Forehead Lift Using Botulinum Toxin

Forehead Lift Using Botulinum Toxin Abstract Background The principle of dynamic muscular activity affecting eyebrow height and shape is well known. We postulate that similarly, dynamics of the fronto-galea-occipital muscles affect forehead height. Objectives To present a forehead lift technique using Botulinum toxin injection and evaluate its clinical efficacy and safety. Methods Twenty-nine female patients comprised the study group. Forty units of prepared abobutolinumtoxinA (Dysport, 10 U/0.05 mL) were injected into 4 points in the hair-bearing scalp, simulating the points of frontalis origin. The glabella and forehead regions were treated with 50 U each. Standard photographs and measurements were taken before and at 2 weeks following treatment. Forehead height was measured bilaterally drawing a vertical line from mid-pupil to frontal hairline (MPFH) and from medial canthus to frontal hairline (MCFH). We assessed outcome differences in patients with low vs high forehead (cutoff value 5.5 cm forehead height). Results Mean age was 48 years (range, 29-66 years). Two weeks following treatment, mean frontal height had increased significantly in all measurement points (MCFH right: 4.1 ± 1.8 mm, MCFH left 4.4 ± 1.8 mm, MPFH right 4.4 ± 2.0 mm, MPFH left 4.7 ± 2.3 mm; P <0.001). Low forehead subgroup achieved significantly higher forehead lift compared with high forehead subgroup both in MCFH (6.9% ± 2.0% vs 5.3% ± 2.2%, P = 0.043) and MPFH (8.6% ± 2.5% vs 5.7% ± 2.6%, P = 0.008). No adverse events were documented in any participant. Conclusions Botulinum toxin type A injection into frontalis origin can effectively and safely extend forehead height in selected patients. The effect of this technique is greater on patients with low foreheads. Level of Evidence: 4 The principle of dynamic muscular activity governs the interplay between agonist and antagonist functions of facial musculature, and applies for various aesthetic manifestations, such as brow position, shape and height, eyelid position, jawline definition and contour, and possibly forehead height and shape.1 First proposed by Isse in 1994,2 this principle served a fundamental role and was the rationale for endoscopic forehead lift: weakening through myotomy, the primary brow depressors, ie, the corrugator, procerus, depressor supercilii, and orbital portion of the orbicularis oculi muscles allows the primary brow elevator, the frontalis muscle, to raise the brow to the desired position. Another surgical application of this innovative concept, selective orbicularis myectomy, was described by Fagien3 for the treatment of minor degree upper eyelid ptosis for mild lid tissue/fold asymmetries. Weakening by selective myectomy of the primary lid depressor (the orbicularis oculi muscle) enables the primary lid elevators (the levator and the Müller muscle) to raise the upper lid and improve symmetry. Selective chemodenervation using botulinum toxin type A was substantiated as an effective modality to elevate the eyebrow, the temporal brow,4 and the jawline5 by alleviating the brow depressor, the orbital portion of the orbicularis oculi muscle, and the platysma, respectively. By negating the action of these protagonists (target and active muscles) the respective antagonists are left to act unopposed, thus exhibiting overactivity.5 The aim of the present study was to determine whether targeted paralysis of the downward pull of the forehead, through directed injection of botulinum toxin A to the cranial fibers of the frontalis muscle, results in forehead elevation from the unopposed action of the occipitalis muscle. Anatomic Considerations The epicranius (occipitofrontalis) is a broad musculofibrotic layer covering the entire scalp from the nuchal line to the eyebrows. It consists of 2 parts—the occipitalis and the frontalis, connected by an intervening tendinous aponeurosis, the galea aponeurotica. The galea is firmly attached to the overlying skin by the firm superficial fascia which continues as the temporoparietal fascia (eventually attaching to the zygoma). On its deep surface, the galea is connected to the pericranium by loose connective areolar tissue in the subgaleal plane which allows movement of the galea and the scalp.1 Based on fresh cadaver dissections, Knize6 concluded that the movement between the deep galea plane and the subgaleal plane allowed less than 6 to 8 mm of mobility in the superior forehead area (up until the lower 2 to 2.5 cm of the forehead). In the inferior forehead area (the lower 2 to 2.5 cm of the forehead) no movement occurred between the deep galeal plane and the subgaleal plane because here, these layers were fused with the periosteum. The frontalis is a thin bi-belly quadrilateral muscle in the anterior scalp. It originates from the galea aponeurotica at or in front of the coronal suture and inserts into the glabellar musculature when the medial fibers intermingle with the procerus while the intermediate fibers mingle with the corrugator superficilii and orbicularis oculi. The medial fibers of the frontalis bellies may be interlaced together for a variable distance above the root of the nose. The lateral margin of the frontalis muscle almost always end or became markedly attenuated along or just lateral to the temporal fusion line and its continuation as the superior temporal line.6 Its course across the forehead is slightly oblique, more lateral superiorly than inferiorly. As a vertically oriented muscle, muscle contraction shortens the muscle fibers in an “accordion-like” effect, thus allowing displacements of the muscle fiber edges both at the origin and at the insertion. The frontalis elevates the eyebrow (at the insertion) and pulls the scalp forward, thus shortening the forehead (as the muscle fibers at the origin point contract). The occipitalis is a thick bi-belly quadrilateral muscle in the posterior scalp. These two-paired muscle bellies lie on the same anatomic plane and act in opposition. While the frontalis muscle pulls the scalp forward, the antagonist muscle, the occipitalis, pulls the scalp backward. METHODS Study Settings and Population The study was conducted at an aesthetic practice during January to June 2016. The study group comprised 29 women aged 29 to 66 years who sought upper-third facial rejuvenation. Signed informed consent was obtained from all participants, emphasizing that the only on-label FDA approved indications for Botulinum toxin type A are glabellar frown lines and crow’s feet. Women of childbearing potential were required to have negative urine pregnancy test results. Exclusion criteria were those who had had previous surgical browlifting procedure, facial cosmetic procedure planned during the study, visible scars, or prior cosmetic procedures that could interfere with the evaluation of response, marked facial asymmetry, blepharoptosis, excessive dermatochalasis, deep dermal scarring, thick sebaceous skin (or an inability to substantially lessen glabellar lines even by physically spreading them apart), myasthenia gravis, Eaton-Lambert syndrome, amyotrophic lateral sclerosis, or any other disease that might interfere with neuromuscular function, profound atrophy, or excessive weakness of the muscles in the target injection areas, history of facial nerve palsy, systemic infection or an infection at the injection site, recent evidence of alcohol or drug abuse, participation in an investigational drug study during the 30 days prior to the study, and treatment with any botulinum toxin serotype within the past 12 months. Prior to treatment, patients were asked to pull down the scalp as low as possible, as if trying to reach the brow. Vertical shortening of the forehead length with this action is an indication for successful treatment. Forceful intentional contraction of the frontalis cranial fibers might recruit the caudal fibers as well, thus amplifying the accordion effect of the frontalis contraction (Figure 1B). However, while brow elevation can be performed voluntarily and upon request, pulling the scalp in a downward position exhibits variable predisposition among patients and it can take several seconds for the patient to pull the scalp down intentionally upon request. This time interval can be explained by the infrequent use of this action and possibly by the corresponding recruitment and pulling forward of the galea and occipitalis. Relaxation of the occipitalis can be verified by palpating cranial movement of the occipitalis. Figure 1. View largeDownload slide Frontal views of a 49-year-old woman. (A) Before treatment in full repose position (MPFH-Rt; MCFH-Rt; MPFH-Lt; MCFH-Lt equal to 6.5; 6; 6.5; 6 cm, respectively). (B) Whilst intentionally asked to pull down scalp. Forceful contraction of the cranial fibers of the frontalis recruits the caudal fibers. Note how the resultant accordion effect of frontalis muscle contraction significantly shortens forehead height. (C) Two weeks following abobotulinumtoxinA (Dysport) injection demonstrating increase in forehead height (MPFH-Rt; MCFH-Rt; MPFH-Lt; MCFH-Lt, equal to 7; 6.5; 7; 6.5 cm, respectively). Figure 1. View largeDownload slide Frontal views of a 49-year-old woman. (A) Before treatment in full repose position (MPFH-Rt; MCFH-Rt; MPFH-Lt; MCFH-Lt equal to 6.5; 6; 6.5; 6 cm, respectively). (B) Whilst intentionally asked to pull down scalp. Forceful contraction of the cranial fibers of the frontalis recruits the caudal fibers. Note how the resultant accordion effect of frontalis muscle contraction significantly shortens forehead height. (C) Two weeks following abobotulinumtoxinA (Dysport) injection demonstrating increase in forehead height (MPFH-Rt; MCFH-Rt; MPFH-Lt; MCFH-Lt, equal to 7; 6.5; 7; 6.5 cm, respectively). The study was IRB approved by Assaf Harofeh Medical Center. Treatment Regimen Lyophilised abobotulinumtoxinA (Dysport, Ipsen Biopharm Ltd., Wrexham, UK) was dissolved in 2.5 cc sterile normal saline to produce a concentration of 10 U/0.05 mL. Prepared abobotulinumtoxinA (Dysport) was administered with a 30-gauge needle on a tuberculin syringe. A total of 140 units of abobotulinumtoxinA (Dysport) were injected directly, as follows: 50 units in 5 points into the glabellar region, and 50 units in 5 points into the forehead region, in accordance with the consensus recommendations.7,8 An additional 40 units were injected in 4 points in the hair-bearing frontal scalp region (Figure 2). These included two discrete points of injection at each hemi-frontal scalp, simulating the point of insertion of the frontalis into the galea aponeurotica. The first point was situated at 1.5 cm inside the hair-bearing region, on a vertical line drawn from the midpupillary line. An additional point was located at 1.5 cm inside the hair-bearing region, on a vertical line drawn from the medial canthus. Figure 2. View largeDownload slide Proposed injection points for forehead lift. Two points are injected at each hemi-forehead. Point 1 corresponds to a vertical line drawn from the medial canthus, 1.5 cm inside the hair bearing scalp. Point 2 corresponds to a vertical line drawn from the mid-pupillary line, 1.5 cm inside the hair bearing scalp. Figure 2. View largeDownload slide Proposed injection points for forehead lift. Two points are injected at each hemi-forehead. Point 1 corresponds to a vertical line drawn from the medial canthus, 1.5 cm inside the hair bearing scalp. Point 2 corresponds to a vertical line drawn from the mid-pupillary line, 1.5 cm inside the hair bearing scalp. Photographic Documentation and Efficacy Outcome Measures Standard photographs were taken of all patients in full repose position before the procedure and 2 weeks following treatment.9 Pretreatment anthropometric measurements were taken dividing the face into horizontal thirds (trichion-nasion, nasion-subnasale, subnasale-gnathion). To objectively evaluate the effect of abobotulinumtoxinA (Dysport) on forehead height, pre- and 2 weeks’ postintervention forehead measurements were taken. All measurements were made by a digital caliper (CD-15 CP, Mitutoyo, Kawasaki, Japan) with a resolution of 0.01 mm. Forehead heights were measured bilaterally from 2 points, in the following manner: the vertical distance from the midpupil to the frontal hairline (MPFH) while the patient was in a predetermined position and height, and the eyes focused on a fixed and constant point in space; and the vertical distance from the medial canthus to the frontal hairline (MCFH). These anatomical landmarks were chosen as reference points to avoid potential measurement bias. All pre- and postmeasurements were taken by the primary investigator (S.C.). Each data set was analyzed for mean, median, minimal value, maximal value, and range. At the 2-week follow up, each patient was evaluated for adverse events (bruising at the injection sites, headache, and brow and lid ptosis) and outcome was assessed anonymously by patients using a validated Global Aesthetic Improvement Scale (GAIS). The 5-point scale ranges from 1 (very much improved) to 5 (worse) and rates global aesthetic improvement in forehead length compared with pretreatment levels. Data Analysis Statistical analysis was performed using SPSS software v24.01 (IBM, USA). Data sets were paired to compare pretreatment and posttreatment measurements at both the MCFH and the MPFH, and were subjected to the Wilcoxon paired test. Subgroup analysis was undertaken to compare improvement of all measurements between patients with short forehead (defined as distance of 5.5 cm or less between trichion and nasion) and long forehead (defined as distance of above 5.5 cm between trichion and nasion) using Mann Whitney test. Statistically significant level was defined as α < 0.05. RESULTS All 29 patients completed the study. Mean age was 48.9 ± 8.4 years (range, 29-66 years). Mean distance for subnasale-gnathion was 6.5 ± 0.5 cm, for nasion-subnasale, 6.2 ± 0.4 cm, and for trichion-nasion, 5.9 ± 0.7 cm (Table 1). Table 1. Baseline Characteristics and Anthropometric Measurements of Study Patients   Low forehead (≤5.5 cm) N = 12  High forehead (≥5.5 cm) N = 17  P value*  Total N = 29    Mean ± SD  Range  Mean ± SD  Range    Mean ± SD  Range  Age (years)  48.2 ± 7.6  29.0-56.0  49.5 ± 9.1  37.0-66.0  0.77  48.9 ± 8.4  29.0-66.0  Subnasale-gnathion (cm)  6.4 ± 0.5  5.5-7.0  6.6 ± 0.5  5.5-7.5  0.29  6.5 ± 0.5  5.5-7.5  Nasion-subnasale (cm)  6.0 ± 0.5  5.5-7.0  6.3 ± 0.4  5.5-7.0  0.08  6.2 ± 0.4  5.5-7.0  Trichion-nasion (cm)  5.2 ± 0.3  4.8-5.5  6.4 ± 0.4  6.0-7.0  <0.001  5.9 ± 0.7  4.8-7.0  MPFH (cm)                 Right  6.8 ± 0.6  5.6-7.8  7.7 ± 0.7  6.5-8.8  0.001  7.3 ± 0.8  5.6-8.8   Left  6.8 ± 0.6  5.5-7.5  7.8 ± 0.7  6.5-9.0  <0.001  7.4 ± 0.8  5.5-9.0  MCFH (cm)                 Right  6.4 ± 0.7  5.3-7.8  7.1 ± 0.9  5.8-8.5  0.01  6.8 ± 0.9  5.3-8.5   Left  6.3 ± 0.6  5.2-7.5  7.1 ± 0.8  6.0-8.5  0.003  6.8 ± 0.8  5.2-8.5    Low forehead (≤5.5 cm) N = 12  High forehead (≥5.5 cm) N = 17  P value*  Total N = 29    Mean ± SD  Range  Mean ± SD  Range    Mean ± SD  Range  Age (years)  48.2 ± 7.6  29.0-56.0  49.5 ± 9.1  37.0-66.0  0.77  48.9 ± 8.4  29.0-66.0  Subnasale-gnathion (cm)  6.4 ± 0.5  5.5-7.0  6.6 ± 0.5  5.5-7.5  0.29  6.5 ± 0.5  5.5-7.5  Nasion-subnasale (cm)  6.0 ± 0.5  5.5-7.0  6.3 ± 0.4  5.5-7.0  0.08  6.2 ± 0.4  5.5-7.0  Trichion-nasion (cm)  5.2 ± 0.3  4.8-5.5  6.4 ± 0.4  6.0-7.0  <0.001  5.9 ± 0.7  4.8-7.0  MPFH (cm)                 Right  6.8 ± 0.6  5.6-7.8  7.7 ± 0.7  6.5-8.8  0.001  7.3 ± 0.8  5.6-8.8   Left  6.8 ± 0.6  5.5-7.5  7.8 ± 0.7  6.5-9.0  <0.001  7.4 ± 0.8  5.5-9.0  MCFH (cm)                 Right  6.4 ± 0.7  5.3-7.8  7.1 ± 0.9  5.8-8.5  0.01  6.8 ± 0.9  5.3-8.5   Left  6.3 ± 0.6  5.2-7.5  7.1 ± 0.8  6.0-8.5  0.003  6.8 ± 0.8  5.2-8.5  *Wilcoxon paired test. MCFH, medial canthus to frontal hairline; MPFH, mid-pupil to frontal hairline. View Large Statistically significant increase in MPFH and MCFH were documented bilaterally 2 weeks following treatment (posttreatment MCFH right: 4.1 ± 1.8 mm, posttreatment MCFH left 4.4 ± 1.8 mm, posttreatment MPFH right 4.4 ± 2.0 mm, posttreatment MPFH left 4.7 ± 2.3 mm; P < 0.001). Mean increment in all 4 measurement points ranged between 4.1 to 4.7 mm (P < 0.001) (Figures 1 and 3 to 5). Only one patient had a 3 mm decrease in the MCFH. No significant differences were noted between right and left side measurements (MPFH P = 0.48, MCFH P = 0.98), with high correlation (MPFH r2 = 0.95, P<0.001, MCFH r2 = 0.93, P < 0.001). Figure 3. View largeDownload slide Frontal views of a 46-year-old woman in full repose position. (A) Before abobutolinumtoxinA (Dysport) injection (MPFH-Rt; MCFH-Rt; MPFH-Lt; MCFH-Lt, equal to 6.8; 7.4; 6.5; 7.2 cm, respectively). The white spots on the patient’s forehead represent the planned injection sites. (B) Two weeks following forehead lift using abobotulinumtoxin A (Dysport) injection (MPFH-Rt; MCFH-Rt; MPFH-Lt; MCFH-Lt, equal to 7.4; 7.9; 7.2; 7.8 cm, respectively), demonstrating visible forehead elongation. Figure 3. View largeDownload slide Frontal views of a 46-year-old woman in full repose position. (A) Before abobutolinumtoxinA (Dysport) injection (MPFH-Rt; MCFH-Rt; MPFH-Lt; MCFH-Lt, equal to 6.8; 7.4; 6.5; 7.2 cm, respectively). The white spots on the patient’s forehead represent the planned injection sites. (B) Two weeks following forehead lift using abobotulinumtoxin A (Dysport) injection (MPFH-Rt; MCFH-Rt; MPFH-Lt; MCFH-Lt, equal to 7.4; 7.9; 7.2; 7.8 cm, respectively), demonstrating visible forehead elongation. Figure 4. View largeDownload slide Frontal views of a 49-year-old woman in full repose position. (A) Before abobotulinumtoxinA (Dysport) injection (MPFH-Rt; MCFH-Rt; MPFH-Lt; MCFH-Lt, equal to 6.2; 6.5; 6.5; 6.8 cm, respectively). (B) Two weeks following forehead lift using abobotulinumtoxin A (Dysport) injection (MPFH-Rt; MCFH-Rt; MPFH-Lt; MCFH-Lt, equal to 6.6; 6.9; 6.8; 7.2 cm, respectively). Figure 4. View largeDownload slide Frontal views of a 49-year-old woman in full repose position. (A) Before abobotulinumtoxinA (Dysport) injection (MPFH-Rt; MCFH-Rt; MPFH-Lt; MCFH-Lt, equal