clinical anatomy/regional approaches

Upper Face: Clinical Anatomy and Regional

Approaches with Injectable Fillers
Jonathan M. Sykes, MD Background: The use of facial fillers has been rapidly increased as the range
Sebastian Cotofana, MD, PhD of injectable products and indications continues to expand. Complications
Patrick Trevidic, MD may arise from improper placement or technique. This article highlights the
Nowell Solish, MD, FRCP importance of anatomic knowledge when using injectable fillers in the face.
Jean Carruthers, MD, Methods: A detailed review of the clinical anatomy of the upper face is per-
FRCSC, FRC(OPHTH) formed. Regional approaches are described using the applied anatomy to ef-
Alastair Carruthers, ficiently and safely augment the different subunits of the upper face.
MA, BM, BCh, FRCPC, Results: Key aspects of safe and successful injection of fillers in the upper face
FRCP(Lon) include a thorough knowledge of the location of fat compartments and neu-
Amir Moradi, MD rovascular structures. Awareness of these structures enables the practitioner to
Arthur Swift, MD, CM, maximize injections, while avoiding damage to important nerves and vessels.
FRCS(C) Conclusion: A detailed knowledge of the anatomy and properties of the prod-
Guy G. Massry, MD uct is paramount to maximize the efficacy while minimizing the risk of com-
Val Lambros, MD, FACS plications.  (Plast. Reconstr. Surg. 136: 204S, 2015.)
B. Kent Remington, MD,
FRCP
Sacramento, Vista, Los Angeles,
Beverly Hills, and Irvine, Calif.;
­Salzburg, Austria; Paris, France;
and Toronto, Ontario, Vancouver,
British Columbia, Montreal
and Westmount, Quebec;
and Calgary, Alberta, Canada

I
njection of facial fillers has been increasing
globally as new injectable products have been Disclosure: Dr. Solish is a consultant for Allergan and
developed and new applications have been Galderma and researcher for Allergan, Revance, Evo-
identified. The basis for successful filler injec- lus, and Merz. Dr. Jean Carruthers and Dr. Alastair
tions is a thorough knowledge of anatomy and Carruthers are consultants and researchers for Allergan
an understanding of the products to be injected. Pharmaceuticals, Merz USA, and Kythera Biopharma.
Knowledge of the applied anatomy can maximize Dr. Moradi serves as a consultant for Galderma. He
did not receive compensation for this article. Dr. Swift
is a consultant/clinical investigator for Allergan, Merz,
From Facial Plastic Surgery, University of California, Davis
Medical Center; Institute of Anatomy, Paracelsus Medical
and Galderma. Dr. Massry receives royalties from Else-
University Salzburg & Nuremberg; Expert2expert Group; vier and Springer. Dr. Sykes, Dr. Cotofana, Dr. Trevidic,
Department of Dermatology, University of Toronto; Depart- Dr. Lambros, and Dr. Remington have no financial in-
ment of Ophthalmology and Department of Dermatology, terest in any of the products, devices, or drugs mentioned
Faculty of Medicine, University of British Columbia; private in this article. Dr. Remington did not receive any finan-
practice; Westmount Institute of Plastic Surgery; Victoria cial aid or reimbursement or honorarium for the project.
Park MediSpa; St. Mary’s Hospital, McGill University;
Department of Ophthalmology, Keck School of Medicine,
­University of Southern California; Beverly Hills Ophthalmic
Plastic and Reconstructive Surgery; Department of Plastic Supplemental digital content is available for this
Surgery, University of California, Irvine; and Remington article. Direct URL citations appear in the text;
Laser Dermatology Centre. simply type the URL address into any Web browser
Received for publication June 1, 2015; accepted August 6, to access this content. Clickable links to the mate-
2015. rial are provided in the HTML text of this article
Copyright © 2015 by the American Society of Plastic Surgeons on the Journal’s website (www.PRSJournal.com).
DOI: 10.1097/PRS.0000000000001830

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 Volume 136, Number 5S • Injectable Fillers in the Upper Face

the efficacy of injections and minimize the poten-

tial complications.

Applied Anatomy for Injectable Fillers: Upper

Face and Temporal Region
Any practitioner who injects fillers should have
a thorough knowledge of all soft tissue and skel-
etal structures, from superficial to deep. An under-
standing of the volume deficiencies and the lifting
capacity of the various filler substances is essential.
It is important for the injector to know where the
important neurovascular structures are located,
in order to avoid injury. Because of the unique
periorbital anastomoses of the internal and exter-
nal carotid vascular system, devastating complica-
tions after periorbital filler injections are possible.
These anatomical danger zones should be known
and avoided. This article will provide an in-depth
discussion of the layered anatomy of the upper
face and temples as it applies to filler injections.

The Temporal Fossa

Fig. 1. Layers of the temple. I, skin; II, subcutaneous tissue; III,
The temporal fossa is bounded by the curved TPF (superficial temporal fascia); FP, temporal fat pad; V, DTF; VI,
superior temporal line (anteriorly and superiorly), temporalis muscle.
the frontal process of the zygomatic bone (antero-
inferiorly), and the zygomatic arch (inferiorly). also termed the superficial temporal fascia, lies
The fossa contains the superior aspect of the tem- just beneath the subcutaneous fat of the temporal
poralis muscle and its layered fascia, the superficial region. It is a thin, pliable, and vascular layer that
temporal artery and vein, and the auriculotempo-
is tightly bound to the overlying skin. Dissection
ral nerve (V3). At the superior temporal line (the
in the plane just superficial to the TPF layer con-
region of the conjoined tendon), the temple tran-
tains and is supplied by the superficial temporal
sitions to the forehead, and at the zygomatic arch
narrow-caliber vessel and is one of the terminal
inferiorly, the temple transitions to the midface.
The temporal hairline courses variably and branches of the external carotid artery2 (Fig. 3). It
obliquely through the temporal region. The supplies the TPF and makes this a reliable tissue
anteroinferior region is non–hair bearing, and the source for auricular and midface reconstruction.
superolateral region contains the temporal hair.
The hair-bearing region is vascular, with thick skin
and abundant subcutaneous tissue.
The anatomical layers of the temporal fossa
from superficial to deep begin with the skin (layer
I), the subcutaneous tissue (layer II), the super-
ficial fascia (layer III), the loose areolar tissue
(layer IV), and the deep temporal fascia (DTF)
(layer V) (Fig.  1). The temporalis muscle, deep
to the DTF, is designated layer VI (Fig.  2). The
fascial layers of the temporal fossa have been iden-
tified by many names1 (Table 1). Lack of precise
nomenclature has caused confusion in the litera-
ture and added to misunderstanding of the anat-
omy in this region. As in all regions of the head
and neck, both superficial and deep fascia exist,
and these 2 fascial layers are separated by loose Fig. 2. Cadaver dissection after reflection of the DTF showing
areolar tissue. The temporoparietal fascia (TPF), the temporalis muscle (TM).

