An evidence-based, peer-reviewed journal for practicing clinicians in the field of dermatology
Issue link: https://jcadonline.epubxp.com/i/934167
40 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 are suboptimal in re-creating the contours of youth. The smooth, full, three-dimensional shape created by the subcutaneous and deep fat pads characterizes the eyebrow. 12,13 This contour covers the orbital rim and extends variably into the eyelid space itself. By projecting the skin forward, the three dimensional volume essentially elevates the eyelid skin out of the orbital space in a similar way that a full balloon stretches and smoothes the rubber surface. We noted heavy eyebrows and puffiness in three patients; this could have been due to the filler substance accumulation over repeated injections. There have been various recommendations about the position of injection. Lucarelli and colleagues 14 demonstrated that injecting in the pre-periosteal plane requires less volume while achieving a robust result. Lambros 15 recommends injecting into the sub-orbicularis and subcutaneous fat, while Glasgold 16 recommends injecting into the subcutaneous plane. The ROOF extends from the eyebrow region that drapes over the superior orbital rim to the upper eyelid. This fat pad contributes to the smooth contour over the superior orbital rim. We find that injecting into the plane of the ROOF is effective in creating smooth, appropriate contours. Growing out of this three-dimensional structure of the eyebrow fat pad and three-dimensional shape are the eyebrow hairs. The thickness, geographic distribution, and shape of the eyebrow hair vary substantially. Certainly, the eyebrow hairs effect appearance and are the subject of a vast industry focused on shaping, coloring, thinning, removing or tattooing hairs to effect the geographic distribution. We suggest avoiding being distracted by the distribution of the eyebrow hairs when assessing the three-dimensional shape of the eyebrow. CONCLUSION We have had good success filling the eyebrow fat pad to change the three-dimensional shape of the eyebrow complex. The shape of the eyebrow fat pad, and its extensions into the superior orbital space and temporalis fossa, varies across individuals. HAG filler alone is particularly useful for patients who are poor candidates for surgery or want to avoid surgery. It might also be a useful tool in conjunction with surgery to address the volume depletion seen with aging. The primary goal of eyebrow surgery or filling should be to improve the three-dimensional shape of the eyebrow complex, rather than focusing on the distribution of the eyebrow hairs. For optimal results, the distribution of filler should be customized to the patient in an artistic manner. In our anecdotal experience, subtle sculpting of the shape of the eyebrow complex with HAG fillers can help achieve acceptable cosmetic endpoints for eyebrow contouring. REFERENCES 1. Lambros V. Observations on periorbital and midface aging. Plast Reconstr Surg. 2007;120:1367–1376. 2. Lambros V. Models of facial aging and implications for treatment. Clin Plast Surg. 2008;35:319–327. 3. Shaw RB Jr, Katzel EB, Koltz PF, et al. Aging of the facial skeleton: aesthetic implications and rejuvenation strategies. Plast Reconstr Surg. 2011;127:374–383. 4. Goldwyn RM. The paraffin story. Plast Reconstr Surg. 1980;65:517–522. 5. Lambros V. Fat injection for the aging midface. Oper Tech Plast Reconstr Surg. 1998;5:130–137. 6. Goldberg RA, Fiaschetti D. Filling the periorbital hollows with hyaluronic acid gel: initial experience with 244 injections. Ophthal Plast Reconstr Surg. 2006;22:335–341. 7. Hoenig J, Hoenig D. Minimally invasive periorbital rejuvenation. Facial Plast Surg. 2013 Aug;29(4): 295–309. 8. Kornstein AN. Soft-tissue reconstruction of the brow with Restylane. Plast Reconstr Surg. 2005;116: 2017–2020. 9. Rootman DB, Lin JL, Goldberg R. Does the Tyndall effect describe the blue hue periodically observed in subdermal hyaluronic acid gel placement? Ophthal Plast Reconstr Surg. 2014;30:524–527 10. Gunter JP, Antrobus SD. Aesthetic analysis of the eyebrows. Plast Reconstr Surg.1997;99(7):1808–1816. 11. Papageorgiou KI, Mancini R, Garneau HC, et al. A three- dimensional construct of the aging eyebrow: the illusion of volume loss. Aesthet Surg J. 2012;32:46–57. 12. Hwang SH, Hwang K, Jin S, et al. Location and nature of retro-orbicularis 141 oculus fat and suborbicularis oculi fat. J Craniofac Surg. 2007;18:387–390. 13. Charpy M. Le coussinex adipoeux du sourcil. Bibliog Anat. 1909;19:47–52. 14. Griepentrog GJ, Lucarelli MJ. Anatomical position of hyaluronic acid gel following injection to the eyebrow. Ophthal Plast Reconstr Surg. 2013;29:364–366. 15. Lambros V. Volumizing the brow with hyaluronic acid fillers. Aesthet Surg J. 2009;29:174–179. 16. Glasgold M, Lam SM, Glasgold R. Volumetric rejuvenation of the periorbital region. Facial Plast Surg. 2010 Aug;26(3):252–259. JCAD FIGURE 2A–C. Case 1: Customization of the three- dimensional shape of the eyebrow FIGURE 3A–B. Case 2: Customization of the eyebrow projection FIGURE 4A–D. Case 3: Enhancement of the inferior eyebrow retro-orbicularis oculi fat pad