Introduction:

The growing demand to enhance the quality and contour of forehead skin has surged, driven by the limitations of standalone botulinum toxin (BTx) treatments, which may prove insufficient for effectively addressing deep wrinkles and depressions.

The predominant challenge in forehead procedures, aimed at restoring volume and structure, is the significant risk associated with potential blindness.1,2 Hyaluronic acid (HA) emerges as the most extensively employed and secure polymer for forehead treatment. However, comprehension of facial anatomy and adherence to key recommendations is crucial in this area.3–5 Here, we present two cases of safely addressing frontal deep wrinkles using a combination of BTx and HA gels.
Materials and Methods
Two male patients seeking treatment for deep forehead wrinkles underwent a comprehensive procedure. In both cases, abobotulinumtoxinA (Abo - Galderma,Upsala, Sweden) was administered 30 minutes prior to the forehead filling. HA was injected using a multi-layer approach (Figures 1 and 2). Initially, several 0.05 mL boluses of Restylane® (Q-Med AB, Galderma, Sweden) were strategically placed along the wrinkles in the supraperiosteal plane, utilizing a 29G ultra-thin wall needle positioned at 90 degrees. Each injection point involved a pinch maneuver, and a prior 10-second aspiration was performed. Then, Restylane Skinboosters® Vital (Q-Med AB, Galderma, Sweden) was distributed in the subcutaneous by retroinjections (0.1 – 0.2 mL per wrinkle), using a 22G cannula (TSK Laboratory Europe B.V., The Netherlands), with entry points positioned laterally to the wrinkles. This process was followed by digital accommodation with gentle pressure (Supplementary Information – digital content/video procedure: https://youtu.be/r7RtNTPIDMw). The procedures did not involve any pre- or post-operative medication, and only topical anesthesia was applied at puncture sites. Follow-up assessments, documented through photographic registers and stereophotogrammetry quantification (3D-LifeViz™ Quantificare) were conducted before, immediately after, and 30 days after the procedure.

Graphical Abstract – Forehead Rejuvenation Technique

Graphical representation of a multi-layer forehead rejuvenation technique using botulinum toxin (BTx) and hyaluronic acid (HA). BTx is injected into the frontalis muscle to reduce dynamic lines. HA is delivered supraperiosteally with a needle for structural support and into the subcutaneous fat with a cannula to improve skin quality. This anatomical approach enables natural and harmonized results.

Case 1 (Figure 1): A 33-year-old male received a total of 195 speywood units (sU) of Abo. Thirty minutes later, 0.65 mL of Restylane® (Galderma, Upsala, Sweden) was injected supraperiostially, and 0.69 ml of Restylane Skinboosters® Vital were injected subcutaneoslly. Additionally, a HA treatment was also administered to address the tear trough and midface regions.

Figure 1: Case 1 methods description. (a and b) Schematic representation of botulinum toxin injection, (c) Schematic representation of filler injection.

Case 2 (Figure 2): A 32-year-old male received a total of 97.5 sU of Abo. Then, 0.2 mL of Restylane® were injected in the supraperiosteal region, and 0.1 mL of Restylane Skinboosters® Vital were injected subcutaneosly. Additionally, the tear trough and malar regions were also treated with HA.

Figure 2: Case 2 methods description. (a) Schematic representation of botulinum toxin injection, (b) Schematic representation of filler injection.

Results

Patients reported minimal pain and no complications, during and after the procedure. Transient erythema, edema, and some irregularities, were observed immediately after the procedure, and softened in the next few days. In the 30-day follow-up, a noticeable enhancement in depression and a smoother post-procedure contour, with minimal volume and natural appearance, were observed and confirmed by stereophotogrammetry assessment (Figures 3 and 4). In Case 1, there was an increase in forehead volume by 7.42 mL immediately post-treatment, attributed to injected products and procedure-related swelling. After 30 days, the depression marks became nearly imperceptible, and the forehead volume retain an increased by 1.58 mL compared to the pre-treatment state, indicating the resolution of the acute inflammatory response and a reduction in edema (Figure 3).

Figure 3: Case 1 outcomes (a) dynamic frontal photo 30 days post procedures, (b) stereophotogrammetry* right after the procedure, (c) stereophotogrammetry* 30 days post procedure, (d) static lateral photo 30 days after the procedure (d) static frontal photo 30 days after the procedure (* 3D-SQ LifeViz™ Quantificare)

In Case 2, there was an increase in forehead volume by 0.33 mL immediately post-treatment, attributed to injected products and procedure-related swelling. After 30 days, there was improved scarring, a smoother contour, and the forehead volume retain an increased by 0.17 mL compared to the pre-treatment state, indicating the resolution of the acute inflammatory response and a reduction in edema (Figure 4).

Figure 4: Case 2 outcomes. (a) dynamic frontal photo 30 days post procedures, (b) stereophotogrammetry* right after the procedure, (c) stereophotogrammetry* 30 days post procedure, (d) static lateral photo 30 days after the procedure (d) static frontal photo 30 days after the procedure (* 3D-SQ LifeViz™ Quantificare).