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I’d like you to meet Shelly, who is 57 and has 3 main concerns. Her number one concern is that she has noticed the existence of some horizontal forehead lines, which have increasingly started to bother her. She also has some hollowness under the eyes, and finally she is looking for an overall lift. Let’s begin by doing a full face assessment so that we can make a treatment plan for her. If we look at her face from the front view, we notice she has reasonable structure in the lateral cheek region and also in the chin. However, due to significant volume depletion in the temple and midface her face appears elongated and rectangular in shape. Therefore, we will have to give her some volume replacement, and as Shelly has good bone support, you will notice that by replacing volume in this area, we will get a nice lift in the lower face.
Now let’s look at the individual parts of her face, beginning by assessing her upper third. The upper third of Shelly’s face, from tricheon to glabella, is significant for one finding. We notice there is a very obvious central concavity, and she also has some very prominent supraorbital ridges bilaterally. Above this region we can see a flattening of the forehead laterally as well as centrally. When I turn Shelly to the side, we can see she should have a gentle convexity in the mid forehead, but she has significant hollowing, which exacerbates the supraorbital ridges. These prominent ridges are a masculinising feature, and ideally we need to augment this region with some filler to give her a softer transition from the hairline to the brow.
Next, we can also see that she has some volume loss in her temples, and she has a moderate recession in the temples bilaterally. We can see this more obviously if we tilt her head down. One of the consequences of recession in the temple is we lose support for the lateral tail of the brow, and we can see that in Shelly the brows are both low lying and horizontal, and the tail in particular is collapsed in line with the volume loss in the temple. As noted, Shelly’s are low and horizontal, and you’ll recall that her first concern was her horizontal forehead lines. Accordingly, we have to be very careful treating her in this region with Botulinum toxin because the brows are already low lying, and further weakening the frontalis may lead to an unwanted brow ptosis. Because of this, we will volumise the forehead before considering treatment with Botulinum toxin. Finally, observe the asymmetry – you will notice the left brow is higher than the right brow, and she has a deeper sulcus on the upper left orbit compared to the right side.
Let’s now move to the mid third, which is considered the region from the glabella to the subnasale. In this region, we can see significant infraorbital hollowness comprising bilaterally of a tear trough from the medial canthus to the mid pupillary line. This extends laterally as the lateral lid cheek junction and inferiorly as the mid cheek groove. We can see that this hollowness accentuates with upward gaze and she also has a mild eye bag appearance due to herniation of the infraorbital fat compartment through the orbital septum. This is also exacerbated by the volume loss anteriorly. The volume loss in the anterior cheek plus ptosis of the superficial fat exacerbates the nasolabial fold. Treatment in the anterior cheek gives us three outcomes: improving the depth of the lid cheek junction, effacing an early nasolabial fold, and giving projection of the midface anteriorly. If I turn Shelly to the side, we can clearly see the volume loss in the infraorbital region, and can see that if we do give her lateral support it does improve the hollowness in the infraorbital region. At the same time, it also improves the sagginess in the nasolabial fold.
Now let’s move on to the lower third, the region from the subnasale to the soft tissue mentum. The first thing we will notice is she has a mild nasolabial fold. We can see the lip has a nice definition, however, she has an increased length of the upper cutaneous white lip. What we notice is that, if we can evert the lip, we can decrease the distance from the base of the nose to the red vermillion. When we look at the chin, we can see it appears dominant, and the bimental width is also wide, in line with the oral commissures, which is a male trait. In a female patient, we would prefer a thinner chin, in line with the nasal flare. Finally, from the side, we notice she has a nice definition along the mandibular border, but is hollow in the sub zygomatic region. We can see this is a nice target for filler, which will give us a lift, improving the nasolabial fold and giving her the rejuvenation in the lower face that she is seeking.
