The Psychological Impacts of Horizontal Frontalis Lines, Glabellar Lines, and Lateral Canthal Lines:  
Qualitative, Patient-Centered Studies 

Steven Dayan, MD1; Steven G. Yoelin, MD2; Koenraad De Boulle, MD3; Ilia L. Ferrusi, PhD4
1DeNova Research, Chicago, IL, USA; 2Medical Associates Inc., Newport Beach, CA, USA; 3Aalst Dermatology Clinic, Aalst, Belgium; 4Allergan plc, Irvine, CA, USA

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INTRODUCTION
• Facial lines or wrinkles are a common sign of aging, developing slowly over time 

due to repeated contraction of underlying facial muscles1-3 
• In the upper face, 3 types of facial lines are common: lateral canthal lines (crow’s feet 

lines; CFL), caused by smiling or squinting; horizontal frontalis lines (forehead lines; 
FHL), caused by raising of the eyebrows; and glabellar lines (GL), caused by frowning1 

• With age, these upper facial lines (UFL) tend to become static and visible, even 
when facial muscles are at rest1

• The development of UFL can influence self-perception and may have a variety of 
psychological impacts3-5

OBJECTIVE
• To determine the psychological impact of CFL and FHL individually and of the  

3 UFL areas combined
• To evaluate whether the 11-item Facial Line Outcomes (FLO-11) Questionnaire3 is 

an adequate measure to assess CFL, FHL, and UFL psychological impacts

METHODS
Subjects
• Two qualitative research studies (Figure 1) were conducted in adults with moderate 

or severe UFL (ie, CFL, FHL, and GL) at maximum contraction, as measured using 
the investigator-rated Facial Wrinkle Scale with photonumeric guide (FWS; 0=none; 
1=mild; 2=moderate; 3=severe)

• Study 1 enrolled subjects aged ≥18 years with moderate or severe CFL at  
maximum smile

• Study 2 enrolled subjects aged 18–65 years with moderate or severe FHL at 
maximum eyebrow elevation only, or in conjunction with moderate or severe CFL at 
maximum smile, and moderate or severe GL at maximum frown

• All subjects were fluent in English
• Key exclusion criteria:

 ─ Prior periorbital surgery, facial or brow lift, or related procedure, or midfacial or 
periorbital treatment with permanent soft-tissue fillers, polytetrafluorethylene 
(Gore-Tex) implantation, or autologous fat transplantation 

 ─ Nonablative resurfacing laser/light treatment, microdermabrasion, or superficial 
peels within 3 months 

 ─ Cosmetic procedure with medium depth to deep facial chemical peels, midfacial 
or periorbital laser skin resurfacing, or permanent make-up within 6 months 

 ─ Midfacial or periorbital treatment with non-permanent soft-tissue filler within  
the previous 12 months 

 ─ Botulinum toxin treatment within 6 months 

Figure 1. Study Designs

Study 1 Study 2

Concept elicitation 
interview: open-ended 

questions about
psychological impacts 

of CFL

Subjects complete the FLO-11 questionnaire 

Targeted questions about 
relevancy of FLO-11 items 

and FLO-11 overall
for assessing psychological

impacts of CFL   

Concept elicitation interview:
open-ended questions about 

impacts of FHL (n=20) or 
UFL (n=20); subjects

were also asked to define 
the psychological impacta    

Targeted questions about 
relevancy of FLO-11 items 

and FLO-11 overall for
assessing psychological 
impacts of FHL or UFL   

Subjects aged ≥18 years 
with moderate or severe 

CFL at maximum 
contraction

(n=41)

Subjects aged 18–65 years 
with moderate or severe 
FHL only (n=9) or with 

moderate or severe 
UFL (CFL, FHL, 

and GL) at maximum
contraction (n=20)

aEleven subjects in addition to the 9 subjects with FHL only completed interviews about the impact of FHL. 
CFL, crow’s feet lines; FHL, forehead lines; GL, glabellar lines; UFL, upper facial lines.