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 Plastic and Reconstructive Surgery • November Supplement 2015

Table 1.   Layers of the Temporal Fossa

Accepted Nomenclature Other Names Used
Skin (layer 1)
Subcutaneous tissue (layer 2)
TPF (layer 3) Superficial temporal fascia
Loose areolar tissue (layer 4)
DTF (layer 5)
Superficial layer
Deep layer Intermediate fascia
Temporalis muscle (layer 6)
Pericranium
Temporal bone

The TPF (layer III) is the superior extension

of the superficial musculoaponeurotic system
(SMAS) of the midface3 (Fig. 4). The SMAS of the
midface is discontinuous at the level of the zygo-
matic arch, where it is contiguous with the TPF. Fig. 4. Left-sided cadaver dissection depicting the continuity of
At the superior temporal line, the TPF becomes the TPF of the temporal region with the SMAS of the midface.
continuous with the epicranial aponeurosis of the
forehead.
The TPF is separated from the underlying DTF temporal vessels, which along with the deep tem-
by loose areolar tissue (layer IV). The loose areo- poral artery and vein, supply the temporalis
lar tissue thickens into a superior temporal sep- muscle. The DTF is a single layer in the superior
tum, which is located at the temporal crest (also portion of the temporal fossa. In the inferior
designated the superior temporal line), and an temporal fossa, the DTF divides approximately
inferior temporal septum4 (Fig.  5). The inferior 2–3 cm above the zygomatic arch. The DTF splits
temporal septum separates the temporal region into 2 layers to envelope the temporal fat and
into a superior and an inferior compartment. The then to ensheathe the zygomatic arch. The super-
superior and inferior temporal septi fuse anteri- ficial layer of this DTF is termed the “intermedi-
orly near the tail of the brow. ate” fascia.5
The DTF, also termed the temporalis muscle The fat compartments in the temporal fossa
fascia, is a thickened layer of connective tissue have confusing terminology (Table  2). The fat
which covers the underlying temporalis muscle that is deep to the TPF and lies within the 2 lay-
(Fig. 6). Traveling within the DTF are the middle ers of the DTF is often termed the “superficial” fat
pad of the temple. This is a misnomer, as this fat
layer is contiguous with the sub–orbicularis oculi

Fig. 5. Left-sided cadaver dissection showing the inferior tem-

Fig. 3. Cadaver dissection after reflection of the skin and the poral septum (ITS) and the superior temporal septum (STS).
subcutaneous tissue showing the TPF with the arrow pointing These septi join near the tail of the brow and connect the galea
to the frontal branch of the superior temporal artery. (level III) with the periosteum (level V).

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 Volume 136, Number 5S • Injectable Fillers in the Upper Face

the TPF), (2) just deep to the TPF (between the

superficial and deep fascia), and (3) deep to the
temporalis muscle (see Video, Supplemental Digi-
tal Content 1, http://links.lww.com/PRS/B449).
The desirable plane for placement of inject-
able filler or implant is based on the augmen-
tation material used. Hyaluronic acids (HAs)
should be placed in either the subcutaneous
plane or the plane between the superficial and
DTF. Alloplast implants, such as expanded
polytetrafluoroethylene, or injection of filler
substances, such as poly-l-lactic acid, calcium
hydroxylapatite, or hyaluronic acid gels (HAGs)
with a high G′, should be placed deep to the tem-
poralis muscle to assure maximal soft-tissue cov-
Fig. 6. Right-sided cadaver dissection with inferior reflection of
erage. This is especially true in the temple, where
the skin, subcutaneous tissue, and TPF. The DTF is shown ele-
the temporalis muscle has a strong contraction.
vated off the temporalis muscle (TM). The temporal branch of
If these substances are placed within the tempo-
the facial nerve (FN) is shown with an arrow underling the TPF.
ralis muscle, migration or lumping of the parti-
The zygomatic arch (ZA) is shown at the inferior aspect of the
cles can occur.
photograph.
Anatomy of the Forehead
fat of the midface. This fat is, of course, deep fat. The boundaries of the forehead are the fron-
The fat enveloped by the DTF would therefore be tal hairline (superiorly), the eyebrows and the
more appropriately termed suprazygomatic fat of nasal root (inferiorly), and the temples (laterally).
the temple. There is a deeper layer of fat of the In patients with hairline recession, the superior
temple which lies deep to the zygomatic arch and extent of the forehead is considered at the supe-
is continuous with the buccal fat of the midface. rior border of the paired frontalis muscles. The
This fat could be termed the deep or retrozygo- transition between the forehead and the temporal
matic fat of the temple. (See Video, Supplemental regions is the superior temporal lines or the anter-
Digital Content 1, which demonstrates the clinical osuperior extent of the temporalis muscles. In this
anatomy of the upper face and temporal region, region, the fascial planes fuse and are termed the
available in the “Related Videos” section of the conjoined tendons. The skull in the temporal
full-text article on PRSJournal.com or, for Ovid fossa is concave, accommodating the temporalis
users, at http://links.lww.com/PRS/B449.) muscle, while the shape of the forehead is convex.
The central forehead and scalp consist of
Filler Injection of the Temple 5 distinct layers identified by the mnemonic
Augmentation of the deficient temporal fossa
can be accomplished with surgical alloplasts, aug-
mentation with autologous fat, or injection with a
variety of “off-the-shelf” filling agents. Safe place-
ment of a substance for temple augmentation is
dependent on the agent used. The 3 potential
planes for augmentation are as follows: (1) The
immediate subcutaneous plane (superficial to

Table 2.   Fat Compartments of the Temporal Fossa

Widely Used Names More Appropriate Anatomical Terms
Subcutaneous fat Video 1. Supplemental Digital Content 1, demonstrating the
Superficial temporal
fat pad Suprazygomatic temporal fat clinical anatomy of the upper face and temporal region, is
Retrozygomatic (deep) temporal fat available in the “Related Videos” section of the full-text arti-
Deep temporal (contiguous with buccal fat of the cle on PRSJournal.com or, for Ovid users, at http://links.lww.
fat pad midface) com/PRS/B449.

