Forehead and temporal recontouring using calcium hydroxylapatite pre-mixed with lidocaine

13 Forehead and temporal recontouring using calcium hydroxylapatite pre-mixed with lidocaine






Introduction


Although fillers are typically used for restoring volume loss to create a youthful appearance, an additional role of fillers is often overlooked – facial recontouring. The recontouring process not only corrects for defects but aims to restore facial proportion that may or may not have been present naturally in the patient who presents desiring correction.


One of the prime areas amenable to restructuring through fillers is the forehead and temple area. With time, the upper third of the face elongates as the hairline moves upward and the brow moves downward. Both intrinsic and extrinsic factors play a role. Sex, age, family history, and styling practices can influence hairline position while gravity, smoking, and sun exposure can cause keratinocytic dysplasia, which manifests as coarse wrinkles and a rough skin surface.


Initially, changes associated with aging such as rhytides can be corrected through neurotoxin use. Over time, skin laxity and relative muscle atrophy create temporal wasting and some brow ptosis, leading to decreased efficacy of neurotoxin for this area. Even in patients who are neurotoxin naïve, brow descent can occur through repetitive contractions of forehead depressor muscles and loss of elastic fibers. While many physicians focus on brow elevation, it is important to consider complementary filler placement in the forehead to optimize a younger appearance. (Coincidentally, brow elevation is on occasion noted in patients treated for forehead recontouring.)


In this chapter, we review a simple technique to replenish volume loss in the forehead and temples, improve skin laxity, and reposition facial structures to correct for descent using calcium hydroxylapatite (CaHA; Radiesse® [Merz Aesthetics, San Mateo, CA]). Though we primarily use CaHA, autologous fat and poly-L-lactic acid (PLLA; Sculptra® [Sanofi-Aventis US, Bridgewater, NJ] ) are also options and will be reviewed briefly.




Anatomy



Temple


The tissue layers in the temporal region are as follows: skin, subcutaneous fat, superficial temporal fascia, deep temporal fascia, and temporal muscle. When injecting in the temple, there are two main anatomical structures physicians want to avoid: the superficial temporal artery and the frontal branch of the facial nerve. Both of these structures are closely associated with the superficial temporal fascia. The superficial temporal fascia is loosely adherent to the subdermal fat and is a continuation of the galea aponeurotica system of the scalp and the superficial musculoaponeurotic system of the face.


The superficial temporal artery is a terminal branch of the external carotid artery. It originates in the parotid gland and crosses the zygomatic arch about 10 millimeters anterior to the tragus. The superficial temporal artery gives off numerous terminal branches, including the transverse facial, the middle temporal, the parietal, and the frontal artery. It is possible to palpate the pulse from this artery in the temporal region.


The frontal branch of the facial nerve supplies motor innervation to the muscles of facial expression of the eyebrows and forehead. It is found along the deep surface of the superficial temporal fascia and is considered to be a nerve at risk when performing procedures at the temple. The most common method of finding this ‘danger zone’ is to draw a line from the ear lobe to the lateral eyebrow and then from the tragus to the superior most forehead rhytid. The result will be a zone that corresponds to the usual trajectory path of the frontal branch. Transection with a needle can result in brow ptosis.


When injecting the temples it is important to stay superficial to the superficial temporal fascia and to avoid these vital structures in the subcutaneous fat. Rather than using a fanning technique to deposit product, as is often deployed in treatment of the cheeks, nasolabial folds, and other areas of the mid- and lower face, the physician should instead deposit product in a depot and distribute it to the temporal region via massage.




Mar 12, 2016 | Posted by in General Surgery | Comments Off on Forehead and temporal recontouring using calcium hydroxylapatite pre-mixed with lidocaine

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