Color Atlas of Cosmetic Oculofacial Surgery

308
Chapter 16: Advanced Concept of a Glide Zone
With patient looking downward, the examiner

■
uses the thumb and index finger to try to pinch
the preseptal zone’s anterior skin layer (located
at least 10mm above the central ciliary border)
from the lid tissue underneath it. When this is
not possible, as indicated by the posterior layer
and upper eyelid margin also coming off the
surface of the globe, this is suggestive of an
obliteration of the glide zone, constituting an
abnormal ‘pinch sign’ (Fig. 16.7).
The patient is asked to look down and the

■
ipsilateral eyebrow is splinted by the examiner’s
other hand to prevent brow action on upgaze.
Then, with the examiner pinching the preseptal
skin, the patient is instructed to look upward. As
the patient looks up, the superior rectus and
levator muscle both contract. A normal finding
should be the upper eyelid margin underneath
moving up independently without the pinched
skin going upward. If the pinching fingers should
feel an upward tug, it indicates the levator and
preseptal skin are fused together, and is an
abnormal ‘upgaze skin traction sign’ (Fig. 16.8).
The above findings apply more to young or middle-
aged adults, and would not be accurate in those rare
revisional cases where there are actually redundant skin
remaining in the preseptal area, or where aging-related
dehiscence between preseptal skin and orbicularis such
that a false-normal may occur (in a situation where
although the glide zone has been obliterated, it is still
possible to glide and pinch the skin relative to orbicula-
ris that became adherent to levator, and showed no skin
traction on upgaze). It is possible that a patient with
fused anterior and posterior layers may manifest a
false-negative finding in any one or two of the above
tests, but it is unlikely that all three are ‘normal’ upon
evaluation. This combination of glide sign, pinch sign,
and upgaze skin traction sign have been helpful for this
author and are additional tools to help in one’s clinical
assessment of those patients with revisional issues.
In the chapter on Asian blepharoplasty (p. 73)7 using
the technique of trapezoidal debulking of preaponeurotic
platform, one observes that the excision of skin and some
orbicularis in a beveled fashion would remove no more
than several millimeters of orbital septum along the upper
wound edge. After wound closure, the septum’s inferior
edge is laid back on the front surface of the distal aponeu-
rosis at or just slightly above the superior tarsal border,
forming the anterior boundary of the glide zone.
During revisional attempts, it is crucial to be able
to identify and reach this third space and restore a
Figure 16.7 The pinch sign. When the glide
zone is intact, the preseptal skin–muscle
(anterior) layer can be lifted away from the
posterior layer of the eyelid for several
millimeters, as shown here, without the tarsus
coming off of the globe. An abnormal finding
indicates adherence of the anterior and posterior
layers.

309
Advanced Concept of a Glide Zone
glide zone. At the same time, any scar tissue within
this potential space can be approached and cleared,
including removal of any buried sutures, and correc-
tion of any cause that is impeding this glide (shift) of
the posterior layer. The skin–orbicularis layers may
have been improperly laid onto the levator during
previous surgery from lack of proper loosening of the
surgical drape on the forehead. The re-establishment
of the glide zone, as well as downward and appropri-
ate positioning of the skin and eyebrow–forehead
complex, allows the now ‘released’ tarsal plate to be
properly pulled upward by the freed posterior levator
muscle, whose contraction then yields a crease at the
superior tarsal border. This can be apparent as the
patient lies on the surgical table even without any
sutures closing wound edges together (Fig. 16.9).
The various methods of crease construction, includ-
ing the tightening of the tarso-aponeurotic junctional
zone by suture ligation7–10 or external incision meth-
ods, all work in facilitating the upward vectoring of
the tarsus against the anterior eyelid layer to form the
crease, provided that the glide zone is preserved or has
not been greatly disturbed.
Complications that are challenging to correct often
follows obliteration of the glide zone. During the sim-
pler techniques of transconjunctival or transcutaneous
suture ligation method, unexpected and sudden bleed-
ing has been reported and may occur from injury to
the vertically oriented anastomotic vessels of the mar-
ginal and peripheral arcades of the upper lid11 as well
as the deep orbital arcade.12,13 It can also involve the
recently described lateral septo-aponeurotic artery
found in a certain percentage of the population.14 The
bleeding may occur in the post-aponeurotic plane if
the vessel retracts after it is transected in front of the
tarsus or aponeurosis, or within the preaponeurotic
space(the glide zone) itself. Residual adhesion may
follow resolution of blood clots and lead to irregular-
ity in the crease thus created. Partial, segmental, or
complete disappearance of the crease may result.
The concepts discussed above arose from clinical
observation as well as surgical findings of this author,
Figure 16.8 Upgaze skin traction sign. Patient is
asked to look up while the skin is secured with the
examiner’s fingers, here showing a lack of
adhesion. A direct pulling force from the levator
indicates an abnormal traction sign and suggests
that there is obliteration of the preaponeurotic
space or glide zone.

310
Chapter 16: Advanced Concept of a Glide Zone
and has been applied in his practice to handle com-
plex revisional issues. The use of the beveled approach
in revisional Asian blepharoplasty, discussed in the
following chapter, is a direct application of the glide
zone concepts discussed here.
REFERENCES
1. Cheng J, Xu Feng-Zhi. Anatomic microstructure
of the upper eyelid in the Oriental double eyelid.
Plast Reconstrc Surgery 2001; 107(7):1665–1668.
2. Hwang K, Kim DJ, Chung RS, et al. An
anatomical study of the junction of the orbital
septum and the levator aponeurosis in Orientals.
Brit J Plast Surg 1998; 51:594–598.
3. Chen WPD. Concept of triangular, rectangular
and trapezoidal debulking of eyelid
tissues:application in Asian blepharoplasty. Plast
Reconstr Surg 1996; 97(1):212–218.
4. Boo-Chai K. Further experience with cosmetic
surgery of the upper eyelid. Proceedings of the
Third International Congress of Plastic Surgery,
reprinted from Excerpta Medica International
Congress Series 1963; 66:518–524.
5. Boo-Chai K. Secondary blepharoplasty in Orientals.
Problems Plast Reconstr Surg 1991; 1(3):520–535.
6. Flowers RS. Upper blepharoplasty by eyelid
invagination – anchor blepharoplasty. Clin
Plastic Surg 1993; 20(2):193–207.
7. Mutou Y, Mutou H. Intradermal double eyelid
operation and its follow-up results. Brit J Plast
Surg. 1972; 25(3):285–291.
8. Tsurukiri K. Double eyelid plasty: reliability and
unfavorable results to the patients (abstract).
Journal Japanese Aesth Plast Surg 1999; 20:38.
9. Homma K, Mutou Y, Mutou H, et al.
Intradermal stitch for Orientals: does it
disappear. Aesth Plast Surg 2000; 24:289–291.
10. Shirakabe Y. Mikamo’s double-eyelid operation:
the advent of Japanese aesthetic surgery
(discussion by Yukio Shirakabe MD). Plast
Reconstr Surg 1997; 99(3):668–669.
11. Kawai K, Imanishi N, Nakajima H, et al.
Arterial anatomic features of the upper palpebra.
Plast Reconstr Surg 2004; 113(2):479–484.
12. Boo-Chai K. Perioperative bleeding in the
pretarsal (post-aponeurotic) space in Oriental
blepharoplasty. Brit J Plast Surg 2001; 54:370.
13. Kim BG, Youn DY, Yoon ES, et al. Unexpected
bleeding caused by arterial variation inferolateral
to levator palpebrae. Aesthetic Plast Surg 2003;
27:123–125.
14. Hwang K, Kim BG, Kim YJ, et al. Lateral
septoaponeurotic artery: source of bleeding in
blepharoplasty performed in Asians. Ann Plastic
Surg 2003; 50(2):16–159.
Figure 16.9 Intraoperative view of crease
following revision, just prior to application of
crease-fixation sutures and closure. The globe is
protected by a black scleral shell.

311
Chapter 17
In suboptimal results of aesthetic surgery of the Asian
upper eyelid, one may see spreading of the wound
scar, high placement of the upper eyelid crease, induced
lagophthalmos on downgaze, and induced secondary
ptosis on straight gaze as well as in upgaze.
Intraoperatively, one may observe middle lamellar
scar involving the orbicularis oculi as well as orbital
septum, or presence of dense scar tissue plaques that
may bind the anterior orbicularis oculi as well as the
posterior levator aponeurosis. Instead of having a
physiologically preserved ‘glide zone’ where preaponeu-
rotic fat pads are still present in the lowest aspect of
the glide space, there is now a condensed apron (or
plaque) of tissue that is not allowing the posterior
layer from up-vectoring properly against a passive and
flexible skin–orbicularis. The use of a superiorly bev-
eled approach in revisional Asian blepharoplasty can
allow the glide zone to be partially restored and the
middle lamellar scar removed. The preaponeurotic
platform can be cleared of any interfering tissues. The
combination of techniques described in this chapter
often allows an abnormally high and static scar line to
be repositioned into a lower and more dynamic crease,
to the point of being acceptable for the patient. The
need for skin grafting may often be avoided.
This author has advocated1–6 the trapezoidal
debulking of preaponeurotic platform through a bev-
eled approach (along the upper incision line) in Asian
blepharoplasty as a logical and efficient way of per-
forming primary cases. Included among the advan-
tages are a safe approach to the preaponeurotic space
through the orbital septum, allowance for a control-
led, uniform debulking of junctional tissues overlying
the supratarsal and pretarsal areas, as well as provid-
ing an optimal adhesion between levator aponeurosis
and the subcutaneous tissues along the lid crease inci-
sion line. This approach virtually eliminates any
potential for an uneven plane of surgical dissection,
thereby lowering the complication rate.
The Preaponeurotic Space and
the Glide Zone
The upper eyelid consists of the anterior skin–orbic-
ularis oculi layers as well as the posterior levator–
Muller’s muscle–conjunctival layers. In between is the
middle zone, where the orbital septum and preaponeu-
rotic fat reside. Normally, the preaponeurotic fat is
fluctuant and acts as a glide layer and offers relatively
little resistance to movement between the anterior and
posterior layers of the upper lid. This middle zone
may be conceptualized as a glide zone. Following
primary upper blepharoplasty, skin, muscle, and
preaponeurotic fat are reduced through limited exci-
sion. Upon closure, the preaponeurotic space is set
inferiorly towards the superior tarsal border.
Three scenarios may follow after primary blepharo-
plasty. If there has been total excision of exposed
preaponeurotic fat, the septum and overlying preseptal
orbicularis is now lying directly in contact with the
levator aponeurosis, without any buffering fat. There is
a good probability that the preaponeurotic space (glide
zone) is obliterated. One sees a deep supratarsal sulcus
as well as poor crease formation. Secondly, if there were
only partial or minimal removal of fat, some fat may
remain interposed between the preseptal orbicularis
(anterior layer) and aponeurosis (posterior layer).
Thirdly, in a beveled approach, the upper skin edge is
attached to the underlying aponeurosis along the super-
ior tarsal border as well as lower skin edge; there is
also a preservation of the preaponeurotic space and
some fat buffering in the glide zone. There are more
orbicularis fibers removed along the upper incisional
edge since the orbicularis was transected in an upwardly
beveled fashion. This allows the immediate vicinity of
the upper incisional skin edge to be in contact with the
preaponeurotic space thus created. In these last two
scenarios, where fat was only partially excised (or repo-
sitioned superiorly), the preaponeurotic space over the
The Technique of Beveled
Approach in Revisional Asian
Blepharoplasty: Resetting of
a High Crease
William PD Chen

