Forehead Reflation

Introduction

Although fillers are typically used for restoring volume loss to create a youthful appearance, an additional role of fillers is often overlooked—facial recontouring. The recontouring process not only corrects for defects but also aims to restore facial proportion that may or may not have been present naturally in the patient who presents for correction. As the use of toxin occurs consistently over years to decades in many patients, muscular atrophy also presents more commonly in our patients than it did in the past.

One of the prime areas amenable to restructuring through fillers is the forehead area. With time, the upper third of the face elongates as the hairline moves upward and the brow moves downward. Both intrinsic and extrinsic factors play a role. Gender, age, family history, and styling practices can influence hairline position, while gravity, smoking, and sun exposure can cause keratinocytic dysplasia, which manifests as coarse wrinkles and a rough skin surface.

Initially, changes associated with aging, such as rhytides, can be corrected through neurotoxin use. Over time, skin laxity and relative muscle atrophy create temporal wasting and some brow ptosis, leading to decreased efficacy of neurotoxin for this area. Even in patients who are neurotoxin naïve, brow descent can occur through repetitive contractions of forehead depressor muscles and loss of elastic fibers. Although many physicians focus on brow elevation, it is important to consider complementary filler placement in the forehead to optimize a younger appearance. (Coincidentally, brow elevation is on occasion noted in patients treated for forehead recontouring.)

In this chapter, we review a simple technique to replenish volume loss in the forehead, improve skin laxity, and reposition facial structures to correct for descent using calcium hydroxylapatite (CaHA; Radiesse or Radiesse Plus [Merz Aesthetics, Raleigh, NC]) and hyaluronic acid (HA) fillers. Although we primarily use CaHA and HA, autologous fat and poly-L-lactic acid (PLLA; Sculptra [Galderma Laboratories LP, Forth Worth, TX]) are also options and will be reviewed briefly.

Patient Evaluation

Changes in the forehead region in terms of texture are typically sun related, whereas age-related changes cause volume loss, descent of brow position, and muscle atrophy, along with a seeming permanence of horizontal lines. For horizontal lines that are etched into the skin surface, it is important to use neurotoxin first to assess the degree of amelioration through that route, and evaluation for fillers in this region should only occur after the full effect of the neurotoxins has taken place. Questions regarding malignancy, human immunodeficiency virus (HIV) status, diabetes, and thyroid dysfunction should be asked because these are all medical conditions that can contribute to lipoatrophy. In addition, it is important to be aware if the patient is allergic to lidocaine or if he or she has had an adverse reaction to fillers in the past. This is especially important when using PLLA, which can cause granulomas. Informed consent should always be obtained in addition to preoperative photographs. Baseline facial asymmetry is also important to assess. Prior to injection, these authors recommend prepping the skin with alcohol or with chlorhexidine gluconate. Because additional diluted anesthetic is added to the product (CaHA is now available with lidocaine added to it), it is not necessary to anesthetize the patient topically prior to the procedure.

Patient Consent

As with any cosmetic procedure, informed consent is a must. In addition to the usual side effects of filler use, including bruising and edema, it is important to discuss the risk of nodule formation. In the forehead, incorrect placement of filler is unforgiving as this area of the face is mobile and even small nodules become very apparent depending on the lighting the patient is in. Filler migration should be discussed with patients as well as the possibility of vascular event. As will be discussed in the anatomy section, while intravascular injection is only sporadically reported in the literature, it can occur and can lead to skin necrosis. It is important to discuss this with patients and to include signs and symptoms in postfiller care so that patients know when to seek immediate medical attention. It is also imperative that staff receiving patient calls be aware of reports of bruising in this area which could be a sign of something more serious and may need physician evaluation.