Volumizing Forehead Plastic Surgery

Anatomical improvements in dead dissection and medical imaging have emphasized volume loss as a primary driver of facial aging over the last 3 decades. Initial volumization procedures prioritized dermal and superficial subcutaneous injections, but deep tissue correction has recently become more popular in treating the aging face. Due to the increasing growth of minimally invasive cosmetic facial procedures, aesthetic surgeons must maintain proficiency in these techniques in order to optimize patient outcomes in a long-term and productive way. It's also crucial to educate non-core medical doctors who perform non-surgical cosmetic rejuvenation on the limitations and risks of these therapies, as well as when they might not be appropriate for a certain patient.

 

Why Volumize the Face?

The loss of volume in the cheeks, forehead, lips, mouth, and area beneath the eyes, which gives a hollow look and shadowing, is a primary cause of the aging face. You can minimize shadows and reestablish the reflection of light and the look of youth by replacing volume loss with dermal fillers.

 

Fillers and Their Characteristics

Hyaluronic acid and calcium hydroxylapatite are the two main types of temporary fillers approved by the US Food and Drug Administration for forehead rejuvenation. Polymethylmethacrylate, a semi-permanent filler, poly-L-lactic acid, and autologous fat, all of which have different biological properties and injection procedures. In the United States, hyaluronic acid fillers were first offered for intradermal injection in the 2000s, and they have since become the most popular fillers for soft-tissue enhancement. Non-animal stabilized hyaluronic acid technology is now used to make FDA-approved hyaluronic acid fillers; however, novel fillers are made with alternate technologies, such as the Emervel (Galderma, Lausanne, Switzerland) line, which uses optimal balance technology, will likely join the market. Another transient filler with properties comparable to hyaluronic acids is calcium hydroxylapatite (Galderma).

The constitution and rheologic features of temporary soft-tissue fillers are characterized as elasticity (G′), viscosity (n*), hydrophilicity, particle size, particle concentration, and crosslinking. The ability of a material to withstand compression is denoted by G′, whereas the ability to withstand shearing forces is denoted by n*. The capacity of a product to absorb and expand water is known as hydrophilicity. The filler's total lifting and filling power are influenced by particle size, which is determined by the polymerization of glycosaminoglycan chains and straining procedures. The resistance to endogenous enzymes of hyaluronic acid is strengthened by increased particle concentration and crosslinking. These characteristics differ between fillers, with each product having its own set of rheologic characteristics. As a result, during facial volumization, these factors must be carefully considered in relation to a patient's particular anatomy and soft tissue characteristics.

 

Fillers Injection Techniques

Soft tissue volumization can be achieved using a variety of injection procedures. The correct technique is determined by the injector's preference and training, the product chosen, and the anatomical location being treated. Injectors utilize threading or, less frequently, fanning or cross-hatching procedures in a retrograde or anterograde fashion for superficial and dermal filling. Towering, layering, and depot administrations are more commonly used in the subcutaneous and periosteal regions for deep volumization. To avoid intravascular injection, aspiration before product administration is recommended regardless of injection technique or tissue depth. To modify rheologic qualities, product blending with sterile saline, lidocaine, or lidocaine with adrenaline can be used in certain anatomical areas and product combinations.

Sharp needles have recently been replaced by blunt cannulas in injectors. This method may result in improved patient comfort, reduced edema and ecchymosis, and more consistent recovery.

In areas prone to bruising or at greater risk for intravascular injection, or when the patient cannot tolerate a typical recovery period, cannulas may be preferred over needles. Despite these advantages, many injectors still favor needle injection techniques, claiming the necessity for more training, higher costs, difficulties threading cannulas, and a reduced capacity to treat all areas properly as concerns. In the United States, it is unclear if cannula-based treatments will expand and possibly replace needle-based techniques.

 

Facial Volume Loss Characterization and Treatment

Consider the structure of the face as being divided into thirds for reliable and successful facial analysis (i.e., the upper face, midface, and lower face). Each region experiences typical volume atrophy or hypertrophy, which is accompanied by greater total facial strain and a loss of soft-tissue integrity. Based on the patient's underlying bone structure, weight, and soft-tissue quality, specific modifications differ from person to person. To replicate clinical scenarios for facial assessment and structural volumization planning, anatomical changes related to aging are documented for each third of the face, from the top down and deep to superficial. Volume restoration will address both bone and soft-tissue atrophy in each location.

 

Forehead Volumization Methodology

General Idea

Dates for filler injections were chosen to coincide with age-related volume decrease in the face. Before the injection, patients were told to stay away from aspirin and nonsteroidal anti-inflammatory medications for a week. The Canfield Vectra System and normal digital photography were used to take three-dimensional photographs of the patients' faces after they were cleaned of makeup. For 15 minutes, the sites to be injected were covered in LMX 4 percent topical anesthetic cream. Before injection, the LMX cream was eliminated and the patients' faces were washed with isopropyl alcohol and then chlorhexidine gluconate 4 percent solution. Following the operation, the injection sites were given 10 minutes of cold packs before being imaged. Two weeks following injection, patients' pictures were taken again.

