Forehead Augmentation Research Articles

Mapping High-Risk Arteries Using Doppler Ultrasound for Forehead Contouring in Korean Patients.

Forehead flatness is common in Korean populations, and one of the most straightforward techniques for adding volume and achieving a concave forehead is injecting hyaluronic acid (HA) filler. However, definitive guidelines for this procedure are lacking, and careful attention to the arterial anatomy is required to avoid vascular complications. The authors aimed to establish guidelines for performing forehead augmentation using Doppler ultrasound to identify vasculature before HA injection. Arterial mapping of the faces of 34 patients was performed using Doppler ultrasound. Each anatomic layer (skin, subcutaneous fat, and galea aponeurotica) of the forehead with blood vessels was identified. An average volume of 2.85 mL of HA filler was injected. Postoperative complications, such as infection, hematoma, bruising, nodules, skin necrosis, and blindness, were evaluated. Using Doppler ultrasound, the authors successfully traced all 3 blood vessels (supraorbital, supratrochlear, and frontal branch of the superficial temporal arteries) and avoided them during HA injection. None of the patients experienced arterial complications. Doppler ultrasound proves to be an effective technique for arterial mapping, enabling the identification and avoidance of the major blood vessels of the forehead before HA filler injection.

Endoscopic-Assisted Forehead Augmentation with Polyetheretherketone (PEEK) Patient-Specific Implant (PSI) for Aesthetic Considerations.

Forehead augmentation have become popular aesthetic procedures among Asians in recent years. However, the use of polyetheretherketone (PEEK) patient-specific implant (PSI) in the facial contouring surgery for aesthetic considerations is not well documented in the existing studies. The purpose of this study was to develop a novel method for forehead augmentation and assess the clinical outcomes and complications in patients who underwent forehead augmentation with PEEK PSI assisted by endoscopy. The PEEK PSIs were fabricated using the virtual surgical planning (VSP) and the computer-aided manufacturing (CAM) for each patient, preoperatively. The implant pockets were dissected in the subperiosteal plane, and PEEK PSIs were placed in their designed position and fixed assisting by endoscopy via small incision within the hairline. All patients were asked to complete the FACE-Q questionnaire before and 6 months after the operation. Pre- and postoperative demographics, photographs, and other clinical data of patients were collected and analyzed. 11 patients underwent forehead augmentation were enrolled in this study. All procedures were completed successfully with the help of endoscope. The average patient age was 30.63 ± 2.54years. The mean thickness and size of PEEK PSI were 4.44 ± 1.77mm and 38.43 ± 22.66cm2, respectively. The mean operative time was 83.00 ± 29.44min, and the mean postoperative follow-up period was 11.00 ± 6.50months. No implant exposure, extrusion or removal were reported. The FACE-Q scores of patients in satisfaction with the forehead increased from 47.64 ± 7.15 to 78.81 ± 6.35. PEEK PSIs can be prefabricated to achieve accurate remodeling of the frontal contour with good esthetic outcomes. The endoscope provides direct and magnified vision, which allow easy access to the supraorbital rim and lateral edge of the eyebrow arch and confirming the position of the implants without damaging nerves and vessels. Endoscopic-assisted forehead augmentation with PEEK PSI is safe and effective. This journal requires that authors assign a level of evidence to each article. For a full description of these evidence-based medicine ratings, please refer to the Table of contents or the online Instructions to Authors www.springer.com/00266 .

Evolving Forehead Augmentation: A Five-step Approach with High G Prime Hyaluronic Acid.

