- My main concern is my frown in the middle here
and the lines across the top of my forehead,
I don't like them.
It always looks like I'm a little bit angry
and, you know, people have commented and said,
oh, you know, that I look a bit angry.
So, no, I don't like that.
- It's a great area to treat, frown and forehead lines.
Often it's the first thing
that people come in to see us for.
And it makes a big difference to people
because people hate being seen as angry or worried
when simply they're not.
- It's not a face that I'm pulling,
I'm not trying to pull it.
It's just there.
What I'm hoping to achieve for today
is that I'd like to lessen the grooves
between my eyes here, that frowning,
and lessen the wrinkles in my forehead.
- I'm gonna take you through the treatment today,
step by step, and actually show you what's involved.
So, firstly, if we just have a look here
at Jackie's forehead and frown.
Actually what the first thing you can probably notice is
a few static lines there,
which means basically that she's not trying
to express at the moment,
but they're lines that are etched in.
The actual reason for this,
probably Jackie doesn't even notice herself,
but she used to have very heavy upper eyelids.
She used to have to raise her eyebrows like this
actually to bring the upper eyelids
out of the field of vision.
So that became actually a bit of a habit.
So as a result these lines would have occurred.
But thankfully she got her upper eyelids treated
and that was good, not only for her upper eyelids,
but also good for the forehead lines.
In term of treatment with fillers,
fillers actually are not particularly good
at filling lines.
They're actually better at volumising areas.
But in actual line treatment,
you have to pick a fairly soft filler
and it's actually very difficult to get it into the skin
so that it's perfectly smooth.
So my expectation for you, Jackie,
we could put some fillers in there,
but what you'll find is that the lines will still be there
but they just might be softened just a little bit,
so it's actually a very difficult treatment
to get perfectly smooth.
In many cases, it's not possible.
So that's the first thing.
It's important to have the right expectations.
A youthful forehead should be a nice, convex forehead,
and as we get older, you start to get some concavities,
like the ones here.
Now, Jackie's not too bad at all,
but they're just beginning.
We might fill those in as well for her.
We are gonna put some anti-wrinkle injections
into Jackie's forehead and that will help
stop the raising of the eyebrows.
So just raise your eyebrows there.
So that will help reduce that expression,
which will in turn help
prevent the lines from becoming deeper.
These Golden Calipers help with the assessment of the face
and what we can do is actually use this end
to measure the distance between the eyes,
which is actually a fixed distance.
That doesn't change with aging.
So if we look at these calipers, the distance here,
which is the distance between Jackie's eyes,
we count that as one, and this distance is 1.618.
And that's knows as the golden ratio.
So we look for this ratio in the face.
So we can measure the distance between her eyes
and then measure the distance
between her forehead and the other side.
And you can see that it almost is spot on
to 1.618 times the distance between the eyes.
So actually Jackie has the ideal height forehead.
If for example she had a higher forehead than the ideal,
as measured by this, or a lower one,
it might be advisable, say, for the patient
to cut a fringe to help reduce the effect
of that height disproportion.
The frown is probably one of the most
popular areas we treat and often one of the first things
that brings people in to see us.
If we look at Jackie's frown,
the first thing you probably notice
is there's a few fine lines there.
But in addition to that,
there's a little bit of volume loss.
You can see there's actually a fold in there
and that actually interrupts the transition
between the nose and the brow.
Ideally that should be a nice smooth Y shape there.
So by filling this area, you can actually get
a much smoother transition.
We can also fill the lines there.
The fine lines are very difficult to fill with fillers
because of the nature of dermal fillers
is that they're not fine enough generally
to fill fine lines, but certainly the folds
and the break in the transition there,
we can help smooth that with a bit of dermal filler.
It's important to understand that anti-wrinkle injections
in this area don't actually relieve lines.
Well, not straight away anyway.
The lines generally are there at rest
and they've got not a lot to do
with the current muscle activity.
So what they're from is from years of frowning.
