Volumetric correction of the upper third of the face

Aya KORENEVSKAYA , dermatologist-cosmetologist, doctor at the Maria Shirshakova Aesthetic Medicine Clinic (Russia)

Maria SHIRSHAKOVA , Ph.D., dermatologist-cosmetologist, chief physician of the Maria Shirshakova Aesthetic Medicine clinic (Russia)

CRITERIA FOR NATURAL FACIAL REJUVENATION

Traditionally, the strategy for rejuvenating the upper third of the face involves eyebrow lifting and blepharoplasty of the upper and lower eyelids. Excessive removal of fatty tissue and skin in the upper eyelids in combination with raising the eyebrows leads to emphasizing the contours of the orbit and, as a result, to excessive angularity of the face as a whole. As a result, the patient often looks disharmonious and even older than he actually is. The goal of modern aesthetic medicine is the natural rejuvenation of the upper third of the face, and the most effective way to determine the “ideal appearance” for each patient is to compare modern and youth photographs. With a comparative analysis of photographs, the distinctive features of a young face and acquired age-related changes can be identified, thereby using a youthful photo as a guide to action will allow the doctor to achieve the most natural results for this particular patient.

Youthful appearance is determined by the following characteristics:

• the fullness of the upper eyelids extends from their lower borders to the eyebrows (that is, the upper borders). This creates a smooth transition, preventing the appearance of brow shadow; the absence of a shadow between the lower orbital margin and the cheek is similarly manifested;
• the absence or slight convexities of the temporal fossa prevent the phenomenon of skeletonization of the periorbital bones;
• the extent of visible pretarsal skin flap of the upper eyelids is variable in youth. Most often, a minimal strip of skin is visible between the upper eyelid and the lash line. However, some young people have a greater degree of prominence of the pretarsal fold, which gives the upper eyelids a more “sculpted” appearance.

The upper third of the face is not only an important component of a youthful appearance, it is also involved in expressing emotions. Interesting observations were shared by B. Knoll et al. in their work devoted to the study of factors influencing the display of emotions on the face of young people: using a computer program, scientists changed the position of the eyebrows, upper eyelids, pretarsal zone and periorbital wrinkles in photographs of the upper third of the face of sixteen young people. The resulting modified images were rated by respondents for dominant emotions such as surprise, anger, fatigue, sadness, disgust, fear and joy. As a result, it turned out that changes in the position of the eyebrows and upper eyelids had the greatest impact on the perception of the emotional state of the depicted persons.

Thus, modeling the position and shape of the eyebrows is of fundamental importance from both an aesthetic and emotional point of view for injection correction of the upper third of the face .

EYEBROW AESTHETICS

By definition, the eyebrow forms a thin arch, the highest part of which is located at the junction of the middle and outer thirds on a vertical line touching the lateral edge of the iris. In this case, the medial and central parts of the eyebrow should be wider compared to the lateral part. The ideal brow forms an arch with the apex at the junction of the medial two-thirds and lateral one-third. The apex is also located between the lateral edge of the iris and the lateral canthus. Ellenbogen R. illustrated the aesthetic proportions between the eyebrow and other parts of the face :

• medially, the eyebrow begins on a vertical line mentally drawn from the wing of the nose;
• in women, the eyebrow forms a curve above the edge of the orbit; in men, the eyebrow is located along it;
• in the lateral part, the end of the eyebrow coincides with a line drawn through the ala of the nose and the lateral canthal ligament.

Gunter J. described several more aesthetic criteria:

• the medial part of the eyebrow is a continuation of the line of the back of the nose;
• the medial part of the eyebrow begins above the medial canthus;
• the apex is no higher than 10 mm of the beginning of the medial part of the eyebrow;
• the medial part of the eyebrow is located below the lateral;
• a man's eyebrow practically has the shape of a straight horizontal line.

Note that for successful aesthetic correction of eyebrows it is necessary to take into account not only generally accepted visual criteria of beauty, but also some mathematical values, that is, verified average indicators of proportionality of the periorbital region. The authors of several publications have provided parameters useful for planning the final outcome. The length from the hairline to the eyebrow along the midpupil line is 5–6 cm. The distance from the eyebrow to the orbital margin and the eyebrow to the middle of the pupil is 1 and 2.5 cm, respectively. Connell B. et al. added a distance between the fold of the upper eyelid and the upper edge of the eyebrow, which is approximately 15 mm.

