AESTHETIC SURGERY

Aesthetic Durable Forehead Contouring in Asians With Fat Grafting

and Botulinum Toxin
Gavin Chun-Wui Kang, MD, MEng,* Yen-Chang Hsiao, MD,† Jung-Ju Huang, MD,† Jyh-Ping Chen, PhD,‡
Philip Kuo-Ting Chen, MD,† Yu-Ray Chen, MD,† and Chun-Shin Chang, MD, MS†‡

seek to attain a more harmoniously curved and smooth forehead. Older

Background: Augmentative forehead contouring to create a full rounded smooth
patients wish for forehead rejuvenation that addresses forehead skin and
forehead is increasingly popular worldwide especially in East Asia where a flat
subcutaneous atrophy and rhytides. Autologous fat grafting to the
and/or concave irregular forehead is considered unaesthetic. We present our out-
forehead-glabella is a simple minimally invasive technique to volumize
comes performing fat transfer to the forehead in combination with botulinum
and rejuvenate the forehead, and autologous fat offers a durability and
Downloaded from http://journals.lww.com/annalsplasticsurgery by BhDMf5ePHKbH4TTImqenVHKmFUQmZBMKbTQ0+en521X+t1Nlg0yJJGCge2TNBehUwA+jfxbHN0A= on 01/17/2019

toxin (Botox) corrugator-frontalis injection where indicated in East Asians.