312
Chapter 17: The Technique of Beveled Approach in Revisional Asian Blepharoplasty
preseptal midregion of the upper lid has been preserved.
There is fat buffering as well as a soft tissue mass (con-
sisting of the preseptal skin, orbicularis, orbital septum
and preaponeurotic fat) billowing on top of a dynam-
ically elevating tarsal plate. The crease formed is
dynamic and natural from an aesthetic viewpoint.
The restoration and preservation of this preaponeu-
rotic space is an essential element in the surgical crea-
tion of a lid crease for an Asian, for it is the
up-vectoring of the tarsal plate coupled with the
attendant presence of fat in the preserved preaponeu-
rotic space that helps create the aesthetic appearance
of a well-formed crease.
Patients seeking revisional surgery may present a
complex combination of findings. Often, a patient will
exhibit a flattened or absent upper lid crease with a
mild hollowing of the sulcus. The patient may have
poor crease formation due to a combination of factors
including poor surgical adhesion between the skin
edges and the aponeurosis after the first operation, or
the presence of an amorphous sheet of preaponeurotic
fat that appears plastered down over the entire aponeu-
rosis within the preaponeurotic space between skin
and levator. This latter finding may be intrinsic or sec-
ondary following postoperative hemorrhage into fat.
The eyelid may show spreading of the incisional scar,
high placement of the eyelid crease, induced lagoph-
thalmos on downgaze, and induced secondary ptosis
on straight gaze as well as upgaze. Intraoperatively,
one sees thickened middle lamellar scar involving the
orbicularis oculi as well as orbital septum, or presence
of dense scar tissue plaques that may bind the anterior
orbicularis oculi as well as the posterior levator aponeu-
rosis (Fig. 17.1). Instead of having a physiologically
preserved ‘glide zone’ where significant preaponeurotic
fat pads are still present in the lowest aspect of the
Lid open
(looking ahead)
Lid (levator)
at rest
Mid-lamellar
scar obliterates
glide zone
Figure 17.1 Scarring seen in suboptimal cases of aesthetic surgery of the Asian upper eyelid may include spreading of incisional skin, high placement
of upper eyelid crease, induced lagophthalmos on downgaze, and induced secondary ptosis on straight gaze as well as upgaze. Intraoperatively, one
sees middle lamellar scar involving the orbicularis oculi as well as orbital septum, or presence of dense scar tissue plaques that may bind the anterior
orbicularis oculi as well as the posterior levator aponeurosis. Instead of having a physiologically preserved ‘glide zone’ where preaponeurotic fat pads
are still present in the lowest aspect of the glide space, there is now a condensed apron-like plaque of tissue that is preventing the posterior layer from
up-vectoring properly against a passive and flexible skin–orbicularis. Despite efforts, there no observable crease formation. Patients often complains of
fatigue, a feeling of tightness, and may show brow and forehead overaction.

313
Technique of Beveled Approach in Revisional Asian Blepharoplasty
glide space, there is now a condensed apron (plaque)
of tissue that is not allowing the posterior layer to
up-vector properly against a passive and flexible skin–
orbicularis. Despite efforts by the patient, there is no
observable crease formation. Patient often complains
of fatigue, a feeling of tightness and may show brow
and forehead overaction.
In dealing with revisional cases, one of the greatest
dilemmas one faces is where to make the incision such
that it does not add to or compound the already com-
promised area, from both an anterior viewpoint (and
therefore aesthetic concern) as well as through lamellar
scarring and contracture (with further functional com-
promise). To finish with improved aesthetic results as
well as without any further functional setback is a major
triumph for any surgeon familiar with and undertaking
this type of re-operative surgery. Not only is the surgery
difficult, the patient often has a heavily burdened heart
and is anxious for a rapid outcome, something that is
never easily realized in practice when dealing with cica-
trix and suboptimal outcome. One is often struck by
how devastated these patients are and how grateful they
are when the improvement turned out to be significant.
It is important for both patient and doctor to be realistic
in their expectation as well as their projection of the
time course for healing following revisional surgery.
It is critical that one does not cause further skin short-
age or increased midlamellar contraction, with lid
retraction and poor eyelid closure leading to symptoms
of exposure and dryness. If there is insufficient skin in
reserve, it is unlikely that there is any probability of
revisional improvement, unless one wants to supple-
ment it with full-thickness skin graft. This latter will
require exquisite techniques, experience, and special
splinting over the skin graft in order to get the skin graft
placed in an esthetically acceptable fashion. There are,
however, many young adults or middle-aged patients
who need revisional surgery, where their problems are
severe and they are unlikely to have any skin reserve ‘in
the bank’ any time soon from natural involutional
changes. These patients who possess just enough eyelid
closure to avoid corneal exposure problems can develop
these problems if one proceeds to the usual method of
performing excision of skin scar and lysis of adhesion of
the middle lamella. The amount of skin removed can be
as little as one to two millimeters and they may become
symptomatic of poor eyelid closure.
An ideal solution to this quagmire is to approach
this scarred anterior and middle lamellar complex
through a superiorly beveled approach. To do this, the
following condition must be met. The crease height is
evaluated and if it should be high, then the degree of
lowering planned (in millimeters) by the surgeon will
determine the minimal amount of skin redundancy
above the existent crease height (over the preseptal
region) that needs to be in reserve. For example, if the
suboptimal crease is currently at 10.5mm and ideally
it needs to be lowered to 7.5mm, then the patient will
need to have 3mm of reserve skin above the crease
before this is feasible. If the patient should have only
2mm, then the patient should be informed that one
can only revise it down to 8.5mm in the current situa-
tion, or the patient can opt to wait further for some
skin to be made available ‘in reserve’ from the natural
aging before proceeding to revision at a later time. If
this cannot be met and the patient is desperate due to
either functional and/or psychological reasons, then
one has to discuss the choice for a free skin graft.
Technique of Beveled Approach
in Revisional Asian Blepharoplasty
For the majority who may be candidates for revisions
without the need for skin grafting, the author’s surgi-
cal approach to the revision proceeds initially along
the same way as does his primary cases, with the
major difference being that the upper and lower lines
of incisions are marked directly adjacent to each other
on each side of the existing incisional scar of the lid
crease. Patients in this category are more likely to
have had their lid crease incision made in the 8–9 mm
range, as measured from the central lid margin. The
separation of the upper and lower line of incisions
should be no more than 1 mm (and, very rarely,
2 mm). A No. 15 Bard-Parker blade is used to make a
full-thickness skin incision along the marked upper
and lower incisional lines (Fig. 17.2). Instead of using
cutting cautery to go through orbicularis to reach the
orbital septum, one uses a sharp-tipped Westcott
spring scissors to incise across the upper line of inci-
sion in a superiorly beveled fashion, involving skin-
to-orbicularis adhesions (Fig. 17.3). Small, scissoring
motions are then applied as the scissor blades transect
17.1

314
Chapter 17: The Technique of Beveled Approach in Revisional Asian Blepharoplasty
Figure 17.2 A full-thickness skin incision has
been made along the upper and lower lines of
crease markings.
Figure 17.3 Westcott spring scissors is used to
lyse along the upper incisional edge in a beveled
fashion, involving skin and orbicularis.

315
Technique of Beveled Approach in Revisional Asian Blepharoplasty
the middle lamella scar, going through whitish,
scarred fascial layers that are between orbicularis
and underlying levator aponeurosis (involving orbic-
ularis-to-levator adhesions) (Fig. 17.4). This is car-
ried out through the width of the incision along the
previous scar. The beveled approach is quite similar
but at a steeper tilt (plane) compared to primary
cases (Fig. 17.5). In this scarred middle zone, one will
not see much of the preaponeurotic fat pad as it may
have already been excised; one may observe some
residual fat lobules combined with scattered, smaller
amorphous fat globules or aprons of scattered fat
droplets may be seen (Fig. 17.6). The scarred tissues
in the anterior layer as well as midlamellar zone,
encompassed by the tissues between the dotted supe-
riorly beveled vector in the drawing and the lower
skin incision (along the super ior tarsal border), may
be excised after the forehead–eyebrow–preseptal skin
layer are carefully reset by releasing any restrictive
surgical adhesive or head drapes on the patient’s
forehead, for as long as the remaining skin still allows
passive eyelid closure. All fat is preserved. The leva-
tor and aponeurosis can be identified when the scar
is released and it is important to check for restriction
Figure 17.4 Small, scissoring motions are
applied as the scissor blades transect the middle
lamella scar after going through whitish, scarred
fascial layers that is between orbicularis and
underlying levator aponeurosis.

