Essentials of Aesthetic Surgery

372
FACE AND NECK ANATOMY
Mastery of the three-dimensional anatomy of the face and neck is essential for safe and

Anatomic variation is the rule, not the exception.
SOFT TISSUE LAYERS OF THE FACE
The face is anatomically arranged in related concentric layers to create a balanced
structure that produces facial movement.
• Skin


• Mimetic muscles
• Deep fat and anatomic spaces (buccal space)
• Deep facial fascia (parotidomasseteric fascia)
• Deepest plane
1,2
• The epidermis is composed of keratinocytes, melanocytes, and antigen-presenting


• Dermal thickness is variable throughout the face and neck and is related to its
function.


thickest.
• Thinner dermis is more susceptible to deterioration and signs of aging.
1,2,4,5
• Comprises two components
Provides facial volume
Binds dermis to the underlying musculoaponeurotic
system
is the name given to the portion of a retaining ligament as it
passes through the subcutaneous layer.

regions of the face.


predisposed to weakening with age.

373
Chapter 30 Face and Neck Anatomy

1,2,6-10 (Fig.
30-1)
• Subcutaneous fat in
the face is partitioned
into distinct anatomic
compartments and may

mass.
• A youthful face has
smooth transitions
between compartments,
whereas aging can lead to
abrupt contour changes.
• Shearing between adjacent
compartments may
contribute to soft tissue
malpositioning.


middle temporal compartment and inferiorly by the nasal dorsum

that borders this compartment.
On either side of central forehead fat. Inferior border is
orbicularis retaining ligament, lateral border is superior temporal septum.
Connects lateral forehead fat to lateral cheek and cervical fat

Bounded by the orbicularis retaining ligament as it courses around the
superior orbit
Thin subcutaneous layer immediately below the inferior lid tarsus
Superior border is the inferior temporal septum, inferior border is the
superior cheek septum.



retaining ligament and the lateral orbital compartment.
– Perforating vessels from the facial and infraorbital arteries are found
within the medial limiting septum.
– Facial vein is found on the deep surface of the medial cheek fat.

– Perforating vessels of the transverse facial artery course within the middle
cheek septum.
– The plane between the middle and lateral cheek compartments can
easily lead to into the deepest plane and buccal fat pad with associated
neurovascular structures.
FPO
Periorbital fat:
Superior
Inferior

Nasolabial fat
Forehead fat:
Central
Middle
Malar fat:
Medial
Middle

374
Part VII Facial Surgery

connects temporal fat the cervical subcutaneous fat
– The lateral cheek septum is anterior to the laterotemporal compartment



inferior to orbicularis oculi muscle

TIP: Potential space for fat transfer exists between the periosteum and the deep
medial fat (Ristow space).





TIP: One reason for a prominent nasolabial fold with aging is a pseudoptosis of the
nasolabial fat secondary to loss of volume of the deep medial fat compartment and





of platysma muscle
1-3,11-14



invests.

(also called )

• The SMAS is divided into and portions.
Firmly adherent, relatively immobile, found in the lateral face over the
parotid gland
Nonadherent to underlying structures, found directly over mimetic
muscles and parotid duct and anterior to parotid gland
2,15
• Mimetic muscles are responsible for the coordinated movement of the midface and
lips and control the size and shape of the mouth. These muscles commonly overlap
and are described in

2. Platysma, risorius, zygomaticus major, deeper portion of zygomaticus minor,
levator labii superioris alaeque nasi

4. Mentalis, levator anguli oris, buccinator

375
Chapter 30 Face and Neck Anatomy
• Muscles of the are innervated by the facial nerve on their deep
surfaces, whereas muscles of the are innervated by the facial nerve on their
surfaces.
SENIOR AUTHOR TIP: This is a common test question.
2,3,16

muscles.

fascia from the neck onto the face.
• Branches of the facial nerve within the cheek, as well as the parotid duct, are deep to
the deep facial fascia.

region of the face.
or investing fascia of the parotid




each other.



this plane is the deep temporal fascia (deep facial fascia).
TIP: The frontal branch becomes invested by temporoparietal fascia.

arch, overlying the parotid gland, and along the anterior border of the
masseter.
2,3,15
• Found deep to the deep facial fascia (parotidomasseteric fascia)
• As the facial nerve branches continue peripherally, they pierce the
parotidomasseteric fascia to innervate the mimetic musculature.
• The buccal fat pad, parotid duct, facial artery/facial vein, and zygomatic and buccal
branches of the facial nerve are found within this plane.

15,17



buccal extension.

18





sternocleidomastoid and trapezius muscles.

376
Part VII Facial Surgery
• Deep fascia


fascia.

– No vital midline structures are present in the subplatysmal space while

SENIOR AUTHOR TIP: Preservation of the cervical investing fascia is essential to
addressing and placating the platysmal bands. To achieve a longer-lasting result
without dehiscence, obtain suture bites of both and anterior AND posterior investing








cartilage



the posterior triangle of the neck
NERVES
SENSORY INNERVATION
Sensation to the scalp, face, and neck is supplied by divisions of the trigeminal nerve
(CN V1, V2, V3) and cervical spinal nerves (dorsal and ventral rami), and the auditory

(CN V1)

divides into and branches.

supratrochlear artery to innervate the central forehead.
19,20

with the supraorbital artery to supply the remaining forehead and scalp.

scalp and runs along or medial to the temporal crest.
SENIOR AUTHOR TIP: The supraorbital nerve and supratrochlear nerve can exit
through a true bony foramen (40% and 18%, respectively) or through a notch, which

377
Chapter 30 Face and Neck Anatomy
(CN V2)

zygomaticofacial, and infraorbital branches of the maxillary division of the
trigeminal nerve.
(CN V3)

mandibular division of the trigeminal nerve.

supplies sensation to the temple superior to the ear
Communicates with the buccal branches of the facial nerve
and supplies sensation to the skin of the cheek over the buccinator
Supplies sensation to the chin and lower lip
(Fig. 30-2)
Posterior
auricular
nerve

occipital
nerve
Great
auricular
nerve
External
jugular
vein
Sternocleidomastoid
muscle
A
0.5 cm
6.5 cm
1
Sternocleidomastoid
muscle
B
Anatomy of the great auricular nerve. B, Danger zone for the great auricular nerve.

scalp
Provides sensation over the postauricular mastoid
area
21
SENIOR AUTHOR TIP: The lesser occipital nerve arises behind the posterior edge
of the sternocleidomastoid muscle, cephalad to the great auricular nerve, and
approximately 5.3 cm below the lowest part of the external auditory canal and 6.5 cm
from the posterior midline.
is a medial branch of the dorsal ramus of C2 that
runs up to supply the posterior scalp to the vertex.
22
arises from the dorsal rami of C2-3.

378
Part VII Facial Surgery
TIP: The great auricular nerve is found at McKinney point: 6.5 cm below the external
auditory canal at the midtransverse belly of the sternocleidomastoid.
Supplies the skin of the face over the parotid
Supplies the medial and lateral surfaces of the ear, including
the concha and lobule
MOTOR INNERVATION: FACIAL NERVE2,11
Type I
(13%)
Type II
(20%)
Type III
(28%)
Type IV
(24%)
T

B
M
C
T

B
M
C
T

B
M
C
T

B
M
C
Variations in the branching pattern of the facial nerve. (B, Buccal branch; C, cervical
branch; M, mandibular branch; T, temporal branch; Z, zygomatic branch.)
The facial nerve exits the stylomastoid foramen and is protected as it pierces the
parotid gland.
The nerve divides into an upper and lower portion and then into
within the parotid gland.
1. Temporal (or frontal)

3. Buccal
4. Marginal mandibular
5. Cervical

the masseter. This is deep to the deep facial fascia.
Anterior to the masseter the facial nerve branches are found over the buccal fat pad at
the same depth as the parotid duct and facial vessels in the so-called deepest plane.

their deep surface and the fourth and deepest layer (mentalis, levator anguli oris, and

379
Chapter 30 Face and Neck Anatomy
Frontal or
temporal branch
0.5 cm
1.5 cm
Tail of
eyebrow
Pitanguy line
Frontal branch course.
11 (Fig. 30-4)

at approximately the midpoint of a line drawn from the tragus to the lateral canthus.


eventually becomes invested by the temporoparietal fascia.

