Cosmetic Facial Surgery

cosmetic
FACIAL SURGERY

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cosmetic
FACIAL SURGERY
JOE NIAMTU, III, DMD, FAACS
PRIVATE PRACTICE
COSMETIC FACIAL SURGERY
RICHMOND, VIRGINIA
FELLOW, AMERICAN ACADEMY OF COSMETIC SURGERY

3251 Riverport Lane
St. Louis, Missouri 63043
COSMETIC FACIAL SURGERY
ISBN 978-0-323-07400-1
Copyright © 2011 by Mosby, Inc., an affiliate of Elsevier Inc.
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(other than as may be noted herein).
Notices
Knowledge and best practice in this field are constantly changing. As new research and experience broaden
our understanding, changes in research methods, professional practices, or medical treatment may become
necessary.
Practitioners and researchers must always rely on their own experience and knowledge in evaluating and
using any information, methods, compounds, or experiments described herein. In using such information or
methods they should be mindful of their own safety and the safety of others, including parties for whom they
have a professional responsibility.
With respect to any drug or pharmaceutical products identified, readers are advised to check the most
current information provided (i) on procedures featured or (ii) by the manufacturer of each product to be
administered, to verify the recommended dose or formula, the method and duration of administration, and
contraindications. It is the responsibility of practitioners, relying on their own experience and knowledge of
their patients, to make diagnoses, to determine dosages and the best treatment for each individual patient, and
to take all appropriate safety precautions.
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otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the
material herein.
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v
Contributor
ANGELO CUZALINA, MD, DDS
Adjunct Assistant Professor of Surgery
The Ohio State University
College of Medicine
Columbus, Ohio;
Private Practice, Tulsa Surgical Arts
Tulsa, Oklahoma;
Chairman, AACS Accredited General
Cosmetic Surgery Fellowship Program;
President Elect (2010) of the American
Academy of Cosmetic Surgery;
Member of the Board of Trustees for the
American Board of Cosmetic Surgery

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vii
Dedication
This text represents the pinnacle of my academic and clinical career to date and the
communal effort of those around me.
When I wrote the final chapter I felt like a weight had been lifted from my shoulders,
but that was only the beginning of the work. Elsevier employees John Dolan, Courtney
Sprehe, and Karen Rehwinkel then began barraging me with thousands of pictures (there
are 3,300 in this book!) to review and chapters to proof. One of the hardest things for an
author is to read his or her own work. Since it is original and you wrote it, it is hard
to concentrate. John, Courtney, and Karen have been paramount in keeping me on
track; they are the most gifted and hardest workers I have ever had the pleasure of
working with.
I dedicate this book to my parents Joe Niamtu, Jr and the late Elsie Niamtu, whose
guidance and nurturing instilled in me the quest for success and the attribute to never,
ever quit, no matter what. I was raised with the advice that an ordinary person can
achieve extraordinary goals with hard work and dedication and to never lose sight of
one’s goals.
I would be remiss not to include my wife April in this dedication as she became a “book
widow” for the 12 months of continuous writing, photography, filming, and editing
required for a single-author text of this size. She gave up many date nights and social
events, and supported me to the fullest as I was slumped over my computer, sometimes
for 11 hours in a single day. Her support was invaluable.
Finally, I dedicate this book to my two special needs sons, Joey and Evan Niamtu. These
angels have many challenges in their lives and they are my soldiers. They have taught
me so much about love and about life, and they are my heroes. They cannot walk or talk
and will never write a book, but their smiles and inspiration provide me the fortitude and
drive in my life, personal and academic.

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ix
Foreword
We are honored that Dr. Joe Niamtu has asked us to write the foreword for his new book, Cosmetic
Facial Surgery. Please allow us to introduce to you Dr. Niamtu and his book. We have known Joe
for approximately 15 years and have always appreciated his energy, enthusiasm, and knowledge. At
the same time, his sense of humor enlivens whatever topic he is addressing, and in consequence, he
is much in demand as a world-class expert and excellent communicator.
Dr. Niamtu is passionate about cosmetic surgery. He is a Fellow of the American Academy of
Cosmetic Surgery and has served on the board of the Cosmetic Surgery Foundation. He appreciates
the value of having numerous specialties contributing to the world of cosmetic surgery and also that
not one specialty can “own” the cosmetic world.
Joe is a surgeon, author, and teacher who has written hundreds of articles on the topic of cosmetic
facial surgery, which includes many different areas in this field. In addition, he has edited two
previous cosmetic surgery texts and contributed to more than 20 chapters in other textbooks. He
has trained hundreds of doctors from numerous specialties and lectures on average at 20 meetings
a year.
Dr. Niamtu was honored when Elsevier Publishing invited him to write this text. It has 17
chapters, and to produce a book of this size as a solo author (with the assistance of Dr. Cuzalina
for the rhinoplasty chapter), is a herculean task. It was his goal to create a book that presents
information that is accurate, up to date, and clear. The book has over 3,300 photographs and nearly
800 pages of text, making it very comprehensive. It is designed to present step-by-step descriptions
of procedures covering diagnosis, surgical mapping, the procedure itself, postsurgery considerations,
and complications. Chapters on clinical photography, evaluating the cosmetic patient, and cosmetic
surgery anesthesia make this a complete and well-rounded text.
Dr. Niamtu has committed 2 years of his life to translating his 30 years of facial surgery
experience into this valuable reference text. We hope you will enjoy reading it as much as we have.
ALASTAIR AND JEAN CARRUTHERS
Alastair Carruthers, MA, BM, BCH, FRCPC, FRCP(Lon)
Clinical Professor
Department of Dermatology and Skin Science
University of British Columbia
Vancouver, BC, Canada;
Past President, American Society for Dermatologic Surgery;
Past President, Canadian Dermatology Association;
Past President, Canadian Society for Dermatologic Surgery
Jean Carruthers, MD, FRCSC, FRC(Ophth)
Fellow, American Society of Ophthalmic Plastic and Reconstructive Surgery;
Diplomate, American Boards Cosmetic Surgery;
Clinical Professor
Department of Ophthalmology
University of British Columbia
Vancouver, BC, Canada;
Past President, Canadian Society for Dermatologic Surgery

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xi
Preface
From Idea to Opus
While strolling through the exhibit hall at a meeting in 2007,
I walked by the Elsevier booth and was stopped by an Editor.
He told me that he had read and enjoyed many of my writings
and, much to my surprise, asked if I would be interested in
writing a textbook on cosmetic facial surgery for Elsevier. I told
him that it was something I had always wanted to do and that
I have cosmetic facial surgery friends all over the globe from
every specialty and that we could put together a world-class text.
The Editor rather abruptly cut me off and said that he wanted
me to be the sole author! This caught me off guard. Although
I have written hundreds of articles on cosmetic facial surgery,
as well as contributed to more than 20 textbooks and authored
several small textbooks, I knew that writing a sole-author text
that covers the entire panorama of contemporary cosmetic facial
surgery would be a daunting task. The Editor assured me that
I “could do it” and that writing the book on my own would
maintain the voice and practical nature of my teaching and he
asked me to consider it. I have to be honest. I kind of back-
burnered the idea and put it in my “someday I will do that”
bucket list. Each time I entertained the thought of taking on
the project I got an uneasy feeling, knowing the serious amount
of work that it would require. I was already spending entirely
too much personal time lecturing, publishing, and teaching
while trying to balance a busy cosmetic facial surgery practice
and a marriage with two severely mentally and physically dis-
abled children. Again, each time I thought about writing this
big, sole-author text, I quickly put it out of my mind.
I have always been the type of person who hates to turn down
a challenge, and this particular challenge kept gnawing at my
mind. Writing a definitive text on cosmetic facial surgery was
something that I always intended to do, but I envisioned it as
something I would do later in my career. Cosmetic facial surgery
is my passion and I wanted to leave a legacy of the wonderful
knowledge I have learned to the profession that I enjoy so much.
I have always been a teacher at heart and here I was, being
offered the chance to write a book on what I love for the most-
respected textbook publisher in the world. Pretty hard to turn
down! So in September 2008, while on a plane to speak at a
meeting (I do some of my best writing on airplanes!), I pulled
out my laptop and put together a table of contents for 17 chap-
ters that would encompass the major procedures in cosmetic
facial surgery. Bang! There it was. I had started my book.
Over the next year I began to work on the chapters outlined
in the table of contents. I wanted this book to be a text that
would interest students, residents, and experienced practitioners
alike. I wanted it to be a book that was so comprehensive and
had so many color photographs that it would cross all specialty
lines involved with cosmetic facial surgery. I wanted it to be an
atlas that would not simply sit on a surgeon’s bookshelf, but one
that would become tattered and worn from serving as a great
surgical reference. All of these thoughts led me to search for an
unofficial title for the book, which came to be called “My
Opus”. If all of this sounds boastful, it is not at all. I am a very
humble person, but was raised with an extremely hard work
ethic (thank you Joe Niamtu, Jr.). I was taught that if a person
puts everything they have into a project, the result will usually
be good. Any surgeon that has ever written an article is aware
that sometimes it is easy to cut corners when adding informa-
tion that requires research, exactness, and credibility. To that
end, if I was unsure of a fact, I stopped writing and started
researching.
One thing that made this text possible was my obsession with
clinical photography. Over the past 12 years I have taken over
80,000 surgical pictures and have photo documented all of my
procedures, complications, and patients, much to the dismay of
my wonderful staff who tirelessly puts up with my stopping
surgery, cleaning the field, and taking high-quality pictures.
My staff took many of the photos and did a great job. While
writing this text, if I came across a poor-quality photo that
would not complement the Opus, I retook the photo on the
next case I performed. I also created many of the diagrams used
in this book, spending countless hours with the camera and
Photoshop—definitely a task of awesome proportion!
I begin this text with chapters on facial aging, evaluating the
cosmetic surgery patient, digital photography, and anesthesia. It
took several weeks of writing to complete these chapters. It was
after that, however, that the real work began. My goal was to
start at the top of the head and write chapters detailing con­
temporary diagnosis, surgery, followup, complications, and case
presentations and work my way down to the clavicles. Over the
next 10 months I became a keyboard hermit and less of a
husband and father. There were weekends when I typed for 11
hours a day and my fingers hurt. At work, I typed between
patients. Slowly but surely, the text began to take shape.
Although this is a single-author text, rhinoplasty is a proce-
dure that I rarely perform. I needed an author for the rhino-
plasty chapter that would complement this text. I have met
some of the leading rhinoplasty surgeons in the world and
thought about asking one of them to do a chapter, but my fear

xii
Preface
was that since they are so recognized and have written exten-
sively they would present me with an anemic chapter of material
that they had laying around from previous writings. With this
thought, I decided that what I really needed was an excellent
rhinoplasty surgeon with lots of experience. Coupled with these
requirements was the need for someone that is as driven as I am
and who could deliver superlative writing and photography on
schedule. My dad always told me that “if you want something
done, ask a busy person”. With all of this in mind, there was
only one person that I knew could fit that bill and that was
Angelo Cuzalina, MD, DDS. In addition to being president
elect of the American Academy of Cosmetic Surgery, Angelo
is as involved as I am with teaching, lecturing, publishing,
and practicing. Since he has “can’t say no” disease, I asked and
thankfully he accepted and provided a world-class rhinoplasty
chapter.
How long does it take to write a comprehensive text on
cosmetic facial surgery? The answer is about 2 years, and that is
2 years of daily work, not sporadic toil. This has been the hardest
project I have ever done in my life and will likely remain my
biggest, as the required commitment truly necessitates putting
the rest of your life on hold. My honest hope is that the readers
of this book will agree that it is a useful resource and valuable
addition to their practice and knowledge base. It was truly my
honor and privilege to be selected for this text and a labor of
love to write the “Opus” of my career.
JOE NIAMTU, III