316
Chapter 17: The Technique of Beveled Approach in Revisional Asian Blepharoplasty
Figure 17.5 (A) Beveled approaches in
Asian blepharoplasty1 and (B) superiorly
beveled approach in revisional Asian
blepharoplasty. Note the gentler beveled
approach in primary case versus the much
steeper beveled (oblique) approach taken
in revisional attempts. This is necessary in
the latter situation to preserve skin and to
allow an approach towards identifying the
former preaponeurotic zone. In this
scarred middle zone, one frequently finds
some residual larger fat lobules combined
with scattered smaller amorphous fat
globules or aprons of scattered fat
droplets. The scarred tissues in the
anterior layer as well as mid-lamellar zone,
encompassed by the tissues between the
dotted superiorly bevelled vector in the
drawing and the lower skin incision (along
the superior tarsal border), may be excised
after the forehead–eyebrow–preseptal skin
layer are carefully reset, for as far as the
remaining skin still allows passive eyelid
closure. All fat is preserved.
Figure 17.6 After the preaponeurotic space is
reached, within this scarred middle zone one
frequently finds some residual larger fat lobules
combined with scattered smaller amorphous fat
globules or aprons of scattered fat droplets.
Müller’s
muscle
Levator
aponeurosis
Conjunctiva
A
B

317
Technique of Beveled Approach in Revisional Asian Blepharoplasty
Lid open
(looking ahead)
Lid (levator)
at rest
Figure 17.7 Following revisional Asian blepharoplasty using a superiorly beveled approach (see Fig. 17.6), the glide space has been partially restored and
the scar removed. The preaponeurotic platform is cleared of any interfering tissues. Although the surgeon is often forced to make a skin incision that is still
further from the lid margin than one would for a primary Asian blepharoplasty, upon closure the incision wound (white dot) is free to indent inward when
the levator contracts, forming a better crease. The residual fat pads in the middle (glide) zone are preserved and allowed to fill in this glide space where
appropriate. Skin denoted by the red and blue dots above the incision is now free to hang down and around to form the contrasting eyelid fold. Note that
the position of the white dot representing the revised lid crease should be aligned along the superior tarsal border, although this is often not feasible due
to the shortage of skin in revisional attempt.
objectively (by gently pulling the tarsal plate down),
as well as subjectively by asking the patient to per-
form upgaze and downgaze.
After revision using a superiorly beveled approach,
the glide space has been partially restored and the scar
removed (Fig. 17.7). The preaponeurotic platform is
cleared of any interfering tissues. Although the surgeon
is often forced to make a skin incision that is still further
from the lid margin than one would for a primary Asian
blepharoplasty, upon closure, the incision wound (white
dot) is free to indent inward when the levator contracts,
forming a better crease. The resi dual fat pads in the
middle (glide) zone are preserved and allowed to fill in
this glide space where appropriate. (In severe cases, fat
graft may be considered in this space.) Skin denoted by
the red and blue dots above the incision is now free to
hang down and around to form the contrasting eyelid
fold. Figure 17.8 shows the before-and-after images of a
young woman who underwent revisional correction for
a high crease, using this approach.
By approaching the preaponeurotic space very close to
and barely superior to the scarred crease line, one can
avoid adding additional incision scar or the taking out of
a precious 0.5 or 1mm of good skin. The bevelled
approach allows the previously explored preaponeurotic
space to be reached again, without injury to underlying
levator muscle, Muller’s muscle, and anastomotic vascu-
lar arcades. In some cases, this beveled maneuver towards
the preaponeurotic space frees up the vertical excursion
of the upper eyelid significantly, releasing any restriction
that may have contributed to lagophthalmos and acquired
ptosis. This maneuver in itself may correct the mild ptosis

318
Chapter 17: The Technique of Beveled Approach in Revisional Asian Blepharoplasty
such that resetting of the previously high crease is then
feasible. Any residual preaponeurotic fat which may have
been spread out and plastered down on the levator mus-
cle can be peeled off and repositioned into a higher level
within the sulcus to help reverse some of the concavity.
Midlamellar scar that has previously bonded the anterior
and posterior layers can be safely removed or reduced,
allowing partial restoration of the glide zone.
This reasoning is applied to revisional blepharo-
plasty. By utilizing the superiorly beveled approach in
revision, the integrity of the preaponeurotic space may
be restored. If the patient had previously undergone a
traditional blepharoplasty with partial excision of fat,
this approach will allow one to locate the preaponeu-
rotic space with ease. If the prior surgeon had per-
formed the trapezoidal debulking method,1 it is very
easy to locate the preaponeurotic space again, as this
author often does when performing touch-up enhance-
ment of the crease. With a prior history of total fat
removal, the beveled approach will still allow a higher
probability of reaching the preaponeurotic space.
Within the author’s practice, a series of 26 patients
and 48 eyelids underwent revisional blepharoplasty
over the last 4 years for the specific purpose of revising
a postsurgical high crease to a lower position. Excluded
from this series were all primary Asian blepharoplasty,
including any patients with pre-existent high crease,
touch-up surgery for the purpose of enhancing (deep-
ening) an existing or surgically created crease, correc-
tion of incomplete crease or crease shape alone, and
simultaneous correction of acquired or involutional
ptosis in conjunction with primary Asian blepharo-
plasty. There were 5 males and 21 females and, with
the exception of 4 patients who requested unilateral
crease revisions, all others were bilateral.
The data were arranged in two separate groups of
columns, OD for the right upper lid, OS for the left
upper lid. The first two columns reflect the pre- and
postoperative crease height in millimeters. The third
column of each of these two clusters of data reflects
the difference between the preoperative and postop-
erative changes in crease height. There were 24 eye-
lids in each category, for a total of 48 eyelids. The
data were pooled together to arrive at the overall
mean.
The pre-revisional crease height was measured in
the office using a millimeter scale and ranges between
8 and 14 mm, with the overall mean being 9.9mm.
The crease height designed during revision (in 0.5mm
increments) varied between 6.0 and 8.5mm, based on
the circumstances, with the mean being 7.15mm; and
7mm was the most often applied measurement during
Figure 17.8 (A) Before and (B) after photographs of a
patient who underwent revisional surgery to reset a
high crease.
A
B

319
Technique of Beveled Approach in Revisional Asian Blepharoplasty
Table 17.1: Data on revisional surgery for high crease height in Asian upper eyelids.

Age & Gender
Preop OD
Postop OD
Change
Preop OS
Postop OS
Change
1
42F
12
7.5
4.5
11
7.5
3.5
2
38F
11
7.5
3.5
10
7.5
2.5
3
46F
11
7
4
10
7
3
4
60F
10
6
4
10
6
4
5
54F
9.5
7.5
2
9.5
7.5
2
6
32F
9
7
2
9
7
2
7
32F



8.5
6.5
2
8
22F
8.5
7
1.5
8.5
7
1.5
9
23M
8
7
1
8
7
1
10
63F
9
7
2
9
7
2
11
36F
12
8
4
14
8
6
12
58F
12
7
5
12
7
5
13
65F
11
7
4
11
7
4
14
29M
9
7
2
9
7
2
15
22F
9
8
1
9
8
1
16
55F
10
7.5
2.5
10
7.5
2.5
17
66F
9
6
3
8.5
6
2.5
18
30F
11
8.5
2.5
10
8
2
19
34F
9.5
8
1.5


20
25F
8.5
7
1.5
8.5
7
1.5
21
39F
9
7
2
9
7
2
22
47F
11
8
3
11
8
3
23
28F



8
6.5
1.5
24
63F
10
7
3


25
26F
9.5
6.5
3
9.5
6.5
3
26
28F
12
6
6
12
8
4

Subtotal =
240.5
172
68.5
235
171.5
63.5

Statistical mean = 10.02
7.16
2.85
9.79
7.14
2.65

Overall mean
9.9
7.15
2.75


surgery under local anesthetic. The effective lowering
of the crease height ranges from 1 to 6mm when reas-
sessed during their 2 months’ post-revisional visits.
The mean lowering of crease height is 2.75mm in this
series based on 2 months’ follow-up. In other words,
it is possible to recruit, on average, close to 2.75mm
of skin in an attempt to lower crease height in some-
one who has very little skin to spare. The typical
course is such that the crease height will continue to
settle down with cessation of swelling and wound

320
Chapter 17: The Technique of Beveled Approach in Revisional Asian Blepharoplasty
healing, such that the effective lowering of the crease
will likely increase had it been possible for all of these
patients to return for a lengthier follow-up period
(Table 17.1).
The beveled approach allows the surgeon to reach
the preaponeurotic space safely, to reposition or
release any residual fat superiorly to fill in the hollow,
and avoid further skin excision. A glide interface as
well as a relatively physiologic crease can be created.
REFERENCES
1. Chen WPD. Concept of triangular, rectangular
and trapezoidal debulking of eyelid tissues:
application in Asian blepharoplasty. Plast
Reconstr Surg 1996; 97(1):212–218.
2. Chen WPD. Asian blepharoplasty: a surgical atlas.
London: Butterworth-Heinemann; 1995: 192.
3. Chen WPD. Asian blepharoplasty – update on
anatomy and technique. J Ophthal Plast
Reconstr Surg 1987; 3(3):135–140.
4. Chen WPD. Aesthetic eyelid surgery in Asians:
an East-West view. Hong Kong J Ophthalmol
2000; 3(1):27–31.
5. Chen WPD, ed. Oculoplastic surgery - the
essentials (A medical textbook). Stuttgart and
New York: Thieme Medical Publishers; 2001.
6. Chen WPD. Color atlas of cosmetic oculoplastic
surgery (A surgical textbook). London:
Butterworth-Heinemann; 2004.