safety profile superior to other current soft-tissue fillers for this purpose.1,2
Methods: From 2013 to 2017, 62 consecutive patients with flat and/or concave
Currently, there is limited literature detailing the specific tech-
irregular unaesthetic foreheads underwent forehead fat transfer using a
nique of forehead lipofilling to achieve consistently good outcomes,
microautologous fat transplantation gun. Concomitant Botox injection to mini-
and to our best knowledge, no objective study on forehead fat-
mize corrugator and frontalis contraction-mediated fat displacement was indi-
grafting outcomes in East Asians. To address this void, we present our
cated in 23 patients (thin forehead skin and/or excessive forehead animation or
long-term experience with fat transfer to the forehead combined with
rhytides) to prevent forehead vertical crease formation. Thirty-nine subjects with
botulinum toxin (Botox) injection when indicated to consistently
a mean follow-up of 16 months (range = 3–44 months) had their pregraft and
achieve ideal augmented forehead aesthetic contours in a series of East
postgraft forehead contours assessed on an aesthetic grading scale. Of these 39,
Asian patients.
17 completed forehead fat graft volumetric analysis using preoperative and post-
operative 3D photography.
Results: Aesthetic results were durable at latest follow-up, and all patients were
satisfied with their final appearance. The mean amount of fat transferred was PATIENTS AND METHODS
7.72 mL (range = 1.5–33 mL). One subject required a repeat fat grafting (with
Forehead contouring was performed with fat grafting to the fore-
Botox) because of vertical crease formation after the index procedure (without
head and glabella in this retrospective study from 2013 to 2017, approved
Botox). Another 12 needed a second fat-grafting session to optimize the contour.
by the Chang Gung Memorial Hospital Institutional Review Board (IRB
All who received Botox did not develop vertical creases. The mean ± SD fore-
#201701699B0). There were 62 consecutive ethnic Chinese patients—of
head contour grade improved from 2.29 ± 0.77 to 3.24 ± 0.67 (P < 0.001). The
whom 7 were male—with a mean age of 20.7 years (range = 20–69 years).
percentage mean ± SD retention of grafted fat was 46.71% ± 5.77% with Botox
The abdomen was infiltrated with a tumescent solution (20 mL of
versus 39.12% ± 5.24% without Botox (P = 0.006).
2% xylocaine with 0.4 mL epinephrine [1:1000] and 10 mL of sodium
Conclusions: Fat grafting to the forehead using our technique with selective Botox
bicarbonate in 380 mL of normal saline) until skin and subcutaneous tis-
administration is an effective, simple, fast, inexpensive, and safe strategy for aes-
sues were tense. Fat was harvested using a 10-mL syringe at low suction
thetic forehead contouring especially for flat and/or concave foreheads. Forehead
attached to a 10-gauge cannula with 2 side ports. The fat was then filtered
fat survival rate is objectively improved with simultaneous Botox injection. There
through sterile nylon gauze and transferred into 1-mL syringes.
is minimum downtime and long-lasting results with high patient satisfaction rates.
Forehead fat grafting entailed the following critical steps (Fig. 1).
Key Words: autologous fat graft, fat injection, frontal depression, A single midline anterior forehead entry point was made just approxi-
frontal augmentation, botulinum toxin a mately 1- to 1.5-cm anterior to the hairline using an 18-gauge needle.
(Ann Plast Surg 2019;82: S59–S65)
Through this port, fat was injected evenly into both superficial (below
dermis and above frontalis) and deep planes (below frontalis) in a fan-
ning motion using a loaded microautologous fat transplantation
T he popularity of forehead aesthetic augmentation is growing world-
wide. Increasingly in East Asia, the younger demographic with flat
or recessed foreheads or prominently angular forehead-glabella regions
(MAFT)-Gun (Dermato-Plastica Beauty Co, Ltd, Kaohsiung, Taiwan)
until a point of approximately 20% overcorrection. (See Video, Supple-
mental Digital Content 1 http://links.lww.com/SAP/A327, which dem-
onstrates the process of forehead fat grafting in a female patient to
achieve augmentation for a fuller convex forehead appearance). The
Received September 19, 2018, and accepted for publication, after revision MAFT-Gun setting was adjusted to deliver 1/60 mL of fat through an
September 21, 2018. 18-gauge cannula per injection.3 Typically approximately 4 to 5 mL
From the *Department of Plastic, Reconstructive, and Aesthetic Surgery, KK Women's of fat was delivered this way into the forehead-glabella unit. Additional stab
and Children's Hospital, Singapore; †Craniofacial Research Center, Craniofacial
Surgery, Department of Plastic & Reconstructive Surgery, Chang Gung Memorial
entry points were created along the hairline for fat grafting as required to
Hospital, Linkou, Taiwan; and ‡Department of Chemical and Materials Engineering, shape the desired forehead more laterally and tridimensionally (Fig. 1).
College of Engineering, Chang Gung University, Taoyuan, Taiwan. Where indicated at the conclusion of fat grafting, 2.5 units per
Conflicts of interest and sources of funding: none declared. point of Botox A (Allergan, Irvine, Calif ) were injected into bilateral
Reprints: Chun-Shin Chang, MD, MS, Department of Plastic and Reconstructive Surgery,
Chang Gung Memorial Hospital, No 5, Fu-Hsing St, Guishan District, Taoyuan City
corrugators at 6 points and into the frontalis at nine points (Fig. 1).
333, Taiwan, Republic of China. E-mail: [email protected]. Botox injection was indicated in patients with thin lax forehead skin,
Supplemental digital content is available for this article. Direct URL citations appear in excessive forehead-brow animation, or significant forehead rhytides—
the printed text and are provided in the HTML and PDF versions of this article on these predisposed them to formation of vertical forehead creases from
the journal’s Web site (www.annalsplasticsurgery.com).
Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.
frontalis and corrugator contraction that would undermine the
ISSN: 0148-7043/19/8201–0S59 lipofilling outcome. The average time taken to perform the entire proce-
DOI: 10.1097/SAP.0000000000001704 dure was approximately 1 hour. All patients were instructed to regularly

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Chun-Wui Kang et al Annals of Plastic Surgery • Volume 82, Supplement 1, January 2019

forehead volume difference was then calculated using the 3dMDvultus

“volume measurements” function.
All 62 patients were asked to report their degree of satisfaction
(dissatisfied, somewhat satisfied, satisfied, very satisfied) with the out-
come at latest follow-up. We also examined at every follow-up for nod-
ules and asymmetry.
All statistical analyses were performed with SPSS 17.0 (SPSS,
Inc, Chicago, Ill). A P value of less than 0.05 denoted a statistically sig-
nificant difference. Mean results were provided with standard deviations.

