Kỹ Thuật Bậc Thầy Trong Trẻ Hóa Khuôn Mặt

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ISBN-13: 978-1-4160-0146-1
MASTER TECHNIQUES IN FACIAL REJUVENATION
ISBN-10: 1-4160-0146-8
Copyright © 2007, by Saunders, an imprint of Elsevier Inc.
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NOTICE
Knowledge and best practice in this field are constantly changing. As new research and experience broaden
our knowledge, changes in practice, treatment and drug therapy may become necessary or appropriate.
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 the practitioner, relying on their
own experience and knowledge of the patient, to make diagnoses, to determine dosages and the best treatment
for each individual patient, and to take all appropriate safety precautions. To the fullest extent of the law,
neither the Publisher nor the Editors assume any liability for any injury and/or damage to persons or property
arising out or related to any use of the material contained in this book.
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Library of Congress Control Number: 2006934728
Editor: Rebecca Schmidt Gaertner
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Babak Azizzadeh
To Jessica, my beautiful and loving wife. My life would be meaningless without her.
To Kylie and Logan for being the most amazing children any father can ask for. To
my parents, Yafa and Habib, as well as my loving sister, Katrin, who set the
foundation for my personal and professional life.
Mark R. Murphy
This book is dedicated to my wife, Sherry, who has enabled me to fulfill my dreams.
To our beautiful children Ned, Nicholas, and Grayson, you are the lights that guide
us. To my mother and father, Maureen and Robert, for preparing me for a life of
happiness. And to my sister and brother, Diane and David, for sharing in our joy.
Dedication

Editors
Babak Azizzadeh, MD, FACS
Director
The Center for Facial and Nasal Plastic Surgery
Assistant Clinical Professor
David Geffen School of Medicine at UCLA
Audrey Skirball-Kenis Center for Plastic & Reconstructive Surgery
Cedars-Sinai Medical Center
Beverly Hills, California
The Aging Face Consultation, Short-Flap SMAS Rhytidectomy,
Aesthetic Midface Implants
Mark R. Murphy, MD
Director
Palm Beach Facial Plastic Surgery
West Palm Beach, Florida
The Aging Face Consultation, The Open Browlift, The Deep Plane
Facelift
Calvin M. Johnson Jr., MD
Clinical Associate Professor
Division of Facial Plastic & Reconstructive Surgery
Tulane University School of Medicine;
Director
Hedgewood Surgical Center
New Orleans, Louisiana
The Aging Face Consultation, The Open Browlift, The Deep Plane
Facelift
Contributors
Daniel C. Baker, MD
Associate Professor
Department of Plastic Surgery
New York University School of Medicine;
Attending Surgeon
New York University Medical Center;
Attending Surgeon
Department of Plastic Surgery
Manhattan Eye, Ear & Throat Hospital;
Attending Surgeon
Department of Plastic Surgery
Bellevue Hospital
New York, New York
Lateral SMASectomy Facelift
William J. Binder, MD, FACS
Assistant Clinical Professor
Department of Head and Neck Surgery
UCLA School of Medicine
Attending Surgeon
Department of Head and Neck Surgery
Cedars Sinai Medical Center
Los Angeles, California
Aesthetic Midface Implants
Dewayne T. Bradley, MD
Department of Otolaryngology-Facial Plastic Surgery
Virginia Mason Medical Center
Seattle, Washington
Facial Embryology and Anatomy
Andres Bustillo, MD
Facial Plastic & Reconstructive Surgery
Coral Gables, Florida
Blepharoplasty
Mack L. Cheney, MD, FACS
Professor
Department of Otolaryngology-Head and Neck Surgery
Harvard Medical School;
Director of Facial Plastic and Reconstructive Surgery
Department of Otolaryngology-HNS
Massachusetts Eye and Ear Infirmary
Boston, Massachusetts
Short-Flap SMAS Rhytidectomy
Jeannie H. Chung, MD
Associate Staff
Department of Otolaryngology-Head and Neck Surgery
Massachusetts Eye and Ear Infirmary
Boston, Massachusetts;
Active Staff
Department of Otolaryngology-Head and Neck Surgery
North Shore Medical Center
Salem, Massachusetts;
Medical Director
North Shore Dermatology and Cosmetic Surgery Center
Andover, Massachusetts
Facial Suction Lipectomy
Steven C. Dresner, MD
Associate Clinical Professor of Ophthalmology
The University of Southern California Keck School of Medicine
Los Angeles, California;
Director
Fellowship in Ophthalmic Plastic Surgery
Eyesthetica
Santa Monica, California;
Transconjunctival Lower Blepharoplasty
Contributors

Alvin I. Glasgold, MD
Clinical Professor of Surgery
Department of Surgery
University of Medicine and Dentistry of New Jersey-Robert Wood
Johnson Medical School
New Brunswick, New Jersey
Mentoplasty
Mark J. Glasgold, MD
Clinical Assistant Professor
Department of Surgery
University of Medicine and Dentistry of New Jersey-Robert Wood
Johnson Medical School
New Brunswick, New Jersey
Mentoplasty, Complementary Fat Grafting
Robert A. Glasgold, MD
Assistant Professor
Department of Surgery
University of Medicine and Dentistry of New Jersey-Robert Wood
Johnson Medical School
New Brunswick, New Jersey
Mentoplasty, Complementary Fat Grafting
Ryan M. Greene, MD, PhD
Resident
Department of Otolaryngology-Head and Neck Surgery
The University of Illinois at Chicago
Chicago, Illinois
Rhinoplasty in the Aging Patient
Tessa A. Hadlock, MD
Assistant Professor
Department of Otology and Laryngology
Harvard Medical School;
Division of Facial Plastic and Reconstructive Surgery
Department of Otolaryngology
Massachusetts Eye and Ear Infirmary
Boston, Massachusetts
Short-Flap SMAS Rhytidectomy
Douglas Hamilton, MD
Assistant Clinical Professor
Department of Dermatology
University of California, Los Angeles School of Medicine
Los Angeles, California
Nonsurgical Facial Rejuvenation
Carlo P. Honrado, MD
Assistant Professor
Department of Facial Plastic and Reconstructive Surgery
New York Eye and Ear Infirmary
New York, New York;
Assistant Professor
Department of Facial Plastic and Reconstructive Surgery
New York Medical College
Valhalla, New York
Facial Embryology and Anatomy
Nicanor Isse, MD
Assistant Clinical Professor
Department of Surgery
University of California Los Angeles
Volunteer Faculty
Department of Surgery
University of Southern California
Los Angeles, California:
Professor of Post Graduate Courses and Master Courses
University of Padua
Padua, Italy;
Active Member and Staff
Department of Surgery
Hoag Memorial Hospital Presbyterian
Newport Beach, California;
Provisional Status and Staff
Department of Surgery
Providence Saint Joseph Medical Center
Burbank, California;
Volunteer Faculty Appointment and Staff
Department of Surgery
University of California, Irvine
Irvine, California
Endoscopic Foreheadplasty
Brian P. Kim, MD
Resident Physician
Department of Otolaryngology-Head and Neck Surgery
University of California, Los Angeles School of Medicine
Los Angeles, California;
Fellow
Department of Otolaryngology-Head and Neck Surgery
Stanford University School of Medicine
Stanford, California
Aesthetic Midface Implants
Young Kyoon Kim, MD, PhD
Professor
Department of Dermatology
Cho-Sun University Medical School
Gwangju, South Korea;
Professor
Department of Dermatology
Dong-A University Medical School
Busan, South Korea;
Full Fellowship
Department of Cosmetic Surgery
International Academy of Cosmetic Surgery
Tokyo, Japan;
Director
Department of Cosmetic Surgery
5050 Clinic
Bucheon, South Korea
Asian Blepharoplasty
Samuel M. Lam, MD
Director
Lam Facial Plastic Surgery Center and Hair Restoration Institute
Plano and Dallas, Texas
Asian Blepharoplasty, Complementary Fat Grafting
Wayne F. Larrabee Jr., MD, FACS
Clinical Professor
Department of Otolaryngology-Head and Neck Surgery
University of Washington School of Medicine;
Swedish Hospital;
Director
Larrabee Center for Facial Plastic Surgery
Seattle, Washington
Facial Embryology and Anatomy
viii
Contributors

Robert E. Levine, MD
Clinical Professor of Ophthalmology
Department of Ophthalmology
University of Southern California Keck School of Medicine;
Co-Founder and Co-Director
Center for Facial Nerve Function
House Ear Clinic
Los Angeles, California
Lateral Canthoplasty
Harry Marshak, MD
Former Clinical Instructor
Ophthalmic Plastic and Reconstructive Surgery
Doheny Eye Institute
Keck School of Medicine of University of Southern California
Los Angeles, California;
Ophthalmic Plastic and Reconstructive Surgery
The Morrow Institute
Rancho Mirage, California
Transconjunctival Lower Blepharoplasty
Norman Pastorek, MD, FACS
Clinical Professor and Director
Facial Plastic Fellowship
Department of Otolaryngology
New York University College of Medicine;
Clinical Professor and Clinical Director of Facial Plastic Surgery
Department of Otolaryngology
New York Presbyterian Hospital-Weill Cornell Medical Center;
Surgeon Director
Department of Otolaryngology
Manhattan Eye, Ear, & Throat Hospital
New York, New York
Blepharoplasty
Oscar M. Ramirez, MD, FACS
Esthétique Internationale
Timonium, Maryland
Tridimensional Endoscopic Facelift
Dean M. Toriumi, MD
Professor
Division of Facial Plastic and Reconstructive Surgery
Department of Otolaryngology-Head and Neck Surgery
University of Illinois at Chicago
Chicago, Illinois
Rhinoplasty in the Aging Patient
Charles R. Volpe, MD
Esthétique International
Timonium, Maryland
Tridimensional Endoscopic Facelift
Edwin F. Williams, III, MD, FACS
Fellowship Director
American College of Surgeons;
Clinical Instructor and Fellow
Department of Otolaryngology-Head and Neck Surgery
University of Illinois
Chicago, Illinois;
Chief
Department of Facial Plastic and Reconstructive Surgery
Clinical Associate Professor of Surgery
Albany Medical Center
Albany, New York;
Medical Director and Founder
New England Laser & Cosmetic Surgery Center;
Medical Director
Williams Center for Excellence
Latham, New York
Facial Suction Lipectomy
Contributors
ix

When we decided to embark on this project, there were no
books available that presented competing and alternative
surgical viewpoints to facial rejuvenation. Most available
texts either covered a broad spectrum of plastic and
reconstructive surgery methods or presented a single
author’s surgical technique. This text presents multiple
facial rejuvenation procedures from those who do it best.
So much of surgery is experience, not just with technique
but, more important, with the reasoning and knowledge
that have guided surgeons over the years. We have chosen
contributing authors from various specialties based on
their accomplishments and expertise with facial
rejuvenation. Only the most pioneering and time-tested
procedures are presented so that both young and
experienced surgeons may understand and master the
essentials and fine subtleties of facial aesthetic surgery.
With the initial emphasis on anatomy, the pillar of all
successful surgery, the text moves forward through the
authors’ individual preferences and, more important,
their rationale for those preferences. Once the reader
understands these foundations, the surgical technique is
described in detail through text, intraoperative photos,
illustrations, and a comprehensive DVD surgical atlas. By
providing the reader with these components, we hope to
inspire and educate the next generation of masters.
Preface

There are many people to whom we owe a great deal of
gratitude for the completion of the textbook. First and
foremost our patients, who have entrusted us in the most
personal way. Our mentors, Norman Pastorek, Mack
Cheney, Keith Blackwell, Daniel Deschler, Mark Vavares
and Rinaldo Canalis. Our family, Ned and Cindy
Lautenbach, for their motivation and inspiration. Siamak
Daneshmand for his unrelenting support throughout the
years. Our current partners, Robert Dattolo, David
Lehman, Carolyn Agresti, Carlos Heaton, John Murray,
David Alessi, Babak Larian, Lance Wyatt, and Kami
Parsa, whose unflinching support has aided us in the
pursuit of our passion. Finally, we must acknowledge the
unbelievable amount of work that Rebecca Gaertner,
Suzanne Flint, Krystyna Srodulski, and Stasia Droze put
forth in making this book a reality.
Acknowledgments

HISTORY
The elusive features of beauty have been studied for
millennia. The facets of beauty change with time, and
with every era new components take on a greater or lesser
importance. Alhough this quest leads to many definitions,
it has also identified certain specific features that define
beauty. We must search through the art or writing of an
era to understand what constituted beauty at that time.
From ancient Egyptian depictions of Queen Nefertiti to
the paintings of Leonardo da Vinci, the pursuit of facial
beauty has been attempted by history’s greatest artists
(Fig. 1-1). Through their work, we can glean the details
that, when brought together, create beauty. In ancient
times, combinations of facial features, body proportions,
hair color, and skin tone could remain popular for
centuries. As time progressed, however, these preferences
began to change more quickly, first by decades, later by
seasons, and now by weeks.
The ideal of universal beauty is just that, an ideal.
Differences in epochs, cultures, and ethnicity dictate that
a unanimous definition of beauty will be ever elusive.
However, there are common threads in the proportions
and harmony of the face that throughout time and
civilizations confer an overall sense of attractiveness.1
Beauty can be defined and measured.2 It has also been
shown that attractiveness plays a covert but significant
role in the way people behave and how they react to
another.3 Through the centuries we can see the ever-
changing definition of beauty, and recognizing its
perception is an innate human trait.4 Indeed, infants have
been shown to prefer faces that have been deemed more
attractive.5 This tendency continues through adulthood.
Faces that deviate the least amount from standard
averages have been found to be more attractive among
older study participants.6 The traits that subjects have
found to be consistently more attractive in females are
high cheekbones, large eyes, a smaller vertical third of the
face, and a narrow jaw.7
ANCIENT GREECE
The ancient Greek civilization is considered by many to
be the progenitor of modern facial analysis. The Greek
artist Praxiteles (370–330 BC) provided a model of beauty
with his sculpture of Aphrodite. His work, and that of
others influenced by him, displays the evolution of beauty
by incorporating human expression into the classic
context of a goddess (Fig. 1-2). With her triangular
forehead and eyes that express warmth, innocence, and
sadness, she conveyed components of reality that had
been overlooked by Praxiteles’s predecessors. Her features
were regular and depicted imperfections that added to her
beauty by making her more human. In creating the
sculpture of Aphrodite, Praxiteles emphasized subtlety
versus the more rigid, precise expressions popular at that
time. Her facial features emanated beauty without
overwhelming the observer. Aphrodite became a standard
of beauty passed on to subsequent generations.3,8,9
The origin of the pursuit of beauty is often associated
with the ancient Greeks, and their effect still permeates
our modern conceptions of desirability. It was the Greek
civilization, Plato specifically, that defined beauty as an
The Aging Face Consultation
Mark R. Murphy, MD • Calvin M. Johnson Jr., MD • Babak Azizzadeh, MD, FACS
1
C H A P T E R O N E
Figure 1-1 The classical beauty of the Egyptian Nefertiti continues to be
seen as an ideal image of beauty and elegance. Copyright © Bildarchiv
Preussischer Kulturbesitz/Art Resource, NY.

appropriate balance. We see this concept mirrored today
as we analyze the face into fifths, vertically, and thirds,
horizontally. To the Greeks the concept of balance went
beyond physical characteristics and included wealth,
health, and beauty.3 Indeed, the Greeks considered
physical beauty to be worthy of fame. They delved into
the meaning of these factors in the context of an orderly
universe. In this vein, they attempted to understand the
concept of beauty as they sought to define it through
mathematical terms.10 The Greeks, and others throughout
history, also realized beauty is attained when good taste,
balance, and proportion are in harmony.
This sentiment was echoed by Polyclitus (fifth century
BC). He defined a series of proportions that he believed
would produce an image of faultless beauty. For his
doubters, he would create two sculptures, one naturalistic
and one according to his proportioned principles. Viewers
of the works agreed the statue following strict proportions
was more beautiful by far.3,11 This balance, known as the
elusive “golden mean,” has been the topic of debate for
centuries as artists, architects, and philosophers have
sought to define beauty through mathematical terms.12
RENAISSANCE
The Greek influence reemerged in the late 14th century at
the birth of the Renaissance. The Renaissance covered
many aspects of human endeavor and included the
search, definition, and expression of beauty. The goal of
the artists of the time was not merely the depiction of
objects, but the creation of them from various forms to
attain an ideal. The positive tone of this time is echoed in
its artistic impressions. No longer were women depicted in
the harsh terms of earlier times. They emerged as
independent and intelligent.3
Peter Paul Rubens
(1577–1640) depicted vigorous female forms that were
once seen as the ideal portrayal of female beauty, perhaps
due to the spirit they emanated as opposed to the forms
themselves. The women Rubens created were intelligent
and alert, with dark eyes, long necks, and round heads
(Fig. 1-3). This ideal evolved as Rubens aged and the
vigor of his early paintings was slowly displaced by
softness in form in his later works.3,13
Although the Renaissance is noted for its humanistic
approach to art, it valued the mathematical method that
dated back to the Greeks. The artists of the era desired to
discover scientific explanations of beauty. The science of
beauty intrigued the artists of this age as never before.
The theories of Vitruvius Pollios (first century BC), a
Roman architect, on using the human form to derive
2
Mark R. Murphy • Calvin M. Johnson Jr. • Babak Azizzadeh
Figure 1-2 The face of Aphrodite serves as a model of facial proportion
and beauty. Copyright © 2004 Museum of Fine Arts, Boston, MA.
Figure 1-3 The societal evolution of the perception of beauty is
evidenced in Rubens’ portrait of the young women whose dark eyes and
manner belie an advanced intelligence. Copyright © Erich Lessing/Art
Resource, NY.

