An evidence-based, peer-reviewed journal for practicing clinicians in the field of dermatology
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38 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 T The eyelid-eyebrow unit plays an important role in facial aesthetics. The eyebrow is distinctive in its structure and forms the framework for the upper eyelid. In younger individuals, the eye looks longer and fuller with thicker, elastic skin. As we age, the skin loses elasticity, the tissues deflate, and the underlying bony orbital rim is exposed. 1,2 In addition, the eyebrows simultaneously undergo characteristic aging changes. The brow position droops by a few millimeters, more laterally than medially, and the eyebrow fat pad shrinks, leading to a flatter appearance and loss of three-dimensional projection. 1–3 Facial re-inflation has been practiced for centuries, with reports of paraffin being used in Greece in the early 19th century. 4 Autologous fat injection, in combination with blepharoplasty and fillers, has been used with variable success in the peri-orbital region. 5–7 Volume enhancement of the aging face, although not a substitute for conventional surgery, is a promising alternative. 6,7,8 The concept of nonsurgical rejuvenation and tissue inflation rather than excision is gaining attention as our understanding of aging improves. There is a subset of patients who are poor candidates for surgical rejuvenation. For these patients, volume enhancement with hyaluronic acid gels is a promising treatment modality. When assessing the eyebrow unit aesthetically, it is important to differentiate the eyebrow hairs from the three-dimensional eyebrow shape. The geographic distribution of the eyebrow hairs can be altered by reduction (e.g., waxing, plucking, threading) or by augmentation (e.g., makeup, tattooing, microblading). The three-dimensional shape is very important in facial aesthetics and changes with aging; it can be improved with reduction (e.g., eyebrow fat debulking, orbital rim shaving) or augmentation (e.g., fat, synthetic fillers). In this retrospective chart review, we report our long-term experience with hyaluronic acid gels (HAG) as a treatment modality for adding volume to the three- dimensional eyebrow shape. METHODS This retrospective study reviewed the charts of patients who were administered HAG. All the patients who had eyebrow filler injections within the past ten years with the following criteria were included: 1) minimum follow-up of five years; 2) no history of eyelid or eyebrow surgery within the follow-up duration; and 3) no history of neurological disease. All the injections were performed by a single oculoplastic surgeon. Using the HAG Restylane-L (Galderma, Fort Worth, Texas), use of which was based on surgeon experience and preference. Injections were carried out under topical anesthesia that was applied 30 to 60 minutes before the procedure. Treatment area was sterilized with alcohol immediately before the injections. Using a 30-gauge needle, the HAG was applied in the retro-orbicularis oculi fat (ROOF) pad in the tissue plane deep to the orbicularis oculi muscle (Figure 1A–B). A feathering technique was employed using multiple passes of the needle to create a haystack configuration of multiple fine threads, layered and feathered to create the desired three-dimensional A B S T R A C T Background: The eyebrow region presents challenges for filling: the skin is thick, the three-dimensional anatomy is complex and there is a predisposition towards fat atrophy and skeletonization with aging. Hyaluronic acid gel fillers are well known for their use in the periorbital region. We report our long-term experience with eyebrow filling over a period of five years. Methods: Twenty cases of periorbital eyebrow filling with hyaluronic acid gel fillers were followed up over a period of five years. The eyebrow filling was customized based on the patient's anatomical features in a three-dimensional plane. Standardized photographs before and after the procedure in standard lighting conditions were evaluated. Results: Hyaluronic acid gel fillers were tolerated well in the eyebrow region. There were no cases with blue-gray dyschromia or prolonged edema as is the case with lower eyelid injections. The eyebrow gained volume and looked fuller immediately after the injection. There were three cases with excessive eyebrow puffiness noted on a long-term follow-up which may be the accumulated filler weighing the eyebrow. No other adverse events were noted. Conclusion: The eyebrow anatomy is a complex three-dimensional structure. Deflation in the eyebrow area along with the superior sulcus occurs with aging. Filling the eyebrow with hyaluronic acid gel fillers is a useful tool in the armamentarium of the cosmetic facial surgeon and can be used in isolation in select patients or as an adjunct to surgical rehabilitation. We believe the fillers last longer and are well tolerated in the eyebrow region due to the complex anatomy specific to this region. KEY WORDS: Eyebrow, filler, facial rejuvenation Eyebrow Contouring with Hyaluronic Acid Gel Filler Injections by HAMZAH MUSTAK, FCOphth (SA); DANICA FIASCHETTI, LVN, COA; ADIT GUPTA, MD; and ROBERT GOLDBERG, MD Dr. Mustak is with the University of Cape Town Groote Schuur Hospital in Cape Town, Western Cape, South Africa. Drs. Mustak, Fiaschetti, Gupta, and Goldberg are with the Stein Eye Institute, University of California in Los Angeles, California. J Clin Aesthet Dermatol. 2018;11(2):xx–xx FUNDING: No funding was provided for this article. DISCLOSURES: The authors have no conflicts of interest to relevant to the content of this article. CORRESPONDENCE: Hamzah Mustak, FCOphth(SA); Email: shmustak@hotmail.com