• Injuries to the buccal and zygomatic branches of the facial nerve are rare, or rarely
noticed, because of their location (deep to SMAS and deep facial fascia) and multiple
redundant interconnections between these branches.
23,24
• Extends anteriorly and inferiorly within parotid
• After exiting parotid, it is protected by thick SMAS-platysma layer and is found at or
below the mandibular border.


for 1.5 cm before turning upward to cross the inferior border. However, it usually
runs above the border of the mandible at the landmark of the facial vessels.


approximately 1 cm below this line at the level of the angle of the mandible.
25
• Exits the inferior portion of the parotid slightly anterior to the angle of the mandible.

tissue that attaches to the platysma at its superolateral border
• Platysma should be dissected at this superolateral border from the deep fascia
bluntly to prevent injury.
• Injury to the cervical branch leads to “pseudoparalysis of the mandibular branch,”
with an asymmetrical full denture smile. This is distinguished from marginal
mandibular nerve injury by the ability to evert and purse the lower lip.
26,27
• Cervical branch injury is generally associated with complete recovery within
3-4 weeks on average.27
TIP: To prevent injury to the marginal mandibular branch, begin dissection at least
2 cm below the mandibular angle.

380
Part VII Facial Surgery
FACIAL DANGER ZONES

Supraorbital/
supratrochlear nerves
Mental nerve
Infraorbital nerve
Temporal branches
of facial nerve
Zygomatic and
buccal branches of
facial nerve
Marginal mandibular
branch of facial nerve
Great auricular nerve
1
2
3
4
5
6
7


Zone





1
6.5 cm below external
auditory canal
Great auricular
Posterior to
Numbness of inferior
two thirds of ear,
adjacent cheek and
neck
2
Below a line drawn
from 0.5 cm below
tragus to 2 cm above
lateral eyebrow and
above zygoma
Temporal branch of
facial
Beneath
Paralysis of the
forehead
3
Midmandible 2 cm
posterior to oral
commissure
Marginal mandibular
branch of facial
Beneath
Paralysis of the lower
lip
4
Triangle formed by
connecting dots on
malar eminence,
posterior border of
mandibular angle,
and oral commissure

buccal branches of
facial
Beneath
Paralysis of the upper
lip and cheek
5
Superior orbital rim
above midpupil
Supraorbital and
supratrochlear
Anterior to
Numbness of
forehead, upper
eyelid, nasal dorsum,
scalp
6
1 cm below inferior
orbital rim below
midpupil
Infraorbital
Anterior to
Numbness of side of
upper nose, cheek,
upper lip, lower eyelid
7
Midmandible below
second premolar
Mental
Anterior to
Numbness of half of
lower lip and chin

Facial danger zones: motor and sensory nerves.

381
Chapter 30 Face and Neck Anatomy
VASCULAR SUPPLY
ARTERIAL SYSTEM
The blood supply to the face, scalp, and neck is robust and is based on the carotid
system.
Branches from the are the main vascular supply.
• Superior thyroid
• Ascending pharyngeal

• Facial
• Occipital
• Posterior auricular
• Maxillary


The contributes a small portion to the vascular territory by supplying
and of the ophthalmic artery.

Facial, superior labial, inferior labial, supratrochlear,
supraorbital
Transverse facial, submental, zygomaticoorbital,
anterior auricular

branches, posterior auricular, occipital
The face is supplied by a large network of perforators.
The face, scalp, and forehead are supplied by perforators.
The transition between the anterior skin supplied by musculocutaneous perforators
and the lateral region supplied by fasciocutaneous perforators consistently occurs
immediately lateral to the nasolabial fold.
TIP: Undermining skin during a facelift will divide the lateral fasciocutaneous perfora-

VENOUS SYSTEM
The venous drainage of the face and neck is divided into a and deep


The larger (and more medial) of the paired zygomaticotemporal veins,
located above the zygoma and lateral to the orbital rim
• Anatomic landmark for identifying the frontal (temporal) branch of the facial nerve

382
Part VII Facial Surgery
Pharyngeal vein
Superior thyroid vein
Lingual vein
Anterior jugular vein
Internal jugular vein
Occipital vein
Transverse
cervical vein
Maxillary vein
Sternocleidomastoid muscle
Retromandibular vein
External jugular vein
Posterior external jugular vein
Lower end of facial vein
Posterior auricular vein
Submental vein
Inferior labial vein
Superior labial vein
Facial vein
Supratrochlear vein
Superficial temporal
vein
Supraorbital vein
Middle temporal vein
Frontal branch of
superficial temporal vein
Parietal branch of
superficial temporal vein
Venous anatomy.
TIP: The frontal nerve often will course 1 cm above the sentinel vein.
Facial vein: Supratrochlear and supraorbital veins drain forehead and join to form the
facial vein. It eventually crosses the inferior border of the mandible, runs over the
submandibular gland and posterior belly of digastric muscle, and joins the internal
jugular vein at the level of the hyoid bone.
• Communicates with cavernous sinus through its tributaries
• Contains no valves
TIP: Because of the lack of valves and anatomic connection, any infection involving
the facial vein may extend into the intracranial system.
Originates at the level of the mandibular angle, courses down
the neck to the midclavicle, and enters subclavian posterior to the clavicle. It is covered
by platysma over most of its course.
• Great auricular nerve (C2-C3) ascends, along with vein, toward the head.
Course along mylohyoid and sternohyoid musculature
descending toward the sternal notch
TIP: Both external jugular and anterior jugular veins are at risk during subplatysmal
dissection and may cause substantial bleeding if not respected.

383
Chapter 30 Face and Neck Anatomy
FACIAL BONES2
FRONTAL
Forms the forehead
Articulates with the zygoma anterolaterally, and with the nasal bones, maxilla, and
lacrimal bone centrally
Above the orbits are paired supraciliary arches that are more prominent in males. The
smooth area between these arches is the glabella.
The supraorbital neurovascular structures run through the supraorbital notch or
foramen located at the junction of the medial third and lateral two thirds of the
supraorbital rim.
Half of all patients will have a frontal notch or foramen 1 cm medial to the supraorbital
foramen through which pass the supratrochlear neurovascular structures.
ZYGOMA
Forms the cheek and contributes to the lateral wall of the orbit
The lateral canthal ligament inserts into Whitnall tubercle located behind and within
the orbital margin approximately 1 cm below the zygomaticofrontal suture.
One or two foramina are located on the lateral surface of the bone near the orbital
border through which pass the zygomaticofacial neurovascular structures.
NASAL BONES
Nasal bones are paired, oblong, thin, and variable in size and shape.
The bones are covered by the nasalis and procerus muscles.
MAXILLA

Connects to the zygoma, frontal, and nasal bones
The is located approximately
Vertical height undergoes substantial loss with age and tooth loss.
MANDIBLE
Forms the lower jaw, the largest and strongest of the facial bones
Body is arch shaped with two vertical rami.
Midline symphysis marks the line of fusion during fetal development.
The through which pass the mental neurovascular structures, is
located approximately
The mandible is reduced in size with age and the alveolar portion is resorbed after
tooth loss.
The angle between the mandibular body and rami becomes more obtuse with age.

