Download Forehead rejuvenation and contouring strategies

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one
point
CPD
Forehead
Forehead
rejuvenation
and contouring
strategies
Mr Dalvi Humzah and Anna Baker discuss
anatomically-sound approaches to treating
and re-contouring the forehead
The aesthetic practitioner is able to address and successfully
treat many of the senescent changes of the upper face, in
particular the forehead and glabellar, through a variety of nonsurgical injectable modalities. To achieve an effective result,
a current and accurate anatomical awareness and detailed
understanding of product suitability is imperative to reduce
complications and yield an excellent cosmesis. In this article, a
variety of techniques will be analysed in terms of their suitability to
refine skin texture and re-contour this region.
Key words
Dermal filler, botulinum toxin A, anatomy, forehead, re-contouring
Introduction
When considering a ‘beautiful’ face, the forehead, in terms of height,
contour and appearance, is accepted as one of the seven keystone
areas to acknowledge.1 In this article, the anatomy of the forehead
and glabellar will be reviewed with regard to the application of
specific non-surgical cosmetic treatments. It is acknowledged
that botulinum toxin is used to effectively reduce and soften the
appearance of static and dynamic rhytides at the forehead and
glabellar.2 The use of dermal fillers to re-contour this region can
provide exceptional results.3 The current literature covers varied
injection techniques to treat the upper face using botulinum toxin,
Figure 1: S.C.A.L.P
Layer one: Skin
Layer two: Subcutaneous layer
Layer three: Aponeurotic layer, commonly referred to as the
SMAS layer; a strong musculo-aponeurotic sheet, encasing the
whole face
Layer four: Loose areolar tissue; a gliding plane to allow for
mimetic expression
Layer five: Periosteum/ deep tissue (muscle/fascia)
but little is available in the context of forehead re-contouring. In
this article, the authors will share their specialised techniques,
underpinned by regional anatomy, with discussion of approaches
described within the current literature available. The acronym below
(used by many medical students) will be alluded to throughout the
article, to allow the reader to clearly visualise the anatomical planes
described for product placement.4 DH to reference -book
The Forehead
Topographically the forehead may be defined as the area bounded
laterally by the superior temporal septum which arises from the
temporal crest, inferiorly by the orbital rims with the supra orbital
adhesion and nasion and superiorly the hairline (a variable which is
difficult in those who are follicularly challenged).5 When describing
the regional anatomy, many texts will address the course and
details of individual structures, which while correct, fails to provide
a three-dimensional description of the areas of interest for a nonsurgical practitioner.
A different view is required when treating an area with what is
essentially a blind approach, as the practitioner can not see the
structures under the skin whether using a needle or cannula. The
five-layered approach outlined above will enable a practitioner
to quickly determine the position of product placement, and
also understand where important structures are in relation to
the approach utilised. It is, however, imperative when using this
approach that the practitioner has an in-depth knowledge of the
named structures in each area.
Layer One: Skin
A lot of vital anatomical information can be learnt by examination
of this important structure. Apart from the overall appearance of
the skin, and the ageing changes, superficial arterial and venous
structures may be visible that will alert the injector to avoid
puncturing these – and in doing so, avoid adverse events. The
dynamic lines in the glabellar region define the underlying median/
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The separation between
the middle temporal
compartment and lateral
temporal compartment
may occasionally be seen
as an oblique depression
on the skin in some
patients.