Achieving effective upper-face rejuvenation through forehead augmentation is essential; however, complications such as vascular occlusion leading to skin necrosis or vision loss can occur. The complex forehead anatomy, characterized by ligaments and septa, often results in uneven outcomes with dermal filler treatment. The learning curve for successful forehead augmentation was longer than that anticipated. Herein, we present a specialized program for clinicians to expedite the learning process. This study explores a five-step technique for forehead augmentation using high elastic (G prime) hyaluronic acid fillers. We enrolled 10 Asian female participants with no history of dermal filler injections, surgery, or nonsurgical forehead procedures. All participants provided written informed consent, and their progress was assessed using photography and the Global Aesthetic Improvement Scale. Immediate post-treatment Global Aesthetic Improvement Scale ratings averaged 3.0 ± 0.0, decreasing to 2.5 ± 0.5 at 6 months, and 1.8 ± 0.6 at 12 months. Mild tenderness (10%), temporary swelling (30%), and a rapid recovery period underscored the safety and reliability of our approach. Importantly, no adverse vascular events were observed. Our five-step injection technique utilizing high-G prime hyaluronic acid leverages a profound understanding of the forehead anatomy, systematic methodology, and dynamic potential of advanced fillers. By implementing this paradigm, plastic and reconstructive surgeons can increase the standards of forehead augmentation and consistently achieve harmonious and effective results.

Finger Compression Technique with an OK Gesture on the Bilateral Emerging Points of the Ophthalmic Artery: A Simple Three-Step Method with Dual Real-Time Imaging to Reduce the Risk of Filler-Associated Blindness.

Filler injections to the glabella, nose, or forehead have increased probabilities of catastrophic, irreversible vascular complications, including skin necrosis, blindness, and cerebrovascular accidents.1 Filler-associated blindness is mainly attributed to intravascular injection of filler material through the branches of the ophthalmic artery (OA), such as the supratrochlear artery, supraorbital artery, and dorsal nasal artery.1 The ophthalmic artery runs through the emerging points of the OA (EMP/OA), giving branches through the superior part of the medial orbital rim (SMOR) and supraorbital foramen or notch [SOF(N)] to nose, glabella, and forehead.1 Because intravascular occlusions are rare, recommendations for prevention have been based on expert consensus.2 Finger compression is one of the measures used to reduce the risk of filler-associated blindness in facial danger zones,2 but no demonstrations of precise positioning and hand gestures are available. In addition, patterns of the OA main branches emanating from the orbital fossa and the precise location of EMP/OA of the SMOR are variable within individuals.3 We propose a practical finger compression method under dual real-time imaging guidance that has been used in our daily practice of filler injection to the danger zones of the face. First, the SOF(N) can be palpated easily and is marked. Second, a transillumination device (Vein Viewer; Christie Medical Holdings, Inc., Memphis, TN) is used on the SMOR to determine the precise location of EMP/OA (Fig. 1), which are subsequently marked. Then, Doppler ultrasound examination (LeSono LU700L; Leltek, Inc., New Taipei City, Taiwan) is performed to confirm the locations of the EMP/OA of the SMOR and the SOF(N). [See Figure, Supplemental Digital Content 1, which shows the EMP/OA of the SMOR demonstrated in Doppler ultrasound examination. High Doppler signals indicate the EMP/OA with a 10-MHz ultrasound transducer (LeSono LU700L; Leltek, Inc.), https://links.lww.com/PRS/F601. See Figure, Supplemental Digital Content 2, which shows the EMP/OA of the SOF(N) demonstrated in Doppler ultrasound examination. High Doppler signals indicate the EMP/OA with a 10-MHz ultrasound transducer (LeSono LU700L; Leltek, Inc.), https://links.lww.com/PRS/F602.] Third, the bilateral EMP/OA of the SMOR and SOF(N) are compressed with the fingers of the nondominant hand in an “OK” gesture (Fig. 2) as fillers are injected with the dominant hand simultaneously. Additional compression force of the fingertips and finger pulps is targeted at the EMP/OA of the SMOR and SOF(N), respectively. Finger compression with an OK gesture is a basic and one-person technique to reduce the risk of filler-associated blindness during nose and forehead augmentation with a blunt cannula or for filling deep wrinkles of the glabella with a sharp needle.Fig. 1.: The emerging points of the ophthalmic artery (EMP/OA) shown by a transillumination device. The superior part of the medial orbital rim (SMOR) and supraorbital foramen or notch [SOF(N)] can be palpated and marked. Next, the precise emerging point of the ophthalmic artery of the superior part of the medial orbital rim is demonstrated by a transillumination device (Vein Viewer).Fig. 2.: OK gesture finger compression method. After the anatomic landmarks have been confirmed, bilateral emerging points of the ophthalmic artery of the superior part of the medial orbital rim and supraorbital foramen or notch are compressed with the nondominant hand in an OK gesture at the same time; fillers can be injected by the dominant hand simultaneously.Other finger compression techniques are modified based on the same concept and can be used to temporarily occlude unilateral or bilateral main branches of the OA [See Figure, Supplemental Digital Content 3, which shows the application of various finger compression techniques for injections in different danger zones. Various finger compression techniques can be used to temporarily occlude unilateral or bilateral main branches of the OA https://links.lww.com/PRS/F603.] This three-step method with dual real-time imaging is not aimed to eliminate vascular complications attributable to other coexistent pathways associated with filler-associated blindness, such as arteriovenous shunting and true anastomoses with the external carotid artery. Other strategies for reducing the risk of filler-associated blindness are encouraged to be performed simultaneously or sequentially to enhance the safety of facial volumetric rejuvenation.2 Investigation of the effectiveness of this method in large-scale studies is worthwhile. DISCLOSURE The authors have no financial interest to declare in relation to the content of this article. No funding was received for this article.

