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Appreciation of the Vascular Anatomy of Aesthetic Forehead Reflation

Carruthers, Jean D.A., MD*; Carruthers, J. Alastair, MD

doi: 10.1097/DSS.0000000000001688
Original Article

BACKGROUND Worldwide, the brow is the most common facial site to receive aesthetic treatment. However, the forehead above the brows has been comparatively less well studied with respect to both neuromodulators and fillers. Age-related remodeling of the forehead with loss of facial bone has been demonstrated on detailed radiographic studies. Concurrent loss of facial fat deposits also adds to the volume depletion. The resulting shallow scalloped depressions in the central 2/3 of the forehead give a tired and aged appearance as do the deep etched horizontal forehead lines which are often associated. Temporal hollowing may be an important associated feature.

METHODS Combination treatment of the upper face with neuromodulators to elevate the brows and diluted hyaluronic acid (HA) fillers to smooth the medial glabellar complex and reflate the forehead and temple has recently become a desired and popular treatment. Several techniques have been described in the literature. All these techniques are designed to allow forehead reflation with reduction of the possibility of vascular compromise.

CONCLUSION Avoidance of the supratrochlear and supraorbital vasculature with cosmetic filler injections is possible by insertion of needle or cannula into the subgaleal space above their transition from preperiosteal to subcutaneous level. Using this technique we have so far not seen any vascular compromise and we present this technique in the interest of patient safety.

*Department of Ophthalmology, University of British Columbia, Vancouver, British Columbia, Canada;

Department of Dermatology, Carruthers Dermatology Centre, Vancouver, British Columbia, Canada

J.D.A. Carruthers and J.A. Carruthers are consultants and researchers with Allergan, Merz, Revance, Alphaeon, and Zeltiq.

The supratrochlear and supraorbital arteries emerge from the bony orbit at its superior margin and become more superficial approximately half way up the forehead on their way to the superior aspect of the skull (Figure 1). The subgaleal plane is thus relatively safer from vascular compromise in the superior half of the forehead.1,2

Figure 1

Figure 1

The authors describe a modification of the excellent forehead reflation approach described by Bae and colleagues.3 The authors inject very dilute HA fillers in the subgaleal preperiosteal plane from insertion points anterior to and inferior to the anterior hairline and between the known supratrochlear, supraorbital, and superficial temporal vascular arcades (Figure 1). The authors believe this technique may be even less likely to cause vascular compromise because the vessels have completed their transition from deep to subcutaneous and intracutaneous levels, so that the deep level the authors inject is relatively safe (Figure 2).

Figure 2

Figure 2

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Treatment Method

After discussion, photography, and full informed consent, the authors mark the vessels to be avoided on the forehead—supratrochlear, supraorbital, and temporal arteries. The authors use a cross-linked HA product (Juvederm Voluma, Allergan, Irvine, CA; Hyaluronic Acid Voluma (HAV)). The product comes in a 1-mL syringe, and the authors use a sterile fluid dispensing connector (Braun Bethlehem, Pa, FDC1000) plastic double Luer-Lok to transfer 0.5 mL of HAV into another sterile, Luer Lok 1 mL polycarbonate syringe. The authors now have 2 half mL syringes of HAV to which they add 0.05 mL of 2% lidocaine with 1/200,000 epinephrine. The volume in each syringe is now 0.55 mL. The authors add a further 0.45 mL 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. One half of this 50% mixture is then rediluted with 0.25 mL of bacteriostatic saline and mixed back and forth a further 20 times. 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.D.A.C.) prefers to use the 27/28-G Exel needle, and the other (J.A.C.) prefers to use a 38-mm 27-gauge cannula to insert the product.

Three to 5 injection points are used in each forehead—centrally between the supratrochlear vessels, more laterally between the supraorbital and supratrochlear vessels, and most laterally between the supraorbital vessels and the superficial temporal vessels (Figure 1). The temples themselves are injected as previously described using 30% diluted HAV.4

After topical cleansing with Hibiclens and after analgesia using the Palomar Cold 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 elevated using the nondominant hand (Figure 3). The plunger on the syringe is then withdrawn, and the authors wait to see whether any blood comes into the hub of the needle or cannula (Figure 3A–D). If it does, the authors immediately withdraw the needle/cannula and reinsert it and again repeat the withdrawal on the plunger. The authors have once experienced blood being drawn into the hub and captured this event on video.

Figure 3

Figure 3

The authors use the larger 27/28-G needle or cannula because the larger bore facilitates the deposition of the filler bolus.

The bolus of diluted HAV is gently pushed into the subgaleal space and is immediately visible as a subcutaneous “egg.” On average, the authors use 1.0 mL of HAV, which is diluted by this method to 40%. The authors use a thin gel (Cytotec) to facilitate gentle redistribution of the filler over the local region of the forehead, digitally transcutaneously blending it with the filler injected through the other portals.

The smooth new forehead contour is immediately appreciated by the subject. There may be some transient drooping of the brow because of the effect of the lidocaine in the filler on the frontalis, but this usually resolves in 40 to 60 minutes. The authors find that the revolumizing effect is present for 6 to 9 months or longer and also nicely softens the etched appearance of the horizontal forehead lines.

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As aesthetic physicians and surgeons, the authors are most used to analyzing and treating their patients with their heads held in the normal upright posture. The authors know that the trajectory of the blood vessel arcades of the forehead is to start deep and transition to superficial. This simple approach of inserting the needle or cannula into the subgaleal space from above avoids the vessels as they transition. In our experience, to date, the authors have not had any episodes of vascular occlusion. Using very dilute HAV enhances the spreadability of the filler restoring a smooth uniform youthful contour. The combination with neuromodulators and energy-based devices also enhances the final result.

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1. Shaw RB, Kahn DM. Aging of the midface bony elements: a three dimensional computed tomographic study. Plast Reconstr Surg 2007;119:675.
2. Beleznay K, Carruthers JDA, Humphrey S, Jones D. Avoiding and treating blindness from fillers: a review of the world literature. Dermatol Surg 2015;41:1097–117.
3. Bae B, Lee G, Seewoong OH, Hong K. Safety and long term efficacy of forehead reflation with a polycaprolactone-based dermal filler. Dermatol Surg 2016;42:1256–60.
4. Sykes JM, Cotofana S, Trevidic P, Solish N, et al. Upper face: clinical anatomy and regional approaches with injectable fillers. Plast Reconstr Surg 2015;136(5 suppl):204S–218S.
© 2018 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. All rights reserved.