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 Plastic and Reconstructive Surgery • November Supplement 2015

Fig. 9. Right-sided cadaver dissection with inferior reflection of

Fig. 7. Left-sided cadaver dissection with removal of the skin the galea aponeurosis and frontalis muscle showing the retroor-
showing thick subcutaneous tissue, galea aponeurosis, and bicularis oculi fat (ROOF), the supraorbital neurovascular bundle
underling frontalis muscle. (black arrow). Note that the ROOF is deep to the orbicularis oculi
muscle (red arrow).

SCALP (skin, connective tissue, aponeuoro-

sis, loose areolar connective tissue, and peri- frontalis, the occipitalis, the procerus, and the
cranium). The skin of the forehead and scalp periauricular muscles.
is thick, averaging 2381 microns in thickness6 The loose areolar tissue of the forehead and
(Fig. 7). Only the epidermis overlying the men- scalp is an avascular layer connecting the overly-
tum, approximately 2500 microns, is thicker. ing galea and the underling pericranium.
The thick and well-vascularized forehead skin
contrasts sharply with the adjacent thin and del- Filler Injection of the Brow and Upper Eyelid
icate skin of the eyelid. The retroorbicularis oculi fat is the deep fat
The galea aponeurosis, or epicranial aponeu- compartment of the upper eyelid and brow. This
rosis, is the fibromuscular extension of the SMAS fat gives shape to the brow and to the upper eye-
of temple and lower face (Fig. 8). The galea is a lid above the supratarsal fold.7 The fat pad lies
tendinous sheet connective tissue, which encircles deep to the orbicularis oculi muscle and the infe-
the entire skull. The galea splits to envelop the rior extension of the galea aponeurosis and lies

Fig. 10. Oblique photograph of the right side of the cadaver

Fig. 8. Left-sided cadaver dissection with reflection of the galea showing the retroorbicularis oculi fat and its relationship with
aponeurosis (arrow) which envelops the frontalis muscle (FM). the supraorbital neurovascular bundle (arrow).

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 Volume 136, Number 5S • Injectable Fillers in the Upper Face

superficial to the pericranium (Figs.  9 and 10). a thorough knowledge of pertinent anatomy is
Loss of volume within this fat compartment con- required to maximize the efficiency of injection
tributes to deflation and descent of the tail of the and to minimize the incidence of complications.
brow and can create a deep sulcus of the upper
eyelid.8,9
REGIONAL APPROACHES
Augmentation of the lateral brow and upper
eyelid can enhance periorbital appearance. When Forehead
the filling agent is placed deep to the tail of the Nowell Solish, MD, FRCP; Toronto, Ontario,
brow, 3-dimensional brow correction including Canada
vertical lifting and horizontal brow projection is The shape and contour of the forehead is
achieved. The filler should be placed lateral to variable. Most consider an esthetically pleasing
the supraorbital neurovascular bundle (to avoid forehead to be round and smooth. Injectable fill-
injury) and deep to the orbicularis oculi muscle ers have become a much less invasive treatment
(Fig.  11). If the supraorbital notch can be pal- option for reshaping of the forehead.
pated, injection in the avascular subgaleal glide In my practice, I prefer to use HA fillers.
plane between the supraorbital and supratroch- They have the advantages of being moldable and
lear neurovascular bundles can be performed. reversible. I do not feel that any one product
Augmentation of the superior sulcus of is superior over another. I would suggest using
the upper eyelid can be accomplished with an one that has the ability to aid in projection of
injection just inferior to the supraorbital rim. the forehead. Typical examples for me include
Placement of HAG below the rim, deep to the Volift, Voluma, or Perlane, but many others can
orbicularis muscle, and superficial to the leva- be used.
tor aponeurosis can provide volume into a skel- Typically, the area to be injected is the mid
etonized orbit, improving the appearance of the forehead. At this level (mid forehead), the
upper eyelid. It is important to avoid injury to the supraorbital and supratrochlear vessels have
underlying septum orbitalis, upper eyelid fat pad,
become more superficial. To decrease the risk
and levator mechanism of the upper eyelid. These
of intravascular injection, the filler should be
structures should be deep and inferior to the area
placed at the level of the periosteum. At this
of injection.
level, one is likely to be underneath the ves-
sels. I am not sure how reliable aspiration is
Summary with a 30-gauge needle, but one can try to aspi-
Augmentation of the temple and periorbital rate before injecting to help decrease the risk
region can provide significant enhancement of of being intravascular. I prefer to use a tech-
the upper facial appearance. To accomplish this, nique where I inject small boluses of approxi-
mately 0.2 mL of filler across the forehead. The
boluses are placed like small tent poles in order
to increase the projection of the forehead. I
will gently mold the boluses to make sure that
the contour looks even. Typical volumes for me
are approximately 1 cc in total.
I use a syringe with a needle, I often transfer
my HA in to insulin syringes for control, but this
is a personal preference and is not necessary.
I use the B–D syringes with a 30­ gauge needle,
which is similar in diameter to most needles that
are co-packed with the HA syringes. I do not
dilute my filler. I have no data to prove if there
is any disruption of the product through these
syringes but clinically have not noticed any dif-
Fig. 11. Left-sided cadaver dissection shown in a subgaleal dis- ference. Others prefer the use of a cannula in
section plane with the black arrow pointing to the supraorbital this area. I do not over inject this area, I use a
nerve and the red arrow pointing to the retroorbicularis oculi fat profile view to judge my endpoint and inject to
pad. The safe zone for injection of autologous fat of fillers is lat- full correction. (See Video, Supplemental Digi-
eral to the supraorbital neurovascular bundle. tal Content 2, which demonstrates Dr. Solish’s

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 Plastic and Reconstructive Surgery • November Supplement 2015