321
Chapter 18
Botulinum Toxin and Dermal Filler
Use in the Periorbital Areas
Stuart R Seiff
We currently live in a society that places a premium on
youthful appearance. However, our busy lives limit the
amount of time we can spend in pursuit of the fountain
of youth. Therefore, quick interventions with minimal
recovery time are becoming extremely popular.
There are several modalities available for minimally
invasive rejuvenation of the periorbital region. They
include microdermabrasion, laser therapy including
intense pulsed light, radiofrequency techniques, and
‘cosmeceuticals.’ Cosmeceutical agents would include
retinoic acid, alpha/beta hydroxyl and glycolic acid
treatments, moisturizers and sunscreens, as well as
neuromodulating agents such as botulinum toxin, and
dermal fillers.
Botulinum toxin and dermal fillers are currently
very popular, given their minimal time investment,
modest cost, minimal recovery time, efficacy, and dura-
tion of action. Maximum benefit seems to occur in
patients who use botulinum toxin and fillers together.
Botulinum A Toxin
Botulinum toxin is a neuromuscular blocking agent
produced by Clostridium botulinum. Botulinum toxin
paralyzes muscle by inhibiting the release of acetyl-
choline from the presynaptic nerve terminal of the
neuromuscular junction. We must remember that botu-
linum toxin is a paralytic agent, not a filler. It relieves
rhytides formed by repetitive movements. The toxin
must be injected into the offending muscle, not into
the rhytid. Further, the injection must be placed at the
proper level to maximally affect the muscle in ques-
tion and minimize side effects. The effect typically
lasts 3–4 months.
Botulinum A toxin (BOTOX®, Allergan, Irvine,
CA) is approved by the United States Food and Drug
Administration for the management of glabellar fur-
rows. Off label uses in the periorbital region include
management of canthal lines (crow’s feet), brow eleva-
tion, and reduction of frontal lines.
Authors vary in their preferred dosing of botulinum
A toxin in the periorbital area. This author prefers a
concentration of 2.5 units per 0.1cc. A tuberculin
syringe with 30-guage needle works well. Some patients
prefer to be injected after placement of a topical anes-
thetic, but most find this to be of limited value. When
injecting a superficial muscle, a bleb should be raised.
The toxin should be placed deeper for less superficial
muscles.

322
Chapter 18: Botulinum Toxin and Dermal Filler Use in the Periorbital Areas
Lateral canthal lines (crow’s feet)
The crow’s feet lines are generally formed by contrac-
tion of the lateral portion of the superior and inferior
orbicularis muscle during squinting and laughing.
Therefore, these injections should be placed laterally
in an intradermal fashion with bleb formation, given
the superficial location of the orbicularis muscles.
The author typically places one injection above the
lateral raphe (aids in brow elevation) and two injec-
tions below (Fig. 18.1 & Fig. 18.3). Unfortunately,
management of crow’s feet tends to be more variable
than the typical success seen with glabellar injections.
Figure 18.2 Before-and-after picture following BOTOX® treatment of
glabellar furrow (frown lines), as well as lateral brow lift.
Figure 18.3 Before-and-after photos of patient following treatment for
lateral crow’s feet.
Figure 18.1 Injection pattern for BOTOX® treatment of glabellar furrows.
A
B
A
B
Glabellar furrows (frown lines)The target muscles
for the management of glabellar furrows include the
medial orbicularis oculi of the upper eyelid, the
corrugator supercilii, and the procerus. The injections
should be just anterior to the periosteum, as these
muscles are deep. Two injections are generally placed
for the corrugators and one centrally for the procerus
(Fig. 18.1). This region seems to have the most
reliable outcomes (Fig. 18.2).

323
Botulinum A Toxin
Brow lift
Botulinum toxin can be useful in gently elevating
ptotic brows, especially temporally. The target muscle
is the temporal orbital orbicularis oculi, which
depresses the lateral brow. This muscle is, again,
superficial so intradermal placement with bleb forma-
tion is appropriate (Fig. 18.1). Injection of 0.1–0.2cc
is generally adequate. This, combined with the medial
glabellar treatment, can produce nice brow elevation
and reduction of secondary dermatochalasis in the
lids (Fig. 18.2). This chemical brow lift is most effec-
tive when combined with fillers, as described below.
Frontal rhytides
Many patients desire to have their frontal furrows
reduced, both with and without facial expression.
The target muscle is the frontalis, which lies just
anterior to the pericranium. Therefore, injections
targeting this muscle must be placed deeply. Anywhere
from 0.2 to 0.4cc per side tend to be effective. The
frontalis lies between the brows and normal hairline
(Fig. 18.4). Overtreatment can lead to eyebrow
depression, counteracting the effect of brow lift
efforts and closing down the eyelid space. Injections
in this area are also often effective in decreasing
migraine headaches.
Approach to botulinum toxin injection regimen
Botulinum toxin injections work by paralyzing mus-
cles that cause skin wrinkling through repetitive con-
traction. For the medication to be effective, the
offending muscles must be inactive for sufficient time
such that the skin wrinkles can relax. It must be empha-
sized to patients that the effect is not instantaneous
and they must continue treatment for at least 6 months
to see the effect. They must be regularly treated during
this time or they are wasting their money.
The patient should receive the first set of injections
at an initial visit when this discussion occurs. They
should then receive additional injections 3 months
later and return for a 6-month evaluation. If they are
satisfied at that point, they should receive another set
of injections, and persistent deep rhytides may be
amenable to dermal filler therapy. The patient should
return at 3- to 4-month intervals when movement in
the treated areas begins to be seen. Minor movement
will not cause the rhytides to reform, but this indicates
the patient needs to return for reinjection.
Complications of periorbital botulinum toxin use
Inadequate effect is probably the most commonly seen
side effect of botulinum toxin use in the periorbital
region. This may be related to inadequate dosing or
less-potent medication. Retreatment will address this
problem. Also, local bruising from the injection may
occur. This can be minimized by having the patients
stop aspirin and other anticoagulant drugs before
their injection sessions, if safe to do so. Some patients
also experience a minor headache the day after injec-
tion. Mild analgesics are effective in managing this.
Injection of the glabellar area may cause formation
of a vertical frontal line due to recruitment of the lat-
eral orbicularis muscle. Additional orbicularis injec-
tions lateral to this line will minimize its appearance.
Aggressive injection of the frontalis muscle may
cause frontal collapse, dropping the brows and clos-
ing down the eyelid space. No acute management is
available but frontalis injections in the future should
be less aggressive.
Injections in the periorbital area can also result in the
rare occurrence of standard botulinum toxin side effects
of ptosis, diplopia, and dry eyes. Careful placement of
the injections should minimize these complications.
Figure 18.4 Placement of BOTOX® for treatment of frontal rhytides.

324
Chapter 18: Botulinum Toxin and Dermal Filler Use in the Periorbital Areas
Periorbital Augmentation with Dermal
Fillers
The original dermal filler was bovine collagen which
was used to treat fine facial lines and rhytides. More
recently, calcium hydroxyapatite (Radiesse; Bioform,
San Mateo, CA) and poly-L-lactic acid (Sculptra;
Sanofi Aventis, Bridgewater, NJ) were FDA-approved
for treatment of HIV lipoatrophy, while the calcium
hydroxyapatite and non-animal stabilized hyaluronic
acid (NASHA) (Restylane; Medicis, Scottsdale, AZ
and Juvederm; Allergan, Irvine, CA) fillers have
received approval for treatment of the nasolabial
folds. Off label uses of these fillers include the lips and
periorbital region including brows, tear trough, deep
glabellar furrows, and hollow superior sulcus. The
calcium hydroxyapatite and NASHA fillers tend to be
the most versatile and best for the periorbital region.
Hyaluronic acid is unlikely to cause nodules and
molds well. However, if placed too superficially, it can
leave a bluish discoloration. NASHA products such as
Restylane typically remain effective for 6–8 months. If
a hyaluronic acid filler placement is a problem for the
physician or patient, it can be dissolved with approxi-
mately 5 units of hyaluronidase.
The calcium hydroxyapatite filler has been known
to cause nodules when placed superficially or in the
lips. However, it is typically placed deeper and tends
to provide greater filling per volume than the NASHA.
The calcium hydroxyapatite fillers also seem to last
somewhat longer. However, if the result is unsatisfac-
tory, this filler cannot be removed easily.
Brow filler
In keeping with current concepts of aesthetics, a fuller
brow is a sign of youth. Fat atrophy and settling occur
with time along the supraorbital rim. As previously
mentioned, botulinum toxin injection can be used to
passively allow the brow to elevate. Dermal filler placed
along the supraorbital rim can enhance this effect.
It is best to start with an HA filler as it is easily
moldable and can be dissolved if necessary. The filler
should be placed deep, just anterior to the periosteum.
Typically, a 0.5-inch 27- or 30-gauge needle is used
with the bevel directed toward the periosteum. The
maximum benefit is derived from placement along the
lateral aspect of the supraorbital rim, but some filler
can be placed along the entire rim. A fanning tech-
nique works well, with 0.1–0.2cc deposited with each
penetration. Less than 0.3cc is usually used for each
brow (Fig. 18.5). If the patient likes the effect, CA
hydroxyapatite can be used for subsequent filling,
which may provide a longer-lasting effect.
Tear trough
The lower lid–midface complex is one of the more
challenging regions for rejuvenation. Again, we have
realized that fullness along the inferior orbital rim is a
sign of youth. Patients often have a hard time visual-
izing increased fullness in the malar area as an option
for dealing with what they perceive as lower lid bags.
Dermal fillers offer a wonderful way to increase
youthful fullness in the tear trough region in a tempo-
rary fashion, prior to proceeding with more complex,
longer-lasting procedures.
It is again best to start with the HA for midface fill-
ing. Given the thin skin in the tear trough region, it is
best to keep the filler deep, just anterior to the perios-
teum, to prevent a blue discoloration. A 0.5-inch 27-
or 30-gauge needle should be used, bevel down.
A finger should be placed on the inferior orbital rim
to prevent inadvertent deposition of the material in
the orbit or globe penetration.
Figure 18.5 Injection technique for fillers along the superolateral orbital
rim for creation of brow fullness.