perfect proportions in building sacred edifices were not
merely taken as reference but as foundation.
Perhaps no other artist is more closely defined by this
period than Leonardo da Vinci (1452–1519). Da Vinci’s
passionate pursuit of proportion is seen throughout his
copious works. Da Vinci was relentless in his pursuit of
the balance between science and beauty. His numerous
studies of the face and head stand as masterpieces of the
human form. Da Vinci first broke the face into thirds to
assess their individual contributions to the whole.
The Renaissance artist Sandro Botticelli (1444–1510)
again illustrated the desire to place classic concepts in a
modern format.3 By combining the traditional features of
beauty with the partialities of his time, Botticelli
epitomized the Renaissance ideal. In The Birth of Venus,
Botticelli depicted a traditional subject with current
features. Her long, angular face had previously been
depicted as a standard oval. Her emotions emanate from
her geometrically regular and perfectly calm facial
expression (Fig. 1-4).3 The two common threads in the
pursuit of beauty are adherence to classic forms and a
modern manipulation of those forms to meet the taste of
the times.
The Romantic period was heralded by Prud’hon’s
interpretation of female beauty. In his images of his
mistress this ideal woman merges dream and sensuality.
The woman in the painting titled The Happy Mother gazes
adoringly at her nursing infant (Fig. 1-5). Prud’hon
stressed the natural beauty of maternity—and with this
physical and emotional bond, the beauty of feminine
tenderness is skillfully portrayed.
HISTORY OF FACIAL REJUVENATION
Aesthetic surgery is the pursuit of what is described by the
Greek word aisthetikos, meaning a passion for that which
is beautiful. The surgical enhancement of appearance was
roundly dismissed until the late 1800s. Before this time,
such perceived vanity was socially unacceptable and the
procedures themselves were considerably dangerous. As
the constraints of the Victorian era receded, women
became empowered to alter their appearance as they
chose. Makeup and hair styling became commonplace and
the shroud surrounding the world of cosmetic surgery
began to slowly unravel. Surgery, however, was a perilous
endeavor at the beginning of the 20th century. Anesthesia
methods were crude at best and antibiotics were not in
existence yet. It would not be until the middle of the
century that these two vital components to surgical
management of complex problems came into common use.3
The surgeons during this time had little to no
appreciation of the challenges they faced. The knowledge
of facial anatomy and function was marginal. Little was
known about the complex interplay of skin, muscle, fat,
cartilage, and bone. Manipulation of these components
could not be confidently addressed until the physiology of
blood supply, lymphatic drainage, and flap dynamics was
more completely understood.
This field has rapidly evolved over the past 20 years
as aesthetic surgery has blossomed to the forefront of
CHAPTER 1
The Aging Face Consultation
3
Figure 1-4 The flowing, obvious beauty of Venus epitomizes the
Renaissance ideal of beauty. Copyright © Erich Lessing/Art Resource, NY.
Figure 1-5 The soft, feminine portrait of this mother gazing at her child
depicted the Romantic sense of beauty. Copyright © The J. Paul Getty
Museum.

American culture. The final barriers to cosmetic
alterations have been removed with the advent of less
invasive methods and glamorization of plastic surgery in
the media. Cosmetic surgery has indeed become common-
place with magazines and television shows promoting it
on a daily basis.
CONSULTATION
HISTORY
A complete history and physical examination must be
performed prior to the analysis of the patient’s cosmetic
desires and possibilities. This is especially true in cosmetic
surgery. There can be no excuse for an overlooked medical
issue that can compromise the health of a patient under-
going an elective procedure. General issues that should be
investigated include previous surgeries, medications,
alcohol use, allergies, and any coexisting medical conditions.
Specific issues to facial rejuvenation such as the use of
aspirin and other nonsteroidal anti-inflammatory medica-
tions, hypertension, and smoking history should be
thoroughly explored.
If the patient plans to undergo eyelid rejuvenation, a
complete ophthalmologic history should be obtained with
emphasis on dry eye symptoms. There is significant
controversy for the role of a formal ophthalmologic
consultation.14-16 Each patient should be individually
evaluated in order to determine the need for an ophthal-
mology evaluation. A history of dry eyes usually requires
formal testing of tear production using the Schirmer
test. Thyroid-related diseases, facial palsy, and prior
blepharoplasty are also important conditions that increase
the risks of eyelid malposition in the postoperative period.
PHYSICAL EXAMINATION AND FACIAL ANALYSIS
The physical examination is specific to each surgeon and
there is no right or wrong way to examine the patient.
However, certain components of the physical examination
should always be included. We prefer to analyze the overall
appearance of the face. The ethnicity, body habitus, and
general proportions of the face should be considered. A
three-dimensional approach must be considered to
account for the patient’s facial volume, skin texture,
muscular activity, and bony skeletal support. Several
landmarks and known relationships should be appreciated
by all surgeons performing aesthetic surgery (Table 1-1;
Fig. 1-6). The face is generally broken down into fifths
vertically, based on the width of an eye, and thirds hori-
zontally, as measured from the hairline to the glabella,
glabella to the subnasale, and subnasale to menton (Fig.
1-7). Any facial asymmetry should be noted at this time.
All normal faces have some level of asymmetry, which
should be conveyed to the patient.
Facial rejuvenation procedures must create an overall
harmony to the face without any major discrepancies. All
facial regions must therefore be assessed during the
consultation. The upper third of the face encompassing
the forehead, brow, and eyes is generally evaluated jointly.
The middle third of the face is composed of the midface,
malar eminence, submalar soft tissue, nasolabial fold, and
nose. The lower third of the face is assessed by evaluating
the perioral, jowl, and neck regions. Specific aspects of the
evaluation will be discussed in the following sections.
Skin
Our preference is to first examine the condition of the
patient’s skin. Whether for facial rejuvenation or
rhinoplasty, the status of the skin will have profound
ramifications on the result of the planned procedure. The
texture, thickness, pigmentation, degree of sun exposure,
and smoking-related skin changes should be completely
evaluated. The youthful face has smooth elastic skin with
ample subcutaneous tissue. Subcutaneous fat and muscle
begin to atrophy with time and the skin becomes less
elastic. For facial rejuvenation, the skin should be mani-
pulated in vectors similar to those of the proposed procedure
to assess its mobility. Dynamic and gravitational rhytids
must be evaluated and the surgeon should note any
previous procedures, scars, or skin lesions. Fitzpatrick
scale can be utilized to evaluate appropriate candidates
for skin resurfacing (Table 1-2).17,18
The surgeon should at this time educate the patient as
to the consequences of certain skin types and conditions.
Thick, oily, porous skin tends to mask fine irregularities
4
Mark R. Murphy • Calvin M. Johnson Jr. • Babak Azizzadeh
Table 1-1
Standard Facial Angles
Angle
Description
Nasofrontal angle
Angle between the nasion,
glabella, and the dorsal line of the
nose (~115 to 135 degrees)
Nasofacial angle
Angle between the dorsum of the
nose and the facial plane (~30 to
40 degrees)
Nasomental angle
Angle between the dorsal line of
the nose and a line from the
pogonion to the nasal tip (~120 to
132 degrees)
Mentocervical angle
Angle between a line from the
menton to the cervical point and
the facial plane (~80 to 95
degrees)
Nasolabial angle
Angle between the line of the nasal
columella and tangent of the upper
lip (~90 to 105 degrees)

but at the cost of increased scarring. Thin skin generally
heals better than thick skin at the expense of the patient’s
perceiving slight irregularities that might otherwise go
unnoticed. This is especially true when the surgeon
performs rhinoplasty, a procedure increasingly popular
CHAPTER 1
The Aging Face Consultation
5
with the aging population. The ideal skin type lies
between these two extremes.
The patient’s facial volume also needs to be
thoroughly assessed. This is an area which has been
historically undervalued in facial rejuvenation. During the
Tr
G
N
FH
Sn
Pg
“0° Meridian”
M
C
A
B
NFA
115°–135°
NLA
90°–105°
MCA
80°–95°
Figure 1-6 Facial landmarks (A and B). The Frankfort horizontal plane (FH)
is determined by drawing a straight line from the supratragal notch to the
infraorbital rim. The cervical point (C) is the junction of the submental area and
neck. The glabella (G) is the prominence of the forehead at the level of the
supraorbital rim in the lateral view. The menton (M) is the lowest point of the
chin. The nasion (N) is the deepest depression at the superior aspect of the
nose. The pogonion (Pg) is the anteriormost projection of the chin. The
subnasale (Sn) is the junction of the nasal columella and upper lip. The trichion
(Tr) is the anterior border of the hairline in the midline. The 0° meridian
determines chin and facial projection; a line is drawn at the level of the nasion
and perpendicular to the Frankfort horizontal plane. The nasofrontal angle
(NFA) is the angle between the nasion, glabella, and the dorsal line of the nose
(C). The mentocervical angle (MCA) is the angle in between the facial plane and
a line drawn from the menton to the cervical point. The nasolabial angle (NLA)
is the angle between the nasal columella and the tangent line of the upper lip.
C

aging process, the subcutaneous fat and muscles not only
shift secondary to gravitational forces, but also deflate
and atrophy. Furthermore, the skeletal framework may
also recede in the edentulous patient.
Forehead and Brow Complex
The upper third of the face is initially evaluated by
looking at the relationship of the forehead, brow, and
eyes. This region of the face is often overlooked by
patients. Outside observers, however, tend to focus on the
forehead and eyes to a greater degree than the lower face.
We feel it imperative to highlight this region and educate
the patient on its importance. The exact configuration of
the brow is a topic of debate, though the general shape is
agreed upon.19,20 Ellenbogen used the following criteria
for the ideal brow position: the brow usually begins
medially through a vertical line drawn perpendicularly
from the alar base; the lateral aspect of the brow should
terminate laterally at a line drawn obliquely through the
lateral canthus of the eye and the alar base; the medial
and lateral portions of the brow should lie at the same
horizontal level; the brow should be fuller medially and
gently taper as it progresses laterally; and the apex of the
brow should lie on a vertical line drawn from the lateral
limbus (Fig. 1-8).19 Others argue that the apex should lie
farther laterally at a similar line drawn through the lateral
canthus.20 In females, the brow should lie just above the
orbital rim, especially laterally. The ideal position of the
brow for men is along the superior orbital rim itself.21
6
Mark R. Murphy • Calvin M. Johnson Jr. • Babak Azizzadeh
1\5
1\5
1\5
1\5
1\5
1\3
1\3
1\3
2\3
1\3
A
B
Figure 1-7 Facial proportions. The vertical facial proportions are generally broken down into fifths based on the width of an eye (A). The horizontal facial
proportions are divided into thirds as measured from the hairline to the glabella, from the glabella to the subnasale, and from the subnasale the menton (B).
The lower third can be further broken down to the upper one third, from the subnasale to the junction of the lips, and the lower two thirds, from the junction
of the lips to the menton.
Table 1-2
Fitzpatrick Skin Evaluation
Skin Type
Skin Color
Reaction to Sun
Type I
Very white or freckled
Always burns
Type II
White
Usually burns
Type III
White to olive
Sometimes burns
Type IV
Brown
Rarely burns
Type V
Dark brown
Very rarely burns
Type VI
Black
Never burns

The aging forehead is highlighted by dynamic rhytids
and ptotic tissue. The soft tissues of the brow complex are
continuously drawn inferiorly by gravity and depressor
muscle activity. These forces are exacerbated in the aging
population owing to the loss of soft tissue volume and skin
elasticity. Young patients can also present with brow
ptosis secondary to overactive depressor muscle activity.
Brow ptosis can have a significant impact on accentuating
upper eyelid dermatochalazia. A manual lifting of the
brow and upper lid complex with a gentle upward sweep
makes this point evident to the patient. Asymmetries are
common and should be conveyed to the patient after the
evaluation of the brow complex. Patients are usually not
aware of these irregularities at the time of the
consultation. It is very common, however, for the patient
to notice them postoperatively.
In addition to the static examination of the patient,
the dynamic movements of the upper third must be fully
understood. There are four key muscles to consider:
frontalis, procerus, corrugator supercilii, and the orbital
portion of the orbicularis oculi. The frontalis muscle is the
primary elevator of the brow complex contributing to the
horizontal forehead rhytids. The contraction of the
corrugators serves to bring the brow inferior and medial.
This movement causes the patient to have a rather
menacing appearance that, when coupled with the ptosis
of the aging brow, gives the look of a tired, unpleasant
individual. These muscles also contribute to the formation
of vertical rhytids in the glabella. The procerus, like the
corrugators, also causes the medial aspects of the brows to
move inferiorly. However, the procerus’s slightly different
vector of action causes horizontal glabellar rhytids. The
orbital portion of the orbicularis oculi muscle also
significantly impacts the appearance of the brow by
causing an inferomedial movement of the brow.
Alopecia should be discussed with all men consid-
ering brow rejuvenation. Personal and family history of
hair loss should be obtained in all cases. Women also have
unique concerns that arise when considering brow
manipulations. The hairline, style, and volume of the hair
are but a few of these topics that dictate the approach to
the brow.
Eyelids and Periorbital Region
Dermatochalazia and pseudoherniation of the orbital fat
are the most common reasons patients present for eyelid
rejuvenation. Other conditions seen in the periorbital area
include festooning secondary to excess skin, soft tissue,
and orbicularis muscle; malar bags due to edematous
sagging soft tissue containing fluid or fat; and orbicularis
hypertrophy.
The physical examination of the periorbital region is
vital. Basic ophthalmologic examination must be
performed. This includes the evaluation of the extraocular
muscles, visual acuity, and Bell’s phenomenon (upward
rotation of eye with attempted eyelid closure). Other key
components of the assessment include the outline and size
of the palpebral fissure, the relative positions of the medial
and lateral canthi, the intercanthal distance, skin lesions,
asymmetry, exophthalmos, enophthalmos, crow’s-feet,
and signs of previous surgery. In the Caucasian patient the
CHAPTER 1
The Aging Face Consultation
7
Figure 1-8 The ideal eyebrow position. The brow begins medially
through a vertical line drawn perpendicularly from the alar base. The lateral
aspect of the brow should terminate laterally at a line drawn obliquely
through the lateral canthus of the eye and the alar base. The brow should
lie at the same horizontal level and be fuller medially, gently tapering while
progressing laterally. The apex of the brow should lie on a vertical line
drawn from the lateral limbus.
Treatment Considerations: Forehead and Brow Complex
The aging process of the forehead and brow complex
has been historically undertreated. In the treatment
protocol, rhytids and ptotic tissue should be seen as two
independent processes that each require specific
management. Neuromuscular paralytic agents such as
botulinum toxin type A (Botox) should be utilized to treat
the dynamic forehead and glabellar rhytids. Fillers can
augment the results of botulinum toxin type A in cases of
deep glabellar and forehead rhytids. Free fat transfer and
injectables such as stabilized hyaluronic acid can also
improve the volume deflation of the brow region. Brow
ptosis is almost always treated surgically. The coronal and
endoscopic browlifts are the most commonly used
techniques. The pretrichial foreheadlift should be
considered in patients who present with high hairline.