xiii
Features and Organization
Key Features
• Comprehensive coverage—the full range of procedures from
the upper face to the lower face/neck area
• Accessible, easy-to-grasp writing style—first-person narra-
tive teaches concepts based on real cases and experiences,
making the surgical procedures tangible and easy to
understand
• Over 3,000 illustrations—extensive number of drawings
and before and after photos help clarify important concepts
and techniques and show the dramatic results that can be
achieved
• DVD—videos showing the author performing the proce-
dures discussed in the book bring the surgeries to life
Organization
Chapter 1: The Aging Face—addresses regional facial aging,
upper facial aging, midfacial aging, nasal aging, lower facial
aging, and aging in the submental region
Chapter 2: Diagnosis of the Cosmetic Facial Surgery Patient:
The Art of the Consult and the Office Patient Experience—
addresses how to have a productive consult, how to choose the
right patient, the preoperative appointment, the day of surgery,
and postsurgery followup
Chapter 3: Clinical Digital Photography—addresses the pho-
tography equipment (including cameras and software), taking
and making photos, radiographs, ultraviolet images, and
archiving
Chapter 4: Anesthesia Considerations for Cosmetic Facial
Surgery—looks at the mechanism of local anesthetics, sensory
anatomy of the head and neck, local anesthetic techniques, local
anesthesia of the neck, tumescent anesthesia, and conscious
sedation
Chapter 5: Mini Open Brow Lift: The Transfollicular Subcu-
taneous Approach—looks at the technique of transfollicular
subcutaneous brow and forehead lift (TFSBFL), an alternative
to other brow-lift techniques, including endoscopic brow and
forehead lift (EBFL)
Chapter 6: Brow and Forehead Lifting—focuses on endoscopic
and open-brow techniques, including upper facial diagnosis,
patient acceptance of brow and forehead lifting, the surgical
procedure, and complications
Chapter 7: Cosmetic Blepharoplasty—looks at orbital anatomy,
aging conditions of the eyelids and periorbital areas, diagnosis
and patient selection, treatment planning, preo­perative marking,
surgical preparation and anesthesia, instrumentation, upper-
eyelid incision, lower-eyelid blepharoplasty, alternative treat-
ments, and complications
Chapter 8: Rhinoplasty—designed to provide a good, basic
knowledge and covers topics such as anatomy, the nasal muscu-
lature and blood supply, nasal bone and cartilage anatomy,
examination and consultation, clinical evaluation of the nasal
tip, treatment planning, external versus endonasal technique,
incision options, open rhinoplasty, and complications
Chapter 9: Cervicofacial Rhytidectomy (Facelift)—addresses
the history of facelift surgery, facelift anatomy, patient selection,
determining status for potential cosmetic facial surgery, pre­
operative consultation workup, facility, instrumentation, the
day of the surgery, anesthetic considerations, facelift procedure,
SMAS techniques, postoperative care, short scar/weekend face-
lift, simultaneous laser skin resurfacing, concomitant or ancil-
lary procedures, revision facelift surgery, complications and their
prevention, postsurgical revision, and the informed consent
procedure
Chapter 10: Facial Implants—looks at midface implants
(including implant selection, preoperative planning, surgical
placement, postoperative care, and complications) and addresses
chin implants, mandibular angle implants, and custom implants
Chapter 11: Cosmetic Otoplasty and Related Ear Condi-
tions—addresses ear deformities and the two techniques that
can be applied to most common ear deformities, the Mustardé
and Davis procedures, and also looks at earlobe reduction, the
repair of torn earlobes, complications in earlobe repair, and
keloid excision
Chapter 12: Skin Resurfacing—looks at both laser resurfacing
and chemical peels, popular adjuncts in the contemporary cos-
metic facial surgery practice
Chapter 13: Neurotoxins in Cosmetic Facial Surgery—looks
at botulinum toxin A, including its history and physiology,
clinical usage, nasal indications, perioral treatment, facial pain/
TMJ/headache, and complications

xiv
Features and Organization
Chapter 14: Use of Injectable Fillers in Cosmetic Facial Sur-
gery—looks at recent historical overview of facial fillers available
in the United States, tissue deposition of injectable fillers, treat-
ment considerations, injection techniques, diag­nostic decisions,
patient expectations, complications, and lip implants
Chapter 15: Lip Reduction (Reduction Cheiloplasty)—looks
at lip reduction, including diagnosis and consultation, differen-
tial diagnosis, lip anatomy and histology, the surgical procedure,
subtotal lip reduction, postoperative care, complications, and
lip shortening
Chapter 16: Cosmetic Removal of Nevi and Lesions with 4.0
MhZ Radiowave Surgery—addresses the technique for aes-
thetic removal of nevi and various other lesions, rhinophyma,
postoperative care, and complications
Chapter 17: Laser Treatment of Vascular Lesions—addresses
532- and 940-nm wavelengths in solid-state lasers, treating
larger or deeper vessels, equipment considerations, pigmented
lesions, anesthesia concerns, and complications
DVD Features
Chapter 5
Trichophytic Brow Lift
Part 1
Part 2
Part 3
Chapter 7
Unilateral Upper and Lower CO2 Blepharoplasty
Chapter 8
Open Rhinoplasty
Chapter 9
Facelift
Part 1
Part 2
Part 3
Part 4
Chapter 10
Extraoral Chin
Small Combined Submalars
Part 1
Part 2
Chapter 11
Davis and Mustardé Otoplasty
Part 1
Part 2
Chapter 12
TCA Peel
Chapter 13
Botox—Marking and Three Areas
Chapter 14
Juvederm Comprehensive Filler Needle and Cannula
Juvederm Injection to Nasolabial Folds and Lips
Chapter 16
Ellman Large Cheek Mole

xv
Contents
1
The Aging Face  1
2
Diagnosis of the Cosmetic Facial Surgery Patient: The Art of the
Consult and the Office Patient Experience  13
3
Clinical Digital Photography  23
4
Anesthesia Considerations for Cosmetic Facial Surgery  35
5
Mini Open Brow Lift: The Transfollicular Subcutaneous Approach  54
6
Brow and Forehead Lifting  90
7
Cosmetic Blepharoplasty  129
8
Rhinoplasty  175

ANGELO CUZALINA
9
Cervicofacial Rhytidectomy  247
10
Facial Implants  369
11
Cosmetic Otoplasty and Related Ear Conditions  434
12
Skin Resurfacing  517
13
Neurotoxins in Cosmetic Facial Surgery  604
14
Use of Injectable Fillers in Cosmetic Facial Surgery  640
15
Lip Reduction (Reduction Cheiloplasty)  701
16
Cosmetic Removal of Nevi and Lesions with 4.0 MhZ Radiowave Surgery  718
17
Laser Treatment of Vascular Lesions  734

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cosmetic
FACIAL SURGERY

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1
1
The Aging Face
A
ging is a physiologic process of the body in response to
the passage of time. Since the beginning of time, people
have sought treatments to retard or reverse aging, with
little avail. Aging can be accelerated by intrinsic and extrinsic
factors. Aging cannot be stopped or reversed, but its effects can
be mitigated. Trying to make a 60-year-old patient look 30 is
unreasonable; a 60-year-old patient who wants to look as good
as possible for 60 is very reasonable.
It is imperative that cosmetic surgeons fully understand the
pathophysiology of aging, and educating patients on this process
also helps them appreciate the basis for rejuvenation. Although
we may feel we know much about aging, in reality we know
little. Most textbook descriptions of facial aging are very
mechanical and relate to loss of volume and support. Although
this is certainly a factor and important to reversing the effects
of aging through cosmetic surgery, there are many other intrin-
sic factors that make aging happen. Most cosmetic facial surgery
patients are female, and the nuisances of metabolic aging influ-
ences are significant. Menopause produces decreased estrogen
levels with elevated androgen levels, which contribute to epider-
mal and dermal changes. The decrease in basal metabolic rates
(in men and women) facilitates weight gain and fat distribution
in unwanted places such as thighs, abdomen, hips, buttocks,
face, and neck. Add the ravages of childbearing to the skin and
muscle, and it is easy to understand the aging process in females.
Subcutaneous fat also decreases, which affects the support of the
skin. The face and neck are rich in glandular structures that
are less frequently discussed in volume loss but are probably
moderate contributors. Finally, osteoporosis plays a key role in
bone resorption; the majority of women in their fifth decade
are osteoporotic. Osteoporotic changes also occur in males and
in both sexes contribute to facial skeletal and dental resorption.
As the facial skeleton shrinks, even more soft-tissue support
is lost.
One unique factor to facial aging is that in most cultures,
the face is exposed. Clothes can masquerade somatic aging, but
the face and hands give it all away.
Like all other theories or processes, surgeons and anatomists
argue about what exactly happens during aging. Although most
surgeons agree that atrophy, ligamentous laxity, and ptosis are
causative factors, others argue against this. What is universally
agreed upon is that aging is a gradual process of structural
weakening, and its effects begin in the third decade and progress
throughout an individual’s lifetime. Aging is basically a
process of deflation, similar to the transition from grape to raisin
(Figure 1-1).
Babies and toddlers have full, rounded faces with full, convex
contours. Adolescence includes rapid but disharmonious growth
of bone, cartilage, muscle, and fat, which produces a sometimes
awkward appearance in the preteen years. Through the teen
years, puberty produces secondary sexual characteristics, includ-
ing rapid growth phases that produce hereditary but predictable
and distinguishable facial changes. Middle age brings the onset
of aging changes that progress until death, as described later in
this chapter.
The youthful face is tapered like an upside down egg, owing
to the distinct volume and tight tissue retention (Figure 1-2, A).
The aging face is more a reverse taper, similar to a right-side-up
egg, due to the descent of volume and fat-compartment changes
(Figure 1-2, B).
Aging changes are not only from volume loss and support
changes but also intrinsic and extrinsic factors1-3 (Box 1-1).
It is interesting that biological aging can sometimes exceed
chronologic aging, and we all know 45-year-olds who look 60
(or the inverse).
Lifestyle and heredity are significant contributors to the
aging equation. Some aging factors are controllable whereas
others are not. Studies of monozygotic twins have revealed that
aging is affected greatly by environmental and lifestyle factors,
as measured by physical appearance. The factors that exert the
greatest influence seem to be substance or alcohol abuse, sun
exposure, and emotional distress.4 These aging changes are
shown with supporting images in the various procedure
chapters.
In the first clinic I wrote, Dr. Tom Faerber contributed a
chapter on facial aging. To compare aging changes, he per-
formed an interesting study in which he obtained computed
tomography (CT) scans on his 9-year-old daughter, 42-year-old
FIGURE 1-1.  The analogy of a grape transforming into a raisin symbolizes
the loss of volume in facial aging.