to 6.2; 6.5; 6.5; 6.8 cm, respectively). (B) Two weeks following forehead lift using abobotulinumtoxin A (Dysport) injection (MPFH-Rt; MCFH-Rt; MPFH-Lt; MCFH-Lt, equal to 6.6; 6.9; 6.8; 7.2 cm, respectively). Figure 5. View largeDownload slide Frontal views of a 27-year-old woman in full repose (MPFH-Rt; MCFH-Rt; MPFH-Lt; MCFH-Lt, equal to 8.2; 9; 8; 8.6 cm, respectively). (A) Before abobutolinumtoxinA (Dysport) injection. (B) Two weeks following forehead lift using abotolinumtoxinA (Dysport) injection (MPFH-Rt; MCFH-Rt; MPFH-Lt; MCFH-Lt, equal to 8.7; 9.4; 8.5; 9.2 cm, respectively). A substantial increase in forehead length is evident. Figure 5. View largeDownload slide Frontal views of a 27-year-old woman in full repose (MPFH-Rt; MCFH-Rt; MPFH-Lt; MCFH-Lt, equal to 8.2; 9; 8; 8.6 cm, respectively). (A) Before abobutolinumtoxinA (Dysport) injection. (B) Two weeks following forehead lift using abotolinumtoxinA (Dysport) injection (MPFH-Rt; MCFH-Rt; MPFH-Lt; MCFH-Lt, equal to 8.7; 9.4; 8.5; 9.2 cm, respectively). A substantial increase in forehead length is evident. Mean subject-rated GAIS scores were 2.05 ± 0.45 (range, 1-3) at 2 weeks posttreatment indicating a “much improved” appearance in forehead length compared with baseline. No adverse events were documented during study follow-up period. Subgroup Analysis The low forehead subgroup (trichion-nasion) included 12 patients. MCFH increment in this group was significantly higher than in high forehead subgroup (right: 5.2 ± 2.0 mm vs 3.9 ± 1.9 mm; P = 0.03; left: 5.6 ± 2.1 mm vs 4.0 ± 2.3 mm; P = 0.046 (Table 2). Forehead height percentage increment was significantly higher in the low forehead subgroup in 3 out of 4 measurement points compared to patients in the high forehead subgroup (MCFH right: 8.3% ± 3.5% vs 5.7% ± 3.0%; P = 0.014; MCFH left: 9.0% ± 3.3% vs 5.7% ± 3.1%; P = 0.008, MPFH right: 6.5% ± 3.0% vs 5.1% ± 2.3%; P = 0.16 and MPFH left: 7.3% ± 2.4% vs 5.4% ± 2.5%; P = 0.02). Table 2. Change in Forehead Height Measurements Two Weeks Following Botulinum Toxin A Treatment   Low forehead (≤5.5 cm) N = 12  High forehead (>5.5 cm) N = 17  P value*  Total N = 29  P value**    Mean ± SD  Range  Mean ± SD  Range    Mean ± SD  Range    MPFH (mm)                   Right  4.4 ± 2.0  2-8  3.9 ± 1.7  1-8  0.57  4.1 ± 1.8  1-8  <0.001   Left  4.9 ± 1.6  2-8  4.1 ± 1.9  0-8  0.18  4.4 ± 2.0  1-10  <0.001  Total  4.7 ± 1.3  2-8  4.0 ± 1.6  0-8  0.13  4.3 ± 1.5  1-10  <0.001  MCFH (mm)                   Right  5.2 ± 2.0  1-8  3.9 ± 1.9  2-10  0.03  4.4 ± 1.8  0-8  <0.001   Left  5.6 ± 2.1  1-8  4.0 ± 2.3  (−3)-7  0.046  4.7 ± 2.3  (−3)-8  <0.001  Total  5.4 ± 1.5  1-8  4.0 ± 1.7  (−3)-10  0.024  4.6 ± 1.7  (−3)-8  <0.001    Low forehead (≤5.5 cm) N = 12  High forehead (>5.5 cm) N = 17  P value*  Total N = 29  P value**    Mean ± SD  Range  Mean ± SD  Range    Mean ± SD  Range    MPFH (mm)                   Right  4.4 ± 2.0  2-8  3.9 ± 1.7  1-8  0.57  4.1 ± 1.8  1-8  <0.001   Left  4.9 ± 1.6  2-8  4.1 ± 1.9  0-8  0.18  4.4 ± 2.0  1-10  <0.001  Total  4.7 ± 1.3  2-8  4.0 ± 1.6  0-8  0.13  4.3 ± 1.5  1-10  <0.001  MCFH (mm)                   Right  5.2 ± 2.0  1-8  3.9 ± 1.9  2-10  0.03  4.4 ± 1.8  0-8  <0.001   Left  5.6 ± 2.1  1-8  4.0 ± 2.3  (−3)-7  0.046  4.7 ± 2.3  (−3)-8  <0.001  Total  5.4 ± 1.5  1-8  4.0 ± 1.7  (−3)-10  0.024  4.6 ± 1.7  (−3)-8  <0.001  *Comparison between low and high forehead subgroup measurements performed by Mann Whitney test. **Comparison of total group measurement change from zero value by Wilcoxon paired test. MCFH, medial canthus to frontal hairline; MPFH, mid-pupil to frontal hairline. View Large DISCUSSION Facial aesthetics has consistently been defined by proportionality. The tri-section canon states equal heights of trichion (hairline) to nasion, nasion to subnasale, and subnasale to gnathion. The forehead comprises the upper third of facial height (trichion to nasion). Farkas et al evaluated this relationship on actual subjects and determined that the average height from trichion to glabella was 57 ± 7 mm for men and 53 ± 6 mm for women.10,11 Accordingly, a forehead height less than 6 cm in men and less than 5.5 cm in women is considered as a short forehead which might benefit from forehead lift. This criterion is in line with the Mckinney criteria for forehead lift (an additional measurement of the distance from mid-pupil to brow of <2.5 cm).12 The first forehead lift, the classic transcoronal browlift has become less favorable due to the occasional hypertrophic scars, scar alopecia, sensory denervation, and hairline elevation. Over the past two decades, rejuvenation of the forehead/brow region has undergone revolutionary transformation from the classic open coronal or anterior hairline brow line to limited-incision techniques such as the endoscopic browlift in the early 1990s and the limited temporal incision browlift. Apart from the inherent need for expensive endoscopic instrumentation, the significant learning curve, the relatively unpredictable results and the tendency towards overelevation of the medial brow have made endoscopic browlift less popular. The quest for minimally invasive facial rejuvenation procedures with no downtime has made botulinum toxin A chemodenervation the most popular cosmetic procedure since 2000. Over the past three decades, botulinum toxin injections have been substantiated as a powerful tool for alleviating dynamic expression wrinkles in diverse cosmetic applications. Strategic application of botulinum toxin can govern the interplay between agonist-antagonist relationship (ie, elevator-depressor or push-pull functions) of facial muscles, thus selectively favoring desired cosmetic result. Ahn et al4 demonstrated a significant brow elevation both at the midpupil line (1.0 mm) and at the lateral canthus (4.8 mm) in 22 consecutive patients following targeted paralysis of the primary depressor of the lateral brow, the orbital portion of the orbicularis oculi muscle. Temporal brow elevation resulted from the unopposed action of the frontalis muscle. The Nefertiti lift5 for jawline elevation and recontouring refers to targeted paralysis of the platysma muscle near the jawline, aiming to release the downward pull of the platysma on the jawline and alleviate the depressor effect. Thus, the skin is released to the elevated muscle lifting action. In selected cases, this technique allows for improved jawline definition and contour.3 The platysma muscle has many similarities with the frontalis in terms of fiber orientation, configuration, resultant wrinkles/creases, and dual functionality both at the origin and insertion. Both muscles are vertically oriented (slightly oblique), and quadrilaterally flat. Their medial fiber interlace for a variable distance at the median line forming a “V” shaped configuration (or inverted “V” in the case of platysma) and both muscles lie on the same anatomic plane. Both have a depressor effect in their cranial portion (or downward-pull effect) on the jawline/cheek and the scalp for the platysma and the frontalis, respectively, and an elevator function (upward-pull effect) on the corresponding caudal portion. With contraction, the platysma elevates the skin over the clavicle, and the frontalis elevates the eyebrows. The principle of dynamic muscular activity, first described by Isse2 for browlift (brow elevator/depressors), served as the basis for endoscopic browlift and later on for chemo-denervation to affect brow position. This principle can be applied similarly to affect forehead length: the occipitalis and the frontalis muscles lie on the same anatomic plane and act in opposition. While the frontalis muscle pulls the scalp forward, the antagonist muscle, the occipitalis, pulls the scalp backward. By negating the action of the cranial fibers of the frontalis (downward pull of the forehead), the respective antagonist, the occipitalis is left to act unopposed, thus exhibiting overactivity. Considering the dynamic muscular forces acting on the scalp, and the above-mentioned similarities between the platysma and the frontalis muscles, we attempted to determine the efficacy of targeted paralysis of the cranial portion of the frontalis muscle on forehead height. Our data demonstrate that significant mean forehead elevation is achieved both at the MCFH (4.3 ± 1.5 mm, P < 0.001) and at the MPFH (4.6 ± 2.9 mm, P < 0.001) (Table 2). This substantial increase in forehead length verifies the role of the cranial fibers of the frontalis in forehead position and illustrates the dynamic muscular forces affecting forehead position and length. Only one patient had a 3 mm decrease in the MCFH. This decrease might be attributed to anatomical variability of the frontalis muscle origin among different individuals13 and variation related to its medial border.14 It is our assumption that the relatively higher percentage increment in MPFH compared to MCFH might be explained by the greater abundance of muscular fibers in the middle portion of the muscle compared to the medial portion. The low forehead