Forehead and temple markings
Let’s begin by reviewing the strategy and markings for treating Shelly’s forehead. In the white area, I have outlined the area we wish to fill, which correlates with the area of main concavity in the central part of the upper forehead. The main risks when treating the forehead are due to the blood vessels in this region. If we look at the area around the glabella, you’ll notice I have drawn on medially the two supratrochlear arteries. When I get Shelly to frown, the medial most crease is the surface marking for the supratrochlear artery. Just lateral to this region you will notice the supraorbital arteries, which typically emerge through a notch, or in a small minority of patients, a foramen. Both of these arteries start off deep and become superficial after passing through the frontalis muscle. This will happen at a variable distance above the orbital rim, but by 1.5 cm we usually find that all of the vessels are superficial – either in or above the frontalis muscle. Accordingly, as long as we inject deep in this region, we will be in a safe plane. As Shelly’s concavity is very wide we will use a cannula, approaching the area from the two lateral points. This way we can inject horizontally, which is safer because the vessels lie superiorly.
We will now have a look at the markings for the temple fossa injection. Superiorly, we have the temporal crest, anteriorly we have the lateral orbital rim, inferiorly the surface of the upper zygomatic bone, and posteriorly we have the hairline. Think of the temple a little bit like a swimming pool, with a shallow end at the top and a deeper end at the bottom. The idea of treating the temple is to inject the product in the deepest part of the temple fossa. Accordingly, if we choose an injection point superiorly, we can reach our depth by using the shortest possible needle. This avoids the need for bigger needles, which could cause more damage. We should also be aware of the structures we pass through when we inject the temple. Superficially, we have the skin, then some scant subcutaneous fat, the superficial temporal fascia, loose areolar tissue, the deep temporal fascia, the temporalis muscle, and the periosteum.
I learned this particular technique of injecting the temple from Dr Arthur Swift. It relies on using a point located 1 cm along the temporal fusion line and 1cm down. As mentioned before, this allows us to get deep without using an excessively long needle. The temporal fusion line will limit the product spreading superiorly, the lateral orbital rim will prevent anterior spread, and we want the product to go inferiorly. Accordingly, the only direction it could go is posteriorly, and we will use a finger to prevent this. After inserting the needle, I aspirate and watch for the air bubble in the hub of the syringe to ensure that I am not within a vessel, then after placing the finger to prevent posterior spread, I will inject very slowly. Just below my finger, you will notice a red mark, which represents the course of the superficial temporal artery in the patient. Remember, there are multiple vessels in this region, both the superficial and deep temporal arteries, as well as the middle temporal vein and the sentinel vein. Accordingly, aspiration is heavily recommended to ensure that we avoid an intravascular injection. The key to injecting in this region is slow injection. This allows us to analyse the fill as we’re injecting, and it is also more comfortable for the patient.
As I mentioned earlier, I am aiming to deposit the product as deep as possible, ideally under the temporalis muscle. However, because this muscle is so densely adherent to the periosteum, we cannot get under the muscle, and instead the product will track up the needle path and fill the temporalis muscle itself. If we overfill this region, the product could get into the deep temporal fascial layer, and as this layer communicates with the buccal fat, you can get an instance where a patient treated in the temple has product tracked down into the midface. I am using Juvederm Voluma for its lifting capacity, and I am going to use a total of 1 ml in this region. After treating Shelly’s left temple, we will notice that compared to the treated side that remains hollow, we now have a pleasing convexity in the temple region. This gives her a better transition from the forehead down into the temple region to the lateral cheek area. This is also evident if we get her to tilt forward, where again on her right untreated side we can see a hollowness, whereas on the left treated side she is fuller.
We will now proceed to treat the right temple region. As before, I insert the needle and then aspirate to ensure that I am not injecting intravascularly. I use the finger of my non-injecting hand to prevent posterior spread of the product back towards the hairline. At the same time, I can feel the pulsation of the superficial temporal artery underneath my finger. While I inject, I am constantly observing the surrounding tissue to ensure that I don’t cause overinflation in this region. Following treatment of her right temple I will withdraw my needle and then apply a gauze swab to give compression for a minute before assessing.