2
Chapter 1  •  The Aging Face
Skin
The most plentiful facial tissue is skin. The facial integumentary,
like the exposed hands, rarely gets a rest from the ravaging
effects of the environment. Photodamage from sun exposure is
especially harmful and coupled with extrinsic factors such
smoking can accelerate the effects of aging.
Photodamage describes aging changes of the skin from
chronic ultraviolet (UV) light exposure. Cumulative photo­
damage can be seen in almost every patient by comparing
the sun-exposed and sun-protected areas of skin (Figure 1-4).
The most obvious clinical cutaneous aging changes include
markedly increased skin roughness, increased mottled hyperpig-
mentation, increased loss of elasticity, increased wrinkling, and
sallowness.
Genetic contributions to skin aging result in numerous
biochemical, histologic, and physiologic changes: a reduction of
vascularity, increased dermal/epidermal thickness, collagen
changes, proteoglycan and dermal cellularity, and loss of elastic
fibers.9-11
Photoaging causes functional and anatomic modifications in
the exposed regions. Ultraviolet B (UVB) radiation produces
direct damage to the DNA of skin cells and also modulates the
activity of cytokines and adhesion molecules.12,13 Ultraviolet A
(UVA) radiation initiates the formation of reactive oxygen
species (ROS), which also damage nuclear and mitochondrial
DNA and activate matrix metalloproteinases (MMPs).13
Histologically, the effects of skin photoaging include epider-
mal thickening, keratinocyte atypia, loss of polarity, and
increased melanogenesis14 (Box 1-2). A fragmented and disor-
ganized dermal fibrillar network is present and forms amor-
phous groups.15 Collagenous changes occur in the appearance
of fragmented collagen fibrils, senescent fibroblasts, loss of func-
tion of glycosaminoglycans, and alterations in the cutaneous
microvasculature.16
Contributing to exogenous skin aging is the decrease in skin
functions that occur with age: decreases in cell replacement,
A
B
FIGURE 1-2.  The youthful face is the shape of an upside-
down egg; the volume is in the midface, with a tapering
lower face (A). The aging face has volume loss, descent
of tissues, and loss of the taper, giving it a right-side-up
egg shape (B).
Box 1-1  Etiology of Aging
Intrinsic Aging
Extrinsic Aging
• Cellular senescence
• Decreased proliferative capacity
• Decrease in cellular DNA repair capacity
and chromosomal abnormalities
• Hormone reductions
• Oxidative stress
• Gene mutation
• Fat and muscle changes
• Bone and cartilage remodeling
• Loss of dental structure
• Ultraviolet radiation
• Environmental factors
• Smoking
• Ethanol abuse
• Gravitational effects
• Elasticity changes
• Emotional stress
wife, and 75-year-old mother-in-law. These women’s ages were
separated by roughly 35 years.5 Of particular note is that the
youthful face is convex, whereas the aging face is concave due
to fat atrophy, muscle atrophy, and gravitational and ptotic
changes (Figure 1-3). A pattern of muscle atrophy was demon-
strated in the masseter and buccinator muscles in the oldest
family member. The parotid gland maintained its volume, but
the surrounding perimuscular and subcutaneous fat showed
atrophy. Fat and muscle atrophy in the temporal, buccal, and
malar regions were also seen and contributed to the concavities
in those regions that develop with age, as evidenced in the
progressive CT scans.
Osseous volume-loss changes have also been implicated in
midfacial aging.6,7 Other studies show osseous volume increases
in the lower face.8
Regional Facial Aging
The most logical means to address facial aging and rejuvenation
is to start at the top and work downward. If the novice surgeon
keeps this in mind, an orderly progression is always completed
with consultation, diagnosis, and treatment.

Chapter 1  •  The Aging Face
3
A
B
FIGURE 1-3.  A, Computed tomography (CT) scan showing the facial anatomy of a 9-year-old female. B, CT scan showing the
facial anatomy of a 42-year-old female.
injury response barrier function, sensory perception, immune
and vascular responsiveness, thermoregulation, sweat produc-
tion, sebum production, and vitamin D production.5
Upper Facial Aging
Hair
Aging in the scalp manifests as the pigment changes of graying,
thinning, hair shaft fragility, pattern baldness, and recession.
These changes are largely genetically controlled and less at the
Box 1-2  Histologic Effects of Photoaging
• A thickened, more basket-woven stratum corneum
• A thinner, more atrophic epidermis
• Epidermal atypia
• Irregular melanin dispersion in the epidermis
• Decreased glycosaminoglycans in the dermis
• Abnormal-appearing elastic fibers in the dermis
Continued

4
Chapter 1  •  The Aging Face
Although some people, even in youth, never have elevated
or arched brows, many do. Most youthful females have brows
that arch at the junction of the central and lateral brow (which
corresponds to the lateral pupillary limbus). The youthful male
brow lies at or slightly above the superior orbital rim. The
aforementioned aging changes coupled with the atrophic
changes in brow fat and the upper periorbital complex cause the
brows to descend in many patients. This is manifested as lateral
hooding and/or generalized ptosis, which gives the appearance
of smaller eyes (Figure 1-5). In severe cases, the eyebrow sits on
the lashes. A ptotic brow associated with upper periorbital
changes produces a sad, tired appearance that leads some indi-
viduals to spend their waking lives subconsciously raising their
brows. Any surgeon who performs brow lift surgery can attest
to the difficulty—if not impossibility—of getting some patients
to relax their brow for a preoperative photo.
The treatment for brow and forehead ptosis is an endoscopic
or open brow technique. Unfortunately, many patients who
should have a brow lift end up with blepharoplasty. This can
actually worsen the aging situation by further pulling down the
brow. The correct diagnosis of brow and forehead ptosis is para-
mount in aesthetic rejuvenation.
The upper facial mimetic muscles allow us to communicate
with complex facial expressions, but continual flexing of the
procerus and corrugator muscles takes a toll by causing rhytids
in the glabellar region. The “11” is what some patients call the
two prominent, vertical glabellar rhytids. Treatment of glabellar
rhytids includes injectable neuromodulators, injectable fillers,
radiofrequency nerve ablation, laser skin resurfacing, and muscle
disruption with concomitant brow lift.
Upper Eyelids
The upper lids are inseparable from brow and forehead aging,
because the ptotic brow enhances upper lid skin redundancy.
C
FIGURE 1-4.  Sun damage is evident on most individuals, and the difference
between the sun-protected and sun-exposed skin is obvious.
C, CT scan showing the facial anatomy of a 75-year-old female. (From Faerber TH: Evaluation of the aging
face. In Niamtu J (ed): Cosmetic facial surgery. Oral Maxillofac Surg Clin North Am, pp 523–530, 2000.)
FIGURE 1-3, cont’d
mercy of the environment compared to the skin. Additionally,
“hair aging” is less of an indicator of age; some 20-year-olds lose
their hair, while some 70-year-olds have a full head of thick,
dark hair.
The aging scalp is treated surgically with follicular grafts,
flaps, and other techniques. The medical treatment of hair loss,
although in its infancy, will probably overcome surgical treat-
ments in the lifetime of many of the readers of this text. The
FDA clearance of bimatoprost (Latisse, Allergan Inc., Irvine,
CA) is an indicator of things to come.
The Forehead and Brow
Younger people have smooth foreheads. Photodamage with its
resultant skin changes, tissue ptosis, and gravity all contribute
to brow and forehead changes. Continual flexing of the frontalis
muscles creates horizontal forehead rhytids.

Chapter 1  •  The Aging Face
5
lateral canthal tendinous attachments can become weakened
and contribute to lower lid laxity. This can manifest in increased
scleral show and lateral canthal rounding. The sum of these
changes coupled with fat protrusion gives patients a tired and
aged appearance. The upper face frequently presents with aging
changes before the lower face, and it is not uncommon for
younger patients to present for cosmetic consultation for their
“tired” look (Figure 1-6).
The nasojugal groove is the depression that represents the
transition between the lower lid, malar fat pad, and lateral nose.
The lower lid aging changes and the descent of the malar fat
pad expose the inferior orbital rim and accentuate the nasojugal
groove, also called the tear trough deformity. The tear trough can
be treated with injectable fillers, fat, or with lower blepharo-
plasty fat transpositioning. Laser skin resurfacing or chemical
peeling can also improve this region. Tear trough silicone
implants are a less frequent option.
Cheeks
The cheeks are the foundation of the midface and basically are
composed of the malar fat pads. In youth, the malar fat pads
are full and in a superior position. With aging, the fat undergoes
atrophy, and the malar fat pad becomes ptotic (Figure 1-7).
A
B
FIGURE 1-5.  A patient with the described brow and upper lid changes before and after subcutaneous brow lift.
The upper eyelid skin is extremely thin, and aging and photo-
damage lead to the redundant and crinkly looking skin known
as dermatochalasis. Weakening of the orbital septum causes the
upper periorbital fat to protrude and produce aged contours. In
some patients, the lacrimal gland also becomes ptotic and can
obstruct the upper eyelid sulcus. Laxity in the orbicularis retain-
ing ligaments in both the upper and lower eyelids also contrib-
ute to this process.17 The youthful eyelid has a slight upward
slope from medial to lateral. Weakening of the lateral canthal
support produces a downward slant of the eyes. These changes
can be seen in the preoperative photo in Figure 1-5. Continual
flexing of the orbicularis oculi muscle causes lateral canthal
creases (crow’s foot wrinkles), which also contribute to upper
facial aging.
The treatment of upper eyelid aging includes blepharoplasty,
brow and forehead lifting, and skin resurfacing.
Midfacial Aging
Lower Eyelids
The lower eyelid complex is one of the biggest contributors to
facial aging. The same skin and fat changes discussed in regard
to the upper lid apply to the lower lids. Also, the medial and
A
B
FIGURE 1-6.  Dermatochalasis and fat protrusion through a weakened orbital septum produce an aged and tired appearance.
This patient was treated with transconjunctival blepharoplasty and periorbital laser skin resurfacing as well as upper lid
blepharoplasty.

6
Chapter 1  •  The Aging Face
In youth, the skin is held taught over the bone by two types
of retaining ligaments. Osteocutaneous ligaments represent
fibrous bands with osseous (periosteal) origins and dermal inser-
tions. The zygomatic and mandibular retaining ligaments are
representative of “true” osteocutaneous retaining ligaments. An
additional support system is formed by the coalescence of the
superficial and deep fasciae. These soft tissue–to–soft tissue
B
C
A
FIGURE 1-7.  The author’s 8-year-old son (A), the author at 56 years of age (B), and the author’s father at 83 years of age (C).
Progressive atrophy, ptosis, and volumetric aging changes are evident and predictable.
1
2
3
4
A
B
FIGURE 1-8.  A, A representation of facial ligaments. The osteocutaneous retaining ligaments, such as the zygomatic (1) and
mandibular (2), originate on bone and insert on dermis. Cutaneous ligaments such as the masseteric retaining ligament (3) and
the parotid retaining ligament (4) are thickenings of connective tissue that join deeper soft-tissue structures to the dermis. Col-
lectively, these ligaments support the facial structures and may be violated during facelift dissection. B, A cadaver dissection
of cutaneous retaining ligaments.
retaining ligaments occur over the parotid gland (parotid cuta-
neous ligaments) and the masseter muscle (masseteric cutaneous
ligaments) and also lend support against gravitational forces
through fibrous septa that extend into the dermis18 (Figure 1-8).
Weakening of all the aforementioned ligaments also con­
tributes to tissue descent. In essence, the cheeks become
the jowls (Figure 1-9). These midface changes coupled with

