Aesthetic Surgery Techniques

Aesthetic Surgery
Techniques
A Case-Based Approach

Aesthetic Surgery
Techniques
A Case-Based Approach
James D. Frame FRCS, FRCS (Plast)
Consultant Plastic Surgeon,
Professor of Aesthetic Plastic Surgery,
School of Medicine,
Anglia Ruskin University, Chelmsford, Essex, UK
Shahrokh C. Bagheri BS, DMD, MD, FACS, FICD
Chief of Oral and Maxillofacial Surgery,
Northside Hospital, Atlanta and Forsyth, GA, USA
David J. Smith Jr. MD
Professor of Surgery, Division of Plastic and Reconstructive Surgery,
University of South Florida; Richard G. Connar Professor and Chairman, Department of Surgery,
University of South Florida; Chief Medical Officer, Center for Advanced Medical Learning and
Simulation, Tampa, FL, USA
Husain Ali Khan MD, DMD, FACS
Attending Surgeon, Oral and Maxillofacial Surgery,
Northside Hospital, Atlanta and Forsyth, GA, USA
For additional online content visit ExpertConsult.com
Edinburgh  London  New York  Oxford  Philadelphia  St Louis  Sydney  2019

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• Video 34.2 Prone position with marking
• Video 34.3 Right posterior skin excision following
liposuction for pseudoundermining
• Video 34.4 Left posterior skin excision following
liposuction
• Video 34.5 Completed bilateral posterior skin excision
• Video 34.6 Skin closure of posterior wound
• Video 34.7 Final dressing of posterior wound
following insertion of suction drain
• Video 34.8 Patient turned supine and ventral torso
prepared
• Video 34.9 Power-assisted liposuction with 4-mm
cannula
• Video 34.10 Incision for skin excision
• Video 34.11 Preserving Scarpa’s fascia
• Video 34.12 Midline dissection
• Video 34.13 Completed dissection for excision of skin
flap
• Video 34.14 Excised skin flap
• Video 34.15 Marking for plication of the anterior rectus
sheath
• Video 34.16 Completed plication
• Video 34.17 Progressive tension sutures (quilting
sutures)
• Video 34.18 Umbilical transposition
• Video 34.19 Skin approximation in lower abdomen
and exteriorization of umbilicus
• Video 34.20 Deep dermal sutures with the halving
method
• Video 34.21 Skin closure of lower abdomen
• Video 34.22 Appearance after closure of anterior
wound
• Video 34.23 Application of Steri-Strips
Chapter 35: Gluteal Augmentation
• Video 35.1 Gluteal augmentation: surgical technique
Chapter 39: Inner Thigh Reduction: Reshaping Using a
Two-Way Vector Technique
• Video 39.1 Skin markings for two-way vector
technique for inner thigh reduction
• Video 39.2 Operative technique for two-way vector
technique for inner thigh reduction
Chapter 2: Aesthetic Medicine: Surgical Pearls
• Video 2.1 Botulinum toxin to corrugator, depressor
supercilli; botulinum toxin to frontalis muscle and
procerus muscle complex
• Video 2.2 Tear trough and lateral orbital rim
enhancement
• Video 2.3 Temple filler: volumization of temple area
• Video 2.4 Nonsurgical rhinoplasty
• Video 2.5 Periocular rejuvenation
• Video 2.6 Cheek filler
• Video 2.7 Upper lip augmentation
• Video 2.8 Lip augmentation
• Video 2.9 Hyaluronic acid to prejowl sulcus,
marionette, and lower nasolabial fold
• Video 2.10 Nefertiti lift with botulinum
• Video 2.11 Hand rejuvenation with hyaluronic acid
Chapter 12: Management of the Neck
• Video 12.1 oVio360 dynamic imaging link. 50-year-old
woman before and after trampoline platysmaplasty
and neck-defining suture. (Courtesy of G. Mueller,
M.D. and oVio Technologies, Newport Beach, CA,
USA.)
Chapter 13: The Turkey Neck: Surgical Management
• Video 13.1 Identification of elevation point and
window under platysma
• Video 13.2 Triple-cable suture fixation to Lore’s fascia
• Video 13.3 Horizontal and vertical tightening of
platysma to Lore’s fascia using the triple-cable suture
technique
• Video 13.4 Redundant platysma band resection by
submental incision
Chapter 16: Aesthetic Nasal Tip Surgery
• Video 16.1 Second interdomal stitch (SIDS)
Chapter 30: Transaxillary Excision of Gynecomastia
(Andromastia)
• Video 30.1 Surgical management of gynaecomastia
(andromastia): the Levick technique
Chapter 34: Body Contouring Following Massive
Weight Loss
• Video 34.1 Preoperative circumferential marking in
standing position
Video Contents

Like many surgical disciplines, the practice of aesthetic
surgery has evolved by developing improved surgical tech­
niques to meet increasing patient expectations. In most cosmetic
procedures, the vast majority of advances are from the teaching
of surgical skill sets to younger surgeons through operative
training, textbooks, lectures, and symposia. The difficulty of
developing randomized or prospective cohort studies and
multicenter analyses for aesthetic procedures contributes to
the progression via more traditional modes of teaching. Aesthetic
surgery is unique due to constantly changing trends, as well
as the racial and regional ethnic preferences that drive patient
desires to achieve what is considered an aesthetic result.
There are few books that deliver a case-based approach to
common aesthetic problems, particularly with a global perspec­
tive. The topics included in this book are based on the basic
competencies recognized for hands-on training of an aesthetic
surgeon and include the latest tips and tricks in the aesthetic
and beauty industry. The authors are selected from experienced
clinicians across the globe, and each presents cases that are
easily identified in a normal practice, describing their technique
and outcomes with minimal but relevant bibliography and
operative videos.
We the editors hope that the inquiring clinician will be
stimulated to improve his or her best practice.
JDF
SCB
DJS
HAK
This book is dedicated to all those who suffer from deformity
and disfigurement and seek an opportunity to improve their
appearance and restore function. The skills of the Aesthetic
Surgeon in helping Cosmetic Surgery patients, as illustrated
in this book, can be translated to helping those such individuals.
It is up to the Surgeons to learn these specialty skills and put
them into practice. This concept is known as Aesthetica and
our book, with elaborate illustrations and videos, provides
many tips and tricks on how to improve as a Surgeon and,
more importantly, improve patient outcomes. Congratulations
to Elsevier for their insight and support throughout.
There is no substitute for clinical experience in aesthetic
medicine and surgery. It is the Hippocratic responsibility of
those with experience to enhance the knowledge base of those
embarking on their new careers. We (the editors) represent the
current interdisciplinary approach to educating for the many
specialties associated with the beauty industry.
A clinician’s aesthetic practice should represent her or his
fundamental roots in medical training. There must be limitations
to the unqualified extension of practice, all in the patients’ best
interests.
There are many traps for the unwary clinician that can be
largely circumvented with an understanding of the needs
and realistic expectations of the patient. The dysmorphic and
psychologically vulnerable patient must be identified and
protected from harm at all times. Similarly, if a surgeon can
provide for an appropriately selected patient’s desires, then
modern aesthetic medicine and surgical practice can be
immensely satisfying and rewarding.
Preface

We would like to thank James D. Frame (Jnr), BSc, MSc, who
worked hard to help reorganize and, in some cases, rewrite
chapters to fit in with style and assisted with the electronic
submissions. Without his work, none of this would have started.
Also, we would like to thank our wives who have put up with
our 30 year “working friendship.”
JDF
DJS
Acknowledgments
This project would not be possible without the deduction and
hard work of our contributors, all of whom, without hesitation,
offered their time and expertise to realize this unique textbook
of Aesthetic Surgery. We thank you for your kind contribution
and time. We would like to also acknowledge the team at
Elsevier whose continuous support throughout this project
has once again resulted in an outstanding publication for the
readers of Aesthetic Surgery.
SCB
HAK

Henrique P.L. Cintra MD
Assistant Professor of Plastic Surgery
Pontifical Catholic University of Rio de Janeiro
Rio de Janeiro
Medical Director
Craniofacial Surgery Center
State University of Rio de Janeiro
Rio de Janeiro, Brazil
25. Small Breast
Clifford Clark MD
Medical Director
Orlando Aesthetic Institute
Orlando, FL, USA
Assistant Clinical Professor
University of South Florida
Tampa, FL, USA
20. Male Rhinoplasty
Pedro S. Coltro MD, PhD
Professor of Plastic Surgery
Ribeirão Preto Medical School
University of São Paulo
São Paulo, Brazil
38. Inner Thigh Lift
Fernanda B. Correa MD
Plastic Surgeon
Ribeirão Preto Medical School
University of São Paulo
Brazil
38. Inner Thigh Lift
Marcelo A. Cuadrado MD
Plastic Surgeon
Hospital Britanico de Buenos Aires
Buenos Aires, Argentina
39. Inner Thigh Reduction: Reshaping Using a
Two-Way Vector Technique
Anne Dancey, FRCS (Plast), MBChB
(Hons), MMedSci (Hons) MCh (PASP)
Plastic and Reconstructive Surgeon
Birmingham, UK
32. Postbariatric Abdominoplasty
Petrus V. van Deventer MBChB, BSc,
MMedSc (UOVS), MMed (US)
Lecturer in Plastic & Reconstructive Surgery
University of Stellenbosch
Bellville, Western Cape, South Africa
27. Mastopexy with Mesh for Breast Ptosis
Charles East MBBS, FRSC
Consultant Surgeon at the Royal National Throat
Nose and Ear Hospital and University College
London Hospitals
NHS Trust
London UK
Director of Rhinoplasty
ENT@150
Harley Street
London, UK
17. Crooked Nose
Bernard S. Alpert MD
Plastic Surgeon
California Pacific Medical Center Davies
Campus (CPMC)
San Francisco, CA, USA
11. High SMAS Face Lift
Hazem M. Aly MBBCh, MSc, PhD
Professor of Plastic Surgery
Ain Shams University
Cairo, Egypt
Assistant Professor of Plastic Surgery
Dalhousie University
Saint John, New Brunswick, Canada
9. Anatomic Relationship of SOOF and ROOF in
Eyelid Rejuvenation
Claudio Angrigiani MD
Chief of Plastic Surgery
Hospital Santollani
Buenos Aires, Argentina
28. Simultaneous Augmentation and Periareolar
Mastopexy: Indications and Limitations
Peter Arnstein FRCS (Plast)
Consultant Plastic Surgeon
McIndoe Hospital
East Grinstead, Sussex, UK
5. Endoscopic Endotine Brow Lift Made Easy
Phillipe Bellity MD
Plastic Surgeon
Hartmann Clinic
Paris, France
3. Aesthetic Applications for Fillers
Miles G. Berry MS, FRCS (Plast)
Cosmetic Surgeon
Cosmetic Surgery Partners
London Welbeck Hospital
London, UK
14. Platysma Bands
Nazim Çerkeş MD
Aesthetic Plastic Surgeon
Cosmed Aesthetic Plastic Surgery Center
Istanbul, Turkey
18. The Middle Eastern–Mediterranean Nose
Kaushik Chakrabarty MBChB, MD, FRCS,
FRCS (Plast)
Consultant Plastic Surgeon
University Hospital of South Manchester
Wythenshawe, Manchester, UK
37. Aesthetic Management of the Aging Hand
List of Contributors
Jayme A. Farina Jr. MD, PhD
Professor
Head of Division of Plastic Surgery
Ribeirão Preto Medical School
University of São Paulo
Brazil
38. Inner Thigh Lift
Alexandre S.F. Fonseca MD, PhD
Plastic Surgeon
Breast Reconstruction Division
ICESP Cancer Center
University of São Paulo School of Medicine
São Paulo, Brazil
Centro Médico Viver Melhor
São Paulo, Brazil
26. Breast Reduction: Superomedial Pedicle
Wise-Pattern Approach
James D. Frame FRCS, FRCS (Plast)
Consultant Plastic Surgeon
Professor of Aesthetic Plastic Surgery
School of Medicine
Anglia Ruskin University
Chelmsford, Essex, UK
9. Anatomic Relationship of SOOF and ROOF in
Eyelid Rejuvenation
Riccardo Frati MD, PhD
Consultant Plastic Surgeon
Highgate Private Hospital
London, UK
33. Nonexcisional Management of the Anterior
Abdominal Wall
Garrick Georgeu MBChB, MSc, FRCS
(Plast)
Consultant Aesthetic Plastic Surgeon
Cadogan Clinic
London
Consultant Aesthetic Surgeon
Chelmsford, UK
29. Asymmetric Breast
Grant Hamlet MBChB
Director
The Hamlet Clinic
Harley Street
London, UK
33. Nonexcisional Management of the Anterior
Abdominal Wall
Hugh Henderson FRCS
Consultant Plastic Surgeon
Leicester
Medico Legal Advisor and Claims Examiner
Leicester, UK
1. Informed Consent: Protecting the Patient and
the Surgeon

