Three-Dimensional Reflation of the Glabella and Adjacent Forehead

Introduction

The arc of the forehead denotes youth and has been considered a sign of beauty since the Middle Ages. This contour is created by both forehead skin thickness and subcutaneous volume. Age brings about deflation and descent of soft tissue. This process begins earlier in women (i.e., 25 years) than in men (i.e., 45 years). Similar changes also affect the brow, glabella, and orbit, particularly the lateral orbicularis oculi. The result is flattened brows, furrowed glabellar and forehead skin, hooded upper eyelids, and a tired or discouraged expression ( Fig. 18.1 ). Both women and men wish to eliminate this disempowered appearance. As such, the forehead and brow are an important focus of facial aging.

Botulinum toxin A (BoNT-A) alone may not be enough for the treatment of the aging forehead, especially in settings where treatment of the frontalis muscle results in further flattening and descent of the brow. Such brow ptosis produces a flat, uncaring, and rather wooden lack of forehead expression. The addition of intradermal hyaluronic acid (HA) fillers to BoNT-A to support glabella lines has been, for many years, typically successful. But this combination does not fully address age-related changes to forehead contour. An acceptable alternative, detailed in this chapter, is the deeper injection of soft tissue filler to restore forehead shape and a relaxed, open expression.