Master Techniques in Facial Rejuvenation 2

MASTER TECHNIQUES IN
FACIAL REJUVENATION

MASTER TECHNIQUES
IN FACIAL
REJUVENATION
Babak Azizzadeh, MD, FACS
Clinical Director
Center for Advanced Facial Plastic Surgery
Beverly Hills, California;
Associate Clinical Professor
Division of Head & Neck Surgery
David Geffen School of Medicine
University of California, Los Angeles
Los Angeles, California
Mark R. Murphy, MD
Director
Palm Beach Facial Plastic Surgery
West Palm Beach, Florida
Calvin M. Johnson Jr., MD
Clinical Associate Professor
Division of Facial Plastic & Reconstructive Surgery
Tulane University School of Medicine;
Director
Hedgewood Surgical Center
New Orleans, Louisiana
Guy G. Massry, MD
Clinical Professor of Ophthalmology
Keck School of Medicine
University of Southern California
Beverly Hills Ophthalmic Plastic & Reconstructive
Surgery
Beverly Hills, California
Rebecca Fitzgerald, MD
Private Practice & David Geffen School of Medicine
University of California Los Angeles
Los Angeles, California
Edinburgh  London  New York  Oxford  Philadelphia  St Louis  Sydney  Toronto 2018
SECOND EDITION
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vii
Chapter 7 The Open Browlift
Video 7.1 Open Browlift/Deep Plane Facelift – Calvin M. Johnson Jr
Chapter 9 Nonsurgical Brow and Eyelid Rejuvenation
Video 9.1 Volumizing the Periorbita with Cannula – Catherine J. Hwang
Chapter 10 Minimally Invasive Complementary Adjuncts to Upper Blepharoplasty
Video 10.1 Surgical Adjuncts – Guy G. Massry
Chapter 11 Ptosis Repair and Blepharoplasty
Video 11.1 External Levator Advancement – Daniel Straka and Jill Foster
Video 11.1 Conjunctival Müller’s Muscle Resection – Daniel Straka and Jill Foster
Chapter 12 Transconjunctival Lower Blepharoplasty With and Without Fat Repositioning
Video 12.1 Transconjunctival Lower Blepharoplasty with Fat Repositioning – Guy G. Massry
and David B. Samimi
Chapter 14 The Spectrum of Canthal Suspension Techniques in Lower Blepharoplasty
Video 14.1 Canthal Suspension Procedures for Lower Blepharoplasty – Guy G. Massry and
Andrea Lora Kossler
Chapter 18 Lateral SMASectomy Facelift
Video 18.1 Lateral SMASectomy Facelift – Daniel C. Baker
Chapter 19 Reshaping Rhytidectomy
Video 19.1 Reshaping Rhytidectomy – Babak Azizzadeh
Chapter 20 Tridimensional Endoscopic Facelift
Video 20.1 Tridimensnional Endoscopic Facelift – Oscar M. Ramirez
Chapter 22 Mentoplasty
Video 22.1 Complete mentoplasty – Intraoperative prep and demo – Robert A. Glasgold,
Mark J. Glasgold, and Alvin I. Glasgold
VIDEO CONTENTS

viii
This latest edition of our Masters series revisits our initial
intention of providing those who seek to improve other’s
lives by rejuvenating their appearance, and thus them­
selves, with a thorough guide crafted by the acknowl­
edged experts in the field. The genesis of these volumes
was a desire to craft a comprehensive reference for all sur­
geons blessed with the charge of this art. Having emerged
from two excellent but different training programs we
felt the need to bring the various voices across multiple
specialties together in one source. By the grace and gener­
osity of our co-editors and contributing authors we were
successful attaining this goal ten years ago. During the
ensuing decade we have been fortunate to see our field
blossom even further. The evolution of technologies to
manipulate tissue beyond the scalpel has enabled a new
wave of rejuvenation, while its limitations has reminded
us of the continued need for surgical options. By combin­
ing these modalities, we can now help our patients even
further. This text reflects the changes of the last decade
and hopefully will inspire those boundaries to be pushed
even further forward.