central fat compartment (see below). The glabella line also indicates
the line of the supratrochlear vessels located near the subdermis,
and the deep insertion of the medial portion of the corrugator. The
lateral dermal attachments of the corrugator are often seen as a
semicircular depression laterally.6 The horizontal forehead lines
represent septal dermal attachments to the underlying frontalis,
and when running horizontally indicate the contiguous nature of
the frontalis muscle.7 The midline dip and lateral appearance of the
forehead lines indicate the point of separation and lateral position
of the muscle. This approach to injection, named the ‘objectivemuscle-identification approach’, will help the injector to accurately
and effectively tailor toxin placement.8
Layer Two: Subcutaneous
This is an important layer as many structures are located here and
understanding this area in detail will allow a practitioner to reduce
adverse events. Prior to the seminal work by Rohrich and Pessa,
the subcutaneous fat was viewed as an amorphous structure under
the skin. However, these authors identified three compartments.7
The (median) central compartment is located in the midline region
of the forehead. It has a consistent location that abuts the middle
temporal compartments on either side with an inferior border at the
nasal dorsum (supratrochlear artery). The lateral boundary is possibly
a septal barrier and could be referred to as the central temporal
septum. The middle temporal fat compartments lie on either side of
the central forehead, the inferior border is the orbicularis retaining
ligament, and the lateral border corresponds to the superior
temporal septum. The lateral temporal-cheek compartment connects
the lateral forehead fat to the lateral cheek and cervical fat. The
separation between the middle temporal compartment and lateral
temporal compartment may occasionally be seen as an oblique
depression on the skin in some patients. While these are important
anatomic concepts, it is interesting to note that we are unclear as
yet what their role is in the ageing of the forehead, unlike other
regions that have been examined, for example the mid-face fat
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compartments as described by Gierloff et al.9
Other important structures are the nerves and vessels. The
Trigeminal nerve (Cranial nerve V) branches supply the sensory
innervation to the forehead.5 Lateral to the medial end of the
upper margin of the orbit, the supraorbital nerve indents the bone
into a foramen. The nerve passes superiorly and penetrates the
frontalis around the superior orbital adhesion and runs superiorly
in the forehead fat (layer two) to supply the scalp and vertex. The
smaller supratrochlear nerve passes up on the medial side of the
supraorbital nerve penetrating frontalis similarly to innervate the
medial forehead and the infratrochlear nerve supplies skin on the
medial eyelid(s), passing above the medial palpebral ligament.10
Frontal branches of the facial nerve transition subcutaneously in the
temple to innervate the frontalis segmentally in the subcutaneous
plane (layer two).11
Accompanying the nerves, the arteries follow a similar course.
The skin of the glabellar and forehead region is mainly supplied
by branches from the bilateral supratrochlear, supraorbital and
superficial temporal arteries.12 The supreatrochlear artery branches
from the ophthalmic artery in the orbit and emerges by piercing
the orbital septum above the medial canthal tendon.10 It runs in the
vicinity of the procerus and corrugator muscles in the nasal root
and the glabellar area, passing subcutaneously in level two on its
superior path. The artery has several branches during its course and
anastomoses with the supraorbital artery and supratrochlear artery.10
Within the corrugator complex, the artery is vulnerable to injury from
needle puncture from toxin needle placement and caution is advised
here due to its superficial path. The main artery runs in the glabellar
line often just under the subdermis in layer two.12
The supraorbital artery is the larger of the two; it divides into a
superficial and deep branch, and the former penetrates the frontalis
and enters layer two; then anastomosing with the superficial
temporal artery and lacrimal artery. It thus connects the internal and
external carotid systems.12 Due to these anastomoses within this
layer, the injector must approach layer two with a high degree of
caution to reduce potentially irreversible complications. The deep
branch runs on the deep surface of the frontalis and runs obliquely
laterally – often leaving an indentation on the bone. Occasionally
the deep branch will separate in the orbital cavity and enters the
forehead through a separate bony canal approximately one cm
above the midportion of the orbital rim.13 Deep injections of toxin
in this region may spread down this canal and enter the orbital
contents, resulting in ptosis.13
The venous return from the face is usually superficial; the
supraorbital and supratrochlear veins traverse to the medial
canthus where they unite to form the angular vein.14 This becomes
the facial vein, which pursues a straight course behind the facial
artery, just below the border of the mandible. Blood from the
upper lateral forehead is also collected into the tributaries of the
superficial temporal vein.14
Layer Three: Frontalis
The occipito-frontalis is an exceptionally thin muscle, fusing with
the galea aponeurotica from the lateral two thirds of the highest
nuchal line of the occipital bone, extending its fine fibres anteriorly
to fuse with the procerus muscle at the nasal bone.15 It is part of
a group of musculoaponeurotic muscles, which elevate the brow
with medial fibres blending inferiorly with the corrugator supercilli
and orbicularis oculi muscles blending laterally with orbicularis oculi
over the external frontal bone.