Chapter 1  •  The Aging Face
7
superioris, zygomatic major/minor, and the risorius cross the
superficial musculoaponeurotic system (SMAS) to form the
nasolabial fold.19 The nasolabial fold is also formed by the mus-
cular SMAS (modiolus) and the nonmuscular SMAS (subcuta-
neous tissue and fat). A muscular and tonic modiolus and
SMAS support the nasolabial fold in youth. The SMAS supports
the buccal fat pad and holds it in place, preventing forward
protrusion that contributes to a deep (concave) nasolabial fold.
The loss of muscle tone of the modiolus and SMAS, with the
resultant ptosis, contribute to the deepening of the nasolabial
fold with aging. This, along with the overlying fat and dermal
atrophy and osseous contraction, add to the gradual deepening
of the nasolabial fold over time.5 With the weakening of the
cheek-retaining ligament system, the malar tissues become
ptotic, but fat cannot “cross” the nasolabial fold because of the
dense fascia-to-dermis adherence within the fold.
Nasal Aging
The youthful nose possesses a well-defined dorsum, a well-
defined tip with good projection, and a nasolabial angle of 90
to 110 degrees. The aging nose undergoes a gradual ptosis for
numerous reasons, including weakening of the junction of the
nasal bone and cartilage interface, which results in nasal tip
droop. Laxity in the supporting intercartilaginous fibers, fat
atrophy in the upper lip, and alveolar and paranasal bone loss
contribute to nasal anatomy ptosis. As the soft tissue atrophies
in the region of the anterior nasal spine, the medial crura foot-
plates become retrodisplaced. Ptosis also occurs as the relation-
ship of the upper and lower cartilages weakens over time, with
a gradual dehiscence of supporting ligamentous structures.5
Age-related changes in the nose are usually related to an over-
growth of the nasal tip cartilage or skin. Any change that dis-
rupts the proper proportions of the nose can affect its appearance.
Cartilage makes up the lower half of the nose, and the lower
third is very prone to enlargement with age—the classic bulbous
nasal tip that seems to get worse over time. The two lateral crus
of the lower lateral cartilages are the main culprits. Cartilage
enlargement can not only make the nasal tip bigger, but it can
also cause it to grow in a downward (ptotic nasal tip) direction.
The combination of loss of teeth with aging and nasal tip
enlargement or ptosis can create the appearance of the nose
touching the chin.
Swelling or growth of the sebaceous glands on the nasal skin
can also occur with age and is commonly associated with excess
alcohol consumption. WC Fields had the classic example of
sebaceous hyperplasia, or rhinophyma, where skin in the nasal
tip enlarges and becomes red and lumpy because of the over-
growth of sebaceous glands below the surface. Enlargement of
the nose, whether from skin, cartilage, or bone, can be treated
by rhinoplasty. Rhinophyma is treated with laser or radiowave
ablation.
Ears
The earlobes can become wrinkled and thinned and appear to
enlarge in some patients. While writing this text, I attempted
to research the question, Do the ears continue to grow in adult-
hood? Otoplasty surgeons are aware that the external ear reaches
85% of growth by 3 years of age and is fully grown by 7 to
FIGURE 1-9.  Coronal computed tomography scan showing adipose tissue
in the jowl region of an older patient.
A
B
FIGURE 1-10.  A, A youthful profile has a single-convexity configuration.
B, The aging face has a double-convexity configuration due to midfacial
and lower-lid senescent changes.
photodamage, loss of tooth structure, and skeletal changes all
contribute to the drawn, gaunt, or hollow midface.
A youthful lower lid and cheek complex has a single-
convexity configuration. The aging midface, owing to the
protrusion of lower lid fat and cheek ptosis, develops a dual-
convexity configuration (Figure 1-10). Midface aging is treated
with facial implants, injectable fillers and fat, midface lifting
procedures, and skin resurfacing.
Nasolabial Folds
The sum of the aforementioned midfacial changes and related
ptosis produces a deepening of the nasolabial folds. Maxillary
skeletal regression and loss of dental vertical dimension are
contributors. The dermal muscle insertions of the levator labii

8
Chapter 1  •  The Aging Face
of dental vertical dimension as well as soft changes in the lips.
Prominent mandibulolabial folds (so-called “marionette lines”
or “drool lines”) develop lateral to the oral commissures. The
lips become thin from fat and muscle atrophy, and the vermilion
border diminishes. Vertical upper and lower lip rhytids develop,
especially in females. The loss of muscle tone and atrophy of the
lip elevators, depressors, and modiolus allow this “sling”-like
anatomy to weaken and produce generalized loss of lip support.
The youthful upper lip is shorter and curvaceous, whereas the
senescent lip becomes elongated and flat (Figure 1-11). The
mentalis muscle, partially responsible for lip competence, can
sag and become atrophic, with changes in the chin that can also
affect the lower lip. Skeletal maxillary and mandibular bone and
alveolar resorption and the loss of dental structure are also
strong contributors to the aging perioral region.
Jowls
As later addressed in the facelift chapter, a series of ligaments
keep the facial tissues taut in youth. The laxity associated with
aging allows cheek and jowl ptosis (Figure 1-12). In youth, a
tight, well-defined mandibular border is present. With aging,
the combination of ligamentous laxity from the masseteric
cutaneous and mandibular ligaments, photodamage, midface
descent, and weight gain obscures mandibular definition.
Jowling is a result of two jowl fat compartments, the mandibular
septum and submandibular fat compartments, and the overly-
ing skin.25 Superior and inferior jowl fat-compartment position
change is seen in patients with ptotic jowls, suggesting a shift
of volume inferiorly. Dehiscence of the mandibular septum
allows fat to flow across the mandibular border into the sub-
mandibular fat compartment.25 In addition, dermal muscular
attachments are weak in the cheek, mandibular angle, and neck,
also contributing to cheek, jowl, and neck aging.5
Jowls are treated with lifting and SMAS procedures, liposuc-
tion, and skin resurfacing procedures.
8 years of age.20 Continual ear growth is not addressed in
most texts, but I found rather scholarly discussions on the
Internet.21
The size of the ear canal does not increase with age.22 The
ear canal is defined by skin and cartilage as well as bone. That
suggests there is no overall ear cartilage growth in adulthood.
Does the pinna, or outside flappy part of the ear, grow during
adulthood? Do old men really have big ears? Maybe their ears
look bigger relative to their head size because they don’t have as
much hair. Maybe their ears just get flabbier due to skin changes,
and the lobes become more pendulous. Several studies have
found that ears are larger in older people.23 Heathcote24 studied
206 patients with a mean age of 53.75 and a range of 30 to 93
years. The length of the left external ear was measured from the
top to the lowest part with a transparent ruler; the result,
together with the patient’s age, was recorded. The mean ear
length was 67.5 mm (range 520 to 840 mm), and the linear
regression equation was: ear length = 55.9 + (0.22 × patient’s
age) (95% confidence intervals 0.17 to 0.27). This study con-
cluded that the ears get bigger with age, on average by 0.22 mm
a year. Heathcote further stated in this article, “Why ears should
get bigger when the rest of the body stops growing is not
answered by this research. Nor did we consider whether this
change in a particular part of the anatomy is a marker of some-
thing less easily measurable elsewhere or throughout the body.”
Like many anatomic and physiologic studies, results can be
conflicting.
The aging ear is treated with skin resurfacing, earlobe reduc-
tion, and filler injection to volumize senescent lobules.
Lower Face
Perioral Region
Perioral aging is a significant contributor to the aged look. The
corners of the mouth turn downward from cheek ptosis and loss
A
B
FIGURE 1-11.  A, The youthful lip is shorter, curvaceous, and volumized. B, The senescent lip is elongated and has loss of volume and shape.

Chapter 1  •  The Aging Face
9
with changes in the hyoid structure and muscular support
can affect youthful submental sling (Figure 1-14). This produces
a loss of definition of the cervicomental angle, fatty loss of
chin definition, and a generalized fullness of the submental
region.
Rejuvenation of this region is accomplished with chin
implants, submentoplasty, liposuction, platysmaplasty, and
facelift.
Neck
“I hate my neck” are words cosmetic facial surgeons hear on a
daily basis. There is no more demoralizing feature to aging
patients than excess and floppy neck skin.
Platysmal banding begins in the late 4th decade and results
in two separate cordlike structures from the mandibular border
Chin
The chin and submental area undergo significant aging changes.
Skin changes, fat atrophy, muscle atrophy, dental changes, and
contributing submental anatomy can cause the chin to become
quite ptotic, especially in females; a witch’s chin is the term often
used to describe this phenomenon (Figure 1-13). Generalized
weight gain with aging decreases the definition of the chin. Loss
of tone of the mentalis dermal insertions also probably contrib-
ute to chin aging.
Chin aging is treated with chin implants, lifting procedures,
and submentoplasty.
Submental Region
The submental region is well defined in most young people;
numerous changes occur with age. Generalized fat deposition
A
B
FIGURE 1-12.  Jowl formation is a result of weakening of the mandibular septum, shifting of fat in the lower face, and generalized soft-tissue ptosis.
A
B
FIGURE 1-13.  A patient with senescent chin aging before and after facelift, with chin implant to improve her profile and chin support.

10
Chapter 1  •  The Aging Face
A
B
FIGURE 1-14.  A, common areas of fat deposition in the aging face. B, A Hollywood “fat suit prosthesis” used to make actors
appear fatter and older. The augmented regions correspond to aging and weight gain.
A
B
FIGURE 1-15.  A, Platysmal dehiscence with banding. B, A rendition of midline platysmaplasty.
extending down the neck (Figure 1-15). The appearance of
platysmal bands and neck fat is thought to be associated with
fascial dehiscence. Similarly, fat across the neck in a confluent
mass can blunt the definition of the jawline with dehiscence of
the mandibular septum.25
Sagging skin is also a strong contributor to the aging neck
(Figure 1-16), and this laxity is very evident during a facelift
procedure (Figure 1-17).
Treatment options in the neck are very limited. Other than
rhytidectomy (and sometimes isolated platysmaplasty and sub-
mentoplasty), very few rejuvenative options exist.
Conclusion
Facial aging is an inevitable process that affects all humans in a
similar manner. Significant variability exists with intrinsic,
extrinsic, and hereditary factors, but the sum of the process
includes volume loss, gravitational ptosis, and integumental
changes. Recent emphasis has also been placed on skeletal and
dental changes in the cumulative aging picture. Although the
future may portend the ability to manipulate genes and aging
factors, current therapy focuses on surgical and nonsurgical
correction of ptosis, volume loss, and integumentary changes.