325
Periorbital Augmentation with Dermal Fillers
Figure 18.6 Injection technique for fillers to the tear trough area of the
lower lid–midface area.
Figures 18.7 Preoperative and postoperative views following correction
of tear trough deformity using hyaluronic acid.
Figures 18.8 Preoperative and postoperative views following correction
of tear trough deformity using hyaluronic acid.
Injection of 0.1–0.3cc per side is usually adequate
(Fig. 18.6). If the effect is satisfactory with HA,
calcium hydroxyapatite can be considered for future
injections (Figs 18.7 & 18.8).
Persistent glabellar furrows
As previously mentioned, glabellar furrows are best man-
aged with botulinum toxin. However, very deep furrows
may not completely resolve. Therefore, it may be appro-
priate to inject these with a NASHA filler. In this case, it is
important to be deep enough to prevent a blue discolora-
tion (cannot see needle below the skin), but not so deep as
to produce a generalized elevation of the glabella. One of
the softer NASHA products should be used. Further care
should be taken to be certain that the injection is not intra-
vascular. Necrosis has been reported as a complication of
injecting in this region.
Hollow superior sulcus
This is a frequent problem encountered by the facial
surgeon. It may be caused by inadequate orbital vol-
ume, inferior displacement of the globe, or a levator
aponeurosis dehiscence without ptosis. Clearly, once
the cause of the hollow is identified, therapy can be
directed at the source. However, there are times when
that approach represents aggressive and unpredictable
therapy and something simpler is sought. Dermal fillers
can be used in this regard. Again, the NASHA products
should be used initially. Injection of 0.1–0.2cc can be
placed just below the superior orbital rim in the region
of the hollowness. The filler can be molded to create a
smooth appearance. Multiple smaller treatments a cou-
ple of weeks apart are usually preferable to trying to
get the desired effect at one session.
Complications of dermal filler
Most of the side effects and complications have been
discussed above. The most obvious is the inadvertent
placement of the filler. With NASHA, this is easily
dealt with using hyaluronidase. Approximately 5 units
of the enzyme are sufficient to dissolve any offending
nodule. Other materials are not so easily removed, but
will generally resolve with time.
Superficial placement of NASHA products can pro-
duce a blue discoloration of the skin. This generally
resolves but can also be handled as described above.

326
Chapter 18: Botulinum Toxin and Dermal Filler Use in the Periorbital Areas
Nodules can form with calcium hydroxyapatite,
but are generally not observed when placed deeply. If
they occur, they will resolve with time or can be surgi-
cally debrided.
Necrosis of tissues around fillers has been reported.
It is unclear whether this is due to intravascular
injection or vascular compression. Local nitropaste
has been suggested.
Botulinum toxin and dermal fillers do not represent
the fountain of youth, but they certainly have offered
some wonderful options in maintaining a youthful
fresh appearance for many of our patients.

327
Chapter 19
Hyaluronic Acid Filler Injection
Michael S McCracken and Jemshed A Khan
Introduction and History
Injectable fillers provide a quick and predictable
method of replacing lost facial volume, and they yield
high patient satisfaction (Fig. 19.1). Fillers are gener-
ally classified as either volumizers or stimulators based
upon the mechanism of action. Volumizers are rela-
Figure 19.1 (A) Patient prior to filler treatment of nasolabial, mesolabial and lips. (B) Patient immediately after hyaluronic acid filler treatment with
make-up applied.
tively inert substances that add bulk or volume, e.g.
silicone,
collagen,
and
non-animal,
stabilized
hyaluronic acid (NASHA). Stimulators have a biologic
activity that creates additional volume through either
a foreign body reaction (e.g. poly-L-lactic acid, dex-
tran) or collagen stimulation (e.g. polymethyl meth-
acrylate, calcium hydroxylapatite).
Volumizers
Hyaluronic Acid

■
Silicone

■
Collagen

■
e-PTFE

■
Stimulators
Poly-L-lactic acid

■
Dextran

■
Polymethyl methacrylate

■
Calcium hydroxyapatite

■
A
B
19.1
19.2

328
Chapter 19: Hyaluronic Acid Filler Injection
328
Chapter 19: Hyaluronic Acid Filler Injection
Figure 19.2 Hyaluronic acid filler is available as a
clear gel in a preloaded syringe.
Fillers vary considerably in the duration of effect.
Permanent fillers seem to be associated with higher
rates of late-onset infection, granuloma, and indura-
tion. Furthermore, a permanent filler may yield unnat-
ural results over time as it stays stationary while the
face changes with aging.
Cosmoderm and Cosmoplast are composed of human
collagen derived from a cell line from a newborn’s fore-
skin. Unlike the bovine collagen products, Cosmoderm
and Cosmoplast do not require allergy testing. They
contain lidocaine to reduce discomfort during injection,
so rhytides require slight overfilling. Evolence®
(OrthoNeutrogena, Morris Plains, NJ) is porcine colla-
gen, which was recently approved by the FDA.
Non-animal source hyaluronic acid
Currently, our filler class of choice is non-animal, sta-
bilized hyaluronic acid (NASHA) which is a clear vis-
cous gel (Fig. 19.2). NASHA fillers provide 6–12
months of tissue fill, are longer lasting than collagen,
have a favorable side effect profile, do not risk disease
transmission from an animal or human source, and
avoid the theoretical risks of long-lasting solid parti-
cles. One of the most beneficial characteristics of
NASHA fillers is that they can be immediately degraded
by the injection of hyaluronidase. In December, 2003,
Restylane® became the first FDA-approved NASHA
product. It is produced from streptococci by bacterial

329
Introduction and History
fermentation and undergoes cross-linking to increase
its resistance to enzymatic degradation. The FDA
approved Restylane® (Medicis, Scottsdale, AZ) in
December, 2003, for use in mid to deep dermal implan-
tation for the correction of rhytides, but it has been
available in Europe since 1996. Restylane® is distrib-
uted in 1.0cc and 0.4cc syringes, and does not contain
any local anesthetic. Although this necessitates topical
and/or local anesthesia, it also eliminates the need for
overcorrection. One milliliter of Restylane® contains
100 000 gel particles. In May, 2007, the FDA approved
Perlane® (Medicis, Scottsdale, AZ). Perlane® has
(10 000 particles/mL) and is used to correct deeper
folds. Perlane® is dispensed in a 1.0cc syringe.
Juvéderm™ Ultra and Juvéderm™ Ultra Plus (Allergan,
Irvine, CA) are NASHA fillers that were approved by
the FDA in June, 2006. They are both dispensed in
0.8cc syringes. These NASHA products are in a pure
gel rather than particle-suspension formulation.
Juvéderm™ Ultra is used for medium-depth wrinkles,
and Juvéderm™ Ultra Plus is used for deep wrinkles
and folds (Table 19.1).
Table 19.1: NASHA products and characteristics.
Product
Syringe
Common injection depth
Restylane®
0.4, 1.0
Mid dermis
Perlane®
1.0
Deep dermis, subcutaneous
Juvéderm™ Ultra
0.8
Mid dermis
Juvéderm™ Ultra Plus
0.8
Deep dermis, subcutaneous

330
Chapter 19: Hyaluronic Acid Filler Injection
Orbicularis
Orbitomalar ligament
Zygomatic ligament
Masseteric cutaneous ligament
Zygomaticus minor and major
Masseter
Figure 19.3 Ligamentous support of the face. Modified with permission from McCracken MS, del Prado JD, Kikkawa DO. Eyebrows, eyelids and face.
In: Tasman, W, Jaeger EA: Duane’s Foundations of Clinical Ophthalmology. Vol. II New York: Lippincott, Williams and Wilkins, 1995.
Anatomy and Aging
The structural aspect of facial aging consists of both
descent of tissues (due to gravity and chronic activity
of the muscles of facial expression), and loss of vol-
ume (bone and soft tissue). These changes are in addi-
tion to changes in the skin, such as elastosis, irregular
pigmentation, roughness or dryness, telangiectasia,
atrophy, deep wrinkling, and a variety of neoplasms.
In the dermis, they include attenuation in number and
diameter of elastic fibers in the papillary dermis, an
increase in number and thickness of elastic fibers in
the reticular fibers, and a coarsening of collagen fib-
ers with an increase in density of the collagen net-
work.
The SMAS and facial soft tissues are supported by
several ligamentous structures. These include the orbi-
tomalar ligament, zygomatic ligaments, masseteric
cutaneous ligaments, and mandibular ligaments
(Fig. 19.3). The deeper muscles of facial expression,
the zygomaticus major and levator labii superioris,
also penetrate the SMAS and provide fixation.
The face undergoes generalized volume loss with
aging, and squaring off of its youthful triangular
shape. Superficial changes of the facial skin include
brow ptosis, glabellar rhytides, malar festoons,

331
Anatomy and Aging
Figure 19.4 Manifestations of facial aging.
Forehead rhytides
Glabellar rhytides
Brow ptosis
Upper lid
dermatochalasis
Malar fat descent
Deepening of
nasojugal fold
Nasal tip ptosis
Deepening of
nasolabial fold
Smokers creases
Jowl formation
deepening of the nasolabial fold and formation of
melolabial folds (‘marionette lines’), smokers lines
(circumferential rhytides around the mouth), jowl for-
mation, and loss of lip volume (Fig. 19.4). Midfacial
ptosis is most likely caused by attenuation of the orbi-
tomalar ligament rather than by sagging of the orbic-
ularis oculi, zygomaticus major, zygomaticus minor,
or the SOOF. Bulging of the lower eyelid fat due to
weakening of the orbital septum combines with
descent of the SOOF and cheek fat pad to produce a
double convexity deformity, which is commonly
referred to as the ‘tear trough.’

332
Chapter 19: Hyaluronic Acid Filler Injection
Chapter 19: Hyaluronic Acid Filler Injection
Forehead rhytides
Glabellar rhytides
Brow ptosis
Upper lid
dermatochalasis
Malar fat descent
Deepening of
nasojugal fold
Nasal tip ptosis
Deepening of
nasolabial fold
Smokers creases
Jowl formation
Figure 19.5 The green zones indicate safe areas for beginning injectors. With experience, one may proceed to treat the yellow zones. Significant
caution and experience is required to achieve safe and satisfactory results in the red zones.
Clinical Indications, Physician
Experience, and Patient Selection
The nasolabial folds are the area most commonly
injected with NASHA fillers (Fig. 19.5). This area has a
high safety profile and a high patient satisfaction rate.
The melolabial folds, jowls, and lips are the next areas
that injectors expand into as they gain experience.
Because of its slightly higher complication rate, the gla-
bella is usually an area injected by injectors with exper-
tise. This area requires a high degree of caution. With
experience, the tear trough and brow may be injected.

333
Clinical Indications, Physician Experience, and Patient Selection
Injection is contraindicated in the presence of infec-
tion at the injection site, in patients with prior history
of hypersensitivity to NASHA products or Gram-
positive bacteria, in minors, and in women who are
pregnant or breast-feeding. Juvéderm™ is the only
product with FDA approval for injection in African-
American patients, but we are unaware of complica-
tions in African-Americans after Restylane® or
Perlane® injection. Patients need to understand the
temporary nature of the injections, and realize that
deep folds will improve with injection but will not be
eliminated. Also, patients need to understand that
although the injections should not appear lumpy, they
will be able to feel the product and that at times it
may feel lumpy. Patients need to be instructed to watch
for signs of skin necrosis.
Figure 19.6 Note the intradermal depth of
injection. There is visible mounding of filler and
the needle shaft is barely visible.