intercanthal distance should be equal to the interalar
width. The lateral canthus should be about 2 mm superior
to the medial canthal angle. The periorbital area should
be assessed individually and as a component of the
midface and forehead.
The upper eyelid examination usually focuses on the
level of brow ptosis, dermatochalazia, and extent of
lateral hooding. The brow should be elevated manually so
that the patient may fully understand its contribution to
upper lid dermatochalasis. A gentle sweep of the upper lid
excess skin, if present, will also provide the patient with a
firm grasp of the potential postblepharoplasty outcome. If
patients are complaining of peripheral visual loss
secondary to excess dermatochalazia, they should have a
formal ophthalmologic evaluation and testing. Other
conditions such as lagophthalmos and eyelid ptosis
(blepharoptosis) should also be ruled out at this time. The
superior eyelid margin should lie about 1.5 mm below the
superior corneal limbus in a neutral gaze. Blepharoptosis
(Fig. 1-9) can be quantitatively determined by measuring
the margin reflex distance-1 (MRD1), which is the
distance between the corneal reflex and the upper eyelid
lash line (normal range 4–4.5 mm).
In the lower eyelid, careful attention is needed to
evaluate eyelid laxity, pseudoherniation of orbital fat, and
double convexity deformity as well as conditions that may
lead to postblepharoplasty complications. The degree of
lower lid fat pseudoherniation can be assessed by gently
pressing on the globe while the patient is looking up.
Lower eyelid skin excess should also be determined by
having the patient look up, thereby stretching the skin
and revealing the exact amount of redundancy. Double
convexity deformity occurs when the malar fat pads and
suborbital orbicularis oculi fat (SOOF) descend inferiorly
while the orbital fat pads herniate through a weakened
septum (Fig. 1-10).22 Retaining ligaments in the lower
eyelid also cause characteristic creases and hollows in
patients with ptotic soft tissue, decreased skin elasticity,
and volume atrophy.23
Postoperative blepharoplasty complications such as
ectropion and lower lid retraction can be avoided if the
surgeon properly evaluates the resting position and
strength of the lower lid. The margin of the lower eyelid
should lie just above the inferior limbus (see Fig. 1-9).
The margin reflex distance-2 (MRD2) can be used to
objectively determine the extent of lid retraction. Excess
scleral show in this area is a sign of eyelid malposition,
which needs be addressed at the time of blepharoplasty.
The lid distraction and snap tests are performed to
evaluate the integrity of the lower lid (Fig. 1-11). During
the snap test, gentle inferior traction of the lower lid from
the globe is performed to assess how quickly it returns to
its normal position. The eyelid should normally “snap”
8
Mark R. Murphy • Calvin M. Johnson Jr. • Babak Azizzadeh
Figure 1-9 Margin reflex distance (MRD) –is used in the evaluation of
upper eyelid ptosis and lower lid retraction. Eyelid ptosis can be
quantitatively determined by measuring the margin reflex distance-1 (MRD1)
(A). The MRD1 is determined by measuring the distance between the corneal
reflex and the upper eyelid lash line and has a normal range of 4.0 to
4.5 mm. The margin reflex distance-2 (MRD2) is utilized to determine the
amount of lid retraction (scleral show) by measuring the distance between
the corneal light reflex and the lower eyelid lash line during a neutral gaze
(B). The lash line should normally be adjacent to the lower limbus with an
MRD2 of 5 mm. In patients with lower lid retraction with scleral show, this
distance is usually greater than 7 mm.
Figure 1-10 Double convexity deformity. Double convexity deformity
results from the descent of the malar fat pad and suborbicularis oculi fat pad
(SOOF) coupled with herniation of lower eyelid orbital fat through a
weakened septum.
A
B

back to its normal position in less than 1 second. Excess
lid laxity is noted if the puncta is displaced by more than
3 mm from the medial canthal tendon, if the lid is slow to
return to its normal position, or if blinking reflex is
needed to bring it back to its resting location.24 In the lid
distraction test, the lower lid is grasped and pulled away
from the globe. Distraction of more than 7 to 10 mm
indicates a lax lid.25 Patients with a negative orbital
vector are also at an increased risk for untoward surgical
complications such as lower eyelid malposition and
hollowed appearance. The orbital vector is determined by
drawing a straight vertical line between the cornea and
the inferior orbital rim from the lateral view; if the orbital
rim falls behind this line, then the patient is diagnosed
with a negative vector. Proptosis secondary to thyroid-
related ophthalmic disorders are a leading cause of a
negative orbital vector. A hypoplastic malar eminence
may also contribute to, or magnify, a proptotic eye.
If the patient has signs and symptoms of dry eye
syndrome, a formal ophthalmologic evaluation should be
considered. The Schirmer test is the preferred method for
evaluating patients who are at risk of developing
postoperative dry eye syndrome. After the placement of
topical anesthetic, a Schirmer strip (Cooper Laboratories,
Puerto Rico) is positioned in the lateral fornix. Normal
individuals will have more than 10 mm of moisture after
a 5-minute placement.
The Midface
The midface is the region medial to the preauricular
crease and lateral to the nasolabial fold. This area has
gained increasing attention over the last two decades.
Multiple approaches to mid-face rejuvenation are now
available. The main components of the aging process in
this region include the descent and atrophy of the cheek
soft tissue. This ptotic and atrophic midface tissue not
only accentuates the nasolabial fold and other retaining
ligaments but also creates depressions and hollowness in
the submalar and lower eyelid region. One of the most
important aspects of the midface examination is the
relationship of the malar skeletal framework to the
submalar soft tissue (see Chapter 12). Prominent malar
eminence is of great assistance to the surgeon in providing
the patient with excellent surgical results. The layman’s
“high cheekbones” are classically associated with youth
and beauty. They serve as the scaffolding that enables the
surgeon to suspend the ptotic tissues of the aging face.
However, high cheekbone with significant submalar
CHAPTER 1
The Aging Face Consultation
9
Figure 1-11 Lower lid laxity
evaluation. In the snap test, the
lower lid is pulled downward
and away from the globe and
the patient is asked not to blink
(A). Lid laxity is present if the
puncta is displaced by more
than 3 mm from the medial
canthal tendon. The lid should
return to its normal position in
less than 1 second. The lid
distraction test is performed by
grasping the lid and pulling it
away from the globe (B).
Distraction of more the 7 to
10 mm indicates a lax lid.
A
B
Treatment Considerations: Eyelid and Periorbital Region
Eyelid rejuvenation can yield dramatic results. Dynamic
rhytids in the crow’s-feet can be successfully treated with
botulinum toxin type A. Upper blepharoplasty has
become standardized, although recently there has been
a movement toward orbicularis- and fat-sparing
procedures. Lower blepharoplasty can be performed
using the skin-muscle flap or transconjunctival
techniques. Patients with tear-trough deformity may need
to undergo fat transposition and limited resection of
orbital fat. Significant double convexity deformity should
be treated with midface lifts and volume restoration
utilizing soft tissue fillers. Canthoplasty procedure should
be considered in patients with lower lid laxity. The
treatment considerations in eyelid rejuvenation should
always include addressing the aging changes affecting the
eyebrows and midface.

volume loss may increase the “skeletonization” of the face,
which is associated with an aged appearance.
The contribution of the nose to the aging face has also
gained increased attention. The importance of the nose to
the overall facial appearance is evident by its central
location and often overwhelming effect on the patient’s
sense of facial beauty. The skin, cartilage, and soft tissue
of the mid and lower thirds of the nose are malleable
unlike the nasal bone. Just like the rest of the midfacial
region, the nose is significantly affected by decades of
shearing forces and decreasing skin elasticity. Patients are
often under the impression that noses “get bigger” or
“continue to grow.” This is not completely incorrect.
Aging forces do cause the nasal tip to droop with time,
giving the impression that the lower third is indeed
“getting larger.” The nasal support structures also lose
strength over time. As such, the nasal base may widen and
buckling may become evident in noses that have not had
preceding trauma or surgery (Fig. 1-12). Rhinoplasty in
this patient population requires unique techniques to
address the complex anatomical changes of the nose.
Lower Face and Neck
The key elements of the lower third of the face are the
perioral region, jowls, chin projection, and neck. The
perioral region encompasses the lips, chin, and soft tissue
from the menton to the nasal base bordered by the
nasolabial folds. Several aging changes are noted here.
First, there is a loss of volume in the lips as they become
thinner over time, usually with the upper lip being more
affected. Vertical perioral rhytids form in a radial pattern
around the oral orifice secondary to the orbicularis oris
hypertrophy and decreased skin elasticity. These rhytids
are more common and difficult to treat in smokers.
Marionette furrows also emerge during this time as the
inferior extensions of the oral commissure and the
nasolabial lines. These furrows result from the descent of
the lower and midfacial tissue as they abut the rather
static soft tissue of the perioral area.
10
Mark R. Murphy • Calvin M. Johnson Jr. • Babak Azizzadeh
Figure 1-12 Frontal (A) and base (B) views of a patient with an aging
nose.
A
B
Treatment Considerations: The Midface
As a result of the complex three-dimensional anatomy,
facial analysis plays a vital role in the protocol for midface
rejuvenation. Aesthetic surgeons must utilize multiple
techniques to achieve satisfactory results in this difficult
region. Patients with early signs of aging can be treated
with soft tissue fillers to restore facial volume, efface the
nasobalial fold, and improve depressions near the lower
eyelid. Individuals with moderate midface ptosis without
significant volume loss can be surgically treated with deep
plane rhytidectomy or endoscopic midface lift. Patients
with advanced volume loss will additionally require
volume enhancements via fat grafting, submalar implants,
or volumizing fillers such as injectable poly-L-lactic acid.
Individuals with double convexity deformity may require
endoscopic midface lift, lower blepharoplasty, or soft
tissue fillers in order to efface the infraorbital rim and
improve the cavitary depression in the region.

Chin projection is another key component of the
lower third of the face. Similar to the malar eminence in
the midface, a strong mandible provides an advantageous
anatomic feature for facial rejuvenation. In addition to
congenital microgenia and orthognathic malocclusion, the
aging population can also develop soft tissue atrophy and
bony erosion of the symphyseal region leading to a
decreased chin projection. During the assessment, the
patient’s occlusion must be first evaluated (Table 1-3).
The chin position is then assessed from the lateral view.
Gonzalez-Ulloa developed a simple method based on the
Frankfort line to analyze facial and chin projection.26 The
Frankfort plane is a straight horizontal line drawn from
the supratragal notch to the infraorbital rim (see Fig.
1-6). A perpendicular line, designated as the 0° meridian,
is then drawn from the Frankfort plane at the level of the
nasion to determine the amount of chin projection. If the
pogonion is posterior to this line, the patient has
microgenia. In women, the 0° meridian is generally 1 to
2 mm anterior to the pogonion.
The jowls are perhaps the most prominent feature of
the aging face. The prejowl sulcus specifically results from
soft tissue and bony atrophy of the anterior mandibular
groove inferior to the mental foramen. Mandibular
erosion in edentulous patients can lead to an exaggeration
of the jowls and prejowl sulcus.
The last area of the lower face examined during the
consultation is the neck. In the appropriate candidate,
tremendous gains can be attained in the neck, ensuring a
satisfied patient. The young, attractive neck is one with
scant soft tissue in the submental area and a defined,
strong mandibular line. Several components of the aging
neck should be evaluated. The amount of submental fat
(superficial and deep to the platysma), platysmal
banding, hyoid position, skin redundancy and ptotic
submandibular glands should all be taken into account.
The Dedo cervical classification is a useful tool for neck
analysis (Table 1-4; Fig. 1-13).27 The hyoid should
CHAPTER 1
The Aging Face Consultation
11
Table 1-3
Edward Angle Dental Occlusion Classification
Angle Class
Description
Angle class I
The mesiobuccal cusp of the maxillary
(normal)
first molar articulates within the
mesiobuccal groove of the mandibular
first molar
Angle class II
The mandibular first molar articulates
(overbite)
distal to the mesiobuccal cusp of the
maxillary first molar
Angle class III
The mesiobuccal groove of the
(underbite)
mandibular first molar is mesial to the
mesiobucccal cusp of the maxillary first
molar
Table 1-4
Dedo Classification of Cervical Abnormalities
Class
Description
Class I
Minimal deformity
Well-defined cervicomental angle
Normal platysmal tone
Minimal fat accumulation
Class II
Cutaneous laxity
Normal platysmal tone
Class III
Accumulation of fat
Class IV
Platysmal banding
Class V
Retrognathia
Class VI
Low positioned hyoid
Treatment Considerations: Lower Face
The lower face and neck require a combination of
surgical and nonsurgical methods to achieve the best
possible aesthetic outcome. The perioral region, for
example, is a very difficult area to treat surgically. Soft
tissue fillers as well as skin resurfacing are indispensable
tools in the management of this area. The marionette
furrows are also not significantly improved with facelift
techniques and almost always require fat grafting or
injectable fillers.
Patients with microgenia and class I occlusion are
candidates for chin augmentation. Alloplastic chin
implants are straightforward procedures and represent an
excellent technique for chin augmentation in patients
with mild to moderate microgenia and shallow
labiomental sulcus. Sliding genioplasty is a technically
more demanding operation that should be reserved for
patients with vertical microgenia or deep labiomental
sulcus. Individuals with class II or III occlusion should be
referred for orthognathic surgical evaluation. If patients
with severe malocclusion do not desire orthognathic
surgery, they should be educated as to the limitations of
facial rejuvenation.
The jowls are very well treated with most types of
facelifts including the deep plane rhytidectomy, lateral
SMASectomy, and short-flap SMAS (superficial
musculoaponeurotic system) rhytidectomy. The prejowl
sulcus is difficult to address even with aggressive
facelifting techniques. Extended chin implants can
successfully address this region and should be
considered if this is an aesthetic complaint the patient
wants remedied.
Suction-assisted lipectomy, corset platysmaplasty, chin
augmentation, and cervicofacial rhytidectomy are
indispensable techniques for neck rejuvenation. Isolated
platysmal banding can be successfully treated with high
doses of botulinum toxin type A in patients who do not
desire surgical intervention.

12
Mark R. Murphy • Calvin M. Johnson Jr. • Babak Azizzadeh
Class I
Class II
Class III
Class IV
A
C
B
D
Figure 1-13 Dedo neck classification system. Class I patients have minimal deformity with well defined cervicomental angle, normal platysmal tone, and
minimal fat accumulation. Class II patients have cervical skin laxity with normal platysmal tone. Class III patients show signs of fat accumulation. Class IV patients
have platysmal banding.

ideally be situated at the level of the fourth cervical
vertebra. The hyoid at this position serves to create a
sharp demarcation of the cervicomental angle providing
the patient with an attractive angular appearance.
Individuals with anteriorly positioned hyoids do not
obtain satisfactory cervicofacial rhytidectomy results and
therefore should be appropriately consulted. The appear-
ance of the neck is also greatly affected by the surrounding
anatomy such as microgenia and excessive jowling.
IMAGING
PHOTOGRAPHY
Photography is an essential component of the consultation
process. Excellent standardized photographs allow better
communication between the surgeon and patient. Patient
photographs assist the surgeon in several different ways.
In the planning stages, photographs can display facial
features not readily obvious on the initial physical
examination. In the operating room, they act as a guide
when the patient is in the recumbent position and local
anesthesia has distorted the anatomy. Postoperatively, the
images serve as a reminder of the improvements gained
for both the patient and the surgeon. They enhance
communication between colleagues and are required for
medicolegal documentation.
In the last decade digital photography has overtaken
standard 35-mm film photography in many practices.
The images with digital photography are arguably not as
precise as those of film; however, the ease and economy of
this method have allowed it to become the preferred
medium for patient documentation. One of the key
advantages of digital imaging is the potential for savings.
There are three main costs involved with digital
photography: initial set-up, photograph development,
and storage. Although the initial set-up is more expensive
than standard photography, the processing, printing, and
storage of digital photographs can save a practice thousands
of dollars over the long term. Digital photographs can be
printed in the office, stored on a hard drive, and backed
up on a server for a nominal cost, whereas standard
photographs must be developed at an outside facility and
then stored, incurring additional physical space and labor
overhead. The printing of quality digital photographs is
CHAPTER 1
The Aging Face Consultation
13
Class V
Class VI
E
F
Figure 1-13 Continued. Class V individuals have retrognathia. Class VI patients have an anterior and low positioned hyoid bone.

relatively expensive at this point. But, in a similar pattern
to the costs of digital cameras, we expect this cost to
decrease over time. In addition, retrieval of digital images
for medicolegal, research or other reasons is far simpler
than for standard photographs, which are often stored in
cumbersome file cabinets. The accelerated evolution of
single lens reflex (SLR) digital photography will continue
to improve the quality of digital photographs.
There are several other advantages to choosing digital
over 35-mm film format. Standard 35-mm photographs
age poorly compared to the electronic format. There is
also the increased security of this medium, which allows
for remote storage to avoid loss from fire or other disaster.
Digital medium allows the surgeon to better present his or
her work during Power Point presentations. Last, the
digital medium allows the visualization of the images in
real time and permits instant communication with other
physicians when one is faced with complicated cases.
Two predominant factors determine the quality of
digital images: resolution and dynamic range. Resolution
is determined by the size and number of the individual
pixels. Dynamic range refers to the extent of the range of
color choices that exist for each pixel. When a camera
creates a digital image it converts the captured image into
numbers. This process divides the subject into distinct
numeric units. In digital photography, these units are
named pixels. The precision of replicating the captured
image relies on the number of pixels. Within each pixel
the camera assigns a particular value to represent the
color of the image. This function is dictated by the
hardware employed to take the photograph. Increasing
the color depth, referred to as the bit depth, increases the
dynamic range of the camera. Storage of full-color images
requires 24 bits of information per pixel. At this range,
the photographer can represent nearly 16 million colors,
allowing for film quality images.28
When the digital camera obtains an image, it focuses
light onto a specialized device called a charge-coupled
device (CCD) versus the film of standard photography.
The CCD then takes the light and converts it into
electrical signals. These signals are then processed by an
amplifier and sent to an analog-to-digital converter that
digitizes these signals. These digits are then processed by
a computer within the camera. The processed image is
then stored on a memory card.28 Two primary file formats
are employed by digital photographers for storage: TIFF
and JPEG. JPEG compresses images whereas TIFF does
not. Compression can save a significant amount of space,
at the cost of image quality. High-quality compression
ratios are generally in the 3:1 to 4:1 range. We prefer the
JPEG format for its ease of use in retrieving files and
minimized storage space. TIFF formats are uncompressed
and thus consume a significant amount of storage space.
Their advantage is superior preservation of data and lack
of compression artifacts seen with JPEG formats.
Currently, there is no general consensus on the
number of pixels required for digital cameras to match
the resolution of a 35-mm film. For most surgeons,
resolutions between 1.5 and 2.7 million pixels are more
than adequate. We prefer digital SLR systems for the
flexibility and greater image quality. In brief, the SLR
system is actually defined by its viewing system. Light
enters the SLR camera via the lens and strikes a mirror.
This mirror then directs the light to a focusing screen
where the image is resolved. A prism then inverts the
image to the viewfinder so that the photographer can view
the image properly. Owing to the dynamics of this system,
any slight change in focus, essential for excellent
photographs, can be viewed directly through the view-
finder as opposed to an image on an LCD screen in non-
SLR digital cameras. In addition, parallax errors, seen in
cameras that use a viewfinder that does not look through
the lens, are alleviated in SLR systems. SLR cameras also
provide superior depth-of-field perception.
A 1:1 aspect ratio, the ratio of an image’s length to its
width, is ideal. Most digital cameras use a 4:3 aspect ratio,
while some higher end cameras employ a 3:2 ratio.28 To
ensure a 1:1 image the size of the CCD must be known.
Consultation with the manufacturer should be under-
taken prior to purchasing a lens, a vital component of all
SLR systems.
Before purchasing digital equipment, the reader is
advised to consult with a local professional and the latest
publications because this technology is rapidly progressing.
The key to excellent, dependable digital photography is
the continual use of the same camera in an identical
fashion. Digital cameras are individually unique in the
way they capture images and thus it is recommended to
use the same camera in a dedicated photography room for
consistency. The photography room should be isolated
from daily light fluctuations and other variables that can
alter the image. The lighting methods, flash or lamps, is
an individual decision. This is true for either digital or
35-mm film. We prefer a tripod-mounted camera to
minimize shake and the slight movements that invariably
arise with handheld photographs. A fixed tripod also
minimizes the variable distance between the photog-
rapher and subject. Markings should be placed in the
room to ensure consistency. The patient should sit on a
rotating stool that allows for the recommended positions
without excessive manipulations. A light blue background
provides for a greater depth of field and thus a more
three-dimensional appearance than darker colors. The
background should be a solid color with a nonreflective
surface. All forms of glasses should be removed. In
addition, hair should withdrawn from the field either via
ties or headbands to ensure adequate evaluation of the
brow and upper lid complex. Standard reference points
should be created to further ensure consistent
photographs.29 Several standard views are required for
patient evaluation: frontal, left and right lateral, left and
right oblique, and close-up views of certain areas of con-
cern, predominantly the eyes (Fig. 1-14). The Frankfort
line should be parallel to the floor and is utilized to obtain
14
Mark R. Murphy • Calvin M. Johnson Jr. • Babak Azizzadeh

