Abstract
The area of the upper face occupies about one third of the surface area of the whole face. The anatomical landmarks involve the forehead, brow, glabella and the upper lids. Gravitational and intrinsic changes, as well as familial problems affect the aesthetics of the upper face. The author describes the anatomy and pathophysiology of ageing and the importance of making a correct diagnosis. Surgical and non surgical solutions are discussed. The concept of the beneficial effect of antioxidants such as curcumin is introduced. The efficacy of non ablation laser in dermal rejuvenation is explained. The author aims to impart a thorough understanding of the different surgical and non-surgical options for rejuventating the upper face to achieve an unoperated outcome with a healthy looking forehead.
The upper face is a dynamic, expressive area of the face. Da Vinci’s facial division of one-third gives a boundary from the hairline to the glabella areas. Farkas quantified this area as approximately 61.9 mm 2 . In reality, because it is in a region of expressions, emotions and personality, the upper face should include the forehead, brows, glabella, upper eyelids and up to the lateral canthal ligaments. Any rejuvenation attempts should consider these anatomical boundaries in the planning process. The areas to consider are the aesthetics of the forehead, the shape of the eyebrow, upper lid contour and the quality of the skin.
The physiology and the function of the upper face to some degree involve protection of the eye and emotional expression. Three basic pattern of behaviour can be identified regarding the animation of the upper half of the face: eyebrow raising caused by the frontalis activity; frowning using mainly corrugators muscle; and squinting using the orbicularis oculi muscles. The aesthetics of the upper face as a unit affect young and older patients; in addition the latter will exhibit the ageing process. This is in contrast to the aesthetics of the mid and lower face where ageing plays a major role as a result of gravitational and intrinsic changes.
The quality of the skin of the forehead and the upper lid is similar to the rest of the face and is affected by chronological ageing and photoageing. Chronological or intrinsic skin ageing is a universal and inevitable process characterized primarily by physiological alterations in skin function. In contrast, photoageing results from excessive exposure to the ultraviolet radiation (UVR) of sunlight and thus becomes apparent in sun-exposed skin such as the forehead. These two overlapping, simultaneously occurring, processes contribute to the overall changes in skin ageing. Chronologically aged skin appears dry and pale with fine wrinkles and a certain degree of laxity and has a variety of benign neoplasms. Age-associated decrements of epidermal and dermal components are responsible for most of these changes. In the stratum corneum, the average thickness and the degree of compaction do not change with age. However, the keratinocytes are unable to properly terminally differentiate to form functional stratum corneum, and the rate of formation of neutral lipids and other elements that contribute to the barrier function slows. Together with atrophy of eccrine glands, these events precipitate dry skin in the elderly. On the other hand, photodamaged skin appears dry and shallow and displays both fine wrinkles and deep furrows. Extensive telangiectasias, freckling, lentigines, guttate hypermelanosis and premalignant lesions such as actinic keratosis are frequently observed. The main histological change is disorganization of the epidermal and dermal components associated with elastosis and heliodermatitis.
The muscles of the forehead are divided according to their function as elevators or depressors ( Fig. 1 ). The medial and lateral elevators are the frontalis muscles. The medial depressors are the corrugator supercilli, procerus and the depressor orbicularis oculi, whereas the lateral depressors are the lateral fibres of the orbicularis oculi muscles.
The aesthetics of eyebrow changes with time and trend also depend on ethnicity, so any correction should take these into consideration. Ideal eyebrow definition ( Fig. 2 ) is where the medial end of the brow, lateral canthus and alar of the nose are in an oblique line. The lateral and medial ends are in the same horizontal line; and the apex of the brow is in a vertical line directly above the lateral limbus. However, an anthropometric analysis failed to fall into the Westmore guidelines. Other studies in various populations quantify some of the differences among and within ethnic groups and demonstrate how far these measurements diverge from Caucasian ideals. Planning aesthetic improvement should therefore consider anthropometric measurements, time, trend and ethnicity.
The sensory innervation of the forehead includes the supraorbital, supratrochlear and zygomatico temporal nerves. The main motor nerve is the frontal branch of the facial nerve and knowledge of its spatial position and depth is of paramount importance to the surgeon. Other anatomical structures such as the retro-orbicularis oculi fat (ROOF), the periosteum of the forehead, medial fat herniation of the upper lid and the laxity of the lateral canthal ligaments play a major role in upper face aesthetics.
Clinical presentations
Clinical presentations requiring upper face rejuvenation are skin quality, the multiple lines of the forehead, glabella and crow’s feet, lateral and medial brow ptosis, hooding of the upper lid, medial fat herniation, and prominence of the lachrymal glands with malpositioned ROOF.