Babak Azizzadeh and Mark Murphy
PREFACE

ix
Ramzi M. Alameddine, MD
Assistant Professor, Division of Oculofacial Plastic
and Reconstructive Surgery, Department of
Ophthalmology, American University of Beirut
Medical Center, Beirut, Lebanon
Chapter 15, Aesthetic Rejuvenation in the Patient of Asian Ancestry
Mathew M. Avram, MD
Director, Massachusetts General Hospital Dermatology
Laser & Cosmetic Center, Boston, Massachusetts
Chapter 6, Skin Resurfacing
Daniel C. Baker, MD
Associate Professor, Department of Plastic Surgery,
New York University School of Medicine, New York,
New York; Attending Surgeon, New York University
Medical Center; Attending Surgeon, Department
of Plastic Surgery, Manhattan Eye, Ear & Throat
Hospital, New York, New York; Attending Surgeon,
Department of Plastic Surgery, Bellevue Hospital,
New York, New York
Chapter 18, Lateral SMASectomy Facelift
Dewayne T. Bradley, MD
Department of Otolaryngology-Facial Plastic Surgery,
The Polyclinic, Seattle, Washington
Chapter 1, Facial Embryology
Andrew Breithaupt, MD
Department of Medicine, David Geffen School of
Medicine, University of California, Los Angeles, Los
Angeles, California
Chapter 6, Skin Resurfacing
César A. Briceño, MD
Assistant Professor of Ophthalmology, Scheie Eye
Institute, University of Pennsylvania, Philadelphia,
Pennsylvania
Chapter 10, Minimally Invasive Complementary Adjuncts to Upper
Blepharoplasty
Jeannie H. Chung, MD
Associate Staff, Department of Otolaryngology-
Head and Neck Surgery, Massachusetts Eye and
Ear Infirmary, Boston, Massachusetts; Active Staff,
Department of Otolaryngology-Head and Neck
Surgery, North Shore Medical Center, Salem,
Massachusetts; Medical Director, North Shore
Dermatology and Cosmetic Surgery Center, Andover,
Massachusetts
Chapter 24, Facial and Cervical Lipectomy
Victor Chung, MD
Director, La Jolla Facial Plastic Surgery, San Diego,
California
Chapter 26, Rhinoplasty in the Aging Patient
Sebastian Cotofana, MD, PhD
Associate Professor, Department of Medical Education,
Albany Medical College, Albany, New York
Chapter 2, Applied Facial Anatomy
Patricia K. Farris, MD
Clinical Associate Professor, Department of
Dermatology, Tulane University School of Medicine,
New Orleans, Louisiana; Old Metairie Dermatology,
Metairie, Louisiana
Chapter 5, Topical Skin Care and the Cosmetic Patient
Jill Foster, MD, FACS
Associate Clinical Professor of Ophthalmology, The
Ohio State University Wexner Medical Center,
Columbus, Ohio; Attending Surgeon, Oculofacial
Plastic Surgery, Plastic Surgery Ohio, Columbus,
Ohio; Attending Surgeon, Division of Oculofacial
Plastic Surgery, Nationwide Children’s Hospital,
Columbus, Ohio
Chapter 11, Ptosis Repair and Blepharoplasty
John W. Frederick, MD
Division of Facial Plastic Surgery, Department of Head
and Neck Surgery, David Geffen School of Medicine,
University of California, Los Angeles
Chapter 8, Endoscopic Foreheadplasty: A Twenty-Seven-Year
Experience
Alvin I. Glasgold, MD
Clinical Professor Emeritus, Division of Facial
Plastic and Reconstructive Surgery, Department of
Otolaryngology-Head and Neck Surgery, Rutgers,
Robert Wood Johnson Medical School, New
Brunswick, New Jersey
Chapter 22, Mentoplasty
Mark J. Glasgold, MD
Clinical Associate Professor, Division of Facial
Plastic and Reconstructive Surgery, Department of
Otolaryngology-Head and Neck Surgery, Rutgers,
Robert Wood Johnson Medical School, New
Brunswick, New Jersey
Chapter 22, Mentoplasty
Chapter 25, Complementary Fat Grafting
LIST OF CONTRIBUTORS
The editors would like to acknowledge and offer grateful thanks for the input of all contributors to the previous
edition, without whom this new edition would not have been possible.