So it's actually necessary to use a filler,
or use anti-wrinkle injections over a long period of time
so that the skin can get a bit of a rest
and relax a bit more.
But in the short-term,
fillers are an excellent treatment for this area.
Okay, so we're gonna start the treatment
with a bit of filler to the area.
And before we do the filler,
we're just gonna do a quick vein scan
just to see where the veins are so we can avoid them,
to avoid the possibility of bruising.
She's got a few veins, particularly on the right side here.
We'll mark them out before we treat.
Because what we're gonna do is
actually a lot of fine filler injections
through these forehead lines,
what I'm gonna do for Jackie is actually give her
a bit of a nerve block, just like the dentist,
except we're gonna be treating her forehead.
So I'll put a bit of ice on there,
just to numb the skin for a little while first,
might give her brain freeze.
And then we'll give her a little bit of local anesthetic
just to numb the whole area,
actually numb the whole forehead.
It'll be completely numb.
Okay, little scratch here.
So we've just put a nerve block in Jackie's forehead
and she's starting to go a bit numb in both sides,
just beginning.
Now, that'll make it really comfortable for her.
The forehead will remain numb for about four hours.
Now, I've got the filler here
in a very, very fine syringe needle.
So I can actually inject it at a very superficial level
and basically get the best chance
of getting a nice smooth result.
So I'll do lots of little injections
into the wrinkles themselves.
And initially it might look a little bit lumpy
but as time goes by and you give it a little bit of massage
it usually settles in nicely.
So this is just very, very superficial filler,
just into the lines.
Now, Jackie's completely comfortable here
because I've given her the nerve block,
she doesn't feel a thing.
Pretty unusual sensation, well lack of sensation.
- [Jackie] I don't feel anything at all.
- And I'm just sort of going through the line,
multiple injections, drop at a time,
drop into each line here.
With these injections,
the longevity seems to be fairly good.
I've had patients where I've done this for
and their results last over two years.
I wonder whether it's,
you know, you'd expect the filler to have gone by then,
but it's possible that the actual process
of doing this treatment, the actual putting the needle in,
is stimulating more collagen,
so you're actually getting improvement of the line
through, you know, your own body
creating more collagen in that line.
You might see that sort of phenomenon
when we do treatments like skin needling,
where we use a needle to roll over the face
or wrinkles, or acne scars multiple times
and it generates new collagen.
Pretty good, you look at little bit dotty now, Jackie,
but it's not too bad.
There's no bruises or anything like that.
Usually with this sort of thing, superficial treatment,
there's not a lot of bruising
because we're above the depth of the vein.
In terms of laser treatment,
what the laser actually does is
it takes a layer of skin off
and then you grow new skin back.
But obviously limitations to how deep you can go.
So if you have a very deep wrinkle,
you can't burn all the skin off and start again.
You're limited to how deep you can go with the laser,
so it's better for finer sort of lines.
Not only that, you'll find that laser improves
the general skin quality of the area,
whereas fillers, you don't get a real general improvement
in the skin quality.
It's really just treating the areas you're putting it in.
We've treated Jackie's fine lines,
now we're gonna go and treat the little concavities here
in the lateral or the outer side of the forehead.
Now we've got filler here in the syringe,
which we'll use, again, a fairly fine needle.
Not as fine as the previous one,
but this time we're aiming to go a little bit deeper.
Now you see a little bit of a bump there,
that's quite deep, this filler.
All we do is massage it in
and you see an instant improvement in the forehead.
So that looks great.
There's actually a minor hollow
just following across, about a centimeter above the brow,
which we can fill in for Jackie as well,
give her a very youthful forehead.
The thing is that we often forget about the forehead
and a lot of doctors, including myself,
we treat other areas and we forget that
the forehead is just as important
a part of the face as anywhere else.
And patients don't tend to be as concerned with the forehead
possibly because you can cover it with hair,
or it's just not a primary concern.
But when you do have a really nice forehead,
it really makes a big difference
to the appearance of the patient.