CHAPTER 1
The Aging Face Consultation
15
A
B
Figure 1-14 Standard photographic views for
patient evaluation. The Frankfort line is a straight
horizontal line drawn from the supratragal notch
to the infraorbital rim. This plane is used to obtain
consistent photographic results: frontal view (A),
left and right lateral views (B and C), left and right
oblique views (D and E), close-up views of the
eyes (F and G).
C
D
E
F
G

constant photographs. The Frankfort line is a straight
horizontal line drawn from the supratragal notch to the
infraorbital rim. The surgeon should be sure to obtain the
oblique view in a consistent manner as it can be acquired
from a variety of angles. Some have argued that the tip of
the nose should be in line with the opposite cheek.30
Others recommend less rotation, aligning the medial
canthus with the oral commissure.31
MORPHING SOFTWARE
Another component of digital photography that merits
discussion is that of morphing software programs. With
the use of these complex tools, patients can actually view
the proposed changes that are being discussed. These
programs assist in planning the procedure and guide
patients in exactly what they desire and the limitations of
what can be achieved. By employing these devices the
patient and surgeon can clearly articulate to one another
their respective goals. It also allows the surgeon to reveal
certain aspects of facial appearance that the patient may
not have fully appreciated. For example, patients are
often uninformed of the effect of chin projection on the
appearance of the nose. Obviously, such a powerful tool
must be used with caution. The patient must be
consistently reminded that these are computer images and
should not be taken as a guarantee of results. This
technology also has its shortcomings. It excels at two-
dimensional manipulations such as dorsal hump reduction
but does not perform as well with three-dimensional
changes. Other components of the program, such as facial
resurfacing, are also not optimal. In summary, this tool
has several unique advantages that must be employed
wisely by the facial cosmetic surgeon.
REFERENCES
1. Gonzales-Ulloa M: A quantum method for the appreciation of
the morphology of the face. Plast Reconstr Surg 1964;36:241.
2. Patzer GL: The Physical Attractiveness Phenomena.
New York: Plenum Press, 1985, p 16.
3. Romm S: The Changing Face of Beauty. Baltimore: Mosby
Year Book, 1992.
4. Ricketts RM: Divine proportion in facial esthetics. Clin Plast
Surg 1982;9:401.
5. Langlois JH, Roggman LA, Casey RJ, et al: Infant preferences
for attractive faces. Dev Psychol 1987;23:363.
6. Langlois JH, Roggman LA: Attractive faces are only average.
Psychol Sci 1990;1:115.
7. Perrett DI, May KA, Yoshikawa S: Facial shapes and judgment
of female attractiveness. Nature 1994;368:239.
8. Richter GMA: The Sculpture and Sculptors of the Greeks.
New Haven: Yale University Press, 1970, p 200.
9. Gardner EA: Six Greek Sculptors. London, Duckworth, 1910.
10. Tolleth H: Concepts for the plastic surgeon from art and
sculpture. Clin Plast Surg 1987;14:585.
11. Richter GMA: The Sculpture and Sculptors of the Greeks.
New Haven: Yale University Press, 1970, p 212.
12. Seghers MJ, Longacre JJ, de Stefano GA: The golden
proportion and beauty. Plast Reconstr Surg 1964;34:382.
13. Brophy J: The Face in Western Art. London: Harrup, 1963.
14. Pastorek N: Preoperative ophthalmic evaluation is a personal
choice. Arch Otolaryngol Head Neck Surg 2001;127(6):724.
15. Tarbet KJ: Ophthalmic evaluation should be a preoperative
requirement prior to blepharoplasty. Arch Otolaryngol Head
Neck Surg 2001;127(6):723.
16. Burke AJ, Wang T: Should formal ophthalmologic evaluation
be a preoperative requirement prior to blepharoplasty? Arch
Otolaryngol Head Neck Surg 2001;127(6):719.
17. Fitzpatrick RA: Facial resurfacing with the pulsed carbon
dioxide laser. A review. Facial Plast Surg Clin North Am
1996;4(2):236.
18. Fitzpatrick TB: The validity and practicality of sun-reactive
skin types I through VI. Arch Dermatol 1988;124(6):869.
19. Ellenbogen R: Transcoronal eyebrow lift with concomitant
upper blepharoplasty. Plast Reconstr Surg 1983;71:490.
20. Cook TA, Brownrigg PJ, Wang TD, et al: The versatile
midforehead browlift. Arch Otolaryngol Head Neck Surg
1989;115:163.
21. Rafaty FM, Brennan G: Current concepts of browpexy. Arch
Otolaryngol 1983;109:152.
22. Goldberg RA, Edelstein C, Balch K, et al: Fat repositioning in
lower eyelid blepharoplasty. Semin Ophthalmol
1998;13(3):103.
23. Muzaffar AR, Mendelson BC, Adams WP Jr: Surgical anatomy
of the ligamentous attachments of the lower lid and lateral
canthus. Plast Reconstr Surg 2002;110(3):873, discussion
897.
24. Beehuis GJ: Blepharoplasty. Otolaryngol Clin North Am
1982;15:1979.
25. Holt JE, Holt GR: Blepharoplasty: Indications and pre-
operative assessment. Arch Otolaryngol 1985;111:394.
26. Gonzalez-Ulloa M, Stevens E: The role of chin correction in
profileplasty. Plast Reconstr Surg 1968;41(5):477.
27. Dedo DD: A preoperative classification of the neck for
cervicofacial rhytidectomy. Laryngoscope 1980;90:1894.
28. Long B: Complete Digital Photography, 2nd ed. Hingham,
Mass: Charles River Media, 2003, p 485.
29. Powell N, Humphrey B: Proportions of the Aesthetic Face.
New York: Thieme-Stratton, 1984.
30. Zarem HA: Standards of photography. Plast Reconstr Surg
1984;74:137.
31. Ellenbogen R, Jankauskas S, Collini FJ: Achieving
standardized photographs in aesthetic surgery. Plast Reconstr
Surg 1990;86(5):955.
16
Mark R. Murphy • Calvin M. Johnson Jr. • Babak Azizzadeh

EMBRYOGENESIS
Embryogenesis is a dynamic multiple-step process that
begins when an oocyte from a female is fertilized by the
sperm from a male (the pre-embryonic period). The first
2 weeks after fertilization focuses on rapid proliferation
and differentiation of the embryo with subsequent
implantation of the egg into the wall of the uterus. Also,
the development of the amniotic cavity and the embryonic
disc gives rise to the three germ layers of the embryo
during this period.
The start of the third week marks the beginning of
the embryonic period (weeks 3 through 8) and is
characterized by the formation of the primitive streak,
notochord, and the three germ layers (ectoderm,
endoderm, and mesoderm) from which all embryonic
tissues and organs develop.1 The ectoderm gives rise to
structures such as the epidermis and nervous system. The
linings of the respiratory system and gastrointestinal
tracts as well as certain glandular organs arise from the
endoderm layer. The mesoderm is the source of muscle,
bone, connective tissue, and blood vessels. The embryonic
period is of particular importance because most organ
systems develop during this time, and by the end of the
eighth week the embryo has a distinctly human appear-
ance. However, because the origins of major structures
are established during this critical phase, congenital
abnormalities may first appear at this time if there is any
teratogenic exposure to the embryo.
The fetal period spans from the ninth week after
fertilization to the birth of the fetus. This period is charac-
terized by rapid growth and maturation of the developing
organ systems. Head growth slows significantly in
comparison to growth of the fetal body.
This chapter focuses on aspects of embryogenesis that
pertain to facial plastic and reconstructive surgery.
Embryology of the branchial/pharyngeal arches and their
derivatives, orbit/eyelid complex, auricle, face, nose, and
palate will be discussed in detail. A description of facial
anatomy will follow.
EMBRYOLOGY
THE BRANCHIAL/PHARYNGEAL APPARATUS
The branchial, or pharyngeal, apparatus greatly con-
tributes to the formation of the head and neck and begins
to form during the fourth week of gestation.2 This
apparatus consists of branchial arches, pharyngeal
pouches, branchial grooves, and branchial membranes.
By the end of the fourth week of gestation, four well-
defined arches are visible on the external surface of the
embryo. The fifth arch (also referred to as the sixth arch,
depending on the theory one follows) is also present but is
not visible externally (Fig. 2-1A). Each arch is composed
of mesoderm-derived mesenchymal tissue and contains an
aortic arch artery, a branchiometric nerve, a cartilaginous
bar, and a muscle component.3 These arches are sep-
arated by prominent grooves, or clefts, which are derived
from ectoderm, and pharyngeal pouches that are lined by
endoderm. As the grooves develop, they push medially
through the surrounding mesenchyme and approach the
medially positioned pharyngeal pouches.
The first branchial arch is often referred to as the
mandibular arch and plays a significant role in the devel-
opment of the face. This arch develops one small promi-
nence, which forms the maxilla, zygoma, and squamous
portion of the temporal bone, and one large prominence,
which forms the mandible. Important structures that arise
from this arch are the muscles of mastication, the
maxillary artery, and cranial nerve V3 (CN V3). Other
derivatives from the first arch are listed in Table 2-1.
The second branchial arch is also known as the hyoid
arch. Around the fifth week of development, this arch will
overgrow the third and fourth arches, resulting in the
formation of the cervical sinus of His (Fig. 2-1B). This
sinus and the second, third, and fourth branchial grooves
subsequently obliterate, resulting in the smooth contour
of the neck. Failure of this area to fully obliterate may
possibly lead to the formation of a branchial sinus.4 Table
2-1 lists the second through fifth arch derivatives.
Facial Embryology and Anatomy
Carlo P. Honrado, MD • Dewayne T. Bradley, MD • Wayne F. Larrabee Jr., MD, FACS
17
C H A P T E R T W O

Corresponding to each branchial groove are pharyn-
geal pouches, which represent outpouchings of the primitive
pharynx. These pouchings are lined by endoderm and
also push through the surrounding mesenchyme during
the fourth and fifth weeks of the embryonic period. Each
pouch contains a ventral and dorsal wing and gives rise to
several important organs such as the parathyroid glands
and thymus.5
EMBRYOLOGY OF THE EXTERNAL EAR
The first sign of the developing ear is seen by the presence
of the otic disc, which appears as a thickening on the
surface of the ectoderm at the end of the third week of
gestation.6 The disc soon invaginates and is called the
otic pit.
Six small elevations known as hillocks develop at the
dorsal ends of the first and second arches (Fig. 2-2). The
18
Carlo P. Honrado • Dewayne T. Bradley • Wayne F. Larrabee Jr.
Figure 2-1 Lateral view of a human embryo at approximately 4 weeks (A). During the fifth week of development, the second arch overgrows the third
and fourth arches, forming the cervical sinus of His (B).
Table 2-1
Structures Derived from the Branchial (Pharyngeal) Arches
Arch
Cranial Nerve
Skeletal Structure
Muscles
Ligaments
I (mandibular)
Trigeminal (V3)
Meckel’s cartilage:
Muscles of mastication,
Anterior ligament of
malleus head and neck,
tensor tympani, tensor
malleus,
incus short process and
veli palatini, stylohyoid,
sphenomandibular
body, mandible
anterior belly of digastric
ligament
II (hyoid)
Facial (VII)
Reichart’s cartilage:
Muscles of facial expression, Stylohyoid ligament
malleus manubrium,
stapedius, stylohyoid,
incus long process and
posterior belly of digastric,
lenticular process, stapes,
buccinator
styloid process, lesser
cornu of hyoid, upper part
of hyoid body
III
Glossopharyngeal (IX)
Greater cornu of hyoid,
Stylopharyngeus, superior
lower part of hyoid body
and middle constrictors
IV
Superior laryngeal (X)
Thyroid cartilage,
Inferior constrictor,
cuneiform cartilage
cricopharyngeus, cricothyroid
V/VI
Recurrent laryngeal (X) Cricoid, arytenoid, and
Intrinsic laryngeal muscles
corniculate cartilages,
(except cricothyroid)
trachea
A
B

CHAPTER 2
Facial Embryology and Anatomy
19
1
2
3
4
5
6
1
3
4
5
6
1
3
4
5
2
Figure 2-2 Formation of the external ear during the sixth week of
development (A–C). Shown are the six hillocks.
A
C
B

first branchial groove, which is located between the first
and second arches, deepens and canalizes to form the
external auditory canal. The first three hillocks arise
anteriorly from the mandibular arch, and the other three
hillocks develop from the hyoid arch.7 These hillocks will
gradually fuse to form the auricle of the external ear.
Although there is much controversy, it is generally
accepted that the tragus, helical crus, and helix are formed
from the mesodermal components of the first arch,
corresponding to the first, second, and third hillocks, and
that the fourth through sixth hillocks from the second
arch give shape to the antihelix, antitragus, and lobule,
respectively. By the 20th week of development, an
anatomically complete ear can be seen. The final shape of
the auricle is determined by the intrinsic and extrinsic
muscles of the ear that cause plical folding of the cartilage.8
Initial positioning of the auricle lies in the ventro-
caudal part of the neck region.1 But as the mandible
develops, the developing ear is pushed in a dorsocranial
direction and subsequently lies on the side of the head at
the level of the eyes by approximately the 32nd week of
gestation.
Most abnormalities of the ear, such as anotia or
microtia, arise from insults that occur during the first
7 weeks of gestation.
EMBRYOLOGY OF THE EYE
Eye formation is evident by the beginning of the fourth
week and has its origins from neuroectoderm, ectoderm,
and mesoderm. Thickening of the surface ectoderm in the
area of the future eye occurs in response to signals
produced by the optic vesicles, which are evaginations
from the brain. This thickening results in the formation of
the lens placodes. The central portion of the placode
invaginates to form the lens pit, which subsequently
separates from the surface epithelium to form a spherical
lens vesicle, the precursor of the lens of the eye.
During the fifth week of embryogenesis, small
depressions develop above and below the eye, forming the
primitive upper and lower eyelids.9 As they become more
distinct during the embryonic period, the lids approach
each other and subsequently fuse by the ninth week. Prior
to fusion, the lacrimal gland and its ducts also develop.
Mesodermal components are responsible for the formation
of the ocular muscles, orbicularis oculi muscle, and tarsus,
which develop while the eyelids are fused. Separation of the
eyelid complex begins during the 20th week in an anterior
to posterior fashion and takes approximately 3 weeks.3
EMBRYOLOGY OF THE FACE AND NOSE
The embryology of the face begins early in the fourth
week around a large stomodeum, which becomes the
future mouth. Proliferation of neural crest cells occurs in
the developing brain and migrate to form, together with
mesodermal cells, the facial primordia. These neural crest
cells play a major role in forming the bone, cartilage, and
ligaments of the facial region. Five facial primordia
appear as prominences around the stomodeum: the single
median frontonasal prominence and the paired maxillary
and mandibular prominences (Fig. 2-3).
Facial development continues until around the eighth
week of gestation. The frontonasal prominence is
primarily responsible for forming the forehead and the
nose. However, the first part of the face to form is the
mandible and lower lip. This occurs from the medial
migration and fusion along the median plane of the two
mandibular prominences. Toward the end of the fourth
week, bilateral thickenings, called nasal (olfactory)
placodes, occur on the surface of the ectoderm on the
ventrolateral part of the frontonasal prominence. The nasal
placodes initially are convex but subsequently invaginate
during the sixth week. Mesenchymal proliferation also
occurs around the rim of the placodes, creating elevations
known as the medial and lateral nasal prominences. The
depressed nasal placodes are now referred to as nasal pits,
which are the primordia of the nostrils and nasal cavities
(Fig. 2-4). Owing to the continuing proliferation of the
nasal prominences, the nasal pits deepen and are called
nasal sacs.
Proliferation of the paired maxillary prominences also
occurs during this period. They migrate medially and
contact the medial and lateral nasal processes. Lying
between the maxillary prominence and the lateral nasal
process is the nasal groove, which marks the future site of
the nasolacrimal duct. Merging of the medial nasal
process and maxillary prominences results in continuity of
the lip and upper jaw with formation of the philtrum,
premaxilla, and primary palate (Fig. 2-5). Separation of
the nasal pits from the stomodeum also occurs. Failure of
20
Carlo P. Honrado • Dewayne T. Bradley • Wayne F. Larrabee Jr.
Frontal process
Nasal placodes
Maxillary prominences
Mandibular prominences
Figure 2-3 The five facial primordia comprise the frontal prominence,
the paired maxillary prominences, and the paired mandibular prominences.
The nasal placodes are also shown.