x
List of Contributors
Robert A. Glasgold, MD
Clinical Assistant Professor, Division of Facial
Plastic and Reconstructive Surgery, Department of
Otolaryngology-Head and Neck Surgery, Rutgers,
Robert Wood Johnson Medical School, New
Brunswick, New Jersey
Chapter 22, Mentoplasty
Chapter 25, Complementary Fat Grafting
Shani Golan, MD
Clinical Fellow, Division of Oculofacial Plastic Surgery,
Jules Stein Eye Institute, University of California Los
Angeles, Los Angeles, California
Chapter 9, Nonsurgical Brow and Eyelid Rejuvenation
Robert Goldberg, MD
Professor, Division of Oculofacial Plastic Surgery, Jules
Stein Eye Institute, University of California Los
Angeles, Los Angeles, California
Chapter 9, Nonsurgical Brow and Eyelid Rejuvenation
Carlo P. Honrado, MD
Private Practice, Los Angeles, California
Chapter 1, Facial Embryology
Catherine J. Hwang, MD
Assistant Clinical Professor, Division of Oculofacial
Plastic Surgery, Cole Eye Institute, Cleveland Clinic
Foundation, Cleveland, Ohio
Chapter 9, Nonsurgical Brow and Eyelid Rejuvenation
Andrew A. Jacono, MD, FACS
New York Center for Facial Plastic and Laser Surgery,
Section Head of Facial Plastic and Reconstructive
Surgery, North Shore University Hospital, New York,
New York; Clinical Assistant Professor of Facial
Plastic and Reconstructive Surgery, New York Eye
and Ear Infirmary, New York, New York; Assistant
Clinical Professor, Facial Plastic Surgery, Albert
Einstein College of Medicine, New York
Chapter 13, Transcutaneous Lower Blepharoplasty
Chapter 17, Deep Plane Rhytidectomy Modifications
H. Ray Jalian, MD
Private Practice, Los Angeles, California
Chapter 6, Skin Resurfacing
Michael Kane, BS, MD
Attending Surgeon, Plastic Surgery, Manhattan Eye,
Ear, and Throat Hospital, New York, New York
Chapter 4, Injectables and Resurfacing Techniques: Botulinum
toxin (BoNT-A)
Gregory S. Keller, MD, FACS
Clinical Professor of Head and Neck Surgery, Division
of Facial Plastic Surgery, Department of Head and
Neck Surgery, David Geffen School of Medicine,
University of California, Los Angeles, Private
Practice, Santa Barbara, California
Chapter 8, Endoscopic Foreheadplasty: A Twenty-Seven-Year
Experience
Don O. Kikkawa, MD, FACS
Division of Oculofacial Plastic and Reconstructive
Surgery, UCSD Department of Ophthalmology, Shiley
Eye Institute, Division of Plastic and Reconstructive
Surgery, UCSD Department of Surgery, La Jolla,
California
Chapter 15, Aesthetic Rejuvenation in the Patient of Asian Ancestry
Bobby S. Korn, MD, PhD, FACS
Professor of Ophthalmology and Plastic Surgery,
Division of Oculofacial Plastic and Reconstructive
Surgery, Department of Ophthalmology, Shiley Eye
Institute, Division of Plastic and Reconstructive
Surgery, Department of Surgery, UC San Diego
School of Medicine, La Jolla, California
Chapter 15, Aesthetic Rejuvenation in the Patient of Asian Ancestry
Andrea Lora Kossler, MD
Assistant Professor of Ophthalmology, Director,
Oculofacial Plastic Surgery and Orbital Oncology,
Stanford School of Medicine, Byers Eye Institute at
Stanford, Palo Alto, California
Chapter 14, The Spectrum of Canthal Suspension Techniques in
Lower Blepharoplasty
Samuel M. Lam, MD
Director, Lam Facial Plastic Surgery Center and Hair
Restoration Institute, Plano and Dallas, Texas
Chapter 25, Complementary Fat Grafting
Wayne F. Larrabee Jr., MD, FACS
Clinical Professor, Department of Otolaryngology-Head
and Neck Surgery, University of Washington School
of Medicine, Seattle, Washington; Swedish Hospital;
Director, Larrabee Center for Facial Plastic Surgery,
Seattle, Washington
Chapter 1, Facial Embryology
Bradford W. Lee, MD, MSc
Assistant Professor, Division of Oculofacial Plastic and
Reconstructive Surgery, Bascom Palmer Eye Institute,
University of Miami Miller School of Medicine,
Miami, Florida
Chapter 15, Aesthetic Rejuvenation in the Patient of Asian Ancestry
Steven M. Levine, MD
Assistant Professor of Surgery (Plastic), Hofstra Medical
School, Northwell Health, New York, New York
Chapter 18, Lateral SMASectomy Facelift

List of Contributors
xi
Daniel Straka, MD
Assistant Clinical Professor of Ophthalmology, The
Ohio State University Wexner Medical Center,
Columbus, Ohio; Attending Surgeon, Oculofacial
Plastic Surgery, Plastic Surgery Ohio, Columbus,
Ohio; Attending Surgeon, Division of Oculofacial
Plastic Surgery, Nationwide Children’s Hospital,
Columbus, Ohio
Chapter 11, Ptosis Repair and Blepharoplasty
Gustavo A. Suárez
Department of Otolaryngology-Head and Neck Surgery,
University of Barcelona, Bellvitge University Hospital,
Barcelona, Spain
Chapter 2, Applied Facial Anatomy
Chapter 23, Orthognathic Aesthetic Facial Surgery
Jonathan M. Sykes, MD