Facial Masculinization from Procedures to Payment: A Review.

As the demand for gender-affirming procedures continues to increase, patients and providers have a greater imperative to understand the current state of facial masculinization. Facial reconstruction for transgender women has been shown to treat gender dysphoria effectively and reduce rates of discrimination and victimization. Although facial masculinization surgery for transgender men is less common, there are multiple surgical and nonsurgical options to supplement the effect of hormone therapy on facial appearance, including but not limited to: receding the hair line, flattening the forehead, expanding the supraorbital ridge, increasing the dorsal nasal projection, squaring the jaw, and augmenting the chin. This review aims to summarize these techniques for providers who wish to inform transgender male patients about their options and discuss them in the context of patient satisfaction and availability of insurance coverage.

Superior Ophthalmic Vein Embolism Following Forehead Augmentation with Autologous Fat Injection

BackgroundFacial rejuvenation and reconstruction with autologous fat injection are a common and effective procedure used worldwide. Most surgeons and patients are satisfied with the favorable outcomes. However, catastrophic complications from arterial and venous occlusion resulting in visual loss and stroke may occur.Case presentationWe herein report a case of isolated venous occlusion from fat embolism. The patient developed acute painful proptosis and blurred vision of her right eye while undergoing an esthetic autologous fat injection into her forehead. Based on her clinical manifestations and radiologic findings, the patient was diagnosed with superior ophthalmic vein occlusion. Symptomatic and supportive treatments were given. Spontaneous clinical improvement occurred without secondary complications. Therefore, the initially planned endovascular therapy with transfemoral transvenous embolectomy of the right superior ophthalmic vein was canceled.ConclusionsFacial augmentation with autologous fat injection can cause superior ophthalmic vein embolism. Surgeons should therefore perform this procedure very cautiously. Prompt ophthalmological evaluation and proper management are important for improving clinical outcomes.Level of Evidence VThis journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Forehead and Hairline Surgery for Gender Affirmation.

Background:With the improvement of the results of surgical treatment for facial transformation globally, many female transgender individuals seek surgical management for their faces, especially the forehead and hairline. These are critical aspects in the surgical management of the frontonasal-orbital area because the anatomy of the frontal sinuses is complicated and shows a high variation.Methods:The author presents a grid method to measure the boundary of the frontal sinus in the female transgender forehead contouring and reconstruction. The surgical technique of forehead set back and simultaneous hairline advancement is described.Results:Between January 2015 and December 2017, there were 23 cases of forehead and hairline feminization procedures by the author. Patient age was between 20 and 74 years (mean 32.56). There were 11 Asians and 12 White patients. Eleven patients underwent supraorbital ridge contouring, and 12 underwent forehead reconstruction. Hairline advancement was simultaneously performed in 9 patients, and 3 underwent forehead augmentation at the supraorbital ridge. The postoperative follow-up time ranged from 3 weeks to 18 months.Conclusions:The key to the success of forehead contouring surgery in female transgender patients is the precise measurement of the boundary of the frontal sinus. This technique offers a practical way to estimate the frontal sinus sizes and shapes to avoid intraoperative complications and reduces the possibility of surface irregularity.

