Filler injection

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Complete Reflection

Forehead assessment

I would like to introduce our next model here, who is Hayley, and interestingly Hayley’s primary concern was to do with the shape of her forehead. I say interesting because it is quite rare for patients to present with this particular concern. Hayley feels that the forehead is very flat, and this gives her almost a continual line from the forehead to the tip of the nose. This can be quite hard to appreciate in the frontal view, so let’s turn Hayley into the profile so that we can evaluate further. When I have Hayley facing me, we can see what she is talking about. We can see that instead of having a convexity in the middle of the forehead, there is in fact a slight concavity, and this gives a flat appearance. If I take this Phi caliper, which shows what the proper forehead curvature should be, we will see there is a deficit in the mid part of the forehead where we can actually observe the flattening. I don’t think that Hayley’s frontonasal angle is completely 180 degrees, which she thinks it is, but we can certainly improve the convexity. We will therefore proceed to treating Hayley by injecting her with dermal filler. Also, if I get her to raise, we will see that she has a prominent mid-forehead line exactly in line with where the maximum concavity is.


Anatomy injection markings


Let’s now review the injection anatomy that is relevant when injecting the forehead. If I get Hayley to frown, and I look at the medialmost creases for either corrugator contraction, these will line up very nicely with the course of the supratrochlear artery. This artery starts deep and then cross through the frontalis to become more superficial. Lateral to the supratrochlear artery, we will find the supraorbital artery. In 80% of patients, this will come out through a notch and in 20% there will be a foramen. The actual location of the foramen or notch will be anywhere from the medial limbal line to the mid-pupillary line. These are the two main vessels that we will encounter when treating the forehead. It is important to understand that both of these vessels have a deep origin and then become more after they cross through the frontalis muscle, so if we draw a line approximately 1.5-2 cm above the superior orbital rim this will then denote a danger zone below and a safe zone above. We will avoid the area that I am marking in the black crosses, and as long as we inject above this line and we inject deep we will miss the blood vessels because they are more superficial. If I also mark out the temporal fusion line laterally, there is one more structure we need to be aware of. This is the deep branch of the supraorbital nerve. This also comes out of the supraorbital foramen. It traverses laterally and then ascends vertically, approximately 1 cm medial to the temporal fusion line. The importance of this nerve is that it can be painful if we inadvertently inject near it, so we tend to keep our injection points more medial. We can now see where we will propose the patient, which is above the black cross bar and within the temporal fusion line, avoiding the supraorbital nerve. We can now see the injection markings for Hayley’s treatment. I will be injecting a bolus of product in each of these white circles and the product of choice here will be Juvederm Volbella, injected with a needle.


Forehead treatment


I will now commence the treatment of Hayley’s forehead with Juvederm Volbella with a needle. I am pinching the skin, and the bevel of my needle is down. I enter at about a 45 degree angle and I make sure that I go deep, aiming to place my needle on the periosteum. I then inject a small bolus of product, 0.1 ml in each bolus. Occasionally when doing this, you will notice that instead of a round bolus, you get a vertical sausage-like shape, and this is due to the existence of some cutis retinaculum. If you see this, all you need to do is just massage them out. Whenever we inject the bolus, we will then use some manual pressure with our finger just to ease the product down and soften it out. After injecting one area, we just move along to the next circle. I am using Volbella here because it is very mouldable, and Hayley’s indication is not very severe. I have also used both Volift and Voluma here using the same technique. Because her indication is mild, I am happy to use Volbella and the needle, but if she had a greater degree of concavity I might be tempted to use the Volift and a cannula. This technique has been demonstrated on another patient in another video. You will notice that I am staying above the black line so I know that there are no deep vessels in this region and all the vessels are superficial. Of course, just because there are no vessels deep, that does not mean I will not encounter a vessel as I am entering with my needle, but the worst case scenario there will be that we will cause a small bruise or haemotoma, which we can apply compression with. We know that by staying deep we are avoiding injecting inadvertently into any of the major blood vessels.


After injecting all five circles, I will apply gentle pressure and then just mould the product. To do this, I will apply a little bit of traction to the skin, take a sterile wipe, and then apply a gentle massage to the treated area. Because I am using Volbella, it is very easy to mould and massage. If I was using a more firm product I might be a little more apprehensive about using a bolus technique because it can lead to a lumpy appearance post-treatment.


Let’s have a little look at how Hayley looks after the first phase of her treatment. When I sit her up I am aware of a few irregularities, looking at her from the front view, and if I turn her to the side I can see that there is already a small improvement. She is not yet convex, but certainly the concavity seems to have disappeared and we have a straighter appearance of the forehead. I will therefore go ahead and administer some further treatment. This time, what I will do is inject the product in between the previous injections. This will avoid the little depressions between the boluses that we injected in the first round. I am also going slightly higher than my previous round, and this allows us to miss out the areas that we have already injected. As I injected 5 points in the first round, I will now inject a further four. The technique is exactly the same, so I am pinching the skin and then angling my bevel down and injecting 0.1 ml boluses in each one of these four circles. You will notice that she is very comfortable during the treatment and the product, as it contains Lidocaine, will already have given her a numbing effect so I can continue to inject without being concerned that she is experiencing any discomfort. Every time I inject, I will give a brief mould to the bolus I have injected. However, I will wait until I have finished to do my final massage. The whole time I am injecting I am looking at the tip of her nose and the whole face just to make sure that there isn’t any sudden spasm or blanching that could indicate a vascular occlusion. Having injected the last of my four areas in the second round of injections I will then proceed to giving her more moulding and massaging. When treating the forehead, it is important to understand that it will often require pressure with the massage. If you do feel any surface irregularities, do take time to make sure that you really get a smooth result because sometimes if patients are sent home with an obvious lump it may take a long time for it to settle. In this view, you will be able to see that there is an obvious line of demarcation from treated to untreated and therefore I have to spend a bit of time easing this out.




At the end of Hayley’s treatment, if I get her to raise her eyebrows you will notice there is diminished movement. Some of this is due to the presence of the filler, but it is mainly due to the Lidocaine in the product. Accordingly, this will not be a longstanding effect. You can see that on the untreated side in the lateral areas there is still normal movement. If I turn her to the profile, we are now aware of a much better convexity and shape of the forehead. We can further evaluate the result by reusing our Phi caliper. I will place the caliper along the forehead, and you may recall that before treatment there was an obvious concavity in the mid part of the forehead, and this led to an obvious gap underneath the caliper. Now, we can see that there is a much better angle and projection of her forehead and, particularly in the mid region where we had the concavity, there is a more pleasing convexity. This gives her the ideal female forehead shape and angle.