subgroup achieved a significantly higher forehead lift compared with the high forehead group both in MCFH (6.9% ± 2.0% vs 5.3% ± 2.2%, P = 0.043) and MPFH (8.6% ± 2.5% vs 5.7% ± 2.6%, P = 0.008). Subjects’ satisfaction with forehead lift using abobutolinumtoxinA (Dysport) injection into the cranial fibers of the frontalis muscle was high with mean GAIS scores of 2 (“much improved”) forehead length compared with baseline. The study group included only female patients. Given the frontal hairline recession in some men, forehead elongation is much less of an aesthetic concern to male patients compared to female patients. Female patients with both low and high forehead length were included. The inclusion of patients with high forehead was twofold: first, to verify our study objective regardless of pretreatment forehead length, thereby omitting selection bias; and second, to compare the percentage of forehead elevation between patients with short vs long forehead. The low forehead subgroup achieved a significantly higher forehead lift than the high forehead group, both in MCFH and MPFH. This observation served as the basis for using this technique, with preference for patients with short forehead. The longevity of browlift using botulinum toxin type A (BTX)-injection is on average 3 to 4 months. This is similar to the documented longevity of BTX injections to other facial areas (ie, glabella and transverse forehead lines). At the 2-week follow up, full response was encountered. However, the median onset of response was at 2 to 3 days following treatment, in accordance with the published data.15,16 This study presents several concerns due to its observational design. First, measurements were performed by the principal investigator alone, which can potentially reduce validity and reliability of the results. Such a possibility was minimized by the primary investigator (S.C.) not knowing the preintervention forehead height when taking the postinjection measurement. Nevertheless, if a measurement bias exists, it is nondifferential and therefore less likely to significantly affect study outcome. Second, intermeasurement variability can be applied to the data set at both the MCFH and the MPFH even though measurements were taken while the patients were in a predetermined position and height, and the eyes were focused on a fixed and constant point in space. However, these anatomical landmarks were chosen as reference points to avoid potential measurement bias. Moreover, taking into consideration that the glabellar musculature was treated as well negates this possibility. Furthermore, if the brow is elevated, forehead length will be shortened due to the accordion effect of the vertically oriented frontalis muscle. Third, one may argue that concomitant treatment of the glabellar musculature and the transverse forehead lines can potentially affect outcome. Nevertheless, chemodenervation of brow depressors and brow elevator have no documented effect on forehead length. Similarly, targeted paralysis of the cranial portion of the frontalis muscle has no direct effect on brow position as the positions of the forehead and brow are affected by two different muscular forces. Yet, we postulate that indirect browlift might be attributed to better spatial orientation of the brow following forehead lift. Finally, the relatively small sample size was chosen primarily to assess technique efficacy and safety. Limitations pertinent to the technique itself are those inherent to the toxin nature (its temporary effect) and the variability in the magnitude of response among different individuals. To the best of our knowledge, forehead lift using botulinum toxin has never been published in the English literature. AbobutolinumtoxinA (Dysport) injection into the cranial fibers of the frontalis can achieve a substantial and visibly appreciable forehead lift. Hence, it is a favorable alternative to surgery in the young patient population and for patients who refuse to undergo surgery or are not surgical candidates. The technique could be especially applicable for patients with a short forehead and might well serve to improve facial aesthetic proportions for this patient population. Forehead lift using botulinum toxin adds to the armamentarium of minimally invasive treatments of the aging and short forehead. CONCLUSIONS The technique presented herein achieved a significant improvement in forehead height. Forehead lift using Botulinum toxin injection is an effective and safe, minimally invasive technique. Although its effect is temporary, it is a favorable alternative to surgery for selected patients and adds to the armamentarium for the treatment of the forehead. We propose to further evaluate this technique using a randomized double-blind controlled clinical trial which will examine its efficacy on a wider population scale and different ethnic and gender subgroups. Disclosures The authors declared no potential conflicts of interest with respect to the research, authorship, and publication of this article. Funding The authors received no financial support for the research, authorship, and publication of this article. REFERENCES 1. Nahai F. Applied anatomy of the face and neck. In: Nahai F, ed. The Art of Aesthetic Surgery: Principles & Techniques . 2nd ed. Vol. II, part VIII. St. Louis, MO: Quality Medical Pubishing; 2011: 1273. 2. Isse NG. Endoscopic facial rejuvenation: endoforehead, the functional lift. Case reports. Aesthetic Plast Surg . 1994; 18( 1): 21- 29. Google Scholar CrossRef Search ADS PubMed  3. Fagien S. The role of the orbicularis oculi muscle and the eyelid crease in optimizing results in aesthetic upper blepharoplasty: a new look at the surgical treatment of mild upper eyelid fissure and fold asymmetries. Plast Reconstr Surg . 2010; 125( 2): 653- 666. Google Scholar CrossRef Search ADS PubMed  4. Ahn MS, Catten M, Maas CS. Temporal brow lift using botulinum toxin A. Plast Reconstr Surg . 2000; 105( 3): 1129- 1135; discussion 1136. Google Scholar CrossRef Search ADS PubMed  5. Levy PM. The ‘Nefertiti lift’: a new technique for specific re-contouring of the jawline. J Cosmet Laser Ther . 2007; 9( 4): 249- 252. Google Scholar CrossRef Search ADS PubMed  6. Knize DM. An anatomically based study of the mechanism of eyebrow ptosis. Plast Reconstr Surg . 1996; 97( 7): 1321- 1333. Google Scholar CrossRef Search ADS PubMed  7. Ascher B, Talarico S, Cassuto Det al.   International consensus recommendations on the aesthetic usage of botulinum toxin type A (Speywood Unit)-Part I: Upper facial wrinkles. J Eur Acad Dermatol Venereol . 2010; 24( 11): 1278- 1284. Google Scholar CrossRef Search ADS PubMed  8. Kane M, Donofrio L, Ascher Bet al.   Expanding the use of neurotoxins in facial aesthetics: a consensus panel’s assessment and recommendations. J Drugs Dermatol . 2010; 9( 1 Suppl): s7- s22; quiz s23. Google Scholar PubMed  9. Yavuzer R, Smirnes S, Jackson IT. Guidelines for standard photography in plastic surgery. Ann Plast Surg . 2001; 46( 3): 293- 300. Google Scholar CrossRef Search ADS PubMed  10. Farkas LG, Katic MJ, Forrest CRet al.   International anthropometric study of facial morphology in various ethnic groups/races. J Craniofac Surg . 2005; 16( 4): 615- 646. Google Scholar CrossRef Search ADS PubMed  11. Farkas LG, Kolar JC. Anthropometrics and art in the aesthetics of women’s faces. Clin Plast Surg . 1987; 14( 4): 599- 616. Google Scholar PubMed  12. McKinney P, Mossie RD, Zukowski ML. Criteria for the forehead lift. Aesthetic Plast Surg . 1991; 15( 2): 141- 147. Google Scholar CrossRef Search ADS PubMed  13. Choi YJ, Won SY, Lee JGet al.   Characterizing the lateral border of the frontalis for safe and effective injection of botulinum toxin. Aesthet Surg J . 2016; 36( 3): 344- 348. Google Scholar CrossRef Search ADS PubMed  14. Spiegel JH, Goerig RC, Lufler RS, Hoagland TM. Frontalis midline dehiscence: an anatomical study and discussion of clinical relevance. J Plast Reconstr Aesthet Surg . 2009; 62( 7): 950- 954. Google Scholar CrossRef Search ADS PubMed  15. Schlessinger J, Monheit G, Kane MA, Mendelsohn N. Time to onset of response of abobotulinumtoxina in the treatment of glabellar lines: a subset analysis of phase 3 clinical trials of a new botulinum toxin type A. Dermatol Surg . 2011; 37( 10): 1434- 1442. Google Scholar CrossRef Search ADS PubMed  16. Moy R, Maas C, Monheit G, Huber MB; Reloxin Investigational Group. Long-term safety and efficacy of a new botulinum toxin type A in treating glabellar lines. Arch Facial Plast Surg . 2009; 11( 2): 77- 83. Google Scholar CrossRef Search ADS PubMed  © 2017 The American Society for Aesthetic Plastic Surgery, Inc. Reprints and permission: journals.permissions@oup.com http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Aesthetic Surgery Journal Oxford University Press

Forehead Lift Using Botulinum Toxin

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© 2017 The American Society for Aesthetic Plastic Surgery, Inc. Reprints and permission: journals.permissions@oup.com
