Forehead and temporal recontouring using calcium hydroxylapatite pre-mixed with lidocaine

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13 Forehead and temporal recontouring using calcium hydroxylapatite pre-mixed with lidocaine

Marianno Busso, Kavita Mariwalla, David J. Howell

Summary and Key Features

• Rejuvenation of the upper face should include correction of skin laxity at the temples and placement of volume in the forehead concavity

• Although multiple fillers are available to correct the upper third of the face, we recommend calcium hydroxylapatite for these sites specifically

• Temple correction is best achieved through placement of boluses beginning at the temple and extending to the lateral canthus, followed by massage

• Forehead correction is achieved by placing a bolus of material into the inferior frontal eminence

• Postoperative edema is a common side effect that resolves spontaneously by 72 hours

• Relative ptosis of the eyebrows is also a temporary side effect and is a result of lidocaine and edema, typically resolving within 24 hours

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 aims to restore facial proportion that may or may not have been present naturally in the patient who presents desiring correction.

One of the prime areas amenable to restructuring through fillers is the forehead and temple 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. Sex, 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. While 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 and temples, improve skin laxity, and reposition facial structures to correct for descent using calcium hydroxylapatite (CaHA; Radiesse® [Merz Aesthetics, San Mateo, CA]). Though we primarily use CaHA, autologous fat and poly-L-lactic acid (PLLA; Sculptra® [Sanofi-Aventis US, Bridgewater, NJ] ) are also options and will be reviewed briefly.

Patient evaluation

While the majority of changes in the temple and forehead region are age related, it is important to screen for medical conditions that can cause lipoatrophy. Questions regarding malignancy, HIV status, diabetes, and thyroid dysfunction should be asked. In addition, it is important to be aware if the patient is allergic to lidocaine or if he / 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 anesthetic is added to the product, it is not necessary to anesthetize the patient topically prior to the procedure.

Pearl 1

Prior to injection in the temple area, three preoperative photographs should be taken at the following angles: full face, face at 45° angle looking to the right, and face at 45° angle looking to the left.

Anatomy

Temple

The tissue layers in the temporal region are as follows: skin, subcutaneous fat, superficial temporal fascia, deep temporal fascia, and temporal muscle. When injecting in the temple, there are two main anatomical structures physicians want to avoid: the superficial temporal artery and the frontal branch of the facial nerve. Both of these structures are closely associated with the superficial temporal fascia. The superficial temporal fascia is loosely adherent to the subdermal fat and is a continuation of the galea aponeurotica system of the scalp and the superficial musculoaponeurotic system of the face.

The superficial temporal artery is a terminal branch of the external carotid artery. It originates in the parotid gland and crosses the zygomatic arch about 10 millimeters anterior to the tragus. The superficial temporal artery gives off numerous terminal branches, including the transverse facial, the middle temporal, the parietal, and the frontal artery. It is possible to palpate the pulse from this artery in the temporal region.

The frontal branch of the facial nerve supplies motor innervation to the muscles of facial expression of the eyebrows and forehead. It is found along the deep surface of the superficial temporal fascia and is considered to be a nerve at risk when performing procedures at the temple. The most common method of finding this ‘danger zone’ is to draw a line from the ear lobe to the lateral eyebrow and then from the tragus to the superior most forehead rhytid. The result will be a zone that corresponds to the usual trajectory path of the frontal branch. Transection with a needle can result in brow ptosis.

When injecting the temples it is important to stay superficial to the superficial temporal fascia and to avoid these vital structures in the subcutaneous fat. Rather than using a fanning technique to deposit product, as is often deployed in treatment of the cheeks, nasolabial folds, and other areas of the mid- and lower face, the physician should instead deposit product in a depot and distribute it to the temporal region via massage.

Pearl 2

In order to avoid vital structures in the temple area, it is important to tent the skin prior to insertion of the needle and inject in a retrograde motion. It is important to pull back on the syringe slightly to ensure that injection is not inadvertently placed in a vessel.

Forehead

Though the forehead appears to be a convex structure, there is a concavity that becomes more prominent with age in the suprabrow region. It is located between the frontal eminence of the forehead and the supraciliary arches. Injury to the supraorbital nerve is of concern when treating this area. The nerve exits the supraorbital notch, which lies along the orbital rim medially and is readily palpated. A compression injury to the nerve can be avoided by injecting laterally and at least 1 centimeter from the supraorbital foramen. The preferred injection plane is posterior to the frontalis muscle. The subcutaneous prefrontalis muscle level has been used for PLLA injections. More cohesive fillers like CaHA may not spread as easily and may require multiple injections, thus causing more tissue trauma.

Adjacent to the supraorbital nerve is the supraorbital artery. Retrograde injection can decrease the risk of vascular embolization, as can the use of blunt-tipped cannulas.

Selecting the right filler

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