Tensed glabella region between the eyebrows · corrugator muscle · practice of Dr. Thomas Ackermann

frown line

Individual cost plan after consultation

The vertical line between the eyebrows is created by three muscles working together. Botulinum toxin type A relaxes them in a targeted way — anatomically planned, dosed by sex and muscle strength, without taking away your expression in conversation. The best-studied application in aesthetic medicine: duration of effect usually 3–4 months. Treatment provided by a board-certified anesthesiologist.

Expression lines · Glabella · Between the brows

Frown Lines

The vertical line between the eyebrows is created by the interplay of three muscles that pull the brows inward and down. Botulinum toxin type A relaxes these muscles in a targeted way — anatomically planned, individually dosed, without taking away your expression in conversation. It is the best-studied application in aesthetic medicine.

Duration of effect3–4 monthsFor most patients. Some notably longer — up to 12 months in one dose-ranging study.

Treatment time15–20 minIncluding assessment and marking. No downtime.

Onset2–5 daysFull effect after 10–14 days. Follow-up appointment falls within this window.

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In short

Frown lines are expression lines folded into the skin by three small muscles between the brows when you frown. Botulinum toxin type A interrupts the signal from nerve to these muscles for several months. The skin above smooths out because it is no longer pulled together with every frown. The treatment was first described in 1992, has been supported by controlled trials since 2002, and is approved for this use. If you want to understand the anatomy in more depth: the in-depth page on the glabella explains the three muscles involved and the individual dosing logic. Reading time about 9 minutes.

Dr. Thomas Ackermann's practice · Clinical approach

The glabella is not a standard-dose region. Three muscles — corrugator, procerus, depressor supercilii — differ from person to person, in muscle mass, line depth and brow position. Anyone who applies a fixed unit count across every patient is treating a statistic, not the person sitting in front of them.

— Dr. med. Thomas Ackermann · Board-Certified Anesthesiologist

Safety profile

What you can realistically expect

A note on terminology: Many patients search for “Botox” — a brand name of one single product that has become a colloquial umbrella term. The active substance is botulinum toxin type A, contained in several licensed medicinal products. All of them are prescription-only and are injected exclusively by the physician after a medical examination. This page uses the substance name throughout — it refers to the same treatment commonly known as a Botox treatment.

Observation	Frequency	Duration
Bruising at the injection site	common	3–7 days
Pressure or heaviness between the brows	common (altered eyelid sensation: 2.5% versus 0.3% under placebo)	1–2 days, rarely longer
Headache after treatment	occasional — similarly frequent as placebo in the trials	1–2 days
Uneven brow height	occasional	2–8 weeks, adjustable at the follow-up appointment
Brow drop	occasional, more common with a pre-existing low brow	3–8 weeks
Drooping upper eyelid (ptosis)	1.8% (pooled, 9 trials) to 5.4% (2002 pivotal trial)	3–8 weeks; eye drops can bridge the interval
Raised outer brow ("Mephisto sign")	rare	2–6 weeks, correctable with a targeted touch-up

Frequencies according to Brin et al. 2009 (pooled data from 9 pivotal trials, 1,678 participants), Carruthers et al. 2002 and the Sommer/Bergfeld/Sattler 2007 consensus recommendations. Ptosis is the only side effect that occurred significantly more often than placebo in the 2021 Cochrane review. More detail in the safety overview.

Common reasons patients come in

Does this sound familiar?

"People ask me if I'm tired"

The corrugator pulls the brows inward and down — even at rest, a faint vertical line remains. The face looks exhausted or annoyed without the person feeling that way. Relaxing the brow depressors often lifts the inner brow slightly — a common side effect that opens up the gaze.

"Screen work, constant tension"

Focused reading on a monitor activates the muscles between the brows for hours at a time. Over the years, the expression line becomes a line that stays even at rest. Many patients also notice tension extending into the temples.

"I look stern — even when I'm not"

Pronounced activity between the brows is often read in conversation as scepticism or disapproval. The treatment doesn't change your personality — it decouples the automatic frown from the expression you actually want to show.

Important to know

What botulinum toxin in the glabella is not

It is not a filler. No volume is added — muscle activity is paused. Some patients with very deeply etched lines that remain even at complete rest may also benefit from hyaluronic acid — this is assessed during the consultation, not decided in the same appointment.
It does not remove the line — it relaxes the muscle that creates it. The skin above smooths out passively because it is no longer folded. With lines etched in over decades, some residual texture can remain.
It is not "smoothing the forehead." Frown lines and horizontal forehead lines are two different treatments involving muscles that work in opposite directions. Treating the forehead alone without accounting for the brow depressors risks a dropped brow. That's why I plan both together — or the frown lines first.
It is not a lift. The slight lift of the inner brow is a side effect, not a substitute for a surgical brow lift.