CHAP-Hyaluronic Acid (CHAP-HA) Filler as an Optimal Candidate for Forehead Filler Augmentation Using a 3-Point Injection Technique

Minimally invasive forehead augmentation is becoming increasingly popular in Asia. However, treatment of the glabella is associated with injection-related complications. The safety of injections can be increased through a thorough understanding of the anatomy and precise injection planes. The authors propose a 3-point injection technique for forehead augmentation in Asian patients that uses CHAP-hyaluronic acid (CHAP-HA) filler. The longevity of the filler was assessed using high-resolution ultrasound (HRU) imaging. Fifteen patients were examined using HRU before and immediately after treatment and at 1 month, 3 months, 6 months, and 12 months. As evident in HRU imaging, CHAP-HA remained visible within surrounding tissue for 6.4 ± 3.7 months. The mean Global Aesthetic Improvement Scale rating was 2.4 ± 0.5 immediately after treatment, 2.8 ± 0.3 at 1 month, 2.7 ± 0.5 at 3 months, 2.1 ± 0.6 at 6 months, and 1.5 ± 0.6 at 12 months. Minimal side effects were reported. The authors demonstrated that CHAP-HA filler may be an optimal candidate for forehead filler augmentation using a 3-point injection technique.

Aesthetic Zygoma Reduction in Asian Patients.

Zygoma reduction is indicated in patients where the primary aim of surgery is reduction in the width of cheekbones to achieve smoother and more feminine facial aesthetic lines. Surgeons should evaluate the width of midface (bizygomatic width) and the protrusion of zygoma (volume and position of the zygomatic body) when evaluating patients where such a procedure is indicated. Intraoral high-L osteotomy is the most useful method to successfully treat a wide spectrum of zygomatic protrusions and is widely accepted as the treatment of choice for aesthetic purposes. The amount of ostectomy is determined by evaluating the volume of zygomatic body. The zygomatic body and arch are usually moved posteromedially during surgery; the point of maximal malar projection is evaluated and transposed to a new ideal position. Zygoma reduction can be performed solely or in combination with other facial bone contouring procedures such as mandible reduction, genioplasty, or forehead augmentation. Soft tissue sagging, nonunion, malunion, and paresthesia are the most common complications of this procedure. Undercorrection and asymmetry are the most common aesthetically unfavorable sequelae and should be carefully prevented by proper preoperative planning and meticulous execution of surgical technique.

A Procedure for Designing Custom-Made Implants for Forehead Augmentation in People Suffering from Apert Syndrome

This paper presents a methodological procedure, based on the anatomical reconstruction and constrained deformation, to design custom-made implants for forehead augmentation in people affected by Apert syndrome, experiencing a frontal bone deficiency. According to the anthropometric theory, a cranial landmarks identification procedure was applied to retrieve, from a repository, a healthy skull, used as reference geometry for implant modelling. Then, using constrained deformation and free-form modelling techniques, it was possible to design a patient-specific implant. At last, the implant was realised using a custom mould, specially designed according to the patient’s needs to provide an accurate fit of the defect site. The design procedure was tested on a patient suffering from Apert syndrome. Three implants were virtually modelled and 3D-printed for pre-surgical evaluation. Their shapes were 3D compared with a reference one (handcrafted by a surgeon) to test the accuracy. Deviations are negligible, and the customised implant fulfilled the surgeon’s requirements.

Localization and Topography of the Arteries on the Middle Forehead Region for Eluding Complications Following Forehead Augmentation: Conventional Cadaveric Dissection and Ultrasonography Investigation.

