Part III Periorbital Rejuvenation

Rod J. Rohrich and Erez Dayan

Abstract

A modern paradigm shift in facial rejuvenation focuses on volume restoration in addition to facial recontouring. The concept of facial volume restoration has long been advocated, and ultimately accepted into common practice with our improved understanding of facial aging. Forehead and eyebrow revolumization is often neglected during facial fat grafting. The purpose of this chapter is to describe the technique for volume restoration of these areas.

Fat grafting – forehead – eyebrow – temporal hollowing – facial revolumization

35 Brow and Forehead: Fat Grafting to the Brow, Temples, and Forehead

Key Points

Fat grafting to the forehead, temples, and brows is a key component of pan facial revolumization (Fig. 35.1 and Fig. 35.2).
Injections are performed in the subcutaneous plane.
Injection of the superior brow regions not only corrects age-related changes, but also creates the illusion of more lifted brows.
Correction of temporal hollowing requires disruption of the temporal fusion line.

35.1 Preoperative Steps

Fat harvest is accomplished using manual low-pressure lipoaspiration using a blunt 3-mm cannula.
Inner thighs and abdomen are the ideal donor sites, which contain the highest concentration of stromal vascular cells with the least amount of pain, as shown in previous studies and clinical experience.
The lipoaspirate is then processed using centrifugation at 2,250 rpm for 1 minute. The supranatant and infranatant are discarded before transferring the fat graft into 1-cc syringes.
Fractionated fat is used for periorbital injections. Fat is processed via mechanical emulsification by pushing centrifuged fat between two 10-cc syringes through a 2-mm filter 60 to 80 times. This results in fragmentation of adipose tissue structure.

**Fig. 35.1** Superficial fat compartments of the face. (Reproduced with permission from Leatherbarrow B, ed. Oculoplastic Surgery. 3rd ed. Thieme; 2019.)

**Fig. 35.2** The deep fat compartments of the face. ROOF, retro-orbicularis oculi (muscle) fat; SOOF, lateral sub-orbicularis oculi fat. (Reproduced with permission from Leatherbarrow B, ed. Oculoplastic Surgery. 3rd ed. Thieme; 2019.)

35.2 Operative Steps

Temporal and forehead fat grafting addresses age-related hollowing and has the added benefit of mildly lifting the brows.
Temporal injection is performed using a single port access within the temporal hairline. The key principle is disrupting the temporal fusion line to allow uniform fill. This typically requires 1 cc of fat graft. Another 1 cc injection is then needed to correct the hollowing in a radial fashion just lateral to the lateral brow.
The central forehead injections must correct three distinct compartments—the glabella and the two superior brow regions. Injection is performed in the subcutaneous plane using a port either in a crease in the mid-forehead for those with a tall forehead, or in the hairline for those with a shorter forehead.
Injection of the superior brow regions not only corrects age-related changes, but also creates the illusion of more lifted brows. A second stab incision along the medial brow line allows additional access to the superior brow, and disruption of the temporal fusion line from the medial aspect and full correction of temporal hollowing.