 

Volumizing Forehead

A modest convexity of the temple, forehead, and lateral brow, as well as fullness of the top eyelids, describe the youthful upper face. In these areas, there is a gradual loss in volume as people age. Despite the fact that the severity of volume loss differs from patient to patient, the resulting temporal narrowing and periorbital hollowing go unnoticed and untreated. The temporal narrowing can lead to a loss of lateral brow support, resulting in lateral brow ptosis and upper lid pseudo-dermatochalasis. These alterations give the upper face a tired, old expression, and they're often the first indicators of facial aging in the fourth decade. Both bony and deep soft-tissue alterations cause volume loss in the upper face.

In particular, periorbital bone remodeling occurs in the superomedial and inferolateral directions, leading to a vertically extended orbital opening and higher vulnerability to lower lid hollowing and contour abnormalities. In defined areas of fat accumulation, soft-tissue shrinkage of the upper face develops. The deep temporal fat pad and the temporal outgrowth of the buccal fat pad atrophy at the temple. The subcutaneous plane of the forehead and lateral brow thins, and the upper lids normally lose volume in the retro-orbicularis oculi fat pad, as well as the medial and lateral fat pads. Fillers with adequate rheologic qualities for deep volumization, notably a raised G′ and n*, are required to treat upper facial volume loss at the temple and upper brow, whereas fillers for volumization of the upper lid, forehead, and crow's feet should have lower G′ and n* profiles. There are presently no FDA-approved fillers for the treatment of these areas, hence fillers are used off-label for these applications.

Restylane Lyft, Radiesse, Juvederm VolumaXC, and Juvederm Ultra Plus XC are all good options for treating the temples and high-brow. These products' higher G′ allows for accurate placement on the periosteum, giving structural and lifting support to overlying tissues with less risk of displacement. For superficial therapy of the temple, upper brow, and eyelid, Restylane-L, Restylane-Silk, Belotero Balance, and Juvederm Ultra XC are acceptable fillers. Injector experience, intended product duration, and cost are all factors in the decision. We've learned that the anatomical sequence of contouring has an impact on the final result of facial volumization. Temple augmentation alone may give lateral brow support; thus, it should be addressed before advancing farther caudally. When injecting the forehead, it's important to pay close attention to the temporal vessels and superficial veins. Supra-periosteal injections are the preferred injection plane. The needle is introduced to the periosteum using a 27-gauge needle and the perpendicular depot method. The product is injected after the aspiration. Serial injections are linked to an increased risk of ecchymosis and important structure injury, although they may offer more discriminative outcomes.

Although other injectors have claimed similarly effective results with more shallow injections, this method delivers the longest lasting and most natural repair. For individuals who want to keep the cost and amount of product administered to a minimum, superficial repair in the sub-galeal plane is an option. After volumizing the temples, the brow and upper lid are given special attention. Both bone and more superficial tissues, such as subcutaneous fat and the retro-orbicularis oculi fat pad, reduce the volume in this area. To address this deficiency, doctors choose to inject product straight into the periosteum around 1 cm above the upper lateral orbital rim or slightly above the superior lateral brow hairline. Due to the rarity of medial brow ptosis, a medial brow injection is rarely required. If more volume is needed, a small amount of product can be used. Some authors, for example, recommend injecting the sub-orbicularis directly into the upper lid. Although direct injection in this plane may be a useful strategy to address upper lid hollowing, because of the relative closeness to the globe and its vasculature, this approach carries significant hazards and should only be used by experienced injectors.

 

How does Volumizing the Face with Dermal Fillers Compare to a Facelift?

Dermal fillers raise the skin, and because the results may be so dramatic, treatments like Liquid Facelift and Lunchtime Facelift have been established. The excess skin is removed during a surgical facelift, but the volume is not restored. Face revolumization offers three unique advantages: 1- the outcome is more natural, 2- there is shorter recovery because it is non-surgical, and 3- the result may be reversed if someone wants to look his age.

 

Are All Dermal Fillers the Same?

There are distinctions. Although all injectable fillers will correct a line, a crease, or an area, not all dermal fillers are suitable for all types of wrinkles. Restylane, Juvederm, and Voluma are the most common dermal fillers. They are relatively similar in composition but address different areas of the face. Sculptra is a collagen stimulator that works overtime to restore lost collagen and volume, the results aren't as noticeable immediately, but they last for two years.

 

What Areas of the Face do You Treat?

Face lines, crow's feet, droopy eyebrows, hollow eyes, marionette lines, wrinkled, sagging lips, sunken cheeks, and a hollow jawline can all be corrected. Patients can always tell doctors what they want to change, and we'll use their years of experience and training to come up with the best plan to help them achieve their objectives.  Patients are thrilled to see that they will appear like themselves, only younger, due to innovative technology that shows them what they will look like when the volume has been put back to their face. some doctors also have Visia technology, which measures wrinkles, brown spots, and red regions on the skin so that patients can see and measure how effectively therapies and medical-grade skincare products are functioning.