gently withdrawn. Used in this fashion, allows the

injecting module the opportunity to inadvertently
lacerate or penetrate a blood vessel.
In our anterograde technique, the needle or
cannula tip is inserted into the subgaleal space,
and then after safe aspiration, the product is gen-
tly deposited as the injecting module is moved for-
ward. This adds to the safety profile because the
bolus of HA being introduced is much softer than
a tip of either a needle or a cannula.
The subsequent massage of the diluted prod-
uct in the subgaleal plane avoids further needle
Video 2. Supplemental Digital Content 2, demonstrating
insertion and also gives a smooth and soft youth-
Dr. Solish’s personal technique for injecting HA fillers into the
ful appearance to the forehead as it elevates the
forehead, is available in the “Related Videos” section of the
brow and reduces the severity of the etched hori-
­full-text article on PRSJournal.com or, for Ovid users, at http://
zontal forehead lines.
links.lww.com/PRS/B450.
We always withdraw the plunger whether we
are using a needle or a cannula—you can see
personal technique for injecting HA fillers into in this video blood coming into the hub of the
the forehead, available in the “Related Videos” needle. At this point, it is necessary to remove the
section of the full-text article on PRSJournal. needle and reinsert, again withdrawing to be sure
com or, for Ovid users, at http://links.lww.com/ the needle tip is not intravascular.
PRS/B450.) This technique allows for a natural look with
J ean Carruthers, MD, FRCSC, preservation of expressive forehead movement. It
FRC(OPHTH), and Alastair Carruthers, MA, lasts for 9–12 months. (See Video, Supplemental
BM, BCh, FRCPC, FRCP(Lon); Vancouver, Digital Content 3, which demonstrates Drs. Jean
British Columbia, Canada and Alastair Carruthers’ personal technique for
Many middle-aged individuals develop a scal- reflating the forehead using diluted HA, available
loped area in their mid forehead, which gives them in the “Related Videos” section of the full-text
the appearance of age and also being careworn. article on PRSJournal.com or, for Ovid users, at
Because they usually have some moderate degree http://links.lww.com/PRS/B451.)
of associated brow ptosis, using neuromodulator Amir Moradi, MD; Vista, Calif.
to smooth out the horizontal forehead lines is not Restylane is a transparent, viscous gel com-
helpful as it drops their brows and makes them posed of HA biosynthesized by Streptococcus spe-
both look and feel angry. cies of bacteria, chemically cross-linked with 1,4
Reflating the forehead with a diluted HA filler butanediol diglycidyl ether, and suspended in
allows them to again present a smooth forehead, physiologic buffer at pH = 7 and concentration of
to lift their brows to express interest and compas-
sion, and to reduce the etched appearance of the
horizontal frontalis lines.
We deposit 2 cc of HA filler, diluted 100–150%
with preserved saline (total volume now 4 cc) in 3
locations. One at each lateral brow at its junction
with the temporal fusion line and in mid glabella
between the supratrochlear vessels, we deposit
about 1.3 cc of the diluted product into the sub-
galeal glide plane. We then massage the product
using a thin gel lubricant (Cytotec) so that the
forehead is smooth.
The technique requires the delivery of approx-
imately 1.3 cc of the diluted HA filler at each Video 3. Supplemental Digital Content 3, demonstrating
injection portal using the anterograde injection Drs. Jean and Alastair Carruthers’ personal technique for reflat-
technique. Most injectors use the retrograde tech- ing the forehead using diluted HA, is available in the “Related
nique where the needle or cannula is inserted, Videos” section of the full-text article on PRSJournal.com or, for
and injection occurs as the injecting module is Ovid users, at http://links.lww.com/PRS/B451.

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 Volume 136, Number 5S • Injectable Fillers in the Upper Face

20 mg/mL. Restylane is intended for mid-to-deep

dermal implantation. One of the consequences of
the aging process includes loss of volume in the
face, due to loss of bone, collagen, and fat in the
subcutaneous area. Restylane is approved by the
US Food and Drug Administration for the cor-
rection of moderate-to-severe facial wrinkles and
folds. Its texture is ideal for correction of forehead
lines because of its small particle size and hydro-
philic potentials as compared with other HAs.
The treatment site should be cleaned with
a suitable antiseptic solution and a topical anes- Video 4. Supplemental Digital Content 4, demonstrating Dr.
thetic ointment. Restylane is administered using Moradi’s personal technique for injecting Restylane into the
a 30- to 32-gauge needle by injecting the material superficial dermis of the forehead, is available in the “Related
into the superficial dermis. (See Video, Supple- Videos” section of the full-text article on PRSJournal.com or, for
mental Digital Content 4, which demonstrates Ovid users, at http://links.lww.com/PRS/B452.
Dr. Moradi’s personal technique for injecting
Restylane into the superficial dermis of the fore- Safety considerations include using the cor-
head, available in the “Related Videos” section rect volume to correct the deficiency. Expected
of the full-text article on PRSJournal.com or, for adverse events can include bruising, swelling,
Ovid users, at http://links.lww.com/PRS/B452.) bumps lasting for up to 7 days, and redness lasting
Each injection site should be massaged to con- 1–2 days. Unanticipated adverse events include
form to the contour of the surrounding tissues. bumps lasting longer than 7 days, redness as a sign
The aesthetic endpoint should be the improve- of infection, skin necrosis, hyperpigmentation of
ment of the lines. Care should be taken to not the skin, irregularity at the skin surface, allergic
over correct. To ensure safety when injecting the reaction at injection site (itching, swelling, and
forehead lines, all injections must be performed redness), anaphylactic reaction (generalized rash,
superficially in the mid to superficial dermis. swelling, and shortness of breath), and a drop in
This will decrease the possibility of intra-arterial blood pressure.
injection. The main arterial supply to the fore-
head is through the supraorbital, supratrochlear, Temples
and superficial temporal artery. Small branches Arthur Swift, MD, CM, FRCS (C); Montreal,
from these arteries enter the undersurface of the Quebec, Canada
deep dermis radially and branch out into small Treatment of Temple Hollows (One Up, One Over).
caliber vessels; therefore, all injections must be Safe correction of overly scaphoid temporal
performed superficial to this layer to avoid intra- hollows can be achieved only through a solid
arterial injections. The possibility and magnitude understanding of the injection anatomy of the
of skin necrosis is directly correlated to the loca- region. The temporal crest or fusion line is an
tion of the artery embolized (proximal vs distal) important forehead surface landmark that is
and the volume of the bolus injected. Proximal most palpable at the eyebrow level. This delin-
injection and larger volumes would cause embo- eates the temporal fossa that houses the tempo-
lization of a larger zone and lead to occlusion of ralis muscle, a muscle of mastication. Unlike the
end arterioles, which can make collateral circula- gliding muscles of facial expression, the tempo-
tion ineffective. ralis must generate significant pull on the man-
The complications can be catastrophic when dible and so is firmly anchored high up to the
a larger caliber artery is injected with high pres- temporal bone. The fan-like muscle is thin in its
sure or large lumen needle or cannula. In those upper portion and thickens into a fibrotendinous
cases, a retrograde displacement of the particles muscle as it converges to insert onto the coronoid
can enter the larger arteries, such as the internal process of the mandible. The dense galea fascia
maxillary artery, and subsequently cause a much of the forehead therefore continues laterally over
larger necrotic effect and possibly blindness the temporalis muscle as the DTF, an anatomical
due to retinal artery occlusion. It is vital to keep oddity of which the injection specialist can take
the boluses under 0.02 cc and not to penetrate advantage for dispersion of filler product with
beyond the dermis. this technique.

