The authors have been asked to describe our teachings for forehead reflation with hyaluronic acid fillers.
Loss of periocular and frontal bone and subcutaneous fat can leave a hollowed frontal contour and lowered brow position and deeper etched horizontal forehead rhytides.1,21,2 The process begins earlier in women than men, but is seen in both genders in middle age. Brow descent and flattening are common. Most physicians are careful to inject botulinum toxin A (BoNT-A) only into the brow depressors (corrugator superciliaris, procerus, orbicularis oculi) and not the frontalis if they feel the injected frontalis would subsequently allow the brow to descend or if the brow position is already low.3 The use of 3 dimensional brow reflation gives the “glow” back to the forehead, softens the horizontal rhytides, elevates the medial and lateral brow, and recontours the mid forehead depressions without risking the complication of bilateral brow ptosis with associated diminution of expressivity.
Materials and Methods
After discussion, photography, and full informed consent, the authors mark the vessels to be avoided on the forehead-supratrochlear, supraorbital, and temporal.
The authors use a cross-linked hyaluronic acid product (Juvederm Voluma; Allergan, Irvine, CA; hyaluronic acid voluma). The product comes in a 1 cc syringe, and the authors use a sterile fluid dispensing connector (FDC1000; Braun, Bethlehem, PA) plastic double Luer-Lok to transfer 0.5 cc of HAV into another sterile, Luer-Lok 1 cc polycarbonate syringe. The authors now have 2 half cc syringes of HAV to which the authors add 0.05 cc of 2% lidocaine with 1/200,000 epinephrine. The volume in each syringe is now 0.55 cc. The authors add a further 0.45 cc of preserved bacteriostatic saline, producing a final dilution of 50%. This mixture is then pushed back and forth 20 times through the fluid dispensing connector to ensure even mixing. This maneuver achieves the reduction in viscosity and thus the increase in moldability required. Each subject is photographed before and after the injection session and the digital photographs are printed for the subject's chart and also kept electronically.
One of us (J.C.) prefers to use the 27/28G Exel needle and the other (AC) prefers to use a 38-mm 27-gauge 1.5″ cannula to insert the product. Three injection points are used in each forehead-central above the nasal bridge between the supratrochlear vessels and at the tail of the right and left brows between the temporal and supraorbital vessels (Figure 1). After topical cleansing with Hibiclens and after anesthesia using the Palomar Cool Roller or topical lidocaine 30% in plasticized base, the needle or cannula is inserted gently into the subgaleal space. To enter the correct tissue plane, the skin is pinched up at the lateral brow and also in the glabellar area (Figure 2A–C).4 The plunger on the syringe is then withdrawn and the authors wait to see if any blood comes into the hub of the needle or cannula. If it does, the authors immediately withdraw the needle/cannula and reinsert it and again repeat the withdrawal on the plunger.
The authors have only once had the withdrawal maneuver bring blood into the hub. A subgaleal anterograde injection technique is used. The subgaleal plane is the subfrontalis plane anterior to the periosteum. The origins of the vasculature of the supratrochlear and supraorbital vessels are on the periosteum, which is why the authors lift the skin away from the periosteum while the authors are inserting the needle or cannula and then injecting. The temporal vessels are more lateral and are both subcutaneous and deeper. There is a definite “give” as the needle or cannula tip traverses the frontalis into the subgaleal space. There is no resistance to the flow of the product injected in this bolus manner in that plane.
The authors like to keep the product as the soft leading edge rather than moving the tip of the cannula or needle as the authors believe the soft product is much less dangerous to any adjacent vasculature than the metal of the needle or cannula. Because of this, very limited radial fanning is used for each injection point.
After the filler bolus is deposited, the needle/cannula is removed. The authors use a topical gel on the forehead skin to enhance the subsequent digital massage (Figure 2C) of the product in the subgaleal plane without further needle punctures. Ice can be applied immediately after the procedure to reduce transient swelling and redness. The volume of product used is usually between 2 and 3 cc of HAV diluted to approximately 4 to 6 mL.
The subjects are very happy because they have a soft nonhollowed forehead with reduction in the etched horizontal forehead lines, mild brow elevation, and retained forehead expressivity (Figures 3A,B and 4A,B).
The authors have witnessed few side effects, save the immediate bilateral brow ptosis caused by the lidocaine in the solution. This iatrogenic brow ptosis reverses between 30 and 60 minutes after the injection. Bruising is occasionally seen and is treated with intense pulsed light if needed. There is a need for further treatment after 2 to 3 weeks in approximately 30 percent of subjects to ensure symmetry and an ideal correction. The results typically lasts for approximately 10 to 12 months, although the duration of effect can be further extended if the subject has simultaneous treatment with BoNT-A.
The authors are very concerned about inadvertent canalization of the periocular and midface vasculature6 and believe that careful subgaleal injection of a bolus of filler diluted to produce easy malleability for massage to is so much safer than repeated needle or cannula insertions and movement.5
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© 2015 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. All rights reserved.
6. Carruthers J, Fagien S, Rohrich R, Weinkle S. Blindness caused by cosmetic filler injection. Plast Reconstr Surg 2014;34:1–5.