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1090-820X
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1527-330X
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10.1093/asj/sjx162
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Abstract

Abstract Background The principle of dynamic muscular activity affecting eyebrow height and shape is well known. We postulate that similarly, dynamics of the fronto-galea-occipital muscles affect forehead height. Objectives To present a forehead lift technique using Botulinum toxin injection and evaluate its clinical efficacy and safety. Methods Twenty-nine female patients comprised the study group. Forty units of prepared abobutolinumtoxinA (Dysport, 10 U/0.05 mL) were injected into 4 points in the hair-bearing scalp, simulating the points of frontalis origin. The glabella and forehead regions were treated with 50 U each. Standard photographs and measurements were taken before and at 2 weeks following treatment. Forehead height was measured bilaterally drawing a vertical line from mid-pupil to frontal hairline (MPFH) and from medial canthus to frontal hairline (MCFH). We assessed outcome differences in patients with low vs high forehead (cutoff value 5.5 cm forehead height). Results Mean age was 48 years (range, 29-66 years). Two weeks following treatment, mean frontal height had increased significantly in all measurement points (MCFH right: 4.1 ± 1.8 mm, MCFH left 4.4 ± 1.8 mm, MPFH right 4.4 ± 2.0 mm, MPFH left 4.7 ± 2.3 mm; P <0.001). Low forehead subgroup achieved significantly higher forehead lift compared with high forehead subgroup both in MCFH (6.9% ± 2.0% vs 5.3% ± 2.2%, P = 0.043) and MPFH (8.6% ± 2.5% vs 5.7% ± 2.6%, P = 0.008). No adverse events were documented in any participant. Conclusions Botulinum toxin type A injection into frontalis origin can effectively and safely extend forehead height in selected patients. The effect of this technique is greater on patients with low foreheads. Level of Evidence: 4 The principle of dynamic muscular activity governs the interplay between agonist and antagonist functions of facial musculature, and applies for various aesthetic manifestations, such as brow position, shape and height, eyelid position, jawline definition and contour, and possibly forehead height and shape.1 First proposed by Isse in 1994,2 this principle served a fundamental role and was the rationale for endoscopic forehead lift: weakening through myotomy, the primary brow depressors, ie, the corrugator, procerus, depressor supercilii, and orbital portion of the orbicularis oculi muscles allows the primary brow elevator, the frontalis muscle, to raise the brow to the desired position. Another surgical application of this innovative concept, selective orbicularis myectomy, was described by Fagien3 for the treatment of minor degree upper eyelid ptosis for mild lid tissue/fold asymmetries. Weakening by selective myectomy of the primary lid depressor (the orbicularis oculi muscle) enables the primary lid elevators (the levator and the Müller muscle) to raise the upper lid and improve symmetry. Selective chemodenervation using botulinum toxin type A was substantiated as an effective modality to elevate the eyebrow, the temporal brow,4 and the jawline5 by alleviating the brow depressor, the orbital portion of the orbicularis oculi muscle, and the platysma, respectively. By negating the action of these protagonists (target and active muscles) the respective antagonists are left to act unopposed, thus exhibiting overactivity.5 The aim of the present study was to determine whether targeted paralysis of the downward pull of the forehead, through directed injection of botulinum toxin A to the cranial fibers of the frontalis muscle, results in forehead elevation from the unopposed action of the occipitalis muscle. Anatomic Considerations The epicranius (occipitofrontalis) is a broad musculofibrotic layer covering the entire scalp from the nuchal line to the eyebrows. It consists of 2 parts—the occipitalis and the frontalis, connected by an intervening tendinous aponeurosis, the galea aponeurotica. The galea is firmly attached to the overlying skin by the firm superficial fascia which continues as the temporoparietal fascia (eventually attaching to the zygoma). On its deep surface, the galea is connected to the pericranium by loose connective areolar tissue in the subgaleal plane which allows movement of the galea and the scalp.1 Based on fresh cadaver dissections, Knize6 concluded that the movement between the deep galea plane and the subgaleal plane allowed less than 6 to 8 mm of mobility in the superior forehead area (up until the lower 2 to 2.5 cm of the forehead). In the inferior forehead area (the lower 2 to 2.5 cm of the forehead) no movement occurred between the deep galeal plane and the subgaleal plane because here, these layers were fused with the periosteum. The frontalis is a thin bi-belly quadrilateral muscle in the anterior scalp. It originates from the galea aponeurotica at or in front of the coronal suture and inserts into the glabellar musculature when the medial fibers intermingle with the procerus while the intermediate fibers mingle with the corrugator superficilii and orbicularis oculi. The medial fibers of the frontalis bellies may be interlaced together for a variable distance above the root of the nose. The lateral margin of the frontalis muscle almost always end or became markedly attenuated along or just lateral to the temporal fusion line and its continuation as the superior temporal line.6 Its course across the forehead is slightly oblique, more lateral superiorly than inferiorly. As a vertically oriented muscle, muscle contraction shortens the muscle fibers in an “accordion-like” effect, thus allowing displacements of the muscle fiber edges both at the origin and at the insertion. The frontalis elevates the eyebrow (at the insertion) and pulls the scalp forward, thus shortening the forehead (as the muscle fibers at the origin point contract). The occipitalis is a thick bi-belly quadrilateral muscle in the posterior scalp. These two-paired muscle bellies lie on the same anatomic plane and act in opposition. While the frontalis muscle pulls the scalp forward, the antagonist muscle, the occipitalis, pulls the scalp backward. METHODS Study Settings and Population The study was conducted at an aesthetic practice during January to June 2016. The study group comprised 29 women aged 29 to 66 years who sought upper-third facial rejuvenation. Signed informed consent was obtained from all participants, emphasizing that the only on-label FDA approved indications for Botulinum toxin type A are glabellar frown lines and crow’s feet. Women of childbearing potential were required to have negative urine pregnancy test results. Exclusion criteria were those who had had previous surgical browlifting procedure, facial cosmetic procedure planned during the study, visible scars, or prior cosmetic procedures that could interfere with the evaluation of response, marked facial asymmetry, blepharoptosis, excessive dermatochalasis, deep dermal scarring, thick sebaceous skin (or an inability to substantially lessen glabellar lines even by physically spreading them apart), myasthenia gravis, Eaton-Lambert syndrome, amyotrophic lateral sclerosis, or any other disease that might interfere with neuromuscular function, profound atrophy, or excessive weakness of the muscles in the target injection areas, history of facial nerve palsy, systemic infection or an infection at the injection site, recent evidence of alcohol or drug abuse, participation in an investigational drug study during the 30 days prior to the study, and treatment with any botulinum toxin serotype within the past 12 months. Prior to treatment, patients were asked to pull down the scalp as low as possible, as if trying to reach the brow. Vertical shortening of the forehead length with this action is an indication for successful treatment. Forceful intentional contraction of the frontalis cranial fibers might recruit the caudal fibers as well, thus amplifying the accordion effect of the frontalis contraction (Figure 1B). However, while brow elevation can be performed voluntarily and upon request, pulling the scalp in a downward position exhibits variable predisposition among patients and it can take several seconds for the patient to pull the scalp down intentionally upon request. This time interval can be explained by the infrequent use of this action and possibly by the corresponding recruitment and pulling forward of the galea and occipitalis. Relaxation of the occipitalis can be verified by palpating cranial movement of the occipitalis. Figure 1. View largeDownload slide Frontal views of a 49-year-old woman. (A) Before treatment in full repose position (MPFH-Rt; MCFH-Rt; MPFH-Lt; MCFH-Lt equal to 6.5; 6; 6.5; 6 cm, respectively). (B) Whilst intentionally asked to pull down scalp. Forceful contraction of the cranial fibers of the frontalis recruits the caudal fibers. Note how the resultant accordion effect of frontalis muscle