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 Plastic and Reconstructive Surgery • November Supplement 2015

The ramus frontalis branch of the superficial where the muscle fibers are sparse, remains rela-
temporal artery traverses the fossa in the deep tively avascular in that any terminal branches of
leaves of the superficial temporal fascia overly- the more posterior deep temporal vessels are of
ing the DTF on the muscle surface, anastomosing no relative consequence to injection. Inadvertent
more commonly with the ipsilateral supratroch- piercing of a more superficial artery or vein will
lear artery of the forehead. Superficial needle result in deposition of product deep to the vessel
injection of filler in this region should be avoided, on bone and should limit adverse events to pos-
as inadvertent intravascular injection into this sible bruising in the area. Again, in this region of
system of vessels can pass retrograde into the the fossa, it is mandatory to be close to the tempo-
ophthalmic artery causing central retinal artery ral fasciae lata (1 cm lateral), anterior (1 cm supe-
occlusion. The deep temporal arteries (anterior rior to the supraorbital rim), and absolutely deep
and posterior), branches of the second division of (the needle must be touching bone) to deposit
the internal maxillary artery, as well as the middle filler in this relatively avascular plane that is devoid
temporal artery, pass within the deep substance of any significant vessels. Maintaining the needle
of the muscle, diminishing in diameter as they on bone during the entire slow injection period is
ascend the fossa. A superficial plexus of veins, if fundamental for a safe outcome.
not apparent through the temporal skin, can be Using a product of significant G′ and cohe-
better visualized and marked once engorged by sivity, a vertical tent pole will be created that tra-
placing the head in a forward position. verses the thin fibers of the temporalis muscle in
Planned injection is a single puncture, verti- this region and then spreads between the DTF
cally oriented down to bone, 1 cm up the temporal and muscle creating a canopy effect, filling the
fusion line and 1 cm lateral, parallel to the supra- hollow. The product will spread circumferentially
orbital rim (one up, one over). (See Video, Sup- from the injection point, stopping at the fused
plemental Digital Content 5, which demonstrates fascia/bone interface of the tensor fasciae lata
Dr. Swift’s personal “one up, one over” technique and supraorbital rim but continuing inferiorly, as
to treat signs of aging in the temple hollows, avail- intended, toward the zygomatic arch. Placement
able in the “Related Videos” section of the full-text of an index finger posterior (behind) the injec-
article on PRSJournal.com or, for Ovid users, at tion point during injection will prevent the unde-
http://links.lww.com/PRS/B453.) Digital pressure sirable and irrelevant spread of product under
confirms the absence of a pulse at the injection the hair-bearing scalp. The author has found this
site, and any obvious veins are avoided. Aspira- technique to be the most economical, with typical
tion prior to injection is suggested, although the volumes of HA filler ranging from 0.25 to 0.75 cc
absence of blood reflux is not a guarantee of per temporal hollow. Withdrawal of the needle,
extravascular location of the needle tip. Main- which may have injured a deeper vessel (exter-
taining the tip of the needle on bone is crucial to nal sentinel vein), mandates gentle pressure for
avoiding inadvertent intravascular injection. This several minutes. This pressure is important in the
location, selected high up near the temporal crest absence of any obvious bleeding from the punc-
ture site, in order to avoid delayed ecchymosis.
Mild molding of product or gentle massage of the
temple posttreatment is occasionally indicated.
Superficial treatment of temporal hollows is
also possible with the use of a lower G′ product
through a blunt cannula, preferably in a direction
perpendicular to the superficial temporal arte-
rial branches. Sharp needle penetration into the
deeper portion of the temporal fossa above the
zygomatic arch is strictly contraindicated, due to
the presence of the branches of the second por-
tion of the internal maxillary artery, the emboliza-
tion of which has led to necrosis of the ipsilateral
Video 5. Supplemental Digital Content 5, demonstrating palate.
Dr. Swift’s personal “one up, one over” technique to treat signs of The aesthetic goal of temple fill in the female
aging in the temple hollows, is available in the “Related Videos” is to maintain a flat or slightly concave or convex
section of the full-text article on PRSJournal.com or, for Ovid curvature to the temple region. Obvious convexity
users, at http://links.lww.com/PRS/B453. signifies large muscle mass and is a masculinizing

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 Volume 136, Number 5S • Injectable Fillers in the Upper Face

feature which must be avoided. An upward and users, at http://links.lww.com/PRS/B454.) Care

outward elevation of the tail of the eyebrow is com- should be taken to not over correct.
monly noted posttreatment and will often persist The vascular supply to the temple is through
for several months. Patient satisfaction with the 3 branches of external carotid artery: superficial
technique is noted to be high, as rather than “dis- temporal, middle temporal, and deep temporal
appearing around the corner” and falling into the arteries. The superficial temporal artery is encased
hollow of the temple, the beautiful aspect of the in the superficial temporal fascia, which first trav-
tail of the brow is now visible when looking in the els superiorly above the tragus and then turns
mirror on the anteroposterior view. horizontal toward the midline. The deep tempo-
ral artery lies in the DTF over the periosteum at
Amir Moradi, MD; Vista, Calif.
the depth of the temporal fossa and middle tem-
Restylane is approved by the US Food and
poral artery, a proximal branch of the superficial
Drug Administration for the correction of moder-
temporal artery supplies the mid musculofascial
ate-to-severe facial wrinkles and folds. Its texture is
zone. Deeper injections beyond the subcutaneous
ideal for temporal fossa volumization because of
layer place these arteries at risk. The deep tempo-
its small particle size and hydrophilic potentials.
ral artery is a branch of internal maxillary artery.
The treatment site should be cleaned with
Retrograde injection of this artery can lead to
a suitable antiseptic solution and a topical anes-
catastrophic complications beyond skin necrosis,
thetic ointment. Restylane is administered using
such as blindness.
a 30-gauge needle by injecting the material into
We prefer the use of a 29- to 30-gauge needle
the subcutaneous tissue. To minimize trauma, the
based on the precision when intersecting multi-
needle should be inserted perpendicular to the
ple small aliquots of 0.01–0.02 cc. We believe that
skin. Once passed through the dermis, the angle
the superficial injections allow more precise and
can be changed to 45 degrees so that the Restylane
direct correction of the subcutaneous volume
can be placed in the subdermal space at the level
loss.
of the superficial temporal fascia. Each injection
Safety considerations include using the cor-
site should be massaged to conform to the con-
rect volume to correct the deficiency. Expected
tour of the surrounding tissues. A touch-up can be
adverse events can include bruising, swelling,
administered 4 weeks after the initial treatment.
bumps lasting for up to 7 days, and redness lasting
The aesthetic endpoint should be a correction
1–2 days.
of the volume deficit in the temporal fossa and a
Unanticipated adverse events include bumps
more youthful appearance for the patient. (See
lasting longer than 7 days, redness as a sign of
Video, Supplemental Digital Content 6, which
infection, skin necrosis, hyperpigmentation of
demonstrates Dr. Moradi’s personal technique
the skin, irregularity at the skin surface, allergic
for temporal fossa volumization using Restylane,
reaction at injection site (itching, swelling, and
available in the “Related Videos” section of the
redness), anaphylactic reaction (generalized rash,
full-text article on PRSJournal.com or, for Ovid
swelling, and shortness of breath), and a drop in
blood pressure.

