Pilot Retrospective Evaluation of a Balancing and Optimizing Injection Pattern for the Frontalis Muscle Using LetibotulinumtoxinA

Signs of aging in the upper face arise from multimodal changes in facial anatomy, contributing to concerns such as eyebrow ptosis and forehead lines. While neurotoxin injections are widely used to address these lines, the anatomical variability of the frontalis muscle presents procedural challenges. This retrospective analysis aimed to introduce and preliminarily evaluate a structured injection pattern for forehead treatment, developed with attention to the biomechanics of upper facial musculature. A total of 24 patients (mean age 42.5 ± 9.1 years) treated with a standardized injection scheme using letibotulinumtoxinA were included. All subjects also received concomitant glabellar treatment. The protocol incorporated identification of the line of convergence and targeted injections at defined points to balance elevation, optimize muscular activity, and minimize the risk of eyebrow descent. Forehead line severity was assessed at rest and during animation, and three-dimensional surface imaging was used to quantify vertical skin displacement. At baseline, 79.2% of patients presented with severe dynamic forehead lines, and 29.1% exhibited severe static lines. After two weeks, 62.5% showed no dynamic lines and 41.7% showed no static lines. All subjects demonstrated a ≥1-point improvement in dynamic line severity, with 87.5% achieving a ≥2-point improvement. For static lines, 95.8% achieved a ≥1-point improvement and 20.8% showed a ≥2-point improvement after two weeks. The mean dosage was 17.8 ± 0.7 U. Two patients (8.3%) required a touch-up, and no adverse events were observed. These findings suggest that this structured injection approach may offer a consistent method for addressing forehead lines; however, the results should be interpreted within the limitations of a small, uncontrolled retrospective series. Prospective controlled studies with larger populations are needed to further validate the technique.