 

Forehead Lipotransfer

Low volume subcutaneous injections show good changes in skin texture and diffuse volume, despite being used largely as an adjuvant to botulinum toxin. Individualized treatment of certain focal areas of age-related tissue deflation is possible. Two mirrored trocar entry locations on either side of the midline are employed to treat the glabella and forehead: two above the glabella and two in the upper forehead. Contour irregularity can be reduced by spreading the injections in a subcutaneous plane with about 0.1 mL of fat administered per pass. 5 to 6 mL is commonly injected between the glabella and the forehead. Patient satisfaction is usually determined by two factors: the duration of the results and the degree of correction. A latency period of 1 to 2.5 years is acceptable if repeat lipotransfer is required. When the level of satisfaction, price, procedure-related aspects, effect longevity, and potential complications are considered, autologous fat transfer is an excellent value and can be used as a facial volumizer.

 

Forehead Volumization Complications

In the hands of really well injectors, soft-tissue fillers have a low complication incidence. It's critical to discern between side effects and true complications, though. In general, the amount of tissue trauma caused by the former is proportional to the type of filler used, the volume administered, the anatomical region (lips inflate more than malar), and the injection technique used. Optimization of all preinjection and intrainjection variables, as well as strict adherence to postprocedural regimens, can help to reduce side effects. True injectable filler problems, though uncommon, are best classified as immediate-, early-, and late-onset occurrences, with mild, moderate, and severe subcategories.

 

Immediate Complications

Immediate problems arise within 2 days of injection and are either related to the amount and qualities of the injectable utilized or are secondary to vascular impairment. In the case of the former, the injector must have a thorough understanding of the products utilized as well as suitable dissolving techniques, regardless of the anatomical area enhanced. To avoid vascular compromise, the injector is needed to have a thorough understanding of the three-dimensional anatomy of face vessels in order to avoid arterial embolization or occlusion. Immediate pain, skin blanching in the relevant anatomical distribution, and skin coldness are all signs of arterial compromise. If this happens, the injector must end instantly, try to aspirate the product, and provide hyaluronidase if the substance contains hyaluronic acid. After intravascular compromise, some injectors recommend regular (hourly) hyaluronidase injections until indicators of tissue compromise subside. The compromised area can be treated with nitro-paste, and the patient should be checked and treated for probable tissue loss on a daily basis. If a product is accidentally injected into a vein, the patient will experience gradually increased discomfort and swelling, as well as a purple tint in the affected area. Overfilling an area causes venous compromise, which can be managed by decreasing the amount of injection utilized and allowing the product to dissolve.

 

Early Complications

Early problems usually appear 2 to 14 days following injection and are caused by filler-induced inflammation and hypersensitivity. The patient may experience nodularity in the injected areas for up to two weeks after the injection. However, if this persists, the nodularity must be classified as inflammatory or noninflammatory based on further symptomatology such as redness, discomfort, and drainage. Noninflammatory nodules can be softly massaged, or if the nodules are amenable, they can be dissolved using hyaluronidase or an intralesional steroid injection. If inflammatory or infectious nodules are present, a culture sample should be taken and sent for gram staining. In addition to oral steroids, the patient may be managed with an oral antibiotic course (including treatment for methicillin-resistant Staphylococcus aureus) for 4 to 6 weeks and continuously monitored. To speed infection clearance, the filler should be dissolved if at all possible. These individuals may be at a greater risk of biofilm development, and any repeat injections should be done with great caution. To reduce the likelihood of these issues, we recommend following a rigorous facial cleansing and preparation procedure.

 

Late Complications

Late problems can arise beyond 14 days and are primarily caused by the body's immunological response to the substance. Because all fillers are foreign matter, a patient can develop a chronic granuloma, which can lead to a low-grade chronic infection that manifests as solid, sometimes painful nodules that may necessitate needle disintegration or, in the end, surgical removal.

 

Conclusion

Our understanding of facial aging and structural contouring has progressed significantly over time. Deflationary changes of the face arise from volume loss from the bone level to the skin, which can be effectively treated with tissue volumizers. Autologous fat and poly-L-lactic acid represent excellent choices and are occasionally preferred in specific circumstances. However, because of their relative ease of use, large range of materials, and low and infrequent side effects, hyaluronic acid fillers and, to a lesser degree, calcium hydroxylapatite have become the fillers of choice for the majority of injectors. We believe that facial volumization should be conducted in a cephalic-caudal way, from deeper to more superficial tissue planes. Based on the anatomical location, injector knowledge, and patient-specific soft-tissue characteristics, the best filler should be chosen. Although structural facial volumization with temporary fillers has greatly expanded treatment options for facial rejuvenation and contouring, this procedure must be performed in the right context by professionally trained injectors to be a useful addition to multidisciplinary facial restoration techniques.