384
Part VII Facial Surgery
RETAINING LIGAMENTS OF THE FACE AND NECK

periosteum or deep facial fascia and travel perpendicularly through fascial layers to
insert onto dermis.


skeleton in predictable anatomic locations.
TEMPORAL AREA12
Currently, there is no consensus on the accurate nomenclature of the retaining
ligaments of the temporal area.
The lateral third of the brow above the orbit is held in position by the
or orbital ligament.
Extending posteriorly along the temporal crest is the (or

Coursing medially along the supraorbital rim is the
This is where the deepest layer of the deep galea is adherent to the
periosteum.
29-31
Retaining ligaments of the temporal and orbital regions.
Temporal
ligamentous
adhesion
Adhesions
Temporal branches
of facial nerve
Supraorbital ligamentous
adhesion
Zygomatico-
temporal nerve
Inferior
temporal
septum
Sentinel vein
Lateral brow thickening
of periorbital septum
Lateral orbital thickening
of periorbital septum
Periorbital septum
Thickenings
Septum
Zygomatic branch
of facial nerve
Temporalis
muscle
A
Lower lid bulge
Malar bag
Orbitomalar
ligament
Suborbicularis
oculi fat
Orbitomalar
ligament
Zygomaticocutaneous
ligament
B
TIP: This descriptive confusion should not detract from the importance of the role of
the retaining ligaments in mobilization for surgical facial rejuvenation.

385
Chapter 30 Face and Neck Anatomy
PERIORBITAL AREA see F
The
osteocutaneous ligament that originates from the perisoteum of the orbital rim.
• It passes through the orbicularis oculi and inserts into the skin of the lid-cheek

orbit where it terminates as the
lateral orbital thickening is known as the

deep fascia (septum orbitale) and the tarsal plate. This forms a single anatomic
unit.
A has been described along the adherent medial origin of the
24
CHEEK AND MANDIBLE
of retaining ligaments
are often described:


because of their direct
connection from the periosteum
to the dermis



inferior border of the
zygomatic arch and
course anteriorly to the
junction with the zygoma
through the malar fat pad
extending to dermis.



third of mandible 1 cm
above inferior border
and inserts directly onto
dermis
Coalescence


overlying dermis




border of masseter muscle and along the parotid, respectively, where


Inferior temporal
adhesion
SMAS plane
Zygomatic ligament
Masseteric ligament
Periorbital septum
Subgaleal plane
Galeal plane
Sub-SMAS plane
Temporal ligamentous
adhesion
Superior
temporal adhesion
Adhesion
Septa
Orbicularis
muscle
Ligament
Skin
Bone
Periosteum
Deep fascial plane
Sub-SMAS plane
SMAS plane
Retaining ligaments of the cheek and
mandible regions.

386
Part VII Facial Surgery
TIP: From the original description, the exact structure McGregor35 described as a
“patch” is not clear. Conventionally, this term is used as a descriptor for part of the
zygomatic ligament. McGregor described the association of a buccal branch of the facial
nerve with an arterial perforator at this location, and bleeding at this point should be
attended to with caution.
NECK
Platysma-auricular
ligaments
Platysma-mandibular
ligaments
Mandibular ligament
Submental ligaments
Paramedian platysma
retaining ligaments
Hyoid ligament
Medial platysma–cutaneous
filaments
Skin crease–platysma
filaments
Earlobe ligament
Mastoid-cutaneous
ligaments
Submandibular platysma
retaining ligaments
Medial sternomastoid–
cutaneous f laments
Posterior border of
sternomastoid muscle
Lateral sternomastoid–
cutaneous ligaments
Clavicular-cutaneous ligaments

The retaining structures that anchor the neck skin in position comprise six ligaments



Mandibular
Submental
Mastoid cutaneous
Platysma-auricular

cutaneous
Clavicular-cutaneous ligaments
Medial platysma–cutaneous
Medial sternomastoid–cutaneous
Skin crease–platysma
Three retaining ligaments anchor the platysma to deeper tissue: Hyoid ligament,
paramedian platysma retaining ligament, and submandibular platysma retaining
ligament

387
Chapter 30 Face and Neck Anatomy

to the facial structures is to understand, at least in part, the anatomic basis for the
stigmata of the aging face.
2
The retaining ligaments can weaken and relax with age, causing facial soft tissue,
particularly fad pads, to pivot around them.
• Weakened lead to
• Weakened lead to migration of cheek tissue below
the mandibular border, with resultant as the tissue is tethered by the
mandibular ligament.
ANTERIOR TRIANGLE OF THE NECK
Bound by the sternocleidomastoid, the median line of the neck, and the lower border of
the mandible




CN V.


the hyoid bone



mandibular branch of the facial nerve

bulk of which is under the body of the mandible.


9




contour.
TOP TAKEAWAYS

Subcutaneous fat in the face is partitioned into distinct anatomic compartments




it invests.


surfaces, whereas only the mentalis, levator anguli oris, and the buccinator are


The inconsistent nomenclature of the retaining ligaments should not detract
from the importance of their role in mobilization for surgical facial rejuvenation.
Continued

388
Part VII Facial Surgery

Anatomic variation is the rule, not the exception.

The face is anatomically arranged in related concentric layers to create a
balanced structure that produces facial movement.

The epidermis is composed of keratinocytes, melanocytes, and antigen-


Potential space for fat transfer exists between the periosteum and the deep
medial fat (Ristow space).

The lesser occipital nerve arises behind the posterior edge of the sterno-
cleidomastoid muscle cephalad to the great auricular nerve approximately
5.3 cm below the lowest part of the external auditory canal and 6.5 cm from the
posterior midline.

To prevent injury to the marginal mandibular branch, begin dissection at least
2 cm below the mandibular angle.
REFERENCES
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ed 3. Aesthetic. New York: Elsevier, 2013.
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Aesthetic Surgery: Principles and Techniques, ed 2. New York: Thieme Publishers, 2010.

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5. Chopra K, Calva D, Sosin M, et al. A comprehensive examination of topographic thickness of
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Reconstr Surg 121:2107, 2008.
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cosmetic surgery. Plast Reconstr Surg 119:2219, 2007.
8. Rohrich RJ, Pessa JE. The retaining system of the face: histologic evaluation of the septal bound-
aries of the subcutaneous fat compartments. Plast Reconstr Surg 121:1804, 2008.
9. Rohrich RJ, Pessa JE. The subplatysmal supramylohyoid fat. Plast Reconstr Surg 126:589, 2010.
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11. Barton FE. Aesthetic surgery of the face and neck. Aesthet Surg J 29:449, 2009.
12. Mendelson BC. Extended sub-SMAS: dissection and cheek elevation. Clin Plast Surg 22:325,
1995.

cheek area. Plast Reconstr Surg 58:80, 1976.

rejuvenation. Clin Plast Surg 22:295, 1995.
15. Freilinger G, Gruber H, Happal W, et al. Surgical anatomy of the mimic muscle system and the
facial nerve: importance for reconstructive and aesthetic surgery. Plast Reconstr Surg 80:686,
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389
Chapter 30 Face and Neck Anatomy

Thieme Publishers, 1994.

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23. Dingman RO, Grabb WC. Surgical anatomy of the mandibular ramus of the facial nerve based
on the dissection of 100 facial halves. Plast Reconstr Surg 29:266, 1962.
24. Wong CH, Hsieh MKH, Mendelson B. The tear trough ligament: anatomical basis for the tear
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26. Ellenbogen R. Pseudo-paralysis of the mandibular branch of the facial nerve after platysmal
face-lift operation. Plast Reconstr Surg 63:364, 1979.
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of Plastic Surgeons. Yosemite, California, 1959.

390
SKIN QUALITY1,2

• Ranks the skin’s tendency to tan or burn after actinic
exposure (Table 31-1)

• Total dermal thickness decreases approximately 6% per decade.
• Actinic exposure and smoking increase the rate of dermal deterioration.

