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Cotofana, Sebastian; Freytag, David L.; Frank, Konstantin; Sattler, Sonja; Landau, Marina; Pavicic, Tatjana; Fabi, Sabrina; Lachman, Nirusha; Hernandez, Claudia A.; Green, Jeremy B. (2020): The Bidirectional Movement of the Frontalis Muscle: Introducing the Line of Convergence and Its Potential Clinical Relevance. In: Plastic and Reconstructive Surgery, Vol. 145, No. 5: pp. 1155-1162
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Abstract

Background: Cosmetic treatment of the forehead using neuromodulators is challenging. To avoid adverse events, the underlying anatomy has to be understood and thoughtfully targeted. Clinical observations indicate that eyebrow ptosis can be avoided if neuromodulators are injected in the upper forehead, despite the frontalis muscle being the primary elevator. Methods: Twenty-seven healthy volunteers (11 men and 16 women) with a mean age of 37.5 +/- 13.7 years (range, 22 to 73 years) and of diverse ethnicity (14 Caucasians, four African Americans, three Asians, and six of Middle Eastern descent) were enrolled. Skin displacement vector analyses were conducted on maximal frontalis muscle contraction to calculate magnitude and direction of forehead skin movement. Results: In 100 percent of investigated volunteers, a bidirectional movement of the forehead skin was observed: the skin of the lower forehead moved cranially, whereas the skin of the upper forehead moved caudally. Both movements converged at a horizontal forehead line termed the line of convergence, or C-line. The position of the C-line relative to the total height of the forehead was 60.9 +/- 10.2 percent in men and 60.6 +/- 9.6 percent in women (p = 0.941). Independent of sex, the C-line was located at the second horizontal forehead line when counting from superior to inferior (men, n = 2;women, n = 2). No difference across ethnicities was detected. Conclusions: The identification of the C-line may potentially guide practitioners toward more predictable outcomes for forehead neuromodulator injections. Injections above the C-line could mitigate the risk of neuromodulator-induced brow ptosis.