Asians view an evenly rounded forehead without angular protrusions as beautiful, although the preferred forehead shapes may differ across different cultures. Unfortunately, bilateral frontal eminence exists in the frontal bone from birth. The supraorbital rim projects forward which can create a hollowness between the frontal eminence and supraorbital rim. Therefore, the key area of the forehead augmentation procedure is the cross shape between two frontal eminences and two supraorbital ridges (Fig.5.1).

Frontalis Muscle

The frontalis muscle lies above the frontal bone. This muscle is attached to the eyebrow and is an antagonist to the procerus, corrugator supercilii, depressor supercilii, and orbicularis oculi muscles. The galea aponeurotica that includes the frontalis muscle is posteriorly connected to the occipitalis muscle and forms the superior temporal septum (STS) at the border with supercial temporal fascia.

In the past, Spiegel et al. reported that the frontalis muscle bifurcates at about 3.5cm above the superior orbital rim. Based on this, the uppermid portion of the forehead was thought to lack muscle, and botulinum neurotoxin was useless in

Fig. 5.1 Forehead and frontalis muscle (STS superior

temporal septum)

this area. However, such ndings were based on gross examination. Costin et al. found cases where the bifurcation of the frontalis muscle occurred higher and those where the frontalis muscle continued without bifurcation. Histological examination of the upper-mid forehead conrmed existence of muscle and disproved the previous reports based on gross examination. This indicated that botulinum neurotoxin may be necessary in the upper-mid portion as well. The depth of the frontalis muscle is around 3–5mm below the skin surface and the horizontal width varied among individuals.

Corrugator Supercilii Muscle

Among muscles that pull the eyebrows down, the corrugator supercilii muscle lies the deepest under the skin. The muscle is sometimes divided into the transverse head and oblique head; however, such categorization has little clinical signi-

https://doi.org/10.1007/978-981-96-9215-6_5

129

130

Fig. 5.2 Corrugator supercilii muscle and procerus muscle

cance. This muscle originates from the bone

2.9mm lateral to the midline and 9.8mm superior to the nasion. It rises supercially as it courses to the right and upward to insert into the skin. Although the course of the muscle and insertion vary between individuals, have the patient furrow the eyebrows to create glabella lines, and nd skin dimpling to closely observe the area of muscle insertion. Areas lying lateral to this dimpling are the actual site of skin insertion, and the muscle stretches more laterally than we expect. This muscle is the thickest between the medial canthal line and mid-pupil line measuring about 2~3mm (Fig.5.2).

Procerus Muscle

The corrugator supercilii muscle creates vertical lines in the glabella, whereas the procerus muscle forms horizontal lines. The procerus muscle originates from the nasal SMAS near the nasal bone and reaches the skin of the eyebrow. This muscle stretches up to the supraorbital rim and down to the medial canthal line or nasion level.

The frontalis muscle, corrugator supercilii muscle, and procerus muscle discussed above have particular clinical importance as they are the main targets of botulinum neurotoxin injection of the forehead. The frontalis muscle is the single muscle in charge of lifting the eyebrow, and excessive injection of botulinum neurotoxin can cause eyebrow ptosis. Currently, the preferred injection method is lower-dose injection of botulinum neurotoxin followed by additional injection if necessary. Injection into the corrugator supercilii muscle and procerus muscle, two rela-

5 Filler Procedures Based ontheFacial Area

tively smaller muscles, require correct knowledge of the level and location of the muscle.

Supratrochlear Artery and Supraorbital Artery

The most serious complication of injectable dermal llers is visual loss, which is most common with injections in the glabella. Data on the frequency of visual loss at this site are consistent in domestic and foreign literature. The supratrochlear artery is often involved, and we need to be clearly aware of the course of the supratrochlear artery to avoid it during injection. However, controversy still exists over exactly where the supratrochlear artery perforates the frontalis muscle for its supercial emergence or which structures it lies above. Pessa named the crease in the lateral glabella as “corrugator crease” and argued that this crease coincides with the course of the supratrochlear artery. He also argued that the artery passes below the frontalis muscle and corrugator supercilii muscle.