xiv
List of Contributors
Darryl J. Hodgkinson MBB (Hons), FRCS
(C), FACS, FACCS
Plastic and Reconstructive Surgeon
The Cosmetic and Restorative Surgery Clinic
Sydney, Australia
13. The Turkey Neck: Surgical Management
Janek S. Januszkiewicz MBChB, FRACS
(Plast)
Plastic Surgeon
New Zealand Institute of Plastic and Cosmetic
Surgery
Auckland, New Zealand
6. Upper Blepharoplasty
Kazunari Karahashi MD
Clinical Fellow of Plastic Surgery
St Luke’s International Hospital
Tokyo, Japan
19. The Asian Rhinoplasty
Jaffer Khan MBBS, FRCSI, FRCS (Plast),
FACS
Chief Executive Officer
Aesthetics International
Consultant Plastic and Reconstructive Surgeon
Aesthetics International
United Arab Emirates
Senior Lecturer in Aesthetic Surgery
Anglia Ruskin University
Cambridge, UK
2. Aesthetic Medicine: Surgical Pearls
Natasha Jaffer Khan MBBCh, BAO, LRCP,
LRCSI
Aesthetics International
United Arab Emirates
2. Aesthetic Medicine: Surgical Pearls
Paul Levick MS, FRCS (Ed), FRCS (Eng)
Consultant Plastic Surgeon
Birmingham, UK
30. Transaxillary Excision of Gynecomastia
(Andromastia)
Michael R. Markiewicz MD, DDS, MPH
Assistant Professor
Department of Oral and Maxillofacial Surgery
University of Illinois
Chicago
Attending Surgeon
Northwestern Memorial Hospital and Ann &
Robert H. Lurie Children’s Hospital of Chicago
Chicago, IL, USA
22. Orthognathic Surgery
Michael Miloro MD, DMD, FACS
Professor and Head of Department of Oral and
Maxillofacial Surgery
University of Illinois
Chicago, IL, USA
22. Orthognathic Surgery
Bassem M. Mossaad MRCS, MSc (Aesth
Plast), FEBOPRAS, MD
Lecturer and Consultant Plastic Surgeon
Plastic Surgery Unit
Suez Canal University
Ismailia, Egypt
31. Improving the Waistline with the Modified
Brazilian Abdominoplasty
Gregory P. Mueller MD, FACS
Plastic Surgeon
Private Practice
Beverly Hills, CA, USA
12. Management of the Neck
Arun Nayyar DMD, MS
Private practitioner in Prosthodontics
Former Director of Fixed Prosthodontics
Medical College of Georgia School of Dentistry
Augusta, GA
Former Principle Research Scientist, (Adjunct)
Georgia Tech Research Institute
Atlanta, GA, USA
24. Aesthetic Dentistry of the Smile Line
Igor Niechajev MD, PhD
Chief
Plastic Surgery
Lidingö Clinic
Stockholm, Lidingö, Sweden
15. Prominent Nose
Nicholas R. Nikolov MD, FACS
Plastic Surgeon
The Nikolov Center for Plastic Surgery
Beverly Hills, CA, USA
12. Management of the Neck
Naoyuki Ohtake MD, PhD
Director of Plastic Surgery
St Luke’s International Hospital
Tokyo, Japan
7. Asian Blepharoplasty
19. The Asian Rhinoplasty
Marcelo Olivan MD, PhD
Consultant Plastic Surgeon
University of Sao Paulo
São Paulo, Brazil
35. Gluteal Augmentation
Alenka Paddle MBBS (Hons), FRACS
(Plast), PGDipSurgAnat
Advanced Aesthetic Plastic Surgery Fellow
Melbourne Institute of Plastic Surgery
Melbourne, Australia
36. Upper Arms: Rejuvenation of the Arm
Philip Peirce MBBCh, FCS (SA) (Ophth)
Ophthalmic and Oculoplastic Surgeon
Sandhurst Eye Centre
Sandton, South Africa
4. Brow Lift
Kirill Pshenisnov MD, PhD
Professor and Chief of Plastic Surgery
European Medical Center
Moscow
Professor of Plastic Surgery
Russian National Research Medical University
Moscow
Professor of Traumatology and Plastic Surgery
Yaroslavl State Medical University
Yaroslavl, Russia
16. Aesthetic Nasal Tip Surgery
Alberto Rancati MD, PhD
Chief Division Oncoplastic Surgery
Instituto Oncologico Henry Moore
Universidad de Buenos Aires
Buenos Aires, Argentina
Assistant Professor Plastic Surgery
Florida International University
Miami, FL, USA
28. Simultaneous Augmentation and Periareolar
Mastopexy: Indications and Limitations
Neal R. Reisman MD, JD, FACS
Past President
The Aesthetic Surgery Education and Research
Foundation
Clinical Professor Plastic Surgery
Baylor College of Medicine
Immediate Past Chief Plastic Surgery
CHI Baylor St. Luke’s Medical Center
Attorney at Law
Houston, TX, USA
1. Informed Consent: Protecting the Patient and
the Surgeon
Christopher M.E. Rowland Payne MB, BS,
MRCP
Consultant Dermatologist
The London Clinic
Harley Street
London, UK
21. Medical Rhinoplasty
Ernesto J. Ruas MD, FACS
Associate Clinical Professor
Plastic Surgery
University of South Florida College of Medicine
Tampa, FL, USA
8. Midface Descent and Malar Support
Edward R. Schlissel DDS, MS
Professor Emeritus
General Dentistry
Stony Brook University School of Dental
Medicine
New York, NY, USA
23. Implantology
Peter Scott, MBBCh, BSc (Hons), FRCS
(Edin)
Consultant Plastic Surgeon
Morningside Clinic
Johannesburg, South Africa
4. Brow Lift
Nobuyuki Shioya MD, FACS
Professor Emeritus of Plastic Surgery
Kitasato University School of Medicine
Sagamihara, Kanagawa, Japan
7. Asian Blepharoplasty
19. The Asian Rhinoplasty

xv
List of Contributors
Graeme Southwick OAM, MBBS (Hons),
FRACS, FACS
Consultant Plastic Surgeon
Chairman
Melbourne Institute of Plastic Surgery
Adjunct Senior Lecturer
Anatomy and Cell Biology
Hudson Institute of Medical Research
Monash University
Melbourne, Victoria, Australia
36. Upper Arms: Rejuvenation of the Arm
Jan J. Stanek MA, FRCS
Cosmetic Plastic Surgeon
Surgical Aesthetics
London, UK
14. Platysma Bands
Guilherme Flosi Stocchero MD
Plastic Surgeon
Centro Médico Viver Melhor
São Paulo, Brazil
26. Breast Reduction: Superomedial Pedicle
Wise-Pattern Approach
Gustavo Flosi Stocchero MD
Plastic Surgeon
University of São Paulo Hospital
São Paulo, Brazil
Centro Médico Viver Melhor
São Paulo, Brazil
26. Breast Reduction: Superomedial Pedicle
Wise-Pattern Approach
Patrick J. Treacy MBBCh, LRCSI, MICGP,
MBCAM, HDip Derm, BSc (Hons)
Dermatologist, Founder and President of the
Ailesbury Clinic
Dublin, Ireland
10. Nonsurgical Rejuvenation of the Periorbital
Area
Dharmadev Trivedi MBBS, MS, MRCS,
FHEA (UK)
Registrar in Upper Gastrointestinal /
Hepatopancreatobiliary Surgery
Bristol Royal Infirmary
Bristol
Research Registrar in Cosmetic Surgery
Medical Arts for Cosmetic Surgery
Watford, UK
34. Body Contouring Following Massive Weight
Loss
Jared Troy MD
Plastic Surgeon
Winter Park, FL, USA
20. Male Rhinoplasty
Shailesh Vadodaria MBBS, MS, MCh, FRCS
(Plast)
Consultant Plastic and Reconstructive Surgeon
London Welbeck Hospital
London
Consultant Plastic and Reconstructive Surgeon
Clementine Churchill Hospital
Harrow
Middlesex
Director
Medical Arts for Cosmetic Surgery
Watford, UK
Consultant Plastic and Reconstructive Surgeon
Kokilaben Dhirubhai Ambani Hospital and
Medical Research Institute
Mumbai, India
34. Body Contouring Following Massive Weight
Loss
Takanori Yamawaki MD
Plastic Surgeon
St Luke’s International Hospital Tokyo
Japan
7. Asian Blepharoplasty
Zara Yousufzai MBBS, MS (Plast)
Aesthetics International
United Arab Emirates
2. Aesthetic Medicine: Surgical Pearls

3
The Process of Informed Consent
3
1 
Informed Consent: Protecting the Patient and
the Surgeon
Neal R. Reisman MD, JD, FACS
Hugh Henderson FRCS
The Process of Informed Consent
Neal R. Reisman MD, JD, FACS
The process of informed consent is very important to the practice
of plastic surgery. Not only is it a requirement from a legal
standpoint, but it should assist in clarifying goals and expecta­
tions. Understanding informed consent is a process and not
specifically the document that becomes signed; the process
should include not only the surgeon, but the team interacting
with the patient. There are legal standards that every jurisdiction
adheres to defining requirements in accomplishing informed
consent. The majority of states in the United States follow a
“reasonable patient” standard which defines informed consent
information necessary for a reasonable patient to make an
informed decision. The minority standard is what a “reasonable
physician” deems appropriate to accomplish informed consent.
Such standards do not mean that all information pertinent to
a procedure must be discussed but only such information as
a reasonable prospective patient would need to understand
to make an informed decision. Practices spend much time
creating and discussing informed consent. The reality is that
there are very few litigation cases specifically lost on a lack of
informed consent. It is important to have the consent discussion
and documents in the patient’s language. In addition to language
issues, the bigger task is having the patient “understand” what
the risks, hazards, inherent risks, and concerns are. The
understanding of this information becomes the main issue in
creating and achieving informed consent. A mere signature at
the bottom of the document only demonstrates that the patient
signed it and not that it is understood.
Informed consent documents present and discuss death and
significant morbidity. It may be difficult for a jury to believe
the plaintiff is objecting to a scar or a less than desirable result
when they have understood and signed to say that they
acknowledge that death is an acceptable risk. The scar seems
much less significant. Herein lies the challenge to achieve
informed consent, and I suggest to accomplish the legal
requirement by going beyond the document itself and using
the discussion to better interpret and decide whether goals
can be reached.
The reasonable patient would inquire about the different
procedures suggested, their complications and inherent risks,
anesthesia concerns, drug interactions, cost and expenses, and
the risk of doing nothing. It behooves the practice to see the
prospective patient more than once and to utilize multiple
learning style techniques in providing necessary information.
There are many learning styles, but the most common three
are visual, auditory, and kinesthetic. Understanding is enhanced
when all three styles are incorporated in the informed consent
process. Many patients are visual learners and achieve under­
standing by looking at photographs, schematics, and other
tools the patient can see. One must be cautious in not having
photographs interpreted as a warranty of results but rather
representative of different aspects of the procedure. Demonstra­
tive tools should clearly not be presented as the prospective
patient’s result but rather a general representation. Patients
may bring in their own photographs of goals and expectations
that are helpful in defining their desires, but these should not
be made part of or included in the medical record. Auditory
learners are the next most common group. The auditory learner
listens in great detail to describing information pertaining to
the procedure, follow-up, and care. Your words paint a picture
for them, achieving a better understanding of the procedure
and inherent risks. Often the more detail you can provide in
advance, the more comfortable the patient is with the entire
event. The third learning style is the kinesthetic learner. This
can be more of a challenge in discussing how the procedure
specifically relates to the patient and past experiences the patient
can recognize. An example might be, when attempting to
determine size goals in a breast augmentation, to have the
patient reflect on a past pregnancy where breast size dramati­
cally increased. The patient may disclose that they liked their
shape as they reached a full C in size, but the full D size they
reached was too large. Such a personalized experience and
understanding significantly helps the patient in understanding
options and achieving their goal.

4
    CHAPTER 1  •  Informed Consent: Protecting the Patient and the Surgeon
selection choice. I have issues with the propriety of less than
desirable options being selected by the patient. One might say
that a patient cannot consent to a negligent procedure. The
surgeon has a duty to protect the patient, sometimes from
themselves. Remember that the informed consent standard is a
reasonableness standard. That is, what a reasonable physician
or a reasonable patient would want to discuss or know for the
patient to make an informed decision. Many have utilized a
checklist to cover the large amount of information that may be
necessary in a complex case. The concern with a large checklist is
that one item may be unintentionally omitted. If that is the one
complication the patient suffers, the perception may be that it
was omitted intentionally. Educational aids to assist with visual,
auditory, and kinesthetic learning are valuable. The concern is
not to create a warranty, either express or implied. An express
warranty includes a specific demonstrative in the medical record
that establishes an agreed-upon result. Patients bring pictures
from magazines and the Internet as a goal for their expectation.
While these are valuable, I would suggest they not be made
part of the medical record. Similarly your preoperative and
postoperative photographs should clearly represent a range of
results and not imply specific results for this patient. An implied
warranty can be more confusing, as it relates to expressed
concerns and desires the patient has that are not negated or
addressed. An example might be an important meeting 2
weeks following surgery that must be attended. Failing to offer
rescheduling or a disclaimer that meeting attendance may not be
possible may establish an implied warranty that the patient will
be able to attend. I like the additional paragraph “no warranties
express or implied are included and the patient understands
what can and cannot be done and, understanding this, elects to
proceed.”
Additional information as part of this informed consent
process includes a financial disclosure statement and a surgi­
cal revision policy statement. Finances are always significant
to the patient, and misunderstandings are quite common. It
is important to have a separate document that incorporates
expectations of named procedure, estimated time, and fees
including surgeon, anesthesia, facility, and any additional costs
that may be incurred, such as devices and instrumentation.
The patient should understand and acknowledge such a docu­
ment in advance of the procedure. The revision policy is also
important to avoid misunderstandings. Despite best intentions
patients may heal quite differently and unexpectedly. I like the
revision policy to include an understanding that the patient is
required to be compliant and not miss follow-up appointments
or postoperative suggestions of care. The surgeon can certainly
for some period not charge for agreed revisions, but there may
be additional charges for anesthesia, facility, or devices. I do not
believe that not billing is an admission of negligence and have
advised adding a clause in the policy manual stating “from
time to time, as an executive decision, fees may be waived,
discounted, or not created.”
There are so many aspects of the informed consent document;
I do not want to minimize its importance. I would, however,
seize the opportunity to have a robust and complete discussion
with the prospective patient about their goals and desires and
use this interactive informed consent process to determine
if such goals are realistic and achievable. Avoid letting the
patient dictate care and procedure selections unless such choices
are well within an appropriate peer-accepted range. Failed
expectations still remain a leading cause of unhappy patients
Achieving informed consent can be a team event. The
surgeon has the responsibility to discuss aspects of the treat­
ment; however, some portions can be delegated to the office
team nurse or coordinator. In my opinion it is difficult to allow
or delegate others beside the surgeon to discuss and obtain
informed consent when these non-surgeon team members have
not received the training or credentials, or had the privilege
to ever perform such surgeries. It is wise to develop a team
approach in presenting such information, with the patient
coordinator and the nurse confirming and corroborating the
surgeon’s discussions.
The details of the informed consent document should reflect
the discussions had on the multiple visits prior to the actual
procedure. I have chosen to divide the document into general
risks and specific procedure risks to help the patient understand
what is involved.
General risks of surgery include healing issues, delayed
or undesirable results, bleeding, infection, scarring, pain,
complications related to anesthesia, cardiac pulmonary, deep
venous thrombosis (DVT) and sequelae, allergic reactions,
drug reactions, and unsatisfactory results, to name some of
the included discussions. Additional general advisories relate
to smoking and its negative effect on healing, off-label US
Food and Drug Administration issues, the negative effects
of sun exposure, and general concerns in the postoperative
period relating to travel and family interaction. Additional
discussions should include the possible need for additional
surgery, the importance of patient compliance, a revision policy
covering how long and what, and a separate financial disclosure
document covering patient responsibility, cosmetic surgery
component, present and future expenses, and cancellation policy.
The revision policy should include the period of time after
surgery in which a revision will not incur a fee. Ten months after
surgery might not be unreasonable for the surgeon to consider
a scar revision without additional fees while five years later
might be unreasonable. In addition, the limitations of a revision
would only cover the performed surgeries and not additional
areas or procedures. Revision of an abdominal scar might be
appropriate but additional liposuction or a body lift would not
be considered a ‘revision’. Lastly it is wise to state the revision
policy will only be effective when the patient attends their
postoperative appointments and adheres to recommended care.
Non-compliance waives the revision policy. A communications
consent is important to document and acknowledge how the
practice may communicate with the patient. This should include
permission for telephone numbers, email choices, texting and
cell phone permissions, and social media and other methods.
A general consent should also include the use of photographs
to be kept by the practice and commercial photograph consent
should any patient medical information or likeness be used for
marketing, advertising, or educational purposes. The general
Health Insurance Portability and Accountability Act (HIPAA)
consent would not be adequate for any use beyond practice
storage. The commercial consent is specific regarding where the
likeness would be used, for how long, and for what purpose.
Specific procedural consent should include technical and
specific information relevant to the selected treatment question.
This is the area where specific options related to the procedure
and patient choices are covered. Inherent risks and complications
specific to the procedure should be outlined carefully and in an
educational fashion. Choices offered to a patient or demanded
by a patient should fall within a peer-approved appropriate

