53 Filler Finesse: Forehead

Steven Fagien, Rod J. Rohrich, and Yash J. Avashia

Abstract

Prior to a greater understanding of the aging forehead, neurotoxins had been the main focus for the elimination of forehead lines and glabellar furrows. A youthful forehead exhibits certain qualities that include smooth contours. Current applications of forehead rejuvenation include addressing these contours of the forehead including the temple region and improvement or elimination of static rhytides with the combined use of neurotoxins and fillers. A review of the relevant anatomy is essential so that one is aware of the best target regions as well as to avoid inadvertent injection into regional arteries, veins, and nerve bundles. Slow, smooth, and careful injection technique with appropriate volumes is critical. Detailed assessment of areas of soft tissue paucity will aid in tailoring volume restoration technique.

Hyaluronic acid filler – intravascular injection – augmentation – temporal volumization – forehead filler

53 Filler Finesse: Forehead

Key Points

Filler products illustrated here will include Juvederm® Ultra (Allergan plc, Dublin, Ireland) but similar results can be obtained with other hyaluronic acid filler products from both Vycross or Hylacross technologies, the Restylane® (Galderma) family of products, Belotero® (MERZ) and the RHA products (Revance).
Understanding relevant anatomy is essential to achieve optimal results and to avoid inadvertent injection into regional arteries, veins, and nerve bundles with subsequent adverse events.
Slow, smooth, and careful injection technique is critical.
Injection technique may vary but must consider ways to maximize results while avoiding complications.
Aspiration does not guarantee extravascular location, but is advised in many situations to ensure proper placement of needle or cannula.
Injection volume should be tailored to achieve desired treatment effect and avoid potential complications.

53.1 Upper Facial Assessment

The temple should be flat, slightly concave, or slightly convex, without any significant concavity, depression, hollowing, or marked step-off from the lateral zygoma posteriorly.
Age-related volume loss in the upper face can result in hollowing of the temples. Youthful temples are typically flat or slightly convex; temple volumization is indicated for temples that have become overly concave.
The aesthetically desirable female eyebrow should be over the supraorbital margin with middle aspect slightly lower than lateral aspect.
The position and/or shape of the eyebrow may change with aging. Fillers can enhance eyebrow contour and volume, and may be used for improving the elevation of the eyebrow tail in cases where onabotulinumtoxinA provides insufficient eyebrow lifting.
The upper face should be assessed for volume loss in the temples and forehead, position of the eyebrow, and the presence of excess skin in the upper and lower eyelids.
Dynamic forehead lines are usually treated with a neuromodulators, but hyaluronic acid fillers can be safely used to treat deep horizontal (static) wrinkles (or horizontal lines that treated with neuromodulators induces brow ptosis) to create a smooth contour across the forehead.
Most hyaluronic acid fillers are not designed for fine-line filling, as is the case with Juvederm® Ultra that must be reconstituted to a lower concentration to be optimal for superficial dermal injection/placement.

53.2 Upper Facial Filler

53.2.1 Preparation

Makeup and other contaminants on the face should be removed before the injection and should be avoided on the day of the procedure.
Aseptic technique should be used, which includes thorough hand washing and wearing gloves, and sterile technique with needle transfer or when reconstituting product.
Skin site preparation for Vycross® products should include either chlorhexidine, povidone-iodine, or similar and for Hylacross® products alcohol will suffice.
The skin should be visibly assessed for local dermatologic disorders (comedones, acne), active bacterial or viral infections, or inflammatory disease processes.
Treatment in irritated or inflamed skin should be avoided.

53.2.2 Technical Aspects

For fine-line filling, 30- or 32-gauge, 0.5-inch needles are suggested depending on product used or method of reconstitution.
The injection needle should be changed regularly to minimize the risk of infection and increased discomfort from blunting.
A slow injection speed with smaller needles is essential for avoidance of product spread when the needle is inadvertently placed intravascularly.
Smaller needles also tend to cause less bruising and limit volumes, reducing local adverse events.
In treatment areas with challenging anatomy or a higher risk of complications, it may be advisable to use blunt cannulas instead of needles; however, these do not guarantee against complications.

53.2.3 Forehead Line Filling (Fig. 53.1)

Static forehead lines that are not appropriate for chemodenervation of the frontalis are best treated with reconstituted Juvederm® Ultra.
Reconstitution is variable and depends on the skin thickness and rhytid depth but usually is accomplished by (author Steven Fagien’s preference) mixing, blending, or “dilution” of the products to approximately 50% of the packaged concentration of 24 mg/mL to around 12 mg/mL by adding equal amounts of anesthetic solution (i.e., add 1 mL of lidocaine with epinephrine to 1 mL of Juvederm® Ultra, yielding 2 mL of reconstituted product).
A 32-gauge needle is used and rhytid reduction/elimination is accomplished by serial threading or serial puncture with the needle nearly parallel to the skin surface with particular caution to inject intradermally.
Injections proceed to full correction without overcorrection.
Blanching from epinephrine is expected and looks completely different from an inadvertent arteriolar injection.

Fig. 53.1 (a, b) Horizontal rhytid correction with fillers.