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Let’s now meet our next patient, Simon. Simon has just turned 50 and has never had any type of cosmetic treatment previously. I asked him what he was interested in having treated, and he pointed to his forehead, then when I asked him to be more specific, he said that the main concern he had was the presence of some horizontal forehead lines. We can see that if Simon was to elevate his brows, he certainly does have some quite severe dynamic horizontal forehead lines, and when he relaxes his brows we can see that there are also significant static lines running all the way across his forehead. He also pointed out some oblique lines above the lateral part of his brow, however, when I examined him it was evident that these were caused by the way he sleeps. Many patients have these, and they need to be advised that they cannot be treated with cosmetic interventions. You will also notice that he has a very deep line in the midline, and this is present at rest but considerably increased with contraction of his brow depressor complex. We can see that he has got very powerful corrugator muscles.
It can be easy to observe contour changes from the front, but when I turn him to the side you will notice that in the central area especially he has a deep concavity, which extends all the way down into the glabella area. This is definitely causing a worsening of his deep central line, therefore he is a good candidate for filler in both the central forehead and also the glabella region. Simon’s treatment will consist of dermal filler to the central part of his forehead and also the glabella region. Once we have reviewed him, we can then consider Botox to his frown complex and also his frontalis muscle.
Markings and strategy
Let’s review the surface anatomy involved when we’re injecting in the forehead. You will notice that the area we wish to inject is the central part of the lower forehead, but also leading down into the glabella. Accordingly, we need to be very mindful of the blood supply to this region. You will see the two main vessels here are the supratrochlear and the supraorbital arteries. It is an almost universal finding that the supratrochlear artery will lie beneath the most medial corrugator crease in almost every patient. The supraorbital artery, which is more lateral, emerges from a notch usually just medial to the mid-pupillary line. Both arteries have a deep origin, emerging through the bone and then as they ascend vertically they will cross through the frontalis muscle to lie more superficially. Therefore, we have to be careful about our depth, depending on which particular zone we are injecting. If we draw a line approximately 1.5 cm above the orbital rim, we can inject safely as long as we are deep. However, in the glabella area, because the vessels are deep, the ideal position is intradermal. In Simon’s case, however, because there is so much volume loss, we need to be deep in the glabella, therefore we will have to use a cannula in this region to be as safe as possible. Finally, do be aware of the deep branch of the supraorbital nerve as injecting in this area may be painful for the patient.
As we prepare to treat in the forehead and glabella with filler, you will notice that I have a sterile drape over his hairline, secondly I have a piece of ice in a sterile glove. This serves two purposes: it reduces pain, but it also gives us some vasoconstriction, which means that he will bleed less when we start the procedure. I will be using a cannula and therefore I will begin by marking the area of concavity that I wish to treat. I use a white skin marker to do this and I will then reclean the area using an alcohol swab. Before doing any of the treatment, the patient’s skin has been thoroughly cleansed with chlorhexidine. I then use some local anaesthetic mixed with adrenaline just to anaesthetise the entry point of the cannula. This will also help reduce bleeding. I use a 0.1 ml bleb intradermally, and I will give that a minute to take action. I now make a prehole with a 23 gauge needle, and I am pinching the skin as my anticipated depth will be deep. I now use a 25 gauge cannula and my product of choice here is Juvederm Volift.
I pinch the skin so that I can guide my cannula through the skin, through the muscle, and under the muscle onto the periosteum, which is the ideal layer for the product. You will notice that I just tether the skin with my non-injecting hand, but it’s vital not to touch the cannula so that we can remain sterile. I can guide the cannula quite easily in this plane to all the areas in which I wish to inject. It is really important when you use a cannula not to force it, and if you do encounter any resistance, just inject a little bit of product that will often open up the tissue plane. If, however, you really can’t advance the cannula, it is better to pull out and start again. You will notice that with the hand that I am not using to inject, I am just palpating so that I can feel how the product is starting to fill up the concavity. As I am pleased with the fill in the middle of the forehead, I will start advancing a little bit deeper. I also want to go a little bit lateral, though remember that this is the territory of the supratrochlear and supraorbital arteries, so the entire time that I am treating, I am very mindful of the fact that I need to watch the tissue. I am watching not only in the region I am injecting, but I am also watching the tip of the nose and also the skin around the forehead, just to make sure that we are not causing any inadvertent vascular occlusion.
I am now injecting in the glabella, and my plane is deep. This is a relatively safe plane, as in the midline we tend not to find vessels, however we inject slowly, and ensure that the placement of the cannula is nice and deep. You will notice that I am injecting slowly, which makes it more comfortable for the patient. One single midline entry point allows me to swing my cannula round and reach a very wide treatment arc. I now pull out the cannula, and I will then proceed to use gentle pressure to manipulate and mold the product in the treatment area. Sometimes there are vertical fibrous bands in the forehead which can compartmentalise the product, however this tends to be more of an issue when you use a needle, as when you use a cannula it tends to push the product through these bands.
Just after his treatment, we can see that he has an immediate improvement; we can see that appears smoother and the line is visibly diminished. We can see that he still has movement and it’s very natural and we can look to target this with Botox in a future treatment session. If we turn Simon to the side, we will notice that he has a significantly improved convexity compared to pre-treatment. We can see this from his right side and also if we turn him to the left we are aware that the central area, which was so evident before treatment is now significantly filled, giving him a better profile.
We now see Simon at approximately 6 weeks following his treatment of dermal filler to the central forehead and glabella region. We can see that there is significant improvement in the very obvious glabella line he had before treatment, and he still looks natural and very rested. If I get Simon to frown, we can see he has movement there as we would expect, but it’s considerably diminished compared to pre-treatment. We will however look to treat this with some Botox.
We will now see Simon as he elevates his eyebrows, and as expected, he still has the horizontal furrows. You will notice in the central region where we filled him, they appear to be diminished. If we observe Simon from the side, we can see that the very obvious hollow he had in the central part of his forehead is now giving rise to a pleasing convexity from the hairline down to the glabella. As Simon was primarily worried about the forehead lines, we can now proceed to the Botox treatment.
We have now marked Simon up for treatment with botulinum toxin, and we will treat him in the glabella and also the forehead region. He has had significant improvement of the vertical glabellar line, so we will treat him with a three injection strategy. In the forehead, we will use two rows of injection points. We start with his forehead, and I’m injecting 1.5 units at each of 11 injections in total. This may prove to be a little light for Simon given that he is male and has good muscle contraction, however, I am concerned that I do not want to leave him completely devoid of expression, and therefore I have already told him that I will see him in another 2 weeks, and if at that point he has any residual activity, then I will happily add a little bit more product in if he requires it.
After treating the forehead, we can move on to treat his glabella frown complex. Pinching the skin, injecting deep for the procerus and we’ll go ahead and inject the first 4 units. We will then treat both his left head of corrugator with 4 units and then finally we’ll move down and treat his right head of corrugator with 4 units.