5
Informed Consent: Protecting the Surgeon
patient have drawn to show the areas to be treated and the
type of changes that you agree will be attempted.
A recent court of appeal ruling (The Montgomery Case)1
not only expects you to inform the patient of the details of the
operation which you have agreed, but also requires that you
have explained all the alternative options and their merits and
demerits (see Fig. 1.2).
Patients tend to remember only 50% or less of what they
are told verbally in an initial consultation. The longer the
consultation, the more likely that they will “switch off” after
a certain time and forget important points. A lot of surgeons
think that one consultation is sufficient, but if you test a patient’s
knowledge of what has been discussed in that first consultation,
you will be saddened to find that they haven’t really taken in
quite a lot of important matters (Fig. 1.3).
If you give them one consultation plus a detailed informa­
tion sheet and then test them, their knowledge is much better.
If you give them one consultation and an information sheet
and make sure they read it and then see them for a second
consultation, most patients will have absorbed everything you
want them to know and you will have obtained proper informed
consent. Just because it is logistically difficult to arrange a
second consultation, it is not an excuse for not arranging one.
I have dealt with over 1000 medical negligence cases, and I
know that at least 200 of these would have never occurred if
there had been a second consultation before the day of surgery.
and litigation. The wise old statement “if I tell you in advance
of a complication and you get it, I look smart, where if I tell
you the same statements after your complication I’m making
excuses” becomes significant when complications occur. Use the
informed consent process as an educational tool, recognizing
learning styles as well as the dialogue assessing patient goals.
Such a process often results in an educated, content, and satisfied
patient and a successful postoperative course.
Informed Consent: Protecting the
Surgeon
Hugh Henderson FRCS
The Legal Situation
“Justice must not only be done, but must be seen to be done,”
and so it is with informed consent. Surgeons need written proof
about what they have advised a patient. You are as often as
not assumed guilty until you prove your innocence (Fig. 1.1).
Courtroom Scenario
“Well Mr. Jones, did you really spend 45 minutes explaining
this operation to Mrs. Smith or only the 10 minutes as she
alleges? Did you think to make note of the duration of your
consultation and did you give her any written information
about the common risks of what you were proposing? Did
you show her photographs and suggest a second consultation
to ensure that she really understood…?”
If you want to avoid this sort of courtroom confrontation
with an aggressive barrister, you must get a watertight informed
consent which will convince a judge that the patient was well
informed and able to make a considered decision about whether
to have the operation and that the patient understood the risks.
Different surgeons have different ways of achieving this and
there are no mandatory or statutory rules about how to do it.
You can make a close record of what your verbal discussion
covered, you can enclose it in a letter to the general practitioner,
or you can give it to the patient in the form of an information
sheet that you can prove was actually delivered to the patient.
You can get photographs in hard copy on which you and the
FIGURE 1.1  An infected abdominoplasty wound.
FIGURE 1.2  Breast augmentation: the available implant options to be discussed
with a patient.
FIGURE 1.3  High right breast implant and sliding ptosis of breast tissue. Patient
unaware that this could happen after augmentation mastopexy.

6
    CHAPTER 1  •  Informed Consent: Protecting the Patient and the Surgeon
never asked you to make my breasts bigger, I simply asked
you to lift them to make them look fuller.” Having recorded
what the patient is asking for, you should then record the
topics of discussion in relation to this request. It is quite possible
that the patient will change their mind as a result of this discus­
sion and you should then record what their secondary request
is. You must also record what you have recommended and
why and then, separately, what has been agreed.
It is always sensible to show photographs of both good and
bad results so that you can never be accused of showing atypi­
cally perfect results.
If a patient decides to have an operation, but wishes to
delay it for more than a few weeks, it is essential to see them
again for a brief reminder consultation a few days before the
operation. This is to remind you, the surgeon, and also the
patient of what has been agreed and of the risks, and it gives
the patient the chance to ask further questions.
If a patient asks you for a little bit of extra surgery on the
day of the operation, you have the dilemma of causing offense
by refusing or putting yourself in jeopardy if you haven’t sorted
it out properly in advance.
Summary
1. Record the time of the start of the consultation and its
duration.
2. Write down what the patient first asked for, not what you
think might suit them.
3. Write down the options for treatment.
4. Write down what you recommend for them.
5. Write down what you agree to do.
6. Write down the risks and separately the percentage
occurrence of the complications and the consequences of
the complications.
7. Give a comprehensive information sheet.
8. Insist upon a second consultation to run over what has
been discussed already, emphasizing the risks.
9. Discuss the costs of surgery, the financial consequences of
dealing with complications, and who is going to pay for
this.
Reference
1.
Montgomery (Appellant) vs. Lanarkshire Health Board (Respondent)
(Scotland) before Lord Neuberger, President, Lady Hale, Deputy
President, Lord Kerr, Lord Clarke, Lord Wilson, Lord Reed, Lord
Hodge. Judgement given on 11 March 2015. Heard on 22 and 23 July
2014.
Most hospital consent forms nowadays include reference
to whether an information sheet has been given. This is rec­
ognition that information sheets are important in the consent
process. Although information sheets are not mandatory as
yet, I think they should be because they can contain a lot
more information than is mentioned or highlighted in an
oral consultation. My own policy has always been to write
information sheets as comprehensively as possible so that a
lawyer will have a hard time trying to prove lack of consent.
They can be equivalent to a second consultation and can be
included on your website or sent to a patient in advance of the
first consultation or given to the patient at the time of the first
consultation.
Are tick lists proof of adequate discussion? It is only too
easy for a surgeon in a hurried consultation to speak to a
patient and then at the end of the consultation when the patient
has left to tick all the boxes. A more trustworthy way of using
a tick list is to give the patient a copy of your tick list at the
time of the consultation and invite them to tick the subjects
off and to sign it and hand it back to you as evidence that
these points have been discussed. It is also wise to record the
length of time spent going through this tick list.
It is important to indicate a percentage risk of occurrence
of the various complications you describe. It is also vital to
discuss the potential consequences of the complications rather
than simply giving a list of the name of complications. Thus,
for example, in breast reduction it is sensible to tell a patient
that most infections are of minor consequence but about 1%
to 2% of breast infections after breast reduction can be absolutely
devastating and can ruin the result and cause months of pain
and morbidity.
It is important to establish the financial consequences of
complications. Who will pay for “re-dos”? Some hospitals cover
the costs of complication for 1 month postoperatively. This
must be discussed and explained. Emphasize that you won’t
insure the patient for life. Some patients think they deserve
free correction years after their initial surgery.
It is essential to write down exactly what the patient asked
for in their own words rather than your translation of what
you interpret that they are asking for. The very first record
that you make of the consultation should be what the patient
is actually asking for. It is remarkable how few surgeons actually
do this. I have been involved in lots of medico-legal cases in
which the surgeon has failed to record what the patient actually
requests. If you don’t record it, the patient can come back and
blame the surgeon for doing the wrong operation. They can
say that they never asked for what the surgeon has recom­
mended. Therefore, if their request is ambiguous, then you
must clarify it. “I want nicer fuller breasts” could mean lots
of different things, but it doesn’t necessarily mean breast
augmentation. The patient might subsequently say, “Doctor I

7
Multimodality Nonsurgical Rejuvenation With a Regional Approach
7
2 
Aesthetic Medicine: Surgical Pearls
Jaffer Khan MBBS, FRCSI, FRCS (Plast), FACS
Zara Yousufzai MBBS, MS (Plast)
Natasha Jaffer Khan MBBCh, BAO, LRCP, LRCSI
Introduction
Aesthetic medicine comprises all medical procedures that are
aimed at improving the physical appearance and satisfaction
of the patient, using noninvasive to minimally invasive cosmetic
procedures.
These aesthetic procedures consist of:
■ injections of neurotoxins
■ dermal fillers/fat grafting
■ chemical peels
■ radiofrequency
■ cryotherapy
■ lasers and intense pulsed light (IPL)
■ ultrasound treatment
■ platelet-rich plasma (PRP)
The author used a combination of these procedures for
nonsurgical rejuvenation. This chapter provides an overview
of each of these with their clinical implications, recommended
indications, management, advantages, and disadvantages.
Multimodality Nonsurgical
Rejuvenation With a Regional
Approach
Botulinum Toxin (Botox)
In aesthetic medicine botulinum toxin (see Table 2.1 and Fig.
2.1) is the most commonly used nonsurgical treatment world­
wide. In 2014, 4.89 million Botox treatments were done
worldwide. Its popularity is due to its excellent safety record
and predictable outcomes.
Commercially available botulinum toxin A are:
■ onabotulinum toxin A (Botox)
■ abobotulinum toxin A (Dysport)
■ incobotulinum toxin A (Xeomin)
Dilution
■ 1 B.U. = 2.5 s.U
1 vial of Dysport (500 s.U) + 2.5 mL saline = 20 U/0.1 mL
(can be rediluted in the syringe with 1 : 1 ratio to create a
concentration of 10 s.U/0.1 mL)
■ 1 vial of Botox (100 U) + 2.5 mL of saline = 4 U/0.1 mL
30- to 32-gauge needle (a smaller needle is preferred in
sensitive patients)
4 U Botox = 10 U Dysport
PREPROCEDURE MANAGEMENT OF
NEUROMODULATORS
■ Conduct an assessment of the patient.
■ Note the location and depth of rhytids.
■ Obtain a history of the patient’s concerns.
• Brow position is important.
• Check for the presence or absence of compensatory
brow elevation.
• Check for blepharochalasis and dermatochalasis.
• Check for collagen depletion.
• Measure the width of the forehead (a wide forehead
would need more neuromodulator/Botox).
• Assess strength of frontalis muscle and length of
corrugator.
■ Take a preoperative photograph.
■ Apply a eutectic mixture of local anesthetics (EMLA) 30
minutes prior to procedure.
■ Give counseling about potential complications.
■ Obtain consent.

8
    CHAPTER 2  •  Aesthetic Medicine: Surgical Pearls
■ Optionally, the patient can start taking an Arnica tablet
for 1 week prior to treatment and 4 days posttreatment.
The standard dosage is three Arnica tablets (30 CH) three
times a day 30 minutes before or after a meal.
■ Enquire about allergy or sensitivity to lidocaine.
■ Mild bruising is common and can last 7 to 14 days.
■ Take a preoperative photograph.
■ Apply EMLA 30 minutes prior to the procedure.
■ Give counseling about potential complications and obtain
consent.
POSTOPERATIVE MANAGEMENT
■ Follow up after 2 weeks for touch-up.
■ Take a postoperative photograph.
■ Counsel the patient that the volume will go down by
approximately 20%.
■ Give Voltarol for pain relief.
■ Massage with Arnica.
■ Avoid hot beverages after the dental block (for lip
augmentation).
■ Avoid cold compression to prevent headache (in the
temporal area).
■ Minimize movement of the treated area.
■ Avoid applying heat to the treated area until bruising or
any swelling has resolved.
■ On the day of treatment, avoid activities that cause facial
flushing including consuming alcohol, hot tub or sauna
use, exercising, hot wax, and tanning. Avoid extreme-cold
activities, like skiing or hiking outdoors.
■ Gently apply a cool compress or wrapped ice pack to the
treated areas for 15 minutes every few hours as needed
to reduce discomfort, swelling, or bruising up to a few
days after treatment. When bruising occurs it typically
resolves within 7 to 14 days.
■ Results last approximately 6 to 12 months.
■ For more than 4 cc of filler used, prednisolone 40 mg
with Nexium 40 mg daily for 2 days after meals may be
considered.
Upper Face
Forehead and Brow Rejuvenation (Fig. 2.2)
ASSESSMENT (TABLE 2.2)
■ Check the brow position (this is important).
■ Check for the presence or absence of compensatory brow
elevation.
■ Check for blepharochalasis or dermatochalasis.
■ Check for collagen depletion.
■ Assess the strength of muscle.
■ Measure the width of the forehead.
TECHNIQUE
■ The brow elevator (frontalis) and depressors (corrugator,
procerus, depressor supercilli [DSC] for the medial brow
and the superolateral fibers of the orbicularis oculi for the
lateral brow) should be treated as a single unit to prevent
brow ptosis.
■ Preventing brow ptosis should be the priority.
POSTOPERATIVE CARE FOR NEUROMODULATORS
■ The lumps on the area injected will go down in 15 to 30
minutes.
■ Do not rub or apply pressure on the area that was
injected with Botox.
■ For 6 hours, avoid bending or stooping down; instead lie
down flat on your back.
■ Do not go to the gym or do any sports until the next day.
■ Follow up after 10 days.
■ Take a postoperative photograph.
Hyaluronic Acid (Fillers)
Adding volume along with short-scar face lift has largely
overtaken surgical correction for midface. The choice of filler
is dependent on the anatomy of each individual and the specific
treatment goals. Injectable soft-tissue fillers are durable, well
tolerated, and potentially reversible in unfavorable clinical
outcomes. Small-particle hyaluronic acid (HA) with lidocaine
(Restylane Silk, Galderma, Uppsala, Sweden) is used for
submucosal implantation for lip augmentation and dermal
implantation for correction of perioral rhytids. Side effects are
generally mild and transient.
PREPROCEDURE MANAGEMENT
■ Conduct a general assessment of the patient.
■ The patient should avoid aspirin (any product containing
acetylsalicylic acid), vitamin E, and other dietary
supplements, including gingko, evening primrose oil,
garlic, feverfew, and ginseng, for 2 weeks.
■ The patient should also avoid blood thinners such as
aspirin, ibuprofen (Advil, Motrin), and naproxen (Aleve,
Naprosyn) 1 week before the treatment.
■ Enquire about history of cold sores (or fever blisters)
prior to treatment.
Table 2.1  Uses of botulinum toxin in aesthetic medicine
Dynamic rhytids
• Forehead horizontal lines
• Glabellar vertical lines
• Periocular rhytids (crow’s feet)
• Hyperdynamic orbicularis/pretarsal
orbicularis (under the eyes)
• “Bunny” lines
• Perioral (smoker’s lines)
Diminishing the
depressor activity
of certain muscles
• Lateral fibers of orbicularis (brow
elevation)
• Depressor septi (nasal tip elevation)
• Platysma (Nefertiti lift)
• Mentalis (chin deformity)
• DAO (for marionette lines)
Hypertrophic muscles
• Masseter
• Nasalis (alar flare muscle)
• LLSAN (“gummy” smile and alar flare)
• Masseter
• Deltoid
• Medial head of gastrocnemius
DAO, Depressor anguli oris; LLSAN, levator labii superioris alaeque nasi.