Forehead augmentation with filler injection is one of the most dangerous procedures associated with iatrogenic intravascular injection resulting in the severe complications. Nonetheless, few studies have determined the explicit arterial localization and topography related to the facial soft tissues and landmarks. Therefore, this study aimed to determine an arterial distribution and topography on the middle forehead region correlated with facial landmarks to grant an appropriate guideline for enhancing the safety of injection. Nineteen Thai embalmed cadavers were discovered with conventional dissection and 14 Thai healthy volunteers were investigated with ultrasonographic examination on the middle forehead. This study found that at the level of mid-frontal depression point, the transverse distance from the medial canthal vertical line to the superficial and deep branches of supraorbital artery were 9.1 mm and 15.1 mm, respectively. Whereas the depths from the skin of these arteries were 4.1 mm and 4.3 mm, respectively. Furthermore, the frontal branch of superficial temporal artery was detectable in 42.1% as an artery entering the forehead area. At the level of lateral canthal vertical line, the vertical distance of frontal branch was 31.6 mm, and the depth from skin of the artery was 2.7 mm. In conclusion, a proper injection technique could be performed based on an intensive arterial distribution and topography, and ultrasonographic examination before the injection is also suggested in order to restrict the opportunity of severe complications.

The localization and topography of the arteries on the middle forehead region for eluding complications following forehead augmentation: Conventional cadaveric dissection and ultrasonography investigation

Forehead augmentation with filler injection is one of the most dangerous procedures associated with iatrogenic intravascular injection resulting in the severe complications. Nonetheless, few studies have determined the explicit arterial localization and topography related to the facial soft tissues and landmarks. Therefore, this study aimed to determine an arterial distribution and topography on the middle forehead region correlated with facial landmarks to grant an appropriate guideline for enhancing the safety injection. The research procedures of this study were approved by the Institutional Review Board of the Faculty of Medicine, Chulalongkorn University (IRB No. 786/61, COA No. 149/2019) and conducted in accordance with the Declaration of Helsinki of the World Medical Association (WMA). Cadaveric dissection and ultrasonographic investigation in healthy volunteers were employed to study the forehead region. The cadavers were legally donated for medical education and research, and the participants have signed the informed consent prior to the ultrasound operation. Nineteen Thai embalmed cadavers were discovered with conventional dissection and 14 Thai healthy volunteers were investigated with ultrasonographic examination on the middle forehead. At the level of mid‐frontal depression point, the transverse distance from the medial canthal vertical line to the supraorbital artery were 9.1 mm (superficial branch) and 15.1 mm (deep branch). The depths from skin of the artery were 4.1 mm (superficial branch), and 4.3 mm (deep branch). Furthermore, the frontal branch of superficial temporal artery was detectable in 42.1% as an artery entering the forehead area. At the level of lateral canthal vertical line, the vertical distance of frontal branch was 31.6 mm, and the depth from skin of the artery was 2.7 mm. In conclusion, a proper injection technique could be performed based on an intensive arterial distribution and topography, and ultrasonographic examination prior to the injection is also suggested in order to restrict the opportunity of severe complications.Support or Funding InformationThis presentation was supported by Overseas academic presentation scholarship from Faculty of Medicine Vajira Hospital, Navamindradhiraj University.

Forehead Fat Grafting: Asian Facial Contouring and Augmentation.