• : Ranks the degree of skin wrinkling and severity of
photoaging (Table 31-2)

•








I
Never tans; burns easily and severely; extremely fair skin
II
Usually burns; tans minimally
III
Burns moderately; tans moderately
IV
Tans moderately and easily; burns minimally
V
Rarely burns; dark brown skin
VI
Never burns; dark brown or black skin



I
Mild (age 28-35)

II Moderate (age 35-50)
Early wrinkling, mild scarring; sallow color with early actinic keratosis;
requires little makeup
III Advanced (age 50-65)
Persistent wrinkling; discoloration with telangiectasias and actinic
keratosis; wears makeup always
IV Severe (age 60-75)
Wrinkling; photoaging: gravitational, dynamic; actinic keratosis with
or without skin cancer; wears makeup with poor coverage

391
Chapter 31 Facial Analysis
FACIAL CANONS OF DIVINE PROPORTION
Classical Greek canons of proportion were formulated and documented by the Renaissance
artists. These neoclassical canons are as follows (Fig. 31-1):
The head can be divided into equal halves by a horizontal line through the eyes.
The face can be divided into equal thirds, with the nose occupying the middle third.
The head can be divided into equal quarters, with the middle quarters being the forehead
and nose.
The length of the ear is equal to the length of the nose.
The distance between the eyes is equal to the width of the nose.

1:3

1:4
11
Upper
head
height

face
height
1
Forehead
Nasal
length

face
2
Forehead
Calvaria
Upper
face

face

Nasal
length
Ear
length
4
Intraocular
distance
Nasal
width

Intraocular
distance
Eye

length

Nasal
width
1½

Face
width
Nasal
width

Neoclassical canons. 1, The head can be divided into equal halves at a horizontal
line through the eyes. 2, The face can be divided into equal thirds, with the nose occupying the
middle third. The head can be divided into equal quarters, with the middle quarters being the
forehead and nose. 4, The length of the ear is equal to the length of the nose. The distance
between the eyes is equal to the width of the nose. The distance between the eyes is equal to
The width of the mouth
is 11 2 times the width of the nose. The width of the nose is one fourth the width of the face.
The nasal bridge inclination is the same as the ear inclination. The lower face can be divided
into equal thirds. 11, The lower face can be divided into equal quarters.

392
Part VII Facial Surgery
The distance between the eyes is equal to the width of each eye. (The face width can be

The width of the mouth is 11 2 times the width of the nose.
The width of the nose is a fourth the width of the face.
The nasal bridge inclination is the same as the ear inclination.
The lower face can be divided into equal thirds.
The lower face can be divided into equal quarters.
TIP: The golden ratio of Fibonacci (1:1.618) is a common theme seen throughout
facial aesthetics.
FRONTAL VIEW4

lateral canthi, and the medial canthi (Fig. 31-2, )

supraorbital notch level, and hairline
• The lower third can be divided into an upper third and lower two thirds by a line
drawn through the oral commissures (Fig. 31-2, B ).
• The lower third can be divided into halves by a horizontal line adjacent to the lowest
point of the lower lip vermilion (Fig. 31-2, C ).
Horizontal line through the labiomental groove divides the stomion-to-menton
distance into a 1:2 ratio (Fig. 31-2, D ).
Width of the mouth and the stomion-to-menton distance are equal (Fig. 31-2, E ).
Width of the mouth approximates the distance between the medial limbi of the
corneas (Fig. 31-2, F ).
The width of the face at the malar level is equal to the distance from the brows to the
menton (Fig. 31-2, ).
The distance from the infraorbital rim to the base of the nose equals the nasal base
length, which is equal to half of the length of the middle third of the face (Fig. 31-2, ).
LATERAL VIEW4

• The lower third can be divided into an upper third and lower two thirds by a line
drawn through the oral commissure (Fig. 31-3, ).
The distance from the mandibular angle to the menton is half the distance from the
hairline to the menton (Fig. 31-3, B ).
The desired lip-chin complex relationship is an upper lip that projects ~ 2 mm more
than the lower lip (Fig. 31-3, C ).
• In women the chin lies slightly posterior to the lower lip.
• In men the chin is slightly stronger.

393
Chapter 31 Facial Analysis
1 5
1 5
1 5
1 5
1 5
1
2
1 2
1 3
1 3
1
3
2 3
1
3
1
2
1
2
A
B
A = B
A
B
A = B
A
E
B
F
C
G
D
H
2 3
1
3
B, Horizontal thirds. C, Division of the lower third. D, 1:2 ratio of the
lower third. E, Stomion to menton and the width of the mouth are equidistant. F, Distance
between the medial limbi approximates the width of the mouth. G, Width of the face at the malar
level is equal to the distance from the brow to the menton H, Infraorbital rim to base of
nose length is equal to the nasal base length, which is equal to half the length of the middle third
of the face.
1 3
1 3
1 3
1 3
2 3
1 2
1
Natural
horizontal
facial plane
A
B
C
Horizontal thirds. B, Distance from the mandibular angle to menton is half the
distance from the hairline to the menton. C, Desired lip-chin complex relationship.

394
Part VII Facial Surgery

Analysis of the region starts with the upper third, then goes to the middle third, then

UPPER THIRD
1
Assess for proportion and contour.

brow).
Assess for both active and passive frontalis (transverse) forehead rhytids.
Assess for both active and passive corrugator (vertical) and procerus (horizontal) rhytids
at the glabella.
Brow position
• Assess for compensated brow ptosis. (The brow is ptotic but compensated for by
frontalis hyperactivity.)
• Assess the medial and lateral brow position and the relationship of the brow to the
upper lid.


lash line (1.618) is consistent with the golden ratio.

corresponding to lateral edge of the limbus in straight gaze.


hooding).
1
Assess for redundant skin, skin quality, fat herniation, and soft tissue excess
(subcutaneous fat, preseptal fat, lacrimal gland ptosis).
Intercanthal distance is 31-33 mm; however, 33-36 mm can be considered attractive.

canthus is 2 degrees higher.)
Vertical opening is ~ 10 mm.

• Upper lid extends down at least 1.5 mm below the upper limbus but no more than
3 mm.
• Pretarsal skin is visualized on relaxed forward gaze: 3-6 mm (varies with ethnicity).
• The distance from the lower edge of the eyebrow to the open lid center margin
should never be less than three times the measurement of the visualized pretarsal
skin.

395
Chapter 31 Facial Analysis
Supratarsal fold
• 7-11 mm from lash line
• Indicator of levator dehiscence: Elevation of supratarsal fold; accentuated supratar-
sal hollow
5 (Fig. 31-4)
This woman shows classic signs of left levator dehiscence with ptosis, a high lid crease,
and thinning of the lid above the tarsal plate.

Assess for redundant skin, skin quality, rhytids (crow’s-feet), tarsal laxity, skin
pigmentation (blepharomelasma), festoons, fat herniation, tear trough deformity, and
scleral show.
The lower lid ideally covers 0.5 mm of the lower limbus but no more than 1.5 mm.
TIP: The lid-cheek junction must also be assessed and factored into the analysis,
because it is one of the more complex areas of the face.

Determine whether positive, neutral, or negative vector relationship exists.
Assess for globe prominence/proptosis, enophthalmos/exophthalmos, dystopia, visual
acuity, and Bell palsy.
MIDDLE THIRD
Nose
First, evaluate skin type and texture.
• Thick and sebaceous skin does not drape as well, and edema takes longer to subside.
• Thin skin may drape too well and can show small deformities underneath the skin.
Evaluate for deviation: A line drawn from midglabella to menton should bisect the nasal
bridge, nasal tip, and Cupid’s bow (Fig. 31-5, ).
The width of the body of the nose at the nasal-cheek junction should equal 80% of the
alar base width (Fig. 31-5, B ).
The alar base width should be about the same as the intercanthal distance, which
should be the same as the width of an eye (Fig. 31-5, C ).
• If interalar width is wider than intercanthal width, determine whether it is caused by


this, alar base resection should be considered.
• If interalar width is increased, then nostril resection may be indicated.