334
Chapter 19: Hyaluronic Acid Filler Injection
Chapter 19: Hyaluronic Acid Filler Injection
Injection Techniques
Introduction
General Principles: Unless medically necessary, aspirin,
NSAIDs, and other blood-thinning agents should be
discontinued prior to injection. Patient counseling
must be performed and informed consent obtained
prior to injection. It is imperative to remove any make-
up from the injection site. Depending upon the area,
the physician may choose topical or local anesthesia,
or both in combination. Topical anesthetic agents may
include EMLA (AstraZeneca LP, Wilmington, DE),
Betacaine LA (Theraderm, Tampa, FL), LMX4®
(Ferndale Laboratories Inc., Ferndale, MI). Local anes-
thetic may be added in small volumes (e.g., 0.1 mL) to
the filler vial itself.
Ice may also be used for 5 to 10 seconds prior to
injection for anesthetic effect and vasoconstriction.
After removal of any topical anesthetic, a thorough
cleaning with alcohol swabs must be performed before
injection. The label from the syringe should be removed
and placed in the patient’s chart for traceability.
Proper injection depth and technique are filler spe-
cific. For most applications, Restylane® and Juvéderm™
Ultra should be injected at the middermal level.
Perlane® and Juvederm™ Ultra Plus should be injected
in the deep dermis or subdermal plane. If one sees
chalky white blanching with intradermal injection,
one should immediately stop injection as this signals
ischemia and complete interruption of capillary blood
flow (for manage ment, see Complications at the end
of this chapter).
Figure 19.7 Injection techniques. (A) Serial puncture,
RESTYLANE injection techniques
Serial puncture technique
1
There should be no space between the injected material
Make multiple injections serially along the length
of the wrinkle
The injections merge into a continuous line,
lifting the wrinkle
2
3
A
19.3
19.4
19.5
19.6
19.7

335
Basic injection techniques
A number of techniques are used to inject NASHA
into an area (Fig. 19.7). The simplest technique, used
by new injectors, is serial puncture. Multiple pinprick
injections of filler are deposited at the appropriate
depth. This is most commonly used as an adjunct tech-
nique to complete or ‘touch-up’ areas already filled
using other techniques. Linear threading, perhaps the
most commonly used technique, involves advance-
ment of the needle and confirmation of uniform depth
and appropriate location before depressing the plunger
during withdrawal of the needle. The push-ahead
technique involves advancing the needle while depress-
ing the plunger. The flowing product acts to dissect
ahead of the needle and push away surrounding blood
vessels. Once mastered, this is an especially useful
method for the vermillion border, and will reduce
bruising in other facial areas. Cross-hatching involves
the placement of parallel rows of product via the lin-
ear threading or push-ahead technique, followed by a
second set of rows perpendicular to the first. This
technique is the workhorse for nasolabial fold treat-
ment. Fanning involves the placement of multiple
radial linear deposits of product from a single entry
site. This technique is useful for treating angulation
and depression below the oral commisure.
Periodically during the injection, a wet glove can
be used to palpate for smoothness of the injection and
to identify lumps. Massage may be used to smooth
out the product. The treatment is documented in the
chart and the sticker from the syringe is placed in the
patient’s chart.
Injection Techniques
Figure 19.7 (B) linear threading,
RESTYLANE injection techniques
Linear threading technique
1
Inject the gel while pulling the needle slowly backwards
Insert the full length of the needle in the middle of the wrinkle
The threads form one string, lifting the wrinkle
2
3
B

336
Chapter 19: Hyaluronic Acid Filler Injection
Figure 19.7 (C) cross-hatching,
RESTYLANE injection techniques
Cross-hatching technique
1
Inject as when using the linear threading technique
Change the angle and make a new series of
threads at a slightly different level
Withdraw the needle and insert a series of linear
threads 5-10mm from each other
2
3
4
C
After injection, patients are advised to avoid manipu-
lating the filled area. Ice can be used to decrease post-
operative discomfort and swelling. Patients undergoing
perioral injections, especially those with a history of
herpes simplex virus, are placed on oral antiviral proph y-
laxis after treatment. Patients should be instructed to
call in cases of excessive swelling, redness, pain or itch-
ing, signs of necrosis, or persistent bumps.

337
Injection Techniques
Essentials
Unless medically necessary, stop anticoagulation

■
before injection
Ice before and after injection

■
Prep with alcohol swabs before injection

■
Use a wet glove to feel for lumps

■
Massage or use cotton-tipped applicator to smooth

■
out lumps if necessary
Place the label from the syringe in the patient’s chart

■
Oral antiviral therapy is indicated after perioral

■
injection, particularly in patients with a history of HSV
Figure 19.7 (D) fanning. (With permission from Tasman, W. Duane’s foundation of clinical ophthalmology. Vol. II. Philadelphia: Lippincott, Williams &
Wilkins; 1995.
RESTYLANE injection techniques
Fan technique
1
After injecting one line, change the direction of
the needle and inject a new line without
withdrawing the needle
This is an example of how the fan technique
can be used for cheekbone enhancement
Insert the needle as when using the linear
treading technique
Repeat in a ‘fan-shaped’ fashion
2
3
4
D

338
Chapter 19: Hyaluronic Acid Filler Injection
Nasolabial folds
The most common site for NASHA injection is the
nasolabial folds. Most patients will tolerate nasolabial
fold injections with topical anesthesia, but many
require an infraorbital nerve block. This is usually
accomplished by the injection of 0.5cc of lidocaine
2% with epinephrine into the area of each infraorbital
nerve via the mucosa of the superior gingival sulcus in
the plane of the third tooth.
We recommend beginning with a fanning technique
to treat the superior portion of the nasolabial folds,
up to the nasal ala. The needle is inserted into the mid-
dermal plane (Restyane®, Juvéderm™ Ultra) or deep
dermal or subdermal plane (Perlane®, Juvéderm™
Ultra Plus) of the nasolabial fold and advanced toward
the nose to deposit threads in several radial lines orig-
inating from the insertion point. The superior fan
component is in the area of the folds, and the subse-
quent threads fan inferomedially. Linear threading is
then used along the inferior portion of the nasolabial
fold, taking care to leave a smooth transition between
the superior fan and the inferior section of linear
threading. Supplemental correction by cross-hatching
across the fold is then performed. Excessive injection
lateral to the fold may accentuate it. Massage may be
performed to smooth out any irregularities. A typical
patient will require about 0.8–2.0cc of NASHA for
nasolabial fold correction (Fig. 19.8).
Figure 19.8 (A) Patient before nasolabial fold injection with Restylane®. (B) Patient immediately after nasolabial fold injection with Restylane®, make-up
applied.
A
B

339
Injection Techniques
Essentials of nasolabial fold injection
Anesthesia is attained by topical cream or infraorbital

■
nerve block
Fanning is used in the superior aspect of the fold

■
Linear threading is used in the inferior aspect and

■
crevice of the fold
Cross-hatching is used to complete the injection

■
Figure 19.8 (C) Blue area indicates site of HA nasolabial fold injection with Restylane®. (D) Documentation of treatment site.
C
D

340
Chapter 19: Hyaluronic Acid Filler Injection
Figure 19.9 (A) Patient before melolabial fold injection with Restylane®.
(B) Patient immediately following melolabial fold injection with Restylane®.
(C) Treatment area is marked in blue. Patient also received Restylane®
injection to the nasolabial folds.
Essentials of melolabial fold injection
Topical anesthesia with or without infraorbital nerve

■
block
Fanning and serial puncture

■
Palpate for lumps with one finger on the skin surface

■
and one in the mouth
The melolabial folds
Melolabial folds, or marionette lines, are often treated at
the time of nasolabial fold injection. If a block is used for
the nasolabial fold injection, it will not provide adequate
anesthesia to the melolabial folds. These folds should be
treated with topical anesthesia and often a mental nerve
block or infiltrative anesthesia. We recommend a fanning
technique beginning at the oral commissure and extend-
ing inferiorly along the folds. Full correction of this area is
difficult to obtain, and it is easy to overfill and leave lumps.
Care should be taken to palpate for lumps and massage
with one digit in the mouth and one on the skin surface. In
the average patient, roughly 0.5cc of NASHA is used to
treat both melolabial folds (Fig. 19.9).
A
B
C

341
Injection Techniques
Figure 19.10 (A) Patient before and after lip injection with Restylane®. Note the abnormal pretreatment 30:70 ratio of lower to upper lip. (B) Patient
immediately after injection of Restylane® into the vermillion border, as well as volume augmentation to the lower and upper lip. Note the 60:40 ratio
of lower to upper lip height.
Lips
We recommend Restylane® or Juvéderm™ Ultra for use
in the lips. Although some patients may tolerate lip
enhancement under topical anesthesia, most will
require mental and infraorbital nerve blocks with the
injection of lidocaine 2% with epinephrine 1:200 000
into the mucosa of the gingival sulcus, in the plane of
the third tooth from the midline. Each of these four
sites should receive an injection of 0.5–1.0cc. Lidocaine
2% without epinephrine may be used to decrease the
duration of the block. An alternative technique, the
submucosal injection, involves injecting the anesthetic
into multiple locations in the lip mucosa in the area
between the third tooth on either side. The administra-
tion of a block will distort the lips slightly, so it is nec-
essary to note any asymmetry between sides before the
block is administered. It is also crucial to observe the
vertical height of the upper lip in comparison to the
lower lip (Fig. 19.10A & B). In general, the ideal lower
lip is slightly larger and fuller than the upper lip
(i.e. 60% of the height of the combined upper and
lower lip is in the lower lip). During injection, it is
essential to monitor the amount injected in each side
and palpate the lips during the injection to assure
A
B
19.8
19.9