Aesthetic facial contouring procedures, particularly forehead augmentation, continue to increase in popularity in the Asian population. However, there are very few reports in the literature specifically examining the long-term outcomes of forehead fat grafting. In the present study, the authors aimed to objectively evaluate the efficacy of autologous forehead fat grafting through evaluation of facial proportions and patient-reported outcomes. Patients who underwent autologous fat grafting for forehead contouring procedures between July of 2011 and June of 2017 were recruited for participation in the study. Patient demographic and clinical variables were collected preoperatively and postoperatively. Facial proportion analysis was collected and compared from preoperative and postoperative photographs. Satisfaction with outcome was assessed by the patient, the surgeon, and a layperson postoperatively. A related-samples Wilcoxon signed rank test was used for statistical analysis. Postoperative outcomes were evaluated in a total of 24 patients who underwent forehead autologous fat-grafting procedures. The average postoperative follow-up was 8.1 months. There were no intraoperative or postoperative complications. More than 50 percent of the postoperative results were evaluated as "satisfactory" by all three groups (i.e., patient, surgeon, and layperson) in terms of aesthetic contouring. Average forehead projection increased 0.24 U (ratio of horizontal distance from midforehead plane to cornea plane/cornea diameter) after one round of fat grafting (p = 0.01). Seven patients (29.2 percent) required more than a single round of fat grafting to achieve optimal results. Autologous fat grafting remains a viable option for forehead contouring and augmentation. The findings of this study demonstrate that the operation is effective and offers stable satisfactory results after long-term follow-up. Therapeutic, IV.

Forehead/Brow Reduction or Augmentation with Custom Implants for Enhanced Facial Profileplasty.

After studying this article, the reader should be able to understand the basic concepts of aesthetic reshaping of the forehead and the different methods to make those upper facial contour changes. The operative techniques for bony forehead and brow bone reduction and biomaterials for forehead and brow bone augmentation are described. Innovations in bony reduction and implant augmentation methods are emphasized.

Novel Forehead Augmentation Strategy: Forehead Depression Categorization and Calcium-Hydroxyapatite Filler Delivery after Tumescent Injection

The minimally invasive delivery of soft-tissue calcium hydroxyapatite fillers can ameliorate the appearance of forehead depressions and wrinkles. Forehead augmentations using fillers lead to fewer adverse events and to a faster recovery time than those using surgical procedures. However, many physicians avoid using them due to the risk of pain, intravascular injections, and embolisms that can cause skin necrosis and blindness. Strategy to address these issues includes pain reduction through tumescent solution before filler injection considering the vascular pathway. In addition, the strategy is also safer from embolism. The author presents a forehead augmentation technique involving the injection of a tumescent solution for tissue hydrodissection. Not only does this create a pocket of space (TS) for filler placement, it also allows the physician to detect bleeding and prevent vessel compromise It is better to minimize the number of entry-points where no vessel exists. By minimizing the number of entry-points and physical proximity to vessels and nerves during injection, this technique reduces the risks of embolization and bleeding. For optimal, patient-customized results, the author also classifies forehead depressions in 5 different categories, depending on the severity, shape, contour, slope, and quantity of volume deficiency observed. The author treated 218 patients using the author's forehead augmentations (using one central entry-site after TS test injection). The method was easy to perform and safe from adverse effects such as vascular problem, irregularity, infection, and prolonged swelling. Using this simple technique, I demonstrate how calcium hydroxyapatite fillers can be injected with little force or dilution, thus preserving its original properties while increasing procedural safety, minimizing pain, restoring convexity, and creating ideal curvatures.

Clinical application of a new hyaluronic acid filler based on its rheological properties and the anatomical site of injection

BackgroundHyaluronic acid (HA) filler is the most commonly used filler for soft tissue augmentation. There are numerous commercially available HA fillers in the cosmetic market, and there are guidelines for each filler as determined by the manufacturing company. The successful use of injectable fillers requires an understanding of each option available so that the most appropriate form of hyaluronic acid may be selected for patients. The purpose of this study was to determine whether newly developed HA fillers are appropriate for forehead augmentation considering their rheological properties and the anatomical site of injection.MethodsThe rheological properties of new HA fillers were assessed e.t.p.q. S100, S300, S500 (Zetema®). Comparing the rheological properties, the authors chose e.t.p.q. S300® for forehead augmentation. The filler was injected into the foreheads of 40 consecutive patients for esthetic purposes.Resultse.t.p.q. S300® was determined to be an appropriate filler for the forehead. The injection procedure employed was considered to be easy and safe when applied to the preperiosteal layer using a cannula. None of the patients had complications such as vascular compromise, infections, granulomas, or migration.ConclusionsUnderstanding the physical properties of new fillers is necessary. As the preperiosteal layer of the forehead is an appropriate layer for the filler injection, physicians should consider injecting fillers with enough strength to withstand the shearing forces.

