Dermal Filler: Safety and Efficacy

Fillers can be used to restore volume loss and contour in the forehead and temples. This is increasingly becoming popular, especially in Asia where a fuller forehead and temples are highly sought after.

As we age, bone resorption, loss of fat and flattening of the muscles at the forehead and temples cause a hollow appearance. Sunken temples give a skeletonized and haggard appearance, affecting the overall balance of the face. Dermal fillers placed in the temples help restore volume loss and smoothen out the important transition between the cheekbones and the forehead, reducing any unnatural shadows. In addition, it provides support and lift to the outer frame of the face, raising the tail of the eyebrows and creates bigger and brighter looking eyes.

On the other hand, loss of volume in the forehead with age causes the brow (orbital) bone to appear more prominent, giving rise to a fiercer and more masculine appearance. Dermal fillers placed in the sunken parts of the forehead help to smoothen out the facial contour and provides a smooth and full forehead.  This creates a more youthful and feminine look.

Loss of forehead volume causes a concave appearance

It is pertinent to note that dermal fillers in the forehead and temples are technically challenging and requires experience. This is because the upper face has important vasculature that if accidentally injected can cause blindness and skin necrosis. The vascular anatomy in the forehead and temples are complex as they transverse from deep to superficial layers in this region. Therefore, knowledge of the vascular anatomy and all tissue layers of the upper face are extremely important so that vascular mishaps can be avoided.

The vasculature (middle temporal vein) of the temple

Important vasculature of the forehead

Secondly, the overlying skin and the muscle of the forehead are very thin. Therefore, the margin for error in injecting filler into the right layer is much smaller. In addition to injecting filler in the right layer in the forehead, the filler product choice is also extremely important to avoid lumpiness and visibility of the filler while balancing the longevity of the product.

The five tissue layers of the forehead

On the other hand, the temples consist of multiple layers. It is the region bounded by the temporal crest of the skull above, the orbital rim (eye socket) and zygoma (cheekbone) below. Again, understanding of the anatomy is extremely important and experience plays a part in injecting dermal filler into the right layer to avoid lumpiness or uneven filling if injected too superficially versus downward filler migration (as the deep fat layer of the temples is connected to the deep fat pad of the cheek) and lack of significant results if injected too deep.

Dermal fillers for the forehead and temples can be injected either using a needle or blunt tip cannula. The use of a needle to inject fillers in the temples (single point) and forehead (multiple points) is relatively straightforward. To avoid entry of the important vessels, the sharp tip of the needle should be on bone in a perpendicular fashion before injecting the filler slowly. Thereafter, the product is massaged and to be even out. However, this means that much more product will be needed in order to get a significant volumisation.

The use of a blunt cannula on the other hand allows an experienced injector to deliver the filler more superficially. This in turn translates to more efficient use of product as less volume of the product is needed to create a significant volumisation and aesthetic outcome. Further a blunt tip cannula helps to reduce the risk of entry and injury to the blood vessels in the forehead and temples. This however requires experience and clear identification of the correct and safe layers for filler injection using a cannula.

Grey and Purple circles denote entry points for the cannula technique. Yellow denotes injection point using needle-on-bone technique

Temple injection using the cannula technique

In addition, filling of the forehead and temples can be done through the use of the same entry points. This helps to reduce unnecessary creation of additional entry points using a needle, reducing pain and the risk of bruising. It is my philosophy as an injector to provide the best possible results with the least discomfort and downtime as possible for my patients.

In summary, dermal fillers for the forehead and temples can provide a more youthful appearance through restoring volume loss and facial contouring. However, filling the forehead and temples region requires a thorough understanding of the anatomy of different tissue layers and course of the important blood vessels that if occluded can lead to vision loss. Therefore, upper face fillers should be best done by an experienced injector. In addition, the injector should ideally be comfortable to use both the needle and cannula techniques in order to provide the best results with the least downtime and discomfort as possible.

Written by Dr. David Deng,

MBBS,MRCS