Chapter 1  •  The Aging Face
11
an integrated model of midfacial aging. Plast Reconstr Surg 102:205–212,
1998.
  8. Pessa JE, Slice DE, Hanz KR, et al: Aging and the shape of the mandible.
Plast Reconstr Surg 121(1):196–200, 2008 Jan.
  9. Jenkins G: Molecular mechanisms of skin ageing. Mech Aging Dev
123(7):801–810, 2002.
10. Guinot C, Malvy DJ, Ambroisine L, et al: Relative contribution of intrinsic
vs extrinsic factors to skin aging as determined by a validated skin age score.
Arch Dermatol 138(11):1454–1460, 2002.
11. El-Domyati M, Attia S, Saleh F, et al: Intrinsic aging vs. photoaging: a
comparative histopathological, immunohistochemical, and ultrastructural
study of skin. Exp Dermatol 11(5):398–405, 2002.
12. Krutmann J, Grewe M: Involvement of cytokines, DNA damage, and
reactive oxygen intermediates in ultraviolet radiation-induced modulation
of intercellular adhesion molecule-1 expression. J Invest Dermatol 105(1
Suppl):67S–70S, 1995.
13. Wang XY, Bi ZG: UVB-irradiated human keratinocytes and interleukin-
1alpha indirectly increase MAP kinase/AP-1 activation and MMP-1
production in UVA-irradiated dermal fibroblasts. Chin Med J 119(10):
827–831, 2006.
References
  1. Tan SR, Glogau RG: Filler Esthetics. In Carruthers J, Carruthers A, editors;
Dover JS (series editor): Procedures in cosmetic dermatology series: Soft
tissue augmentation. Philadelphia, 2005, Elsevier Saunders, pp 11–18.
  2. Makrantonaki E, Zouboulis CC, William J: Cunliffe Scientific Awards.
Characteristics and pathomechanisms of endogenously aged skin.
Dermatology 214:352–360, 2007.
  3. Klein AW, editor: Tissue augmentation in clinical practice. New York,
2006, Taylor & Francis Group, pp 141–238.
  4. Antel DE: How environmental and lifestyle choices influence the aging
process. Ann Plast Surg 43:585–588, 1999.
  5. Faerber TH: Evaluation of the aging face. In Niamtu J, editor: Cosmetic
facial surgery. Oral Maxillofac Surg Clin North Am, Philadelphia, 2000,
Saunders, pp 523–530.
  6. Pessa JE, Zadoo VP, et al: Concertina effect and facial aging: nonlinear
aspects of youthfulness and skeletal remodeling and why, perhaps, infants
have jowls. Plast Reconstr Surg 103:635–644, 1999.
  7. Pessa JE, Zadoo VP, et al: Relative maxillary retrusion as a natural
consequence of aging: combining skeletal and soft-tissue changes into
A
B
FIGURE 1-16.  The author at 56 years of age and his father at 83 years of age. A shows early submental and neck laxity;
B shows aging changes commensurate with the eighth decade of life.
A
B
FIGURE 1-17.  The extreme amount of skin excess that is repositioned and removed during rhytidectomy, underlining the con-
tribution of skin excess to lower facial aging.

12
Chapter 1  •  The Aging Face
14. Rubin M: Manual of chemical peels, Philadelphia, 1995, Lippincott-
Raven.
15. Wulf HC, Sandby-Moller J, Kobayasi T, et al: Skin aging and natural
photoprotection. Micron 35(3):185–191, 2004.
16. Ma W, Wlaschek M, Tantcheva-Poor I, et al: Chronological aging and
photoaging of the fibroblasts and the dermal connective tissue. Clin Exp
Dermatol 26(7):592–599, 2001.
17. Defatta RJ, Williams EF: Evolution of midface rejuvenation. Arch Facial
Plast Surg 11:6–12, 2009.
18. Stuzin JM, Baker HL, Gordon TJ: Plast Reconstr Surg 89:441, 1992.
19. Zufferey JA: The nasolabial fold: an attempt of synthesis. Plast Reconstr
Surg 104:2318–2320, 1999.
20. Farkas LG, Posnick JC, Hreczko TM: Anthropometric growth study of the
ear. Cleft Palate Craniofac J 29:324, 1992.
21.
22. Liu TC, Chen YS: Aging and external ear resonance. Audiology 39(5):235–
237, 2000.
23. Ferrario VF, Sforza C, et al: Morphometry of the normal human ear: a
cross-sectional study from adolescence to mid-adulthood. J Craniofac
Genet Dev Biol 19(4):226–233, 1999.
24. Heathcote JA: BMJ 311(7021):1668, 2000 Dec 23–30.
25. Reece EM, Pessa JE, Rorich RJ: The mandibular septum: anatomical obser-
vations of the jowls in aging—implications for facial rejuvenation. Plast
Reconstr Surg 121:1414–1420, 2008.

13
2
Diagnosis of the Cosmetic Facial
Surgery Patient
The Art of the Consult and the Office Patient Experience
T
here is no more important aspect of the cosmetic surgery
experience than the initial patient consult. As they say,
you never get a second chance to make a first impres-
sion, and the first impression occurs when the patient phones
the office to make an appointment. Unfortunately, this is where
a lot of patients are lost. Having personable, friendly, energetic
staff answering the phone can be one of your best referral
sources. Patients often tell me they actually saw three or four
other surgeons, but the professionalism and attitude of my staff
persuaded them to come to my office. Many barriers between
the initial phone call and the operating room can be eliminated
by an astute front desk person. A compassionate receptionist
can alleviate many patient apprehensions and get the client into
the office. I call this staff member the patient representative. Our
patient representatives are familiar with every procedure we
perform and can discuss them accurately with prospective
patients.
The cosmetic surgery office should be clean, pleasant, and in
most practices decorated to accommodate females, since the
majority of cosmetic patients are women (Figures 2-1 to 2-4).
Consider your experience at a very high-class hotel and try to
duplicate that in your business. A patient greeter, providing
drinks and snacks, assisting patients with paperwork, and having
educational material available are all amenities appreciated by
patients.
Meeting the Doc
Meeting a stranger and discussing one’s deficiencies can be very
stressful for patients. When I go to examine a new patient, they
are often perspiring from nervousness. A productive consult
requires a relaxed patient. This is best achieved using an inter-
mediary, and in my case this person is my cosmetic coordinator.
She escorts the patient to the room, seats them, and makes
nonsurgical small talk before addressing cosmetic concerns
(Figure 2-5). She tells the patient about the surgeon, performs
an “across-the-room” evaluation, and discusses some of the more
obvious concerns. She may say, “I believe Dr. Niamtu will want
to discuss eyelid surgery, cheek implants, and facelift with you.”
She displays our website on the widescreen TV in each consult
room and goes through specific procedure pages to discuss what
we do and how we do it. She will also show the patient before-
and-after pictures of relative cases (Figure 2-6).
After the preconsult, I am called into the room and intro-
duced. This initial meeting can make or break a relationship. I
always shake hands with the patient as I believe “laying of the
hands” puts patients at ease and subliminally melds the doctor-
patient relationship. A show of personal warmth, an unhurried
attitude, and some small talk with the patient before getting to
the cosmetic problems will be time well spent. I may ask them
what they do for a living, how they heard about our office, how
they are enjoying their summer, etc. Again, putting a patient at
ease is an art form (Figure 2-7).
Most of our patients register online and are asked to bring a
list of cosmetic facial concerns to the first appointment. Nervous
patients often forget to ask key questions. Patients also fre-
quently are also asked to bring in younger pictures of themselves
to see what they considered their strong or weak points and how
they have aged (Figure 2-8).
The most important instrument used in the consult is a hand
mirror. I ask patients to tell me what bothers them or what they
would like to change and to show me in the mirror (Figure 2-9).
Occasionally a patient will say, “Doctor, what do you think I
need?” The novice surgeon should never fall into that trap. It is
imperative that the patient take ownership of what bothers them
or what they would like to change. A patient that cannot com-
municate their cosmetic problems may have other underlying
problems. Some patients are embarrassed to discuss the topic
and need some prodding. The other problem with answering
the question “What do you think I need?” might encourage the
surgeon to say the patient could benefit from eyelid surgery, and
the patient may think their eyes are their best feature and be
offended!
FIGURE 2-1.  The author’s reception room. In addition, the office has a
separate and smaller reception suite for postop patients in bandages, and
so forth.

14
Chapter 2  •  Diagnosis of the Cosmetic Facial Surgery Patient
A
B
FIGURE 2-2.  The author’s consultation and minor treatment rooms.
FIGURE 2-3.  One of the author’s Accreditation Association for Ambulatory
Health Care (AAAHC)–accredited in-office operating rooms.
FIGURE 2-4.  The author’s recovery suite is equipped for outpatient ambula-
tory patients as well as overnight stays.
FIGURE 2-5.  The cosmetic coordinator seats the patient and begins the
preconsult.
FIGURE 2-6.  Having widescreen TVs in each room not only keeps the
patient entertained while waiting to be seen but also is an excellent means
of patient education.

Chapter 2  •  Diagnosis of the Cosmetic Facial Surgery Patient
15
the face is divided into thirds, and we will discuss the upper,
middle, and lower third then discuss the skin as a separate unit.
During this discussion, the surgeon should never assume, for
example, that the patient understands the difference between
brow aging and eyelid aging. Always stay elementary when
explaining diagnosis and treatment. Many patients have never
heard of cheek implants or understand what a browlift or facelift
does. If patients are put off by discussion of multiple procedures,
and if I sense the conversation going that way, I consider
this patient more conservative and stay closer to their main
concerns.
As I talk to the patient, I include my cosmetic coordinator
in the discussion. I may say, “Mrs. Smith, I think you are a great
candidate for laser skin resurfacing. Don’t you agree, Ginger?”
This adds a third opinion to the discussion, puts the patient at
ease, and reinforces my diagnosis. My assistant is continually
recording bullet points of the consultation discussion and pre-
pares a form to give to the patient when they leave that lists the
discussed procedures and their respective fees.
I prefer to do my cosmetic facial consults in a high-end
dental chair that can also double as a treatment platform for
injectables or minor procedures. In almost every consult, I
recline the chair and have the patient elevate their chin and look
in the hand mirror (Figure 2-10). This takes gravity out of the
equation and provides a surprisingly accurate estimation for
facelift, brow lift, or cheek implants.
Having procedure models, Internet access, sample implants,
or other educational aids are also important and help the
patient understand the surgical process. The ability to view a
series of related before-and-after pictures is also very valuable
for the patient’s understanding of what surgery produces what
result.
When the consult is finished, I make sure the patient has no
further questions or concerns, thank them for coming to our
An alternative to using a mirror is to take several pictures of
the patient just before the consult and project those images on
the widescreen monitor. This can have great impact when
showing patients their aging changes. Also giving the patient a
copy of the pictures to take home can go a long way in having
them realize their aging problems.
The best way to discuss cosmetic deficiencies is to make
the consult an educational experience. I explain to the patient
that I am going to discuss the entire head and neck in terms of
diagnosis and potential cosmetic treatments, but this does not
mean that I believe they need surgical correction of all areas
discussed.
The most orderly means of systematically discussing facial
aging and potential treatment is to explain to the patient that
FIGURE 2-7.  After a preconsult is done by the staff, the doctor enters the
room and performs the formal consult.
FIGURE 2-8.  Any information patients supply can assist in accurate diag-
noses and serve as talking points to guide the doctor-patient conversation
about what procedures or results may be realistic.
FIGURE 2-9.  Having patients discuss their deficiencies and desires while
looking in a mirror can assist in diagnostic accuracy.