Brows
Guy G. Massry, MD; Beverly Hills, Calif.
HAG can be used to lift the temporal brow10
and fill primary or secondary (postsurgical) upper
eyelid hollows.11,12 The author has found fewer
contour issues, blue color changes, and hydro-
philic reactions in the upper periorbita as com-
pared with its lower counterpart. This has allowed
a slightly more aggressive approach to injection as
more “room for error” may exist with eyebrow/
upper eyelid injections. This upper/lower eyelid
Video 6. Supplemental Digital Content 6, demonstrating discrepancy may be explained by assessing how
Dr. Moradi’s personal technique for temporal fossa volumiza- HAG fillers clinically behave in these distinct
tion using Restylane, is available in the “Related Videos” section locations. Recently, anatomic cadaveric studies
of the full-text article on PRSJournal.com or, for Ovid users, at of Juvederm injected deeply to the eyebrow and
http://links.lww.com/PRS/B454. infraorbital hollows have shown very different

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 Plastic and Reconstructive Surgery • November Supplement 2015

patterns of migration of the gel after treatment. In over the backstop of the frontal bone, an elegant
the lower eyelid/cheek interface, the gel tends to way to improve contour and the overall result in
spread from deep to superficial and is present in general.12 Typically, 0.5–1 cc of filler is sufficient
multiple planes, while below the eyebrow it stays as more than subtle changes can look artificial.
deep, suggested to be impeded by fibrous septa Restylane is preferred here as its biophysical char-
within the brow fat pad.13,14 This may explain, in acteristics promote a 3-dimensional lift.
part, why edema, color, and contour changes are When addressing upper eyelid hollows, espe-
less frequently encountered in this site. cially after previous overresected blepharoplasty
Volumetric expansion of the subbrow tissue (A-frame deformity), the “lift, inject, massage”
is the principal behind filler-induced brow lift- technique described above is especially useful.12
ing. The author initially noted this potential years In the author’s experience, these combined
ago prior to injecting filler by observing the same maneuvers are more reliable and require less
effect when injecting local anesthetic during brow product than attempting to fill the eyelid hollow
lifting surgery. This has also been shown in the or “black hole” directly. After fill and “massage on
office setting.15 As with infraorbital hollow HAG bone,” when the lid returns to its native position,
filler injections, the skin is prepped, regional the contoured and smooth dispersion of the HAG
nerve blocks (lacrimal/supraorbital) are given, imparts a very natural appearance (Fig. 12). A half
and a cannula entry port is created just lateral cc of filler is often a good starting point in this sce-
to the outer brow. A 25-gauge 1½-inch cannula nario. As a general rule, avoid injecting the eyelid
is advanced parallel to the supraorbital rim just proper (below the rim) to prevent an inadvertent
above bone to an appropriate distance assessed alteration in lid position and function.12,15
clinically (typically to the hub of the cannula). Finally, the author recently described a normal
As shown in the accompanying video, after initial age-related depression at the nasal eyebrow/eye-
resistance from connective tissue elements (a pop lid transition, which has been called the “orbito-
is felt when penetrated), the cannula moves freely glabellar groove” related to its adjacent anatomic
in this plane without resistance. (See Video, Sup- structures.16 This periorbital hollow is continuous
plemental Digital Content 7, which demonstrates with the nasojugal groove (tear trough) at the
Dr. Massry’s personal technique for using HAG lower lid/cheek interface. Like in the infraorbital
filling for the brows, available in the “Related Vid- area, this depression can be effaced with small
eos” section of the full-text article on PRSJournal. amounts of 0.3–0.5 cc of filler. In this location, the
com or, for Ovid users, at http://links.lww.com/PRS/ author injects mid-depth (to avoid supraorbital
B455.) The gel is injected in a retrograde fashion vascular bundle) with adjunctive massage over the
after aspiration on the plunger. Lifting the brow rim for contour. This is the one area of the eye-
with the noninjecting hand elevates the subbrow brow/eyelid complex in which the author prefers
tissue above the orbital rim which more directly Beloteo as it is softer and less viscous.
and precisely expands this plane. The author has
found this, in combination with massage of the gel Val Lambros, MD, FACS; Newport Beach, Calif.
Eye movement tracking shows that when
people interact, the brows and periorbital areas
are among the most observed part of the face,
along with the mouth and perioral areas. These
are the most expressive parts of the face; a large
amount of meaning can be compressed into a
small geography; hence, small alterations in
these areas can make large differences in the
perceived facial information transmitted and
received. Experience shows that filling the brow
and upper lids can improve the look of the eyes
and periorbital area considerably. Here, a tech-
nique of filling the brow is described using HA
Video 7. Supplemental Digital Content 7, demonstrating fillers (Fig. 13).
Dr. Massry’s personal technique for using HAG filling for the Traditional blepharoplasty techniques, being
brows, is available in the “Related Videos” section of the full-text surgical, have relied on the things that surgery
article on PRSJournal.com or, for Ovid users, at http://links.lww. does best, removing skin and fat. Although there
com/PRS/B455. is a long history of successful patient treatments

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 Volume 136, Number 5S • Injectable Fillers in the Upper Face

