Forehead treatments: dermal fillers or BOTOX?

The most common aesthetic concern that patients present with in relation to their forehead is lines and wrinkles – but how do you treat them? Do you immediately reach for the botulinum toxin or Botox®, or do you decide you need some dermal filler instead? After all, there are many other indications for cosmetic enhancement of the forehead, it is not all about horizontal lines.

In this blog, Dr Tim Pearce explains the vascular and muscular anatomy of the forehead, he looks at treatment indications for the use of both dermal filler and botulinum toxin, what you need to know to avoid complications, the types of techniques to use – needle versus cannula, and the best type of dermal filler product to use in the forehead.

Dr Tim will be discussing more medical aesthetic training tips as part of his upcoming webinar series, so if you’re looking to increase your CPD-certified learning and want to learn more skills to make you a better practitioner, then step one is to register for the free webinars by Dr Tim.

Aesthetic treatment indications for the forehead

When thinking about treating the forehead, we must start by thinking about the ideal forehead shape for a male or female face – they do differ. Here are some of the presentations and concerns you may encounter:

• Lines and wrinkles – horizonal lines are dynamic wrinkles caused by the raising of the eyebrows; these can be simply and effectively treated with botulinum toxin.
• Loss of the feminine arch – this presents one of the earliest signs of ageing in the female face. The arch of the eyebrow begins to settle downwards by 1-2 millimetres, resulting in a more flat or linear eyebrow appearance as ageing progresses. From a patient’s early thirties, the aesthetic clinician can combine a small brow lifting effect when delivering botulinum toxin treatments to other areas of the upper face. Complete loss of the eyebrow arch, often combined with heaviness in the eyelids, comes later in life

• Forehead volume loss – this presentation is due to a reduction in the lateral frontal fat pad which causes the appearance of a static wrinkle just above the eyebrow that will not respond to botulinum toxin treatment. It can, however, be addressed with careful volume replacement using dermal fillers. Adding volume to the frontal fat pads will result in a harmonisation of the forehead shape and stop skeletal show of the valley between the frontal eminence and the periorbital ridge. Similarly, there are female patients who may benefit from volume enhancement in this area if they have a recessed frontal eminence, or a more masculine appearance to their forehead, such that it slopes backwards.

Forehead anatomy

Within the tissues of the forehead, we have fat, connective tissue, muscles, skin, bone, blood vessels, nerves, arteries, and veins. When injecting cosmetic products in this area, our biggest concern is the arterial blood supply because the blood vessels in the forehead come from the ophthalmic artery and are derived from the internal carotid blood supply. Therefore, it is vital to understand which areas of the forehead are most vulnerable to vascular compromise.

The vasculature of the forehead is very well described. The supraorbital artery runs parallel with the inside of the iris of the eye – picture a line drawn upwards on the forehead from the iris. Medial to this, in the frontal notch, you will find the supratrochlear artery. Both these arteries will stay deep for approximately 1.5-2 centimetres from the periorbital ridge. Hence, this is an area where you should never put a needle – it is a significant danger zone.

From this point, the vessels start making their way up the forehead more superficially, decreasing in size, and crossing the frontalis muscle, eventually remaining on top of the frontalis where they supply blood to both the skin and muscle. The nerves follow the same path.

Understanding the vascular anatomy of the forehead means that aesthetic clinicians can determine safe injection patterns.

Don’t forget that limited edition anatomy posters are available to buy for your aesthetic business as a helpful reminder of core facial vasculature.

Forehead musculature

Looking at the muscles in the forehead, the frontalis muscle is sandwiched between the skin and hypodermis above it and the loose areolar tissue beneath. Understanding these planes is important for placement of both botulinum toxins and dermal fillers, allowing you to correctly reach the optimal depth for treatment through tactile feedback.

For example, when delivering a botulinum toxin treatment to the forehead you will notice that it is difficult to pass the needle through the tissue initially, suddenly becoming easier. This moment is the transition from the dermis into the hypodermis. Beyond that point, you will notice a difference as you hit the muscle and eventually land down on the hardness of bone.

The optimal placement for the toxin is in the intermediate space between the dermis and the muscle where injection is easier, product movement and spread are not constricted, and the nerves are present just on top of the muscle layer. There is also no risk of blocking an artery with botulinum toxin treatment.

Contrastingly, with dermal filler treatment, you need to be beneath all the arteries present in the forehead so your injections must be deeper, and ideally done using a blunt cannula rather than a sharp needle. If you choose to use a needle, placement ought to be on the periosteum, at least 2 centimetres above the periorbital ridge, with the intention of being underneath the arteries. Dr Tim prefers to perform dermal filler volumising treatments in the forehead using an approach with the blunt cannula at a 90° angle to the arteries in the forehead, to minimise the risk of vascular compromise or occlusion.

Using a cannula also allows for slower injections, thorough observation, and fan-like movements around the area without the need for additional insertion points, or the risk of deposition of large product boluses.

The use of blunt cannula is ideal in this area where clinicians aim to replace lost fat pads and movement is not as pronounced as we see in the chin and jawline where a needle technique may be preferable for an optimal aesthetic result. Read our recent blog which includes 6 tips for safe practice when performing chin augmentation and discusses the pros and cons of cannula versus needle.

Which dermal filler should I use in the forehead?

Although we are replacing volume in the forehead fad pads, the area is relatively thin so a dermal filler product indicated for volumising cheeks, and the mid-face would not be appropriate for use in volumising the forehead; it would be very visible. Aesthetic clinicians should use a softer hyaluronic acid-based product in this area, such as Juvederm® Volbella or Volift.

Why not get in touch with SkinViva Academy to secure your place on one of the many available training courses in mastering dermal filler treatments, including the use of cannulas.

Aesthetics Mastery Show

FOREHEAD ANATOMY: When to use toxin vs filler & how to avoid complications

This blog follows our recent Aesthetics Mastery Show, in which Dr Tim Pearce discusses when to use filler in the forehead vs toxin. He reviews the vital anatomy you need to know in order to avoid complications and considers needle vs cannula as well as what type of filler is best in the forehead.

Are you still anxious about delivering cosmetic injectables safely?

If you want to learn more about mastering medical aesthetic treatments and complications or conquering the anxiety of where to place your needle, then register for the next Dr Tim webinar.

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Dr Tim Pearce eLearning

Dr Tim Pearce MBChB BSc (Hons) MRCGP founded his eLearning concept in 2016 in order to provide readily accessible BOTOX® and dermal filler online courses for fellow Medical Aesthetics practitioners. His objective was to raise standards within the industry – a principle which remains just as relevant today.

Our exclusive video-led courses are designed to build confidence, knowledge and technique at every stage, working from foundation level to advanced treatments and management of complications.

Thousands of delegates have benefited from the courses and we’re highly rated on Trustpilot. For more information or to discuss which course is right for you, please get in touch with our friendly team.