Professor and Director Facial Plastic Surgery, University
of California, Davis Medical Center, Sacramento,
California
Chapter 2, Applied Facial Anatomy
Chapter 23, Orthognathic Aesthetic Facial Surgery
Dean M. Toriumi, MD
Professor, Division of Facial Plastic and Reconstructive
Surgery, Department of Otolaryngology-Head and
Neck Surgery, University of Illinois at Chicago,
Chicago, Illinois
Chapter 26, Rhinoplasty in the Aging Patient
Patrick Trevidic, MD
Expert2Expert Group, Paris, France
Chapter 2, Applied Facial Anatomy
Charles R. Volpe, MD
Esthétique International, Timonium, Maryland
Chapter 20, Tridimensional Endoscopic Facelift
Edwin F. Williams III, MD, FACS
Fellowship Director, American College of Surgeons,
Chicago, Illinois; Clinical Instructor and Fellow,
Department of Otolaryngology-Head and Neck
Surgery, University of Illinois, Chicago, Illinois; Chief,
Department of Facial Plastic and Reconstructive
Surgery, Clinical Associate Professor of Surgery,
Albany Medical Center, Albany, New York; Medical
Director and Founder, New England Laser &
Cosmetic Surgery Center; Medical Director, Williams
Center for Excellence, Latham, New York
Chapter 24, Facial and Cervical Lipectomy
Wei Lu, MD, PhD
Associate Professor of Ophthalmology, Director,
Department of Ocular Plastic and Reconstructive
Surgery, Dalian Medical University, Dalian, China
Chapter 15, Aesthetic Rejuvenation in the Patient of Asian Ancestry
Melanie H. Malone, MD
Assistant Professor, Division of Facial Plastic Surgery,
Albert Einstein College of Medicine, New York,
New York
Chapter 13, Transcutaneous Lower Blepharoplasty
Hyoung Jin Moon, MD
President, Dr. Moon’s Aesthetic Plastic Surgery Clinic,
Seoul, South Korea
Chapter 2, Applied Facial Anatomy
Vishad Nabili, MD, FACS
Associate Clinical Professor of Head and Neck Surgery,
Division of Facial Plastic Surgery, Department of
Head and Neck Surgery, David Geffen School of
Medicine, University of California, Los Angeles
Chapter 8, Endoscopic Foreheadplasty: A Twenty-Seven-Year
Experience
Joe Niamtu, MD, FACS
Private Practice, Cosmetic Facial Surgery, Richmond,
Virginia; Fellow, American Academy of Cosmetic
Surgery; Diplomat, American Board of Cosmetic
Facial Surgery; Diplomat American Board of Oral
and Maxillofacial Surgery
Chapter 21, Midface Implants
Oscar M. Ramirez, MD, FACS
Esthétique Internationale, Timonium, Maryland
Chapter 20, Tridimensional Endoscopic Facelift
Neela Rao, MD
Otolaryngology Resident-in-training, Department of
Otolaryngology – Head and Neck Surgery, University
of Illinois – Chicago, Chicago, Illinois
Chapter 26, Rhinoplasty in the Aging Patient
David B. Samimi, MD
Eyesthetica, Oculofacial and Cosmetic Surgery
Associate; Assistant Professor of Ophthalmology,
Keck School of Medicine, University of Southern
California, Los Angeles, California
Chapter 12, Transconjunctival Lower Blepharoplasty With and
Without Fat Repositioning

xii
There are many people to whom we owe a great deal
of gratitude for the completion and inspiration of this
second edition of Master Techniques in Facial Rejuve­
nation. First and foremost are our patients, who have
entrusted us in the most personal way. We also thank
our family, office staff and fellows who have given us
the opportunity and freedom to take on this substantial
project. We want to acknowledge our mentors Norman
Pastorek, Mack Cheney, Albert Hornblass, John Holds,
Calvin M. Johnson, Frank Kamer, Mark Varvares, Daniel
Deschler, Keith Blackwell, Rinaldo Canalis, Thomas Cal­
caterra, and Usama Hamdan for their motivation and
inspiration, as well as our professional colleagues Babak
Larian, Ray Douglas, John Murray, Ray Jalian, Siamak
Tabib, Helen Fincher, Kamran Jamshidinia, Siamak
Daneshmand, Jimmy Firouz, Kia Michel, Jennifer Kim,
Allen Putterman, Rick Anderson, David Lehman, and
Jonathan Cabin, whose unflinching support has aided
us in the pursuit of our passion. Additionally, we must
acknowledge the Elsevier team for the unbelievable
amount of work that they have put forth in making this
book a reality. Belinda Kuhn, Trinity Hutton, Alexandra
Mortimer, Julie Taylor, Amy Buxton, Karen Giacomucci
and Paul Kim have spent countless hours supporting our
ambitious venture and we cannot thank them enough.
Finally, this second edition would not have been the best
it can be if it weren’t for our new co-editors, Drs. Rebecca
Fitzgerald and Guy Massry, who are true masters of their
subspecialties.
ACKNOWLEDGMENTS

xiii
To Jessica, my wife and best friend who has been
my everything for the past twenty years.
Babak Azizzadeh
To Sherry whose unwavering support has provided
a life of fulfillment, personally and professionally.