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The occiptofrontalis muscle represents the third layer in the scalp,
which equates to the superficial musculoaponeurotic system
(SMAS) layer in the face. Spiegel et al established that superiorly
to the nasion, the frontalis fibres are contiguous for a variable
distance before an aponeurosis is apparent in the space between
the bilateral muscles, which may vary considerably between
individuals.16 Male subjects may display a wide variation in the
medial muscle border as a ‘W’ shape with a variable attenuation
point. Female subjects demonstrate a less irregular central
dehiscence shape with a continuous frontalis and ‘V’ shape
dehiscence. The dynamic forehead lines may indicate the muscle
configuration (see above layer one). These findings are key in
analysing the frontalis muscle activity accurately, to treat effectively
and administer botulinum toxin judiciously.
Appropriate patient selection for botulinum toxin is crucial. Patients with
brow ptosis are poor candidates for correction of forehead ryhtides
with toxin.1 This needs to be assessed prior to considering treatment.
If present, in the authors’ experience, dermal fillers (including skin
boosting or intradermal blanching) may provide superior results, and
may additionally subtly enhance the position of the brows.
Layer Four: Loose Areolar tissue
This layer represents a gliding plane – essentially an avascular
plane. The frontalis glides over this layer and is a safe plane to
place dermal fillers for deep forehead contouring (See below), as
an avascular plane does not comprise any vessels or structures to
compromise.
Layer Five: Periosteum
The final layer is anatomically the point where the ligaments that
define the forehead arise. Moss et al5 describe the following
arrangement of ligamentous attachments in the upper face: the
temporal ligamentous adhesion supports the region immediately
superior to the eyebrow at the junction of its middle and lateral
thirds. Located at the intersection of the temporal, frontal and
periorbital regions are the superior temporal septum, the inferior
temporal septum and the supraorbital adhesion. The temporal
ligament arises from the frontal bone as an expansion at the
anterior end of the superior temporal septum, inserting into the
Figure 2: XXXXXXXXXXXXXXXX
Superior temporal
septum
Inferior temporal
septum
CPD
Forehead
superficial fascia at the junction of the superficial temporal fascia
and galea, on the deep surface of the frontalis muscle. The
base is located parallel to the arcus marginalis of the orbital rim
at a distance of 10mm above it. The superior temporal septum
arises from the periosteum along the superior temporal line
of the skull and inserts into the line of junction between the
superficial temporal fascia and the galea. Anteriorly, this line
of junction occurs between the superficial temporal fascia and
the galea, lining the deep surface of the lateral border of the
frontalis muscle; the expanded end is the temporal ligamentous
adhesion. The supraorbital ligamentous adhesion arises from
the frontal bone above the orbital rim, extending between the
temporal ligament and the origin of the corrugator muscle. The
inferior border is located approximately 6mm above the deep
attachment of the periorbital septum; the ligament is condensed
around the branches of the supra-orbital nerve and corrugator
muscle origin. The periorbital septum originates from threequarters of the circumference of the orbital rim, extending from the
corrugator origin around to the inferomedial boney origin of the
orbicularis oculi. The origin and boundaries of these attachments
are significant in terms of re-contouring the forehead with dermal
fillers within the supraperiosteal plane; placement with a blunt
cannula does not permit dissection of these fixed attachments,
thus, product remains safely enclosed within the desired plane and
anatomical boundary. (Fig 1)
Anaesthesia
For optimum patient comfort when re-contouring the forehead, it
may be preferable to block the supratrochlear and supraorbital
nerves respectively. 3% mepivicaine or 2% lidocaine may utilised
for this purpose, with small volumes used to specifically block these
nerves low in the supraorbital region.17Lidocaine mixed with the
dermal filler may also be used, although the injection technique is
slower and may still be uncomfortable for the patient.
