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I have with me now Eli, and don’t worry if you think you are seeing double, because she does have an identical twin who we have treated in a different video. As you can see, Eli is young and beautiful, and she has requested, like her twin, minimal treatment. She has beautiful cheekbone structure laterally, and she also has a strong, dominant lower face with a good definition of the mandibular border and a prominent chin. Accordingly, she is requesting minimal treatment just to enhance perhaps her lips and also improve the appearance of her eyes.
Upper third assessment
Let’s now look at the upper third, from the tricheon to the glabella. The first thing to notice in Eli is that she has a nice convexity both in the horizontal vector and also in the vertical vector from the front view. If I turn her to the side, you will notice that in fact she is quite flat in the lower part of her forehead, as there would normally be a gentle convexity in this region. The clinical consequence of this is that she has some flattening above her eyebrows. If we assess her dynamic movement, we see that she has got very minimal glabella movement lines, or indeed horizontal forehead lines.
If we look at her eyebrows closely, we can see that the shape of the brow is very low and flat, and there is some degree of asymmetry as her right brow in particular starts low, and where we would normally have a 20-30 degree inclination up towards the apex, her right brow is much flatter and we can see that in the area above there is considerable flattening of the forehead in this region. Accordingly, the apex of her brow is relatively lower than we would like. If I raise the apex, we can see that she looks much more attractive with a higher apex in this region, making her a good candidate for filler to raise the brow, and we have got excellent skin quality, which will enable us to give her a nice outcome with the procedure here. I will be looking to treat this with a soft hyaluronic acid filler.
Before we treat Eli in the eyebrow, I just want to demonstrate the strategy. The idea is that we want to give her a higher apex, and ideally in a young patient we want this apex to be above the lateral canthus. Accordingly, I have delineated in white the area where I want the brow to lie, and we will do this by inflating the retro orbicularis oculi fat.
Injection site markings and treatment
As I want to inject over a considerable portion of the eyebrow, I will use a cannula. I pinch the skin and then make an entry hole with a 23 gauge needle, then I will insert my 25 gauge, 38 mm cannula. My product of choice here is Juvederm Volift. I want to ensure that my cannula will be at a depth on the orbital rim within the retro orbicularis oculi fat, also known as the ROOF. This can be a little bit tender for the patient. Because we are treating lateral to the mid-pupillary line, we will generally be clear of the supratrochlear and the supraorbital vessels, however it is important in this region to inject slowly and be vigilant for any signs of vascular compromise. In the eyebrow, it is preferable to use small quantities of product, and the essence of the treatment is that by reinflating the retro orbicularis oculi fat, we will give better support and projection for the brow. After withdrawing the cannula, I will apply a gentle mould and massage.
We now have Eli at the end of both of her treatments, and you will notice that she has much better brow elevation and symmetry following treatment, but you can also see that she has considerably more attractive and dominant lips, which have reduced the dominance of her chin. Accordingly, the learning point here is that by using very little product, in Eli’s case less than 1 syringe of Juvederm Volbella and 1 syringe of Juvederm Volift. We have created a very high impact result, and if we turn her to the side we can see a beautiful projection she now has in her lip but if we look at the Ricketts line analysis, we can see that the lips are in a very favourable position.
If we look at Eli compared to pretreatment, we can now see that the eyebrows have a much better and more attractive orientation from head up to apex, and we can also see that by giving her a better lip augmentation it has reduced the domination of the chin. The net result is that she looks more attractive and more refreshed but without looking like she has undergone any procedure.