9
Upper Face
■ For the technique, see Video 2.1.
■ Injections placed above the midpupillary line for the
corrugator should be at least 1 cm above the bony orbital
rim to help prevent lid ptosis caused by diffusion of
Botox to levator muscles.
■ Some return for a touch-up in 10 days.
COMPLICATIONS
■ Lid ptosis
■ Brow ptosis
Before
Before
After
After
A
C
D
B
FIGURE 2.1  Combination treatment of hyaluronic acid to periocular midface and marionette areas with botulinum toxin to glabellar forehead and periocular area.
■ This can be achieved by full treatment to the corrugator,
procerus, and DSC, a conservative dose to the frontalis,
and a later touch-up to the frontalis if required in 10 days.
■ Treatment of the superolateral fibers of the orbicularis
oculi will also help to maintain an elevated brow
position.
■ Assess the activity of DSC. If DSC overactivity is missed,
the patient may come back with descent of the medial
brow (an angry look).
■ If there is previous history of heaviness of brow after
treatment, inject only in the central forehead.

10
    CHAPTER 2  •  Aesthetic Medicine: Surgical Pearls
Before
Before
After
After
A
C
D
B
FIGURE 2.2  (A,B) Botulinum toxin to corrugator, depressor supercilli, and procerus muscle complex. (C,D) Botulinum toxin to frontalis muscle.
Table 2.2  Management of forehead and brow rejuvenation
Indication/patient’s
perspective
Muscle
Plane
Treatment
Glabellar frown lines
Corrugator
Subdermal
4–8 injections in females
6-10 injections in males
10 s.U in each injection
Glabellar frown lines
Procerus
Deep subdermal
Glabellar frown lines
Depressor supercilli
Deep subdermal
Dynamic lines on the forehead
Frontalis
Subdermal
One injection centrally and two laterally on forehead.
(between 10 and 30 s.U in divided doses)
To maintain the brow position
To prevent lateral brow ptosis
Orbicularis oculi (superior
lateral fibers)
Subdermal
As a prophylactic measure, 10 s.U on each side to
be given under the tail of the brow to inactivate
the depressor action

11
Hints and Tips
4. Avoid the supraorbital bundle and the infraorbital
bundle.
5. Avoid injecting above the orbital rim.
6. Inject slowly and don’t inject a large bolus.
Temporal Area: Temple Augmentation
(Fig. 2.4)
Management of hollowness of the temporal area is aimed at
volumization.
Periocular Rejuvenation (see Table 2.3,
Fig. 2.3, Video 2.2 and Video 2.5)
☛ Hints and Tips
1. Plunger should be withdrawn three times to avoid
intravascular placement.
2. If oozing, hold for 2 minutes.
3. Always keep hyaluronidase handy.
Before
Before
After
After
C
A
B
D
FIGURE 2.3  Tear trough and lateral orbital rim enhancement with hyaluronic acid.

12
    CHAPTER 2  •  Aesthetic Medicine: Surgical Pearls
Table 2.3  Management of periocular rejuvenation
Patient characteristics
Management
Dark circles
• Mesotherapy
• Carboxytherapy
• Platelet-rich plasma
• Volumization
• Patient in upright position or semirecumbent position
• Low–G prime HA, Teosyal Redensity is my choice of product
• I prefer using a 30-gauge needle or a 25-gauge cannula, which gives accuracy of placement and less
likelihood of irregularity
• Patient is instructed to gently close eyes or open in forward gaze to assess the depth
• Inject deep below the orbicularis. Delivery of small aliquots of low G prime HA subdermally is also possible
• Always withdraw plunger three times with slow delivery and do not overfill
• Inform the patients about upper eyelid heaviness because filler has some lidocaine and causes
infraorbital anesthesia
Prominent eye bags
• In minimal extraocular fat, volumize between the periocular and cheek fat just under the orbital rim to
decrease the disparity
• Volumizing may improve the look but the amount of volume required in the cheek to match the periocular
area would result in swollen eyes
• If periocular fat is normal but looks excessive due to inadequate cheek volume and a disharmonious lid
cheek junction then volumization would give a good effect
Prominent eyes
• Volumize the lateral orbital rim below the rim to create a harmonious lid cheek junction
• For patients who don’t have bulging eyes, volumization would make their eyes look smaller
• Volumization in the lateral orbital rim area gives the effect of higher cheek bones, but eyes become small;
hence for bulging eyes, filling this area gives good results
• Test to assess extraorbital fat
• With the eyes closed, applying digital pressure on the globe would result in bulging of the periocular fat
Sleep lines
• Fractional laser (CO2 laser)
• Volumize with low–G prime HA
Upper lid hollowness
and brow position
• Small amount of local anesthetic is injected at two points:
• 1 cm below the tail of brow, avoiding any superficial veins
• at midbrow area just above the orbital rim
• I use 27-gauge cannula 1.5 inch needle
• Enter into the subgaleal slide plane
• You will hear a pop as you enter
• I use a retrograde threading technique with very small amounts of volume placed above the orbital rim into
and above the eyebrow. No more than 0.5 cc per eye
• Second access point tends to use a smaller 30-gauge cannula
• Product of choice is low–G prime HA
• Massage well
Periocular rhytids
• HA
• CO2 laser
• Botox for dynamic lines (Table 2.4)
• Assessment of extent and depth of rhytids (into cheek or under the eyes)
• Laxity and excess of periocular skin particularly in the infraorbital area
• Avoid injecting too low over the zygoma to prevent diffusion to zygomaticus major, as it would inactivate
cheek elevation upon smiling (masklike smile)
• Patients with excess lower eyelid skin, injections in the lower lid area can lead to descent of skin,
causing a malar crescent at the level of the lateral orbital rim
• Treating the periocular area can result in exaggeration of bunny lines, which may be treated on
subsequent treatment
• While treating the bunny lines, injection placed deep and low on the nasal sidewall can diffuse to LLSAN
may lead to an asymmetric smile
• Complication
• Blurred vision
• Double vision
• Diffusion to the zygomaticus major leading to a asymmetric smile
• Bunny line exaggeration
• In redundant skin injection to the pretarsal area can lead to descent of the skin resulting an arc at the lid
cheek junction
HA, Hyaluronic acid; LLSAN, levator labii superioris alaeque nasi.

13
Midface
TECHNIQUE
■ The temporal fossa is occupied by the temporalis muscle.
There are three planes for injecting the filler:
• the subcutaneous plane (which can lead to
irregularities and less longevity)
• between the leaves of the superficial and deep
temporal fascia (difficult to localize)
• under the muscle above the periosteum (which is safer
and easily located).
■ The injection point is 1 cm behind the temporal crest and
1 cm above the lateral orbital rim, just above the
periosteum. Avoid branches of subtemporal artery.
■ Give local anaesthetic intradermally raising a weal on the
skin (0.1 mL Xylocaine + adrenaline).
Table 2.4  Neuromodulators for occular area
Muscle
Plane
Treatment
Orbicularis oculi
Subdermal
1 cm lateral to the lateral
orbital rim
4–6 injections each side
10 s.U in each injection
Pretarsal orbicularis
(bulge under the
eyes during
smile)
Subdermal
Infraorbital injection
5–10 s.U under the
eyes into the pretarsal
fibers on each side in
divided doses
Bunny lines
Subcutaneous
One injection (5–10 s.U)
high on each side of
the nasal sidewall
(form a bleb)
Before
After
A
B
FIGURE 2.4  Hyaluronic acid to the temporal area.
■ I prefer Restylane as it is soft and flows easily, hence we
can use a smaller, finer 30-gauge needle.
■ Keep your nondominant thumb near the hairline to
prevent wastage of material into the hairline.
■ 0.5 mL to 1 mL is required for each fossa.
■ For the technique see Video 2.3.
☛ Hints & Tips
1. Filler in this region has an immediate and long-lasting
effect (2–3 years).
2. Inject slowly after withdrawing the plunger.
3. Visualize the veins and avoid anastomoses of external
and internal carotid to prevent blindness.
4. Massage.
5. Do not place ice on the area postoperatively, as this can
lead to a headache, but keep compression on the injection
point to prevent oozing.
6. Do not overfill; there should be a slight concavity.
Midface
Nose/Rhinoplasty (Table 2.5, Fig. 2.5)
TECHNIQUE
■ I prefer to use Restylane with a 30-gauge needle, as it
flows easily, is easy to withdraw, has longevity, and is
dissolvable.
■ Give an intraoral block (infraorbital nerve block)
when injecting near the tip, columella, or nasal
spine.
■ For the technique refer to Video 2.4.

14
    CHAPTER 2  •  Aesthetic Medicine: Surgical Pearls
Table 2.5  Nonsurgical rhinoplasty
Patient characteristics
Management
Small nasal hump
Add volume to the dorsum proximal and distal to it to create a straight dorsal nasal profile
Saddle deformity
Volumize at the level of deformity to give a straight profile
Tip elevation
Volumize on top of the alar dome or above the lateral crus of lower lateral cartilages and
also level of nasal spine
Small postrhinoplasty imperfections
May be softened in appearance by placing product around or within it
Crooked nose or high external deviation
Nasal asymmetry caused by high septal deviations can be masked by placing volume
within the concavity on opposing sides to create an illusion of straightness
Alar flare (alar part of nasalis)
Neuromodulators
Plunging of tip (depressor septi muscle)
Neuromodulators
Before
Before
After
After
A
C
D
B
FIGURE 2.5  Nonsurgical rhinoplasty.

15
Hints & Tips
TECHNIQUE
■ Lift the cheek to assess the depth of the fold.
■ The depth of the nasolabial fold is caused by anatomical
structure as well as the descent of the midface; it is
important not to overfill.
■ Correction must involve volumization of the midface in
conjunction with filling of the nasolabial fold in older
patients.
■ For fine lines use a low–G prime HA (Restylane) to place
intradermally. To avoid a “chipmunk” effect, be careful
not to overfill the natural dimple area lateral to the
commissure of the mouth.
☛ Hints & Tips
1. Caution is advised at the columella or nasion if any signs
of blanching are observed. This indicates for immediate
use of hyaluronidase in small quantities of 0.5 mL or
1 mL in total.
Nasolabial Area (Fig. 2.6)
Management of fine lines or deep furrows of the nasolabial
area is aimed at volumization.
Before
Before
After
After
A
C
D
B
FIGURE 2.6  (A,B) Hyaluronic acid (HA) to periocular, nasolabial, and prejowl sulcus areas. (C,D) HA enhancement to nasolabial and marionette areas.

16
    CHAPTER 2  •  Aesthetic Medicine: Surgical Pearls
■ For deep furrows use high–G prime HA (Restalyne/
Juvederm Volift) and starting at the lower end of
nasolabial fold, work your way up to the alar base.
■ In the lower part of the nasolabial fold it is safe to inject
in the superficial plane, but as we reach the piriform
fossa the facial artery becomes superficial and therefore
care should be taken to inject deep against the bone or
very superficial subdermally.
■ Use a 26-gauge needle for Radiesse and a 30-gauge
needle for Restylane.
■ Give a regional block (infraorbital nerve block).
■ For the technique refer to Video 2.9.
☛ Hints & Tips
1. Do not overfill, as this can accentuate the thickness of
cheek because of lateral migration.
2. In the lower part of the nasolabial fold also fill just lateral
to the fold.
3. Be careful while filling to avoid nodules. Fill slowly and
massage bimanually.
4. Nasolabial volumization at the alar base may
cause extrinsic compression and vascular
compromise.
Malar/Cheek Augmentation (Fig. 2.7)
Patient characteristics that indicate this technique include:
■ an extended tear trough into the midface
■ heaviness of the nasolabial fold
■ descent of the midface
■ a hypoplastic malar area
■ negative vector
■ severe weight loss
Malar/cheek augmentation is done in two planes:
1. deep, to correct skeletal hypoplasia
2. subcutaneous, to correct deflation of fat compartments
TECHNIQUE FOR CHEEK AUGMENTATION
■ Draw lines to mark the highest point.
■ Up to 2 mL volume can be added per side.
■ Infiltrate local anesthesia with a long 30-gauge
needle.
■ Inject the local anaesthetic as you withdraw, raising a
weal on the skin.
■ Wait for the area to be anesthetized.
■ Midface and malar area should be harmonious in the
elevation created by the malar arch.
■ Volume should added from the highest point and it
should extend superomedially towards the junction of
the side wall of the nose with the cheek.
■ Product of choice is a high–G prime HA (Restylane
Sub-Q or Teosyal Deep Lines).
■ I use the fanning technique with a long cannula
(2 inch or 25 gauge) and inject through a single
entry point.
■ It is better to use low–G prime HA in patients
with very little subcutaneous tissue, as it is easily
malleable.
■ Use the cannula for the fanning technique just above the
periosteum.
■ For the technique refer to Video 2.6.
TECHNIQUE FOR MIDFACE AUGMENTATION
■ I use the bolus technique with a 30-gauge needle,
building a pillar from deep to superficial.
■ Inject a bolus dose and wait for skin surface to lift/rise
and using conservative amounts (0.1–0.2 mL per
injection).
■ Products of choice are Restylane or Redensity Teosyal in
the subcutaneous to replace volume loss in the deeper fat
compartments of the midface (superior medial cheek fat
compartment).
■ The idea is to inflate the midface extending
superomedially into the tear trough, thereby lifting the
nasolabial fat pad and diminishing the depth of the
nasolabial fold. It can be completed by adding additional
volume just below and lateral to the rim to complete the
arc.
■ It is important to blend with the tear trough area to
create a harmonious arc from the low part of the midface
to the lid cheek junction.
☛ Hints & Tips
1. The patient should be counseled about upper eyelid
heaviness when augmenting the midface with a product
containing lidocaine.
2. It is not advisable to use more than 2 mL per side.
Additional volume should be done in stages.
3. In patients with less subcutaneous tissue, very small
volume should be used over the bony prominences.
4. While augmenting the malar area, place volume medially
and above it so as not to create a skeletonizing
prominence.
5. Be careful with patients who have a sunken periocular
area (in these patients it is not advised to augment
the malar area alone as it would increase the
discrepancy).
6. In patients with hollowness around the orbit, malar
augmentation must be combined with volumization
below the orbital rim, so as not to increase the
discrepancy between the lid cheek junctions.
Masseter
TREATMENT OF MASSETERIC HYPERTROPHY
■ The masseter muscle is in three layers: superficial,
middle, and deep.
■ The point where the layers of the muscle overlap each
other is the thickest part and is palpable when the patient
clenches their teeth.
■ The outline and the border of the muscle are marked.