Interview Conduct
• Both studies included a concept elicitation (CE) phase, followed by targeted 

questions about the relevancy of the FLO-11 questionnaire. All interviews were 
audio or video recorded, with each subject’s permission

• In the CE phase, subjects were asked open-ended questions by trained interviewers 
about the psychological impacts of their particular facial wrinkles: CFL in study 1, 
and FHL or UFL combined (ie, CFL, FHL, and GL) in study 2

 ─ Probing questions were asked, if necessary, to elicit concepts related to the 
psychological impact of their particular facial wrinkles

• Following the CE phase, subjects were asked to complete the FLO-11 questionnaire 
and provide feedback on the relevancy of each item to the psychological impact of 
their particular facial wrinkles

Analysis 
• Interview transcripts were imported into ATLAS.ti version 7.0 (Atlas.ti GmbH; Berlin, 

Germany) to facilitate the organization and analyses of qualitative data. Transcripts 
were analyzed on an ongoing basis, using a grounded theory approach to produce 
rich descriptions and theoretical explanations for the topic

• Codes consisting of root concepts elicited from the subjects and related to the 
research questions were linked to relevant portions of the transcript texts. Each 
coded transcript was reviewed by ≥2 members of the project team until  
a consensus was reached

• At the end of the coding process, the project team evaluated patterns in the data, 
with interpretation performed using a constant comparison method

RESULTS
Subjects
• Study 1 enrolled 41 subjects with moderate or severe CFL (CFL cohort) 
• Study 2 included 29 subjects; 9 had moderate or severe FHL only and 20 had 

moderate or severe CFL, FHL, and GL (UFL cohort)
 ─ In the latter group, 11 subjects in addition to the 9 with FHL only completed 

interviews about their FHL (FHL cohort)
• Study participants ranged in age from 24–72 years, and most were female and white 

(Table 1)

Table 1. Demographics and Baseline Characteristics 

Characteristic Study 1 Study 2

CFL Cohort 
(n=41)

FHL Cohort 
(n=20)

UFL Cohort 
(n=20)

Age, years, mean (SD) 50.7 (20.8) 44.7 (15.6) 50.4 (13.8)

Age, years, range 25–69 24–72 24–72

Female, n (%) 36 (87.8) 14 (70.0) 14 (70.0)

White, n (%) 34 (82.9) 17 (85.0) 17 (85.0)

CFL severity at maximum 
smile, n (%)

Moderate 28 (68.3)a — 11 (55.0)

Severe 11 (26.8) — 9 (45.0)

FHL severity at maximum 
eyebrow elevation, n (%)

Moderate — 8 (40.0) 7 (35.0)

Severe — 12 (60.0) 13 (65.0)

GL severity at maximum 
frown, n (%)

Moderate — — 10 (50.0)

Severe — — 10 (50.0)

aData shown for left side. Corresponding data for right side: 29 (70.7%) with moderate and  
10 (24.4%) with severe CFL.
CFL, crow’s feet lines; FHL, forehead lines; GL, glabellar lines; SD, standard deviation; UFL,  
upper facial lines.

Concept Elicitation Phase Interview
Study 1

•  The most common appearance and behavioral impacts of CFL are shown in  
Figure 2A

• The most common psychological impacts of CFL were looking older than desired, 
feeling depressed/sad, feeling older, and looking less attractive (Figure 2B)

Figure 2. The Most Commonly Reported (≥20% of Subjects) 
Appearance, Emotional, and Physical Impacts (A) and Psychological 
Impacts (B) of Crow’s Feet Lines in Study 1 

20

24

32

37

42

0 5 10 15 20 25 30 35 40 45 50

Feeling less confident

Looking less attractive

Feeling older

Feeling depressed/sad

Looking older than desired

Subjects (%)

CFL Cohort

37

34

44

46

73

32

51

61

63

68

83

85

85

0 10 20 30 40 50 60 70 80 90 100

Using creams

PHYSICAL IMPACTS

Feeling bad about appearance

Feeling less attractive

Feeling bothered

Feeling older

EMOTIONAL IMPACTS

Looking older than actual age

Looking stressed

Looking not well rested

Looking less attractive

Looking tired

Looking older than desired

Looking older

Skin appears not smooth

APPEARANCE IMPACTS

Subjects (%)

CFL Cohort

B. 