contraction significantly shortens forehead height. (C) Two weeks following abobotulinumtoxinA (Dysport) injection demonstrating increase in forehead height (MPFH-Rt; MCFH-Rt; MPFH-Lt; MCFH-Lt, equal to 7; 6.5; 7; 6.5 cm, respectively). Figure 1. View largeDownload slide Frontal views of a 49-year-old woman. (A) Before treatment in full repose position (MPFH-Rt; MCFH-Rt; MPFH-Lt; MCFH-Lt equal to 6.5; 6; 6.5; 6 cm, respectively). (B) Whilst intentionally asked to pull down scalp. Forceful contraction of the cranial fibers of the frontalis recruits the caudal fibers. Note how the resultant accordion effect of frontalis muscle contraction significantly shortens forehead height. (C) Two weeks following abobotulinumtoxinA (Dysport) injection demonstrating increase in forehead height (MPFH-Rt; MCFH-Rt; MPFH-Lt; MCFH-Lt, equal to 7; 6.5; 7; 6.5 cm, respectively). The study was IRB approved by Assaf Harofeh Medical Center. Treatment Regimen Lyophilised abobotulinumtoxinA (Dysport, Ipsen Biopharm Ltd., Wrexham, UK) was dissolved in 2.5 cc sterile normal saline to produce a concentration of 10 U/0.05 mL. Prepared abobotulinumtoxinA (Dysport) was administered with a 30-gauge needle on a tuberculin syringe. A total of 140 units of abobotulinumtoxinA (Dysport) were injected directly, as follows: 50 units in 5 points into the glabellar region, and 50 units in 5 points into the forehead region, in accordance with the consensus recommendations.7,8 An additional 40 units were injected in 4 points in the hair-bearing frontal scalp region (Figure 2). These included two discrete points of injection at each hemi-frontal scalp, simulating the point of insertion of the frontalis into the galea aponeurotica. The first point was situated at 1.5 cm inside the hair-bearing region, on a vertical line drawn from the midpupillary line. An additional point was located at 1.5 cm inside the hair-bearing region, on a vertical line drawn from the medial canthus. Figure 2. View largeDownload slide Proposed injection points for forehead lift. Two points are injected at each hemi-forehead. Point 1 corresponds to a vertical line drawn from the medial canthus, 1.5 cm inside the hair bearing scalp. Point 2 corresponds to a vertical line drawn from the mid-pupillary line, 1.5 cm inside the hair bearing scalp. Figure 2. View largeDownload slide Proposed injection points for forehead lift. Two points are injected at each hemi-forehead. Point 1 corresponds to a vertical line drawn from the medial canthus, 1.5 cm inside the hair bearing scalp. Point 2 corresponds to a vertical line drawn from the mid-pupillary line, 1.5 cm inside the hair bearing scalp. Photographic Documentation and Efficacy Outcome Measures Standard photographs were taken of all patients in full repose position before the procedure and 2 weeks following treatment.9 Pretreatment anthropometric measurements were taken dividing the face into horizontal thirds (trichion-nasion, nasion-subnasale, subnasale-gnathion). To objectively evaluate the effect of abobotulinumtoxinA (Dysport) on forehead height, pre- and 2 weeks’ postintervention forehead measurements were taken. All measurements were made by a digital caliper (CD-15 CP, Mitutoyo, Kawasaki, Japan) with a resolution of 0.01 mm. Forehead heights were measured bilaterally from 2 points, in the following manner: the vertical distance from the midpupil to the frontal hairline (MPFH) while the patient was in a predetermined position and height, and the eyes focused on a fixed and constant point in space; and the vertical distance from the medial canthus to the frontal hairline (MCFH). These anatomical landmarks were chosen as reference points to avoid potential measurement bias. All pre- and postmeasurements were taken by the primary investigator (S.C.). Each data set was analyzed for mean, median, minimal value, maximal value, and range. At the 2-week follow up, each patient was evaluated for adverse events (bruising at the injection sites, headache, and brow and lid ptosis) and outcome was assessed anonymously by patients using a validated Global Aesthetic Improvement Scale (GAIS). The 5-point scale ranges from 1 (very much improved) to 5 (worse) and rates global aesthetic improvement in forehead length compared with pretreatment levels. Data Analysis Statistical analysis was performed using SPSS software v24.01 (IBM, USA). Data sets were paired to compare pretreatment and posttreatment measurements at both the MCFH and the MPFH, and were subjected to the Wilcoxon paired test. Subgroup analysis was undertaken to compare improvement of all measurements between patients with short forehead (defined as distance of 5.5 cm or less between trichion and nasion) and long forehead (defined as distance of above 5.5 cm between trichion and nasion) using Mann Whitney test. Statistically significant level was defined as α < 0.05. RESULTS All 29 patients completed the study. Mean age was 48.9 ± 8.4 years (range, 29-66 years). Mean distance for subnasale-gnathion was 6.5 ± 0.5 cm, for nasion-subnasale, 6.2 ± 0.4 cm, and for trichion-nasion, 5.9 ± 0.7 cm (Table 1). Table 1. Baseline Characteristics and Anthropometric Measurements of Study Patients   Low forehead (≤5.5 cm) N = 12  High forehead (≥5.5 cm) N = 17  P value*  Total N = 29    Mean ± SD  Range  Mean ± SD  Range    Mean ± SD  Range  Age (years)  48.2 ± 7.6  29.0-56.0  49.5 ± 9.1  37.0-66.0  0.77  48.9 ± 8.4  29.0-66.0  Subnasale-gnathion (cm)  6.4 ± 0.5  5.5-7.0  6.6 ± 0.5  5.5-7.5  0.29  6.5 ± 0.5  5.5-7.5  Nasion-subnasale (cm)  6.0 ± 0.5  5.5-7.0  6.3 ± 0.4  5.5-7.0  0.08  6.2 ± 0.4  5.5-7.0  Trichion-nasion (cm)  5.2 ± 0.3  4.8-5.5  6.4 ± 0.4  6.0-7.0  <0.001  5.9 ± 0.7  4.8-7.0  MPFH (cm)                 Right  6.8 ± 0.6  5.6-7.8  7.7 ± 0.7  6.5-8.8  0.001  7.3 ± 0.8  5.6-8.8   Left  6.8 ± 0.6  5.5-7.5  7.8 ± 0.7  6.5-9.0  <0.001  7.4 ± 0.8  5.5-9.0  MCFH (cm)                 Right  6.4 ± 0.7  5.3-7.8  7.1 ± 0.9  5.8-8.5  0.01  6.8 ± 0.9  5.3-8.5   Left  6.3 ± 0.6  5.2-7.5  7.1 ± 0.8  6.0-8.5  0.003  6.8 ± 0.8  5.2-8.5    Low forehead (≤5.5 cm) N = 12  High forehead (≥5.5 cm) N = 17  P value*  Total N = 29    Mean ± SD  Range  Mean ± SD  Range    Mean ± SD  Range  Age (years)  48.2 ± 7.6  29.0-56.0  49.5 ± 9.1  37.0-66.0  0.77  48.9 ± 8.4  29.0-66.0  Subnasale-gnathion (cm)  6.4 ± 0.5  5.5-7.0  6.6 ± 0.5  5.5-7.5  0.29  6.5 ± 0.5  5.5-7.5  Nasion-subnasale (cm)  6.0 ± 0.5  5.5-7.0  6.3 ± 0.4  5.5-7.0  0.08  6.2 ± 0.4  5.5-7.0  Trichion-nasion (cm)  5.2 ± 0.3  4.8-5.5  6.4 ± 0.4  6.0-7.0  <0.001  5.9 ± 0.7  4.8-7.0  MPFH (cm)                 Right  6.8 ± 0.6  5.6-7.8  7.7 ± 0.7  6.5-8.8  0.001  7.3 ± 0.8  5.6-8.8   Left  6.8 ± 0.6  5.5-7.5  7.8 ± 0.7  6.5-9.0  <0.001  7.4 ± 0.8  5.5-9.0  MCFH (cm)                 Right  6.4 ± 0.7  5.3-7.8  7.1 ± 0.9  5.8-8.5  0.01  6.8 ± 0.9  5.3-8.5   Left  6.3 ± 0.6  5.2-7.5  7.1 ± 0.8  6.0-8.5  0.003  6.8 ± 0.8  5.2-8.5  *Wilcoxon paired test. MCFH, medial canthus to frontal hairline; MPFH, mid-pupil to frontal hairline. View Large Statistically significant increase in MPFH and MCFH were documented bilaterally 2 weeks following treatment (posttreatment MCFH right: 4.1 ± 1.8 mm, posttreatment MCFH left 4.4 ± 1.8 mm, posttreatment MPFH right 4.4 ± 2.0 mm, posttreatment MPFH left 4.7 ± 2.3 mm; P < 0.001). Mean increment in all 4 measurement points ranged between 4.1 to 4.7 mm (P < 0.001) (Figures 1 and 3 to 5). Only one patient had a 3 mm decrease in the MCFH. No significant differences were noted between right and left side measurements (MPFH P = 0.48, MCFH P = 0.98), with high correlation (MPFH r2 = 0.95, P<0.001, MCFH r2 = 0.93, P < 0.001). Figure 3. View largeDownload slide Frontal views of a 46-year-old woman in full repose position. (A) Before abobutolinumtoxinA (Dysport) injection (MPFH-Rt; MCFH-Rt; MPFH-Lt; MCFH-Lt, equal to 6.8; 7.4; 6.5; 7.2 cm, respectively). The white spots on the patient’s forehead represent the planned injection sites. (B) Two weeks following forehead lift using abobotulinumtoxin A (Dysport) injection (MPFH-Rt; MCFH-Rt; MPFH-Lt; MCFH-Lt, equal to 7.4; 7.9; 7.2; 7.8 cm, respectively), demonstrating visible forehead elongation. Figure 3. View largeDownload slide Frontal views of a 46-year-old woman in full repose position. (A) Before abobutolinumtoxinA (Dysport) injection (MPFH-Rt; MCFH-Rt; MPFH-Lt; MCFH-Lt, equal to 6.8; 7.4; 6.5; 7.2 cm, respectively). The white spots on the patient’s forehead represent the planned injection sites. (B) Two weeks following forehead lift using abobotulinumtoxin A (Dysport) injection (MPFH-Rt; MCFH-Rt; MPFH-Lt; MCFH-Lt, equal to 7.4; 7.9; 7.2; 7.8 cm, respectively), demonstrating visible forehead elongation. Figure 4. View largeDownload slide Frontal views of a 49-year-old woman in full repose position. (A) Before abobotulinumtoxinA (Dysport) injection (MPFH-Rt; MCFH-Rt; MPFH-Lt; MCFH-Lt, equal to 6.2; 6.5; 6.5; 6.8 cm, respectively). (B) Two weeks following forehead lift using abobotulinumtoxin A (Dysport) injection (MPFH-Rt; MCFH-Rt; MPFH-Lt; MCFH-Lt, equal to 6.6; 6.9; 6.8; 7.2 cm, respectively). Figure 4. View