On the other hand, Ugur etal. reported that the supratrochlear artery courses around the medial canthal line, which lies lateral to the glabellar frown line (corrugator crease) in his Doppler imaging and cadaver study (Fig. 2.21). Reece etal. argued that the supratrochlear artery passes along the periosteum to exit the medial orbit and divides into a supercial and deep branch. The deep branch rises along the periosteum, but the supercial branch perforates the frontalis muscle

1.5mm above the supraorbital rim and runs in the subcutaneous layer.

The course of the supraorbital artery is slightly lateral to the supratrochlear artery. They usually have anastomosis, but it is hard to distinguish each other. The supraorbital artery passes underneath the orbital foramen and separates into supercial and deep branches (Fig. 2.22).

Based on these various reports, I have concluded that the course of the supratrochlear artery mostly coincides with the corrugator crease, the deep branch does exist, and the supercial branch is a thicker main branch. I believe the supercial branch perforates the frontalis muscle slightly above the supraorbital rim. However, there are

5.1 Upper Face

Fig. 5.3 Supratrochlear artery (left) and supraorbital artery (right)

variations to the location of these structures among patients, and glabella injections should be carried out with great caution.

Forehead Fat Compartments

The fat compartment of the forehead only has supercial fat above the frontalis muscle and lacks deep fat. The forehead is divided into the central compartment in the middle and two lateral forehead compartments on both sides. The middle forehead compartment connects with the lateral temporal cheek fat compartment at the

Fig. 5.4 Forehead fat compartments (CTS central temporal septum, STS superior temporal septum)

temple area. Injecting a ller immediately above the periosteum would not affect the septum between these compartments, but if the ller is

nique). Block the dangerous arteries by applying pressure on the superomedial orbital rim.

injected into the subcutaneous layer, the needle or cannula may face resistance by the septum. This may cause difculty in molding the injected ller as it may not be able to be moved to other compartments (Fig.5.3).

Usually, three entry points are used, and ller is injected between the base of the galea and periosteum. Less viscous llers have the advantage of not creating bumps after injection, but are not preferred because they can easily migrate by the

Technique

One must consider both frontal bossing and supraorbital elevation. Mark the sunken area and injection point at the eyebrow apex via which one can reach the center of the forehead using a 5cm cannula (Fig.5.4). Perform a nerve block of the supratrochlear nerve (medial canthal line) and supraorbital nerve (medial pupillary line) using lidocaine. Make an entry for cannula insertion using a 23G needle, and inject ller at the supraperiosteal level using a 23G cannula (bolus tech-

action of surrounding facial expression muscles. If possible, all the llers should be connected, and creating a bolus mass may have a more ideal result (Fig.5.5). Massage with your ngers and wet gauze.

Care should be taken when injecting ller into a patient who has previously performed a forehead lift or a forehead shortening operation. It is difcult to evenly insert the ller because of adhesion between the galea and the periosteum layer (Fig.5.6).

131

132

Fig. 5.5 Entry points of the forehead augmentation

5 Filler Procedures Based ontheFacial Area

5.1.2 Temple

Pre-procedural Considerations

The temporal hollowing that occurs with aging or excessive dieting is an indication for injectable ller or autologous fat graft. Temporal hypertrophy may be corrected by botulinum neurotoxin injection. The interest in the aesthetics of the temple area is increasing with the rising frequency of anchored-type thread lifting. Serious complications such as necrosis or vision loss are less common in this area; however, the risk of bleeding or neural damage still exists. As the thread is commonly xed onto the temple area during anchored-type thread lift, accurate anatomical knowledge is necessary.