Interview question:  Do you think your CFL have any psychological impact on
yourself? If yes, how so? 

A.

If necessary, the following probes were asked: What does psychological impact mean to you? What feelings 
or emotions would you consider are psychological impacts due to CFL? Would you consider any CFL 
impacts already discussed to be a psychological impact?

Study 2

• The most common appearance and behavioral impacts of FHL and UFL are shown 
in Figures 3A and 3B, respectively

• The most common psychological impacts of FHL were feeling bothered, feeling  
self-conscious, feeling older, and feeling less confident (Figure 4A)

• For the UFL cohort, the most common psychological impacts were feeling bothered, 
feeling older, feeling less confident, and feeling less attractive (Figure 4B)

Figure 3: The Most Commonly Reported (≥20% of Subjects) 
Appearance and Emotional Impacts of Forehead Lines (A) and Upper 
Facial Lines (B) in Study 2 

20

25

30

35

45

20

25

30

35

35

50

50

75

85

Feeling less attractive

Feeling less confident

Feeling older

Feeling self-conscious

Feeling bothered

EMOTIONAL IMPACTS

Looking not well rested

Looking stressed

Skin appears less smooth

Looking older than actual age

Looking tired

Looking angry

Looking less attractive

Looking older than desired

Looking older overall

APPEARANCE IMPACTS

FHL Cohort

Subjects (%)

0 10 20 30 40 50 60 70 80 90 100

25

30

30

40

40

20

25

30

40

50

50

65

70

0 10 20 30 40 50 60 70 80 90 100

Feeling good/bad
about appearance

Feeling less attractive

Feeling less confident

Feeling bothered

Feeling older

EMOTIONAL IMPACTS

Looking older than actual age

Looking not well rested

Looking angry

Looking tired

Looking stressed

Looking less attractive

Looking older than desired

Looking older overall

APPEARANCE IMPACTS

UFL Cohort

Subjects (%)

B. 

A.

FHL, forehead lines; UFL, upper facial lines.

Figure 4. The Most Commonly Reported (≥20% of Subjects) 
Psychological Impacts of Forehead Lines (A) and Upper Facial  
Lines (B) in Study 2 

20

25

30

35

45

0 5 10 15 20 25 30 35 40 45 50

Feeling less attractive

Feeling less confident

Feeling older

Feeling self-conscious

Feeling bothered

Subjects (%)

FHL Cohort

25

30

30

40

40

0 5 10 15 20 25 30 35 40 45 50

Feeling good/bad
about appearance

Feeling less attractive

Feeling less confident

Feeling older

Feeling bothered

Subjects (%)

UFL Cohort
B. 

A.

FHL, forehead lines; UFL, upper facial lines.

FLO-11 Questionnaire
• Several items of the FLO-11 questionnaire were frequently reported to be adequate 

measures of the psychological impact of CFL, FHL, and UFL overall. For example, 
Items 1, 3, and 5 elicited >68% response across all cohorts (Table 2)

Table 2. FLO-11 Items Reported as Psychological Impacts of Upper 
Facial Lines 

Interview question: Do you think that this questionnaire asks you questions 
about the psychological impacts of CFL? If so, which questions ask you about the 

psychological impacts of CFL?