The process

Why this practice

Easy to inject. Hard to dose correctly.

Whether frown line treatment has succeeded shows up after two weeks: whether your gaze looks open rather than fixed — and whether you still look like yourself. Anatomy decides this: which muscle pulls how strongly, how deep it lies, where your brow sits. Dose-ranging studies show that men typically need substantially higher doses than women — and that the range within each group is wide.

As a board-certified anesthesiologist, I work daily with nerve pathways and muscle anatomy. I am a certified member of the DGBT (German Society for Aesthetic Botulinum Toxin Therapy) and hold the additional qualification in emergency medicine. I also treat patients who received a result elsewhere that they are not happy with — being able to correct a result changes how you dose from the outset.

How I think about the individual muscle groups: Overview: wrinkle treatment with botulinum toxin · Correction with ultrasound-guided hyaluronidase

How your appointment works

History and assessment. Expression at rest and when frowning, palpation of the three muscles involved, brow position relative to the bony orbital rim. In men, muscle mass tends to be greater; in younger patients, the skin is more elastic. Please disclose blood-thinning medication in advance — and never stop it on your own.
Dose planning. The assessment determines the distribution across typically 5, occasionally 7 injection points. The total dose depends on sex, muscle strength and goal — the trials support a range of 20 to 40 units for women, and 40 units or more for men. It is not a fixed number per patient.
Injection. Very fine needles. The needle tip always points away from the eye, and distance from the orbital rim is maintained — the single most important measure against a drooping upper eyelid. A few seconds per point; most patients describe brief pressure, not pain.
Immediately afterward. No downtime. Make-up after 2–4 hours. In the first 4 hours, no massage or pressure on the area; on the day of treatment, no exercise, no sauna, no sunbed.
Follow-up appointment after 10–14 days. Assessment of symmetry and any residual activity, minor touch-up injection if needed. I avoid early touch-ups — intervals under three months are considered a possible risk factor for antibody formation.

Detailed guidance for the first 24 hours and 14 days is in the aftercare overview.

The next step

First the assessment. Then the decision.

In your initial consultation, we clarify whether this treatment makes sense for you — and what is realistic to expect. Private practice in Herzogenaurach, twelve minutes by car from Erlangen.

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Frequently asked questions

About frown line treatment

When do I see the effect?

An initial effect after 2–5 days, full effect after 10–14 days. Anyone checking the mirror after a week rarely sees the final result — which is why the follow-up appointment deliberately falls in the second week.

How long does the result last?

3 to 4 months for most patients. In the 2005 Carruthers dose-ranging study, some participants showed an effect lasting up to 12 months; in the 2002 pivotal trial, the effect persisted for many until the end of the study at 120 days. Whether the duration lengthens with repeated treatment is often reported but not solidly proven — the 2021 Cochrane review names exactly this gap in the data.

How painful is the injection?

The needles are very fine. Most patients describe a brief pressure at each injection point. If you're sensitive, you can cool the area immediately beforehand — numbing is usually not necessary.

What if my upper eyelid droops?

Ptosis occurs when the substance reaches the eyelid-lifting muscle — usually from injecting too deep or too close to the orbital rim. It occurs in 1.8 to 5.4% of cases in the trials and resolves on its own within 3–8 weeks. Eye drops that activate a small accessory muscle of the upper eyelid can bridge the interval. The most important measure is prevention through technique and distance.

Can I exercise or use a sunbed afterward?

On the day of treatment, I recommend avoiding exercise, sauna and sunbeds — especially head-down positions. From the next day, normal activity is fine again.

What if I'm not happy with the result?

At the follow-up appointment after 10–14 days, we assess whether a small touch-up would refine the result. An effect that is too strong cannot be reversed — it fades on its own. That's why I start conservatively at the first treatment rather than too high.

I've been treated elsewhere before — can I switch practices?

Yes. If you have it, bring information about your previous treatment to the consultation: active substance, dose, last appointment. This helps assess how the effect has been progressing and plan the next session more precisely. I don't need to know who treated you before.

Can frown lines, forehead and crow's feet be treated in the same appointment?

Yes, this is the usual case and has been studied in a trial with 787 participants. Coordinated planning matters: the forehead muscle lifts the brows, the glabella muscles lower them. Treating only one side of this balance shifts brow position.