342
Chapter 19: Hyaluronic Acid Filler Injection
symmetry. To define the lip border, linear threading
may be performed along the vermillion border. This
injection is in the virtual plane between the vermillion
and the orbicularis (Fig. 19.10C). Excessive volume
placement into the upper vermillion border may give
an unnatural, duckbill-like appearance. Injection into
the wet–dry junction and between the junction and
vermillion will increase the volume of the upper and
lower lips. This is done with a series of linear threads
(usually about six for the upper lip or four to five for
the lower lip). The push-ahead technique is particularly
useful in the lips to decrease bruising and swelling.
Figure 19.10 (C) Blue zones indicate injection sites into the vermillion
border and lip.
C

343
Injection Techniques
Figure 19.10 (E) Patient with vertical smoker’s lines before lip injection
with Restylane®.
Adequate volume restoration in the lips will produce
improvement in ‘smokers’ lines,’ the radial lines in the
skin perpendicular to the lips. Caution should be used
in directly filling smoker’s lines with NASHA, as over-
filling and lumpiness may result; however, in some
patients, with careful technique one can fill these radial
lines nicely (Fig. 19.10D–F). Filler materials with
smaller particle size are better suited for smoker’s lines.
We find that many patients are not amenable to the
appearance produced by filling the philtral columns
from the nose to the upper lip. During injection, any
palpable lumps should be massaged. However, excessive
Figure 19.10 (D) Direct injection into the vermillion border is
demonstrated.
D
Figure 19.10 (F) Patient with vertical smoker’s lines immediately following
injection with Restylane® and with make-up applied.
F
Figure 19.10 (G) Blue zones indicate areas of superficial filler injection.
G
E

344
Chapter 19: Hyaluronic Acid Filler Injection
Chapter 19: Hyaluronic Acid Filler Injection
massaging of the lips will increase postoperative swell-
ing. The typical patient will require 1cc or less of
NASHA to fill the lips. One can only fill lips to a given
volume, since beyond a certain point the lips will no
longer fill smoothly with filler, and further injection
will only create a lumpy distended appearance. We
recommend antiviral prophylaxis for lip injections in
patients with a history of oral herpes simplex virus.
Active herpetic infection at the site is a contraindica-
tion to injection.
Essentials for lip injections
Use Restylane

■
® or Juvéderm™ Ultra
Use nerve blocks

■
Note any asymmetry before administering nerve blocks

■
Use push-ahead technique

■
Use small volumes in the vermillion to avoid a duckbill appearance

■
Smoker’s lines may decrease after lip injection as result of vermillion border injection and without direct injection into

■
the smoker’s lines
Identify lumps with a wet glove and massage them

■
Use oral antiviral prophylaxis, especially in patients with a history of HSV

■

345
Advanced Techniques
Advanced Techniques
Glabella
The glabella is injected under topical anesthesia. Mid or
deep dermal linear threading with Restylane® or
Juvéderm™ Ultra is our preferred technique. The gla-
bella is an injection site that should be reserved for expe-
rienced injectors. Filler injection into the glabella has
been associated with localized necrosis and with blind-
ness due to retrograde arterial injection and subsequent
central retinal artery occlusion. Extreme caution must
be exercised to ensure that the injection is placed within
the dermis. It is important to aspirate before injecting
to confirm that the needle is not in a vessel. Continuing
to move the needle during injection and avoiding exces-
sive pressure on the plunger of the syringe will help to
avoid prolonged or forceful retrograde intra-arterial
injection. The glabellar lines are usually best filled by
linear threading of approximately 0.5cc of NASHA.
Concurrent botulinum toxin injection will increase
the duration of effect of glabellar NASHA injections
(Fig. 19.11).
Essentials for glabellar injections
Use Restylane

■
® or Juvéderm™ Ultra
Use topical anesthesia

■
Avoid overfilling to reduce the risk of local skin

■
necrosis
Avoid intra-arterial injection to reduce the risk of

■
retinal arterial occlusion
A
B
Figure 19.11 (A) Patient before glabellar injection with Restylane®.
(B) Patient after glabellar injection with Restylane®. (C) Blue zones indicate
areas of intradermal filler injection.
C

346
Chapter 19: Hyaluronic Acid Filler Injection
Chapter 19: Hyaluronic Acid Filler Injection
Tear trough
With aging, the orbital septum weakens and allows
prolapse of the lower lid fat pads. Descent of subor-
bicularis oculi fat (SOOF) and orbicularis muscle
also occur over time, exposing the orbital rim. Lower
lid fat prolapse and midface descent combine to pro-
duce a double-bubble appearance. This is also
referred to as the nasojugal fold, or tear trough. Tear
trough injections are gaining popularity as an alter-
native to lower lid blepharoplasty in young patients.
Restylane® and Juvéderm™ Ultra can usually be
injected into the tear trough with topical anesthesia
supplemented by ice. Some patients may require an
infraorbital nerve block. We recommend the injec-
tion of Restylane® in the preperiosteal plane, using
the push-ahead technique (Fig. 19.12A–D) or a depot
Figure 19.12 (A) Patient before tear trough injection. (B) Patient after tear trough injection. (C) Patient before tear trough injection. (D) Patient after tear
trough injection.
A
B
C
D

347
Advanced Techniques
injection (Fig. 19.12E–G). With the depot technique
(oral communication, Steven Bosniak, MD), deep
injection is given until a bolus creates a slight over-
correction. This is then massaged to flatten and dis-
perse the product. Three to four injections per lid are
usually required.
Because the eyelid skin is extremely thin, great care
must be taken to inject deep beneath the orbicularis mus-
cle with each pass to avoid superficial beading or a blue
tint to the skin (Tyndall effect). Injecting slowly mini-
mizes retrograde flow in the rare event of an intra-arte-
rial injection. To avoid injury to the eye, care should be
taken to assure that the needle is attached tightly to the
syringe, and the needle should be pointed away from the
globe. Placing a finger of the non-injecting hand on the
inferior orbital rim will give a landmark to avoid ocular
penetration of the needle. A typical patient will require a
total of about 0.8–1.0cc of NASHA for tear trough
correction.
Figure 19.12 (E) Patient before tear trough injection. (F) Patient after tear
trough injection. (G) Blue areas indicate sites of bolus injection.
Essentials for tear trough injection
Use Restylane

■
® or Juvéderm™ Ultra
Use topical anesthesia with ice

■
Inject in the preperiosteal plane, with supplemental

■
injections in the subdermal plane
Avoid globe penetration

■
Inject with low pressure to limit retrograde arterial

■
injection
E
F
G

348
Chapter 19: Hyaluronic Acid Filler Injection
Chapter 19: Hyaluronic Acid Filler Injection
Jowl augmentation
Soft tissue descent and loss of bone structure in the jaw
contribute to jowl formation with aging. Although
jowls are traditionally addressed with face lifting, they
respond well to NASHA injection. Facelifts alone are
two-dimensional and do not always address this
component of descent. NASHA may be injected into
the preperiosteal plane, at the inferior aspect of the
mandible, to restore lost volume and reduce jowling.
NASHA can usually be injected into the jowl with
topical anesthesia supplemented by ice, but some
patients may require an infraorbital nerve block. Care
must be taken to avoid intra-arterial injection.
Withdrawing the plunger before injection and looking
for the aspiration of blood can help to rule out intra-
vascular needle placement. Also, significant pain on
needle placement may indicate that the needle is in the
neurovascular bundle. A typical patient will require
0.5–1.0cc of NASHA to correct the jowls (Fig. 19.13).
Figure 19.13 (A) Patient before jowl augmentation with Perlane®. (B)
Patient received Perlane® injections along the mandibular border in the area
of jowling, as well as to the nasolabial folds, melolabial folds, and temporal
jaw. (C) Blue zones indicate areas of Perlane® injections.
Jowl Augmentation
Use topical anesthesia with ice

■
Inject in the preperiosteal plane

■
Inject the inferior aspect of the mandible

■
Avoid intra-arterial injection

■
A
C
B

349
Complications
Complications
In 1999, the protein content of Restylane® and
Perlane® was purified sixfold, and the strain of bacte-
ria used for fermentation was changed. Since then, the
incidence of complications after NASHA injection has
decreased. Bruising is the most common complication,
but it may be lessened by discontinuing medications
with anticoagulant properties, by practicing careful
technique, and by applying ice or pressure to areas
that begin to bruise during injection. Topical or oral
arnica Montana compounds may also be administered
to decrease bruising. Should bruising occur, it may be
covered with concealer. Pain after injection may last
for several days, and is associated with muscle move-
ment. Usually, it responds to acetaminophen. Swelling
is a common side effect, but may be severe in cases of
lip injections. Some patients experience dramatic swell-
ing immediately after lip injections (Fig. 19.14). This is
not allergic, and may be related to excessive massage
to mold the injection. This swelling usually responds
in several days to oral steroids with oral antiviral
prophylaxis.
Telangiectasias may result from the injection of prod-
uct. Bluish discoloration of the skin is an optical effect
(Tyndall effect) due to superficial injection of hyaluronic
acid. Persistent redness in all treated areas may be a reac-
tion to the hyaluronic acid, and can be treated with con-
cealers. Local steroid injection or excision may be options
if redness persists.
Figure 19.14 (A) Severe lip swelling immediately after Restylane® injection. (B) Three days after injection; patient was treated with oral steroids (Medrol
Dosepack).
A
B

350
Chapter 19: Hyaluronic Acid Filler Injection
Chapter 19: Hyaluronic Acid Filler Injection
Figure 19.15 Sculptra nodules following tear
trough placement of a stimulator product
primarily designed for subcutaneous cheek
placement. Patient presented for a second
opinion. (Image courtesy of Morris Hartstein, MD)
Figure 19.16 Presumed bacterial infection
presenting several days after filler injection. Patient
presented for second opinion. (Image courtesy of
Maziar Bidar, MD)
Nodularity, or beading, is most commonly due to
improper injection. It may be treated by massage of
the product, incision and drainage or division with
an 18-gauge needle, or enzymatic degradation by
hyaluronidase in the case of HA. Superficial eyelid
injection of thicker fillers (i.e. stimulators) designed
for deep placement may result in unsightly nodules
(Fig. 19.15).
Erythematous or fluctuant nodules in the early post-
treatment course could be due to bacterial infection by
Gram-positive skin flora, and should be treated accord-
ingly (Fig. 19.16). Late-onset erythema (2 weeks after
injection) accompanied by tender bumps may be the
result of mycobacterial infection. This may be treated
empirically with clarithromycin 500mg p.o. b.i.d. for 2
weeks, followed by intralesional triamcinolone 2.5mg/
mL at 3–4-week intervals. Should the lesions not
respond, incision and drainage may be performed.
Herpetic outbreaks of the lips necessitate therapeutic-
dose oral antiviral therapy.