Commentary on: Integrated Forehead and Temporal Augmentation Using 3D Printing-Assisted Methyl Methacrylate Implants.

Commentary on: Integrated Forehead and Temporal Augmentation Using 3D Printing-Assisted Methyl Methacrylate Implants.

Integrated Forehead and Temporal Augmentation Using 3D Printing-Assisted Methyl Methacrylate Implants.

Achieving aesthetic results with forehead augmentation procedures remains challenging. We have developed a method of integrated forehead and temporal augmentation using a three-dimensional (3D) printing-assisted methyl methacrylate implant. The study objective was to assess the importance of combined temporal augmentation when performing forehead augmentation. We identified 34 patients (from 2000 to 2010) who underwent forehead augmentation with a methyl methacrylate implant contoured in situ during surgery and 41 patients (from 2010 to 2016) who underwent integrated forehead and temporal augmentation with a prefabricated methyl methacrylate implant. We conducted a retrospective chart review of patient data including operation time, complications, and instances of revision surgery. Two blinded plastic surgeons scored the aesthetic results of the operations on a 4-point scale (1, poor, to 4, excellent) based on preoperative and posttreatment photographs. The integrated augmentation method resulted in a lower frequency of posttreatment implant removal (one [2%] vs. six [18%]; P < .05), a lower frequency of filler injection for touch up (one [2%] vs. six [18%]; P < .05), and higher mean aesthetic scores (3.7 ± 0.5 vs. 2.2 ± 1.0; P < . 001) compared to the forehead augmentation method. There was no statistically significant difference in surgical complications between the two groups. Integrated forehead and temporal augmentation using a 3D printing-assisted methyl methacrylate implant may be the optimal available procedure, enabling the custom fabrication of contours requested by the patient and providing a rejuvenating and balancing effect on facial appearance.

Reply: Topographic Analysis of the Supratrochlear Artery and the Supraorbital Artery: Implication for Improving the Safety of Forehead Augmentation.