17
Lower Face
Before
Before
After
After
A
C
D
B
FIGURE 2.7  Cheek augmentation with hyaluronic acid.
■ Three to five injections are given on the masseter bulk in
the lower half of the muscle below the line drawn from
the tragus to the angle of the mouth, 1 cm away from the
border of the muscle.
■ Depending on the extent of hypertrophy, 15–25 s.U is
injected per side.
COMPLICATIONS
Superficial placement of the injection will only inactivate the
superficial head of the muscle leading to the chipmunk effect
on chewing.
Lower Face
Perioral (see Table 2.6, Fig. 2.8)
TECHNIQUE FOR VOLUMIZATION
■ I use a 30-gauge needle and prefer not to use a
cannula.
■ Inject 0.5 mL xylocaine + adrenaline (1 : 1000) in the
canine fossa with the needle pointing towards the pupil
for the upper lip.

18
    CHAPTER 2  •  Aesthetic Medicine: Surgical Pearls
Table 2.6  Perioral augmentation
Patient characteristics
Management
Perioral rhytids
• Neuromodulators to prevent dynamic movement of the muscles
• Laser (fractional CO2 or Er:YAG) for the upper lip. It stimulates the dermis and produces collagen,
improving the perioral rhytids
• Rehydration
• Correction of asymmetry
• Lip contour
• Vermilion enhancement
• Upper lip eversion
Volumization with hyaluronic acid
Er:YAG, Erbium-doped yttrium aluminium garnet.
Before
Before
After
After
A
C
D
B
FIGURE 2.8  Lip augmentation with hyaluronic acid.

19
Hints & Tips
COMPLICATIONS
■ Reduced oral competency.
■ Inability to suck from a straw or to whistle.
☛ Hints & Tips
1. Augment the upper lip first and then the lower lip in a
40 : 60 ratio.
2. Augmentation of the philtral column gives a more
youthful appearance.
3. Add more volume in the middle and less laterally.
4. If you are not trying to evert the lip, inject below the
vermiliocutaneous junction.
5. For the correction of vertical rhytids of the upper lip,
judicious use is necessary to prevent a “simian” look.
6. Patients with the long upper lip, lip eversion, and
augmentation/creation of philtral columns can decrease
upper lip length.
Melomental Augmentation (Table 2.8,
Fig. 2.9)
TECHNIQUE
■ I use a 30-gauge needle and give a fan block before
volumizing the melomental area (0.5 mL xylocaine with
adrenaline).
■ After the block, wait for the xylocaine to settle down and
not obscure the defect.
■ The blanching effect of adrenaline helps prevent
bruising.
■ At the commissure I prefer a low–G prime HA; moving
down to the lower marionette and prejowl area, I prefer a
high–G prime HA or calcium hydroxyapatite.
■ The product of choice for prejowl sulcus and lower
marionette is a high–G prime HA.
■ When augmenting the melomental fold extending in the
prejowl area start in the inferior part and progressively
volumize upwards until you see the mouth corner
improve.
■ For lower lip anesthesia inject between the incisor and
first premolar at the mental foramen.
■ I use the threading technique, with the needle between
the thumb and the index finger feeling the
vermiliocutaneous junction for contouring.
■ Avoid placing too much volume near the lateral
lip line.
■ The volume should be placed deep into the vermilion,
just below the muscle or, with care, submucosally.
■ Lower lip line enhancement is usually only done for the
middle third to avoid placing too much volume near the
lateral lip line.
■ For vermilion enhancement, product should be
place in the submucosal plane either side of the
midline.
■ The products of choice are Restylane Lip Volume for lip
line or lip contour and Teosyal Kiss for vermilion
enhancement.
■ Massage gently, mainly for irregularities.
■ Do not use excessive pressure, as this can lead to
bruising.
■ For the technique refer to Videos 2.7 and 2.8.
MANAGEMENT OF THE PERIORAL AREA WITH
NEUROMODULATORS (Table 2.7)
■ Start with an ultraconservative dosage, as these muscles
have functional requirements like oral competency,
pursing of the lips, and mastication.
■ Patients should be warned that the efficacy would be of
shorter duration.
■ Dosage may be increased progressively, based on
tolerance.
■ Lower face treatment is less predictable than that of the
upper face.
■ Recommended treatment for perioral rhytids is a
combination of:
• prevention (using neuromodulators)
• fractional CO2 laser or erbium-doped yttrium
aluminium garnet (Er:YAG) resurfacing (for
improvement of fine lines)
• replacement of volume with hyaluronic acid
Table 2.7  Management of perioral area with neuromodulators
Muscle
Plane
Treatment
Upper lip rhytids
• Orbicularis oris
Subdermal
• 5 s.U just above the vermiliocutaneous junction
• Line is drawn from lateral alar border down to the lip on each side
• One injection of 5 s.U each side, and can extend to 4 injections
of 5 s.U along the alar border
Gummy smile
• Excess activity of
LLSAN + LLS
Deep subcutaneous
• Give infraorbital regional block. The block inactivates the muscles
and gives the patient an idea of what Botox action will be like.
• Injections are given just adjacent to the alar margin
• Deep injection at the apical triangle of the upper lip
• One injection 10 s.U each side
Lower lip
• Orbicularis oris
Subdermal
• Try not to do upper and lower lip together
• Line is drawn from lateral alar border down to the lip
• Two injections each side of 5 s.U
LLS, Levator labii superioris; LLSAN, levator labii superioris alaeque nasi.

20
    CHAPTER 2  •  Aesthetic Medicine: Surgical Pearls
Table 2.8  Melomental augmentation management
Patient characteristics
Management
Extended marionette into
prejowl sulcus
Volumization
Downturned oral
commissure
Neurotoxins to prevent the
action of DAO
Volumization to improve the
fine lines
Drooling
Volumization
DAO, Depressor anguli oris.
Before
After
A
B
FIGURE 2.9  Hyaluronic acid to the marionette area.
Table 2.9  Prejowl sulcus augmentation
Patient characteristics
Management
Prominent prejowl sulcus
Jowling
Volumization (not in very heavy
jowl)
Ultherapy
Thread lifts
■ The plane of injection should be as follows:
• At the angle of the mouth, inject in the intradermal
plane.
• In the lower marionette area, inject in the subdermal
plane.
• At the prejowl sulcus, inject in the subcutaneous plane.
■ For the technique refer to Video 2.9.
☛ Hints & Tips
1. Never put too much volume near the corner of the
mouth to avoid lumpiness.
2. Underfill and touch-up after 2 weeks.
Prejowl Sulcus (Table 2.9, Fig. 2.10)
TECHNIQUE
■ Roll forward the soft tissue below the inferior border
of the mandible in the direction of prejowl sulcus
to simulate what the volumization of the area may
look like.
■ Mark the area and place 0.2 mL xylocaine with
adrenaline in the prejowl sulcus to avoid bruising.
■ The products of choice are Radiesse or Teosyal Deep
Lines.
■ I use a 26-gauge needle with Radiesse and a 28-gauge
needle with Teosyal Deep Lines (a cannula can also be
used).
■ Volume should be placed in the subcutaneous plane
under the mandible.
■ For the technique refer to Video 2.9.
☛ Hints & Tips
1. Massage continuously for better results.
Deep Anguli Oris
■ Overactivity can lead to depletion of collagen in the
marionette area.
■ Patients often complain of a sad look in photographs.
■ Inhibition of depressor action with neuromodulators can
create a lifting effect of the corner of the mouth and also
prevent further collagen loss.

21
Hints & Tips
Before
Before
After
After
A
C
B
D
FIGURE 2.10  Hyaluronic acid to prejowl sulcus and marionette area.
■ In cases where HA fillers are being used concurrently in
the same area, this should be done before the
neuromodulators.
TREATMENT
Treatment is in the immediate subdermal plane.
■ A line is drawn from the alar margin to the angle of the
mouth; continuing 2 cm downwards is the point of
injection.
■ Lateral injection is preferred to prevent diffusion to
the depressor labii inferioris causing an asymmetrical
smile.
■ 5–10 s.U on each side to start with one injection (5 s.U on
each side).
COMPLICATIONS
■ Difficulty with chewing
■ Asymmetric smile if there is diffusion to the depressor
labii inferioris

22
    CHAPTER 2  •  Aesthetic Medicine: Surgical Pearls
band will benefit from neuromodulators applied to
the subdermal plane to improve the definition of the
jawline.
■ Any ancillary treatment to the deep anguli oris and the
anterior platysmal bands should be avoided to prevent
abnormal mimic movements.
■ There is no benefit to injecting below the top half of the
posterior platysmal band.
TECHNIQUE
■ Only those patients whose jawline becomes distorted
during grimace will benefit from the treatment.
■ Injections are given along the posterior band and under
the mandible.
■ Inferior injection on the posterior band should be given
in contracted muscle and other injections under the
mandible should be given in relaxed muscle.
■ The patient should be in a sitting position.
■ A line is drawn 1 cm posterior to the junction of the
nasolabial fold and the mandible. The patient is asked to
contract the muscle, and the posterior platysmal band
should be marked on the skin.
■ Three injections are given in the posterior platysmal
band, with 10 s.U in the most prominent point and 5 s.U
in the remaining two points.
■ Under the mandible three injections of 5 s.U are given
with the needle directed towards the angle of the
mandible.
■ For the technique refer to Video 2.10.
COMPLICATIONS
■ Diffusion to the depressor labii inferioris may lead to an
asymmetric smile. To prevent, always inject 1 cm
■ Inability to push the bolus of food from the oral sulcus to
the grinding surface of the molars
• If this occurs, reassure that it will be gone in 10 to 12 days.
Mentalis
■ Causes chin elevation
■ Witch’s chin deformity
■ In conjunction with actions of the deep anguli oris may
cause a crescentic loss of collagen from the lower
marionette area to the supramental crease.
TREATMENT
Treatment is in the deep subcutaneous plane.
■ Injection of 10 s.U into each head of the mentalis slightly
lateral to the midline of the chin.
■ Avoid massage.
COMPLICATIONS
■ Diffusion of neuromodulators to the depressor anguli
inferioris leads to an asymmetric smile.
■ Asymmetric dimpling of the chin can be caused by
partial block of one side of the muscle.
■ Correction can be done on follow up.
Neck
Nefertiti Lift (Fig. 2.11)
■ Selected patients who have demonstrable strong
depression action of the posterior part of the platysmal
Before
After
A
B
FIGURE 2.11  Nefertiti lift with botulinum toxin showing improvement in the jawline.

23
Hints & Tips
posterior to the junction of the nasolabial fold and the
mandible.
■ Dysphagia may occur if too much neurotoxin is placed in
the interior platysmal band.
Hand
Hand Augmentation (see Table 2.10,
Fig. 2.12)
TECHNIQUE
■ Identify and mark the hollows and the areas of concern
with the patient.
■ Inject local anesthesia subdermally with a 30-gauge
needle (0.1 mL at each injection point) to prevent pain
and bruising.
■ Pinch the skin to avoid the veins and inject 0.2 mL
Radiesse subcutaneously from an ampule (where 0.75 mL
Table 2.10  Hand augmentation
Patient characteristics
Management
• Visibility of veins and tendons
• Wrinkling of skin
• Peels, laser, and lights for improvement of sun damage (skin quality), texture, and tone
• Addition of HA subdermally for hydration (Restylane Vital)
• Volumization of the subcutaneous layer around the veins and tendons for diminishing
their prominence
HA, Hyaluronic acid.
Before
After
A
B
FIGURE 2.12  Hand rejuvenation with Radiesse and hyaluronic acid combination treatment.
of Radiesse is mixed with 0.25 mL of xylocaine and
adrenaline).
■ An average volume of 1.5 mL Radiesse with 0.5 mL
xylocaine is used in each hand.
■ For hydration give approximately 1 mL HA intradermally
in each hand (Restylane Vital).
■ Use ice packs to prevent bruising.
■ For the technique refer to Video 2.11.
☛ Hints & Tips
1. Pinch the skin to avoid the veins.
Complications of Hyaluronic Acid Fillers and
Their Management
See Table 2.11.