However, it should be noted that the actual shape and placement of eyebrows varies depending on gender, age , ethnicity, eye socket shape and facial proportions. At the same time, the downward displacement of the lateral portion of the eyebrow is one of the manifestations of age-related changes in the periorbital region, which certainly affects the appearance and self-esteem of our patients. Undoubtedly, the basic factor for successful work within the upper third of the face and its other areas is an impeccable knowledge of anatomy.

ANATOMY OF THE PERIORBITAL ZONE

The periorbital zone consists of bone and soft tissue, as well as a rich vascular network and nerves. In order to better understand the features of the formation of the appearance of the upper third of the face and the possibilities of effective and safe correction of this area, it is necessary to take a closer look at the bone and soft tissue anatomical structures.

Bone structure

The orbit is a pair of bone formations in the facial part of the skull on the sides of the root of the nose, which contains the eyeball. The orbit also contains the optic nerve, extraocular muscles, fatty tissue, vessels and nerves, the orbital part of the lacrimal gland and the fascial apparatus of the orbit. In adults, its depth is on average 4.5 cm, width ⎼ 4 cm, height ⎼ 3.5 cm. The lateral wall is formed in its anterior half by the zygomatic bone, and in the posterior half by the orbital surface of the greater wing of the sphenoid bone. The lateral wall of the orbit separates its contents from the temporal and pterygopalatine fossae, and in the region of the apex from the middle cranial fossa. The upper wall of the orbit consists of the frontal bone, and is represented posteriorly by a portion of the lesser wing of the sphenoid bone. The inner wall of the orbit is the thinnest, formed (in the anteroposterior direction) by the frontal process of the maxilla, the lacrimal and ethmoid bones, as well as the small wing of the sphenoid bone. The lower wall of the orbit is formed mainly by the orbital surface of the body of the upper jaw, in the anterior-outer section by the zygomatic bone, and in the posterior section by the small orbital process of the perpendicular plate of the palatine bone.

In the depth of the orbit there are the optic canal, the superior orbital and inferior orbital fissures. The optic nerve and ophthalmic artery enter the orbit through the optic canal. The superior orbital fissure runs along the border of the upper and outer walls of the orbit, separating the body of the sphenoid bone from its wings, and leads directly into the cranial cavity, into the middle cranial fossa. The superior (sometimes inferior) ophthalmic vein, the main branches of the ophthalmic vein, and the trunks of the trochlear, abducens and oculomotor nerves pass through it. Formed by the lower edge of the greater wing by the sphenoid and zygomatic bones on one side, the body of the upper jaw and the orbital process of the palatine bone on the other, it provides communication between the orbit and the pterygopalatine (in the posterior half) and temporal fossae. Through it, one of the two branches of the inferior ophthalmic vein leaves the orbit, and the infraorbital nerve and artery, the zygomatic nerve and the orbital branches of the pterygopalatine ganglion enter.

At the border of the middle and inner third of the bony edge of the upper wall of the orbit, a notch is noted where the superior orbital artery, vein and nerve pass. At the upper outer corner of the orbit there is a recess for the lacrimal gland.

Muscle structure

The main muscle of interest to us is the orbicularis oculi muscle. The muscle fibers are tightly attached to the bone, as well as to the medial and lateral corners of the eye and the cartilage of the upper and lower eyelids. The muscle has three parts: orbital, preseptal and pretarsal. The orbital portion of the muscle attaches directly to the bones that form the orbit. The preseptal portion passes over the orbital septum, and sometimes there is a free subcutaneous fat space between these two structures. Laterally, the preseptal part of the orbicularis oculi muscle is attached 3–4 mm behind the lateral commissure of the eyelids, medially from the edge of the orbit, on Whitnell's tubercle, forming the external ligament of the eyelids. On the medial side, the muscle is divided into an anterior (or superficial) part, which is attached to the anterior segment of the internal ligament of the eyelid, and a posterior (deep) part, penetrating into the lacrimal sac and lacrimal fascia. The pretarsal part of the orbicularis oculi muscle is tightly attached to the anterior surface of the cartilaginous plate.