Fig. 12. (Above, left) Post–upper blepharoplasty appearance of a woman with hollowed upper lids. (Above, right) Immediately after
fill with Restylane via “lift, inject, massage” technique on left. (Below, left) Immediately after fill with Restylane via “lift, inject, mas-
sage” technique on right. (Below, right) Final result at 6 weeks.
Lambros

doing traditional blepharoplasties, the procedure would seem to be safer to vasoconstrict them to
has its limitations. Being essentially a subtractive avoid arterial embolization. In addition, patients
procedure, the eyelids are defatted, the upper lids do not intuitively understand the idea of filling
become more hollow and defined and the bony the face; it is a visual concept and needs to be
orbit becomes visible. The answer is clearly to fill shown visually. I precede every brow injection
the orbit, but how? with a “local preview” in which about 1–2 cc of
At this time, injected fat is commonly used but local anesthetic with epinephrine is injected into
has some problems with reliability, overgrowth, the brow to demonstrate the intended result.
and irregularities that are difficult to correct. This is difficult to do without some experience,
For these reasons, we prefer the use of HA and the tendency is to make a blobby overfill of
fillers particularly in the brow. I think that it is a the upper lid which is not at all helpful. Small
finer brush than fat … one has more control over strings of local are placed and then massaged
the final contour than fat provides and can eas- into position. It takes a few minutes per eye. The
ily be reversed. The duration of injected HAs in patient is then shown the result and can make
the brow, as well as the temple and lower lid, is at his or her own decision about whether he or she
least 2 years in my experience and a duration of likes it. Patients like this process as it gives them
3–4 years is not uncommon. control over the result; it is like trying on clothes
Technique. before buying them. The location of the product
Although it might be idiosyncratic, I use local placement is in the subQ of the brow, deep to
anesthesia before all HA injection, not just for the orbicularis oculi but not on the periosteum
the numbing effect but for vasoconstriction— where the large vessels can be found. The injec-
there are large vessels in the superior orbit and it tion remains at or superior to the superior orbital

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 Plastic and Reconstructive Surgery • November Supplement 2015

later if necessary. The injected volume per pass is

very small, about 0.02–0.03 cc per pass.
Bruising is always a possibility and the patients
are given ice on leaving.
Complications.
Besides bruising, complications have been low
with this procedure. There have been occasional
irregularities which have been improved by add-
ing more product. I have seen no vascular inci-
dents as the area is vasoconstricted and the plane
of injection is superior to the supraorbital arteries.
Because of the “local preview,” the patients have
Fig. 13. On the patient’s right is shown the approximate area of seen and approved the results of the procedure—
a brow injection. Note that it does not go inferior to the superior like trying on clothes before they buy them—
orbital rim. It is modified according to the patient’s anatomy. On there are remarkably few complaints afterward.
the patient’s left is the pattern of injection. A 1/2-inch 30-gauge The orbital rim and globe should be palpated
needle is used with tiny amounts of filler injected per stroke. before undertaking any injections here; in some
The injection is made at a middle depth, below the orbicularis patients, there is no space between the globe and
muscle but not adjacent to skin or periosteum. the orbital rim and these patients are at risk for a
globe injury if the injection is made too deep.
rim. The upper lid itself is filled by the expansion  . Kent Remington, MD, FRCP; Calgary,
B
of the brow soft tissues. Alberta, Canada
I prefer a 30-gauge 1/2-inch needle, though “Beauti-Phi-ed Eyebrows.”
a cannula may be used as well. I start from lat- Eyebrow restoration and shaping without sur-
erally and place 3 injections per needle stick in gery is a form of biomimicry—trying to mimic
a fanning pattern and proceed to inject across what the patient’s eyebrows looked like say 10
the brow. There are on the average 5 needle years ago. Neuromodulators in a synergistic role
sticks across the brow; thus, there are an average with appropriate HA filler can effectively re-create
15 passes with occasional single injection points the shape and structure of the eyebrow and rees-
where needed in the brow. (See Video, Supple- tablish the peak of the brow in the phi position
mental Digital Content 8, which describes Dr. that is mathematically correct and pleasing to the
Lambros personal technique of filling the brow aesthetic eye. The interplay of agonist and antago-
using HA, available in the “Related Videos” nist muscles, as modified with the application of
section of the full-text article on PRSJournal. neuromodulators, determines not only the degree
com or, for Ovid users, at http://links.lww.com/ of eyebrow expression but also the position of eye-
PRS/B456.) brows in the resting state through static muscle
The most common volume of product used per tension. Choosing the best HA filler and the right
side is 0.5 cc, which can always be supplemented technique re-creates the support and strut work
of the static eyebrow. It is important for all aes-
thetic injectors to fully understand the different
characteristics of HA fillers. These characteristics
include their cohesivity, viscosity, elasticity, plastic-
ity, lift ability, and each fillers complex rheology.
Aesthetic eyebrow restoration and shaping
with injectables begins with a detailed under-
standing of the soft tissue, including the perior-
bital musculature, the skeletal anatomy, and the
importance of the golden ratio of each face. The
technique is based on factors that include detailed
attention to individual animation, appropriate
Video 8. Supplemental Digital Content 8, describing Dr. Lam- dosing of neuromodulator, volume of HA filler,
bros personal technique of filling the brow using HA, is available and where to use cannulas versus needles. Each
in the “Related Videos” section of the full-text article on PRSJour- side of the face is siblings, not twins. This univer-
nal.com or, for Ovid users, at http://links.lww.com/PRS/B456. sal concept is often most apparent in the eyebrow

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 Volume 136, Number 5S • Injectable Fillers in the Upper Face

