Journal of Clinical and Aesthetic Dermatology

FEB 2018

An evidence-based, peer-reviewed journal for practicing clinicians in the field of dermatology

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39 JCAD JOURNAL OF CLINICAL AND AESTHETIC DERMATOLOGY February 2018 • Volume 11 • Number 2 R E T R O S P E C T I V E S T U D Y contour. Bruising is primarily associated with passage of the needle through the orbicularis layer. To minimize bruising, the needle is only withdrawn all the way out through the skin when repositioning is required or for another series of passages. Once the needle is deep to the orbicularis, the surgeon takes advantage of the sub-orbicularis plane by creating a fan-shaped pattern of passes without withdrawing the needle completely. If bruising or hematomas start to form, the area is treated with gentle pressure from a cotton tip applicator. If the needle is placed too superficially, visible lumps or wheals of the HAG will form. It is important, therefore, to avoid depositing large volumes of the filler in one location. Gentle, continuous pressure is applied to the syringe plunger as the needle is slowly fanned through the tissues to create smooth, feathered, three-dimensional contours. The shape is customized to the patient and the degree of volume, whether applied in the superior aspect of the eyebrow fat pad, the inferior aspect of the eyebrow fat pad, feathered laterally into the temporalis muscle fossa, or added along the deep orbital rim to fill the superior sulcus, will vary from patient to patient. A clinical effect with an appreciable change in eyebrow contour is visible during and immediately after the procedure. RESULTS We collected data and analyzed photographs of 20 patients who had been followed for at least five years. There were three men and 17 women. Mean age was 53.5 years (32–62). Average amount of HAG injected was 4.3cc (3.2–8.6cc) over the five-year follow up period. Through example cases, we endeavor to demonstrate the importance of individualized analysis and customized filling. Case 1 (Figure 2). Customization of the three-dimensional shape of the eyebrow. Figure 2A shows pretreatment view of a 64-year-old woman who presented with deflation of the lateral eyebrow fat. Figure 2B shows the injection pattern of 0.3cc HAG injected to both sides using a feathering technique to layer the product in a haystack fashion. The blue markings indicate the injection pattern utilized to create a layered three-dimensional contour. Figure 2C shows post-treatment view, displaying a fuller eyebrow with lifting of the lateral tail, resulting in a more youthful appearance. Case 2 (Figure 3). Eyebrow projection. Figure 3A show the pretreatment view of the left side of a 46-year-old woman's brow with deflation of the lateral eyebrow fat and drooping of the eyebrow tail. HAG 0.2cc was injected in the ROOF plane in order to augment the lateral brow volume. Figure 3B displays post-treatment results, showing a fuller eyebrow contour with enhanced projection of the lateral eyebrow. Case 3 (Figure 4). Enhancement of the inferior eyebrow (ROOF) fat pad. Figures 4A and 4B show pretreatment view of a 50-year old woman with a hollow superior sulcus and deflation of the eyebrow with unveiling of the superior orbital rim (skeletonization). HAG 0.5cc was injected into the left eyebrow fat pad and 0.4cc into the right side in order to augment the sulcus hollowing as well as project the lateral eyebrow. Figures 4C and 4D show post-treatment frontal view (C) and lateral view (D) after HAG injection, demonstrating a softer, more youthful, three-dimensional contour of the superior sulcus-eyebrow complex. There were no complications from the injections. None of the patients developed blue- grey dyschromia. 9 The mean interval between repeat filler injection was 14 months (12–24). Over the follow-up period, we observed heavy eyebrows and puffiness in three patients. DISCUSSION The upper orbital space is a key three- dimensional contour defining periorbital aesthetics. 10 In youth, fullness of the dermis, subcutaneous fat pads, and deep fat pads create a three-dimensional fullness that defines the aesthetics of the youthful eyelid. 1–3 With aging, loss of volume in the dermis and various fat pads can create a sagging appearance, drawing inelastic skin into the eyelid space and creating the appearance of eyebrow drooping. 11 In addition, there is likely some actual gravitational descent of the lateral eyebrow, but this is generally less important than deflation in creating the aged appearance. Rehabilitation of the aging upper orbit is most effective when this loss of volume is taken into account. Conversely, rehabilitative paradigms that focus primarily on elevating the eyebrow FIGURE 1B. Diagram demonstrating the anatomical plane of injection—The HAG filler is injected into the ROOF plane in order to augment the contour of the eyebrow fat pad. FIGURE 1A. Anatomy of the eyebrow fat pad—sagittal magnetic resonance image demonstrating the anatomical location of the subcutaneous (Q), retro-orbicularis oculi/ ROOF (R), and orbital fat pockets (O)

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