396
Part VII Facial Surgery
Deviation of the nose is evaluated by drawing a line from the midglabella to
the menton. B, The body of the nose at the nasal-cheek junction should equal 80% of the alar
base width. C, Alar base width should equal the intercanthal distance. D,
outward inferiorly. E, Slightly curved divergent lines should extend from the medial supraciliary
F,
break above, and the columellar-lobular angle below should form two equilateral triangles.
G, Gull-wing appearance of the columella. H, Basal view. I, Nasal length evaluation; RT = 1.6 ×
TS. J, Evaluation of the nasal tip projection. K, Alar base width equals tip projection L,
Tip projection equals 0.67 RT (nasal length). M, Nasal dorsum evaluation. N, Nasolabial angle.
O, Columellar-lobular angle. (M, Menton; R, radix, stomion; T, tip.)
A
E
B
F
C
D
G
1 3
2 3
H
R
T
S
M
I
A B
A = 50%-
60% of AB
J
B
1.0
0.67
L
M
Natural
horizontal
facial plane
95°-100°
N
30°-45°
O
A
K
A = B

397
Chapter 31 Facial Analysis
).
Two slightly curved divergent lines should extend from the medial supraciliary ridges to
E ).

columellar-lobular angle below; these should form two equilateral triangles (Fig. 31-5, F ).
Columella evaluation: Should hang just inferior to the alar rims, giving a gentle gull-
wing appearance (Fig. 31-5, ).
Basal view: An equilateral triangle is visualized with a 2:1 ratio of columella to lobular
portion; the nostrils should be teardrop shaped (Fig. 31-5, ).
Nasal length evaluation
• Ideal nasal length (RT) should equal the distance from the stomion to menton (SM),
which equals 1.6 × distance from tip to stomion (TS) (Fig. 31-5, ).
• Nasal length should be approximately two thirds of midfacial (middle third) height.
Nasal tip projection evaluation
• A line drawn from the alar-cheek junction to the tip of the nose, when bisected by a
vertical line drawn adjacent to the most projecting portion of the upper lip, should
have 50%-60% of the horizontal line anterior to the vertical line (Fig. 31-5, J ).

should be reduced.

augmented.
TIP: This relationship only holds true if the upper lip projection is normal.
• Tip projection equals the alar base width (Fig. 31-5, K ).
• Tip projection should be approximately 0.67 RT (Fig. 31-5, L).
TIP: This relationship only holds true if the nasal length is correct.
Nasal dorsum evaluation
• In women it lies 2 mm behind and parallel to a line connecting the nasofrontal angle
with the desired tip projection; a slight supratip break is preferred (Fig. 31-5, M ).
• In men it lies slightly more anteriorly.
• If it is too far posterior to this line, augmentation will be required.
• If it is too far anterior to this line, reduction is indicated.
Tip rotation
• This is determined by the degree of the nasolabial angle.
• Draw a straight line through the most anterior and posterior points of the nostrils
on lateral view. Where this bisects with a perpendicular line to the natural horizontal
facial plane is the nasolabial angle (Fig. 31-5, ).

398
Part VII Facial Surgery
TIP: A nose with a high dorsum without a supratip break will appear less rotated than
one with a low dorsum and supratip break, even though the degree of rotation is the
same.
Columellar-lobular angle: Formed by the junction of the columella with the infratip
lobule (Fig. 31-5, )
• It is usually 30-45 degrees.
• Increased fullness in this area (usually caused by prominent caudal septum) will
give the appearance of increased tip rotation even though the angle of rotation
(nasolabial angle) is within normal limits.
Intranasal examination
• Inspect airways, nasal valve, septum, and turbinates.
Ethnic variations in nasal structure
• Compared with nasal ideals for whites, the nose of black patients and those of
Middle Eastern descent have the following characteristics.






Typical characteristics of the noses of black patients.
Wide dorsum



Decreased
nasal length
Diminished tip

Acute
columellar-
labial angle
A
B

399
Chapter 31 Facial Analysis



B
Overprojecting
radix
High dorsum
Acute
columellar-labial
angle
Wide nasal
bones
Slight alar


bulbous tip
Bulky infratip
lobule
A
Typical characteristics of the noses of patients of Middle Eastern descent.

Assess rhytids, lid-cheek junction, volume of facial fat, descent of the malar fat pad, and
skeletal proportions.
A youthful face has high cheekbones with concavity in the buccal area.

Normal ear aesthetics
• The ear is positioned approximately one ear length posterior to the lateral orbital
rim and centered in the middle third horizontal plane.

• Width is ~ 55%-60% of height.
• Anterolateral aspect of helix protrudes 21-30 degrees (1.5-2 cm) from scalp.
• Helix should project 2-5 mm more laterally than antihelix in frontal view.
Normal ear aesthetics.
5.5-6.5 cm
5.5-6.5 cm
20°
55%-60%
of ear
height
A
S
c
a
l
p
21°-30°
Helix
Antihelix
2-5 mm
projection
B

400
Part VII Facial Surgery
LOWER THIRD

Assess dental occlusion.

• Examine key landmarks, including vermilion-cutaneous junction, Cupid’s bow, and
philtral columns.
• Assess for presence of perioral rhytids.
• Assess for volume loss.
• Assess lateral angles of the mouth; aging lowers this, causing downward slant.
• Upper lip length: At rest with the lips slightly
separated, the upper lip should expose
approximately one half of the incisor teeth.
Nasolabial grooves and marionette lines (lines
from the corner of the mouth to the mandibular
border): Assess depth at rest and during
animation.
Chin
Assess projection in relation to other facial
proportions; pogonion should be 3 mm posterior
to the nose-lip-chin plane.
Nasal length (RT) = Vertical chin length (SM).

touch pogonion (Fig. 31-9).

should be approximately 4 mm deep.

Assess skin for quality, tone, excess, and rhytids.
Evaluate for subcutaneous and preplatysmal fat.
Assess for static or dynamic platysmal banding.

Mandibulocutaneous ligament: Tethering of the descending
facial tissues at this ligament produces the appearance of jowls.
Qualities of a youthful neck
• Distinct inferior mandibular border
• Subhyoid depression
• Visible thyroid cartilage bulge
• Visible anterior border of the sternocleidomastoid
• Cervicomental angle of 105-120 degrees
Riedel
plane
Riedel plane.

401
Chapter 31 Facial Analysis
TOP TAKEAWAYS



Consider facial relationships both from a static and dynamic standpoint.

It is equally important to look at both the individual parts of the face as well as
the face as a whole.

Preoperative counseling is imperative. Areas that will not be addressed should
be pointed out to patients so that they can recognize them and accept that they
will be present postoperatively.

These are only guidelines. Many aesthetically pleasing faces do not have these
proportions. These assessments are useful in determining factors that are
responsible for individual appearances.

Ensure that what a patient wants is congruent with what you, the surgeon, can
do. It is acceptable to say NO.
REFERENCES
1. Barton FE Jr, ed. Facial Rejuvenation. New York: Thieme Publishers, 2008.

2005.
3. Bashour M. History and current concepts in the analysis of facial attractiveness. Plast Reconstr
Surg 118:741, 2006.
4. Gunter JP, Rohrich RJ, Adams WP Jr, eds. Dallas Rhinoplasty: Nasal Surgery by the Masters. New
York: Thieme Publishers, 2002.

6. Byrd HS, Hobar PC. Rhinoplasty: a practical guide for surgical planning. Plast Reconstr Surg
91:642; discussion 655, 1993.
7. Janis JE, Rohrich RJ, Gutowski KA. Otoplasty. Plast Reconstr Surg 115:60e, 2005.
8. Ha RY, Trovato MJ. Plastic surgery of the ear. Sel Read Plast Surg 11:1, 2011.
9. Ellenbogen R, Karlin JV. Visual criteria for success in restoring the youthful neck. Plast Reconstr
Surg 66:826, 1980.