position—vertical and horizontal. The goal in

eyebrow restoration and shaping is re-creating
balance, harmony, and a pleasing proportion as
perfect symmetry does not exist.
In the ideal feminine eyebrow, the head of
the brow and the tail of the brow are parallel. The
medial head of the brow should be lined up with
the inner canthus and the nasal ala. The “peak”
of the brow in women for the ideal phi should be
lined up with a line drawn from the ala of the nose
and just lateral to the pupil.
Youthful feminine relationship for the eye- Video 9. Supplemental Digital Content 9, demonstrating
brow, the radix, and the dorsum of nose is a cur- Dr. Remington’s personal technique for brow beautification, is
vilinear line. available in the “Related Videos” section of the full-text article
Step 1: A critical part of the first step is the on PRSJournal.com or, for Ovid users, at http://links.lww.com/
detailed approach to baseline with pretreatment PRS/B457.
photographs. It is important and instructive to
have the patients bring in high-resolution photo-
graphs in their twenties. These past photographs to inject through the same lateral eyebrow trocar
are used to evaluate previous harmony symmetry site or in some patients inject a new place just infe-
and eyebrow balance and shape. Combined with rior to this site. (See Video, Supplemental Digital
this step inject your neuromodulator of choice. The Content 9, which demonstrates Dr. Remington’s
eyebrow shaping with the neuromodulator can be personal technique for brow beautification, avail-
done the same day as fillers or days in advance —do able in the “Related Videos” section of the full-
not forget the influence of the superior and lateral text article on PRSJournal.com or, for Ovid users,
orbicularis oculi on the shape of the eyebrow. at http://links.lww.com/PRS/B457.) Like all zones,
Step 2: Carefully reflate and contour the this area has a sweet spot that is just preperios-
radix, glabella zone, and the head of the brow teal and gently push all the way to the zone just
with a G1 HA filler. I often transfer the fillers like above the medial canthus and inject mostly retro-
Voluma, Perlane, or Emervel Classic into BD II grade. I prefer Restylane Silk—in Canada, we call
insulin syringes that are 0.3 mL size and a 8 mm it Restylane Fine Lines and I have used this for 16
length and 31-gauge needle. With this mini setup, years with great confidence.
it is filled for comfort to about 0.2 mL and I inject Blending and molding with cool ultrasound
right in the preperiosteal zone in an anterograde gel is an essential part of the restoration project—
fashion. Molding with cool ultrasound gel is an both the eyebrow and the “a frame.”
important part of the brow restoration project. Step 5: Reflate and contour the deflated zone
Step 3: To reflate and contour the brow, the that is predictably found 1 cm below the temporal
25-gauge 1/2-inch trocar site is lateral at the tail of fusion line and 1 cm above the upper orbital rim.
the brow. Measure with the 27-gauge 37-mm can- I use the BD II minis 31-gauge 8-mm needle setup
nula right to the head of the brow where I have with Voluma in an anterograde fashion lifting the
already injected with my mini syringes. Inject with tail of the brow back and up with the “smart hand”
Voluma, Volift, Perlane, Restylane, or Emervel Clas- at the same time as I inject.
sic just preperiosteal both retrograde and antero- Jonathan M. Sykes, MD
grade tapered medial to lateral with less lateral 2521 Stockton Boulevard, Suite 6200
and more where I have predetermined the peak Sacramento, CA 95817
to be. The noninjectors “smart hand” is a must for jmsykes.ucdavis.edu;
reflating and contouring brows. Injection of HA or
Plastic and Reconstructive Surgery
at the supraorbital crest will force the eyebrow up 8150 Brookriver Drive, Suite s-415
if the brow is above the promontory. Injection of Dallas, TX 75247
HA at the supraorbital crest will force the eyebrow PRS@plasticsurgery.org
down if the brow is at or below the promontory.
Step 4: In this patient, I also reflated and con-
toured the “A Frame” using a 27-gauge 37-mm patient consent
cannula—I prefer the 3 French brands Magic- Patients provided written consent for the use of their
needle—Derma-Sculpt or TSKs. My technique is images.

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 Plastic and Reconstructive Surgery • November Supplement 2015

ACKNOWLEDGMENTS significance of the temporal fat pad. Plast Reconstr Surg. 1989;83:
265–271.
Dr. Swift acknowledges Mondeal Aesthetics for the 6. Gonzales-Ulloa M, Costillo A, Stevens E, et al. Preliminary
video footage they released. The section “Applied Anat- study of the total restoration of the facial skin. Plast Reconstr
omy for Injectable Fillers: Upper Face and Temporal Surg. 1954;13:151.
Region” was written by Jonathan M. Sykes, MD, Sebas- 7. Goldberg RA, Wu JC, Jesmanowicz A, et al. Eyelid anat-
tian Cotofana, MD, PhD, and Patrick Trevidic, MD. omy revisited. Dynamic high-resolution magnetic reso-
nance images of Whitnall’s ligament and upper eyelid
The section “Regional Approaches” was written by Now- structures with the use of a surface coil. Arch Ophthalmol.
ell Solish, MD, FRCP, Jean Carruthers, MD, FRCSC, 1992;110:1598–1600.
FRC (OPHTH), Alastair Carruthers, MA, BM, BCh, 8. Hetzler L, Sykes J. The brow and forehead in periocular reju-
FRCPC, FRCP (Lon), Amir Moradi, MD, Arthur Swift, venation. Facial Plast Surg Clin North Am. 2010;18:375–384.
MD, CM, FRCS (C), Guy G. Massry, MD, Val Lam- 9. Javidnia H, Sykes J. Endoscopic brow lifts: have they replaced
coronal lifts? Facial Plast Surg Clin North Am. 2013;21:191–199.
bros, MD, FACS, B. Kent Remington, MD, FRCP. 10. Kornstein AN. Soft-tissue reconstruction of the brow with
Restylane. Plast Reconstr Surg. 2005;116:2017–2020.
11. Morley AM, Taban M, Malhotra R, et al. Use of hyaluronic
REFERENCES acid gel for upper eyelid filling and contouring. Ophthal Plast
1. Davidge KM, van Furth WR, Agur A, et al. Naming the soft Reconstr Surg. 2009;25:440–444.
tissue layers of the temporoparietal region: unifying ana- 12. Hartstein M, Massry G. Volumetric Rejuvenation of the
tomic terminology across surgical disciplines. Neurosurgery Hollow Superior Sulcus-the Final Frontier. 45th Fall Scientific
2010;67(3 Suppl Operative):ons120–ons129. Symposium of American Society of Ophthalmic Plastic and
2. Hussein S, Ascher G, Acland R. Surgical anatomy and blood Reconstructive Surgery, Chicago, Il.; October 16, 2014.
supply of the fascial layer of the temporal region. Plast 13. Griepentrog GJ, Lucarelli MJ. Anatomical position of hyal-
Reconstr Surg. 1976;77:17–24. uronic acid gel following injection to the eyebrow. Ophthal
3. Mitz V, Peyronie M. The superficial musculo-aponeurotic Plast Reconstr Surg. 2013;29:364–366.
system (SMAS) in the parotid and cheek area. Plast Reconstr 14. Griepentrog G, Lemke B, Burkat N, et al. Anatomical posi-
Surg. 1976;58:80–88. tion of hyaluronic acid gel following injection to the infraor-
4. Moss CJ, Mendelson BC, Taylor GI. Surgical anatomy of bital hollows. Opthal Plast Reonstr Surg. 2013;29:35–39.
the ligamentous attachments in the temple and periorbital 15. Lambros V. Volumizing the brow with hyaluronic acid fillers.
regions. Plast Reconstr Surg. 2000;105:1475–1490; discussion Aesthet Surg J. 2009;29:174–179.
1491. 16. Yoo DB, Peng GL, Massry GG. Effacing the orbitoglabel-
5. Stuzin JM, Wagstrom L, Kawamoto HK, et al. lar groove with transposed upper eyelid fat. Ophthal Plast
Anatomy of the frontal branch of the facial nerve: the Reconstr Surg. 2013;29:220–224.

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