At the upper edge of the cartilage, the muscle connects with the superficial fibers of the aponeurosis of the levator palpebral muscle, forming the fold of the eyelid. In the lateral part, the muscle is attached to the external ligament of the eyelids. In the medial section, the pretarsal part is also divided into anterior and posterior. The posterior part is inserted 4 mm deeper than the posterior lacrimal crest. The anterior part is attached to the anterior lacrimal crest.

Adipose tissue

Adipose tissue is also an important component of the periorbital and brow zone. Bourguet J. described two fatty compartments in the upper eyelid - medial and central. The medial fat packet is lighter in color and denser in consistency. It is also associated with the infratrochlear nerve and the terminal branch of the ophthalmic artery. Three fat packets were identified in the lower eyelid area. Extraorbital fat is represented by accumulations in the area of the lateral segment of the eyebrow and in the malar region.

Let's take a closer look at the so-called ROOF (retro orbicularis oculi fat). The ROOF is a 5 mm thick fibroadipose tissue that is located beneath the orbicularis oculi muscle and the inferior part of the frontalis muscle.

This structure and anatomical localization of ROOF were confirmed on 12 cadaver materials in a study by Hwang S. et al. The adipose tissue extends vertically, reaching a height of 1 cm at the level of the orbital rim and affecting the forehead area 2–5 cm lateral to the supraorbital foramen. Compared to orbital fat, it contains more fibrous tissue. Interestingly, the amount of fatty tissue varies greatly among representatives of different ethnic groups. For example, ROOF among Asians is more pronounced and has a longer duration in the preseptal space. Due to this feature, it is called the “submuscular fibroadipotic layer” or “preseptal fat pad”.

The ROOF also contains the lacrimal nerve, anastomoses with the supraorbital vein and the lateral part of the head of the m. corrugator supercilii. ROOF determines the volume and mobility of the lateral part of the eyebrow and plays a key role in the pathogenesis of ptosis, since with age, under the influence of gravity, it shifts and migrates downward.

Circulatory system

The blood supply to the tissues of the orbit is provided by the ophthalmic artery, which enters the orbit through the optic canal. The lacrimal artery departs from the arch of the ophthalmic artery at its beginning, then the central retinal artery, posterior short and posterior long ciliary arteries, muscular branches, posterior ethmoidal and anterior ethmoidal arteries, lateral and medial eyelid arteries, and supraorbital artery.

Since the main danger when working with the upper third of the face is the supraorbital and supratrochlear formations, let us consider their anatomy in more detail.

The supraorbital artery is located directly between the superior wall of the orbit and m. levator palpebrae superior. Moving forward, it bends around the supraorbital margin in the area of the supraorbital notch and follows upward to the forehead, where it supplies blood to m. orbicularis oculi, venter frontalis m. occipitofrontalis and skin. The terminal branches anastomose with a. temporalis superficialis. The supratrochlear artery is located medially from a. supraorbitalis. It goes around the supraorbital edge and, going upward, supplies the skin of the medial parts of the forehead and muscles. Its branches anastomose with the branches of the artery of the same name on the opposite side.

Lymphatic system

The lymphatic system of the upper third of the face includes the parotid, submandibular and deep cervical lymph nodes. Lymphatic drainage from the central frontal part, the medial part of the eyebrows, and the medial part of the upper eyelid is carried out to the submandibular nodes. Drainage of the lateral part of the forehead, the lateral part of the upper eyelid, and the temporal region is directed to the parotid and deep cervical lymph nodes.

Nervous system

The innervation of the periorbital region is represented by sensory, motor, and sympathetic nerves.

The sensory nerves are branches of the ophthalmic nerve, which is divided into three main branches - lacrimal, frontal and nasociliary. The lacrimal nerve goes to the lacrimal gland. The frontal nerve gives off a large branch - the supraorbital nerve. The frontal and supraorbital nerves innervate the skin of the forehead and middle part of the upper eyelid. The brow branch of the frontal nerve supplies a small area of the upper eyelid above the internal commissure of the eyelids. The nasociliary nerve is divided into anterior and posterior ethmoidal branches, the infratrochlear nerve, and the short and long ciliary nerves.