the maxillary prominences to fuse results in cleft lip and
palate deformities.
Proliferation of mesenchyme from the first and second
branchial arches results in formation of the muscles in the
face. Mesenchyme from the first arch differentiates into
the muscles of mastication, which are innervated by the
fifth cranial (trigeminal) nerve. The muscles of facial
expression arise from mesenchyme from the second
branchial arch with their nerve supply coming from the
seventh cranial (facial) nerve.
EMBRYOLOGY OF THE NASAL CAVITY AND
PARANASAL SINUSES
As mentioned in the earlier section, the nasal placodes
become depressions called nasal pits. Proliferation of the
mesenchyme around the pits results in formation of the
medial and lateral nasal prominences and deepening of
the pits to form nasal sacs. The nasal sacs lie ventral to
CHAPTER 2
Facial Embryology and Anatomy
21
the developing forebrain and they migrate in a dorsal-
caudal direction. An oronasal membrane separates the
sacs from the oral cavity. This membrane subsequently
ruptures, allowing the oral cavity to communicate with
the nasal cavity in the area of the nasopharynx.
The inferior, middle, and superior turbinates arise
from elevations on the lateral nasal wall. Diverticuli also
occur along the lateral nasal walls, which will give rise to
the future sinuses, which are pneumatic extensions of the
nasal cavities. Only the maxillary and ethmoid sinuses are
present at birth. The frontal sinus develops from an
anterior ethmoid air cell at about 2 years of age. The
sphenoid sinus also develops around age 2 and arises from
a posterior ethmoid air cell.
The nasal septum arises from portions of the merged
medial nasal prominences. In addition, ectoderm along
the roof of the nasal cavities differentiates to form the
olfactory epithelium. Some of these cells become receptor
cells and form the olfactory bulb of the brain.
EMBRYOLOGY OF THE PALATE
The formation of the palate occurs between the 6th and
12th weeks of gestation. The primary palate, also known
as the median palatine process, begins to form from the
innermost portion of the intermaxillary segment of the
maxilla. This segment is formed by the fusion of paired
median nasal processes and maxillary prominences. The
primary palate ultimately forms the premaxilla and
represents only a portion of the hard palate that lies
anterior to the incisive foramen.
The secondary palate is embryologically distinct from
the primary palate and begins to develop during the eighth
week. Formation of the secondary palate results from inferior
and medial growth and migration of the mesenchymal
projections called the lateral palatine processes of the
maxilla, also known as the palatal shelves. The palatal
shelves are initially separated by the tongue. With growth of
the mandible, the tongue moves anteriorly, allowing the
shelves to assume a more horizontal orientation.10
The sequence of normal palatal formation begins
when the nasal septum and the palatal shelves come into
contact. Closure occurs in an anterior to posterior direc-
tion starting at the incisive foramen. Bone formation also
occurs during this period, completing the rest of the hard
palate. Posteriorly, this area does not become ossified,
resulting in the soft palate.
The degree of clefting that can occur from failure of
proper fusion can range from a bifid uvula to a complete
cleft of the secondary palate.
FACIAL ANATOMY
Considerable effort has been made over recent years to
understand facial anatomy. Anatomy traditionally taught
Nasal pit
Lateral nasal prominence
Medial nasal prominence
Maxillary prominence
Figure 2-4 Appearance of the nasal pits from growth of the medial and
lateral nasal processes.
Maxillary prominence
Mandibular prominence
Nasolacrimal groove
Philtrum
Figure 2-5 The nasolacrimal groove forms between the lateral nasal
process and maxillary prominence.

in medical school has failed to describe the complex
relationships that are of interest to surgeons and does not
highlight aspects relevant to surgical approaches. Several
texts have approached the topic of surgical facial
anatomy, as it forms the foundation of all facial plastic
surgical procedures. Nowhere in the body is the anatomy
as complex as in the head and neck region. In this section
of the chapter we have summarized the relevant anatomic
relationships for facial rejuvenation, highlighting critical
features for each of the anatomic regions. The areas
critical to the aging face are presented as the following
regions: eyelid/orbit, forehead/brow, hair/scalp, cheek/
midface, lip/chin, and neck. Each region is reviewed
based on its underlying skeletal framework, skin and soft
tissue covering, motor innervation, sensory innervation,
and lymphovascular supply to facilitate understanding of
complex anatomic relationships. Areas such as the nose
and ears have not been covered to allow a more complete
review of areas most relevant to the aging face.
EYELID AND ORBIT
Skeletal Framework
The orbit forms a roughly conical structure with the base
surrounded by the orbital rim. The orbital rim is
primarily composed of the frontal, zygomatic, and
maxillary bones (Fig. 2-6). The remainder of the orbit has
contributions from the maxilla, sphenoid, frontal,
ethmoid, zygomatic, and lacrimal bones. The orbital rim
is relatively thick bone and is the site of circumferential
periosteal attachment called the arcus marginalis and is
clinically relevant as encountered during endoscopic
forehead lifts with release being essential for mobilization.
Additionally, the orbital rim is the site of orbital septal
attachment. The floor and medial walls, in contrast to the
rims, are thin and easily fractured. Whitnall’s tubercle is
an anatomically important area as it is the site of lateral
canthal tendon attachment. This area is not easily
identified intraoperatively, and its position must be
estimated clinically. Anatomically, it forms a prominence
approximately 5 mm posterior to the lateral orbital rim
and is important when reconstructing the lateral canthal
tendon, as when performing a canthopexy or tarsal strip
procedure. The lateral orbital rim is also a useful land-
mark during numerous surgical procedures and in
assessing eye position. For example, the eye is described
as exophthalmic or enophthalmic, based on the distance
from the lateral orbital rim to the apex of the cornea.
Normally, the apex of the cornea is 12 to 16 mm from
the rim. The bony foramina for the ethmoid arteries are
present on the medial orbital wall. The anterior ethmoid
is approximately 24 mm from the anterior lacrimal crest.
The posterior ethmoid is 12 mm from the anterior
ethmoid. The orbital apex is found 6 mm from the
posterior ethmoid.2
Myocutaneous and Soft Tissue Covering
The skin of the eyelid is very thin and elastic, covering the
orbicularis oculi muscle with little intervening subcu-
taneous fat (Fig. 2-7). The underlying orbicularis muscle
is divided into the palpebral and orbital portions. The
palpebral portion is further subdivided into the pretarsal
and preseptal portions (Fig. 2-8). The orbital septum is
encountered deep to the orbicularis and extends from the
orbital rim down to where it fuses with the levator
22
Carlo P. Honrado • Dewayne T. Bradley • Wayne F. Larrabee Jr.
Zygomaticotemporal
foramen
Zygomatic bone
Zygomaticofacial
foramen
Maxillary bone
Figure 2-6 The orbit is composed of several facial bones.
Figure 2-7 The skin of the eyelid and its relationship to the orbicularis
oculi muscle.
Orbital septum
Orbicularis m.
Levator apononeurosis
Müllers m.
Tarsus
Tarsus
Capsulopalpebral
fascia
Septum

palpebrae aponeurosis (see Fig. 2-7). The levator attaches
near the orbital apex and extends to insert on the front
face of the tarsal plate. The levator does not insert on the
superior edge of the tarsus, and thus exposure of the
tarsus, as in a gold weight procedure, requires
reconstruction of this layer to prevent ptosis. Deep to the
levator is Müller’s muscle, which assists in upper lid
elevation (see Fig. 2-7). As mentioned previously, the
fusion of the levator muscle and orbital septum along with
levator fibers interdigitate with the dermis of the eyelid
skin, forming the lid crease (Fig. 2-9). The configuration
of the levator insertion into the overlying skin and muscle
shows racial variability.11 The absence of dermal attach-
ments of the levator contributes to the absence of a
supratarsal crease seen in Asian eyelids. Deep to the
orbital septum are the orbital fat compartments. The
upper lid has a medial and central compartment with
the lacrimal gland occupying the lateral compartment.
The superior oblique muscle divides the medial and
central compartments (Fig. 2-10).
The lower eyelid has a similar structure with a few
notable differences. The lower lid retractors comprise the
inferior tarsal muscle and capsulopalpebral fascia (see
Fig. 2-7). The lower lid retractors fuse with the orbital
septum 2 to 3 mm below the edge of the tarsus, which is
crucial when approaching the orbital fat via a transcon-
junctival approach or the orbital rim in a preseptal
approach. The orbital fat in the lower eyelid is separated
into lateral, medial, and central compartments with the
inferior oblique separating the latter two (see Fig. 2-10).
The canthal tendons are fascial condensations that
extend medially and laterally. Laterally the canthal tendon
attaches to a bony region called Whitnall’s tubercle, which
has been reviewed. Medially the canthal tendon has an
anterior and a posterior leaf that insert anteriorly and
posteriorly on the lacrimal fossae, respectively. This
arrangement is thought to create a pumping action and
facilitate tear drainage.
Several anatomic areas of the periorbital region are
relevant to the management of the aging face and worthy
of specific mention. First, is the SOOF (suborbicularis
oculi fat), which is a fat pad that lies beneath the orbicu-
laris oculi; its descent leads to skeletonization of the
rim. ROOF (retro-orbicularis oculi fat) lies deep to the
superior orbicularis oculi; in this supraorbital position it is
encountered when the surgeon is performing the inferior
dissection during a brow lift and releasing the arcus
marginalis. The superior portion of the malar fat pad can
also contribute to aging as additional hollowing of the
CHAPTER 2
Facial Embryology and Anatomy
23
Orbital
Preseptal
Pretarsal
Preseptal
Orbital
Figure 2-8 The orbicularis oculi has several constituent components.
Orbital fat
Orbital septum
Orbicularis m.
Levator aponeurosis
Tarsal plate
Figure 2-9 The upper eyelid and the relationship of the orbital septum,
orbicularis oculi, and orbital fat are illustrated. Note the tarsal plate and
levator aponeurosis relationship with the levator attaching to the anterior
surface of the tarsus and interdigitating with the skin at the lid crease.
Middle fat pad
Medial fat pad
Lateral fat pad
Central fat pad
Medial fat
pad
Inferior oblique m.
Figure 2-10 The fat components of the upper and lower lids. Please
note the upper lid contains only two pockets, whereas the lower contains
three.

orbital rim is noticed with its descent. Normally its
superior portion lies over the malar eminence and
smooths the contour with the SOOF of the orbital rim.
The nasojugal fold region corresponds to the fold formed
by the eyelid, cheek, and nose in the medial orbit. When
this area is deep it is referred to as a tear trough deformity.
Last, festoons represent hypertrophied orbicularis oculi
muscle that manifests as folds seen over the lower eyelid
into the malar region.2
Innervation
Motor innervation of the orbicularis oculi is supplied by
branches of the facial nerve. Müller’s muscle is controlled
by sympathetic fibers, and interruption of these fibers
causes ptosis, as in Horner’s syndrome. The levator palpe-
brae is innervated by the oculomotor nerve. Sensory
supply consists of branches from V1 and V2, including
the supraorbital, infraorbital, and supratrochlear nerves.12
Lymphovascular Supply
The eyelid has extensive blood supply with contributions
from multiple sources. The tributaries include the angular,
transverse facial, ophthalmic primarily through the
supraorbital, supratrochlear and dorsal nasal extensions,
infraorbital, zygomaticofacial, and lacrimal arteries. The
main result of these numerous blood supply sources is
the formation of a superior and inferior marginal arcade.
The marginal arcade parallels the lid margin and is
supplied by the medial and lateral palpebral arteries,
which receive blood from many sources as just named.
The venous drainage parallels the named arterial supply.
Particularly notable is that the venous drainage occurs via
both a superficial and a deep route. The deep route occurs
via the orbit and ends in the cavernous sinus. This
valveless system is a possible route of infectious spread.
As a result, infections in this region are taken very
seriously to avoid the dreaded complication of cavernous
sinus thrombosis. Lymphatic drainage occurs primarily to
the parotid area and it is not unusual to see preauricular
lymphadenopathy with severe conjunctivitis. A small
portion of lymphatic drainage from the medial portion of
the lower lid and medial canthal region occurs to the
submandibular region.12
FOREHEAD AND BROW
Skeletal Framework
The underlying calvarium is composed of the thick frontal
bone centrally and the thinner temporal fossae. The
temporal region has contributions from the frontal, greater
wing of the sphenoid, parietal, and temporal bones. The
supraorbital rim varies in prominence and thickness and
contributes to the overall contour of the brow. The frontal
bone is very strong and has a thick outer table,
intervening frontal sinus, and thin inner table.12
Myocutaneous and Soft Tissue Covering
The frontal bone is covered centrally by periosteum that
is adherent at the superior temporal line and at the
supraorbital rim in an area referred to as the arcus
marginalis. The surgeon must release the arcus marginalis
when performing a subperiosteal browlift in order to
adequately mobilize the brow. The galea is a facial sheet
that splits and envelops the frontalis muscle, which is the
primary elevator of the brow. The galea sends dermal
attachments just above the brow, which forms its origin.
Laterally, the galea attaches to the superior temporal line
forming an area of confluence with periosteal attachments
and temporalis muscle fascial attachments referred to as
the conjoint tendon or fascia. The frontalis muscular action
is to elevate the brows and can contribute to transverse
forehead rhytids. Laterally, multiple layers contribute to
the temporal fossae and are of critical importance when
both open and endoscopic browlift procedures are
performed. This area can be confusing partially because
of inconsistencies and variability in nomenclature.
Starting superficially the skin is encountered, followed by
the temporoparietal fascia (TPF) with superficial
temporal arterial branches running within it. Just deep to
the TPF is a thin layer of fat sometimes referred to as the
superficial temporal fat pad. The frontal branch of the
facial nerve runs in the superficial temporal fat pad and
clinically is found on the undersurface of the TPF in this
thin layer of fat. The temporalis fascia proper or deep
temporal fascia attaches to the superior temporal line
anchoring the temporalis muscle to the skull. The
temporalis muscle extends inferiorly from its superior fan
shape to insert on the coronoid process. The deep temporal
fascia lies on the surface of the temporalis muscle and
extends inferiorly, splitting into two leaves, the superficial
layer and the deep layer of the deep temporal fascia.
Between the two layers is the intermediate temporal fat
pad (Fig. 2-11). The temporal fat pad sits on top of the
zygomatic arch and is enveloped by the superficial and
deep layer of the temporalis fascia as it attaches to the
anterior and posterior edge of the arch, respectively. This
relationship is important to appreciate because the frontal
branch of the facial nerve lies just superficial to the
superficial layer of the deep temporal fascia at the level of
the zygomatic arch. Therefore, it is important to stay in
the immediate subcutaneous plane or deep to superficial
layer of the deep temporal fasciae when dissecting in the
area of the arch.2
Please note that the TPF is sometimes referred to as
the superficial temporal fascia and the deep temporal
fascia as the temporalis fascia proper. In addition, the fat
pad between the layers of temporalis fascia as it envelops
the arch is also referred to as the temporal fat pad, as the
thin layer of adipose tissue just deep to the TPF is not
very distinct, and many authors do not refer to it as a
separate structure.
24
Carlo P. Honrado • Dewayne T. Bradley • Wayne F. Larrabee Jr.