16
Chapter 2  •  Diagnosis of the Cosmetic Facial Surgery Patient
flatter you as “being the best.” Other red flags include patients
who don’t follow basic preoperative instructions such as labs and
H&P or those who are not compliant with financial policies.
Patients who are “too busy” for surgery and act put off by
appointments, consents, labs, and the like are also potential
worries.
The Internet is wonderful and has changed my practice from
local to international cosmetic facial surgery. Although I am
happy to accept out-of-town patients, the Internet also brings
me some uniquely problematic ones. I meet young patients
who request cosmetic procedures generally performed on much
older patients and patients who are heavily involved with
“Internet cosmetic surgery,” such as cosmetic surgery bulletin
boards and websites. Also potentially problematic are younger
patients who have already had numerous cosmetic procedures
despite their age. Some of these patients are clearly addicted to
cosmetic surgery, and many have body dysmorphic disorder
(BDD). They are seeking rejuvenation for the wrong reasons,
and once you operate on them, you “own” their result. If they
are unhappy, which they have a strong potential to be, they
may retaliate in ways that put your practice at risk. One of the
hardest things, especially for novice practitioners who are not
busy, is to say no to a patient who is sitting in front of you,
wants surgery, and can pay for it. Use caution and common
sense in patient selection. All a surgeon has to say is, “I don’t
think I can achieve your goals and make you happy.” Following
this practice can save you from very stressful and unhappy
experiences.
Preoperative Appointment
When patients call to schedule a surgical appointment with
me, they are required to pay a $500 deposit. This screens out
insincere patients and prevents broken surgical appointments.
The preoperative appointment is scheduled at least 2 weeks
before the surgery date. At this appointment, we conduct the
informed consent process, make sure proper labs, H&P, and
anesthesia information is in order, and one more time explain
office, give them a business card with my email address and cell
phone number, and encourage them to contact me with any
questions that might arise. My cosmetic coordinator does the
same. When I leave the room, the coordinator sits back down
with the patient to discusses finances and offer literature about
payment plans. We encourage patients to carefully study our
website, a great educational tool, in relation to their anticipated
procedures. Serious patients are given information about
required preoperative history and physical (H&P) and lab tests
so they can begin planning. Roughly a third of consultations
already have their minds made up that they are going to book
a surgery.
We send a follow-up personal notecard thanking the patient
for coming to the office and inviting them to contact us with
further questions. If we do not hear back from the patient in 6
to 8 weeks, a “tickle” letter goes out reminding them we are at
their service for questions or concerns.
Patient Screening
Patient screening has a lot to do with the success of the case. A
patient with a positive attitude and realistic goals and expecta-
tions can make the cosmetic facial surgery transformation sheer
joy. A patient who does not understand the procedure, is unco-
operative, and has unrealistic goals and expectations can present
profound clinical and legal challenges. A frequently quoted
sentence is that “1% of your patients will cause 99% of your
problems” and it is so true. The key to having happiness and
balance in ones professional life is to be able to “weed” out the
patients that will be problematic. Unfortunately, there is no
quantifiable way to do this and sometimes we all get fooled. The
surgeon and staff must be continually on the lookout for patients
who exhibit “red flags” for potential problems (Box 2-1). This
includes patients who don’t listen and do all the talking, patients
who want to tell the surgeon what to do and how to do it, and
patients who speak negatively about previous surgeons and
FIGURE 2-10.  Having an exam chair that reclines is very useful in showing
patients approximate results for facelift, browlift, and cheek implants.
Box 2-1  Potential “Red Flag” Patients
• Unfriendly or impersonal patients
• Patients who don’t smile or make eye contact
• Patients who are “too busy” for surgery
• Patients who speak negatively about previous surgeons but compli-
ment you
• Patients who won’t listen and just talk
• Patients who are having surgery for the wrong reasons, such as saving
a marriage or job
• Patients with unrealistic expectations
• Patients who “know more” about cosmetic surgery than the surgeon
• Patients obsessed with Internet bulletin boards and cosmetic sites
• Young patients who have had numerous surgeries
• Young patients who request surgeries normally reserved for older
patient
• Patients who complain about financial arrangements
• Patients with whom a rapport cannot be established

Chapter 2  •  Diagnosis of the Cosmetic Facial Surgery Patient
17
the procedure and options (Figure 2-11). It can be a scary
experience for the patient signing four or five informed con-
sents; this gives many patients cold feet. I tell them they will
be worried after reading the things that can possibly go wrong,
and I explain that serious complications are very rare. I reassure
them that this is what I do for a living every day and not
something I dabble in. We give them a tour of our accredited
surgery center and show them the emergency equipment and
recovery suite. At this appointment, half of the surgical fee is
due; the remainder will be due on the day of surgery. After
spending 30 to 40 minutes with my nurse, I reenter the business
office and tie up any loose ends. “Before” pictures are taken in
full makeup at this appointment. Patients are given their pre-
scriptions, surgical prep shampoo, and postoperative instruc-
tions. Out-of-town patients or those without caregivers are
offered the option of private-duty assistants or nurses and trans-
portation if needed.
Day of Surgery
The patient arrives at the office NPO and changes into a hospital
gown. Preop photos are taken without makeup, and any perti-
nent questions are answered (Figure 2-12). I mark the patient
with a surgical marker for the specific procedures, then the
anesthesia staff enter the room and discuss their job. A final
“time-out” discussion of planned procedures is discussed with
the patient and staff, and the patient is escorted to the operating
room.
Post Surgery
After surgery, the patient is returned to the recovery room and
kept until stable. Their ride home or caregiver receives postop-
erative instructions and the follow-up appointment date (Figure
2-13). The patient is called on the night of surgery to check on
their recovery.
FIGURE 2-11.  The preoperative appointment is an extremely important
communication opportunity. Because of the volume of information that
must be discussed, the doctor and staff should participate and do every-
thing possible to provide a relaxed environment for the patient.
FIGURE 2-12.  In cosmetic surgery, photos are invaluable for records and
legal and marketing purposes. It is impossible to take too many pictures.
The author has a photographic background on the door of each room.
This background is mounted on a sliding track and can be adjusted for
the patient’s height.
FIGURE 2-13.  It is important to monitor patients in recovery until they are
stable enough for their caregiver to manage them. The caregiver must also
understand the postoperative instructions and be responsible for the
patient’s aftercare.

18
Chapter 2  •  Diagnosis of the Cosmetic Facial Surgery Patient
Patient Recovery and
Biopsychosocial Implications
Getting a patient “in the door”, completing the preoperative
phase, and finishing the surgery are generally considered to be
the bulk of the surgical experience. As every surgeon is aware,
this is often only the beginning and sometimes the recovery
process is the most complex of the entire doctor-patient experi-
ence. Although some patients understand the procedure, prepare
for it, and breeze through their recovery, others are ill prepared,
misinformed, and struggle to maintain the normal balance of
life. In extreme cases, these patients may require psychological
assistance or other intervention to prevent mental decompensa-
tion. Patients who easily recover are a pleasure; patients who
become entwined in a web of complicating factors can literally
suck the energy and spirit out of the surgeon, staff, and the
patient’s family.
Why do some patients do so much better than others
in healing, adapting to recovery, accepting the temporary dis-
ability, and returning to normal life? There is no single answer
other than the complexities or lack thereof that provide unique
constitutions for every being. Simply put, some patients are
more about drama than others. This does not only apply to
surgery; I would bet if complex recovery patients could be
followed before and after surgery throughout their lifetime one
would see these complexities extend into other psychosocial
aspects of their lives. Complexities may include trouble with
intrapersonal relationships, manipulating spouses, problems
interacting with their children’s teachers or neighbors, and
other similar situations that categorize individuals as “high
maintenance”.
These individuals may create an accelerated problematic
environment, having symptoms and reactions that are beyond
the mean for an average patient for a given procedure. Suddenly
their cosmetic recovery becomes abominable. The patient may
wallow in self pity, or experience unimaginable pain. They may
fear that something is terribly wrong or become totally physi-
cally incapacitated and unable to sleep, eat, or drink. Sometimes
these manifestations are not intentional and signal a psycholo­
gical imbalance. At other times they are quite intentional in an
FIGURE 2-14.  How we feel after cosmetic surgery.
Joy
“What’s
next?”
New clothes!
“But what
about....”?
Notice
other’s
reaction
“Wow”
How We Feel After Cosmetic Surgery
Surgery
day 1
Normal Personality Baseline
Low energy
I’m not gonna
make it!
First week
Second week
Third week
Nit picky
What did I do?
I’ve made a big mistake!
Am I ruined for life?
Show off
I can see a
difference
Notice other’s
reactions
“You look wonderful”
“Wow”
“I love it”
“No more boring clothes”
“What’s next”?
It is important for patients to understand that surgery is a strain on the body and that they will
likely have less energy during the early recovery period and need much more rest than usual.
They may be bruised, swollen, and in some discomfort. All of this is a stress on the body and
even watching TV may be a strain. Smart patients plan ahead to ensure they have proper care-
takers and can use the early recovery period to rest and heal. It is not uncommon for patients
to experience an emotional roller coaster during the first several weeks after surgery. Some
patients may become angry or depressed and cry for no reason. Others may become short with
family or caregivers. This is especially true if the patient becomes sleep deprived. A sleepless
patient who is having pain and looking at a swollen, bruised stranger in the mirror can turn into
an emotional zombie. Please let Dr. Niamtu know if you are having these types of problems. The
more you rest, the faster you will heal, and the better you will feel.
“I love it.”

Chapter 2  •  Diagnosis of the Cosmetic Facial Surgery Patient
19
effort to extract pity from the doctor and/or family members,
manipulate relationships, and induce retribution.
A good example of this dichotomy is patient A, who under-
goes facelift, blepharoplasty, full face laser, and cheek implants.
She recovers quickly in the office surgery center, goes home,
and returns the following morning bruised and swollen, but
smiling and joking about her appearance. Her husband is sup-
portive and has been a good caregiver. Patient A has a positive
attitude and wants to make sure she does all she can do to
hasten her recovery. Patient B is the same age with the same
frame, health, and other physical characteristics as patient A
and undergoes the exact same procedures. Patient B is crying
pain immediately after anesthesia recovery and begs for pain
medicine. She is worried that she may not have enough pain
medicine from her preop prescription. She stays in recovery
twice as long as normal for her procedure. Her husband begins
calling the office soon after they arrive home because she has
uncontrollable pain and can be heard crying in the background.
Her husband is confused because she told him that she was just
getting “a little tune up”. The surgeon’s cell phone rings numer-
ous times during the night as the patient is still in pain and
does not know how to perform her recovery care despite having
been given comprehensive instructions and handouts a week
before. Patient B returns the next morning for follow-up care
and can’t get out of the car without assistance. She has the
demeanor of a multisystem trauma patient and will have no
part of conversation, eye contact, or discussion. She still com-
plains of severe pain and is sorry she had the procedure and
states that we did not tell her it would “be like this”.
The differences between patients A and B are notable. Patient
A makes surgery fun; Patient B makes the surgeon wonder why
he or she chose this profession. Not every patient that acts like
patient B has psychological problems. Some patients are merely
fragile and have lower pain thresholds. More often than not,
however, a distinct pattern is seen in this type of patient. Some-
times the surgeon and staff can settle the patient down and get
them back on track. Other times it may require some TLC and
the surgeon explaining to the patient that what she is experienc-
ing can occur and the doctor and staff will support her. Some
patients need increased pain control and sleep medications. The
mix of pain, swelling, sleep deprivation, and fear can put some
patients into an acute psychosis. Even strong and “normal”
patients can become emotional, especially females, and may
have spontaneous crying episodes. When asked what is wrong,
they honestly say “I don’t know”. Emotions can sometimes run
rampant when patients are faced with the combination of
surgery, swelling, bruising, and medications. Although I have
used female examples, males are not exempt from similar behav-
ior. They are just not as emotional in my experience.
To combat the problematic patient I spend significant time
in the preoperative consultation discussing the good, bad, and
ugly aspects of recovery with the patient. I tell them (as does
my staff) that they probably won’t like me for several days and
that they may ride an emotional roller coaster in the immediate
and sometimes extended recovery period. I also provide them
with the following graphics that discuss the various predictable
and (and sometimes unpredictable) stages of recovery (Figures
2-14 to 2-19).
FIGURE 2-15.  Emotions. What a difference 3 weeks can make.
“Zombie”
Wiped out
Zonked
“Antsy”
Irritation
Sadness
Anger
“What have I done”
“Weirdo”
“I wish it was a
month from now”
“You should have
told me about”
Criticize
“How come”
Scared
Impatient
Support person may crash
“I’d do it again!”
Day of
Surgery
Cosmetic surgery can be an emotional roller coaster and some patients may not be themselves
for a short time. Their personalities can vary from “out of it” to “mad at the world” to “I am crying
and I don’t know why”. Sometimes the combination of looking bruised and swollen, not sleeping,
and discomfort can make patients act in a different manner than their normal personality. This
can put stress on their family, caregivers, doctor, and staff. We understand these processes
and how to deal with them, so if you don’t feel yourself, it it important to let us know so we can
help you feel better. Most patients do not have these problems.
Emotions
What a difference three weeks can make

20
Chapter 2  •  Diagnosis of the Cosmetic Facial Surgery Patient
FIGURE 2-16.  Nature’s healing curve.
Nature’s Healing Curve
3 Months
1 Month
2 Weeks
1 Week
3 Days
Healed!
Bruising almost gone
Stitches out
Looks good
Feels tight
“Leave me alone”
Healing does not happen overnight and when a
patient has surgery days can seem like weeks!
Every patient responds to surgery differently
and for some patients it is a breeze, whereas
other patients have a much harder time. Every
butterfly comes from a worm and it simply
takes several weeks for the result to blossom.
FIGURE 2-17.  Swelling chart.
Swelling Chart
Surgery
Day 1
Day 2
Day 3
1 Week
2 Weeks
3 Weeks
“What hit me?”
Still
swollen
Worst
Still
swollen
“When is this
swelling going
to go away?”
“When is this
swelling going
to go away?”
Swelling
much better
Just
gets
better!
Swelling is nature’s response to surgery
and happens in all patients. Swelling is
extremely variable and some people swell
and bruise severely, whereas other patients
may hardly swell or bruise. Although
it seems to take forever for the swelling
and bruising to improve, it always does!