24
    CHAPTER 2  •  Aesthetic Medicine: Surgical Pearls
Table 2.11  Complications of hyaluronic acid fillers and their management
Complication
Management
Hematoma (bruising)
While injecting put gentle pressure for 2–3 minutes
Good lighting to visualize the blood vessels while injecting
Use of knowledge of the anatomic structures
Cold compression
Vascular occlusion
Blindness
Withdraw needle three times prior to injecting
Avoid intraarterial injection.
Use of knowledge of the anatomic structures
Special care required while treating temporal/periocular/nasal areas
Daily monitoring
Aspirin
Vasodilators
Hylase
Steroids
Warm compress
Hyperbaric O2
Anti-viral in case of herpes infection
Frost bite
Avoid prolonged use of ice postinjection, especially if anesthesia is used
Small nodules (lip)
Avoid over or incorrect placement. If occurs can be expressed out by small incision or
dissolved with hyaluronidase.
Avoid injecting large particles of HA rapidly
Acute herpes infection (lip)
Inquire about history of cold sore or chickenpox. If required, give antiviral 3 days prior to
procedure
Lumpiness or nodules
Slow injection, meticulous placement, choice of filler, and bimanual massage if in nasolabial
area
Over volume
Overfilling should always be avoided
Delayed hypersensitivity reaction
(swelling/granulomas)
Systemic steroids and Hyaluronidase
Malar pouch water retention (after
periocular augmentation)
If occurs give steroid injection 1–2 mL of triamcinolone with 0.3 mL of xylocaine or dissolve with
hyaluronidase
Tyndall effect and bluish discoloration
(after subdermal augmentation)
Dissolve it with hyaluronidase
HA, Hyaluronic acid.
Further Reading
Braz, A., Humphrey, S., Weinkle, S., et al., 2015. Lower face: clinical anatomy
and regional approaches with injectable fillers. Plast. Reconstr. Surg.
136, 235S–257S.
Carruthers, J.D.A., Fagien, S., Rohrich, R.J., et al., 2014. Blindness caused
by cosmetic filler injection: a review of cause and therapy. Plast.
Reconstr. Surg. 134, 1197–1201.
Cotofana, S., Schenck, T.L., Trevidic, P., et al., 2015. Midface: clinical anatomy
and regional approaches with injectable fillers. Plast. Reconstr. Surg.
136, 219S–234S.
Dayan, S.H., Bassichis, B.A., 2008. Facial dermal fillers: selection of appropri­
ate products and techniques. Aesthet. Surg. J. 28, 335–347.
Gart, M.S., Gutowski, K.A., 2015. Aesthetic uses of neuromodulators:
current uses and future directions. Plast. Reconstr. Surg. 136, 62S–
71S.
Goldman, A., Wollina, U., 2010. Facial rejuvenation for middle-aged women:
a combined approach with minimally invasive procedures. Clin. Interv.
Aging. 5, 293–299.
Jones, D., Murphy, D.K., 2013. Volumizing hyaluronic acid filler for midface
volume deficit: 2-year results from a pivotal single-blind randomized
controlled study. Dermatol. Surg. 39 (11), 1602–1612.
Kim, H.-J., Seo, K.K., Lee, H.-K., Kim, J., 2016. Clinical Anatomy of the
Face for Filler and Botulinum Toxin Injection. Springer, Singapore.
Kuhne, U., Imhof, M., 2012. Treatment of the ageing hand with dermal
fillers. J. Cutan. Aesthet. Surg. 5 (3), 163–169.
Luebberding, S., Alexiades-Armenakas, M., 2012. Safety of dermal fillers.
J. Drugs Dermatol. 11 (9), 1053–1058.
Ogden, S., Griffiths, T.W., 2008. A review of minimally invasive cosmetic
procedures. Br. J. Dermatol. 159 (5), 1036–1050.
Park, T.H., Yeo, K.K., Seo, S.W., et al., 2012. Clinical experience with
complications of hand rejuvenation. J. Plast. Reconstr. Aesthet. Surg.
65 (12), 1627–1631.
Skyes, J.M., Cotofana, S., Trevidic, P., et al., 2015. Upper face: clinical
anatomy and regional approaches with injectable fillers. Plast. Reconstr.
Surg. 136, 204S–218S.
Vedamurthy, M., Vedamurthy, A., 2008. Dermal fillers: tips to achieve
successful outcomes. J. Cutan. Aesthet. Surg. 1 (2), 64–67.

25
Clinical Examples
25
3 
Aesthetic Applications for Fillers
Phillipe Bellity MD
The Clinical Problem—The Aging Face
(Fig. 3.1)
How Does the Face Age?
Each face ages in its own way according to genetics and external
factors, such as sun, tobacco, diet, life stress, and illness.
■ The main phenomena are the appearance of wrinkles,
loss and shifting of facial volumes, and contraction of the
muscles used in making facial expressions.
■ The solution for the shifting of facial volumes will be
surgical and, for muscle contractions, botulinum toxin
will be used.
■ Hyaluronic acid will treat wrinkles and the loss of facial
volume by supplying good hydration, thus enhancing the
condition of the tissue.
■ Analyzing the face will detect the weak areas to be
treated first. The next step is to determine the healing
and preventive treatment plan by focusing on the facial
areas that tend to age faster.
■ A distinction among wrinkles, skin folding, and
grooves should be made because their treatments are
different.
WRINKLES AND SKIN FOLDING
■ A wrinkle can be described as a fracture of the skin. It
can range from deep to shallow and may appear as being
inscribed or engraved into the skin. When superficial, it
may appear as just a thin line. Most importantly, it is
apparent even when the face is at rest, without
expression or contraction.
■ Wrinkles are due to a modification of the cellular
architecture of the skin. They should be differentiated
from grooves, which are permanent hollows, and from
skin folding, which is visible only when the muscles used
for facial expression contract and then disappear once the
muscles relax. For example, the muscle contraction near
the upper lip shows folds when the vowel “u” is
pronounced. Later in life, a skin fracture may replace
these temporary folds and, as wrinkles, will eventually
cease to disappear at rest. The treatment for wrinkles and
skin folding differs.
GROOVES
Grooves are hollows that do not all have the same origin.
The grooves of glabella are due to the corrugator contrac­
tion, the nasolabial folds are due to multiple factors, such as
zygomatic contraction, fall of the nasolabial fat, and maxillary
bony loss, and so-called bitterness folds, which are due to a
fall of the jowl fat. The medical treatment for these grooves
consists in filling them by raising tissues with a highly
reticulated filler.
Clinical Examples
Treating Wrinkles (Fig. 3.2)
Using a very fine needle, 32 or 33 gauge, hyaluronic acid is
injected to raise the wrinkle level and, in effect, make it disap­
pear or strongly fade. The depth of the injection will depend
on the wrinkle depth. All wrinkles, even the finest, can be
treated. An injection that is too superficial can leave visible
small beads, and too deep an injection can be ineffective. Thus,
the quality of the result will rest on the appropriate depth of
the injection, size of the needle used, and amount of injected
hyaluronic acid.
The effect on superficial wrinkles is remarkable. The skin
texture changes. The product seems to integrate the dermis

26
    CHAPTER 3  •  Aesthetic Applications for Fillers
their wrinkles treated as and when they arise. Patients will
then notice that the annual appointment requires fewer pro­
cedures. People who have been consulting their clinician for
several years enjoy a real rejuvenation because the trophic and
moisturizing effects of the hyaluronic acid on the skin acts a
healing and preventive treatment on the aging process.
and contributes to real tissue regeneration. A well-treated
wrinkle, even if it reappears afterward, will no longer have
the same texture; some will even disappear. It is difficult to
answer the question, “How long does the result last?” People
willing to take care of their skin and face should consult their
clinician annually to receive the necessary treatment and have
Age 20
Age 40
Age 60
Shape of face at different ages
FIGURE 3.1  The aging face. Merely by changing the angularity of the face and the shifting depiction of light and shadow, an artist can render the age of the subject as a
younger person. (From Donofrio, L.M., 2005. Evaluation and management of the aging face. In: Siegel, D. (Ed.), Surgery of the Skin. Mosby, St. Louis, with permission.)
A
B
FIGURE 3.2  Wrinkle treatment. Treating the deep wrinkles individually at early stages will allow a progressive disappearance of the wrinkles with an annual treatment.

27
Clinical Examples
However, if the injection is to be done again 2 weeks
later, the product will have time to penetrate, for a perfect
result.
Bitterness Groove and Chin
Treating these is more challenging. They can appear as mere
hollows at the corner of the mouth or as grooves. The treatment
of the hollows must be very precise and follow the different
depth levels; otherwise, the jowl fat will increase and will yield
a reverse effect. A slow injection, and a two-session injection,
will be more effective. The filling of the lateral parts of the
chin with a cannula will restore the lateral pillar of the lower
lip and raise the chin level to meet the level of the cheek. This
Topping, or Nappage (Fig. 3.3)
The use of the microcannula has opened a new therapeutic
field. Different sizes and diameters have diverse indications.
Topping is also referred to as a nappage technique.
The introduction of a fine microcannula (27 gauge) in the
eye of a needle allows an area to be topped; that is, the product
can be spread over a given surface (e.g., the chin). This is done
by making the deep dermis and hypodermis more dense to
restore an elastic padding and treat an entire wrinkled area,
such as the upper lip or the chin.
Topping with a microcannula (22 gauge) can be used for
the cheeks as well. The use of a long cannula with less reticulated
products can give a so-called healing glow and remarkable
moisturizing effect, but without modifying skin volume (skin
booster).
Skin Folding (Fig. 3.4)
To reduce skin folding, the deep dermis should be made more
dense with hyaluronic acid without inducing bumps. This
applies to the upper lip and frown as well.
Nasolabial Grooves (Fig. 3.5)
The paranasal hollows are treated by filling them with strongly
reticulated hyaluronic acid. Different depths will be treated to
raise the grooves, starting from the deepest ones. If the hollows
are deep, they should be treated with deep, medium, and
shallow reticulations, with each becoming less and less tight.
Note that one should be careful not to allow the product to
rise beyond the nasolabial fat. Here are two suggestions:
1. The injection should be very slow.
2. Once the area is full, the product should not continue
to enter the area or it will tend to rise, giving an
adverse effect.
A
B
FIGURE 3.3  Cheek and treatment of multiple areas. These photos show correction of superficial wrinkles, dermis hydration by cannula nappage, and deep volume
replacement on the cheek nasolabial and bitterness grooves.
FIGURE 3.4  Folding mouth. Folding is the early stage of wrinkle creation. It can
be treated by deep dermis injection as a preventive measure.

28
    CHAPTER 3  •  Aesthetic Applications for Fillers
Forehead
With the use of botulinum acid, it is possible to have a smooth
and relaxed forehead, which is quite important. The domed
and uniform side of the forehead is an essential aesthetic criteria,
although it is often neglected. The tracking of postorbital
hollows, their in-depth filling with a cannula in contact with
the periosteum, and massage give excellent results on the upper
third of the face. The procedure will harmonize the forehead
and raise the eyebrows.
Temples
Temples hollow with age. It is essential that the lost volume
be replaced. Apparent veins will be spotted and pricked deeply,
crossing the temporal fascia. The slow injection will penetrate
the central part while controlling the result. Finally, massage
will spread the product harmoniously.
Dark Circles (Fig. 3.6)
This is a very challenging treatment. A 32-gauge needle or
microcannula can be used. The product has to be injected very
deeply, contacting the orbital border with a certain degree of
undercorrection and avoiding injection of the fat pads.
It is also important to inject the external part if there is a
hollow. I use a very fluid product with the needle on the bone
level, holding the left thumb over it to spread out the product
perfectly.
Nose Reshaping (Fig. 3.7)
It is sometime useful to correct a defect on the dorsum or
correct a tip asymmetry with hyaluronic acid, using a moderate
amount of product. Filling the columella can give a good
opening and provide support to the nasolabial angle. The
treatment has to be redone once annually. Sometimes a long-term
effect can be seen.
procedure provides harmony to the face oval. Frequently, the
chin itself has to be augmented to reconstruct the oval line.
Cheek
Recent anatomic studies have revealed that the face is made
of compartments, which do not have the same result when
treated. The deep compartments of the cheek undergo a sort
of melting effect over time. To restore them is a significant and
efficient step in facial rejuvenation.
It is necessary to feel the cheek between the nasolabial fat
and body of the malar bone to appreciate the lack of volume
and to draw the shape of the hollow to be filled in precisely.
Then, the injection will be given in order of depth, start­
ing at bone level and progressively bringing up the needle
to raise the area between the nose and cheekbone without
excess. In contrast, injections facing the cheekbone should
be very moderate. To redefine or recreate the cheekbone
area, when necessary, I suggest the use of a cannula, starting
from the side whiskers and following the zygomatic arch
and staying in depth to reach the area between the nose and
cheekbone.
Some people will have a hollowed cheek. The volume filling
will have to be done with a cannula (22 gauge) after defining
the area to be filled, starting at the limit of this zone. The filling
of the chin was discussed earlier. This is often very beneficial
when the indication is well set and the volume is well controlled.
A central hole will allow it to be extended laterally, with more
symmetry.
Eyebrow
The eyebrow is an area that ages by loss of volume. Deep
injections in the lateral part of the eyebrow, in contact with
the bone, give excellent results. One has to be very cautious
about the amount used; the so-called boxer effect may appear
faster than expected.
A
B
FIGURE 3.5  Nasolabial groove treatment. Deep, intermediate, and superficial layers are injected to get a complete result.

29
Clinical Examples
A
C
D
B
FIGURE 3.6  Dark circle treatment. Correction includes treatment of the inner and external parts of the dark circles.
A
B
FIGURE 3.7  Nose reshaping. The dorsum is injected with highly reticulated hyaluronic acid.

33
)
33
4 
Brow Lift
Peter Scott MBBCh, BSc (Hons), FRCS (Edin)
Philip Peirce MBBCh, FCS (SA) (Ophth)
The Clinical Problem (Fig. 4.1)
Introduction
Any patients requesting upper blepharoplasty must have an
accurate assessment of the brow, and each portion must be
treated according to its merits. Over-resection of the upper
eyelid to compensate for brow ptosis will lead to a suboptimal
result. The brow position must be checked for mobility;
brow asymmetry might be a sign of upper eyelid ptosis on
that side.
In a female, the lateral brow should be slightly higher than
the medial brow, with the arch at the junction of the lateral
third and the medial two-thirds in line with the lateral edge
of the iris. Elevation of the brow position above the orbital
rim looks unaesthetic. In a male patient, the brow should be
straight at the level of the orbital rim. In our opinion, 70% of the
problem will be improved by upper blepharoplasty and 30%
by a brow lift, either simultaneously or at a later stage. Some
patients are resistant to having a brow lift at the time of upper
blepharoplasty.
There are excellent articles on anatomy,1 but the key to
surgery involves adequate release of the lateral brow-retaining
ligament and care to avoid the frontal branch of the facial
nerve as well as the sentinel vein. A nonsurgical approach may
also be considered.2
Selection of the appropriate technique depends on the
level of the hairline, thickness of the forehead skin, severity of
the rhytids, and whether the brow ptosis is medial or lateral.
The techniques for consideration are as follows3 (Table 4.1;
Fig. 4.2):
■ Transblepharoplasty brow lift
■ Direct brow lift
SECTION 1  •  FOREHEAD AND BROW
James D. Frame
A
B
FIGURE 4.1  (A) Transblepharoplasty brow lift in a 55-year-old woman, preoperative view. (B) Direct brow lift in a 76-year-old man, preoperative view.