Several muscles play important roles in the aging
forehead and include the procerus and the corrugator
supercilii muscle. The procerus extends in an upside-
down pyramidal shape from the nasal bones up to where
it inserts into the overlying subcutaneous tissue. The
corrugator begins at the superior medial orbital rim and
travels in an oblique direction to its dermal attachments.
During the corrugator’s course it pierces the orbicularis
oculi and frontalis muscle. The corrugator runs through a
small fat pad just on the undersurface of the galea
enveloped frontalis muscle, the retro-orbicularis oculi fat
pad. Both the procerus and the corrugator function as
brow depressors. The corrugator action leads to vertical
rhytids in the glabellar region and horizontal rhytids are
created by the procerus (Fig. 2-12). The corrugator has
an intimate relationship with the neurovascular supply of
the forehead as well. The supratrochlear and supraorbital
neurovascular bundles exit the orbit and travel superficial
to the corrugator before piercing the frontalis muscle
approximately 1.5 cm above the rim.
Innervation
Multiple nerves serve both sensory and motor functions
that come into play in the forehead and temporal regions.
The frontal branch of the facial nerve proceeds obliquely
over the arch to provide motor supply to the frontalis
muscle. Because the frontal division is a terminal branch
with little cross innervation, as seen in the buccal region,
injury can lead to significant loss of function. The pattern
of facial nerve branching is quite variable; however,
several landmarks can be used to guide the surgeon as to
the location of this branch. One method described by
Correia and Zani is that the temporal division lies in the
triangular region marked by the inferior attachment of
the ear lobe, brow, and superior forehead crease (Fig.
2-13).13 Additional landmarks use the halfway point
between the lateral edge of the lateral orbital rim and the
root of the helix. Three to five branches generally traverse
the arch in this region. Last, all the branches run anterior
to the superficial temporal vessels and approximately
2 cm posterior to the anterior end of the zygomatic arch
(Fig. 2-14).14
The sensory supply to the forehead region is primarily
from the ophthalmic division of the trigeminal nerve via
the supraorbital and supratrochlear nerves. Laterally, the
auriculotemporal and zygomaticotemporal nerves make
smaller contributions. The relationship of the supraorbital
and supratrochlear nerves to the corrugator has already
been described as they run with the arteries of the same
name and has clinical relevance when sectioning the
corrugator muscle during a brow lift. The supraorbital
nerve emerges either from a notch or foramen that lies
roughly in the midpupillary line. The supraorbital nerve
divides into a superficial and deep branch, supplying the
medial and lateral forehead, respectively. The supra-
trochlear nerve runs vertically approximately 2 cm lateral
to the midline, which corresponds closely to the medial
brow. The supratrochlear nerve then pierces the
CHAPTER 2
Facial Embryology and Anatomy
25
Galea
Temporoparietal
fascia
Deep temporal
fascia
Temporalis m.
Temporal fat pad
Facial n.
Zygomatic arch
Deep temporal
fat pad
Mandible
Parotid duct
Parotid gland
SMAS
Masseter m.
Platysma m.
Figure 2-11 The SMAS (superficial musculoaponeurotic system) is a
fibrofatty layer that transmits the actions of the muscles of facial expression
to the overlying skin. This coronal section illustrates the relationship of the
SMAS with the parotid gland, zygomatic arch, temporalis fascia, and
temporoparietal fascia (TPF). Note that the frontal branch of the facial nerve
is intimately associated with the TPF.
Figure 2-12 The musculature of the brow is responsible for creation of
rhytids in this area, depending on the vector of muscle contraction.
Frontalis m.
Corrugator m.
Procerus m.

orbicularis oculi and frontalis obliquely starting at the
superior brow and then running just superficial to
the frontalis.2
Lymphovascular Supply
The blood supply to the forehead and brow comes from
multiple sources including the supraorbital, supratrochlear,
dorsal nasal, infratrochlear, and superficial temporal
arteries. The vascular pattern of the supraorbital and
supratrochlear arteries parallel the pattern just described
for the corresponding nerves. The venous drainage is by
named veins that correspond to the arterial supply. The
so-called sentinel vein is a prominent venous tributary
found in the region of the zygomaticofrontal suture and is
a branch of the zygomaticotemporal vein. Other branches
can often be appreciated as the dissection is carried
inferiorly past the zygomaticofrontal suture. Lymphatic
drainage occurs primarily to the parotid region, postau-
ricular nodes, and occipital and submandibular nodes.
SCALP AND HAIR
Skeletal Framework
The skeletal framework is described by overlapping terms
that include the calvarium, cranium, and skull. The skull
includes the bones of the head, face, and mandible. In
contrast, the cranium includes the skull without the
mandible and the calvarium includes the cranium without
the skull base and generally is considered to be the region
above the supraorbital rim. The underlying calvarial bone
is membranous bone with a thicker outer table of cortical
bone and a thinner inner table of cortical bone
sandwiching an intervening layer of cancellous bone. The
frontal bone, occipital bone, and paired parietal bones
make up the calvarium.12
Myocutaneous and Soft Tissue Covering
The scalp consists of layers that start with the skin
superficially and overlie subcutaneous tissue. The galea is
26
Carlo P. Honrado • Dewayne T. Bradley • Wayne F. Larrabee Jr.
Figure 2-13 Landmarks for the facial nerve are depicted by drawing a
line from the auricular lobule to the lateral brow and to the superiormost
forehead crease. Within this triangular region at the level of the arch the
nerve is very superficial and is not protected by the parotid gland or muscle.
Figure 2-14 Landmarks for the frontal branch of the facial nerve. Note
that the anterior rami runs approximately 2 cm posterior to the anterior end
of the zygomatic arch.

the next layer encountered and is a thin, fibrous
aponeurosis that surrounds the frontalis and occipitalis
anteriorly and posteriorly, respectively. The galea is
separated from the adherent periosteum by loose areolar
tissue, providing a convenient and easily dissected plane.
The temporalis and frontalis muscles have already been
discussed and the occipitalis does not play an important
role in facial rejuvenation. The skin is rather thick with a
firm, dense subcutaneous layer that is highly vascular and
can bleed profusely, as it is inelastic, preventing vessel
contraction. Hair follicles in the scalp do not emerge at
right angles to the scalp but emerge at angles that vary
with the region of the scalp. The pattern of hair follicle
angulation progresses inferiorly at the vertex and follows
a centripetal pattern. The anterior scalp hair is oriented
in a more linear pattern and is angled anteriorly and
inferiorly.15
Innervation
The neural supply to the anterior scalp has been covered
in the previous section. In addition to the supraorbital
and supratrochlear nerves, the auriculotemporal, great
auricular (C2 and C3), and lesser occipital (C2) nerves
provide sensation laterally. Posteriorly, sensation is
supplied by the greater occipital nerve with C2 and C3
contributions. The greater occipital nerves supply the scalp
to the interauricular line and thus transverse incisions
posterior to this can denervate the scalp. Similarly,
transverse incisions anteriorly can disrupt the supraorbital
and supratrochlear nerves. Vertical incisions along the
superior temporal line lie roughly between the greater and
lesser occipital nerves.12
Lymphovascular Supply
The scalp has an extensive blood supply with contribution
coming from the external carotid artery and includes the
occipital, superficial temporal, and postauricular arteries.
The arterial supply to the temporal region has previously
been partially reviewed in discussion of the forehead.
However, the vascular supply in the scalp is important for
various flap reconstructions in the treatment of alopecia.
The superficial temporal artery originates from the
external carotid artery and continues superiorly to give off
the transverse facial artery that runs along the zygomatic
arch. Shortly thereafter, a middle temporal branch is
given off and supplies the temporalis muscle. The
superficial temporal artery continues superiorly, running
in the TPF and branching into an anterior and posterior
branch. The posterior branch supplies a wide area over
the parietal region with the anterior branch forming
collateral connections with the supraorbital and supra-
trochlear arteries.16 This configuration allows for the
creation of two separate flaps: the temporalis muscle flap
based on the middle temporal artery and the TPF flap
drawing from the superficial temporal artery (Fig. 2-15).
Further, the posterior branch is the supply for the Juri and
related flaps in hair restoration. The venous drainage
generally follows the named arterial supply. Of clinical
CHAPTER 2
Facial Embryology and Anatomy
27
Transverse faciala
Angular a.
Superior labial a.
Facial a.
Submental a.
Lingual a.
Superior thyroid a.
Post. branch sup.
temporal a.
Ant. branch sup. temporal a.
Superficial temporal a.
Middle temporal a.
Post. auricular a.
Occipital a.
External carotid a.
Internal carotid a.
Common carotid a.
Figure 2-15 The primary blood supply to the face is from the external carotid artery and its branches.

importance are the intracranial venous connections,
which provide potential routes for spread of infection. The
first has already been described in the forehead anatomy
section and involves drainage of the ophthalmic tribu-
taries to the cavernous sinus. Second are the emissary
veins, including the parietal vein with connections to the
superior sagittal sinus and mastoid vein with connection
to the sigmoid sinus. The scalp lymphatics drain to the
parotid, postauricular, and occipital nodes.12 Additional
drainage to the posterior triangle and jugulodigastric
region occurs. Adenopathy in these regions during infection
is not uncommon.
MIDFACE AND CHEEK
Skeletal Framework
The zygoma, maxillae, and zygomatic arch with its temporal
bone contribution largely make up the contour of the
midface. This area is important in terms of facial support
and is described as a series of vertical and horizontal
buttresses. The lateral buttress is the zygomaticomaxillary
buttress and the medial buttress is referred to as the
nasomaxillary buttress, based on the bones that contribute
to them. The horizontal buttresses include the maxillary
alveolus, zygomatic arch, and the infraorbital rim. The
buttress system represents an area of thicker and stronger
bone that supports the facial skeleton. The arch is
important in helping to determine the anterior posterior
dimension of the midface.
Myocutaneous and Soft Tissue Covering
The layers of the face are deceptively complex and have
particular relevance to facial rejuvenation and facelift
surgery in particular. The overlying skin is supported by
the underlying fat and SMAS (superficial muscu-
loaponeurotic system). The importance of facial fat is seen
in patients with atrophy leading to a hollow appearance.
One striking example of this is in patients treated with
highly active protease inhibitors for human immuno-
deficiency virus (HIV). The importance of facial fat is also
seen as patients age, with the formation of jowls. Several
fat pads are particularly important and include the malar,
nasolabial, and pre- and subplastysmal fat pads. Soft
tissue fillers to augment these areas are becoming
increasingly popular in the management of the aging face.
Two areas of particular interest are the melolabial crease
and the oromandibular fold, representing the junction
between the cheek and perioral aesthetic units.
An understanding of the SMAS is essential for
rejuvenation of the lower two thirds of the face. SMAS
represents a fibromuscular layer that is continuous with
the platysma inferiorly and the galea and TPF superiorly
(Fig. 2-16). The SMAS is less distinct over the zygoma
and in the perioral regions. The SMAS, as it proceeds
toward the melolabial fold and oromandibular crease,
forms an area of relatively dense attachment to overlying
skin. These two areas represent regions of confluence
with cutaneous attachments contributed by the perioral
musculature and SMAS, which tether these areas. These
relatively fixed points deepen and become conspicuous as
the malar fat pad and nasolabial fat pad descend. This
process leads to a deep melolabial crease and marionette
lines inferiorly. Related to this process is the formation of
jowls, which result largely from the descent of the malar
fat pad over the edge of the mandible and dense
attachments in the region of the oromandibular fold. The
SMAS is distinct from and superficial to the
parotideomasseteric fascia underlying the midface. The
SMAS invests the zygomaticus major and is superficial
to the buccal fat that is found anterior to the parotid (Fig.
2-17). The facial nerve branches lie deep to the SMAS
and will be discussed shortly.17
The soft tissue of the midface is further anchored by
various osseocutaneous retaining ligaments. In these areas
dissection during facelift surgery is more difficult because
the skin is anchored to the underlying periosteum. The so-
called McGregor’s patch or zygomatic retaining ligament
is encountered at the junction of the zygoma and
zygomatic arch (Fig. 2-18). The buccomaxillary ligament
is found in the region of the zygoma and infraorbital rim
near the attachment of the zygomaticus major muscle.
The orbital ligaments suspend the forehead and eyebrow
and are found at the zygomaticofrontal suture. The dense
28
Carlo P. Honrado • Dewayne T. Bradley • Wayne F. Larrabee Jr.
Figure 2-16 The SMAS (superficial musculoaponeurotic system) has
been reflected in this drawing, highlighting its continuous nature with the
galea, temporoparietal fascia, and platysma. The SMAS is relatively
discontinuous at the zygoma. The facial nerve can be seen in relation to the
masseter, Stensen’s duct, and buccal fat.

attachments at the zygomaticofrontal suture are partic-
ularly important, as they must be released to adequately
mobilize the brow during a forehead lift. Last, the
mandibular ligaments are found at the junction of the
anterior and middle thirds of the mandibular body.
The facial muscles comprise the muscles of facial
expression, including the buccinator, which arises at the
ptyergomandibular raphe and attaches to the orbicularis
oris. The zygomaticus minor, levator labii superioris,
levator labii superioris alaeque nasi, risorius, and zygo-
maticus major are elevators of the lip (Fig. 2-19).18,19 The
masseter provides bulk and fullness to the angle of the
mandible region, functioning as a muscle of mastication.
Innervation
The facial nerve constitutes the main motor supply to the
face. It supplies the muscles of facial expression, and the
anatomic considerations are paramount during proce-
dures to rejuvenate the aging face. The facial nerve exits
the stylomastoid foramen and the main trunk can be
found just deep to the tympanomastoid suture.20 It enters
the parotid gland and travels through the substance of the
gland, separating it into anatomically arbitrary superficial
and deep lobes. There is no distinct plane of separation in
the parotid. The main trunk splits at the pes anserinus
into a superior and inferior division. The branching
pattern is complex and variable from patient to patient
with the general pattern consisting of temporal/frontal,
zygomatic, buccal, marginal mandibular, and cervical
divisions. The branches of the nerve exit the parotid gland
running on top of the masseter muscle and associated
parotideomasseteric fascia. The zygomatic branch roughly
parallels Stensen’s duct. As the nerve travels anteriorly it
supplies the facial musculature from the undersurface.
This point is essential when performing deep plane
facelifting techniques to ensure that the surgeon stays
superficial to the zygomaticus major to avoid nerve
transection. The natural tendency when dissecting in the
region of the zygomaticus major is to follow the plane
deep to the muscle as the SMAS invests the muscle.
However, staying on top of the facial musculature protects
the facial nerve. The marginal mandibular nerve has a
variable course and can lie as inferior in the neck as the
submandibular gland, usually 1 to 2 cm but up to 3 or
4 cm below the edge of the mandible. After looping below
the body of the mandible it proceeds superiorly, anterior
to the facial vessels. The marginal branch is deep to the
platysma. The posterior facial vein is a useful landmark
and the nerve is superficial to it.14,21,22
The infraorbital nerve supplies the sensory inner-
vation to the central face from the orbital rim to the
commissure. From the commissure to the mandible buccal
branches of cranial nerve V3 provide sensation. The
auricular temporal nerve innervates the preauricular area.
Lymphovascular Supply
The external carotid artery and its branches are the major
blood supply to the superficial layers of the face. The
contribution by the superficial temporal system has been
covered in the forehead and periorbital sections. The
facial artery travels over the mandible at the anterior
CHAPTER 2
Facial Embryology and Anatomy
29
Figure 2-17 The vital structures on the face are depicted in this
illustration with attention paid to the relationship of the buccal fat pad.
Figure 2-18 The major retaining ligaments of the face are depicted.
These osseocutaneous ligaments are rather strong in the area of the
zygoma, McGregor’s patch, and mandible. Weaker attachments are seen at
the anterior edge of the masseter.
Zygomaticus major m.
Superficial parotid gland
Buccal fat pad

border of the masseter muscle, continuing an oblique
course and becoming the angular artery along the side of
the nose as it continues until the medial canthal region.
The first branches of the facial artery are the inferior and
superior labial arteries. As the facial artery becomes the
angular artery, there is significant anastomosis with
branches of the infraorbital artery. These branches form a
transverse nasal artery that supplies the nasal sidewall.
The majority of the blood supply to the midfacial skin is
via the facial and the infraorbital arteries. They supply
the subdermal plexus, which provides a rich supply and is
the basis for facial flaps. Therefore, protection of the
subdermal plexus is important for flap viability. The
venous drainage is extensive and parallels the named
arterial supply. The facial vein parallels the facial artery
and empties into the internal jugular vein. The
retromandibular or posterior facial vein drains the region
of the parotid and empties either directly into the internal
jugular vein or forms a confluence with the anterior facial
before emptying into the internal jugular vein. The
infraorbital vein drains into the pterygoid plexus, which is
responsible for draining the deeper layers of the face.
The lymphatic drainage from the central face has its
first echelon in the parotid and periparotid nodes. The
lower face and second echelon of the central face drain to
submental and submandibular regions (level I). Drainage
from the temporal and infratemporal fossae is to the
upper cervical nodes (level II).
LIP AND CHIN
Skeletal Framework
The perioral region is supported by the teeth, respective
maxillary and mandibular alveolar ridges, and the
mentum, which corresponds to the symphysis of the
mandible. The position of the chin must be determined in
relation to the occlusion to accurately describe deficiencies
in chin projection. If the chin is small but the occlusion is
normal (class I occlusion), then the patient has
microgenia. If the size of the mandible is normal, as is the
chin, but the chin is retruded due to occlusal problems
(class II occlusion), then the patient is retrognathic. If
various parts of the mandible are small and the patient
has class II occlusion, then the patient has micrognathia.
Myocutaneous and Soft Tissue Covering
The skin and subcutaneous tissue, unlike the cheek, are
closely adherent to the underlying orbicularis oris muscle.
This attachment along with the attachment of the SMAS
in the region of the melolabial fold contribute to the aged
appearance as the more mobile and abundant cheek fat
falls over this relatively fixed area.23 The perioral region is
divided into the chin and lips. The lips have a white and
a red portion. The white portion extends from the
melolabial crease to the vermilion and the labiomental
crease inferiorly to the vermilion. The red portion has wet
and dry components. The junction is where the two meet,
and the appearance is based on the dry portion having a
keratinizing epithelium. The shape is described as a cupid
bow with a central philtral segment. The lips are
surrounded by a white roll at the junction of the white and
red portions of the lip just outside the vermilion border.
The underlying muscular support is by the orbicularis oris
with insertions into the modiolus at each commissure. The
mentalis supports the chin portion of the perioral region.
The lip elevators have been mentioned in the cheek
portion as they originate in the midface and insert into the
orbicularis sphincter. These muscle elevators of the lower
third of the face are counterbalanced by the depressor
muscles: platysma, depressor anguli oris, and depressor
labii inferioris.
30
Carlo P. Honrado • Dewayne T. Bradley • Wayne F. Larrabee Jr.
Temporalis m.
Orbicularis oculi m.
Levator labii aleque nasi m.
Levator labii superioris m.
Zygomaticus minor m.
Zygomaticus major m.
Depressor anguli m.
Depressor anguli oris m.
Depressor labii inferioris m.
Frontalis m.
Corrugator m.
Procerus m.
Levator anguli oris m.
Orbicularis oris m.
Buccinator m.
Mentalis m.
Figure 2-19 The muscles of facial expression.