The supratrochlear and supraorbital nerves require special attention. The supratrochlear nerve originates from the edge of the orbit 1.4–1.7 cm lateral to the middle of the nasal root, while the supraorbital nerve ⎼ 2.4 cm lateral. Beer G. et al. noted in their study variability in the localization of the nerve exit point and the symmetry of their location. The longest distance recorded for the supraorbital nerve was 19 mm. Along its course, the supraorbital nerve is divided into deep and superficial branches. Janis J. describes four possible anatomical patterns regarding m. corrugator supercilii. Pattern I (40%) involves the location of deep branches under the muscle. In pattern II (34%), both (superficial and deep) branches are associated with the above-mentioned muscle. In the case of pattern III (4%), only the superficial branch is connected to the muscle, and in variant IV, all branches are located cranial to the muscle mass.

The superficial branch of the nerve is woven into the frontal muscle at a level of 2–3 cm above the bony edge of the orbit. The deep branch lies between the tendon helmet and the periosteum, moving towards the midline of the forehead. The supratrochlear nerve, after exiting the bony foramen, is woven into the corrugator muscle and the frontalis muscle.

The motor nerves arise from the oculomotor nerve, which divides into superior and inferior branches that innervate all extraocular muscles except the external rectus and superior oblique. The motor nerves of this zone are also represented by the temporal branch of the facial nerve, which is localized on the inner surface of the temporal fascia, under the frontal branch of the temporal artery. This branch innervates the frontalis muscle, the orbicularis oculi muscle, the transverse head of the corrugator muscle, and the upper portion of the proud muscle. The frontal branch of the facial nerve, starting in the temporal zone, reaches the frontal region 1–1.5 cm above the lateral portion of the eyebrow. The nerve passes under the temporoparietal fascia and then continues under the frontalis muscle, providing its innervation. In 60% of cases, a small branch arises from the nerve medially and supplies the transverse head of the corrugator brow muscle.

AESTHETIC EYEBROW CORRECTION

In order to achieve the most successful aesthetic correction of eyebrows, it is necessary to take into account not only the anatomical structure, but also the age-related changes that have occurred. The aging process of the upper third of the face is associated with loss of volume of soft and bone structures in certain areas. Loss of volume due to atrophy and movement of adipose tissue in the area of the superior orbital rim and upper eyelid creates a subbrow depression, manifested by a deep shadow under the upper edge of the orbit. On a youthful face, the upper bony margin of the orbit is usually not visualized due to the volume of soft tissue in the upper eyelid area. Volume loss is most clearly identified in the medial part of the upper eyelid due to the pronounced degree of bone resorption. Kahn D's studies showed that bone loss in the superomedial orbital socket results in elevation of the medial orbital rim. In this aspect , the strategy of restoring the volume deficit in the sub-eyebrow region, rather than additional eyebrow lifting, seems more natural. Knize D. in his work presented the mechanism of eyebrow drooping as an imbalance of forces acting on their raising and lowering (facial muscles and supporting underlying structures). His observations showed that the lateral segment of the eyebrow descends faster than the medial segment. This feature, in his opinion, is due to:

• weakening of the action of the frontal muscle;
• the force of gravity;
• hyperactivity m. corrugator supercilii in combination with the activity of the lateral part of the orbicularis oculi muscle.

The area of the lateral portion of the eyebrow is often the target area for the use of botulinum toxin, but in some cases the use of tissue fillers makes it possible to replenish the lost volume of the skeletonized orbit and improve the position of the eyebrow. The protocol for this procedure includes the use of medium-viscosity hyaluronic acid (HA) tissue filler Belotero® Balance (Merz Pharma) with a HA concentration of 22.5 mg/ml. From 0.1 to 0.3 ml of gel is injected into the subcutaneous layer using a cannula using a linear-retrograde technique. The injection level can also be the periosteum using a bolus technique of 0.05–0.1 ml per injection.

Drug of choice

Our experience with the Belotero® tissue filler has shown that this is the optimal drug for correcting this area. This monophasic filler based on stabilized hyaluronic acid of non-animal origin is plastic, non-allergenic, evenly integrated into the tissue and can be softly modeled, which guarantees no contouring, natural filling and correction of the sub-brow area. The optimal combination of viscosity, elasticity and concentration of hyaluronic acid determines the versatility of the filler. A distinctive feature of the Belotero® production technology is the use, in addition to the classical cross-linking of HA, of the innovative CPM method (Cohesive Polydensified Matrix). The CPM method involves partial dilution of cross-linked HA and its re-polymerization in combination with native hyaluronic acid. This makes it possible to obtain a homogeneous gel with areas of different densities, a high degree of stability and the ability to progradiently distribute in tissues.