34
SECTION 1    CHAPTER 4  •  Brow Lift
Table 4.1  Varied options in brow liftinga
Option
Degree of lift
Effect on hairline
Favorable scar
Potential for
sensory changes
Access to forehead
musculature
Coronal brow lift
✓✓✓✓
Raises
✓✓
✓✓✓
✓✓✓✓
Endoscopic brow lift
✓✓✓
Raises
✓✓✓
✓
✓✓✓✓
Pretricheal
✓✓✓✓
Can raise or lower
✓✓✓✓
✓✓✓
✓✓✓✓
Direct forehead
✓✓✓
No effect
✓✓
✓
✓
Direct brow
✓✓
No effect
✓✓
✓
✓
Transblepharoplasty
✓
No effect
✓✓✓✓
✓
✓✓✓
aValues range from ✓least favorable to ✓✓✓✓ most favorable.
From Nahai, F.R., 2013. The varied options in brow lifting. Clin. Plast. Surg. 40, 101–104.
Table 4.2  Choosing the right approacha
Approach
Coronal brow lift
Endo brow lift
Pretricheal
Direct forehead
Direct brow
Transblepharoplasty
Hairline
High
✓
✓
✓
✓
Normal
✓
✓
✓
✓
✓
✓
Low
✓
✓
✓
✓
Degree of Brow Ptosis
Mild
✓
✓
✓
✓
✓
Moderate
✓
✓
✓
✓
✓
Severe
✓
✓
✓
Skin Rhytids
Mild
✓
✓
✓
✓
Moderate
✓
✓
✓
✓
✓
Severe
✓
✓
✓
✓
✓
✓
a✓ indicates the suitability of the technique for different parameters.
From Nahai, F.R., 2013. The varied options in brow lifting. Clin. Plast. Surg. 40, 101–104.
■ An endoscopic brow lift reserved for younger patients
with mild brow ptosis and a heavy procerus muscle.
■ A pretrichial brow lift is used for patients who tend to
have a fringe and very high forehead.
■ A coronal brow lift is for female patients with a normal,
slightly elevated hairline and that allows for the brow
hairline to be lowered.
■ A temporal brow lift allows for more lateral brow
elevation with less trauma and hairline distortion. It may
be requested by the patient.
Surgical Preparation and Technique
Transblepharoplasty Brow Lift (Fig. 4.3)
A moderate amount of lateral brow elevation can be achieved
via the upper lid skin crease incision.
■ Midforehead lift
■ Endoscopic brow lift
■ Pretrichial brow lift
■ Coronal brow lift
■ Temporal brow lift
Patient Selection (Table 4.2)
■ A transblepharoplasty brow lift is suitable for the
younger patient who only requires a moderate amount of
lateral brow elevation.
■ A direct brow lift is reserved for older male patients with
a very heavy ptotic, brow-receding hairline and can be
done under local anesthetic for those who are at risk for
general anesthesia.
■ A midforehead lift is suitable for an older male patient
who has very deep central creases and is not too
concerned about scarring.

35
Surgical Preparation and Technique
With Endotine
A hole is drilled into the frontal bone and the Endotine is
clipped into it. The brow is elevated over the Endotine and
the tines on the device fixate it at the desired height.
The Endotine is palpable under the skin and sometimes is
visible as a protrusion for approximately 1 year.
Direct Brow Lift (Fig. 4.4)
■ It achieves an excellent lift.
■ It leaves a visible scar.
• Generally used in males with a receding hairline
■ Measure the amount of desired elevation preoperatively,
generally 8 to 15 mm.
■ Mark the supraorbital notch.
■ Carefully mark the excision lines.
■ The inferior line is just into the hair of the superior
border of the brow.
■ The shape is important.
In Males
■ Too much lateral elevation will feminize the
appearance.
■ To avoid feminizing the appearance, excise more
medially. Make a mark 10 mm from the medial margin of
the incision and another 15 mm from the lateral margin;
mark the full extent of the excision at 90 degrees from
these marks. That is, a gentle taper laterally and a steeper
taper medially.
In Females
■ Reverse these measurements—that is, 15 mm
from the medial margin and 10 mm from the
lateral margin—to create or preserve a lateral arch
to the brow.
■ Use a no. 10 BP blade but no electrocautery.
3
7
6
5
2
4
1
FIGURE 4.2  Browpexy (direct brow)—transblepharoplasty (1), direct brow (2),
midforehead (3), temporal lift (4), pretrichial (5), endoscopic (6), coronal (7).
FIGURE 4.3.  Transblepharoplasty brow lift in a 55-year-old woman, postoperative
view. (See Fig. 4.1A for the preoperative view.)
FIGURE 4.4  Direct brow lift in a 76-year-old man, postoperative view. (See Fig.
4.1B for the preoperative view.)
■ Dissect superiorly in the preseptal plane to the superior
orbital rim in the lateral two-thirds of the brow, taking
care to avoid the supraorbital nerve and vessels.
■ At the superior orbital rim, dissect superiorly on the
periosteum to 15 mm above the superior orbital rim.
The brow can be fixated with sutures or an Endotine
transblepharoplasty device (MicroAire Surgical Instruments,
Charlottesville, VA).
With Sutures
With sutures, use 4-0 PDS Z496 (Ethicon, Somerville, NJ). Pass
the needle horizontally through the soft tissue under the inferior
border of the brow—if you catch skin it will cause a dimple—and
again through the periosteum 10 to 12 mm above the rim, in a
square knot. Do the other side before trying to check symmetry.

36
SECTION 1    CHAPTER 4  •  Brow Lift
long-term results were not as good as with open brow lift
techniques.
TEMPORAL BROW LIFT
■ Make a 6-cm incision in the temporal hairline.
■ Mark the path of the frontal branch of the facial nerve,
and take care not to cause a traction injury.
■ A lighted retractor or endoscope can be used.
■ Fixation is by excision of skin excess and the use of
staples.
CORONAL BROW LIFT
■ My operation of choice
■ May be pretrichial or just behind the hairline
■ Tumescent infiltration with 10 ml 2% lignocaine and 1 ml
of 1:1000 adrenaline in 1 L Ringers-Lactate; up to 100 ml
of this solution may be infiltrated
■ Subgaleal plane on top of periosteum centrally and
deep temporal fascia laterally
■ Conversion to subperiosteal approaching the orbital
rim
■ Partial removal of corrugators and procerus to avoid
flattening in this area
■ May incise galea at the rhytids on the forehead flap but
removal of frontalis is too radical, leaving a smooth shiny
forehead
■ 3-0 Monocryl key sutures and staples to avoid damage to
the hair follicles
■ Pull more lateral than central
Pretrichial Brow Lift (Fig. 4.5)
■ The incision for a coronal lift can be placed at the
hairline.
■ This has the advantage of not elevating the hairline.
■ The disadvantage is that the scar is visible with the hair
drawn back.
■ The technique is otherwise as described for the coronal
brow lift.
Problems
■ Loss of sensation in relation to the supraorbital and
supratrochlear nerves
■ Alopecia but reduced by use of staples
I found far more alopecia problems with the endoscopic
brow lift technique. Good reviews of this technique have
been presented by Walrath and McCord and Guyuron
et al.6,7
Summary
See Table 4.1.
■ Excise skin only; in the lateral two-thirds, muscle can be
excised. Take care in the region of the supraorbital
neurovascular bundle. Use minimal cautery in this area.
■ Closure is meticulous to minimize scarring.
■ Sutures
• Interrupted subcutaneous 3-0 Monocryl
• Subcuticular 5-0 Monocryl
■ Apply Steri-Strips over the wound.
POSTOPERATIVE CARE
■ Apply antiseptic ointment bd.
■ Massage bd after 2 weeks.
MINIDIRECT BROW LIFT
A variation is a minidirect brow lift, in which only the lateral
third to half is excised. This gives a good lateral lift and mini­
mizes scarring.
MIDFOREHEAD LIFT
In males with prominent forehead creases, the incisions can
be placed in the creases to camouflage the scars. Separate the
incisions vertically for either side, using different creases, or
use a single crease in a gull wing excision.
ENDOSCOPIC BROW LIFT
Requirements
■ Specialized equipment instrumentation
■ Definite learning curve
■ Three vertical incisions, one midline and two paramedian
Technique
■ Tumescent
■ Subperiosteal centrally
■ Subgaleal laterally over the superficial layer of the deep
temporal fascia
■ Release of temporal fusion line
■ Use of endoscope and optical cavity
■ Release of periosteum from lateral to medial but not
across the midline to avoid overelevation of the medial
brow, leaving a 2-cm bridge of periosteum
■ Traction to be avoided on frontal branch of the facial
nerve
■ Partial resection of procerus corrugator and depressor
supercilii to avoid depression in this area
■ Fixation—our preference is a cortical tunnel and 3-0
permanent sutures.
■ Alternate is a removable screw inserted into a 4-mm drill
hole and staples placed anterior to this, removed at 10 to
14 days postprocedure
Problems include relapse of the lateral brow.4,5 In our practice,
we have largely discontinued this technique because the

37
Summary
A
C
B
FIGURE 4.5  Pretrichial brow lift 68-year-old woman. (A) Preoperative view. (B) Postoperative view. (C) Hairline scar view.
References
1.
Drolet, B.C., Phillips, B.Z., Hoy, E.A., et al., 2014. Finesse in forehead
and brow rejuvenation: modern concepts, including endoscopic
methods. Plast. Reconstr. Surg. 1346, 1141–1150.
2.
Kane, M.A., 2015. Nonsurgical periorbital and brow rejuvenation. Plast.
Reconstr. Surg. 135, 63–71.
3.
Nahai, F.R., 2013. The varied options in brow lifting. Clin. Plast. Surg.
40, 101–104.
4.
Jones, B.M., Lo, S.J., 2013. The impact of endoscopic brow lift on
eyebrow morphology, aesthetics, and longevity: objective and subjective
measurements over a 5-year period. Plast. Reconstr. Surg. 132, 226–238.
5.
Chiu, E.S., Baker, D.C., 2003. Endoscopic brow lift: a retrospective
review of 628 consecutive cases over 5 years. Plast. Reconstr. Surg.
112, 628–635.
6.
Walrath, J.D., McCord, C.D., 2013. The open brow lift. Clin. Plast.
Surg. 40, 117–121.
7.
Guyuron, B., Gatherwright, J., Totonchi, A., et al., 2014. Cessation of
hairline recession following open forehead rejuvenation. Plast. Reconstr.
Surg. 133, 63–71.

39
Surgical Preparation and Technique
39
5 
Endoscopic Endotine Brow Lift Made Easy
Peter Arnstein FRCS (Plast)
The Clinical Problem
The aging brow that requires an endo brow lift has to be
considered within the aging face as a whole if a rejuvenation
procedure is to be successful. A high frontal hairline, a brow
ptosis causing visual field disturbance, a heavily wrinkled or
creased forehead, a tendency to a poor scar, hair loss, or infec­
tion, associated medical conditions, and skin type are reasons
to be careful before proceeding. The patient wants minimal
surgical intervention and inconvenience and a low-risk, high-
reward surgery that improves the appearance of the forehead
and position and symmetry of the eyebrows. Often associated
with this is improvement in the pseudoptosis of the upper
eyelids.
Also associated with the endo brow approach is the final
fixation of the elevated forehead. This can be accomplished
using screws, an Endotine fixation device (MicroAire Surgical
Instruments, Charlottesville, VA), and sutures and may involve
the use of fibrin spray technology.
I believe that an endo browlift combined with a four-lid
blepharoplasty can produce the most dramatic rejuvenation
of the face. It can also be used for facial palsy correction.
The brow lift should always be carried out before upper
lid reduction; otherwise, an upper lid skin shortage may
result.
Surgical Preparation and Technique
Preoperative Assessment
Using a mirror, ask the patient to demonstrate the shape of
eyebrow and degree of elevation that is desired by screwing
up the eyes and then slowly opening them (Fig. 5.1). Leaving
the forehead relaxed shows the degree of brow ptosis. Then,
the patient mimics the pull of an Endotine fixation device using
one finger to create the brow shape that is desired. Mark this
line of pull using a permanent marker.
Preparation for Surgery
While the patient is being anesthetized, ask the nurse to make
up a mixture of the following: hyaluronidase (Hyalase), 1500 IU;
adrenaline, 1 mg; treprostinil sodium (Adcortyl), 20 mg in
500 mL saline ready for injection.
When the patient is settled on the operating table, ensure
that the head is level with the top edge of the table. This will
help access, with the head raised and supported on a head
rest.
Mark the incision for the port sites (Fig. 5.2). I use three,
each extending from just behind the hairline, one center in line
with the nose and the other two in line with the desired line
of pull.
Inject 40 to 60 mL of the solution. Use a white 19-gauge
needle, pushing through the skin and straight onto the bone
and ensuring that the bevel is parallel to the bone so the fluid
will be injected subpericranially (Fig. 5.3).
On completion of the injection, press firmly for a short time
at the point of penetration at the pericranium to avoid extravasa­
tion. I usually inject about 20 mL at each of the three ports.
I inject 10 mL of bupivacaine (Marcaine) 0.5% with adrenaline
1 in 200,000 (Fig. 5.4). The bupivacaine hopefully will block any
supraorbital nerves, and the adrenaline cuts down the bleeding
from the accompanying vessels. I use the same around the
ports and I inject any surplus into the subpericranial.
Now, scrub, prep, and drape. Using a staple gun, create
partings in the hair at the site of the incisions.
When all the preliminaries are complete, enough time should
have elapsed for the hyaluronidase to have done its work.
Using a rolled up swab, I squeeze the injected fluid down
toward the brow. This maneuver achieves most of the undermin­
ing required (Fig. 5.5).