Chapter 2  •  Diagnosis of the Cosmetic Facial Surgery Patient
21
FIGURE 2-18.  Rest–Relax–Recover.
Rest–Relax–Recover
It is important for patients to understand that surgery is a strain on the body and that they will
likely have less energy during the early recovery period and need much more rest than usual.
They may be bruised, swollen, and in some discomfort. All of this is a stress on the body, and
even watching TV may be a strain. Smart patients plan ahead to ensure they have proper care-
takers and can use the early recovery period to rest and heal.
Rest and relaxation are essential for proper healing. The immediate postoperative period is
not a time to clean your garage or work in your garden! Severe complications can occur from
postoperative overexertion, which can complicate and affect the final result. The surgeon is
responsible for the surgery and the patient is responsible for the recovery. If the patient does
not follow instructions, the best surgeon in the world cannot get the desired result.
Use this opportunity to be a queen or king and be catered to. Enjoy your recovery! Rest and
relax, watch those movies you never have time for. Do not perform functions that will increase
your blood pressure or promote bleeding. Drink plenty of fluids and protein. A high-protein shake
several times a day will help ensure proper surgical nutrition. Taking a single multivitamin each
day is also a good idea. Sleep like a baby! The more you rest, the more you heal.
• Know what you are supposed to do after surgery.
• Take your medicines exactly as directed.
• Know what medications not to take.
• Know how to keep your surgical areas clean.
• Know what activities you can and cannot do.
• Know when your follow-up appointments are.
• Remember, the patient has a lot to do with the final result!
FIGURE 2-19.  How will others react to my new look?
• It is always interesting how others view those that have
cosmetic surgery. Some patients are upset if their peers
notice and some are upset if they don’t notice. The
bottom line is that patients should be doing cosmetic
surgery for themselves, not for others. If you are doing
cosmetic surgery for others, you already have a problem.
It is nice that others may notice, but you need to do it
for you!
• Natural cosmetic surgery should whisper, not scream.
Most patients will have subtle changes, but some
patients may have very dramatic changes and must be
prepared to look different; after all, that is the reason to
have cosmetic surgery.
• The reaction of others is also based upon the person-
alities of your friends and associates. Some will be
jealous that they could not have cosmetic surgery
and therefore speak negatively about your result, again,
out of jealousy. Still others may be so unhappy with
their life that they don’t want you to be happy with
yours and this type of person may speak negatively
about your result.
• When we change the way we look, it is sometimes hard
for us to get used to it. Don’t be too quick to judge your
new look. It takes weeks or even months to settle in
and also for you to get used to it.
• The vast majority of patients become very pleased with
their new look.
How Will Others React to My New Look?

22
Chapter 2  •  Diagnosis of the Cosmetic Facial Surgery Patient
Conclusion
We may perform cosmetic surgery every day, but it is important
to remember that most patients may experience it only once in
their life and gear the entire event in that direction.
Cosmetic facial surgery has grown by leaps and bounds
over the past century and transitioned from a frowned-upon
concept to a socially accepted and desirable procedure. In 1920,
the American Medical Association called for a ban on cosmetic
surgery.1 Considering this, we really have come a long way!
Reference
1. Fomon S: The surgery of injury and plastic repair, Baltimore, 1939, Williams
& Wilkins.

23
3
Clinical Digital Photography
here is no more important instrument in cosmetic
surgery than the camera.
their websites, I have a few thousand. Prospective patients are
more likely to migrate to a surgeon who can document hun-
dreds or thousands of cases than to a surgeon with a handful of
images or to a surgeon who uses images from an organization
or—even worse—drawings or another surgeon’s pictures. Images
are everything in cosmetic surgery.
Equipment
A decade ago, many surgeons had complicated, expensive
photographic equipment frequently relegated to a dedicated
“photography room,” but with the digital age, photography
is no longer arduous and cumbersome, it is a breeze.
I am not a proponent of the dedicated photography suite,
mainly because I am constantly taking clinical images; having
to stop and move a patient to a single room in my office would
create an unworkable bottleneck in my busy practice. Instead,
I have the ability to make high-quality, standardized images in
every room in my office. On the back of the door in any room
where patients are evaluated, I have installed a photographic
cloth background (I prefer sky blue) on a movable frame (Figures
3-1 to 3-3). Since some patients are tall and some are short, the
frame is on a moveable track that can be adjusted up or down
to accommodate individual height. Because I only perform head
and neck cosmetic facial surgery, this works perfectly. For cos-
metic surgeons who perform full-body surgery, a longer frame
can be used.
A
B
FIGURE 3-1.  A sliding frame is fabricated and secured to the back of each treatment room door. The track on this frame slides
up and down to adjust to the patient’s height.
T
I feel I have accomplished a lot of academic milestones in
lecturing and publishing in my lifetime, and I was recently
asked what my secret is. My answer was “my camera.” Over the
first decade of my cosmetic surgery career and to date, I have
always taken time to meticulously document my experiences. I
currently have about 75,000 images on my laptop that represent
operations, complications, before-and-after images, and the
like. With this repository of images for every procedure I
perform, I can instantly put together a lecture, publication, or
text, because I have the documentation.
Most cosmetic surgeons collect pictures of their work but fall
short in creating high-quality, standardized images. Nothing
makes a surgeon look shoddier than poor, nonstandardized
images. Quality surgeons should have quality images to share
with clients and colleagues. Pictures serve as diagnostic aids, part
of the operative record, learning and teaching tools, marketing
tools, and legal defense. I have been accused of being “anal”
about my photographs, but they represent my knowledge, skill,
and ultimately, me.
Thanks to the innovations of digital photography, it has
never been easier to make excellent clinical images. There is no
reason why a surgeon (or his or her staff) cannot make high-
quality, standardized images. My before-and-after images have
given me a distinct marketing advantage in my community and
internationally. Although most surgeons have a few images on

24
Chapter 3  •  Clinical Digital Photography
the resolution is comparable. Almost all higher-end digital
cameras have versatile lenses that can accommodate clinical
poses. Most of these cameras also have good macro (some have
supermacro) settings for crystal-clear close-up pictures. Many
higher-end digital cameras also have a “program” mode that
allows the user to make and save default settings. I program my
camera for a profile mode to take head-and-neck shots and a
macro mode to take intraoperative pictures. The program mode
allows the camera to remember preferred settings, so adjustment
is unnecessary for each shot. Most of these cameras also have
more than adequate flash settings for clinical photography.
When shopping for a camera, I make test shots of my wrist-
watch to evaluate the macro mode and also take a head-and-
neck shot to judge that quality.
Although there are numerous 35-mm single-lens reflex
digital cameras with detachable lenses available, I have grown
to prefer the smaller vacation-type cameras for their compact-
ness and portability (Figure 3-4). These cameras can be carried
from room to room in my scrub pants pocket and thrown in
my briefcase without taking up room. These small-format
cameras also have unbelievable video capability. I have a $1500
high-definition digital video camcorder, but I find myself
taking many of my surgical videos with my cigarette pack–sized
camera.
For those surgeons who want a more dedicated clinical
camera, Lester A. Dine, Inc. () has for several
generations made out-of-the-box, high-quality, user-friendly
cameras. These cameras have been modified specifically for clini-
cal photography.
Digital Editing Software
The other integral piece of digital photography is imaging
software. Although Adobe PhotoShop () is the
most popular software, I have been using PhotoImpact (www.
corel.com) for the past 15 years and find it a bit more user
friendly but just as powerful. Imaging software is integral to
producing quality images through enhancement, cropping,
adding text and symbols, and stitching before-and-after pictures
(Figure 3-5).
Cameras
In writing past chapters about digital photography, I directed
much attention to the type of camera to use. This had to do
with needing specialized cameras and flash attachments and
ancillary lighting. Today, camera choice is greatly simplified.
With the rapid advances in digital photography, virtually any
high-quality, name-brand, off-the-shelf camera can be used to
take excellent photographs. I have used $1000 cameras and
$500 dollar cameras, and they perform equally well so long as
FIGURE 3-2.  A sky blue nonreflective photographic cloth is attached to
the frame and serves as the background.
FIGURE 3-3.  Using a simple off-the-shelf digital camera, high-quality
shadowless images are easily made.
FIGURE 3-4.  These common high-end, off-the-shelf general-use cameras
work very well for clinical photography.

Chapter 3  •  Clinical Digital Photography
25
position is critical for standardizing pictures; the chin should
not be raised or lowered, and the Frankfort horizontal plane
should be parallel with the floor. The patient’s gaze must be
directed straight ahead, not up or down. Nothing looks more
contrived than a “before” facelift photo with the chin down and
an “after” photo with the chin raised.
Depending upon the procedure to be performed, I generally
take a full face-and-neck photo straight on, right and left three-
quarter views, and right and left lateral views (Figure 3-6, A).
For blepharoplasty or brow lift, I also take a close-up series of
those views and a picture with the head straight but the eyes in
an upward gaze (see Figure 3-6, B). Obviously, some instances
call for pictures in repose and animation and are procedure
specific. For instance, the surgeon may want animated images
to show the condition of the facial nerve or pre-facelift images
or the muscle movement in a pre-Botox image.
I take a makeup-on image at the preoperative visit and a
makeup-off image just before surgery. All jewelry should be
removed in all instances, and if the patient has full hair, a hair
band or clip should be used to expose the face. Regardless of
how the photos are taken, the before image and after image
should closely match. To guide the patient, marks can be placed
on the wall so every patient is looking at the same spot in every
picture. Alternatively, the assistant can direct the patient’s gaze.
Standardization is everything in photography. To better stan-
dardize the three-quarter views, the patient should be rotated so
the lateral canthus is in line with the soft-tissue nasion (or nasal
radix) (Figure 3-7). By doing this on the right and left side,
every patient will be at the same relative standardized angle.
Background Canvas
Every surgeon should make the effort to fabricate a background.
A nonreflective medium is required. A simple matte poster
board taped to a door will suffice, although a cloth background
is more forgiving for bouncing unwanted light. Images taken
against a bare wood door, wallpaper, or (even worse) with fur-
niture and equipment in the background (Figure 3-8) will look
unprofessional. A suitable background is too simple to ignore.
Background color is surgeon preference. I prefer sky blue
because it looks pleasing and tranquil. Some surgeons prefer a
Taking and Making Pictures
High-quality, standardized clinical photos don’t just happen,
they are a result of getting the right pose with the right back-
ground with the right focus and the right lighting. Digital
photography has made this so easy that many surgeons relegate
this to their staff, but I continue to personally take all of my
pictures.
The biggest problem when photographing a patient is first
getting them to relax. The second you stand someone up against
a background and point a camera at them, they assume an
unnatural position and expression. It is simply a natural human
response to pose, so the patient must be instructed to relax.
Most patients will “stand at attention” with their chin raised,
raise their shoulders, smile, and raise their eyebrows. I ask them
to drop their arms to the side, relax their shoulders and neck,
and not smile, grimace, smirk, frown, or express emotion. I ask
them to think happy thoughts without smiling, spit out gum
or candy in the mouth, lick their lips, and gently touch their
teeth together, which produces a natural oral posture. I remind
them to not raise their brows. Women are notorious for raising
their brows and must be continually reminded not to. Chin
FIGURE 3-5.  Imaging software is the heart and soul of good photographs
and allows the user to modify images in many ways for clinical use,  
marketing, publications, and textbooks.
A
B
FIGURE 3-6.  A, A typical facial surgery series. B, A typical blepharoplasty series.