What happens in the rare event of a complication?

The side effects in the table above resolve on their own within a few weeks. In the pooled analysis of 1,678 study participants, no serious treatment-related events occurred; spread of the effect beyond the injection site was not observed. As an anesthesiologist with additional training in emergency medicine, I am equipped and practiced for the unlikely case of an allergic reaction.

What does the treatment cost?

Physician services are billed according to the German fee schedule for physicians (GOÄ). What applies to your treatment — depending on muscle mass, dose and combination with other regions — is discussed transparently during your consultation beforehand.

Evidence base

What the studies show

Treatment of frown lines with botulinum toxin type A is the best-studied application in aesthetic medicine: of 65 randomized trials in the 2021 Cochrane review, 43 concern the glabella.

Carruthers JD, Carruthers JA, 1992. Treatment of glabellar frown lines with C. botulinum-A exotoxin. J Dermatol Surg Oncol 18(1):17–21. PMID 1740562. First description in 18 patients: improvement lasting 3 to 11 months, minor and transient side effects.
Carruthers JA, Lowe NJ, Menter MA et al., 2002. A multicenter, double-blind, randomized, placebo-controlled study of the efficacy and safety of botulinum toxin type A in the treatment of glabellar lines. J Am Acad Dermatol 46(6):840–849. PMID 12063480. Pivotal trial: 264 participants, 20 units across 5 points versus placebo. Significant improvement at every follow-up point, persisting for many until day 120. Ptosis in 5.4%, mostly mild.
Carruthers A, Carruthers J, Said S, 2005. Dose-ranging study of botulinum toxin type A in the treatment of glabellar rhytids in females. Dermatol Surg 31(4):414–422. PMID 15871316. 80 women, 10 / 20 / 30 / 40 units: 10 units clearly weaker (relapse rate at 4 months 83% versus 28–33%). Most benefited for 3–4 months, some up to 12 months.
Carruthers A, Carruthers J, 2005. Prospective, double-blind, randomized, parallel-group, dose-ranging study of botulinum toxin type A in men with glabellar rhytids. Dermatol Surg 31(10):1297–1303. PMID 16188182. 80 men, 20 / 40 / 60 / 80 units: from 40 units onward, clearly more effective and longer-lasting than 20 units, without an increase in side effects. Basis for sex-specific dosing.
De Boulle K, Werschler WP, Gold MH et al., 2018. Phase 3 Study of OnabotulinumtoxinA Distributed Between Frontalis, Glabellar Complex, and Lateral Canthal Areas for Treatment of Upper Facial Lines. Dermatol Surg 44(11):1437–1448. PMID 30096106. 787 participants; simultaneous treatment of the forehead, glabella and crow's feet was effective and well tolerated — the basis for planning the upper face together.
Brin MF, Boodhoo TI, Pogoda JM et al., 2009. Safety and tolerability of onabotulinumtoxinA in the treatment of facial lines: a meta-analysis of individual patient data from global clinical registration studies in 1,678 participants. J Am Acad Dermatol 61(6):961–970. PMID 19744746. Pooled safety data from 9 trials: ptosis 1.8% versus 0%, altered eyelid sensation 2.5% versus 0.3% under placebo — both only in glabella trials; no serious treatment-related events, no distant spread.
Camargo CP, Xia J, Costa CS et al., 2021. Botulinum toxin type A for facial wrinkles. Cochrane Database Syst Rev 7:CD011301. PMID 34224576. 65 randomized trials, 14,919 participants. For 20 units in the glabella: success rate at 4 weeks 17- to 19-fold higher than placebo (moderate certainty of evidence); serious adverse events, mainly ptosis, likely more frequent. Named gap: long-term data across multiple cycles.
Gadhia K, Walmsley AD, 2009. Facial aesthetics: is botulinum toxin treatment effective and safe? A systematic review of randomised controlled trials. Br Dent J 207(5):E9. PMID 19749689. 11 randomized trials, 1,603 participants: peak effect after about one month, duration 4–6 months, glabellar ptosis 0–5.4%, other side effects at placebo level.
Sommer B, Bergfeld D, Sattler G, 2007. Consensus recommendations on the use of botulinum toxin A in aesthetic medicine. J Dtsch Dermatol Ges 5 Suppl 1:S1–S29. PMID 17229195. German-language consensus on anatomy, injection technique and complication management.

Study details researched via PubMed. The studies cited describe the state of the scientific literature and do not constitute a claim about the outcome of any individual treatment. The pivotal and dose-ranging trials were funded by the manufacturer.