Innervation
The motor supply is via the facial nerve. Sensation
superiorly is via the infraorbital branches and inferiorly
by the mental nerves. The supraorbital, infraorbital, and
mental nerves all exit via foramina roughly in the same
sagittal plane at the midpupillary line. The mental nerve
can be found between the first and second bicuspids.
Lymphovascular Supply
The main blood supply is via the inferior and superior
labial arteries, which are supplied by the facial artery. The
labial arteries run on the intraoral surface of the
orbicularis muscle. Lymphatic spread is bilateral in the
central portion of the lip to the submandibular region and
mental areas. The lateral aspects of the lip drain into the
ipsilateral level I nodes.12
NECK
Skeletal Framework
The soft tissues of the neck are supported by the mandible
superiorly and clavicle inferiorly, along with the
cartilaginous structures of the larynx and trachea.
Myocutaneous and Soft Tissue Covering
The platysma is continuous with the SMAS and has two
flat bellies with a raphe centrally forming an inverted V
shape. Laxity in the central region with the associated
raphe forms platysmal bands. Two fat pads are of note in
rejuvenation. The preplatysmal fat pad generally plays a
lesser role, as it tends to atrophy with age. However, fat
deposition into the subplatysmal fat pad with dehiscence
of the platysmal and resultant pseudoherniation leads to
this fat being superficial and resulting in the submental
waddle.
Innervation
The platysma is innervated by the cervical branch of the
facial nerve. Multiple cervical plexus branches provide
sensation. The great auricular nerve provides sensation to
the ear and superolateral aspect of the neck and is the
most frequently injured nerve during facelift surgery. It
emerges at the lateral border of the sternocleidomastoid in
a region referred to as Erb’s point and runs on top of the
sternocleidomastoid.12
Lymphovascular Supply
The blood supply to the platysma includes the submental
branch of the facial artery as the dominant supply with
minor contributions from the transverse cervical artery.
The relevant vessels include the external jugular found on
the surface of the sternocleidomastoid. The facial vessels
are seen anteriorly and cross the mandible obliquely into
the cheek.12
CONCLUSION
The anatomy of the face is the foundation upon which
procedures for rejuvenation of the face are laid. Detailed
knowledge of the facial embryology has led to a better
understanding of the layered anatomy of the face. This
knowledge is most clearly of value in facelift surgery and
has enabled the increased success of the deep plane
technique. The SMAS and its relationship to the facial
nerve and facial musculature illustrate the central role
anatomy plays in surgical procedures. Although not
exhaustive by any means, this review is intended to provide
a platform on which the remainder of the text can rest.
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2001, pp 1-150.
13. Correia P de C, Zani R: Surgical anatomy of the facial nerve,
as related to ancillary operations in rhytidoplasty. Plast
Reconstr Surg 1973;52:549-552.
14. Bernstein L, Nelson RH: Surgical anatomy of the extraparotid
distribution of the facial nerve. Arch Otolaryngol
1984;110:177-183.
15. Tolhurst DE, Carstens MH, Greco RJ, Hurwitz DJ: The
surgical anatomy of the scalp. Plast Reconstr Surg
1991;87:603-612; discussion 613-614.
16. Abul-Hassan HS, von Drasek Ascher G, Acland RD: Surgical
anatomy and blood supply of the fascial layers of the temporal
region. Plast Reconstr Surg 1986;77:17-28.
CHAPTER 2
Facial Embryology and Anatomy
31

17. Jost G, Levet Y: Parotid fascia and face lifting: A critical
evaluation of the SMAS concept. Plast Reconstr Surg
1984;74:42-51.
18. Matthews TG: The anatomy of a smile. J Prosthet Dent
1978;39:128-134.
19. Philips E: The anatomy of a smile. Oral Health 1996;86:7-9,
11-13.
20. Tabb HG, Tannehill JF: The tympanomastoid fissure: A
reliable approach to the facial nerve in parotid surgery. South
Med J 1973;66:1273-1276.
21. Anson BJ, Donaldson JA, Warpeha RL, et al: Surgical anatomy
of the facial nerve. Arch Otolaryngol 1973;97:201-213.
22. Celesnik F: Surgical anatomy of the intraglandular portion of
the facial nerve. J Maxillofac Surg 1973;1:65-73.
23. Jost G, Levet Y, Wassef M: Superficial musculoaponeurotic
system in the upper lip. Plast Reconstr Surg 1986;77:161,
160.
32
Carlo P. Honrado • Dewayne T. Bradley • Wayne F. Larrabee Jr.

HISTORY
The brow has historically been overlooked in the reju-
venation of the aging face. The focal procedure of facial
rejuvenation has always been the rhytidectomy. Surgical
forehead rejuvenation began at the turn of the 20th
century.1 Passot has been generally recognized as a pioneer
in the field.2 Several other surgeons described their work
over the subsequent years.3-6 The interest in these
procedures waned, as the effects were often found to be
transitory. However, as with most plastic surgery
procedures, interest in brow rejuvenation was renewed in
the latter half of the 20th century, when new techniques
evolved and results improved.7-9
There has been, and continues to be, significant
controversy as to the “correct” technique to rejuvenate the
brow, for example, whether to use an open versus an
endoscopic approach. Although this controversy is now
spilling over to rhytidectomy, the contention that one
operation is superior to the other has left many surgeons
unsure of the appropriate approach. This confusion has
contributed to the subjugation of the browlift to the less
controversial rhytidectomy and blepharoplasty procedures,
and thus choosing to avoid addressing the aging brow in
lieu of correcting the aging face and periorbital regions.
Historically all brow rejuvenation procedures were
performed via the open technique. And although this
procedure has excellent long-term results, patients and
surgeons were often hesitant to undergo such an involved
procedure with extensive incisions and recovery time.
With the advent of the endoscopic techniques in the early
1990s, surgical rejuvenation of the upper third of the face
became increasingly popular.10-14 This trend, coupled
with the advent of noninvasive paralytic agents, brought
brow rejuvenation to the forefront of facial rejuvenation.
PERSONAL PHILOSOPHY
Comprehensive facial rejuvenation merits an appraisal of
all components of the face. This is especially pertinent for
the upper third of the face. This is the focal region of the
face during communication with others. The importance
of the periorbital area is seen in everyday life. Indeed, it is
so common in our observations of others that it is often
overlooked. When speaking to or meeting someone for the
first time, attention is immediately brought to the
periorbital area, much more so than the jowls or the neck
that so bothers the aging patient. Patients with brow ptosis
subconsciously raise their brows when viewing themselves
in the mirror. This cannot be done on the ptotic, sagging
tissue of the middle and lower thirds of the face. Thus, the
patient masks an issue that others see at all times. Though
simple, this is an often-overlooked point that must be
discussed with the patient.
The importance of brow rejuvenation is vital to facial
rejuvenation. In our practice, this procedure is often seen
as the primary operation to rejuvenate the face. In addition,
if the middle- and lower-third rejuvenation is performed
without addressing the brow, the patient may be left with
an overall disharmonious appearance.15
The primary reason for brow rejuvenation in our
practice is to address the patient’s concern about looking
heavy, tired, or angry, especially in the glabellar area. The
goals of any browlifting procedure are to eradicate the
depressing effect of the musculature of the glabellar
region and to raise the lateral aspects of the brow. A key
benefit of the open approach is the excellent exposure, which
allows for precise handling of these problems. There is no
need for overcorrection with the open approach because
the surgeon can be confident that the results will be long-
lasting. This is due to excision, rather than suspension, of
the ptotic tissues.
There have been concerns over the side effect profile
of the open browlift techniques. Likewise, the endoscopic
techniques are being questioned as to the quality and
longevity of the results. Despite the variety of methods to
surgically, or nonsurgically, address this area, it often
remains neglected.
The endoscopic techniques have done a tremendous
amount to reinvigorate interest in the aging upper third of
the face. Surgeons have noted the advantages of smaller
incisions; less downtime; reduced scarring, numbness, and
alopecia; and minimizing the loss of blood.12,16 However,
the endoscopic techniques do have selected disadvantages.
For example, there is still no method of fixation that is
clearly superior to others.17-24 The technique has a limited
ability to correct severe eyebrow ptosis and must be
The Open Browlift
Mark R. Murphy, MD • Calvin M. Johnson Jr., MD
33
C H A P T E R T H R E E

utilized only in certain patients.24,25 In addition, the
endoscopic record is not yet defined.26 A recent report in
the literature has confirmed many surgeons’ trepidations
about this technique. Only 50% of plastic surgeons surveyed
felt that their results were satisfactory more than 2 years
after the operation.27
In addition to the longevity concerns regarding endo-
scopic browlifts, there have also been questions regarding
its impact on the contour of the brow. It has been found
that the greatest impact of the endoscopic browlift is
medially not laterally, thus contributing to the dreaded
“surprised look” and not affecting the lateral brow where
the lift is generally desired.28,29 This highlights another
advantage of the open browlift technique. The coronal
approach allows for more control of the brow contour by
way of its differential scalp incision.30
Although the emphasis in the last decade has been on
endoscopic and less invasive methods such as the use of
botulinum toxin-A, the open browlift has a proven record
of providing excellent, lasting results with minimal side
effects. The open browlift maximizes the optimal removal
of the corrugators and excess skin that accumulates with
time.31 In our opinion, the main role for the endoscopic
approach is in young patients with a minimal amount of
ptosis. In our practice, however, we often suggest deferring
the procedure in younger patients until the concerns have
truly manifested themselves, at which point we perform
what we believe to be the procedure of choice, the open
browlift. We feel the open browlift is the optimal operation
in patients with severe ptosis of the brows, deep glabellar
or midforehead wrinkles, or a preexisting high forehead,
when a trichophytic lift is selected. The results achieved
with this forehead lift are predictable, natural appearing,
long lasting, and aesthetically pleasing with minimal
morbidity.15
Other surgeons have also reported that the open
technique is more effective in achieving the three main
goals of brow surgery: brow elevation, reduction of trans-
verse lines, and reduction of glabellar lines.32 In addition,
even those who favor the endoscopic technique state that
some patients will benefit from the open approach.33
The negative side effects of the open browlift tech-
niques seem to have been unduly emphasized in the
literature. In a recent, unpublished report on the sig-
nificance of the side effects of the open browlift techniques,
the authors found an overwhelming percentage of patients
would recommend the procedure to a friend or relative.34
Recent reports have also thrown light on various vague
detractions of the open technique. The difference in the
rate of alopecia between the two techniques is small, and
sensory loss has been noted to be higher with the
endoscopic techniques.32,35 In summary, the open browlift
technique has a similar complication rate, a comparable
rate of sensory loss, and a higher patient satisfaction rate.32
The other issue commonly mentioned when discussing
the open approach to forehead rejuvenation is the extent
of the incision. We feel that this is predominantly a matter
of proper patient education. Certainly, if patients feel that
they are going to be “scalped,” they will not consent to the
procedure.14,33
The coronal incision can be completely camouflaged
with the patient’s hair. In the case of the trichophytic
incision, only the anterior aspect is exposed, and this
component of the incision can also be masked with hair
when the patient wears her bangs combed forward. In
both instances the incision generally heals imperceptibly
when proper beveling is employed during the incision and
meticulous technique is applied during the closure. The
patient must be counseled as to the amount of time it
requires for the wound to heal completely. If the patient
does not wish to have an open procedure because of the
incision, the endoscopic approach should be explored with
the patient.
The open technique via the pretrichial route enables
the surgeon to manipulate certain situations in unique
ways. For example, the pretrichial lift allows for
shortening of an elongated forehead. A long forehead
disrupts the harmony of the face and adds to the patient’s
age.36 The forehead shortening capabilities of the tri-
chophytic browlift are unobtainable with the endoscopic
technique.37,38 Detractors argue that the incision place-
ment prohibits the use of this technique, but many feel
that with proper planning, technique, and execution this
approach yields an excellent aesthetic result.39 This is not
to say that this procedure may be used in all patients with
an elongated forehead. If the patient is overly self-
conscious of scarring or has a hairstyle that positions the
hair posteriorly the surgeon would be wise to avoid this
technique.
The decision-making process for the coronal vesus
the pretrichial approach has been reported on in the
literature.15,40 We generally agree with these parameters
but do make exceptions in certain cases to the 5 cm rule.
The purpose of this chapter is not to determine which
technique is superior. That is a decision to be made during
the consultation. The open browlift technique should be
familiar to all plastic surgeons rejuvenating the upper
third of the face. Endoscopic and open techniques should
be discussed with all patients. As with any procedure, the
risks and benefits should be fully explained to the patient.
ANATOMY
To appropriately rejuvenate the brow, the surgeon must
be knowledgeable of its anatomy. The position and move-
ment of the brow are determined by several factors. First
among these are the paired frontalis muscles. The frontalis
is the sole elevator of the brow. These paired muscles have
a definitive midline separation41 (Fig. 3-1). Each of these
muscles originates from the galea aponeurotica. This
fascia also encases the muscles, and inserts into the
34
Mark R. Murphy • Calvin M. Johnson Jr.

orbicularis oculi muscles, which then insert into the
eyebrow dermis. Only the lower 20% of the frontalis
muscle is mobile.42
The brow has four depressor muscles: the procerus,
corrugator, depressor supercilii, and the orbital portion
of the orbicularis oculi14 (see Fig. 3-1). The depressor
supercilii is located on the medial arc of the orbicularis
and is considered by some to be part of the orbicularis.43
This muscle aids the corrugator in depressing the medial
head of the brow. The corrugator musculature originates
from the frontal bone near the superomedial orbital rim
and inserts into the dermis of the forehead skin behind
and immediately superior to the middle third of the
brow.41 Contraction of the corrugator complex results in
depression of the brow and deep vertical glabellar rhytids.
The procerus originates from the nasal bone and inserts
into the lower medial skin of the forehead. Its contraction
leads to the most inferior horizontal rhytid over the radix
of the nose.43
The galea is contiguous with the superficial tem-
poralis fascia laterally. The periosteum of the frontal bone
is contiguous with the temporalis fascia. These respective
fascia layers converge just medial to the temporal fusion
line of the skull.
The sensory innervation to the scalp is relatively
straightforward. The two major nerves are the supra-
orbital and supratrochlear, with the supraorbital nerve
supplying the majority of the scalp. The supraorbital
nerve has two main divisions, superficial (medial) and
deep (lateral).44 The deep division of the supraorbital
nerve runs under the deep galeal plane and over the
periosteum toward the superior temporal line before
taking a turn superficially through the galeal fat pad on
its way to the skin of the frontoparietal scalp.14 The
superficial division courses from the orbital rim and over
the frontalis muscle and terminates in the anterior scalp.42
The superficial branch supplies the sensation to the
forehead skin and anterior scalp. The superficial branches
of the supraorbital nerve and the supratrochlear nerve
both travel over the superficial surface of the frontalis
muscle. The frontal branch of the facial nerve runs within
the superficial temporalis fascia on its way to innervate
the frontalis muscle.
PREOPERATIVE ASSESSMENT
Numerous studies have considered the ideal appearance
of the female eyebrow.45-51 A variety of factors determine
the aesthetically pleasing brow. An individual’s ethnicity,
age, sex, culture, and adjacent structures all influence the
perceived beauty of the brow. Though opinions differ on
certain facets of the brow, certain desirable traits
commonly recur: (1) the medial brow should lie at, or
below, the level of the supraorbital rim, (2) the brow
should have an apex lateral slant, (3) the medial brow
should begin in the vertical plane of the inner canthus
and lateral extent of the ala, (4) the brow ends laterally
in line with a tangent drawn from the lateral ala through
the lateral canthus, and (5) the apex of the brow should
lie above either the lateral limbus or lateral
canthus.45,46,47-49,52 Another key feature of brow beauty is
the relationship to the dorsal line of the nose (Fig. 3-2).
When the brow continues this gentle slope (brow-tip
aesthetic line) it adds to the inherent attractiveness of the
face.7,45,53
The decision of trichophytic versus coronal incision
will be discussed with the patient during the preoperative
CHAPTER 3
The Open Browlift
35
Depressor supercilli m.
Galea aponeurotica
Corrugator m.
Frontalis m.
Procerus m.
Orbicularis oculi m.
Figure 3-1 The musculature of the brow.
Figure 3-2 The ideal aesthetic of the brow depends on individual
preferences. The goal is to provide the patient with an elegant slope of the
brow as it evolves into the contour of the nose.

