Volumetric treatment of the brows

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15 Volumetric treatment of the brows

Summary and Key Features

• Orbits that are large, round, and hollow are associated with age, not youth

• Young orbits are almond shaped, the bone is not visible and there may be considerable fullness of the upper lid

• The same configurations that are seen in younger patients may be perceived as looking old in older ones

• Communication is difficult in the periorbital area. Many patients want the eye ‘lifted’ or skin and fat removed since that is what they have been told is done. Moreover, some patients like the hollow and defined look as it may look more dramatic and makeup can be used more liberally

• The author prefers using a trial of local anesthetic in the upper lid to demonstrate the visual effect of filling in the upper lids and brow. If the patient likes the look, the injection is done immediately; there is no need to wait. Local anesthetic provides a vasoconstricted environment. There is no better way of communicating the visual effect of the brow fill

• Putting in the local anesthetic and avoiding overfills and fluid blobs in the upper lid is difficult to do well and easily; some practice is involved. The area is massaged and a few minutes should elapse to let the local distribute before showing the patient

• Underfill is better than overfill. This is not a method to fill in an abundance of skin, though the fill does inflate some skin. Nor is it a method to lift brows, though the brow can elevate in a few patients. Someone with full heavy lids is not a candidate for this procedure

• The author favors non-cross-linked hyaluronic acid (HA) products in the brow as they have more projection

• One should expect at least 2 years’ duration in this location with HA products

• The injector should always be aware of the presence of the globe. Some upper orbits are very shallow and the globe is immediately adjacent to the bone

Introduction

Thinning, deflation, and loss of subcutaneous volume are characteristic of periorbital aging. Though by no means universal, and seen largely in people who have not gained facial weight, this pattern of aging has been known through the ages and is frequently used as a caricature of the aging process. The term ‘nursing home eyes’ provides an instant visual image of the problem.

Traditional treatments around the upper lid have been largely surgical, mainly because until recently the only tools available were excisional. ‘Extra’ skin and fat around the upper lid was removed; for many eyes this proved to be an entirely satisfactory remedy. For some patients, however, the apparent extra skin was secondary to a volume loss in the upper lid and brow, and removing further tissue had the dual effect of making the orbit look more defined, but rounder and more hollow. Both of these have traditionally been considered beneficial. The perceived advantage of this look is that the orbit looks larger and dramatic in the vertical dimension, and leaves more room for makeup. It is also the traditional look of upper lid ‘rejuvenation’ and familiar. However, these are also characteristics of the nursing home eye and in some people the overall appearance of the eye is clearly older, smaller, and more tired. With the advent of tools to re-establish volume in the face, alternatives have become available, which the patient (and clinician) should be aware of before making treatment decisions in the periorbital area.

There is nothing new in these observations. Volume fillers were used exactly as they are now in the 1890s, well before facelift surgery was developed. Unfortunately all that was available at the time was paraffin and petroleum jelly (Vaseline^®); the complication rate was high and these treatments fell into disfavor, as described by Kolle and by Goldwyn.

The ‘local preview’

Patients usually have their own predetermined ideas about what looks good. If one has a choice of filling an area or defining it by removing tissue, the different potential effects must somehow be communicated to the patient. In other words, an adequate consultation should be able to explain the aesthetic alternatives to the patient. We have found no way in words to describe how the effects of filling the brow will improve the patient’s overall look; this is entirely a visual concept. It is like trying to describe a dress and assuming that the customer will like it without trying it on.

What has proved extremely useful is the ‘local preview’, as I have previously described (2009); a milliliter or two of % epinephrine is injected into the brow with the intention of visualizing the effect of filling the area and also to make it numb and vasoconstricted (Fig. 15.1). With the use of an ice cube for the initial injections, this is almost painless.

Figure 15.1 The ‘local preview’. It is difficult to communicate the visual effects of volume around the orbit without actually seeing it. An invaluable way of doing this is to inject the area with local anesthetic, which demonstrates the effect of fill and also numbs and vasoconstricts the area at the same time. Patients approve or disapprove of the visual effect before any product is injected. It usually takes more fill – about –1 mL per side – than the actual product injection. The long-term result looks like the result at the end of the procedure and typically lasts 2–3 years. (A) Before and (B) after injection.

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