feet injections”

We have to be careful when treating crows feet when patients either have lines under the eyes before treating, have crepey skin or are over 35. The photo below shows Dr Brown before and after 8 units of anti-wrinkle product to treat the crows feet. You can see in the before photo that he has lines under the eyes before treatment. These are still present 2 weeks after treatment (indicated in the image by the red arrow).

lines-under-eyes-after-anti-wrinkle-injections
Lines under the eyes after crows feet treatment is normal when you are over 30

Unfortunately we cannot treat under eye lines with anti-wrinkle treatment. Under eye lines are often a problem of skin laxity. Treating the crows feet can, in some patients, emphasise the under eyes lines because the crows feet have softened so nicely that the under eye lines are more noticeable.

Solution – If you develop under eye lines after crows feet treatment, or if they are more noticeable after treatment then there are a few options for next time:

  1. Keep treating the crows feet with the same units and accept that lines under the eyes won’t go away and may be accentuated by treatment
  2. Use less units in the crows feet next time which may reduce the difference between the under eye lines and crows feet
  3. Avoid treating the crows feet entirely – it is totally fine to have some crows feet as we age
  4. If you are over 40 and have substantial skin laxity under the eyelids then a minor surgical procedure called a blepharoplasty could reduce the loose skin

ii) Problem – “My cheeks look bunchy and flatter after crows feet injections” (aka chipmunk cheeks)

crows-feet-problems-after-anti-wrinkle-injections
Lower crows feet are difficult to treat and can cause bunching / flattening of the cheeks

When treating the lower crows feet we have to be really careful. If we don’t treat low enough you may be left with lines in the lower crows feet but none in the middle or upper areas.

If we treat the lower crows feet we are in a difficult area, as shown by the red section in the picture. Close to the lower part of the orbicularis muscle (the muscle that causes crows feet) we have the cheek elevators. Cheek elevators help lift the cheels when you smile.

If we treat the lower crows feet too aggressively then you may find the cheek elevators are affected temporarily by the anti-wrinkle product. This can flatten the cheeks, make them look bunchy or give a ‘chipmunk’ look. Sometimes when you first have your crows feet treated it can feel more difficult to smile but this tends to wear off after a couple of weeks

Solution – If you experience bunching of the cheeks for more than a couple of weeks you may have to use less units in that area next time. There is a case for going very light in the lower crows feet and accepting some lines in that area – this may look better than a bunching cheek.


ii) Problem – “My crows feet treatment seems to wear off quickly”

Longevity of anti-wrinkle treatment tends to depend on a number of factors including:

  1. Anti-wrinkle product used
  2. Number of units
  3. Was your previous treatment more than 4 months ago?
  4. Where the anti-wrinkle injections are placed
  5. How do you define worn off?

At Cityskin we tend to prefer using the European anti-wrinkle brand over the American anti-wrinkle brand as we feel that, for the same cost, you get quicker and longer lasting results using the European brand.

When deciding how many units your crows feet might need to need to take into account your age, depth of the lines, muscle strength and whether your cheeks are likely to bunch after treatment. We could easily use 15 units each side in all patients to give long lasting results but it would look over-treated and strange.

care-when-treating-forehead-lines-anti-wrinkle-injections

Solution – The art of injecting is estimating how much product you need to reduce lines by the desired amount. A good injector should also be upfront and honest about expectation – if you have deep lines, lots of lines, lines that extend down the cheeks or loose skin then we may not be able to fully eradicate the lines. Sometimes we just have to soften lines rather than eliminating them entirely.

A good rule in medicine is ‘do no harm’ – we want to get as close as we can to achieving the desired result without over-treating. It is better to get 80% perfection than over-treat.

If the treatment has worn off quicker than you would have liked we can increase the units in the crows feet but bear in mind that the higher we go with units the higher the chance of causing bunching of the cheeks (if you have low crows feet) or causing lines under the eyes.


iii) Problem – “I’ve noticed more lines under the eyes after crows feet injections”

This usually occurs in patients over 30 where the crows feet have been too aggressively treated, or treated too low down. People with looser skin under eyes and lines under the eyes before treatment are particulary at risk. Sometimes the problem needs to be addressed with Surgery if there is a lot of skin laxity.

under eye lines after anti-wrinkle treatment
Under eye lines can be accentuated by treating crows feet

Solution: Reduce the units in the lower crows feet and treat very gently in the lower crows. Over-treating can accentuate under eyes lines. I have chosen to only treat my crows feet every second treatment for this exact reason!


Summary

As you can see from this guide – anti-wrinkle injections are nuanced and potentially complicated! As an injector there is always a balance between achieving perfection and over-treating.

At Cityskin we love to help – this is why we create articles to help you understand everything there is know about injecting. Consultations at Cityskin are free of charge and can be booked online.

If you have a question about a recent treatment please contact us here to see if we can help or book an free consultation online.

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Consultations at Cityskin are free of charge and you can book your appointment online. If you have a question about any aspect of treatment you can also chat with us - we're here to help

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