To our children Nick, Ned and Grayson, for being
a constant source of motivation to be better.
Mark R. Murphy
In our pursuit of knowledge and wisdom, we
all have much to learn and much to share. I
would like to dedicate this book to all of the
teachers, students, and patients who have given
me this opportunity. I am so grateful for all I
have learned from each of you. I would also like
to acknowledge my appreciation to Drs. Babak
Azizzadeh and Guy Massry for their tireless
dedication to excellence. Their enthusiasm,
discipline, energy, boundless curiosity, and love of
learning have made them truly amazing physicians.
They have been wonderful colleagues and friends,
and invaluable mentors.
Rebecca Fitzgerald
Creating this textbook has been a journey of highs
and lows. Its completion is a testament to my
amazing co-editors, and the staff at Elsevier, who
worked so hard, diligently and efficiently, until
the final page was typeset. Even with this amazing
team, I could not have given the consistent time
and effort needed to contribute my small part to
the project without the unwavering and selfless
support of my family (Shere, Alexis and my
parents and sisters) and office staff (Anna, Maria,
Norie, Jessica) who are always there and always
have my back.
Guy G. Massry
DEDICATIONS

1
EMBRYOGENESIS
Embryogenesis is a dynamic multiple-step process that
begins when an oocyte from a female is fertilized by
the sperm from a male (the pre-embryonic period). The
first 2 weeks after fertilization focus on rapid prolif­
eration and differentiation of the embryo with subse­
quent implantation of the egg into the wall of the uterus.
Also, the development of the amniotic cavity and the
embryonic disc gives rise to the three germ layers of the
embryo during this period. The start of the third week
marks the beginning of the embryonic period (weeks 3–8)
and is characterized by the formation of the primitive
streak, notochord, and the three germ layers (ectoderm,
endoderm, and mesoderm) from which all embryonic
tissues and organs develop [1]. The ectoderm gives rise
to structures such as the epidermis and nervous system.
The linings of the respiratory system and gastrointestinal
tracts as well as certain glandular organs arise from the
endoderm layer. The mesoderm is the source of muscle,
bone, connective tissue, and blood vessels. The embry­
onic period is of particular importance because most
organ systems develop during this time, and by the end
of the eighth week the embryo has a distinctly human
appearance. However, because the origins of major struc­
tures are established during this critical phase, congenital
abnormalities may first appear at this time if there is any
teratogenic exposure to the embryo.
The fetal period spans from the ninth week after fertil­
ization to the birth of the fetus. This period is character­
ized by rapid growth and maturation of the developing
organ systems. Head growth slows significantly in com­
parison to growth of the fetal body.
This chapter focuses on aspects of embryogenesis
that pertain to facial plastic and reconstructive surgery.
Embryology of the branchial/pharyngeal arches and their
derivatives, orbit/eyelid complex, auricle, face, nose, and
palate will be discussed in detail. A description of facial
anatomy will follow.
EMBRYOLOGY
The Branchial/Pharyngeal Apparatus
The branchial, or pharyngeal, apparatus greatly contrib­
utes to the formation of the head and neck, and begins to
form during the fourth week of gestation [2]. This appa­
ratus consists of branchial arches, pharyngeal pouches,
branchial grooves, and branchial membranes. By the end
of the fourth week of gestation, four well-defined arches
are visible on the external surface of the embryo. The fifth
arch (also referred to as the sixth arch, depending on the
theory one follows) is also present but is not externally
visible (Fig. 1.1A). Each arch is composed of mesoderm-
derived mesenchymal tissue and contains an aortic arch
artery, a branchiomeric nerve, a cartilaginous bar, and
a muscle component [3]. These arches are separated by
prominent grooves, or clefts, which are derived from
the ectoderm, and pharyngeal pouches that are lined by
endoderm. As the grooves develop, they push medially
through the surrounding mesenchyme and approach the
medially positioned pharyngeal pouches.
The first branchial arch is often referred to as the
mandibular arch and plays a significant role in the devel­
opment of the face. This arch develops one small promi­
nence, which forms the maxilla, zygoma, and squamous
portion of the temporal bone, and one large prominence,
which forms the mandible. Important structures that
arise from this arch are the muscles of mastication, the
maxillary artery, and cranial nerve V3. Other derivatives
from the first arch are listed in Table 1.1.
The second branchial arch is also known as the hyoid
arch. Around the fifth week of development, this arch
will overgrow the third and fourth arches, resulting in the
formation of the cervical sinus of His (Fig. 1.1B). This
sinus and the second, third, and fourth branchial grooves
subsequently obliterate, resulting in the smooth contour
of the neck. Failure of this area to fully obliterate may
possibly lead to the formation of a branchial sinus [4].
Table 1.1 lists the second through fifth arch derivatives.