40
SECTION 1    CHAPTER 5  •  Endoscopic Endotine Brow Lift Made Easy
Now, elevate the back of the scalp, again subpericranially;
go as far as the instrument will comfortably allow (Fig. 5.8).
Check that the brow is freed equally on both sides using finger
pressure. The tines are now ready to be inserted. Ensure that
the drill bit is firmly held by the chuck.
Make the drill hole with great care, ensuring that it is
perpendicular to the bone surface (Fig. 5.9). Any wobbling
while drilling will make the hole too large, and the Endotine
is liable to slip out. Note that the collar on the drill bit prevents
entering the brain, Remove any bone debris and wash the hole
absolutely clear by flushing with a 10 mL syringe containing
saline.
Open the Endotine box and use the special graspers (Fig.
5.10). Pick up the Endotine and avoid touching it. With an assis­
tant elevating the edges of the lateral port, guide the Endotine
through, advancing one corner. Ensure that the direction of
Surgical Technique
Make small incisions straight down to bone at the proposed
site of the endo ports (Fig. 5.6). Laterally, 1.5 cm long, and
centrally, 1 cm, are usually adequate, depending on the size
of the tools being used. Raise the skin edge with a Cats Paw
retractor or, by holding the hair and using an elevator, make
sure that you are definitely underneath the pericranium. It is
particularly important to leave a substantially intact pericranial
patch directly in front of the lateral incisions, because this is
where the Endotine will later fasten to hold the brow up.
Fig. 5.7 shows the line of elevation of the brow skin. Simply
sweep the instrument across the brow to ensure that all attach­
ments are released. Note that the finger should be protecting
the site of the supraorbital nerve. Keep the elevator clear of
the nerve at this stage.
FIGURE 5.1  Demonstrating the degree of eyebrow ptosis by digitally elevating the
lateral brow. Marking the temporal incision to facilitate a vector elevation of the
lateral brow. The direction of elevation is demonstrated with the alignment of the
incision to the inked arrow mark above the lateral brow (as shown in Figure 5.2).
A
B
FIGURE 5.2  Skin markings within the forehead hairline show the three incisions used to mobilize the tissues and insert the Endotine.
FIGURE 5.3  Elevate the forehead by injecting local anesthetic into the loose
connective tissue layer of the scalp superficially to the periosteum.

41
Surgical Preparation and Technique
FIGURE 5.4  Injection of local anesthetic with adrenaline to the glabellar area is
important in reducing the risk of hematoma.
FIGURE 5.5  A rolled swab is used to exert a milking pressure on the forehead
scalp, pre-elevated with tumescent fluid containing local anesthetic.
A
B
FIGURE 5.6  (A) A periosteal elevator is used to elevate the periosteum to about 2 cm in the depths of the scalp incision. (B) A longer elevator is then used to elevate the
scalp in the loose connective tissue plane superficial to periosteum until just above the supraorbital ridge. Subperiosteal elevation enables forehead mobilization but
protecting the supraorbital and supratrochlear nerves and the lateral brow vein covering the frontal branch of the facial nerve is vital.
FIGURE 5.7  The whole forehead scalp is mobilized using a sweeping motion of
the elevator.
FIGURE 5.8  Mobilization of the scalp continues posteriorly.

42
SECTION 1    CHAPTER 5  •  Endoscopic Endotine Brow Lift Made Easy
the Endotine hooks will hold the pericranium appropriately.
Push the Endotine firmly into the hole. A pop should be heard
as it engages securely. Release the grasping tool.
A tendon hook is useful to pull on the lateral incision skin
to take the tension of the skull flap; firmly, with increasing
tension, pull the eyebrow up and back. Once the correct position
has been attained, push the skin onto the underlying Endotine
hooks. There is a definite sensation of the hook engaging.
You can test the contrast in tension between the side with
the Endotine support and the side without (Fig. 5.11). Repeat
the exercise on the other side.
Close the wound with 4-0 Vicryl rapid interrupted sutures.
Remove the staples. It may be worth counting staples in and
out because, occasionally, some are left in inadvertently—later
to be removed unobtrusively. If the eyes are open at all, apply
a generous amount of eye lubricant (e.g., Lacri-Lube) to stop
the corneas from drying out.
Fig. 5.12 shows the extent of the set I would normally use.
It is rare to require more instruments than this.
A
B
FIGURE 5.9  (A) The Endotine drill is used to penetrate the outer table of skull. A guard on the drill bit prevents deep penetration through the inner cortical bone of skull.
(B) The drill hole is clearly seen. It is important to be accurate and precise in drilling. The hole must be through the outer table and exactly the correct diameter or the
Endotine will loosen.
A
B
FIGURE 5.10  (A) Five spikes or tines are clearly shown on this biodegradable Endotine prior to insertion into the skull using the applicator and tapping with a light
hammer to separate the Endotine from the applicator and burying the “shelf” on the Endotine under the outer table of skull. (B) The Endotine is being inserted into the skull
drill hole.
FIGURE 5.11  The patient’s right brow cannot be depressed by digital traction
because the Endotine has been correctly applied. The left side has not yet had an
Endotine fitted and can still be depressed digitally.

43
Surgical Preparation and Technique
FIGURE 5.12  A standard instrument tray showing the instruments required for
endoscopic brow elevation and also the Endotine kit. The endoscope is not shown
but is required to visualize and so protect the supraorbital and supratrochlear nerves
whilst the pericranium is split transversely along the level of the eyebrows.

45
Surgical Preparation and Technique
45
6 
Upper Blepharoplasty
Janek S. Januszkiewicz MBChB, FRACS (Plast)
The Clinical Problem (Fig. 6.1)
Introduction
The primary physical function of the upper eyelids is protection
of the eyes but, together with the eyebrows and forehead, they
form an expressive aesthetic unit, with significant social
function.
Anatomy and Aging
Ideally, the upper eyelid resting position is 1 to 2 mm below
the superior border of the corneal limbus and has 12 to 15 mm
of lid excursion. Insertion of the levator aponeurosis forms the
upper eyelid crease, which in whites usually ranges 8 to 12 mm
above the margin (men at the lower end, women at the higher
end). The fusion of the levator aponeurosis, orbicularis oculi
fascia, and orbital septum forms a pretarsal condensation of
fascia1 that divides the eyelid into tarsal and orbital portions
(Fig. 6.2). The aponeurosis takes a higher course medially and
is at risk of injury when exposing the medial fat pad during
open blepharoplasty.2
Traditionally, there are two periorbital fat pads in the upper
lid, medial and lateral, although some have reported a third
distinct central pad. The medial fat pad is pale yellow and
histologically different from the other periorbital fat, with more
nerves and vessels within it.3
With aging, the soft fullness of youth disappears (see Fig.
6.1). Excess eyelid skin and forehead lines develop, the temples
hollow with fat atrophy, and the horizontal palpebral aperture
narrows.4 Dehiscence of the levator aponeurosis can lead to
involutional ptosis and, paradoxically, the medial fat pad volume
appears to increase (or at least become more visible). Lambros4
believes that this is the legacy of deflation rather than gravi­
tational descent.
Surgical Preparation and Technique
Assessment
In older adults with brow ptosis, it may be enough simply to
carry out a reductive skin blepharoplasty to address the worst
of the dermatochalasis while accepting a degree of uncorrected
brow ptosis. Occasionally, a direct, so-called suprabrow skin
excision in a man with severe hooding may be indicated, but
the scarring from this surgery limits its usefulness. In more
demanding or cosmetically motivated patients, the treatment
plan should look beyond simple blepharoplasty to consider
the role of brow-lifting procedures, volume augmentation,
neurotoxin modulators, and skin resurfacing.
■ The brow and upper eyelids are interrelated and form an
aesthetic unit. Both must be assessed when planning
periorbital rejuvenation.
■ The preoperative evaluation includes assessment of skin
quality and rhytids, muscle tone, fat pad herniation, lid
and brow position, and symmetry.
■ Examine for signs of upper eyelid ptosis, including
position of the eyelid margin, a high supratarsal crease,
and compensatory brow elevation. In unilateral ptosis,
Hering’s law of equal innervation may be manifest as a
contralateral eyelid elevation.
■ Manually elevating the brow while the patient looks into a
mirror will demonstrate the contribution of brow position
to apparent lid excess. This maneuver is invaluable for
educating the patient about his or her condition and
explaining the limits of upper eyelid surgery alone.
Preparation and Markings
A full medical and ophthalmologic history is taken, including
previous eye trauma or surgery, glaucoma, visual acuity,
SECTION 2  •  Eyes
James D. Frame and David J. Smith

46
SECTION 2    CHAPTER 6  •  Upper Blepharoplasty
autoimmune and connective tissue diseases, dry eye symptoms,
any bleeding disorders, and anticoagulant medications. Pre­
operative photography should include a frowning view as
well as eyebrows raised and at rest.
Preoperative markings are done with the patient awake
and sitting upright, and with the eyes level with the surgeon.
Asymmetries and existing crease position are noted (Fig. 6.3).
Mark the new crease line, measuring with calipers 6 to 7 mm
above the lash margin (5–6 mm in males) and following the
contour of the existing crease to the medial and lateral canthi.
Use forceps to pinch the skin, assess the excess, and plan
the upper incision, first at the midpupillary line and then at
several further points with the brow held up, when necessary,
for exposure. One should create only a gentle upturn of the
lashes with a pinch; the lateral part is more forgiving. Preserve
15 to 20 mm of skin between the upper marking and the lower
eyebrow, and be careful of being misled by plucked eyebrows.
The eccentric ellipse that is drawn will usually extend later­
ally to taper upward into an existing rhytid. In younger patients,
one does not need to extend beyond the lateral canthus.
Try to avoid extending the incisions beyond the lateral orbital
rim. Do not transgress the medial canthus onto nasal skin
because this area will tend to form webbed or prominent scars.
Medially, a small (2–3 mm) triangle or vertical wedge at
right angles to the lower incision will eliminate the remaining
wrinkled excess beyond the main excision pattern and will
leave no perceptible extra scarring.
FIGURE 6.1  Periorbital aging includes dermatochalasis, fat atrophy and temple
hollowing, rhytids, and narrowing of the palpebral aperture. Note the asymmetric
lateral brow position, which makes the left eye looks worse.
Lacrimal
gland
Line of fusion
of aponeurosis
and orbital septum
Orbicularis
oculi m.
Müller’s m.
Levator
aponeurosis
Orbital fat
A
B
Tarsal
plate
Orbital
portion
Tarsal
portion
Levator
aponeurosis
Tarsal plate
Preaponeurotic
lateral and
central fat pads
Medial
fat pad
Medial, central
and lateral fat pads
of lower lid
FIGURE 6.2  Pretarsal fascia inserting into the anterior aspect of the tarsal plate. Note the oblique line of fusion rising medially. Lateral and central periorbital fat pads are
preaponeurotic. (Adapted from Januszkiewicz, J.S., Nahai, F., 1999. Transconjunctival upper blepharoplasty. Plast. Reconstr. Surg. 103, 1015–1018.)

47
Summary
A window is made in orbicularis at the upper lateral orbital
rim where the lateral orbital thickening inserts. Periosteum is
engaged with one or two bites of 5-0 PDS and a point chosen
on the deep aspect of the lateral brow. This creates adherence
between tail of brow and orbital rim that marginally elevates the
eyebrow on table. There will be some minor suture distortion
that resolves over 2 weeks as oedema settles. This stabilization
suture helps prevent further brow descent postoperatively, and
can be useful to protect against unwanted lateral hooding in
the patient with a mobile brow who might otherwise appear to
have been ‘underdone’. It is not designed to achieve a brow lift.
Complications
A superficial hematoma is uncommon and is easily drained.
All patients are counseled about the risk of retrobulbar hema­
toma and blindness, but this is a rare event.
Patients reporting severe pain, visual loss, or scintillating
scotomas should be seen immediately. Proptosis, periorbital
bulge, and tension with reduced eye movements necessitate
urgent action, including removal of all sutures, IV acetazolamide
(Diamox) and corticosteroid, high-dose oxygen, mannitol
infusion, ophthalmology referral, and return to surgery for
surgical evacuation and wide septal release.8
Dry eye symptoms may be exacerbated by any eyelid surgery
but should settle with the use of lubricating eye drops. Chemosis
can be treated with a topical steroid. An inability to close the
eyes early postoperatively is not uncommon and will settle
with eyelid taping, lubricating eye drops, gentle massage of
the lids, and reassurance. Persistent lagophthalmos is usually
due to over-resection of the skin.
Summary
Upper eyelid blepharoplasty remains a popular and successful
plastic surgery procedure. Consistently good outcomes depend
on careful patient selection, a detailed understanding of regional
anatomy, and meticulous planning and technique.
Surgical Technique
Local anesthesia with 2% lidocaine with adrenaline (1 : 80,000)
can be supplemented with IV sedation in the anxious patient.
The local anesthetic is injected superficially with a small bolus
more deeply at the medial fat pad. A skin prep containing
chlorhexidine should be avoided.
The skin is incised under retraction, preserving the underly­
ing orbicularis fibers. At the lateral limit, the muscle is thicker,
and some fibers are trimmed to assist with a smoother contour
on skin closure (Fig. 6.4).
The role of muscle excision in upper blepharoplasty has
been debated,5 but a small strip of muscle may be excised from
the upper border of the tarsal plate, just above the lower incision.
This can help further define the tarsal crease.1 In most cases,
the orbicularis oculi muscle is otherwise preserved, unless it
is hypertrophic and bulky.
Medially, the septum is incised, and the medial fat pad is
revealed. This may be gently teased out. Use cautery to ensure
absolute hemostasis before allowing any remaining fat to retract.
The fat of the central and lateral fat pads is generally preserved
for volume unless there is an obvious surfeit (Fig. 6.5).
The skin edges are approximated centrally, and the lids are
checked for symmetry. The eyelashes should be subtly upturned,
with the eye slightly open. Running continuous 6-0 nylon
sutures are reinforced with a few strategic interrupted sutures
laterally (Figs 6.6 and 6.7). Chloromycetin ointment is applied
to the suture lines and cornea, followed by cold saline eye
pads for 48 hours.
Some prefer to fix the free edge of levator to the pretarsal
orbicularis and upper border of the tarsal plate.1,6 This three-
point fixation technique can be useful in secondary or revisional
blepharoplasty7 or in primary blepharoplasty with blepharop­
tosis due to levator disinsertion.
A brow stabilization suture can be added in patients with
a moderate to severe degree of lateral eyebrow descent who
have declined or are not candidates for more formal brow
repositioning procedures such as lateral temporal brow suspen­
sion, endoscopic brow lift or direct suprabrow lift (Fig. 6.8).
A
B
FIGURE 6.3  Skin markings.