Before treating Shelly in the forehead region with the filler, I will inject some local anaesthetic at the cannula insertion points to make her more comfortable. I am using a mixture of Lidocaine and adrenaline, and I will inject a small bleb of 0.05 ml at the entry points laterally, just medial to the temporal fusion lines. One of the reasons for this is that the deep branch of the supraorbital nerve runs in this region, and injecting in this region can be painful. I am inserting a 23 gauge needle to make the entry hole for my cannula. The cannula I am using is 25 gauge and the product I am using in the forehead is Juvederm Volift. My ideal depth here is deep, between the frontalis and the periosteum. Accordingly, I am pinching the skin and frontalis muscle so that my cannula is at the depth that I require. You will notice that my cannula reaches the midline, and I can then inject small amounts of product into the area above the supraorbital ridge in the central most part of the concave region. The idea is to create a gradual transition from the prominent supraorbital ridge through the concave central forehead region up to the hairline, thereby achieving a gradual convexity throughout the region. You will notice that with the finger of my non-injecting hand I am constantly moulding and manipulating the product. In Shelly’s case, both her skin and the depth of the frontalis muscle are thin and the product is more prominent, however, as we’re using the very mouldable Volift, we can see how easy it is to mould the product with simple digital pressure. It is also important to ensure that we put more product in the central part of the forehead and less laterally, thereby creating a nice gentle curve from one temporal fusion line to the other.
After treating Shelly’s right side, we are aware of a significant improvement on the treated side, and we can see that there is a very smooth forehead transition from the hairline down to the eyebrow without the prominent ridge we see on the untreated side. If I turn her to the oblique and lateral view, you will be aware of the remaining concavity on the untreated side and this is best observed in the oblique view. However, on the treated side you will notice that although we don’t have a convexity yet, we have significantly improved the volume deficit in the central part of her forehead. If I now turn her to the front and get her to raise her eyebrows, there are some diminished lines on the treated side, but this is almost entirely due to the Lidocaine effect of the injected product. We repeat the treatment on Shelly’s left side, again entering laterally with a cannula maintaining a deep level, between the frontalis and the periosteum. When treating in this region, it is important to make sure you can reach the midline, so choose your cannula length accordingly. You may need to overlap slightly in the midline, as if there is any gap between the product treated either side, this may create a little cleft or valley laterally, which can be very obvious. As we inject the product, we can see that it is very prominent, but as on the other side we will simply use gentle massage. After finishing treating both sides, use a swab with a little bit of moisturising cream to simply mould and massage the product further to end up with a nice smooth result.
Cheek marking and strategy
We are now going to treat Shelly in the midface region, and we will treat three aspects of her cheek. We will treat anteriorly, subzygomatically, and also on the cheekbone itself. You will notice from the markings that we have delineated the upper and lower border of the zygomatic arch – along this point we have created a specific apex of cheek for maximum projection. This will allow us to lift and improve the infraorbital hollowness and also improve the nasolabial fold. Secondly, we can notice that if we want to delineate this point, it is the point of maximum light reflection, but we can find this by taking a line from the tragus to the upper alar crease, and bisecting this line with a vertical line coming down from the lateral orbital rim. This point is described by Arthur Swift, and those of you who are familiar with Mauricio de Maio’s MD Codes will know this as point CK2. After treating in this region, we can also see that in the anterior cheek I have delineated an area in white correlating to the deep medial cheek fat and medial suborbicularis oculi fat. We can see that Shelly is clearly deficient in this region and therefore we need to give her volume at a deep level. This will have the effect of increasing the lid cheek junction, giving her anterior projection, but also effacing the nasolabial fold. Finally, we can see that in the subzygomatic region where she has a natural hollowness, we can inject filler to augment the lift that we will get when we inject onto the zygomatic arch itself. The sum total will be to improve the volume and give her a lift.
I am now injecting her on the zygomatic arch. I retract the skin, insert the needle until we are onto the periosteum, aspirate, and slowly inject a bolus of product at this region. It is important to note that there are multiple blood vessels in this region, therefore we aspirate to ensure that we are not injecting directly into a vessel. I will inject a total of 0.2 ml at this level, and it is important when we have finished injecting that we don’t over massage or mould as we want the projection. I then inject a second bolus posterior to first, so that we get a smoother transition from the newly created projection along the zygomatic arch. The volume in my second injection will be less, injecting 0.1 ml. As previously, we will just apply very simple moulding and massaging, ideally just to get a little bit of lift.