Topical anaesthesia is insufficient for this advanced deep
technique, despite the use of a blunt cannula as the supraorbital
nerves innervate the underside of frontalis and periosteum.17
Deep Correction
Re-contouring the forehead using a supraperiosteal approach is
gaining popularity.13 Redefining this anatomical region
provides a youthful contour, and facilitates deep support
in counteracting the morphological age-related bone
resorbtion noted in both male and female individuals at
the glabellar angle.15 Restoring the boney support to the
frontal eminence, as well as the lateral brow, achieves
a subtle redraping of the overlying tissues and the
procedure is popular within certain ethnic populations
who strive achieve a rounded, convex appearance to the
forehead.3 Facial mapping prior to treatment, along with
baseline photography, is key for practitioner and patient
to agree on the expected outcome from treatment.
Once the full face has been thoroughly cleaned with
chlorhexidine and hair tied back, re-contouring may be
achieved by commencing an entry point medial to the
temporal fusion line, utilizing a 25g needle entry point
to the depth of the supraperiosteal plane (layer four).
Calcium hydroxylapatite with its highly viscous, elastic
and cohesive properties without additional lidocaine
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A male patient may
favour augmentation of
the supraciliary arch to
enhance a masculine
brow in conjunction with
the frontal eminence,
with threads placed
supraperiosteally.
provides an ideal product to use in this layer. A 25g cannula is
inserted along the supraperiosteal plane to deposit linear threads
of product to augment the right and left frontal eminences from the
lateral entry points. The volume of product required to achieve the
desired result will vary between individuals, depending upon the
degree of correction required. A cannula length of 38mm or 50mm is
preferable, depending on the dimensions of the frontal bone; within
the supraperiosteal plane, the cannula will glide with ease without
risk of injury to nerves or vascular compromise. Busso and Howell
describe this technique as ‘horse shoe’ placement of product,
which achieves a subtle lift across the length of the brow. 3 A male
patient may favour augmentation of the supraciliary arch to enhance
a masculine brow in conjunction with the frontal eminence, with
threads placed supraperiosteally. Following correction, the product
is then moulded into the desired contour, and the patient advised to
withhold from applying makeup for 48 hours.
Loghem et al concur that a cannula approach is preferable,
and also advocate an entry point from the temporal crest.18 The
ligamentous attachments in the upper face aid in retaining the
product supraperiosteally, facilitated further by cannula placement.18
Superficial correction
To further enhance the result of the deep correction, it is possible
to combine the use of botulinum toxin A to soften dynamic
ryhtides across the forehead and glabellar complex. For more
established ryhtides, a cohesive, polydensified matrix hyaluronic
acid dermal filler may be combined through a ‘blanching’
technique using a 30g needle, described by Micheels et al, who
postulate that blanching is not caused by vasoconstriction, but
instead by the transparent and transient appearance of the gel in
close proximity to the skin’s surface.19 A superficial or intradermal
depth may be established by ‘tenting’ the needle to visualise the
outline in the skin, with the bevel placed downwards, depositing
multiple bead-like punctures, just under the skin until the rhytide
has been eliminated. The product is gently massaged following
correction, providing exceptional levels of correction for static
and/or superficial rhytides.
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Conclusion
The content of this paper has been compiled to equip the clinician
with current evidence and knowledge pertaining to non-surgical
forehead re-contouring. The key to successfully and safely treating
this region is a current and accurate anatomical knowledge and in
particular an understanding of the layered concept in relation to the
forehead (SCALP). Anatomy is a dynamic and three dimensional
subject; as anatomical awareness develops, it is imperative that
practitioners keep abreast of this specialist subject. Didactic and
interactive practical teaching courses will enable an in-depth
analysis in respect to important facial structures. Once this view
is appreciated, it will enable practitioners to develop safe and
effective techniques in treating facial zones.