The lines, such as minor wrinkles and deep furrows, are caused by a combination of muscle overactivity and secondary skin creases. Horizontal lines are caused by the overactive frontalis fibres of the oblique corrugator. Vertical lines are caused by the overactivity of the corrugator supercilli and related muscles. Horizontal frown lines are caused by the procerus and crow’s feet are caused by orbicularis oculi contraction.
Any rejuvenation process should involve a variety of techniques so that the outcome provides an unoperated look. The Hollywood wind tunnel effect, plumbed upper lips, and wobbly chin implants are features that give aesthetic facial surgery a poor reputation in the surgical community. Aesthetic reconstruction should aim to provide a pleasing outcome, which should be the norm in deformity, trauma surgery and to some degree in oncological surgery. In order to provide such an outcome the surgeon should understand how to improve the skin quality using surgical and nonsurgical procedures. The balanced result is akin to a gourmet dish in which the components are not visible but the final product is excellent.
The skin is affected by thinning of the epidermis, with change in its biochemical status resulting in melasma and cholasma, seborrhoic and actinic keratosis. The latter are common presentations in middle aged and elderly patients whereas the former two are predominant in females during pregnancy and the post-menopausal stages of their lives. It has been suggested that melanocytes have oestrogen receptors. The structural changes in the dermis enhance the horizontal lines.
Non-surgical options
Depigmentation treatment of the facial skin has become a major industry in the UK in recent times. The ideal depigmenting agent must act on melanocytes, must not have melanotoxic effects, must induce abnormal pigment elimination without producing hypopigmentation and must be able to intervene at various stages of melanogenesis.
Varied non-surgical techniques are available to enhance the quality of the forehead skin. Dryness is the fundamental cause of most of the problems. The mechanisms should involve reducing transepidermal water loss by reconstituting the lipid components of the stratum corneum and promoting corneocyte desquamation. Hydrodermabrasion using propulsion of saline via small nozzles at 200 m/s supersonic speed will clean dead cells, open pores and allow nutrients into dermis and subdermal planes. Histologically proven evidence supports this revolutionary treatment. Nourishing the stratum corneum is achieved using this technique.
Turmeric is an antioxidant, antimicrobial and anti-inflammatory natural substance. It has been used for centuries in the Far East for treating skin ailments. The active ingredient is curcumin which has the potential to aid skin rejuvenation by enhancing structural repair of dermis and epidermis. Curcumin increases the local and systemic antioxidant status and the levels of vitamin C and E, while it decreases lipid peroxidation and DNA damage by reducing the oxidation stress.
The other non-surgical measures that have played a major role in the last 10 years are fillers. The fillers are synthetic and natural agents. The best natural agent is the patient’s own fat. The limitations are that it needs to be harvested and cannot be stored due to strict regulatory guidelines. The benefits are that it is the patient’s own fat and it can be introduced in large quantities when voluminizing particularly the periorbital and midface areas. The most popular filler is the non-animal based hyaluronic acid. It is a glycosaminoglycan biopolymer found naturally in the skin which can hold moisture in the dermis. During the ageing process, the amount of natural hyaluronic acid decreases leading to dermal dehydration and formation of clinically visible rhytides. When injected into a dermal and subdermal plane these join forces with the body’s own ground substance to create support and volume for a limited period until self degradation takes place in the liver forming carbon dioxide and water. Botulinum toxin prevents presynaptic acetylcholine release, which results in inhibition of the calcium activated release of acetylcholine. Lack of acetylcholine at the post-synaptic receptor prevents muscle contraction. This physiological denervation eliminates muscle pull on the skin and temporarily reduces the appearance of the dynamic lines of facial expressions. Manipulation of depressors and elevators of the forehead will reduce the lines of the forehead, glabella and crow’s feet. To achieve a longer lasting aesthetic response, hyaluronic acid can be combined with botulinum toxin. The author also uses hydromicrodermabrasion followed by botlinum toxin and hyaluronic acid filler and concludes the rejuvenation treatment with minimal ablation laser resurfacing with an Erbium laser. Application of non-ablation fractional resurfacing has been shown to improve the eyelid aperture and tightening.
In recent years, erbium has taken over from carbon dioxide laser as the main resurfacing modality. The main benefits are the reduced downtime, minimal thermal injury and the ability to titrate the laser energy towards the patient’s requirements. The variable square pulse (VSP) technology of the latest laser technology provides the ability while the laser pulses provide unrivalled safety by avoiding the slow rise of laser pulse power and the even longer fall in pulse power. This provides precision, patient comfort, and safety with an excellent outcome. The erbium laser has the ability to carry out epidermal resurfacing, with minimal ablation in a smooth mode and minimal ablation with dermal regeneration in a fractional mode. In the author’s practice, erbium usage supersedes chemical peel and microdermabrasion although they are used in many centres with good effect.