351
Complications
Figure 19.17 Impending local skin necrosis from
arterial compression 18 hours after overinjection
of Restylane® to the tear trough. Necrosis was
avoided with the use of warm compresses, topical
nitroglycerin paste, and local hyaluronidase
injection.
Superficial necrosis (most commonly seen in the
glabella) is most commonly due to compression (after
overfilling or bleeding), but may be the result of vas-
cular obstruction due to intravascular filler injection
or direct vascular injury. Initially, painless blanching
of the glabella is noted, followed by darkening of the
skin over several days (Fig. 19.17). An eschar then
covers an area of ulceration. Whenever necrosis is
suspected, injection must be stopped immediately. If
intradermal bleeding is noted, pressure should be
applied until the bleeding stops. In the event of necro-
sis due to arterial occlusion, immediate cessation of
injection generally leads to resolution of the occlusion.
If necessary, massage can be employed, and will usu-
ally lead to rebound hyperemia. Warm compresses
and the application of 2% nitroglycerin paste may
also prove useful. As a last resort, hyaluronidase may
be injected to degrade the injected NASHA.
One unlikely but devastating complication of
NASHA injection is retrograde occlusion of the reti-
nal vasculature. Once retinal vascular occlusion has
occurred, immediate treatment should be initiated to
attempt to dislodge the embolus distally in an attempt
to restore some perfusion. Visual loss may become
permanent as quickly as 90 minutes after occlusion of
the central retinal artery. In this unlikely event, we
recommend ocular massage and intraocular pressure
lowering agents, followed by anterior chamber para-
centesis. The prognosis for recovery of vision after
retinal arterial occlusion is poor.
Pitfalls
Bruising

■
Telangiectasia

■
Bluish discoloration (Tyndall effect)

■
Nodules

■
Skin necrosis

■
Infection

■
Retinal arterial occlusion

■

352
Chapter 19: Hyaluronic Acid Filler Injection
Figure 19.18 The authors provide this figure as a template for documenting treatment.
Documentation of Treatment
Anatomic documentation of treatment sites and injec-
tion amounts provides a record that is useful in modi-
fying future treatments (Fig. 19.18). When a patient
has experienced undercorrection or overcorrection,
such documentation facilitates the modification of the
next treatment.
19.10
19.11
19.12

353
Informed Consent
Informed Consent
NASHA injections have an excellent safety profile and
very high patient satisfaction. However, because seri-
ous complications can occur, documentation of
informed consent is essential before treatment can
begin (Fig. 19.19).
Figure 19.19 Informed consent form.

354
Chapter 19: Hyaluronic Acid Filler Injection
Chapter 19: Hyaluronic Acid Filler Injection
Figure 19.19 Cont’d

355
Index
Note: Illustration are comprehensively referred to from the text.
Therefore, significant material in illustrations and tables have
only been given a page reference in the absence of their
concomitant mention in the text referring to that figure.
A
ablative laser skin resurfacing, 231
fractionated and,
comparisons, 233–4
procedure/technique, 243–4, 246
safety and anesthesia, 241–2
tissue response, 235
wound healing, 237
acetylcholine and botulinum toxin, 211, 212
acne and laser skin resurfacing, 238–9
acyclovir in laser skin resurfacing, preoperative, 240
adhesions in beveled approach to revisional Asian blepharoplasty,
313–14
adhesives see glues; tapes
age-related changes (face), 330–1
eyebrows, 30
midface/cheeks, 115
air knot, closure of laser upper blepharoplasty, 170
Alloderm, cheeklift, 123, 143
anchoring in cheeklift, 117–32, 141–56
double, 126, 143
problems, 141–56
anesthesia
Dr Chen’s viewpoint, 19
Dr Khan’s viewpoint, 20
Dr McCord’s viewpoint, 19
hyaluronic acid filler injection, 341
laser skin resurfacing, 241–2
see also general anesthesia; local anesthesia; topical anesthesia
antibiotics in laser skin resurfacing
postoperative, 247, 248
preoperative, 240
antivirals
in hyaluronic acid filler injection, 350
of lips, 344
in laser skin resurfacing
postoperative, 247, 248
preoperative, 240
aponeurosis
epicranial (galea aponeurotica), 27, 28, 29
levator see levator aponeurosis
appearance, postoperative accentuation of, 21
arcuate expansion in transconjunctival laser blepharoplasty, 177
Asian blepharoplasty of upper lid (crease creation; so-called
Westernizing blepharoplasty), 8–9, 73–107, 251–301
advanced techniques, 251–301
before and after appearance, 91–7
bevelled approach, 309, 311–19
clinical use, 98
crease measurements, 47
glide zone and, 303, 308
postoperative regimen, 90
premedications and surgical setup, 76
purposes of/reasons for, 8, 73, 75
reversal request, 257, 270
revision see secondary surgery
suboptimal results see complications
surgical method, 76
surgical stages, 78–89
Asian eyelid anatomy, 303–4
crease and see crease
cross-sectional view, 74
fallacies/stereotypic conclusions, 5, 73
glide zone concept and, 303–4
‘Western’ vs, 10
assessment see evaluation
asymmetry of lid creases, 253
correction, 251, 257, 259
AVIS mnemonic, 156
B
balloting maneuver, transconjunctival laser
blepharoplasty, 186
baseball stitch
lower blepharoplasty, 114
upper blepharoplasty, 58
Bell’s phenomenon (in ptotic patients), 195, 197, 207
absence, surgical options, 198
beveled approach to revisional Asian blepharoplasty, 309,
311–19
bifid crease, 253, 258
case commentaries, 272, 276
bipolar cautery, upper blepharoplasty, 52
Asians, 81, 83, 84
wetfield, 81, 83, 84
bleaching agent in laser skin resurfacing
postoperative, 250
preoperative, 240
bleeding and its control (hemostasis)
Asian blepharoplasty, 81
Fasanella–Servat correction of minimal ptosis, 204
laser blepharoplasty of lower lid, 185, 188
laser blepharoplasty of upper lid, 160, 166, 167
tarso-aponeurectomy (McCord’s), 199
Chen’s modification of, 200

356
Index
blepharophimosis, 197
postoperative, correction, 145, 148
blepharoplasty
lower lid, 109–14
laser see laser blepharoplasty
postoperative consideration, 20–2
safety, 22
suboptimal results see complications
upper lid, 43–59
Asians see Asian blepharoplasty
glide zone and, 303–10
laser see laser blepharoplasty
procedure performed before or in conjunction with,
25, 43, 61, 68–70
technique, 46–59
blepharoptosis (lid ptosis), 193–210
Asian blepharoplasty, 98
case commentaries, 271, 286
botulinum toxin injection-related, 227
classification (by cause), 193–5
congenital, 193, 194
evaluation, 198
surgical repair, 199–209
bluish discoloration, hyaluronic acid, 324, 325, 349
blurred vision, postoperative, 21–2
patient concerns, 22
body image, patient concerns, 22
botulinum toxin (mainly BotoxR[O)], 211–29, 321–3
advanced techniques, 223–5
anatomy relating to use, 214
clinical indications and patient selection, 213, 322–3
complications, 227, 323
documentation of treatment, 228
dose for specific site, 216
history, 213
hyaluronic acid filler and, concurrent glabellar
injection, 345
informed consent, 229
injection technique, 218–19
mode of action, 211–13
periorbital areas, 321–3
preparation, 217
regimen, 323
serotypes, 213
Bovie (cautery) tip, upper blepharoplasty, 49, 50, 51, 52, 55
Asians, 82
brow (brow/forehead area)
age-related changes, 30
anatomy, 25–9
botulinum toxin dose, 216
dermal filler, 324
brow lift
botulinum toxin injection, 323
direct, 61, 62–4
in conjunction with other procedures, 43, 61
variations on, 65–7
endoscopic-assisted see endoscopic-assisted eyebrow
forehead lift
lateral see temporal forehead lift
brow ptosis, management algorithm, 59
brow surgery (in general), 61–71
endoscopic-assisted see endoscopic-assisted eyebrow
forehead lift
browpexy, internal, 61, 68–9
in conjunction with other procedures, 43, 61
steps, 68
browplasty, 70
bruising, postoperative, 21
bunching technique, 48
bupivacaine, laser blepharoplasty of upper lid, 163
C
calcium hydroxyapatite for periorbital augmentation, 324
brow filler, 324
complications, 324, 325–6
tear trough, 324
canthoplasty, lateral
in cheeklift
corrective/revisional, 144, 145
primary see canthus/canthal folds, lateral
in lower blepharoplasty, 111
canthus/canthal folds, lateral
anchoring (lateral canthoplasty) in cheeklift, 117, 118–24
problems/failure and their management, 141, 144–9
variety of modifications with varying conditions, 142
in Asians, 73
lines see crow’s feet
canthus/canthal folds, medial, in Asians, 7
blepharoplasty considerations, 89
capsulo-palpebral fascia release, 123, 143
carbon dioxide laser
ablative skin resurfacing systems, 231, 243–4
compared with other systems, 233–4
multiple-pass, 244
procedure/technique, 243–4
safety and anesthesia, 241–2
tissue response, 235
wound healing, 237
blepharoplasty see laser blepharoplasty
fractionated skin resurfacing systems see fractionated
laser skin resurfacing
Caucasians and ‘Westerns’
cross-sectional view, 74
upper eyelid anatomy, 10–15, 44
cautery, upper blepharoplasty, 49, 50, 51, 52, 55
Asians, 81, 82, 83, 84
cellulitis, eyelid, 2
central fat pads in laser blepharoplasty
of lower lids
developing pedicles for repositioning, 189
excision, 184
mobilization, 182
septal incisions over, 181
of upper lids, exposure and excision, 165–8
cheeklift (trans-lid lift; midface lift), primary, 115–39