RESULTS
Forehead aesthetic contouring was successful in all 62 subjects.
The mean amount of fat grafted was 7.72 mL (range = 1.5–33 mL).
Twenty-three patients received 1 injection of Botox to the corrugators
and frontalis on table immediately after fat grafting.
The upper third facial swelling and minimal ecchymosis after fat
grafting cleared within 10 to 12 days on average. One patient early in
our series with thin forehead skin and who tended to excessively ani-
mate her forehead-brow needed a second session of fat grafting to the
forehead 6 months after the index procedure (done without Botox) be-
cause she developed vertical forehead creases during follow-up. During
the second session, she received Botox to the corrugators and frontalis
and subsequently obtained a good effect at latest follow-up. Another
12 patients required an additional session of fat grafting to further refine
the forehead contour. Clinically, there were no instances of palpable or
visible nodules and asymmetry.
The mean ± SD forehead contour grade for the previously men-
tioned 39 subjects improved from 2.29 ± 0.77 to 3.24 ± 0.67
(P < 0.001). The Pearson r correlation coefficient was 0.937
(P < 0.001) and 0.782 (P < 0.001) respectively, for preoperative and
postoperative contour grading.
FIGURE 1. Illustration showing a frontal facial profile showing
our 4 recommended fat graft entry points (red dots) for fat
grafting the forehead on the right side. These entry points are
numbered 1 to 4 from lateral-most to midforehead and are
used as desired to create the full convex forehead 3-dimensionally
during fat transfer. Five recommended points and 3
recommended points (brown dots) are found on the left side for
injection of Botox A into the left frontalis and corrugators
respectively.

cold compress the fat-grafted area for 3 days to expedite resolution of

swelling and ecchymosis.
Among the 62 patients, 39 had at least 3-month follow-up with a
mean follow-up of 16 months (range = 3–44 months). These 39
underwent preoperative and postoperative forehead contour grading
based on a standardized lateral facial photograph using an aesthetic
grading system devised by the authors: grade 1 describes a pronounced
depression over the frontal area; grade 2, mild depression over frontal
area; grade 3, flat frontal area; grade 4, mild fullness over frontal area;
and grade 5, pronounced fullness of the frontal area. Grading was rated
at latest follow-up by 2 independent plastic surgeons who did not per-
form the patients' surgery. The interrater reliability was assessed by
method of errors according to the Pearson correlation coefficient.
Preoperatively and postoperatively at latest follow-up, 17 (9 re-
ceived Botox injection; 8 received no Botox) of the previously men-
tioned 39 subjects had 3-dimensional (3D) photographs taken using
the 3dMD system (3dMD, Atlanta, Ga). Similar to a fat graft quantifi-
cation method we previously described, images were analyzed using the
3dMDvultus software and preoperative and postoperative images were
superimposed digitally at the level of the nose (Fig. 2).4 The forehead
area was isolated and nonforehead areas (eyebrow, nose, area above FIGURE 2. Lateral view of preoperative and postoperative 3D
hairline) were carefully excluded. Preoperative and postoperative images of a forehead fat graft patient superimposed digitally.

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Annals of Plastic Surgery • Volume 82, Supplement 1, January 2019 Aesthetic Asian Forehead Fat Graft

TABLE 1. Forehead Fat Volume Measurement Using 3D Photography in Forehead Fat Graft Patients With and Without Botox Injection

Patients With No Botox (n = 8) Patients With Botox (n = 9) P (Mann-Whitney U Test)

Mean ± SD volume of fat injected into forehead, mL 9.25 ± 3.54 9.11 ± 6.74 0.662
Mean ± SD percentage retention of grafted forehead fat 39.12 ± 5.24 46.71 ± 5.77 0.006
Mean ± SD latest follow-up time for 3D photography, mo 11.03 ± 8.42 7.09 ± 3.82 0.441

FIGURE 3. A and C, Preoperative frontal and left lateral views of a 33-year-old woman with a grade 3 planar forehead. She desired a
rounded fuller forehead. B and D, Postoperative views at 1 year after fat grafting of 6 mL to the forehead. Note the grade 4 voluminous
convex forehead profile lending to the impression of a slimmer smaller face and the harmonious overall look. We routinely overcorrect
by approximately 20% during forehead fat grafting to account for resorption and achieve a durable long-term result.

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Chun-Wui Kang et al Annals of Plastic Surgery • Volume 82, Supplement 1, January 2019

FIGURE 4. A and C, Preoperative frontal and left lateral forehead views of a 33-year-old woman with a hump at the upper forehead and
a depression just between that and her supraorbital ridge (grade 2 forehead contour). She wanted to correct the depression. B and D,
Postoperative views at 1 year after fat grafting of 6 mL to the forehead. Note the postoperative correction of the depression through fat
grafting (grade 3 forehead contour).

