Dr Victoria Dobbie presents her techniques for treating aesthetic concerns around the eyebrows
Every day I have patients asking me to treat the lines that are etched across their forehead and/or between their eyebrows. It is one of the most common requests for aesthetic treatment at my clinic. In my early days of practice I would have only considered botulinum toxin type A for the upper third of the face – primarily because it was the glabella that received the first cosmetic indication for the use of botulinum toxin type A in 2002.1 The basic course on the use of toxin was therefore focused on the lines between the brow, with little consideration to the end position and shape of the female brow. You may have seen patients with poor aesthetic results from toxin treatments, where their brows are too high laterally and too low medially, or too low and flat, giving the patient a heavy, tired appearance. Either way, they are not enhancing the patient’s overall appearance – even if the line that was bothering them was successfully treated. I believe that the eyebrow is the most dominant feature on the forehead and should be a key consideration at the diagnosis and planning stage, in order to improve the aesthetic outcome of forehead and glabella treatments. Practitioners who consider the brow first get optimal results that patients love and want to have repeated.
The ideal brow is based on the principal that PHI or the ratio of 1:1.618 when applied to an individual’s face will make the face more beautiful. By aiming for the brow to be closer to the ideal position for the patient, they will have an aesthetically pleasing result.2
When consulting a patient, examine the brow at rest for any obvious asymmetry and balance. Even younger patients can present with a significant asymmetry, which will need to be factored into your treatment and discussed with the patient before treatment. Watch how the brow shape alters on movement, on elevation of the frontalis, and when contracting the corrugators, procerus and orbicularis oculi. Consider; does the full length of the brow sit on the orbital rim or is there a natural ptosis? If there is a ptosis then you need to ask yourself:
Patient A (Figure 2) has an obvious asymmetry; with the exception of the head of the brow, her upper left brow is higher. In addition, the patient has temporal hollowing, asymmetric forehead hollowing over her right brow, thin skin, loss of elasticity and poor skin quality.
Examine Patient A in Figure 3 – does the patient’s forehead have a 12-15 degree curve? A curve of this description provides ideal bony support to the skin of the forehead and the position of the brow.2 Are there asymmetries in the bony support of the forehead?
I find this is best analysed by laying the patient backwards and viewing their forehead from a superior position. If this is what is causing the lines, then addressing these asymmetries may give the patient the most effective aesthetic outcome. Projection of the brow is another consideration as soft tissue fullness and projection alters as we age. Temporal hollowing also causes lateral brow laxity, excess muscle contraction and lateral lines over the brow.3 Patient A (Figure 2) has flattening of the curve to her forehead and loss of brow projection. Assessment of skin quality is also fundamental to treatment and product choice:
I take all of these factors into account when devising an appropriate treatment plan for my patient. It allows me to explain the limitations of a single modality and frame their expectations, inform the patient of any asymmetry before treatment, explain why and how these may be addressed as they age, and why botulinum toxin alone is unlikely or no longer able to give them an optimum result. Treatment plans should give the patient every treatment option with agreed goals, benefits, risks, financial costs and time involved in appointments. This is our duty of care as medical professionals.
Botulinum toxin is often the first choice for younger patients with good bony support, tight skin and good symmetry. In these patients the result is more predictable and they often see a good result within two weeks. Consider the position of the brows to enhance the overall beauty of the patient when planning a toxin treatment.
It’s believed that 80% of middle-aged women have a brow asymmetry and they often have looser skin and show bony ageing. Dosing of the toxin needs to be adjusted to correct this asymmetry4 and a brow lift of 1-3mm can be achieved.5
Consider using dermal fillers as they enable you to directly lift and address any static lines. You can then combine with toxin to treat dynamic lines with a more predictable outcome. When the brow is asymmetric, low on the orbital rim or there is significant lateral brow droop – you need to decide:
To treat the forehead lines directly, consider the thickness and elasticity of the skin. Following this, select a product that is soft and elastic when placed in the superficially layers of the dermis.
To create structure, shape and lift be aware of the danger areas. These include:
1. Supra trochlear
2. Supra orbital
3. Superficial temporal
The supra orbital and trochlear run deep from the orbital rim and move above the muscle to the dermis at approximately 2cm above the rim. The safest plane to inject is deep or very superficial and not in the dermis where intra vascular injection is possible.7
I use a dermal filler that has elastic, cohesive properties, in order to lift the brow without distorting the skin excessively whilst allowing it to be moulded. I place the dermal filler under the frontalis muscle into the galea space. This can be achieved with a sharp needle on to bone. My preferred method is to use a micro-cannula – as the muscle in this area is tight to the bone, you get a very distinct restriction on the micro-cannula when you are in the correct plane. It is uncomfortable for the patient, due to the restricted space, but this technique avoids dermal filler from being placed sub dermally above the muscle. Dermal filler that is placed sub dermally can shift and sit above the eyebrow, and so should be avoided. Small deposits of dermal filler will give a good mechanical lift that raises the brow.
For those who employ an aesthetician, booking patients in to have unruly brows shaped after their two-week review will enhance the patient’s results and impression of the clinic.
Ultrasound skin tightening devices can be used to contract the muscle to lift the brow and promote collagen production to firm and plump the skin.1 A single treatment can achieve a 2mm brow lift for 89% of patients.9 The treatment is quick and the discomfort tolerable for most patients. Treatment can be done to tighten the muscle layer before placing dermal filler to correct any asymmetry. The upper eyelid can be treated because the device is ultrasound and not laser. Suh et al9 demonstrated by biopsy two months after ultrasound or radiofrequency (RF) treatment, that there was significant neocollagenis deeper in the reticulate dermis and SMAS layer with ultrasound. The neocollagenis induced by radiofrequency was more superficial in the papillary and mid to deep dermis. Consequently, I believe that RF cannot achieve similar results to ultrasound and Bassichis et al 10 demonstrated in 2004 that 24 patients treated with monopolar RF had no decipherable change in brow elevation. RF has FDA indication to treat lines for moderate facial wrinkles and rhytides.10 A series of 6-12 RF treatments, depending on the device, will increase collagenisis leading to skin plumping; but this does not contract and lift the underlying muscle layer.
Ageing is multi-factorial and, as our patients age, a single modality cannot be relied upon to continue to achieve good results. The upper third of the face is especially challenging due to skin laxity and brow ptosis. Treatment planning for the upper third of the face requires combination treatments to regain balance and harmony of the brows, because they are the strongest feature on the forehead and are more prominent then any wrinkle.
Dr Victoria Dobbie will discuss off-label uses of botulinum toxin on the Expert Clinic agenda at the Aesthetics Conference and Exhibition 2016. Visit www.aestheticsconference.com/programme to find out more.