Corresponding to each branchial groove are pharyn­
geal pouches, which represent outpouchings of the primi­
tive pharynx. These pouchings are lined by endoderm and
also push through the surrounding mesenchyme during
the fourth and fifth weeks of the embryonic period. Each
pouch contains a ventral and dorsal wing, and gives
rise to several important organs such as the parathyroid
glands and thymus [5].
Embryology of the External Ear
The first sign of the developing ear is seen by the presence
of the otic disc, which appears as a thickening on the
surface of the ectoderm at the end of the third week of
gestation [6]. The disc soon invaginates and is called the
otic pit. Six small elevations known as hillocks develop
at the dorsal ends of the first and second arches (Fig.
1.2). The first branchial groove, which is located between
the first and second arches, deepens and canalizes to
form the external auditory canal. The first three hillocks
arise anteriorly from the mandibular arch, and the other
three hillocks develop from the hyoid arch [7]. These
C H A P T E R 1 
Facial Embryology
Carlo P. Honrado, MD, Dewayne T. Bradley, MD, and Wayne F. Larrabee Jr., MD, FACS

2
MASTER TECHNIQUES IN FACIAL REJUVENATION
hillocks will gradually fuse to form the auricle of the
external ear. Although there is much controversy, it is
generally accepted that the tragus, helical crus, and helix
are formed from the mesodermal components of the first
arch, corresponding to the first, second, and third hill­
ocks, and that the fourth through sixth hillocks from the
second arch give shape to the antihelix, antitragus, and
lobule, respectively. By the 20th week of development, an
anatomically complete ear can be seen. The final shape
of the auricle is determined by the intrinsic and extrinsic
muscles of the ear that cause plical folding of the carti­
lage [8].
Initial positioning of the auricle lies in the ventrocau­
dal part of the neck region [1]. However, as the mandible
develops, the developing ear is pushed in a dorsocranial
direction and subsequently lies on the side of the head at
the level of the eyes by approximately the 32nd week of
gestation. Most abnormalities of the ear, such as anotia
or microtia, arise from insults that occur during the first
7 weeks of gestation.
Embryology of the Eye
Eye formation is evident by the beginning of the fourth
week and has its origins from the neuroectoderm, ecto­
derm, and mesoderm. Thickening of the surface ectoderm
in the area of the future eye occurs in response to signals
produced by the optic vesicles, which are evaginations
from the brain. This thickening results in the formation
of the lens placodes. The central portion of the placode
invaginates to form the lens pit, which subsequently sepa­
rates from the surface epithelium to form a spherical lens
vesicle, the precursor of the lens of the eye.
During the fifth week of embryogenesis, small depres­
sions develop above and below the eye, forming the prim­
itive upper and lower eyelids [9]. As they become more
distinct during the embryonic period, the lids approach
B
A
Figure 1.1  (A) Lateral view of a human embryo at approximately 4 weeks. (B) During the fifth week of development, the second arch overgrows
the third and fourth arches, forming the cervical sinus of His.
TABLE 1.1  Structures Derived From the Branchial (Pharyngeal) Arches
Arch
Cranial Nerve
Skeletal Structure
Muscles
Ligaments
I (mandibular)
Trigeminal (V3)
Meckel’s cartilage: malleus head
and neck, incus short process
and body, mandible
Muscles of mastication, tensor
tympani, tensor veli palatini,
stylohyoid, anterior belly of
digastric
Anterior ligament of malleus,
sphenomandibular
ligament
II (hyoid)
Facial (VII)
Reichert’s cartilage: malleus
manubrium, incus long process
and lenticular process, stapes,
styloid process, lesser cornu of
hyoid, upper part of hyoid body
Muscles of facial expression,
stapedius, stylohyoid,
posterior belly of digastric,
buccinator
Stylohyoid ligament
III
Glossopharyngeal
(IX)
Greater cornu of hyoid, lower
part of hyoid body
Stylopharyngeus, superior and
middle constrictors
IV
Superior
laryngeal (X)
Thyroid cartilage, cuneiform
cartilage
Inferior constrictor,
cricopharyngeus, cricothyroid
V/VI
Recurrent
laryngeal (X)
Cricoid, arytenoid, and corniculate
cartilages, trachea
Intrinsic laryngeal muscles
(except cricothyroid)

1  Facial Embryology
3
and ligaments of the facial region. Five facial primordia
appear as prominences around the stomodeum: the single
median frontonasal prominence and the paired maxillary
and mandibular prominences (Fig. 1.3).
Facial development continues until around the eighth
week of gestation. The frontonasal prominence is primar­
ily responsible for forming the forehead and the nose.
However, the first part of the face to form is the mandible
and lower lip. This occurs from the medial migration and
fusion along the median plane of the two mandibular
prominences. Toward the end of the fourth week, bilat­
eral thickenings, called nasal (olfactory) placodes, occur
on the surface of the ectoderm on the ventrolateral part of
the frontonasal prominence. The nasal placodes initially
are convex but subsequently invaginate during the sixth
week. Mesenchymal proliferation also occurs around
each other and subsequently fuse by the ninth week. Prior
to fusion, the lacrimal gland and its ducts also develop.