assessment. This judgment is based on the position of the
hairline, low versus high, and the manner in which the
patient wears his or her hair.54 Of course, the personal
preferences of the patient must also be taken into account.
The key to an accurate preoperative assessment is the
relaxation, manual if necessary, of the brow. It is in repose
that the patient must objectively view the resting position
of the brow. As mentioned earlier, the patient reflexively
raises his or her brow when placed in front of a mirror or
when a photo is taken. The surgeon can manually position
the brow as it appears at rest with the patient’s eyes closed
and then instruct her to open her eyes slowly. This
maneuver enlightens the patient as to the issues at hand
and furthers confidence in the surgeon as an expert who
truly sees the face in a different manner from the layman.
TECHNIQUE
The sequence of procedures for facial rejuvenation usually
begins with the forehead lift. We rarely perform a solitary
procedure on the brow. Most often it is in conjunction with
an upper and lower lid blepharoplasty and deep plane
facelift. We choose to do the brow first because it allows
for a more conservative, and accurate, upper lid ble-
pharoplasty. In select cases, such as patients with deep-set
eyes, previous blepharoplasty, or limited redundancy of
upper lid skin, the browlift is all that is needed for upper
third facial rejuvenation.
Marking and shaving of hair can be performed prior
to or after the administration of the anesthetic. Patients
are often very anxious during this time, and the marking
and shaving of hair amplifies these feelings. We prefer
to do these tasks after the administration of general
anesthesia. In an arena in which cost management is a
priority this can be done prior to administering the
anesthetic.
When a coronal approach has been chosen, a fusiform
segment of tissue is shaved and marked for excision
(Fig. 3-3). The markings for the excision should lie 5 to
6 cm posterior to the anterior hairline. The lateral extent
of the incision should terminate approximately 1 to 2 cm
above the superior insertion of the auricle to the skull in
an attempt to incorporate the superficial temporal vessel
within the flap (Fig. 3-4). If this vessel is compromised,
however, the blood supply to this flap is substantial. The
surgeon should ensure that an adequate amount of
temporal hair is left behind. This is particularly important
when this procedure is being performed in conjunction
with a facelift in which a portion of the sideburn is shaved
as well. The incision should parallel the anterior hairline
tapering at the lateral aspects to a point. We prefer to
mark and excise the amount of tissue to be removed at the
beginning of the case rather than making one incision,
anterior or posterior, mobilizing the scalp, and then
deciding on the appropriate amount to excise. We have
found we can reliably gauge the amount to be resected by
assessing the mobility of the scalp and its associated effect
on brow position prior to incision. It is acceptable to
decide on the exact amount of skin to be excised after
raising the flap. However, we have found that precise
incising of this thick tissue, as is mandated when trying to
preserve as many hair follicles as possible, is very
challenging after it has been mobilized. With adequate
experience the surgeon is highly successful in anticipating
the total skin excision prior to the initial incision.
Generally speaking, the amount of skin lies between 1 and
2 cm. If the surgeon discovers that he or she has
miscalculated and resected too much tissue, the posterior
scalp elevation can be performed to aid in the closure.
Obviously, it is better to err on the side of caution and
remove less excess skin if the surgeon is uncertain as to
the exact amount to be removed.
The trichophytic incision is more difficult to plan and
perform but yields a tremendous result when attention is
paid to the details. The marking begins with a trimming,
36
Mark R. Murphy • Calvin M. Johnson Jr.
Figure 3-3 The standard coronal markings.
Figure 3-4 The coronal markings mimic the anterior hairline and taper
laterally.

with scissors, of the first two to three rows of hair in the
anterior aspect of the hairline. Laterally the hair is shaved
as an elongated, curved triangle with its apex above the
superior insertion of the auricle to the scalp (Fig. 3-5).
This area is generally 4 to 5 cm in length and should not
be placed too inferiorly to avoid encroaching on the
temporal hairline. This termination point varies from
patient to patient depending on the position of the
hairline and the contour of the patient’s skull. Once the
incision is created a flap must be mobilized to allow access
to the glabellar musculature. This procedure often
requires folding the flap upon itself, and thus, an
adequate rotation point must be chosen laterally. In the
midline, the incision has gentle undulations closely
following the hairline. This undulation allows improved
camouflage of the incision over a simple straight line. The
posterior aspect of the incision should be placed in the
transition zone between the thick posterior hair of the
scalp and the fine hairs that constitute the anterior
hairline (see Fig. 3-5).
The hair is secured with rubber bands anteriorly and
with a circumferential band of tape posteriorly. In the
trichophytic browlift the only hair that is secured with
rubber bands is the lateral temporal hair. The hair is
shaved in the fusiform ellipse in the coronal approach and
as described in the previous paragraph for the tricophytic
approach. The surgeon should be mindful not to place the
posterior tape too tightly around the circumference of the
head, thus creating a “false” lift that results in under-
resection.
The incisions are re-marked and injected with local
anesthetic. We prefer a mixture of equal parts of
0.5% lidocaine with 1:200,000 epinephrine and 0.5%
bupivacaine with 1:200,000 epinephrine. The injection
should be in the galeal plane where most of the vessels run
their course. Local anesthetic should also be injected into
the subgaleal plane as well. Bilateral supraorbital and
CHAPTER 3
The Open Browlift
37
supratrochlear blocks are administered. And last, the
corrugator and procerus muscles are directly injected to
aid in pain management as well as for vasoconstrictive
purposes. The patient is then prepped and draped in the
standard fashion. We prefer to staple a sterile towel
around the head in a parallel course to the taping, being
mindful not to place the towel too tightly.
The incisions are then performed with a No. 10 blade.
We prefer this blade for its increased surface area, which
reduces the need to change blades frequently. Excessive
use of smaller blades leads to increased cost and operating
time. The forehead skin is thick and will quickly dull
smaller blades. The blade must be sharp and the surgeon
should not hesitate to use several blades in making these
incisions. A dull blade will cut imprecisely, which should
never occur in cosmetic surgery. Proper beveling of both
the pretrichial and coronal incisions is vital to attaining
maximal hair regrowth and scar camouflage. In the
coronal incision the bevel parallels the follicles throughout
the length of the incision (Fig. 3-6). The entire amount of
shaved hair is removed, leaving a hair to hair closure.
Thus, the patient may be reassured preoperatively that
he or she will not have a noticeable region of alopecia
postoperatively. The coronal incision traces further
laterally than the pretrichial incision and the orientation
of hair at the end point of the incision is almost perpen-
dicular to the skin; the blade must mimic this orientation.
The pretrichial incision requires alternating beveling
techniques. In this technique, the surgeon must be
cognizant of three separate areas of the planned incision
(Fig. 3-7 to 3-10). The first is the anterior, visible, aspect
of the incision. In this area the beveling transects the
follicles to allow them to grow through the incision as it
heals over time. The hair in this area generally grows in
an anterior direction, and the incision is almost
perpendicular to the follicles. The bevel must be at an
angle that transects the shaft of the follicle while
maintaining the base of the follicular unit, which has
Figure 3-5 The markings for the trichophytic lift are similar to those for
the coronal lift but have undulations in the center and the angles are slightly
different; note the beveling of the incision.
Figure 3-6 The beveling of the incision for the coronal approach
parallels the hair follicles throughout the incision.

regenerative properties. This bevel pattern is in opposition
to the lateral, hair-bearing area of the incision. When the
surgeon chooses this approach preoperatively, he or she
should assess the growth pattern of these vital anterior
hairs. If the hairs grow posteriorly, the patient may not be
able to mask the incision by wearing the bangs forward,
and this should be discussed with the patient. The second
aspect of the incision is the interface of the anterior region
of the incision with the hair-bearing areas laterally (see
Figs. 3-7 and 3-9). At this juncture the beveling must be
altered from transecting the follicles to running almost
parallel to them. This is a brief transition and should
38
Mark R. Murphy • Calvin M. Johnson Jr.
A
C
B
60°
60°
90°
Figure 3-7 Varying angles of the blade are used during the
trichophytic incision.
A
B
Figure 3-8 The posterior aspect of the trichophytic incision is made
through the first few anterior hairs (A). This incision transects the follicles so
that they grow through, and thus mask, the healing wound. The anterior
aspect of the trichophytic incision is performed; the angle of the bevel must
be identical to that of the posterior portion of the incision to optimize
wound healing (B).
Figure 3-9 The angle of the blade transitions as the incision moves
laterally.
Figure 3-10 The lateral aspect of the trichophytic incision parallels the
hair follicles as in the coronal incision.

quickly evolve into the standard follicle-sparing angle
seen with the coronal lift as the surgeon goes deeper into
the hair laterally (see Figs. 3-7 and 3-10). It should be
noted that the surgeon must utilize the same angle of
incision for both the posterior and anterior portions of the
incision to ensure the best possible closure. The
importance of proper beveling technique cannot be
overemphasized. When done improperly, alopecia and
noticeable—and thereby unattractive—scars result. Lack
of attention to these details has produced results that give
credence to the critics of these techniques. The hair is a
great ally of the cosmetic surgeon as long as it is handled
appropriately.
For the entire coronal incision and the lateral aspects
of the pretrichial incision, the blade is advanced with a
pushing motion, instead of the classical method of pulling
the knife toward oneself. This technique allows better
control of the knife through the thick skin of the forehead.
It also enhances the surgeon’s ability to follow the hair
follicles correctly because the knife blade is visible. This is
vital when considering the exacting manner in which the
knife must be beveled for these procedures. Whether the
coronal or trichophytic lift is performed, the incision must
be beveled correctly throughout all aspects of the incision.
The incision is carried down to the level of the subgaleal
plane of dissection. After the incisions have been created
the excess skin is removed. This is done one side at a time
so that blood loss is kept to a minimum. As all surgeons
who operate in this area know, the blood supply to the
scalp is robust. Removing half of the excess skin and
obtaining hemostasis will help to avoid untoward
complications. Frequently, the superficial temporal vessels
are transected laterally and this bleeding should be
immediately addressed. We prefer bipolar cautery to reduce
thermal damage to adjacent hair follicles. With this concept
in mind, the surgeon should not pursue oozing vessels
above the galea. There are no major vessels superficial to
the galea and we will often attend to bleeding here with a
cold compress in lieu of electrocautery. Cautery above this
level places the hair follicles at undue risk. A complete
examination of the incision should be performed prior to
placing a cool, moist compress on the posterior portion of
the incision. Bleeding can persist in the lateral aspects of
the incisions and go unnoticed by the surgeon as he or she
is focused elsewhere. The surgeon must check both lateral
aspects of the incision periodically throughout the case to
ensure adequate hemostasis. Large amounts of blood can
be lost from scalp incisions. The contralateral skin is
removed, hemostasis is obtained, and the anterior flap is
then elevated.
A subgaleal dissection, with the No. 10 blade, is
performed until slightly superior to the supraorbital rim
(Fig. 3-11). This plane allows ease of dissection. With the
excision of tissue in the open technique, we do not need
to rely upon the periosteum readhering to the cranium
to ensure that the lift holds. Although subperiosteal
dissection is acceptable, this technique does not rely on
periosteal refixation for its result and longevity; thus, it is
easier and equally effective to dissect in the subgaleal
plane.55 We employ the term “sliding plane” because we
feel it is descriptive of the dissection. The plane is elevated
with a No. 10 blade and Anderson bear claw retractor
in the original phase. When approaching neurovascular
structures medially (supraorbital and supratrochlear
nerves) and laterally (frontal branch of facial nerve), a
nonpenetrating retractor is used (Fig. 3-12). The supra-
orbital and supratrochlear bundles are preserved at the
orbital rim or notch, depending on the patient’s anatomy.
The frontal branch is also preserved by dissecting directly
on the superficial layer of the deep temporalis fascia.
When approaching the zygomatic arch we change
dissecting instruments from a No. 10 blade to sharp, fine
scissors and a cotton-tip applicator for blunt dissection
(Fig. 3-13). The dissection is carried down to the arches
bilaterally. We generally do not aggressively cauterize in
this area secondary to potential thermal injury to the facial
nerve; judicious bipolar cautery is advised if necessary.
CHAPTER 3
The Open Browlift
39
Figure 3-11 The subgaleal dissection is performed with the No. 10
blade.
Figure 3-12 A nonpenetrating retractor is employed when
approaching neurovascular structures.

With the flap completely mobilized attention is then
directed to the glabellar musculature (Fig. 3-14). The flap
has been raised to the radix at this juncture, and using,
Adson forceps and sharp, fine dissecting scissors, the
corrugators are dissected free and cauterized with bipolar
cautery. This dissection is greatly aided by the assistant
using a nonpenetrating retractor in the natural vector of
the corrugator to help expose the muscle (Fig. 3-15). Care
must be taken to avoid inadvertent trauma to the supra-
trochlear neurovascular bundle during this phase of the
operation. Often, a supratrochlear vein is encountered in
the region. It should be dealt with accordingly. The medial
2 to 3 cm is dissected free from the galea and the muscle
is transected after bipolar cauterization at its medial
attachment to the bone. The medial free edge of the
muscle is grasped and pulled laterally until approximately
2 cm are freed for excision. Again the muscle is cauterized
and resected with the sharp, fine scissors. This is a true
advantage of the open technique. It allows for unpar-
alleled exposure of this dense muscular complex.
With excision of this muscle the surgeon and patient
can be assured of a long-term benefit unattainable with
other methods such as botulinum toxin-A. The concern
over muscle resection leading to a deficit of expression of
the brow is understandable, but fortunately this conse-
quence is exceedingly rare. Even with aggressive muscle
resection the patient usually has adequate expression
postoperatively.
The procerus is then addressed. With the flap elevated,
the procerus is scored horizontally with a bovie (Fig.
3-16). This should be performed lightly through muscle
alone. If done too deeply, the patient will be left with a
40
Mark R. Murphy • Calvin M. Johnson Jr.
Figure 3-13 A sharp scissors and nonpenetrating retractor are used in
the lateral component of the dissection.
Figure 3-15 The corrugator excision is performed with bipolar cautery
after transecting the muscle. This maneuver is aided by retraction in the
vector of the muscle.
Figure 3-14 The anatomy of the everted forehead flap.
Figure 3-16 The procerus is scored horizontally with monopolar
cautery.
Frontalis m.
Corrugator m.
Supraorbital m.
Procerus m.

soft tissue depression in the glabellar region. The scoring
should center on the medial aspect of the muscle to ensure
that the supratrochlear neurovascular bundles are left
unperturbed. Occasionally, in the heavy brow we will also
perform a vertical myotomy to allow for lateral spread of
the glabella to address vertical rhytids (Fig. 3-17).
In most cases we will also perform a horizontal
myotomy of the frontalis and a galeotomy (Fig. 3-18). We
choose to perform this at the level of the most prominent
midforehead rhytid. This is also performed with monopolar
cautery in the midline. By performing this maneuver in
the midline the surgeon allows the patient to retain muscle
function laterally, permitting lateral brow elevation. The
lateral borders of this incision are the medial aspects of
the orbital rims. We are judicious in the use of this technique
secondary to the concern of imparting a “surprised” look
onto the patient.
A suction drain is then placed above the superior
orbital rims and the field is copiously irrigated with an
antibiotic solution. The drain is brought out through a
puncture in the posterior, nonelevated flap. Care should
be exercised not to traumatize the temporal vessel during
placement of the drain, causing further significant
bleeding. Both open techniques are closed in a two-layer
fashion.
For the coronal incision, a galeal closure is performed
with interrupted 2.0 Dexon (Fig. 3-19). This is followed
by skin closure with wide staples (Fig. 3-20). The pre-
trichial lift closure is more detailed. The deep layer
closure is done with 4.0 Maxon (Fig. 3-21). These deep
sutures will cause a dimpling of the tissue immediately
inferior to the incision in the midline. The patient should
be informed of this preoperatively as this will resolve
when the sutures dissolve. The skin in the visible region of
the incision is then closed with interrupted 5.0 Prolene in
a vertical mattress fashion (Fig. 3-22). Skin eversion is
vital and must be attained with these sutures. Once com-
plete with the vertical mattresses the suture line is further
enhanced with the use of a running, locking 6.0 nylon
suture to maximize the wound approximation (Fig. 3-23).
The hair-bearing areas are closed with wide staples on the
lateral components and standard staples as the surgeon
CHAPTER 3
The Open Browlift
41
Figure 3-17 In select cases the glabellar region is scored vertically to
alleviate excessively heavy brows.
Figure 3-18 The frontalis is scored horizontally at the foremost
forehead rhytid in most cases.
Figure 3-20 The coronal closure is completed with staples at the skin
level. Please note the hair-to-hair apposition, a frequently misunderstood
concept with this technique.
Figure 3-19 The galeal closure is performed with buried, absorbable
sutures in the coronal technique.

nears the skin in the medial aspect of the incision (Fig.
3-24). Though somewhat more time consuming, this
elaborate closure greatly enhances the patient’s wound
healing (Figs. 3-25 and 3-26).
The wound is then coated with antibiotic ointment
and a nonadhesive piece of Telfa is placed over the
incision. A light compressive dressing is then applied.
POSTOPERATIVE CARE
The drain is often removed in the recovery room on the
evening of the procedure to decrease the headache and
nausea that often accompany drains in this area.
Patient comfort dictates whether he or she may return
home, go to a hotel, or spend a night in a medical facility.
The dressing is removed on postoperative day 1 and no
further dressing is necessary. The patient may
immediately begin using hydrogen peroxide to keep the
incision free of crusts. Showering with baby shampoo is
allowed 48 hours after the procedure. The sutures for the
pretrichial lift are removed on postoperative days 3 to 5,
depending on the nature of the healing and logistics of
removing sutures from other rejuvenation procedures that
may have been performed. The staples are removed at
1 week after surgery. The pretrichial incision is immedi-
ately taped in the non–hair-bearing area after application
of adhesive. The tape is worn continuously for 1 week
after the removal of the sutures. After this point, the tape
42
Mark R. Murphy • Calvin M. Johnson Jr.
Figure 3-21 The trichophytic closure is begun with buried, absorbable
sutures at the galeal level.
Figure 3-22 The skin closure is accomplished with vertical mattress
sutures. We prefer nonabsorbable suture at the skin level to minimize the
inflammatory response.
Figure 3-23 A running, locking 6.0 nonabsorbable suture is used to
maximize wound closure and achieve the optimal postoperative result.
Figure 3-24 The lateral portions of the trichophytic incision are closed
with large staples laterally and smaller ones medially.