Soft tissue fillers have become one of the most popular techniques for nonsurgical facial rejuvenation and contouring in the last two decades. Originally concieved to smoothen nasolabial lines and plump up lips, they are now used for a variety of uses which include volumetric restoration and sculptural aesthetic contouring of the face . The upper third of the face which includes the nose, brow, upper eyelids, forehead and temples are important components of overall facial aesthetics and volume improvements in this region can bring about significant changes. This presentation examines the aesthetic considerations of the upper third of the face and presents the injection rationale and techniques of the author. Vascular territories and potential complications are also discussed.
Although the nose, supraorbital brow ridge, upper lids, forehead and temples are separate aesthetic units that can each be contoured independently, these five areas are connected to each other and should flow seamlessly from one to the other creating a balanced, harmonious and aesthetically pleasing upper face.
Prior to the development of reliable soft tissue fillers for facial contouring, a variety of surgical techniques were used to aesthetically improve these areas of the upper face. Fat grafts from the lower lids or periumbilical area have been used to fill out sunken upper eyelid sulci. Silicone and later, bone substitute implants were used for elevating the nasal bridge and reshaping the forehead for decades. Periosteal and temporo-parietal fascial flaps have been used to smoothen out forehead irregularities and more complex craniofacial operations to burr down the supraorbital ridge and recontour the anterior wall of the frontal sinus have also been employed. However all of these procedures require large incisions and involve a significant downtime. Autologous fat injections have in recent years been used to volumise and contour these areas successfully but this remains a surgical procedure with a degree of unpredictability and potential risk of vascular occlusive complications. Good results with fat injections require excellent surgical judgement and skill. Complications are difficult to reverse.
Soft tissue fillers are indicated in patients who wish to achieve significant aesethetic contouring of the nose, brow and forehead with minimal to no downtime. Often used in conjuction with botulinum toxins in the glabellar and forehead regions, significant aesthetic changes can be made within several minutes in the comfort of a non surgical setting. The techniques are easy to learn and if proper precautions and judgement are employed the results can be very satisfying and complications can be minimised. Large volumes (several vials of filler) can be used in a single sitting with pain relief provided by local nerve blocks or by the lidocaine that is present in many top grade fillers today.
Depending on the patient’s request, the appropriate type of filler is chosen. Some patients want only the dorsum and tip of the nose to be reshaped whilst others may want to enhance the naso-orbital line and the columella as well. Others may wish to contour the forehead and fill in the temples at the same time and therefore a variety of different fillers of different softness/hardness may be used. In any of these areas, it is advisable to avoid the use of permanent fillers and only use hyaluronic acid fillers instead, as any contour irregularity or vascular complications can be potentially reversed with the use of hyaluronidase.
Whether to use a cannula versus a sharp needle to deliver the fillers is largely a personal preference based on one’s familiarity and practice with the chosen instrument. With experience, equally good results can be obtained using either technique 10. Some doctors use both techniques in different areas of the face. This author prefers the sharp needle technique using a half inch 30G needle for most of the fillers used in the face whether it be in the upper, middle or lower third of the face. The 30G needle slows down the flow of injection creating a greater awareness of the effect of volumisation and reduces the risk of overfilling and injecting under high pressure. Using a 30G needle, the fillers can be delivered directly and accurately to the desired target and in the correct plane which in most situations should be directly onto bone. One must always be mindful of the underlying vacular anatomy and minimise the risks of vascular compromise. Occasionally, a 30G cannula is used to deliver the softer fillers to the upper lids, brow and forehead. It is difficult to inject consistently on the bone using a cannula as this invariably glides in the plane of least resistance which in the forehead is subgaleal or intramuscular. This is the plane where the facial vessels having emerged through their respective foramina, tend to arborise. Care must be exercised whenever injecting in the periorbital region whether it be with a needle or cannula.
Vascular occlusion is the most dreaded complication of injecting any substance whether it be fat or filler in and around the orbits, glabellar and nose. Focal areas of skin and soft tissue necrosis, loss of vision due to occlusion of the retinal or ophthalmic arteries and even brain infarction have all been reported and remain as risks that must be adequately discussed with every patient receiving these injections. A thorough knowledge of the vascular supply of the orbits and nose is essential, noting the course of the facial and angular arteries, its branches to the nose, the branches of the ophthalmic artery as they emerge through the supratrochlear and supraorbital foramen and in particular the anastamoses between these two systems.
In the face, all arteries emerge from foramina and arborise in and on the overlying muscular layers and never in the interface between the periosteum/perichondrium and the facial/nasal muscles. Therefore the safest place to inject a filler in the upper third of the face and nose is on the bone or periosteum itself, ensuring that the supratrochlear and supraorbital foramina are first indentified by palpation and protected from the needle point. It is unwise to allow a needle to enter any of the facial bony foramina.