Mesodermal components are responsible for the forma­
tion of the ocular muscles, orbicularis oculi muscle, and
tarsus, which develop while the eyelids are fused. Separa­
tion of the eyelid complex begins during the 20th week in
an anterior to posterior fashion and takes approximately
3 weeks [3].
Embryology of the Face and Nose
The embryology of the face begins early in the fourth
week around a large stomodeum, which becomes the
future mouth. Proliferation of neural crest cells occurs in
the developing brain, which migrates to form, together
with mesodermal cells, the facial primordia. These neural
crest cells play a major role in forming the bone, cartilage,
1
3
4
5
2
C
1
3
4
5
6
B
1
2
3
4
5
6
A
Figure 1.2  (A–C) Formation of the external ear during the sixth week of development. Shown are the six hillocks.

4
MASTER TECHNIQUES IN FACIAL REJUVENATION
into the muscles of mastication, which are innervated
by the fifth cranial (trigeminal) nerve. The muscles of
facial expression arise from mesenchyme from the second
branchial arch, with their nerve supply coming from the
seventh cranial (facial) nerve.
Embryology of the Nasal Cavity and Paranasal Sinuses
As mentioned in the earlier section, the nasal placodes
become depressions called nasal pits. Proliferation of the
mesenchyme around the pits results in formation of the
medial and lateral nasal prominences and deepening of
the pits to form nasal sacs. The nasal sacs lie ventral to
the developing forebrain and they migrate in a dorsal-
caudal direction. An oronasal membrane separates the
sacs from the oral cavity. This membrane subsequently
ruptures, allowing the oral cavity to communicate with
the nasal cavity in the area of the nasopharynx.
The inferior, middle, and superior turbinates arise
from elevations on the lateral nasal wall. Diverticuli also
occur along the lateral nasal walls, which will give rise
to the future sinuses, which are pneumatic extensions
of the nasal cavities. Only the maxillary and ethmoid
sinuses are present at birth. The frontal sinus develops
from an anterior ethmoid air cell at about 2 years of age.
The sphenoid sinus also develops around age 2 years and
arises from a posterior ethmoid air cell.
The nasal septum arises from portions of the merged
medial nasal prominences. In addition, ectoderm along
the roof of the nasal cavities differentiates to form the
olfactory epithelium. Some of these cells become receptor
cells and form the olfactory bulb of the brain.
Embryology of the Palate
The formation of the palate occurs between the 6th and
12th weeks of gestation. The primary palate, also known
as the median palatine process, begins to form from the
innermost portion of the intermaxillary segment of the
maxilla. This segment is formed by the fusion of paired
median nasal processes and maxillary prominences. The
primary palate ultimately forms the premaxilla and
Frontal process
Nasal placodes
Maxillary prominences
Mandibular prominences
Figure 1.3  The five facial primordia comprise the frontal prominence,
the paired maxillary prominences, and the paired mandibular promi­
nences. The nasal placodes are also shown.
Nasal pit
Lateral nasal prominence
Medial nasal prominence
Maxillary prominence
Figure 1.4  Appearance of the nasal pits from growth of the medial
and lateral nasal processes.
Maxillary prominence
Mandibular prominence
Nasolacrimal groove
Philtrum
Figure 1.5  The nasolacrimal groove forms between the lateral nasal
process and maxillary prominence.
the rim of the placodes, creating elevations known as
the medial and lateral nasal prominences. The depressed
nasal placodes are now referred to as nasal pits, which are
the primordia of the nostrils and nasal cavities (Fig. 1.4).
Owing to the continuing proliferation of the nasal promi­
nences, the nasal pits deepen and are called nasal sacs.
Proliferation of the paired maxillary prominences also
occurs during this period. They migrate medially and
contact the medial and lateral nasal processes. Lying
between the maxillary prominence and the lateral nasal
process is the nasal groove, which marks the future site
of the nasolacrimal duct. Merging of the medial nasal
process and maxillary prominences results in continuity
of the lip and upper jaw with formation of the philtrum,
premaxilla, and primary palate (Fig. 1.5). Separation of
the nasal pits from the stomodeum also occurs. Failure
of the maxillary prominences to fuse results in cleft lip
and palate deformities.
Proliferation of mesenchyme from the first and second
branchial arches results in formation of the muscles in
the face. Mesenchyme from the first arch differentiates

1  Facial Embryology
5
knowledge of facial embryology has led to a better under­
standing of the layered anatomy of the face. This knowl­
edge is most clearly of value in all aspects of facial plastic
and reconstructive procedures.