Terminology

The temple is one of the most anatomically complicated areas of the face. In this area, blood vessels, nerves, muscles, and fat exist in many layers and scholars have not agreed on the nomenclature

Fig. 5.6 Forehead augmentation using ller

5.1 Upper Face

133

of different structures, frequently leading to confusion. The temporal region refers to the concave area inferior to the superior temporal line where the temporalis muscle originates from. Mendelson divides the face into ve layers, and as shown in Table 5.1, various terms are used to refer to the same structure. Supercial temporal fascia (STF) is called galea aponeurotica superomedial to the temple and its name changes to temporoparietal fascia or mesotemporalis after passing the superior temporal septum (STS, also known as the zone of adhesion or zone of xation). The fourth layer, loose areolar tissue, is also called subgaleal

Table 5.1

1 Skin Skin 2 Subcutaneous

4 Loose areolar

5 Periosteum Deep temporal fascia

Nomenclature of the temple region

Layer Terms at temple area Same terms Subdivision

tissue Musculo-

apneurotic layer

tissue (LAT)

Lateral temporal cheek fat

Supercial temporal fascia (STP)

Subgaleal fascia Upper temporal

(DTF)

Temporalis fascia (TF)

compartment (UTC) = innominate fascia

Temporalis fascia (TF) Supercial

fascia at the temple and is divided into upper temporal compartment (UTC) cephalically and lower temporal compartment (LTC) caudally, based on the inferior temporal septum (ITS, also known as the orbicularis temporal ligament). The fth layer, the periosteum, passes through STS and is divided into deep temporal fascia (DTF) inferiorly and periosteum that actually attaches to the bone. The DTF is also known as the temporalis fascia, temporal aponeurosis, etc. In this section, I will use numbers and acronyms 1-skin, 2-SubQ, 3-STF, 4-UTC, 5-LTC, or 6-DTF to avoid confusion (Table5.1, Fig.5.7).

Lower temporal compartment (LTC) = parotid temporalis fascia (PTF) = Fibrofatty extension

layer Deep layer

Fig. 5.7 Anatomy of temple (TT temporal tunnel, SI superior interval)

134

5 Filler Procedures Based ontheFacial Area

Anatomy of the Temple

As shown in the right image in Fig.5.7, the lateral temporal cheek fat is the 2-subcutaneous tissue under the 1-skin of the temple and stretches to the midface. The fat in this area can be very scant and not readily distinguishable from other structures in some cases. The 3-STF lies under the lateral temporal cheek and connects to the SMAS caudally. The STF is the rst layer of mild resistance against the subcutaneously injected needle or cannula tip. The STF forms a roof over the 4-UTC and 5-LTC. The 6-DTF descends from the periosteum to form the oor of the UTC and LTC. The DTF splits into the supercial layer and deep layer which surround the supercial temporal fat pad in the middle. The supercial and deep layers of the DFT join again near the zygomatic arch. In the past, the supercial layer of the DFT was thought to attach laterally to the zygomatic arch and the deep layer attached medially to the zygomatic arch. However, Ramirez reported that the supercial and deep layers join together 1cm superior to the zygomatic arch. Moreover, Hwang et al. found that 56% of the fusion of the supercial and deep layers of the DTF attaches to the zygomatic arch’s superior margin and 44% of it attaches to the superolateral margin. They also described that the attachment between the zygomatic arch and fused DTF is within 2mm.

Supercial Temporal Fat Pad

The supercial temporal fat pad (STFP) is commonly also called the temporal fat pad (TFP). However, the deep temporal fat pad (DTFP), an extension of the buccal fat pad, lies inferior to the STFP.Therefore, the term TFP may cause confusion with this structure (Fig.5.7). There are many causal factors of temporal hollowing. Agingrelated temporalis muscle thinning may be one, or volume loss of the DTFP due to sagging and thinning of the buccal fat pad could be another. Temporal hollowing is also caused by STFP thinning. Matic etal. reported that the STFP covers 4×5cm of area cephalic to the zygomatic arch. Temporal hollowing is reported to deteriorate with lower body mass index (BMI) related to weight loss. The STFP volume loss was also

observed after surgical trauma such as incision in the area. During coronary incision, suprafascial dissection of the DTF rather than that of the supercial layer was shown to reduce temporal hollowing.