Cheek lift treatment
I then move on to treating Shelly in the subzygomatic region. Ideally, I want to be at a superficial depth in the subcutaneous plane. After making a prehole, I stretch the skin and insert the cannula, which is a 25 gauge, 38 mm cannula. I am using Juvederm Voluma in this region and I am injecting the product in a series of linear threads in a fanning distribution. I will go from the superior part of the zygomatic arch all the way down the angle of the jaw. The idea here is that the product will add support laterally and give a lifting effect. When you treat in this area, you will often encounter a little bit of resistance, and this will typically be the masseteric cutaneous ligaments, which are a false retaining ligament. It is worth letting the patient know that they may be aware of a small popping sound, and as long as they are reassured that this is normal, they will not worry about this. If you cannot proceed with the cannula, then you can inject a small amount of product which will open up the tissue plane and allow easier passage of the cannula. After treating in this region, it is much more important to massage so that we can get a better lift, so you will notice that I take a swab covered in a little bit of chlorhexidine and then apply a posterior and superior massage.
Anterior cheek treatment
We are now treating Shelly in the anterior cheek. I want to be deep so I am pinching the skin, and I make an entry hole with a 23 gauge needle before inserting my 25 gauge, 38 mm cannula. I am using Juvederm Volift here, and protecting the orbital rim and the infraorbital foramen with the finger of my non-injecting hand. At the same time, my non-injecting hand allows me to feel the amount of fill that we are creating. The target for my treatment here is the deep medial cheek fat pad and also the medial part of the suborbicularis oculi fat, also known as the SOOF. The reason for using a cannula here is that there are a number of important blood vessels in this region. Because I need to fan out over a wide area, I favour the cannula as it will be much safer. It is important not to overfill this area otherwise we can get asymmetries and a strange deformity when the patient is smiling. From this angle, you may notice that we can see an improvement in the anterior cheek concavity when compared to the untreated side, which remains very hollow. After treating the medial aspect of the anterior cheek, I can angle my syringe and cannula around so that I can treat the transition zone between the medial anterior cheek and the lateral cheek, and the area in between.
Left side treatment outcome
Following treatment we can see that, compared to the non-treated side, we have a considerable rejuvenation. On the side we have treated, we are aware of a very smooth transition from cheekbone to the anterior cheek, and we can see that there are less shadows and a smoother contour on the treated side. This already improves the infraorbital region, and we can no longer discern the mid cheek groove or the lateral lid-cheek junction. When I turn her to the side, we can see a degree of hollowness and also multiple shadows caused by the irregularities on this untreated side. Conversely, on the treated side we have a more youthful smooth area in the subzygomatic, zygomatic, and anterior cheek area.
Cheek treatments left side
We repeat the treatments on Shelly’s left side. We begin by injecting deep onto the zygomatic arch with a needle using Juvederm Voluma, and we will inject in two locations – the point of maximum malar eminence, or point of maximum light reflection, and as on the right side, we will begin with a bolus of 0.2 ml of product. After injecting in this location, we will inject a further 0.1 ml of Voluma slightly posterior to the newly formed projection. This ensures that we have a smoother transition from the malar eminence along the zygomatic arch as we proceed posterior. This is giving us not only a widening of the midface, but also starts giving us a lift.
Following this, we will proceed to treat the subzygomatic or preauricular area with the Voluma to facilitate a lift in this region. After we have treated in the subzygomatic area, we will proceed to the anterior cheek using the Juvederm Volift. We remain deep to revolumise the deep fat pads, the deep medial cheek fat, and the suborbicularis oculi fat. Remember, the two most important considerations in this area are: use a cannula to avoid vascular damage, and avoid over injecting product in this region to keep the patient looking natural, especially on animation. Following treatment, we can then apply a little gentle massage to ensure that we have injected the product in even distribution.
Philtrum and lip treatment
I am now going to treat Shelly in the philtrum area. I am using some Juvederm Volbella which has been decanted into a syringe. The depth here will be very superficial so I inject just above the Glogau-Klein point and I make sure that my needle is angled towards the midline. I pinch the skin and inject a retrograde linear thread of product, injecting a little bit more just before I exit the skin. This creates a nice defined philtral column. I will then repeat this on the other side. This can be a little bit painful for the patient, so again just warn them before treating. On this side I will not pinch the skin so you can see what the needle is doing, and you will notice that I am very superficial. Following treatment to the philtral columns, you will notice that there is already improvement of the Cupid’s bow. Next, I move on to treating the upper lip, and I am injecting in the red vermillion, just inferior to the vermillion border. This will give us a gentle projection and also a very subtle improvement in the visible volume of the red vermillion. After treating one side, I will move on to the other side and you will notice that I am using very small volumes, 0.02 mls. After treating the medial aspect of the upper lip, I move on just to improve the Cupid’s bow a little bit more. I am using a cotton swab to ensure that I maintain definition, and then I will inject 0.2 mls of product before repeating this on the other side. The reason I am doing this is to try and reduce the apparent distance of her cutaneous white lip.