402

pattern baldness) but also females with androgenic alopecia and iatrogenic alopecia, i.e.,
postrhytidectomy hair loss.

hair transplantation, including eyebrows, eyelashes, moustache and beard, after burns,
and after accidents or tumor removal.
With the latest technology in hair transplantation we have today, we cannot make new
hair, but rather we can only redistribute the patient’s own hair roots. Suitable candidates
have a favorable ratio of supply and density of the donor area as it compares to the size of
the area that needs to be transplanted (the “supply and demand” factor).
DEFINITION OF PROBLEM
Hair loss resulting
from a diminution of visible
hair
1,2
of hair growth:
Anagen, catagen, and telogen
(Fig. 32-1)
: Active growth
Degradation
phase
Resting phase
Thinning and baldness
develop when anagen phase
shortens and telogen phase is
prolonged.
2
GOALS OF TREATMENT2
PROVIDE A NATURAL LOOK
Hair growing in a natural and consistent direction with a natural appearance
• In adult males a natural and mature hairline, with some degree of frontotemporal
recession, and the absence of this recession on the female patient
Absence of detectable scarring


Papilla
Epidermal
strand
Secondary
germ
Secondary
germ
lengthens
New hair
ANAGEN
90% of hairs
CATAGEN
1-2 weeks
TELOGEN
10% of hairs
EARLY
ANAGEN
Club
Three phases of hair growth.

INDICATIONS1,2




CONTRAINDICATIONS


PREOPERATIVE EVALUATION
NORWOOD CLASSIFICATION SYSTEM FOR MALE PATTERN BALDNESS3,4
(Fig. 32-2)
Type I:
Type II:

Type III:
than 2 cm
Type III vertex:

Type IV:

Type V:
Type VI:
Type VII:
Type a variants:

I
II




III
III
Fig. 32-2

404

LUDWIG CLASSIFICATION
SYSTEM FOR FEMALE PATTERN
BALDNESS5 (Fig. 32-3)
Grade I:
Grade II:
Grade III:
OTHER CONSIDERATIONS
Hair density


2
70-110 hairs/cm2
SENIOR AUTHOR TIP:

Male pattern baldness




Donor site dominance

occipital temporal
Straight versus curly hair1

Hair color1


Age1


PREOPERATIVE CARE1,2



INFORMED CONSENT1








Fig. 32-3

EQUIPMENT1










TECHNIQUE1
ANESTHESIA








DONOR SITE HARVESTING (Fig. 32-4)




Posterior
fringe
Donor area for
mature patient
Lower
hairline
50%
50%
Posterior
fringe
Donor area for
younger patient
Lower
hairline
33%
33%
33%
Fig. 32-4

406
Part VII Facial Surgery
SENIOR AUTHOR TIP: Generally 1 cm in width and as long as needed depending on
the number of grafts planned. When planning on 2000, I make an ellipse 1cm in width
and about 20-22 cm in length.
Hair is harvested in the deep subcutaneous plane.
Donor ellipses are harvested segmentally, allowing graft preparation to begin while the
rest of the donor ellipse is harvested.
Donor ellipses are closed primarily and without tension, undermining when necessary,
with running nonabsorbable suture.
GRAFT DISSECTION


Natural grouping patterns of hair follicles are preserved (Fig. 32-5).
contain one or two hairs per graft.
contain three or four hairs per graft.
Subcutaneous
fat
Maximum number
of hairs in graft
Sebaceous
gland
Follicular unit micrograft
(1 or 2 hairs)
Follicular unit minigraft
(3 or 4 hairs)
Minigrafts and micrografts.
GRAFT INSERTION

Stick and place technique: Blade is inserted then tilted to open the entrance of the slit
for graft insertion. Graft is inserted, and the blade holds the graft in place as forceps are
withdrawn (Fig. 32-6).
No. 22.5 Sharpoint blade is used for front 2 cm of the hairline, No. 11 feather blade for
posterior and crown.
CAUTION:
Initially, placed 4-5 mm apart, returning to graft spaces in between after 20 minutes.

likelihood of the graft extrusion.
• Repeated as needed until grafts are

407
Chapter 32 Hair Transplantation
Angle blade
10-15 degrees
Tilt facilitates
graft placement
Gently push in
with tip of blade
Blade holds
graft as forceps
are withdrawn
Graft insertion: stick and place technique.

and ingrown hairs

45-60 degrees
75-80 degrees
90 degrees, whorl pattern
45-60 degrees downward
Following direction of existing hair

408
Part VII Facial Surgery
Inserted in random patterns
Uneven frontal hair design
• 8 cm from eyebrow in males
• 5-8 cm from eyebrow in females

• Can use 2 FU micrografts and minigrafts posterior to this
FOLLICULAR UNIT EXTRACTION
Method of single FU harvest from donor area

Prevents linear scar in donor area
Can extract body hairs (submental beard, chest)
Can be used to thin minigrafts or plugs
Sharp and dull punch systems as well as robotic Artas system (Restoration Robotics)
available
Size of punches range from 0.8-1 mm.
Major challenge
is identifying
subcutaneous course of
the follicles.
COMBINED
FOLLICULAR UNIT
EXTRACTION AND
TRANSPLANTATION
Untouched strip
technique for cases
of more advanced
baldness (Norwood
types V, Va, VI,
occasionally IV and VII)
(Fig. 32-7)
Second procedure
using untouched strip
performed at 1 year as
needed
SENIOR AUTHOR TIP: When planning to do as many grafts as possible you may
combine the strip technique with FUE (Follicular Unit Extraction). This way you may
do an extra 700-800 grafts in a single session. That is you may end up with about
3500-4000 grafts as shown here.
POSTOPERATIVE CARE1,2
Donor grafts are covered with nonstick dressings (Adaptic) and wrapped in Kerlix and
Ace bandage.

45 degrees.



Untouched strip
for the second surgery
Strip technique extraction and transplantation.

409
Chapter 32 Hair Transplantation
Eyelids and forehead can swell from normal saline solution and local anesthetic and
usually resolves by postoperative day 7.
After the postoperative bandage is removed on postoperative day 2, the patient should
wash hair daily with warm water and mild shampoo under low pressure.
Patients should wear a hat for protection.
Optional: 5% minoxidil applied twice daily for 6 months to speed the growth of newly
transplanted hair
Patients should not smoke or perform strenuous exercise for 2 weeks and should avoid
sun and excessive heat for 3 weeks.
Stitches will be removed on postoperative day 10.
Patients are counseled that their hair initially will grow for 10 days and then shed as
grafts shift into telogen phase.
• New hair growth can be seen at 3-4 months with
• Final results are not evident until
COMPLICATIONS
Overall complication rate approximately 4.7%9
GENERAL1,2
Hemorrhage

Hiccups

• Treat with sedation and possibly chlorpromazine
Herpes zoster
• Rare but can manifest on postoperative day 4 or 5
• Treated with acyclovir or valcyclovir
Seborrheic dermatitis
• More common in patients with oily scalp

• Mineral or vegetable oil helps to remove scales.
• Serious cases may require keratolytics.
DONOR SITE1
Bleeding
• Hematoma drained, and drain removed
Wound dehiscence
• Can rarely occur after suture removal

• Temporary, usually from excessive tension and ischemia at closure site
• Treated with local massage
Scar widening or hypertrophic scarring
• Prevented by limiting tension on closure
• Treated by resecting the scar, undermining borders, and closing in two layers
• May require tissue expanders in extreme cases.
Hyperesthesia
• Rare but can be caused by neuroma

410
Part VII Facial Surgery
Hypoesthesia
• More frequent and can last for 3-12 months
• Treated with local massage
RECIPIENT SITE1
Milia
• Rare but can occur after postoperative week 2

• Apply antiseptic solution
• Keep scalp open
• Wash daily with antiseptic soap
Cysts and granulomas
• Can appear after postoperative month 3
• Treated with incision and extrusion of necrotic material
Poor hair growth
• Rare and usually caused by a donor area with poor hair quality and low density
• Treated with minoxidil
Swelling
• By postoperative day 2-4, 10% of patients develop forehead and eyelid edema.
• Usually resolves without problems
TOP TAKEAWAYS

For patients <23 years of age, a trial of medical treatment (e.g., minoxidil

baldness.