Upper Temporal Compartment (UTC) and Lower Temporal Compartment (LTC)

The UTC and LTC are not as extensively discussed in textbooks of anatomy. These two compartments may be thought of as spaces between layers but are also argued to be a separate layer such as fascia. The UTC is colored purple on Fig.5.7 and is separated by the roof of the STF (the third layer) and the oor of the DTF (the fth layer). The STS and ITS form superior and inferior borders, respectively, and are blocked anteriorly by the hard structure of temporal ligamentous adhesion. The UTC lacks major blood vessels or nerves and is often used as a safe area to x the anchored-type thread (Figs.5.7 and 5.8).

The LTC has different characteristics from the UTC.First, whereas the UTC has a hard anterior blockage, the LTC has two anterior openings. It forms a superior interval and temporal tunnel underneath. The temporal tunnel is connected to the prezygomatic space. The second difference is that unlike the UTC that lacks fat, the LTC has more fat tissues with caudal progression. Third, the ITS at the superior border of the LTC is a blocked sheet form, whereas the LTC has no inferior border and is sparsely bordered by the zygomatic ligament. Blood vessels and nerves pass through the openings and caution is needed during surgery to avoid damaging important structures in this area (Fig.5.7). Moreover, the ITS is signicant that it serves as a border blocking superior progression of the facial nerve temporal branch (Fig.5.8).

Supercial Temporal Artery (STA)

The supercial temporal artery proceeds anteriorly and bifurcates into the anterior frontal branch and posterior parietal branch. As shown in (Fig.5.8), the STA sprouts from the horizontal line of the superior orbital rim in most cases. The

5.1 Upper Face

Fig. 5.8 Position of temporal branch of facial nerve

135

bifurcation is above the superior orbital rim in 64% and below the superior orbital rim in 36%. The frontal branch of the STA has superomedial progression at a 60.8° angle toward the lateral margin of the frontalis muscle. The STA is still within the third layer at this point but rises supercially toward the skin surface at the superolateral quadrant of the intersection between the eyebrow upper margin and lateral canthus line (Fig.5.8). That is, small STA branches may exist in the subcutaneous level, medial to this area.

Facial Nerve

To locate the temporal branch of the facial nerve, the 2D course and depth of the nerve along skin landmarks needs to be understood. Two methods are largely used to predict the course of the facial nerve’s temporal branch from the skin surface. First method is to use the frontal branch of STA described above and second is to use Pitanguy’s line. Many scholars have shown that the temporal branch of the facial nerve lies inferomedially to the STA’s frontal branch.

However, a low bifurcation of the STA causes a unique variation where a few distal strands of the temporal branch rise above the STA.In the second method of using Pitanguy’s line, the facial nerve’s temporal branch passes along the imaginary line connecting the points 0.5cm inferior to tragus and 1.5cm superior to the eyebrow lateral margin (Fig.5.8).

Next, the depth also needs to be assessed. Among the ve branches of the facial nerve, the temporal or frontal branch has a unique course. The other four branches pass the parotid gland to progress under the deep facial fascia and insert into the mimetic muscle. However, the temporal branch penetrates the deep fascia (the DTF at the temple) to rise toward the surface. Agarwal etal. explained that the temporal branch travels through the fourth layer of LTC and rises supercially to the oor of the STF at 1.5~3.0cm above the zygomatic arch’s upper border and 0.9~1.4cm posterior to the lateral orbital rim (marked with a star in Fig.5.8).

