Dr Jason believes in lifelong learning and has attended dozens of conferences both locally and overseas to keep up-to-date in new research findings and techniques which he adapts for use in his own patients. He has also attended hands-on cadaveric dissection courses held locally and overseas in order to improve his anatomy knowledge.
There are a few large arteries and veins that can be encountered when doing temple and forehead fillers. It is important to know where these vessels lie and and how deep they are from the skin surface. Furthermore, these blood vessels do not remain in the same tissue layer but cross from deep to superficial layers during their course through the face. A good knowledge of anatomy is required to avoid complications of injecting filler into the blood vessel.
Intricacies of Temple and Forehead Filler
We are all familiar with the use of dermal fillers to define nose, chin and tear trough. However not so many people are aware that dermal fillers can also be used to contour the forehead and temples.
As we age, the temples become hollow, and this gives us a skeletonised and haggard appearance. Bone resorption and loss of fat at the forehead can also make the brow bone more prominent and forehead appear sunken.
The use of temple fillers can restore the volume loss and improve the contour between the cheekbone and the forehead, and it helps to raise the tail of the eyebrow as well. The use of forehead fillers can restore the contour and make the forehead appear smooth. Even for young patients who prefer a rounded forehead, fillers can be used to achieve this result.
However, fillers in the forehead and temples are technically more challenging and come with a higher risk of complications due to the underlying anatomy. Some of the reasons include
Arteries in the forehead and temples (Adapted from Pepper and Baker. Local Flaps: Cheek and Lip Reconstruction. JAMA Facial Plast Surg. 2013;15(5):374-382)
Diagram showing the arteries and veins in the temple and forehead (Carruthers, Jean and Alastair et al. “Suggested Injection Zone for Soft Tissue Fillers in the Temple?” Dermatol Surg. 2017 May;43(5):756-757)
At the forehead, the overlying skin and muscle are thin, hence the correct choice of filler product and even filling is required to avoid lumpiness and visibility of the filler.
The temple region has multiple layers, so only an experienced injector is able to confidently inject into the correct layer. Injections into the wrong layer can lead to lumpiness or uneven filling if it is too superficial, or migration of the filler if it is too deep. The deep fat of the temple is linked to the deep cheek fat, so filler injected into the deep temple fat can potentially migrate down to the deep cheek fat.
(in black circle) The multiple layers of the temple. Accurate placement of filler in temple requires a necessary amount of expertise (Adapted from Kim B., Oh S., Jung W. (2019) Pinch Anatomy for Each Area. In: The Art and Science of Thread Lifting. Springer, Singapore)
There are two ways to inject the temple, using a sharp needle or a cannula (blunt tube). I personally prefer using the cannula method for a couple of reasons.
The temple is a relatively large area, and it is much easier to have an even and smooth result when using a cannula than a sharp needle. Sharp needle injections may cause the filler to appear lumpy.
Reproduced with patient permission
The visible temple is demarcated by A: The temporal crest, B: Orbital rim, C: Cheekbone D: Hairline.. The arrows illustrate how the use of a cannula can be used to fan the filler out into the entire temple using a single entry point.
When using a sharp needle, the filler must be placed deeply on the bone for safety reasons, and this means that more filler product needs to be used to achieve the same amount of lifting. The use of the blunt cannula allows us to fill more superficially in a safe manner and allows for more efficient use of product.
Use of a sharp needle technique increases bruising risk. Use of a blunt cannula nudges aside any large blood vessels and avoids puncturing them.
The forehead is also best injected with a cannula for similar reasons. A cannula allows us to access a large area with minimal entry points (usually 3 to cover the entire forehead), and the blunt nature of the cannula also minimises risk of puncturing blood vessel. The filler product should be placed under the muscle, just above the bone to prevent the filler from appearing lumpy.
Reproduced with patient permission
Boundaries of the forehead. Arrows show the 3 entry points and fanning of the filler product under the muscle.
It is best to find an injector who has attended multiple cadaveric dissection courses and is knowledgeable in the anatomy of the face, as well as being proficient in the techniques for forehead and temple augmentation.