26
Chapter 3  •  Clinical Digital Photography
up, it can simply be too much trouble. I cannot say my images
are flawless, and I don’t purport to be a professional photogra-
pher, but the photographs I take are largely controlled and
standardized, which is more than suitable for the average clini-
cian to use as records, publications, lectures, and so forth.
The problem with fixed camera flashes is that if the camera
is held in the normal position, depending upon the pose and
angle of the subject, unwanted shadows can occur (Figure 3-9).
This can be easily circumvented in most cases by rotating the
camera to an angle in which the flash approaches the subject so
as not to produce a shadow.
I take head-on pictures with the camera in the normal hori-
zontal position but will rotate the camera 90 degrees to take the
profile and lateral views in a manner that has the flash coming
toward the face, nose, and chin as opposed to across those
structures (Figure 3-10).
To prevent shadowing, some surgeons prefer to not use
flash at all, but this produces a very washed-out picture with
poor contrast and hue. My exception to using a flash is when
I photograph otoplasty patients from behind. This is a very
difficult pose to obtain without a shadow; taking the before-
and-after posterior view without a flash solves that problem
(Figure 3-11).
The other instance in which I shoot without a flash is when
I photograph patients with an easily triggered blink reflex. For
these patients, I first attempt numerous flash pictures in hopes
of catching a normal picture. If this does not work, I will try
the “red eye” setting, which produces a pre-image strobe; this
sometimes works. Another method is to ask the patient to count
to three with eyes closed and open them on the “three” count.
If all else fails, I turn off the flash.
Lens and Focus
Lens and focus are the other critical factors in clinical photog-
raphy. Standardized images should be taken from the same focal
white background, but these can often appear gray if the white
balance setting is not exact. A black background looks classy
and shows contrast well but wastes significant ink if image print-
ing is routinely performed.
Light and Shadows
Lighting is the essence of photography and must be controlled.
Absolute purist clinical photographers use axillary flashes or
lights to achieve controlled shadowing that enhances detail, but
this requires a fixed setup and in my experience will translate
into lost photo opportunities. When patients have to be moved
to another room where the more sophisticated equipment is set
FIGURE 3-7.  A convenient means of standardizing oblique profile photos
is to line up the soft-tissue nasion with the lateral canthus.
A
B
FIGURE 3-8.  A, A controlled clinical image with a proper background. B, A “lazy” pose with a distracting background.

Chapter 3  •  Clinical Digital Photography
27
The photographer also needs to keep in mind what a given
picture is attempting to communicate. For instance, if you are
taking pictures for lip augmentation, there is no need to have
the patient’s entire face in the frame. Improper framing takes
away from the focal point and wastes space (Figure 3-13). When
framing a picture, only show the relevant anatomy and close-up
detail. This should also be kept in mind when taking intraopera-
tive clinical pictures. If your goal is to photograph a blepharo-
plasty incision, there is no need to show the entire upper face.
In this instance, it would be best to use the macro mode and
zoom in on the eye. Another photography pearl to remember
is keep the surgical field clean. It only takes a few seconds to
wipe blood from gloves and instruments and place a clean towel
over blood-soaked towels. A bloody clinical image is very dis-
tracting and sloppy.
A frequent mistake involves camera focus. This is especially
common with digital cameras with zoom lenses. In this instance,
the photographer has the lens zoomed out and stands too
close to the patient when framing the picture. Due to parallax,
focal length, depth of field, and other lens physics, the close
anatomy appears bigger than the more recessed anatomy
(Figure 3-14, A). This is why some practitioners show pictures
that look like their patients have giant bulbous noses. To counter
this illusion, the photographer should stand back about 3 feet
and zoom in on the subject so there is no anatomic distortion
(see Figure 3-14, B). Remember, move the lens, not the
photographer.
Image-Editing Pearls and Pitfalls
In the days of slide photography, it was not uncommon (and
in fact excusable) to have before-and-after images that were
less than standardized, because it took great effort to crop or
resize slides. Today there is no excuse (other than laziness or
ignorance) for nonstandardized clinical photographs. One of
length on all patients. This is frequently estimated and corrected
with imaging software, but it can be more accurately performed
by ensuring the camera is at the same fixed distance for each
shot. This can be done by securing a piece of string to the camera
and touching it on the patient’s chin (Figure 3-12) or making
a tape mark on the floor where the photographer stands each
time. All pictures should be taken from the same distance.
A
B
FIGURE 3-9.  When the flash is turned so that the light comes across the patient, unwanted shadows are created. Notice the
arrow on the flash and the direction of the light rays.
FIGURE 3-10.  The same patient and pose is made without a shadow by
rotating the camera 90 degrees so the flash comes into the protruding
structures instead of across them. The key is to keep the flash on the
same side as the nose and chin.

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Chapter 3  •  Clinical Digital Photography
the most common blunders I frequently see at meetings is
before-and-after pictures in which the image sizes are different
(Figure 3-15).
Deceptive Images
Whether intentional or unintentional, many surgeons use
deceptive images that skew the actual before-and-after results.
A common example of this is a before image taken without a
flash (which enhances detail) and an after image taken with a
flash (which washes out detail), making the improvement look
better than it actually is (Figures 3-16 and 3-17). Unfortunately,
many high-profile medical journals allow obviously deceptive
images to be published.
Another frequent example of deceptive photography involves
manipulation (intentional or unintentional) of the patient’s
head posture. When viewing Figure 3-18, the observer may
think significant rejuvenation has been performed, when in
reality this is a picture of the author taken with two different
head postures (Figure 3-19). By retracting the chin and neck in
the preoperative image and extending them in the postoperative
image, the illusion of a better surgical result is portrayed. Many
websites on the Internet exhibit such deceptive images. A quality
surgeon (and astute patients) will realize these pitfalls and not
succumb to trickery.
Specialized Photographic Indications
Radiographs
For those surgeons who require the digitizing of photographs,
the digital camera is simply another scanner. Radiographs
can be accurately copied from a view box by placing the
digital camera in the “auto” mode with the flash turned off
(Figure 3-20).
Depending upon the type of bulb in the view box, the actual
image will generally have a bluish tint. By opening the image
in the editing software and converting it to grayscale, the blue
A
B
FIGURE 3-11.  Taking otoplasty images with a flash will produce shadowing (A), but taking the picture without a flash will negate shadowing (B).
FIGURE 3-12.  Attaching a chain or string to the end of the camera can
serve as a convenient means of standardizing images.
A
B
FIGURE 3-13.  A, A poorly framed image with unnecessary space. B, A
properly framed image that draws the observer’s concentration to the face.

Chapter 3  •  Clinical Digital Photography
29
Making Ultraviolet Images
I have previously published articles dealing with digital
photography1-9 and specifically a convenient and affordable
means to make UL photographs.5 Ultraviolet (UV) light
enhances epidermal melanin, which shows up darker in an
image. Making UV images is important for illustrating sun
and skin damage to patients. In addition, UV images are very
valuable for showing both surgeon and patient the degree
of dyschromia resolution with skin resurfacing. Sometimes
patients cannot accurately gauge the amount of pigment
improvement and are quite surprised and pleased to see the
visible difference.
tint is removed, and the image can be cropped and archived
(Figure 3-21).
Copying Images or Text From Journals or Books
Again, the digital camera is a scanner of sorts and can be used
to copy images from journals, texts, and similar sources. For
matte paper, such as common printer paper, a flash can ordi­
narily be used without reflecting; but for glossy paper stock the
fixed flash will cause reflections and washouts. The best way to
photograph glossy images is to use the “auto” mode with the
flash turned off, and place the subject in indirect sunlight or
shade (Figure 3-22).
A
B
FIGURE 3-14.  A, A proper focal length is established by standing several feet away from the subject and zooming in the lens.
B, A distorted image is produced when the lens is “zoomed out” and the photographer stands too close to the subject.
A distance of about 3 feet, with the lens zoomed in, works well in most instances.

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Chapter 3  •  Clinical Digital Photography
A
B
FIGURE 3-15.  There is no excuse for any surgeon to display images in which the photos are different sizes.
A
B
FIGURE 3-16.  “Before” picture (A) taken without a flash and “after” picture (B) taken with a flash, artificially enhancing the result.
This is the same patient, and no surgery was performed, illustrating how strongly light can influence an image.
A
B
FIGURE 3-17.  “Before” picture (A) taken without a flash and “after” picture (B) taken with a flash, artificially making the result look
better. This is the same patient, and no surgery was performed, illustrating how strongly light can influence an image.

Chapter 3  •  Clinical Digital Photography
31
A
B
FIGURE 3-18.  The before-and-after (A-B) images appear to show a surgi-
cal improvement.
A
B
FIGURE 3-19.  This image shows how two separate photos with different head-and-neck positions can skew the observer’s
perception. No surgery was performed; the author simply retracted his neck and chin in the “before” picture (A) and extended
his neck and raised this chin in the “after” picture (B).
FIGURE 3-20.  Turning off the room lights and photographing a radiograph
on a view box without a flash is an easy means of digitizing x-rays.
UV images can be made in several ways. The simplest is to
purchase several inexpensive black lights, usually available at
party stores. Turning the room lights off and holding the black
light near the patient’s face will illuminate the face with UV
light (Figure 3-23). Taking a picture without a flash will produce
a blue image that shows the melanin enhancement. Opening
this image in editing software and converting it to a grayscale
image will now produce the common black-and-white UV
picture commonly used. By adjusting the brightness and con-
trast, the pigmented lesions can be enhanced.
A more controlled means of producing digital UV images is
to photograph the patient through the viewing port of com-
monly available UV skin scanners (Figures 3-24 and 3-25).
These scanners allow the surgeon and patient to view the epi-
dermal melanin. By placing the camera in the “auto” mode and
turning the flash off, a picture is taken through the scanner
viewing port. Since there is very little light, the camera must be
stabilized so the image does not blur. The same digital editing
is used to convert the bluish image to a grayscale image, which
is then saved and archived (Figure 3-26).
Image Archiving
Although proprietary software is available to archive images, I
have found this unnecessary over the years and rely on a simple