ANATOMY OF THE TEMPORAL AREA

The second, no less important target area within the framework of volumetric correction of the upper third of the face is the temporal zone, within the boundaries corresponding to the superior temporal line (the place of attachment of the temporal aponeurosis to the bones) - above, the zygomatic arch and the base of the mastoid process - below, the outer edge of the orbit - front. In the temporal region, the following anatomical layers are distinguished: skin, subcutaneous fat, superficial fascia, superficial and deep layers of the temporal aponeurosis, interaponeurotic fat, subgaleal fat, temporal muscle, periosteum, temporal bone. Undoubtedly, both for safe operation and for understanding involutionary processes, it is important to consider each of these layers.

The skin in the temple area is relatively thin and mobile. Subcutaneous fat is located between the skin and the superficial fascia. The contents of this layer are the superficial temporal artery, vein and auriculotemporal nerve. The superficial fascia forms a thin sheet and covers the temporal aponeurosis, which consists of two sheets. The outer leaf is attached below to the outer surface of the zygomatic arch, and the inner leaf is attached to its inner surface. Between them there is loose interaponeurotic tissue. It is closed or can connect in the anterior section with the tissue of the zygomatic region through a slit-like space. The contents are the middle temporal artery and the accompanying veins of the same name.

Under the deep layer of the temporal aponeurosis lies the third layer of fatty tissue - subaponeurotic. It is located in the space between the deep layer of the temporal aponeurosis and the outer surface of the temporal muscle, covered with a thin fascial layer. The contents are the posterior process of the cheek fat pad and the vein. A deep layer of fiber is located between the temporal muscle and the periosteum of the temporal fossa along the vessels and nerves supplying the muscle (a., v. et n. temporales profundi). The temporalis muscle is located directly on the periosteum. It lines the entire temporal fossa, starting from the lower temporal line, and passes behind the zygomatic arch into a powerful tendon, which is firmly attached to the coronoid process of the mandible. The deep temporal artery, vein and nerve pass through the thickness of the temporal muscle.

TEMPORAL AREA CORRECTION

Loss of volume in the temporal region creates a hollow and darkened effect and occurs not only as a marker of the aging process, but also in people with a low body mass index . In this case, filling with filler can be done at the level of the periosteum or subcutaneously. Depending on the degree of tissue deficiency, the volume of filler varies from 0.5 to 1 ml per side. When working at the subcutaneous level and to achieve a softer effect, we prefer the fan technique. However, in cases of significant tissue deficiency, the supraperiosteal bolus technique is most justified. Volumetric correction of the temporal region is also possible using a cannula. The cannula is inserted into the subcutaneous fat and slowly moves to the injection site. The drug is administered on the reverse stroke of the needle by slowly filling the correction zone. Upon completion of the injection, a gentle modeling massage is performed to achieve optimal results. An average of 0.5–1 ml of the drug is administered per procedure.

Our proposed method for correcting involutional changes in the temporal zone using a needle or cannula involves the use of a filler based on stabilized hyaluronic acid “Belotero® Intense” (Merz Pharma) with a HA concentration of 25.5 mg/ml. The drug has a stable pH (7.0) and osmolarity equal to the osmolarity of the skin (average 305 mOs), which minimizes swelling after its administration. This sign is especially important when replenishing the volume deficit in the temporal zone, given the tendency of the latter to form post-traumatic edema.

In conclusion, I would like to note that achievements in aesthetic medicine in the correction of involutional changes in the face today sometimes even exceed the expectations of specialists and patients. When developing a therapeutic plan, we use tactics that involve tissue lifting, volume restoration, and a combination of these key components of rejuvenation and prevention of involutional changes in the face. Being an effective, safe and long-lasting method of modeling, injection volumetric correction of the upper third of the face using universal dermal fillers "Belotero®" can be the main or additional method of treating age-related changes in the subglabellar and temporal segments.

First published in Les Nouvelles Esthetiques 2017/№4