Mr Dalvi Humzah is a consultant plastic reconstructive
and aesthetic surgeon, with a BSc in Anatomy. He has
been a tutor for the Royal College of Surgeons of England
and is an examiner for the Intercollegiate MRCS for the
Royal College of Surgeons of Glasgow. He is the lead
tutor for the award-winning Anatomy teaching programme, Facial
Anatomy Teaching, and actively teaches and lectures internationally.
Anna Baker is a dermatology and cosmetic nurse
practitioner. She runs the nurse-led Medicos Rx Skin
Clinic at The Nuffield Health Hospital in Cheltenham,
and is the coordinator for Facial Anatomy Teaching.
Baker runs nurse-led photodynamic therapy clinics for
non-melanoma skin cancer and is currently studying post graduate
Applied Clinical Anatomy at Keele University.
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3. Busso M., Howel J.D., ‘Forehead Recontouring Using Calcium Hydroxylapatite’, Dermatologic Surgery, 36 (2010), pp. 1910-1913.
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7. Rohrich R.J., Pessa J.E. (2007) The Fat Compartments of the Face: Anatomy and Clinical Implications for Cosmetic Surgery. Plastic And Reconstructive Surgery. 119(7):2219-2227.
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9. Gierloff M., Stohring C., Buder T., Gassling V., Acil Y., Wiltfang J., ‘Aging Changes of the Midfacial Fat Compartments: A Computed Tomographic Study’, Plastic And Reconstructive Surgery, 129(1) (2012), pp. 263-273.
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11. Agarwal C.A., Mendenhall S.D., Foreman K.B., Owsley J.Q., ‘The Course of the Frontal Branch of the Facial Nerve in Relation to Facial Planes: An Anatomic Study’, Plastic And Reconstructive Surgery, 125(2) (2010), pp. 532-537.
12. Shimizu, Y., Imanishi N., Nakajima T., Nakajima H., Aiso A., Kishi K., ‘Venous Architecture of the Glabellar to the Forehead Region’, Clinical Anatomy, 26(2) (2013), pp. 183-195.
13. Carruthers J.D.A., Fagien S., Rohrich., R.J., Weinkle S., Carruthers A. (2014). Blindness Caused by Cosmetic Filler Injection: A Review of Cause and Therapy. Plast Reconstr Surg 134(6):1197-1201.
14. Imanishi N., Najajima H., Minabe T., Chang H., Aiso S., ‘Venous Drainage Architecture of the Temporal and Parietal Regiosn: Anatomy of the Superficial Temporal Artery and Vein’, Plastic And Reconstructive Surgery, 109(7) (2002), pp. 2197-2203.
15. Lorenc Z.P., Smith S., Nestor M., Moradi A. ‘Understanding the functional anatomy of the frontalis and glabellar complex for optimal aesthetic botulinum toxin type A therapy’, Aesthetic Plastic Surgery, 37(5) (2013), pp. 975-83.
16. Spiegel J.H., Goerig R.C., Lufler R.S., Hoagland T.M., ‘Frontalis midline dehiscence: An anatomical study and discussion of clinical relevance’, Journal of Plastic, Reconstructive & Aesthetic Surgery, 62 (2009), pp. 950-954.
17. Zide B.M., Swift R. (1998). How to block and tackle the face. Plast Reconstr Surg. 101(3):840-51
18. Loghem J., Yutskovskaya Y.A., Werschler W.P., ‘Calcium Hydroxylapatite: Over a Decade of Clinical Experience’, The Journal of Clinical and Aesthetic Dermatology, 8(11) (2015), pp. 38-49.
19. Micheels P., Sarazin D., Besse S., Sundaram H., Flynn T.C. ‘A Blanching Technique for Intradermal Injection of the Hylauronic Acid Belotero’, Plastic And Reconstructive Surgery, 132(4S-2) (2013), pp. 59S-68S.
Aesthetics | July 2015