largeDownload slide Frontal views of a 49-year-old woman in full repose position. (A) Before abobotulinumtoxinA (Dysport) injection (MPFH-Rt; MCFH-Rt; MPFH-Lt; MCFH-Lt, equal to 6.2; 6.5; 6.5; 6.8 cm, respectively). (B) Two weeks following forehead lift using abobotulinumtoxin A (Dysport) injection (MPFH-Rt; MCFH-Rt; MPFH-Lt; MCFH-Lt, equal to 6.6; 6.9; 6.8; 7.2 cm, respectively). Figure 5. View largeDownload slide Frontal views of a 27-year-old woman in full repose (MPFH-Rt; MCFH-Rt; MPFH-Lt; MCFH-Lt, equal to 8.2; 9; 8; 8.6 cm, respectively). (A) Before abobutolinumtoxinA (Dysport) injection. (B) Two weeks following forehead lift using abotolinumtoxinA (Dysport) injection (MPFH-Rt; MCFH-Rt; MPFH-Lt; MCFH-Lt, equal to 8.7; 9.4; 8.5; 9.2 cm, respectively). A substantial increase in forehead length is evident. Figure 5. View largeDownload slide Frontal views of a 27-year-old woman in full repose (MPFH-Rt; MCFH-Rt; MPFH-Lt; MCFH-Lt, equal to 8.2; 9; 8; 8.6 cm, respectively). (A) Before abobutolinumtoxinA (Dysport) injection. (B) Two weeks following forehead lift using abotolinumtoxinA (Dysport) injection (MPFH-Rt; MCFH-Rt; MPFH-Lt; MCFH-Lt, equal to 8.7; 9.4; 8.5; 9.2 cm, respectively). A substantial increase in forehead length is evident. Mean subject-rated GAIS scores were 2.05 ± 0.45 (range, 1-3) at 2 weeks posttreatment indicating a “much improved” appearance in forehead length compared with baseline. No adverse events were documented during study follow-up period. Subgroup Analysis The low forehead subgroup (trichion-nasion) included 12 patients. MCFH increment in this group was significantly higher than in high forehead subgroup (right: 5.2 ± 2.0 mm vs 3.9 ± 1.9 mm; P = 0.03; left: 5.6 ± 2.1 mm vs 4.0 ± 2.3 mm; P = 0.046 (Table 2). Forehead height percentage increment was significantly higher in the low forehead subgroup in 3 out of 4 measurement points compared to patients in the high forehead subgroup (MCFH right: 8.3% ± 3.5% vs 5.7% ± 3.0%; P = 0.014; MCFH left: 9.0% ± 3.3% vs 5.7% ± 3.1%; P = 0.008, MPFH right: 6.5% ± 3.0% vs 5.1% ± 2.3%; P = 0.16 and MPFH left: 7.3% ± 2.4% vs 5.4% ± 2.5%; P = 0.02). Table 2. Change in Forehead Height Measurements Two Weeks Following Botulinum Toxin A Treatment   Low forehead (≤5.5 cm) N = 12  High forehead (>5.5 cm) N = 17  P value*  Total N = 29  P value**    Mean ± SD  Range  Mean ± SD  Range    Mean ± SD  Range    MPFH (mm)                   Right  4.4 ± 2.0  2-8  3.9 ± 1.7  1-8  0.57  4.1 ± 1.8  1-8  <0.001   Left  4.9 ± 1.6  2-8  4.1 ± 1.9  0-8  0.18  4.4 ± 2.0  1-10  <0.001  Total  4.7 ± 1.3  2-8  4.0 ± 1.6  0-8  0.13  4.3 ± 1.5  1-10  <0.001  MCFH (mm)                   Right  5.2 ± 2.0  1-8  3.9 ± 1.9  2-10  0.03  4.4 ± 1.8  0-8  <0.001   Left  5.6 ± 2.1  1-8  4.0 ± 2.3  (−3)-7  0.046  4.7 ± 2.3  (−3)-8  <0.001  Total  5.4 ± 1.5  1-8  4.0 ± 1.7  (−3)-10  0.024  4.6 ± 1.7  (−3)-8  <0.001    Low forehead (≤5.5 cm) N = 12  High forehead (>5.5 cm) N = 17  P value*  Total N = 29  P value**    Mean ± SD  Range  Mean ± SD  Range    Mean ± SD  Range    MPFH (mm)                   Right  4.4 ± 2.0  2-8  3.9 ± 1.7  1-8  0.57  4.1 ± 1.8  1-8  <0.001   Left  4.9 ± 1.6  2-8  4.1 ± 1.9  0-8  0.18  4.4 ± 2.0  1-10  <0.001  Total  4.7 ± 1.3  2-8  4.0 ± 1.6  0-8  0.13  4.3 ± 1.5  1-10  <0.001  MCFH (mm)                   Right  5.2 ± 2.0  1-8  3.9 ± 1.9  2-10  0.03  4.4 ± 1.8  0-8  <0.001   Left  5.6 ± 2.1  1-8  4.0 ± 2.3  (−3)-7  0.046  4.7 ± 2.3  (−3)-8  <0.001  Total  5.4 ± 1.5  1-8  4.0 ± 1.7  (−3)-10  0.024  4.6 ± 1.7  (−3)-8  <0.001  *Comparison between low and high forehead subgroup measurements performed by Mann Whitney test. **Comparison of total group measurement change from zero value by Wilcoxon paired test. MCFH, medial canthus to frontal hairline; MPFH, mid-pupil to frontal hairline. View Large DISCUSSION Facial aesthetics has consistently been defined by proportionality. The tri-section canon states equal heights of trichion (hairline) to nasion, nasion to subnasale, and subnasale to gnathion. The forehead comprises the upper third of facial height (trichion to nasion). Farkas et al evaluated this relationship on actual subjects and determined that the average height from trichion to glabella was 57 ± 7 mm for men and 53 ± 6 mm for women.10,11 Accordingly, a forehead height less than 6 cm in men and less than 5.5 cm in women is considered as a short forehead which might benefit from forehead lift. This criterion is in line with the Mckinney criteria for forehead lift (an additional measurement of the distance from mid-pupil to brow of <2.5 cm).12 The first forehead lift, the classic transcoronal browlift has become less favorable due to the occasional hypertrophic scars, scar alopecia, sensory denervation, and hairline elevation. Over the past two decades, rejuvenation of the forehead/brow region has undergone revolutionary transformation from the classic open coronal or anterior hairline brow line to limited-incision techniques such as the endoscopic browlift in the early 1990s and the limited temporal incision browlift. Apart from the inherent need for expensive endoscopic instrumentation, the significant learning curve, the relatively unpredictable results and the tendency towards overelevation of the medial brow have made endoscopic browlift less popular. The quest for minimally invasive facial rejuvenation procedures with no downtime has made botulinum toxin A chemodenervation the most popular cosmetic procedure since 2000. Over the past three decades, botulinum toxin injections have been substantiated as a powerful tool for alleviating dynamic expression wrinkles in diverse cosmetic applications. Strategic application of botulinum toxin can govern the interplay between agonist-antagonist relationship (ie, elevator-depressor or push-pull functions) of facial muscles, thus selectively favoring desired cosmetic result. Ahn et al4 demonstrated a significant brow elevation both at the midpupil line (1.0 mm) and at the lateral canthus (4.8 mm) in 22 consecutive patients following targeted paralysis of the primary depressor of the lateral brow, the orbital portion of the orbicularis oculi muscle. Temporal brow elevation resulted from the unopposed action of the frontalis muscle. The Nefertiti lift5 for jawline elevation and recontouring refers to targeted paralysis of the platysma muscle near the jawline, aiming to release the downward pull of the platysma on the jawline and alleviate the depressor effect. Thus, the skin is released to the elevated muscle lifting action. In selected cases, this technique allows for improved jawline definition and contour.3 The platysma muscle has many similarities with the frontalis in terms of fiber orientation, configuration, resultant wrinkles/creases, and dual functionality both at the origin and insertion. Both muscles are vertically oriented (slightly oblique), and quadrilaterally flat. Their medial fiber interlace for a variable distance at the median line forming a “V” shaped configuration (or inverted “V” in the case of platysma) and both muscles lie on the same anatomic plane. Both have a depressor effect in their cranial portion (or downward-pull effect) on the jawline/cheek and the scalp for the platysma and the frontalis, respectively, and an elevator function (upward-pull effect) on the corresponding caudal portion. With contraction, the platysma elevates the skin over the clavicle, and the frontalis elevates the eyebrows. The principle of dynamic muscular activity, first described by Isse2 for browlift (brow elevator/depressors), served as the basis for endoscopic browlift and later on for chemo-denervation to affect brow position. This principle can be applied similarly to affect forehead length: the occipitalis and the frontalis muscles lie on the same anatomic plane and act in opposition. While the frontalis muscle pulls the scalp forward, the antagonist muscle, the occipitalis, pulls the scalp backward. By negating the action of the cranial fibers of the frontalis (downward pull of the forehead), the respective antagonist, the occipitalis is left to act unopposed, thus exhibiting overactivity. Considering the dynamic muscular forces acting on the scalp, and the above-mentioned similarities between the platysma and the frontalis muscles, we attempted to determine the efficacy of targeted paralysis of the cranial portion of the frontalis muscle on forehead height. Our data demonstrate that significant mean forehead elevation is achieved both at the MCFH (4.3 ± 1.5 mm, P < 0.001) and at the MPFH (4.6 ± 2.9 mm, P < 0.001) (Table 2). This substantial increase in forehead length verifies the role of the cranial fibers of the frontalis in forehead position and illustrates the dynamic muscular forces affecting forehead position and length. Only one patient had a 3 mm decrease in the MCFH. This decrease might be attributed to anatomical variability of the frontalis muscle origin among different individuals13 and variation related to its medial border.14 It is our assumption that the relatively higher percentage increment in MPFH compared