Patients must have realistic expectations and understand that the procedure
redistributes existing hair; therefore hair density is limited.

Smoking and strenuous exercise should be avoided for 2 weeks and sun and
excessive heat for 3 weeks.

Hair will initially grow for 10 days and then shed as grafts shift into telogen phase.
REFERENCES
1. Barrera A, Oscar Uebel C. Hair Transplantation: The Art of Follicular Unit Micrografting and
Minigrafting, ed 2. New York: Thieme Publishers, 2014.
2. Janis JE, ed. Essentials of Plastic Surgery, ed 2. New York: Thieme Publishers, 2014.


1984.

the female sex. Br J Dermatol 97:247, 1977.

7. Marritt E. The death of the density debate. Dermatol Surg 25:654, 1999.
8. Bernstein RM, Rassman W. The aesthetics of follicular transplantation. Dermatol Surg 23:785,
1997.

of 533 procedures. Aesthet Surg J 29:72, 2009.

411
IDEAL FACIAL AESTHETICS
FOREHEAD
The forehead, including the eyebrows, comprises the upper third of an aesthetically
proportioned face.
The anterior hairline is typically 5-6 cm superior to the eyebrow level.
Transverse, vertical, oblique, and glabellar forehead skin lines should be subtle and soft
and rarely present without facial animation.
are skin lines present with facial animation. These rhytids are amenable
to chemodenervation with botulinum toxin.
are skin lines present without facial animation but with sustained facial
muscle hypertonicity. Treatment of deep static rhytids may require surgical treatment
with redraping of the involved skin.
IDEAL EYEBROW SHAPE AND POSITION
WILL VARY BY GENDER
(Fig. 33-1)
• The eyebrow forms a gentle arch that peaks
at the junction of the middle and lateral thirds
just above the lateral limbus of the eye.
• Eyebrow level is typically 3-5 mm above the
supraorbital rim.
• Medially, the eyebrow begins at the level
of a perpendicular line extending from the
medial canthus through the outer edge of the
ipsilateral nasal ala.
• The lateral end of the eyebrow is positioned
slightly higher than the medial end and
extends laterally to the level of an oblique line
that passes through the outer edge of the
ipsilateral nasal ala and the lateral canthus.
• The medial end of the eyebrow is club shaped,
whereas the lateral end is tapered.

• Eyebrow level is at or near the level of the supraorbital rim.
• The shape is relatively horizontal with minimal arching or peaking.

• The medial eyebrow segment projects an angry appearance when this segment is
depressed and a surprised appearance when it is elevated.
• The lateral eyebrow segment projects a sad and tired appearance when this
segment is depressed and a quizzical appearance when it is elevated.


A
B
C
E
D
Spatial relationships of
the ideal eyebrow. ( Nasal ala;
B, medial bow; C, lateral tail of brow;
D, lateral limbus; E, brow apex.)

412
Part VII Facial Surgery
ANATOMY
SOFT TISSUE LAYERS OF THE FOREHEAD
Skin
Subcutaneous tissue

Frontalis muscle
Deep plane of the galea aponeurosis

Periosteum
GALEA APONEUROSIS
At the origin of the frontalis muscle from the galea aponeurosis at approximately the
level of the frontal hairline, the galea aponeurosis splits into a and a deep
layer, and these layers
• In the midforehead region, the deep galeal plane splits again to envelop the galeal
fat pad, which extends down over the lower forehead to the eyebrow level.
Deep to the lower third of the galea fat pad in the lower forehead region, the deep
galeal plane splits again to form the glide plane space, located under the transverse head
of the corrugator muscle as this muscle passes through the galeal fat pad area.
The deepest layer of the deep galeal plane extends inferiorly to the supraorbital rims
and bonds with the periosteum over a 2 cm wide horizontal strip just cephalad to the
supraorbital rims.
BONY ANATOMY, ZONES OF FIXATION, AND RETAINING STRUCTURES
The
from which to assess eyebrow ptosis.
The along the lateral margin of the frontal bone is produced by the
temporal fusion line of the skull. The temporal ridge delineates the forehead area from
the temporal fossa area.


the soft tissues.
Just medial to the temporal ridge, the layers of the deep galeal plane of the forehead
and scalp bond with the underlying periosteum and fuse to bone within a 5-6 mm wide

The
superolateral orbital rim near the lateral end of the eyebrow (see Fig. 33-6).
Over the lower 2 cm of the frontal bone just above the supraorbital rims, the deep

previously. Otherwise, the overlying skin, subcutaneous tissue, and frontalis muscle
move freely over the orbital rim without direct attachment to bone.
The than the lateral segment because of the

and pass through the overlying medial frontalis muscle.
SENIOR AUTHOR TIP: Some authors have described a brow-retaining ligament7 under
the medial end of the eyebrow, but I think no ligaments are present between bone and
dermis under the medial end of the eyebrow that restrict movement of the medial eyebrow.

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Chapter 33 Browlift
Deep division
supraorbital nerve
Galea
Frontalis muscle
Temporalis
fascia
Periosteum
Superficial
temporal
fascia
Superior temporal
fusion line
Inferior temporal
fusion line
Frontal
branch VII
Temporal fusion line
Corrugator supercilii
muscle
Procerus muscle


These planes are

just medial to the temporal fusion line and the superior temporal line. The lateral margin of the
frontalis muscle either terminates or abruptly attenuates over this zone. The inferior temporal line
of the skull forms the perimeter of the temporalis fascia. The plane of the frontal branch of the

MUSCLES OF THE FOREHEAD
Frontalis muscle
Temporal branch
of facial nerve
Zygomatic branch
of facial nerve
Orbicularis oculi muscle
Oblique corrugator muscle
Transverse corrugator muscle
Procerus muscle (resected)
Depressor supercilii muscle
Periorbital motor nerves and the muscles they activate. Corrugator supercilii muscle;
depressor supercilii muscle; frontalis muscle; procerus muscle; temporal branch of facial nerve;
zygomatic branch of the facial nerve; zygomaticus major muscle.

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Part VII Facial Surgery
FRONTALIS
Galea aponeurosis (at approximately the level of the typical frontal hairline)
Primarily interdigitates with the orbicularis oculi and procerus muscles,
which insert into the dermis under the eyebrows
Frontal (temporal) branch of facial nerve (CN VII)
Eyebrow elevation primarily produced by suspending the superior orbicularis
oculi muscle. Muscle contraction produces transverse forehead skin lines.
CORRUGATOR SUPERCILII
Superomedial orbital rim

• Oblique head inserts into dermis under the medial head of the eyebrow.
• Transverse head inserts into dermis under the middle third of the eyebrow.
NOTE: Clinically, the two heads of the muscle are often not clearly delineated, because


• Oblique head

• Transverse head

Movement of the medial eyebrow medially and downward, which produces
vertical and oblique lines in the glabellar skin
PROCERUS
Dorsal surface of the nasal bones
Dermis in the glabellar region and interdigitation with the inferior medial

Frontal and zygomatic branches of the facial nerve
Medial eyebrow depression, which produces transverse rhytids at the nasal root
ORBICULARIS OCULI
Various structures in the medial canthal region
Dermis under the medial brow and the lateral palpebral raphe

Flat, circumferential sphincter muscle of the eyelids that primarily provides
eyelid closure
• The medial orbital portion depresses the medial brow and contributes to oblique
skin line formation in the glabellar area.
• The lateral orbital portion depresses the lateral brow and creates radial, lateral
periorbital rhytids with contraction (“crow’s-feet”).