For those enrolled in 3D forehead volume analysis, the per- DISCUSSION

centage mean ± SD retention of grafted fat volume according to 3D
photography measurement was 46.71% ± 5.77% and 39.12% ± 5.24%, Forehead aesthetic contouring is increasingly recognized as a
respectively, for patients with and without Botox injection mainstream procedure in East Asian aesthetic surgical practice. Gener-
(P = 0.006) (Table 1). ally, when compared with whites who have dolichocephalic heads in
All 62 subjects were satisfied or very satisfied with their out- which the fronto-occipital length is greater than the bitemporal width,
comes at latest follow-up (mean follow-up of 9.1 months [range = Asians possess wider heads and planar foreheads and occiputs.5 Flat
1–44 months]) (Figs. 3–7). foreheads are regarded as unaesthetic and give a 2D aged appearance.

FIGURE 5. A and C, Preoperative frontal and right lateral forehead views of a 26-year-old man with an obvious shadowy depression
above his very angular prominent supraorbital ridge (grade 1 forehead contour). This shadowing effect is both unaesthetic and
inauspicious in East Asian physiognomy. He wanted to correct the obvious depression and thereby make the supraorbital ridge less
pronounced. B and D, Postoperative views at 1 year after fat grafting of 8 mL to the forehead. Note the postoperative correction of the
depression through fat grafting, as well as the more aesthetic forehead (grade 5 forehead contour) that no longer had a prominent
aged-looking supraorbital ridge.

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Annals of Plastic Surgery • Volume 82, Supplement 1, January 2019 Aesthetic Asian Forehead Fat Graft

FIGURE 6. A and C, Preoperative frontal and left lateral views of a 50-year-old woman with a shadowy recession above her relatively
prominent supraorbital ridge (grade 2 forehead contour). She did not like the forehead shadow when taking frontal photos and
wanted to correct the recession and camouflage the supraorbital ridge. We noted that she animated her frontalis and corrugators
excessively during preoperative consultations indicating a need for forehead Botox injection during forehead fat grafting. B and D,
Postoperative views at 1 year after fat grafting 5 mL to the forehead with concomitant Botox injection to bilateral frontalis and
corrugators (grade 4 forehead contour). Note the postoperative correction of the recession through fat grafting, as well as the more
aesthetic forehead that no longer casted a frontal supraorbital shadow.

For most East Asian patients—especially females, the forehead occidental literature. The suitably augmented forehead increases the
is a critical aesthetic unit by modern East Asian beauty standards, and proportions of the upper third of the face in relation to the remaining
a full smooth rounded forehead represents the highly desired aesthetic two thirds and can create the illusion of a more feminine narrower
ideal well appreciated in person and in photos especially from the lateral smaller face.6 It is increasingly common in East Asia to pair augmenta-
and oblique views. East Asian physiognomy values a smooth round vo- tion rhinoplasty with forehead augmentation because a planar recessed
luminous forehead that is believed to convey intelligence, favorably im- forehead is aesthetically incongruous with a prominent augmented nose
press others, and inspire trust in interpersonal relationships. Likewise, and lipofilling the forehead is a simple way to harmonize this. Similarly,
positive attributes are believed to be associated with a full forehead in Kornstein and Nikfarjam6 reported autologous fat grafting to the

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Chun-Wui Kang et al Annals of Plastic Surgery • Volume 82, Supplement 1, January 2019

FIGURE 7. A, Preoperative right lateral view of a 39-year-old woman with a grade 2 forehead contour (mild depression over frontal
area). She desired a rounded fuller forehead. B, Postoperative view at 1 year after fat grafting of 6 mL to the forehead. Her forehead
contour had improved to a desirable grade 5 (pronounced fullness of the frontal area).