to MCFH might be explained by the greater abundance of muscular fibers in the middle portion of the muscle compared to the medial portion. The low forehead subgroup achieved a significantly higher forehead lift compared with the high forehead group both in MCFH (6.9% ± 2.0% vs 5.3% ± 2.2%, P = 0.043) and MPFH (8.6% ± 2.5% vs 5.7% ± 2.6%, P = 0.008). Subjects’ satisfaction with forehead lift using abobutolinumtoxinA (Dysport) injection into the cranial fibers of the frontalis muscle was high with mean GAIS scores of 2 (“much improved”) forehead length compared with baseline. The study group included only female patients. Given the frontal hairline recession in some men, forehead elongation is much less of an aesthetic concern to male patients compared to female patients. Female patients with both low and high forehead length were included. The inclusion of patients with high forehead was twofold: first, to verify our study objective regardless of pretreatment forehead length, thereby omitting selection bias; and second, to compare the percentage of forehead elevation between patients with short vs long forehead. The low forehead subgroup achieved a significantly higher forehead lift than the high forehead group, both in MCFH and MPFH. This observation served as the basis for using this technique, with preference for patients with short forehead. The longevity of browlift using botulinum toxin type A (BTX)-injection is on average 3 to 4 months. This is similar to the documented longevity of BTX injections to other facial areas (ie, glabella and transverse forehead lines). At the 2-week follow up, full response was encountered. However, the median onset of response was at 2 to 3 days following treatment, in accordance with the published data.15,16 This study presents several concerns due to its observational design. First, measurements were performed by the principal investigator alone, which can potentially reduce validity and reliability of the results. Such a possibility was minimized by the primary investigator (S.C.) not knowing the preintervention forehead height when taking the postinjection measurement. Nevertheless, if a measurement bias exists, it is nondifferential and therefore less likely to significantly affect study outcome. Second, intermeasurement variability can be applied to the data set at both the MCFH and the MPFH even though measurements were taken while the patients were in a predetermined position and height, and the eyes were focused on a fixed and constant point in space. However, these anatomical landmarks were chosen as reference points to avoid potential measurement bias. Moreover, taking into consideration that the glabellar musculature was treated as well negates this possibility. Furthermore, if the brow is elevated, forehead length will be shortened due to the accordion effect of the vertically oriented frontalis muscle. Third, one may argue that concomitant treatment of the glabellar musculature and the transverse forehead lines can potentially affect outcome. Nevertheless, chemodenervation of brow depressors and brow elevator have no documented effect on forehead length. Similarly, targeted paralysis of the cranial portion of the frontalis muscle has no direct effect on brow position as the positions of the forehead and brow are affected by two different muscular forces. Yet, we postulate that indirect browlift might be attributed to better spatial orientation of the brow following forehead lift. Finally, the relatively small sample size was chosen primarily to assess technique efficacy and safety. Limitations pertinent to the technique itself are those inherent to the toxin nature (its temporary effect) and the variability in the magnitude of response among different individuals. To the best of our knowledge, forehead lift using botulinum toxin has never been published in the English literature. AbobutolinumtoxinA (Dysport) injection into the cranial fibers of the frontalis can achieve a substantial and visibly appreciable forehead lift. Hence, it is a favorable alternative to surgery in the young patient population and for patients who refuse to undergo surgery or are not surgical candidates. The technique could be especially applicable for patients with a short forehead and might well serve to improve facial aesthetic proportions for this patient population. Forehead lift using botulinum toxin adds to the armamentarium of minimally invasive treatments of the aging and short forehead. CONCLUSIONS The technique presented herein achieved a significant improvement in forehead height. Forehead lift using Botulinum toxin injection is an effective and safe, minimally invasive technique. Although its effect is temporary, it is a favorable alternative to surgery for selected patients and adds to the armamentarium for the treatment of the forehead. We propose to further evaluate this technique using a randomized double-blind controlled clinical trial which will examine its efficacy on a wider population scale and different ethnic and gender subgroups. Disclosures The authors declared no potential conflicts of interest with respect to the research, authorship, and publication of this article. Funding The authors received no financial support for the research, authorship, and publication of this article. REFERENCES 1. Nahai F. Applied anatomy of the face and neck. In: Nahai F, ed. The Art of Aesthetic Surgery: Principles & Techniques . 2nd ed. Vol. II, part VIII. St. Louis, MO: Quality Medical Pubishing; 2011: 1273. 2. Isse NG. Endoscopic facial rejuvenation: endoforehead, the functional lift. Case reports. Aesthetic Plast Surg . 1994; 18( 1): 21- 29. Google Scholar CrossRef Search ADS PubMed  3. Fagien S. The role of the orbicularis oculi muscle and the eyelid crease in optimizing results in aesthetic upper blepharoplasty: a new look at the surgical treatment of mild upper eyelid fissure and fold asymmetries. Plast Reconstr Surg . 2010; 125( 2): 653- 666. Google Scholar CrossRef Search ADS PubMed  4. Ahn MS, Catten M, Maas CS. Temporal brow lift using botulinum toxin A. Plast Reconstr Surg . 2000; 105( 3): 1129- 1135; discussion 1136. Google Scholar CrossRef Search ADS PubMed  5. Levy PM. The ‘Nefertiti lift’: a new technique for specific re-contouring of the jawline. J Cosmet Laser Ther . 2007; 9( 4): 249- 252. Google Scholar CrossRef Search ADS PubMed  6. Knize DM. An anatomically based study of the mechanism of eyebrow ptosis. Plast Reconstr Surg . 1996; 97( 7): 1321- 1333. Google Scholar CrossRef Search ADS PubMed  7. Ascher B, Talarico S, Cassuto Det al.   International consensus recommendations on the aesthetic usage of botulinum toxin type A (Speywood Unit)-Part I: Upper facial wrinkles. J Eur Acad Dermatol Venereol . 2010; 24( 11): 1278- 1284. Google Scholar CrossRef Search ADS PubMed  8. Kane M, Donofrio L, Ascher Bet al.   Expanding the use of neurotoxins in facial aesthetics: a consensus panel’s assessment and recommendations. J Drugs Dermatol . 2010; 9( 1 Suppl): s7- s22; quiz s23. Google Scholar PubMed  9. Yavuzer R, Smirnes S, Jackson IT. Guidelines for standard photography in plastic surgery. Ann Plast Surg . 2001; 46( 3): 293- 300. Google Scholar CrossRef Search ADS PubMed  10. Farkas LG, Katic MJ, Forrest CRet al.   International anthropometric study of facial morphology in various ethnic groups/races. J Craniofac Surg . 2005; 16( 4): 615- 646. Google Scholar CrossRef Search ADS PubMed  11. Farkas LG, Kolar JC. Anthropometrics and art in the aesthetics of women’s faces. Clin Plast Surg . 1987; 14( 4): 599- 616. Google Scholar PubMed  12. McKinney P, Mossie RD, Zukowski ML. Criteria for the forehead lift. Aesthetic Plast Surg . 1991; 15( 2): 141- 147. Google Scholar CrossRef Search ADS PubMed  13. Choi YJ, Won SY, Lee JGet al.   Characterizing the lateral border of the frontalis for safe and effective injection of botulinum toxin. Aesthet Surg J . 2016; 36( 3): 344- 348. Google Scholar CrossRef Search ADS PubMed  14. Spiegel JH, Goerig RC, Lufler RS, Hoagland TM. Frontalis midline dehiscence: an anatomical study and discussion of clinical relevance. J Plast Reconstr Aesthet Surg . 2009; 62( 7): 950- 954. Google Scholar CrossRef Search ADS PubMed  15. Schlessinger J, Monheit G, Kane MA, Mendelsohn N. Time to onset of response of abobotulinumtoxina in the treatment of glabellar lines: a subset analysis of phase 3 clinical trials of a new botulinum toxin type A. Dermatol Surg . 2011; 37( 10): 1434- 1442. Google Scholar CrossRef Search ADS PubMed  16. Moy R, Maas C, Monheit G, Huber MB; Reloxin Investigational Group. Long-term safety and efficacy of a new botulinum toxin type A in treating glabellar lines. Arch Facial Plast Surg . 2009; 11( 2): 77- 83. Google Scholar CrossRef Search ADS PubMed  © 2017 The American Society for Aesthetic Plastic Surgery, Inc. Reprints and permission: journals.permissions@oup.com

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Aesthetic Surgery JournalOxford University Press

Published: Mar 1, 2018

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