136

Technique

The target layers for ller injection include A~D in the right image of Fig.5.7. At level A, the ller is injected above the bone inferior to the temporalis muscle and may not show change despite a large amount of injection. However, as the tip of the needle touches the bone, this level is less susceptible to nerve or vascular damage. At level B, the ller is injected between the supercial and deep layers of the DTF.The DTF deep layer is hard, and one can feel the resistance at the tip of the cannula or needle to identify the injection depth. However, a lot of experience is required to be able to feel the deep layer after puncturing the DTF supercial layer. The risk of bleeding exists as the 5mm thick middle temporal vein passes 2cm superior to the zygomatic arch between the supercial and deep layers of the DTF.Level C is at the LTC level, and the needle comfortably reaches this level with cannula or needle injection in cadaver. Great caution is needed as the facial nerve temporal branch and supercial temporal artery pass this area. Lastly, level D is the subcutaneous layer that lacks major nerves or blood vessels and is a safe layer for injection. However, caution is still required as uneven spread of the injected ller may result in bumpy appearance. As this layer has little subcutaneous fat, the doctor may inject in layer C mistaking it for D (Fig.5.7).

5 Filler Procedures Based ontheFacial Area

Fig. 5.9 Filler between the supercial temporal fascia (STF) and deep temporal fascia (DTF)

Make the entry point for cannula insertion using a 23G needle. Insert a 23G cannula until the tip touches the deep temporal fascia.

Inject the ller between the supercial temporal fascia (STF) and deep temporal fascia (DTF) (Fig.5.9). Move the cannula tip gently to prevent sentinel vein injury.

The sentinel vein is located at the anterior part of the temporal compartment.

At the hairline, inject ller between the supercial thermal fascia and the deep thermal fascia using a 5cm 23G cannula (Fig.5.10). Inject the ller with a bolus technique and massage it well to connect the boluses.

Fig. 5.10 Entry points of the temple augmentation

5.2 Midface

137

5.2 Midface

5.2.1 Supraorbital Hollowness

(Sunken Eyelid) andFlat Eyebrows

Pre-procedural Considerations

Supraorbital hollowness or sunken eyelid is a congenital or acquired tissue atrophy that occurs in the upper eyelid. This may cause the individual to appear older, fatigued, or sleepy. The causes of sunken eyelid include genetic factors, reduced eyelid fat due to aging, and excessive removal of orbital fat during blepharoplasty.

Asians have an especially weak levator palpebrae superioris muscle, which, attached to the tarsal plate, is responsible for eye opening. Furthermore, this muscle does not insert into dermal tissue in many Asians. Therefore, doubleeyelid does not form and the upper eyelid does not roll upward while opening the eye. This causes the skin of the upper eyelid to look relatively thicker and droopier.

Furthermore, compared to Caucasians, Asians have more subcutaneous fat in the upper eyelid area, including the eyebrows. Due to the sagging of the subcutaneous fat, the eyelid appears to be swollen. In contrast to the swollen orbital margin, with aging there is atrophy of the fat within the orbital septum causing a sunken furrow. The

strength to lift the eyelid weakens and the skin begins to sag. These factors lead to the formation of the sunken eyelid.

A person with sunken eyelids may look tired or sleepy. The shape of the eye is not dened, giving the appearance of eyelid ptosis. A thick supratarsal lid crease may form between the eyelid and eyebrow. Moreover, even if the person has double eyelids, the lids may not fully roll upward, causing only partial formation of the double eyelid fold. In such cases, lling the hollow area just inferior to the orbital rim may improve the overall appearance. Making the lid creases fainter will make the double eyelid folds look more distinct, adding more denition to the eyes (Fig.5.11).

Technique for Supraorbital Hollowness

Request the patient to sit in an upright position with eyes open. Using the retrograde linear threading tiny injection technique, slowly inject a soft HA ller that is easily moldable. Intramuscular injection into the orbicularis oculi muscle is associated with a high-risk of bleeding. Targeting the atrophied orbital fat deep to the orbital layer may also result in bleeding that is more difcult to control than bleeding in the subcutaneous layer. Moreover, there are spaces deep to the septum where hematomas may form, and the septum, which acts as a lubricating layer when opening and closing the eye, may get injured.

Fig. 5.11 Before and after treatment of the supraorbital hollowness

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Further Reading

5.1 Upper Face

5.1.2 Temple

5.2 Midface