Having treated the upper lip, I will now move to treat her lower lip. I begin by treating Shelly in the lower lateral tubercles. I insert my needle into the skin and ensure that the tip of the needle is in the red vermillion. This technique was taught to me by a German dermatologist called Boris Sommer. We then deposit a small bolus of 0.05 ml of Volbella, and we repeat this on the other side. The advantage of this technique is that it is relatively atraumatic compared to injecting through the red vermillion. Accordingly, as we inject you notice that there is no apparent swelling, and also there is very minimal bleeding. This allows us to assess the symmetry and the result as we treat. It is important to understand that the lower lip should be more projected or volumised in the central portion and less so at the lateral ends. Accordingly, I inject less product to the sides compared to the middle – 0.02 mls in each of the two locations lateral to the central injection points. After injecting in this region, I like to massage the lips with a little petroleum jelly.
We now see Shelly at the end of her treatment, and we can see that she has a nice rejuvenation of her forehead and she appears less hollow in this region. We can also see that the temples have filled out compared to pre treatment. There is better anterior projection of her midface, and we can see that by treating her lips, the apparent distance from the base of the nose to the lip is shortened. We can also see that by treating her in the lateral cheek region, we have widened this dimension, and this gives her overall face shape a more oval structure. If we turn her to the side, we will notice that in line with her very nice defined jawline that she already had, she is less saggy and has a better transition from the lateral to the anterior cheek. She also has a smoother temple and forehead in this region. Finally, I will get her to animate and we will see that she is fuller without causing any deformity or strange animation on smile.
Treatment outcome at 6 weeks
We now welcome back Shelly at her six week review, and we can see that she certainly looks well and very natural. Let’s examine her clinically so we can be more discerning. We treated Shelly by injecting filler to the forehead, temple and cheek, which resulted in giving her a lifting effect in the lower face. We can see that while this has had a nice, subtle improvement, she would benefit from further treatment, in particular to the midface and in the infraorbital region. The main reason for treating her forehead was that her number one concern was horizontal forehead lines, but due to her having a low lying brow, I wanted to give her some volume replacement before considering treatment with neurotoxin. We can now see the extent of this improvement by turning her to the side. You will notice now that Shelly has a very gentle gradient from the hairline down to the brow, and the supraorbital ridges, which were so prominent before treatment, have improved considerably. Accordingly, we will be able to assess her to see now if she would be a better candidate for treatment with neurotoxin. If I ask her to frown you will notice that she has got prominent glabella frown lines. If I then ask her to raise we can see dynamic horizontal forehead lines.
BTX glabella, forehead, and DAO
I will now treat the glabella, forehead, and DAO with Botulinum toxin. If I had tried to treat her before volumising, we would have run the risk of causing a brow ptosis. I begin by treating her in the procerus. I will inject 4 units of Botox deep. I then inject her left head of corrugator with another 4 units, while protecting the infraorbital rim with my finger, and finally I will inject her right corrugator, again protecting the infraorbital rim with my thumb. I am now going to inject her forehead with 5 injection sites, injecting a total of 1.5 units of Botox in each of these 5 sites. My preferred depth for these injections is just intradermal, and you will notice that I create a small bleb. The idea is that the muscle is so close to the skin that simple diffusion of the product will treat the muscle. After treating her in the frontalis, I will then move to treat her in the DAO, so I will begin with her left side. I insert my needle very superficially going from the chin towards the angle of the jaw, where I inject 2 units. I then turn her to the other side and repeat this on her right with another 2 units of Botox. Following treatment to the DAO, I also inject 3 units into the mentalis, as she has excessive activity in this region. I can then invite Shelly to see me for another review in 2 weeks to assess the results of the treatment performed today.