Three-Dimensional Forehead Reflation

Jean Carruthers, MD, and Alastair Carruthers, MD

BACKGROUND The rising popularity of the three-dimensional reflation of the mid and lower face has
prompted interest in upperfacial reflation.

OBJECTIVE We have been asked to share our technique for subgaleal three-dimensional forehead reflation.

MATERIALS AND METHODS We have described our anatomic approach, our modification of the hyaluronic
acid (HA) filler to achieve reduced viscosity and our injection technique.

RESULTS Immediately after the forehead reflation there is mild brow ptosis due to the lidocaine within the
HA filler. This reverses in 30 to 60 minutes post injection. There is a need for further enhancement about 2–3
weeks later in approximately 30 percent of subjects. The results last between 10–12 months.

CONCLUSION Three-dimensional subgaleal forehead reflation is an effective and safe procedure when
performed with an HA filler and a knowledge of the periorbital vascular anatomy.

J. Carruthers and A. Carruthers are both consultants for Allergan.

T he authors have been asked to describe our

teachings for forehead reflation with hyaluronic
acid fillers.
bilateral brow ptosis with associated diminution of
expressivity.

Materials and Methods

Loss of periocular and frontal bone and sub-
cutaneous fat can leave a hollowed frontal contour
and lowered brow position and deeper etched
horizontal forehead rhytides.1,2 The process begins
earlier in women than men, but is seen in both gen-
ders in middle age. Brow descent and flattening are
common. Most physicians are careful to inject
botulinum toxin A (BoNT-A) only into the brow
depressors (corrugator superciliaris, procerus,
orbicularis oculi) and not the frontalis if they feel the
injected frontalis would subsequently allow the brow
to descend or if the brow position is already low.3
The use of 3 dimensional brow reflation gives the
“glow” back to the forehead, softens the
horizontal rhytides, elevates the medial and
lateral brow, and recontours the mid forehead
depressions without risking the complication of
After discussion, photography, and full informed
consent, the authors mark the vessels to be avoided on
the forehead-supratrochlear, supraorbital, and
temporal.
The authors use a cross-linked hyaluronic acid prod-
uct (Juvederm Voluma; Allergan, Irvine, CA; hyalur-
onic acid voluma). The product comes in a 1 cc syringe,
and the authors use a sterile fluid dispensing connector
(FDC1000; Braun, Bethlehem, PA) plastic double
Luer-Lok to transfer 0.5 cc of HAV into another sterile,
Luer-Lok 1 cc polycarbonate syringe. The authors now
have 2 half cc syringes of HAV to which the authors add
0.05 cc of 2% lidocaine with 1/200,000 epinephrine.
The volume in each syringe is now 0.55 cc. The authors
add a further 0.45 cc of preserved bacteriostatic saline,

Department of Ophthalmology and Visual Sciences, University of British Columbia, Vancouver, British Columbia,
Canada; Department of Dermatology and Skin Science, University of British Columbia, Vancouver, British Columbia,
Canada

© 2015 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. All rights reserved.
· ·
ISSN: 1076-0512 Dermatol Surg 2015;41:S321–S324 DOI: 10.1097/DSS.0000000000000559

S321

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 THREE-DIMENSIONAL FOREHEAD REFLATION

Figure 1. Diagrammatic description of the injection sites for 3 dimensional forehead reflation showing the 3 injection
portals used.

producing a final dilution of 50%. This mixture is then
pushed back and forth 20 times through the fluid dis-
pensing connector to ensure even mixing. This
maneuver achieves the reduction in viscosity and thus
the increase in moldability required. Each subject is
photographed before and after the injection session and
the digital photographs are printed for the subject’s
chart and also kept electronically.
One of us (J.C.) prefers to use the 27/28G Exel needle
and the other (AC) prefers to use a 38-mm 27-gauge
1.5$ cannula to insert the product. Three injection
points are used in each forehead-central above the
nasal bridge between the supratrochlear vessels and
at the tail of the right and left brows between the
temporal and supraorbital vessels (Figure 1). After
topical cleansing with Hibiclens and after anesthesia
using the Palomar Cool Roller or topical lidocaine
30% in plasticized base, the needle or cannula is
inserted gently into the subgaleal space. To enter
the correct tissue plane, the skin is pinched up at
the lateral brow and also in the glabellar area
(Figure 2A–C).4 The plunger on the syringe is then
withdrawn and the authors wait to see if any blood
comes into the hub of the needle or cannula. If it does,
the authors immediately withdraw the needle/
cannula and reinsert it and again repeat the with-
drawal on the plunger.
The authors have only once had the withdrawal
maneuver bring blood into the hub. A subgaleal
anterograde injection technique is used. The

Figure 2. (A) Pinching up the lateral brow to enter the subgaleal plane. (B) Pinching up the glabellar skin to enter the
subgaleal plane. (C) Massaging the subgaleal HAV to smoothness.

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© 2015 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
 CARRUTHERS AND CARRUTHERS

Figure 3. (A) Before the 3 dimensional forehead reflation with HAV. (B) After 3 dimensional forehead reflation with HAV.

subgaleal plane is the subfrontalis plane anterior to
the periosteum. The origins of the vasculature of the
supratrochlear and supraorbital vessels are on the
periosteum, which is why the authors lift the skin
away from the periosteum while the authors are
inserting the needle or cannula and then injecting.
The temporal vessels are more lateral and are both
subcutaneous and deeper. There is a definite “give” as
the needle or cannula tip traverses the frontalis into
the subgaleal space. There is no resistance to the
flow of the product injected in this bolus manner in
that plane.
The authors like to keep the product as the soft leading
edge rather than moving the tip of the cannula or
needle as the authors believe the soft product is much
less dangerous to any adjacent vasculature than the
metal of the needle or cannula. Because of this, very
limited radial fanning is used for each injection point.
After the filler bolus is deposited, the needle/cannula
is removed. The authors use a topical gel on the
forehead skin to enhance the subsequent digital
massage (Figure 2C) of the product in the subgaleal
plane without further needle punctures. Ice can be
applied immediately after the procedure to reduce
transient swelling and redness. The volume of prod-
uct used is usually between 2 and 3 cc of HAV diluted
to approximately 4 to 6 mL.
The subjects are very happy because they have a soft
nonhollowed forehead with reduction in the etched

Figure 4. (A) Before 3 dimensional forehead reflation and 30 units onabotulinum toxin A. (B) After 3 dimensional forehead
reflation with HAV and 30 units of glabellar onabotulinum toxin A.

41:12S:DECEMBER SUPPLEMENT 2015 S323

© 2015 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
 THREE-DIMENSIONAL FOREHEAD REFLATION
horizontal forehead lines, mild brow elevation, and
retained forehead expressivity (Figures 3A,B and 4A,B).
The authors have witnessed few side effects, save the
immediate bilateral brow ptosis caused by the lido-
caine in the solution. This iatrogenic brow ptosis
reverses between 30 and 60 minutes after the injection.
Bruising is occasionally seen and is treated with intense
pulsed light if needed. There is a need for further
treatment after 2 to 3 weeks in approximately 30
percent of subjects to ensure symmetry and an ideal
correction. The results typically lasts for approxi-
mately 10 to 12 months, although the duration of
effect can be further extended if the subject has
simultaneous treatment with BoNT-A.
The authors are very concerned about inadvertent
canalization of the periocular and midface vascu-
lature6 and believe that careful subgaleal injection
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© 2015 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
of a bolus of filler diluted to produce easy mallea-
bility for massage to is so much safer than
repeated needle or cannula insertions and
movement.5
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