FLO-11 Item, n (%)
Study 1 Study 2

CFL Cohort 
(n=41)

FHL Cohort 
(n=20)

UFL Cohort 
(n=20)

Item 1: Feeling bothered 28 (68) 16 (80) 14 (70)

Item 2: Looking older than desired 29 (71) 14 (70) 11 (55)

Item 3: Feeling less attractive 32 (78) 17 (85) 16 (80)

Item 4:  Looking older than my 
actual age

19 (46) 15 (75) 13 (65)

Item 5: Looking less attractive 31 (76) 17 (85) 14 (70)

Item 6: Looking not well rested 17 (42) 11 (55) 10 (50)

Item 7: Skin appears less smooth 15 (37) 12 (60) 10 (50)

Item 8: Looking tired 19 (46) 13 (65) 13 (65)

Item 9: Looking stressed 22 (54) 14 (70) 14 (70)

Item 10: Looking angry 20 (49) 13 (65) 11 (55)

Item 11:  Feeling good about  
appearance

23 (56) 16 (80) 14 (70)

CFL, crow’s feet lines; FHL, forehead lines; UFL, upper facial lines.

• The FLO-11 items most frequently reported
 ─ CFL cohort: Item 3 (feeling unattractive; 78.0%) and Item 2 (feeling older than 

desired; 70.7%)
 ─ FHL cohort: Item 3 (85.0%) and Item 5 (feeling less attractive than desired; 85.0%)
 ─ UFL cohort: Items 3 (feeling unattractive; 80.0%) and 1 (bothered by lines),  

5 (looking less attractive than desired), 9 (looking stressed), and 11 (feeling 
good/bad about appearance) (each 70.0%)

• The majority of subjects in each cohort reported that the FLO-11 questionnaire is  
a comprehensive measure of the psychological impacts of their particular facial lines 
(Figure 5)

Figure 5. Subjects Reporting That the FLO-11 Questionnaire Is  
a Comprehensive Measure of Psychological Impacts of Crow’s Feet 
Lines, Forehead Lines, and Upper Facial Lines 

0

10

20

30

40

50

60

70

80

90

100

CFL FHL UFL

n=41 n=20 n=20

73

65
60

S
ub

je
ct

s 
(%

)

CFL, crow’s feet lines; FHL, forehead lines; UFL, upper facial lines. 

CONCLUSIONS
• CFL, FHL, and UFL are associated with multiple psychological impacts, including 

feeling older, less attractive, bothered, self-conscious, and less confident
• These facial lines also affect self-perception, as subjects frequently reported 

looking older than their actual age, looking less attractive, and looking angry
• More than 50% of subjects reported that 6 Items, 9 Items, and all 11 Items on the 

FLO-11 questionnaire assess the psychological impact of CFL, UFL, and FHL, 
respectively

• The majority of subjects reported that the FLO-11 is a comprehensive measure 
of the psychological impacts of their particular facial lines

• Based on these findings, the FLO-11 is an appropriate and comprehensive 
measure of the psychological impact of CFL, FHL, and UFL overall from the 
subject’s perspective

REFERENCES 
1. Finn CJ, et al. Dermatol Surg. 2003;29(5):450-5.
2. Beer K, Beer J. Facial Plast Surg. 2009;25(5):281-4.
3. Yaworsky A, et al. J Cosmet Dermatol. 2014;13(4):297-306.
4. Cox SE, Finn JC. Int Ophthalmol Clin. 2005;45(3):13-24.
5. Gupta MA, Gilchrest BA. Dermatol Clin. 2005;23(4):643-8.

ACKNOWLEDGMENTS 
This study was sponsored by Allergan plc, Dublin, Ireland. Medical writing and editorial assistance was provided 
to the authors by Cactus Communications and was funded by Allergan plc. All authors met the ICMJE authorship 
criteria. Neither honoraria nor other form of payments were made for authorship.

FINANCIAL DISCLOSURES
S Dayan is an employee of DeNova Research, which received remuneration for this research from Allergan plc. 
SG Yoelin serves as an investigator and on a speakers’ bureau for Allergan plc. K De Boulle serves as  
a consultant and investigator and on a speakers’ bureau for Allergan plc. IL Ferrusi was an employee of Allergan 
plc at the time of this research.

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