There are three basic ways in which the shape of the forehead can be altered: the myotomy of the facial expressive muscles which causes brow depressions; chemical denervation of facial expression muscles; and shifting the forehead backward to elevate the brow by surgical intervention. The myotomy will be limited to the glabellar muscles and this can be achieved on its own via a trans upper blepharoplasty approach and chemical denervation by serial injection of botulinum toxin.
Non-surgical options
Depigmentation treatment of the facial skin has become a major industry in the UK in recent times. The ideal depigmenting agent must act on melanocytes, must not have melanotoxic effects, must induce abnormal pigment elimination without producing hypopigmentation and must be able to intervene at various stages of melanogenesis.
Varied non-surgical techniques are available to enhance the quality of the forehead skin. Dryness is the fundamental cause of most of the problems. The mechanisms should involve reducing transepidermal water loss by reconstituting the lipid components of the stratum corneum and promoting corneocyte desquamation. Hydrodermabrasion using propulsion of saline via small nozzles at 200 m/s supersonic speed will clean dead cells, open pores and allow nutrients into dermis and subdermal planes. Histologically proven evidence supports this revolutionary treatment. Nourishing the stratum corneum is achieved using this technique.
Turmeric is an antioxidant, antimicrobial and anti-inflammatory natural substance. It has been used for centuries in the Far East for treating skin ailments. The active ingredient is curcumin which has the potential to aid skin rejuvenation by enhancing structural repair of dermis and epidermis. Curcumin increases the local and systemic antioxidant status and the levels of vitamin C and E, while it decreases lipid peroxidation and DNA damage by reducing the oxidation stress.
The other non-surgical measures that have played a major role in the last 10 years are fillers. The fillers are synthetic and natural agents. The best natural agent is the patient’s own fat. The limitations are that it needs to be harvested and cannot be stored due to strict regulatory guidelines. The benefits are that it is the patient’s own fat and it can be introduced in large quantities when voluminizing particularly the periorbital and midface areas. The most popular filler is the non-animal based hyaluronic acid. It is a glycosaminoglycan biopolymer found naturally in the skin which can hold moisture in the dermis. During the ageing process, the amount of natural hyaluronic acid decreases leading to dermal dehydration and formation of clinically visible rhytides. When injected into a dermal and subdermal plane these join forces with the body’s own ground substance to create support and volume for a limited period until self degradation takes place in the liver forming carbon dioxide and water. Botulinum toxin prevents presynaptic acetylcholine release, which results in inhibition of the calcium activated release of acetylcholine. Lack of acetylcholine at the post-synaptic receptor prevents muscle contraction. This physiological denervation eliminates muscle pull on the skin and temporarily reduces the appearance of the dynamic lines of facial expressions. Manipulation of depressors and elevators of the forehead will reduce the lines of the forehead, glabella and crow’s feet. To achieve a longer lasting aesthetic response, hyaluronic acid can be combined with botulinum toxin. The author also uses hydromicrodermabrasion followed by botlinum toxin and hyaluronic acid filler and concludes the rejuvenation treatment with minimal ablation laser resurfacing with an Erbium laser. Application of non-ablation fractional resurfacing has been shown to improve the eyelid aperture and tightening.
In recent years, erbium has taken over from carbon dioxide laser as the main resurfacing modality. The main benefits are the reduced downtime, minimal thermal injury and the ability to titrate the laser energy towards the patient’s requirements. The variable square pulse (VSP) technology of the latest laser technology provides the ability while the laser pulses provide unrivalled safety by avoiding the slow rise of laser pulse power and the even longer fall in pulse power. This provides precision, patient comfort, and safety with an excellent outcome. The erbium laser has the ability to carry out epidermal resurfacing, with minimal ablation in a smooth mode and minimal ablation with dermal regeneration in a fractional mode. In the author’s practice, erbium usage supersedes chemical peel and microdermabrasion although they are used in many centres with good effect.
There are three basic ways in which the shape of the forehead can be altered: the myotomy of the facial expressive muscles which causes brow depressions; chemical denervation of facial expression muscles; and shifting the forehead backward to elevate the brow by surgical intervention. The myotomy will be limited to the glabellar muscles and this can be achieved on its own via a trans upper blepharoplasty approach and chemical denervation by serial injection of botulinum toxin.
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