You get immediate improvement
and then fillers tend to hydrate.
They tend to gain a bit of water,
like a dry sponge being dipped in water,
and then they smooth out and expand a bit
and that makes it even better usually after a week.
So a lot of massage is required here, even by the patient,
when we do this sort of filler to the forehead.
Okay, so we've done the filler,
both deep filling for shaping the forehead
and fine fillers into the lines.
Actually you can see a nice difference.
Her forehead already looks quite smooth.
The next step is to put a little bit
of anti-wrinkle injection in.
Now, the forehead has one muscle for the frontalis,
which lifts the forehead up
and as a result gives you forehead lines.
It's the only elevator,
or the only muscle which elevates the brow.
So we have to be careful in people with heavy brows
because it can make the brows a bit more heavy,
so we might have to moderate our dose in that situation.
But because Jackie's had her eyelids treated with surgery,
we can be a little bit more aggressive
with our anti-wrinkle treatment.
So I'll just put a few,
again she's still numb from the nerve block.
This will kick in in about four to seven days
and we won't have an exaggerated or worried look
when she raises her eyebrows.
Next part is the frown.
Now, what we're gonna treat firstly is the folds here
that break the transition from the nose to the brow.
So we're gonna put just a little bit more local in here.
What we're gonna use is a bit of dermal filler again.
Make a little needle entry point
for the dermal filler with a needle.
Now it's really important to use a cannula in this area
because one of the risks of doing this with a needle
is that you inject the filler into one of the arteries.
And that can cause serious complications
with both the skin and you're vision.
So by using a cannula because it's blunt,
I can't actually get into the arteries as easily
and that way I'm much safer.
Because they're blunt, they also help
to avoid bruising as well.
So you actually get a dual effect.
You get less risk of entering an artery or important vessel
as well as less risk of causing bruising
by piercing a vein.
The final part of this treatment
will be putting the anti-wrinkle injection
into Jackie's frown.
Now, again, this won't work til about four to seven days.
But we'll just put it into the muscle.
So just give us a frown there.
Yeah, that's good.
Relax now.
She's only partially frowning now
because of the nerve block
so this will be somewhat numb when I do this.
My instructions for Jackie after this
would be probably don't touch it for the next,
until tomorrow morning.
My advice to Jackie would be don't massage it
because you don't want to massage
the anti-wrinkle injections into areas like the eye
or something like that.
So no massage for about 12 hours or so,
and then after that,
if she's got a few little minor bumps or lumps,
then she can actually press on that.
And that's the filler that we're actually massaging in.
You can see it looks smoother already.
- Yeah, definitely.
- [Dr. Chan] Ignore the little bumps
from the anti-wrinkle injections.
So they'll go in half an hour.
But generally even the lines are a bit softer.
I expect them to further improve.
The general contour of the forehead is smoother,
it's more convex now.
- Oh good, thank you, very happy.
- Jackie's results are even better than I expected.
Usually fine lines are difficult to fill.
- I think my skin looks really good.
I'm happy with the overall look of my skin.
I really feel that it's softened,
it's softened everything around my face,
my forehead, my eyes.
- With a combination of filler and anti-wrinkle injections,
that really hit the sweet spot
and her lines were absolutely minimized.
So actually more of a result than I would generally expect,
but very pleasing.
- Gavin explained the procedure,
what he was doing at the time,
how he was doing it,
what I might be feeling.
That was really comforting.
So I sort of knew what to expect.
I get comments like, here, Jac, you look really good today,
or you look nice.
Just the overall general look of me, I suppose,
that they've commented on.
- Jackie is really happy with the result
and you can see it in her general attitude.
She's brightened up not only her forehead and frown
but it's brightened up her whole personality
and her outlook.
- You know, when you just look at yourself in the mirror
its something that you like seeing,
that you just don't concentrate
on those lines that I had before.
They're not there anymore
so you just look at yourself as an overall
and I'm just much happier with how I look.