forehead/glabella/radix complex with or without concurrent rhinoplasty as used for forehead augmentation. Along with its lack of immunogenicity
a reliable method to reduce the nasofrontal angle, thereby diminishing and hypersensitivity reaction elicitation, as well as its unique capability
unharmonious nasal prominence. to improve rhytides and skin texture over where it is grafted, fat is the
Many males and elderly individuals develop an overtly promi- closest thing we have to a perfect facial filler.16–18
nent supraorbital ridge that results in a primitive and/or obvious aged Incorporating Coleman's tenets of structural fat grafting, we ad-
skeletal appearance. An angular forehead-glabella supraorbital promi- vocate grafting tiny fat aliquots in multiple superficial and deeper fore-
nence produces a relative superior concavity with shadowing that is un- head planes (subdermal and subcutaneous) to generate voluminous fill
aesthetic and believed to bring misfortune in East Asian cultures. These and firm skin support.19 In applying our approach, the freedom and
patients dislike photo taking because the prominence juts out on lateral flexibility to easily inject fat as required with relative artistic abandon
views, and the shadowing becomes most obvious in frontal photos and without concern for filler particle size and cost were a clear advan-
taken with a flash. All our patients also expressed concern with their tage over alternative fillers. We usually require only 1 to 3 tiny stab in-
forehead-glabella rhytides and poorer texture. cisions to achieve a good result making this minimally invasive in the
Forehead augmentation and volumization have been described truest sense, in contrast to the need for longer scalp incisions for methyl
using bony advancement and a variety of alloplastic and autologous im- methacrylate.5,7 Bearing in mind these qualities, one can then focus on
plants.6 Among autologous materials, fat graft ranks as the most popu- building a voluminous convex forehead without any reservation. In our
lar, and bone graft and dermal graft have been used for the forehead. practice, the MAFT-Gun is an essential instrument to ensure precise and
Methyl methacrylate and silicone are well-known alloplastic forehead consistent placement—with every trigger pull—of intact microdepots
implants, but they require significant scalp incisions for surgical place- of fat graft parcels (choice of volume delivery settings at 1/60, 1/90,
ment, carry higher infection risk, and may have unnaturally visible or 1/120, 1/150, 1/180, and 1/240 mL) that will stand the highest chance
palpable borders.7,8 Silicone forehead implants have been reported to of vascularization in the recipient site after grafting, in accordance with
migrate, cause seromas, and deform the underlying cranium.5,9,10 Coleman's principles for successful fat grafting.3,14,18,19 We and others
Hyaluronic acid filler is popularly used throughout East Asia for mini- have successfully used the MAFT-Gun to fat graft thin sunken upper
mally invasive forehead augmentation, and calcium hydroxyapatite is eyelids without causing deformity from bolus deposition.3 Large bolus
also recommended for this indication; however, the longevity of alterna- fat deposition and uneven fat distribution were therefore all the more
tive fillers is more limited.11–13 unlikely in the forehead with thicker skin. This may well explain the
Again based on current literature search, there are few publica- overall satisfactory symmetry and absence of forehead nodule and fat
tions detailing the specific technique of forehead lipofilling to achieve necrosis formation during follow-up.
consistently good outcomes.14 Ironically, and to our best knowledge, Fat grafting to the glabella region was previously reported to
no objective study on forehead fat grafting outcomes in East Asians be generally ineffective with most patients showing significant graft
has been published despite the immense popularity of this procedure loss by 3 to 4 months.20 Bucky and Kanchwala12 also had unsatis-
in the said region. The previously mentioned aging forehead changes factory glabella fat graft outcomes until they started injecting Botox
in our study are mostly the result of forehead skin, subcutaneous tissues, into patients' corrugators 1 week before fat grafting and found that
and bone atrophying over time, contributing to forehead flattening, de- just 3 months of corrugator blockade could provide long-term gla-
pression, and rhytides.1,6,15 For these, fat grafting of the forehead is an bella fat graft survival. Theoretically immobilizing the corrugators
efficacious like-for-like tool to correct unaesthetic contours through either chemically or by surgical resection would increase fat graft
soft-tissue volumization and to rejuvenate the overlying skin and under- stability and enhance survival and retention, making overcorrection
lying bone through the effects of many adipose growth factors.1,6 less crucial.1 This suggested that forehead Botox might increase
Proponents of forehead fat grafting are in unison regarding the forehead fat retention rate in part due to decreased muscle tension
advantages of fat. Autologous fat—readily available in just about during graft take. Isik and Sahin21 recruit adhesive tape and a hair
everyone—has a permanence, cost-effectiveness, and safety profile su- band for the purpose of forehead fat graft stabilization and achieved
perior to that of alternative fillers and alloplastic implants commonly satisfactory graft take.

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Annals of Plastic Surgery • Volume 82, Supplement 1, January 2019 Aesthetic Asian Forehead Fat Graft

In agreement with some authors, we did not find routine use of minimum downtime, and the results are long-lasting with high pa-
forehead Botox necessary for forehead lipofilling in all patients.21,22 tient satisfaction rates.
However, in our results, 1 subject with lax thin atrophied forehead skin
and habitual overanimation of her forehead brow developed vertical ACKNOWLEDGMENT
creases (these were much deeper than her native frown lines) in her fat- Informed consent was received for publication of the figures in
grafted forehead likely due to fat displacement by her overcontracting this article.
corrugators and frontalis. We therefore modified our procedure thereafter REFERENCES
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