‘Spock eyebrows’, although amusingly named after the iconic Star Trek character, are a serious concern for those who experience them. This phenomenon, also referred to as ‘Spock brow’ or ‘Joker eyebrows’, occurs when neuromodulating medications are injected incorrectly in the lower forehead and brow area.
It’s important to note that all toxins can cause Spock eyebrows. Any botulinum toxin type A derivative can lead to this undesirable outcome, which is not because of dosage applied, but because of the injector missing the intended target.
Despite being temporary, Spock eyebrows can persist for several months following treatment, making prevention crucial to avoid this aesthetic mishap.
What exactly are Spock eyebrows?
Spock eyebrows are a common side effect of botulinum toxin treatments intended to address forehead lines, glabellar lines or perform brow lifts. Characterised by a distinct outward arching of the eyebrows, this condition typically emerges within a few days of treatment and lasts until the medication’s effects diminish, which is usually around four to six months.
The underlying cause of Spock eyebrows lies in uneven botulinum toxin treatment disrupting the balance of the forehead muscles. This imbalance occurs when botulinum toxin is injected into the procerus and corrugator muscles but neglects the frontalis muscle, which comprises the majority of the forehead’s muscle mass. Consequently, with the procerus and corrugator muscles paralysed, the frontalis muscle pulls upward and outward on the brow, resulting in the characteristic arched appearance.
It is important that we remember that the glabellar process is a series of muscles that are depressors. Conversely, the frontalis is an elevator. Where one is knocked out with neuromodulators, the other wins in the tug-of-war balance. It is essential that we do not leave a depressor unopposed in the glabellar process, because this means that the frown will become heavier and the frontalis will not be able to lift centrally, resulting in a midline drop. Essentially, the injector has missed the intended target, instead overdosing the forehead. So the middle of the brows drop, and the lateral sections rise, giving the Samurai warrior appearance to the brows, or the ‘McDonalds arches’.
Preventing Spock eyebrows: a delicate balance
Preventing Spock eyebrows requires careful consideration and individualised treatment approaches. Each patient’s forehead anatomy varies, and simply adjusting the dosage administered to the frontalis muscle may not suffice.
Some experienced botulinum toxin injectors opt for a two-session approach to forehead treatments. The first session involves administering lower-dose injections, followed by a touch-up session two weeks later. This method allows for more precise adjustments and minimises the risk of overdosing, which can be challenging to rectify with subsequent injections.
The other reason for a Spock brow is that the injector leaves the most lateral part of the frontalis untreated. In other words, the frontalis was under treated, so when the patient raises their brows, frontalis action is still present laterally, causing the super-arches to appear.
Can Spock eyebrows be corrected?
While prevention is the preferred approach, patients who develop Spock eyebrows post-botulinum toxin treatment have options for correction. However, patience is key, as it can take up to two weeks for botulinum toxin type A to fully take effect. Upon noticing an undesirable arch in the brow, scheduling a follow-up appointment for corrective injections is advisable. Ideally, this appointment should be at least two weeks after the initial treatment to allow the medication to reach its maximum efficacy.
To correct a Spock brow, there are some areas that you need to consider:
- Is the glabellar process still active? Ask the patient to frown and if you see depressor action, this is the first point to correct. Once the toxin is active, the middle part of the brow should rise. This is under the assumption that there is still an active frontalis. You can check this by asking the patient to raise their brows. If they can, then treat the glabella.
- Is the Spock arch located laterally on the forehead? For this correction, you need to identify the highest active part of the arch, and inject just half a Speywood unit or a full unit to drop the overly active frontalis laterally. Keep in mind that these injections should be at least one finger width above the superior border of the orbital rim to avoid brow ptosis.
How to approach a patient complaining of Spock brows
As a practitioner, it’s crucial to approach the management of a patient complaining of a Spock brow with open communication and transparency. Rather than dismissing it as a common side effect, it’s important to acknowledge the issue, explain its cause and outline the steps being taken to rectify and prevent it in the future.
Avoiding phrases like “it happens to everyone” is essential, as it can make the patient feel powerless and undermine their trust in the treatment and practitioner. Instead, both the patient and practitioner need to learn from the experience to strengthen their relationship and ensure the patient’s confidence in their injector’s skills and expertise moving forward.
In cases where the patient is significantly distressed by the experience, it may be prudent to explore alternative treatment options to avoid potential future negative outcomes. This consideration is particularly relevant for older patients who may be more sensitive to aesthetic changes and less inclined to undergo repeat treatments if they’ve had a negative experience.
Ultimately, honesty, transparency and a commitment to improving patient care are paramount in managing and resolving issues like Spock brows to maintain a positive patient-provider relationship.
Spock eyebrows can be an unintended consequence of botulinum toxin treatment, but with proper understanding and preventive measures, they can be avoided. It is important that before you treat patients, you understand the anatomy, assess your patient well and treat them with confidence.
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