Aging Gracefully, with Botox

Why We Need Less in the Upper Face and More in the Lower Face as We Age

As a plastic surgeon, one of the most common questions I receive from patients as they navigate the aging process is about the shifting use of neuromodulators like Botox. What surprises many is that our need for neuromodulator treatments evolves with age. For most, the demand for units in the upper face—specifically the forehead, crow’s feet, and glabellar area—decreases over time, while the lower face requires increasing attention. This change is directly related to the natural weakening and descent of the upper face and the strengthening of the depressor muscles in the lower face.

The Upper Face: The Decreasing Need

Let’s start with the upper face, where many patients first notice the visible signs of aging. In our younger years, dynamic lines—those caused by repeated muscle movements—are the primary target of neuromodulators. These lines typically show up as horizontal forehead creases, frown lines (glabellar lines), and crow’s feet. Early on, patients require a higher number of units to control the overactive muscles that create these lines.

However, as we age, the story changes. The muscles in the upper face, particularly the frontalis (forehead) and orbicularis oculi (around the eyes), naturally weaken. Brow descent and upper eyelid hooding start to set in, meaning that heavy-handed use of neuromodulators in these areas can actually cause more harm than good. Excessive weakening of the forehead muscles, for example, can make the brow sag even further, leading to a more tired or aged appearance.

What this means is that, over time, patients need fewer units of neuromodulators in the upper face. The goal shifts from trying to prevent dynamic lines to managing the interplay between muscle relaxation and maintaining the structural integrity of the brow and upper eyelids. It’s a delicate balance—too much neuromodulation, and we risk worsening brow ptosis and accentuating upper lid heaviness. As the upper face ages, neuromodulators are used more strategically, focusing on smoothing specific lines while maintaining muscle support to prevent further drooping.

The Lower Face: The Increasing Need

In contrast to the upper face, the lower face tells a different story. The depressor muscles, which are responsible for pulling down the corners of the mouth, creating jowls, and accentuating platysmal bands in the neck, become more dominant as we age. These muscles—like the depressor anguli oris (which pulls down the corners of the mouth), the mentalis (responsible for chin dimpling), and the platysma (the neck band muscles)—grow stronger over time, contributing to a downturned smile, a resting scowl, and more pronounced neck bands.

Think of the facial musculature like a tug-of-war between elevators and depressors. In our youth, the elevators—the muscles that lift the face, like the zygomaticus (responsible for lifting the corners of the mouth)—are strong and well-balanced against the depressors. But as we age, the elevators weaken and lose tone, while the depressors remain relatively strong or even become more active, leading to the visible effects of gravity on the lower face.

This is why more neuromodulator units are needed in the lower face as we age. By targeting the depressor muscles, we can help restore balance and create a more lifted, relaxed appearance. For example, injecting neuromodulators into the depressor anguli oris can help counteract a downturned mouth, giving patients a more pleasant resting expression. Similarly, treating the platysmal bands in the neck can smooth and lift the jawline, reducing the appearance of sagging.

The Challenge of Dynamic and Static Lines

Another factor to consider is the transition from dynamic to static lines. In younger patients, the lines we treat with neuromodulators are dynamic—they only appear with facial movement. As we age, however, these lines become static, meaning they are visible even when the face is at rest. The focus of treatment shifts from merely preventing lines from forming during movement to addressing the permanent etching of these lines in the skin.

In the upper face, dynamic lines like crow’s feet and forehead creases become less pronounced as the skin loses elasticity, and static lines often take center stage. In the lower face, though, we’re often dealing with static changes from muscle dominance, such as marionette lines and nasolabial folds. Neuromodulators play a key role in softening these lines, but as they are often static, they require ongoing, thoughtful management.

Managing Patient Expectations

One of the most important aspects of this shift in neuromodulator treatment as we age is managing patient expectations. Patients who have been accustomed to receiving regular Botox injections in their foreheads may find it hard to believe that they now need fewer units in that area. Meanwhile, they may not realize that their resting scowl or downturned smile can be softened with more neuromodulators in the lower face.

The key is education. Patients need to understand that aging is not just about wrinkles but about the complex interplay of muscle activity, skin elasticity, and gravity. Neuromodulators are not a one-size-fits-all solution, and what works in their 30s may not be appropriate in their 50s. The goal shifts from freezing muscles to maintaining balance and harmony between facial expressions and the natural aging process.

The Takeaway

As a plastic surgeon, I’ve seen firsthand how our use of neuromodulators must evolve with age. The upper face, once a major focus for treatment, requires fewer units as muscles weaken and brow descent sets in. On the other hand, the lower face demands more attention as depressor muscles grow stronger, contributing to downturned smiles, jowls, and platysmal bands. This shift reflects the natural aging process, and our treatments must adapt accordingly.

Ultimately, the best results come from understanding these changes and approaching neuromodulator use with a thoughtful, strategic plan. The goal is not to chase youth at any cost but to restore balance, smoothness, and a relaxed expression—allowing patients to age gracefully and confidently. After all, beauty in aging is about more than freezing time; it’s about sculpting an appearance that reflects vitality, elegance, and natural harmony.