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Chapter 33 Browlift
DEPRESSOR SUPERCILII
Superomedial orbital rim, where it is often described as a portion of the medial
orbicularis oculi muscle

from the orbicularis oculi muscle and anterior to the dermal insertion of the oblique
head of the corrugator supercilii muscle)

Medial brow depression
VASCULAR SUPPLY TO THE FOREHEAD
Supply is from branches of both the internal and external carotid arteries
Centrally, and artery
from the ophthalmic artery.
artery arise from the
artery.
Vast communications exist between these vessels of the forehead and those of the
posterior scalp, providing rich vascularity.
SENSORY INNERVATION
SUPRATROCHLEAR NERVE
A branch of the ophthalmic division of the trigeminal nerve (V1)
Emerges from its bony foramen within the medial orbit along with the supratrochlear
artery
Pierces the medial end of the corrugator muscle and supplies sensation for the medial
forehead skin on each side
SUPRAORBITAL NERVE
A branch of the 1 The supraorbital
nerve trunk emerges from its bony exit point, the supraorbital notch (or foramen),
along with the supraorbital artery.
The supraorbital nerve trunk divides into a and deep division.

• Pierces the frontalis muscle after dividing from the supraorbital trunk and travels

frontal scalp level
• Supplies sensation to the dermis of the forehead skin and anterior scalp on each side
Deep division
• After dividing from the supraorbital trunk, the deep division initially runs
superolaterally over the surface of the periosteum.
• When the deep branch is almost at the temporal ridge, it turns cephalad and runs
parallel with the temporal ridge to the scalp, remaining within 0.5-1.5 cm medial to
the ridge.

deep galea to terminate in the dermis of the frontoparietal scalp.

branches to periosteum in this part of its course.

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Part VII Facial Surgery
NOTE: Coronal incisions made through the galeal plane always transect the deep branch
at the level of the incision.
CAUTION:


TIP: In about 10% of patients, the deep division of the supraorbital nerve exits the
frontal bone from a foramen lateral to the supraorbital notch. This foramen is usually
just medial to the temporal ridge and just superior to the laterosupraorbital rim.
Surgeons must be prepared for the presence of the aberrant course of the deep division
and prevent inadvertent transection, which would produce dysesthesia or anesthesia
of the ipsilateral frontoparietal scalp.
PATIENT EVALUATION
HISTORY SHOULD INCLUDE
Age
Gender
Bleeding tendency in the past
Medications, including herbal medicines
Other medical comorbities
Patient’s expectations for skin smoothness and eyebrow shape and position
ANALYSIS OF THE FOREHEAD SHOULD INCLUDE
Eyebrow position, shape, and symmetry
Presence of dynamic and/or static rhytids
Presence of upper lid ptosis or dermatochalasis
HAIRLINE11



to prevent further
elevation of the hairline should be considered.
typically describes a brow-to-hairline distance of <5 cm in women and
<6 cm in men. For these cases, a should be considered to allow
elevation of the hairline.
patients are often challenging, with thin or balding hair. Often, small
incisions for are made for these
patients (Fig. 33-4). For males who have residual hair in the temporal scalp area, the
limited incision procedure is often appropriate.
12 have published a treatment algorithm based on forehead
elongation, forehead lines, and brow ptosis (Fig. 33-5).

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Chapter 33 Browlift
Several types of coronal incisions used in browlift surgery. The indications for each are
discussed in the text.
Hairline
Gull-wing
Vertex
B
C
A
Lambdoidal
W Incision
Lambdoidal paddle
Interlocking Ms
E
F
G
D






Lines

Endoscopic forehead lift
Pretrichial incision

Pretrichial incision
Posterior scalp
advancement
Lines

Endoscopic forehead lift
Glabellar muscle
resection
or

and transpalpebral
corrugator resection
Pretrichial incision
Glabellar muscle
resection

Pretrichial incision
Glabellar muscle
resection
Posterior scalp
advancement

Lines

Incision 1-1.5 cm behind
the hairline
Subcutaneous dissection
Glabellar musculature
resection
Pretrichial incision
Subcutaneous dissection
Glabellar musculature
resection

Pretrichial incision
Subcutaneous dissection
Glabellar muscle
resection
Posterior scalp
advancement







Treatment algorithm for a senescent forehead.

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Part VII Facial Surgery
OTHER CONSIDERATIONS
Skin quality issues, such as the presence of actinic damage and/or dyschromia
Adjunctive treatment methods to help restore skin tone and texture and to improve
skin appearance (chemical peels, laser resurfacing, etc.)
PHOTOGRAPHS see C
Photos should include the AP, lateral, and oblique views of the entire face and a
separate series of views of the forehead and periorbita.
Dynamic photos are also useful for planning surgical treatment of frontalis and
corrugator muscles.
TIP:
from their surgical procedure. A review of the preoperative photographs will often help
these patients to more fully appreciate their surgical result.
SURGICAL TECHNIQUES
PREOPERATIVE PLANNING
These surgical techniques should be tailored to each patient, based on thorough
analysis followed by thoughtful preoperative planning.
This planning should include selection of the appropriate skin incision, the plane of

Understanding the relationship between surgical goals and underlying anatomy is
essential to delivering reliable aesthetic outcomes13 (Boxes 33-1 and 33-2).
Box GOALS OF ANY FOREHEADPLASTY PROCEDURE
Smoother glabellar skin lines
Smoother transverse nasal skin lines
Resuspend ptotic eyebrows
Resuspended pseudoexcess upper eyelid skin
Smoother transverse forehead skin lines
Box STRUCTURES THAT MUST BE RELEASED WITH ANY FOREHEADPLASTY PROCEDURE

Orthical ligament
Periosteum/galea plan attachments to the superior orbital rim
INCISION OPTIONS

•

superciliary or midforehead level are used to elevate the eyebrow.
, when possible, or along
the in an attempt to minimize scar visibility.

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Chapter 33 Browlift



eyebrow elevation


coronal, temporal, and endoscopic incision scars cannot be hidden






through an upper blepharoplasty incision.






muscle can be accomplished while using this approach.
9,14


can be done under direct vision in conjunction with this technique, these muscle


SENIOR AUTHOR TIP:
attempt to “push them up” to elevate the tissues. When the transblepharoplasty
approach is used to elevate the eyebrow, the eyebrow tissue must be “pushed up,”
and this limited elevation is maintained with sutures placed into the periosteum. The
range of elevation of the eyebrow is far more limited than with the use of any one of the
other eyebrow suspension procedures. However, it is often the “last resort” procedure
for totally bald males who will not accept more visible scarring than is produced with
a blepharoplasty. In my (D.K.) experience, the transblepharoplasty approach provides
excellent access to treat the corrugator supercilii, depressor supercilii, medial orbicularis
oculi, and procerus muscles that produce glabellar skin lines.



of the scalpel blade positioned to be when the
incision is made.

2-3 cm wide strip of scalp along the anterior edge of the incision can be excised

scar at least 2 cm posterior to the frontal hairline.

.

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Part VII Facial Surgery
TIP: For every 1 mm of eyebrow elevation desired, the frontal hairline must be



with direct visualization of all of the muscles whose actions produce glabellar
skin rhytids.

presenting with a low frontal hairline.




incision

a high frontal hairline (unless the incision is
placed in the anterior hairline position, as
described below).



anterior hairline and carried into the hair-
bearing temporal scalp on each side.

transects the hair follicles at
the hairline, as shown in Fig. 33-6, with the
goal that these transected hair follicles will
regrow through the scar
15 and hide it.
TIP:



for patients who present with a high hairline requesting a lower anterior hairline.



incisional alopecia, etc.).
16



incorporates wide soft tissue release from bone through bilateral 4.5 cm long

eyebrow elevation.


An anterior hairline
incision is beveled perpendicular
to the hair follicles so that hair can
grow into and anterior to the scar.