Sir: We are objectively addressing Dr. Hwang’s comments about our article.1 In our study, we sequentially dissected the upper face based on the conventional methods in the gross anatomy field. This is a fact. For our dissections, we injected red colored latex (Neoprene, lot no. 307L146; DuPont DeNemours, Puteaux, France) into the common carotid artery before detailed dissections.1 Among the preinjected specimens, we excluded specimens that were not injected into the ophthalmic arterial branches before the dissections. In classical anatomy textbooks, the superficial and deep branches of the supraorbital artery have been described. Nevertheless, there are no specific descriptions for their branching. Aside from some anatomical textbooks, few articles focus on the course of the supraorbital artery. It is described simply as follows: “passing through the supra-orbital foramen, supraorbital artery divides into a superficial and deep branch, which supply the integument... anastomosing with the frontal, anterior branch of the temporal, and the artery of the opposite side.” During our dissections, we recognized new branching patterns of the supraorbital artery, which did not correlate with descriptions in the textbook. The main arterial branches of the supraorbital artery ran beneath the orbicularis oculi and the frontalis after passing the supraorbital notch (or foramen). As for the layers at the eyebrow area, the retro-orbicularis oculi fat was located deep to the muscle layer and includes the supraorbital vessels and the nerve branches and the insertion of the corrugator. Clearly, the main trunk of the supraorbital artery is located within the retro-orbicularis oculi fat. Unlike the general anatomical knowledge with which one may be familiar, the extent of the retro-orbicularis oculi fat is wider within the subgaleal layer with a high upper margin from the eyebrow level. Within the retro-orbicularis oculi fat, the supraorbital artery runs singularly or divides into two branches accompanying the supraorbital nerve. We named this supraorbital artery branch within the retro-orbicularis oculi fat the deep branch of the supraorbital artery. After passing the retro-orbicularis oculi fat, the deep branch of the supraorbital artery pierces the frontalis 20.7 mm vertically from the horizontal plane passing through the superior orbital rim. From the piercing points of the frontalis, it runs superficially to the frontalis (superficial branch of the supraorbital artery), and the superficial branches anastomosed with the frontal branches of the superficial temporal artery.1 Based on our dissection experiences, we described the common and clear characteristics of the supraorbital artery courses and illustrated them in detail. In some specimens, we could observe the fine perforations supplying the skin at the upper eyebrow area. We focused on the main arterial branches in the forehead to provide clinical anatomical information. In addition, our article has shown an objective and novel supplement on the supraorbital artery course from a gross anatomy viewpoint. Regarding sample size, we dissected and collected vascular anatomy data from both Korean and Thai subjects (20 hemifaces). As mentioned in the Results section, the deep branch of the supraorbital artery was observed in every case. Simply put, the deep branch of the supraorbital artery is the constant course of the supraorbital artery within the retro-orbicularis oculi. There was no need to dissect more cadavers for clarification. I believe you have already witnessed the strongest form of evidence by means of anatomical dissections from my previous presentations at conferences. Regarding the query about the clinical technique of forehead augmentation, the recommended entry point should be lateral to the vertical plane of the supraorbital foramen to avoid vascular injury from the needle. The needle should first be inserted deep to the frontalis by bone touch to provide a proper opening and tract for the cannula. The entry point and the point where it reaches the periosteum are usually adjacent because of the thin skin and muscular layer. After that, the cannula should be guided along the supraperiosteal layer until it reaches the medial area of the forehead. At that point, the filling material should be released. We developed this technique to maximize forehead augmentation safety during vascular piercing in clinical procedures through our article. Because the needle touches the bone, it is unnecessary to take the thickness of the frontalis into consideration. DISCLOSURE None of the authors has financial or private relationships with commercial, academic, or political organizations or people that could have improperly influenced this research. All cadaveric objects in this study were legally donated to Yonsei Medical Center and Chulalongkorn University. Li-yao Cong, B.Sc.Division in Anatomy and Developmental BiologyDepartment of Oral BiologyHuman Identification Research InstituteBK21 PLUS ProjectYonsei University College of DentistrySeoul, Republic of Korea Weeranut Phothong, M.D.Department of DermatologyFaculty of MedicineSiriraj HospitalMahidol UniversityBangkok, Thailand Iksoo Koh, M.D., Ph.D.Koh Iksoo Aesthetic Clinic Hee-Jin Kim, D.D.S., Ph.D.Division in Anatomy and Developmental BiologyDepartment of Oral BiologyHuman Identification Research InstituteBK21 PLUS ProjectYonsei University College of DentistrySeoul, Republic of Korea

Topographic Analysis of the Supratrochlear Artery and the Supraorbital Artery: Implication for Improving the Safety of Forehead Augmentation.

The supratrochlear and supraorbital artery branches from the ophthalmic artery are the primary suppliers of blood to the forehead. Filler injection into the forehead without precise knowledge of its vascular topography poses a risk of severe complications. Twenty hemifaces from 11 cadavers were dissected. Based on the presence of the deep branch of the supratrochlear artery, two main arterial distribution patterns of the forehead were observed. Type I (deep branch of the supratrochlear artery-present pattern) was classified into two subtypes: type Ia, in which the layer superficial to the frontalis was supplied medially by the superficial branch of the supratrochlear artery and laterally by the superficial branch of the supraorbital artery, and the deep branch of the supratrochlear artery and the deep branch of the supraorbital artery were distributed deep to the frontalis; and type Ib, in which the layer superficial to the frontalis was supplied by the superficial branch of the supratrochlear artery and the superficial branch of the supraorbital artery in addition to the central artery or the paracentral artery, and the layer deep to the frontalis was supplied the same with type Ia. For type II (deep branch of the supratrochlear artery-absent pattern), the layer superficial to the frontalis was supplied the same with type Ia; only the deep branch of the supraorbital artery supplied the layer deep to the frontalis. This study yielded novel arterial systems of the forehead and provided guidance for the safe forehead augmentation.