R E F E R E N C E S
1. Moore KL, Persaud TVN. The developing human: Clinically ori­
ented embryology. 5th ed. Philadelphia: WB Saunders; 1993.
2. Larrabee WF, Makielski KH, Henderson JL. Surgical anatomy of
the face. 2nd ed. Philadelphia: Lippincott Williams & Wilkins;
2004.
3. Goding GS, Eisele DW. Embryology of the face, head and neck. In:
Papel ID. Facial plastic and reconstructive surgery. 2nd ed. New
York: Thieme; 2002.
4. Davies J. Embryology of the head and neck in relation to the
practice of otolaryngology. Rochester, Minn: American Academy
of Ophthalmology and Otolaryngology; 1965.
5. Lee KJ. Essential otolaryngology: Head and neck surgery. 7th ed.
Norwalk, Conn.: Appleton & Lange; 1999.
6. O’Rahilly R. The timing and sequence of events in the development
of the human eye and ear during the embryonic period proper. Anat
Embryol (Berl) 1983;168:87–99.
7. Siegert R, Weerda H, Remmert S. Embryology and surgical anatomy
of the ear. Facial Plast Surg 1994;10(3):232–43.
8. Zerin M, van Allen MI, Smith DW. Intrinsic auricular muscles and
auricular form. Pediatrics 1982;69:91–3.
9. Pearson AA. The development of the eyelids. Part I. External fea­
tures. J Anat 1980;130(1):33–42.
10. Sykes J. Diagnosis and treatment of cleft lip and palate deformities.
In: Papel ID. Facial plastic and reconstructive surgery. 2nd ed. New
York: Thieme; 2002.
represents only a portion of the hard palate that lies
anterior to the incisive foramen.
The secondary palate is embryologically distinct from
the primary palate and begins to develop during the
eighth week. Formation of the secondary palate results
from inferior and medial growth and migration of the
mesenchymal projections called the lateral palatine proc­
esses of the maxilla, also known as the palatal shelves.
The palatal shelves are initially separated by the tongue.
With growth of the mandible, the tongue moves anteri­
orly, allowing the shelves to assume a more horizontal
orientation [10].
The sequence of normal palatal formation begins
when the nasal septum and the palatal shelves come into
contact. Closure occurs in an anterior to posterior direc­
tion starting at the incisive foramen. Bone formation also
occurs during this period, completing the rest of the hard
palate. Posteriorly, this area does not become ossified,
resulting in the soft palate.
The degree of clefting that can occur from failure of
proper fusion can range from a bifid uvula to a complete
cleft of the secondary palate.
CONCLUSION
The anatomy of the face is the foundation upon which
procedures for rejuvenation of the face are laid. Detailed

6
INTRODUCTION
The anatomy of the face is fairly constant. Variant
anatomy is seen in the thickness of the soft tissue layers,
and in the size and orientation of cartilaginous structures
such as the nasal cartilages (nose), tarsal plates (eyelids),
and facial bones (maxilla, mandible, zygoma, etc.). The
relationships of nerves, vessels, and muscles of the face
are fairly uniform. The facial anatomy combines to give
the face form and function.
Plastic surgical procedures can significantly affect facial
form and function. The vast array of surgical and inject­
able procedures have expanded in recent years as the
want and need to improve facial function and appearance
has increased. To successfully perform these procedures,
a thorough knowledge of the variant facial anatomy is
required.
This chapter will discuss the common anatomical rela­
tionship of the face. The layered anatomy of the face will
be outlined, as will the typical position of muscles and
neurovascular structures. Applied anatomy as related to
surgical and injectable procedures will be highlighted.
LAYERS OF THE FACE
Although a few exceptions exist, the skin, subcutaneous
tissues, and superficial and deep fascial layers of the face
are consistent in their relationships and can be designated
with a common numbering system. These layers can be
numbered I to V (Figs. 2.1–2.2). Although the names
of the individual layers differ from various regions of
the forehead, temple, face, and neck, the relative rela­
tionships of these layers remains constant. The muscles,
nerves, and vascular structures, however, vary in their
position and relationship to the layers.
The layering system of the facial levels can be seen
in Table 2.1. The various names of each layer within a
given facial region are described throughout the chapter,
making note of the designated numbering system.
Layer I: Skin
The skin varies in thickness, pigmentation, dermal
appendages, and adherence to the subcutaneous tissues
between different areas of the face [1]. The skin is thick­
est over the mentum and in the region of the forehead
and eyebrows, and is thinnest over the eyelids. In the
infraorbital region and medial to the midpupillary line,
the skin is thin and usually contains no subcutaneous fat.
The skin is firmly attached to the underlying muscles of
the oral commissure and in the region of the nasal tip,
while it is loosely adherent to the underlying soft tissue
in the eyelids and at the root of the nose. As the dermis
of the skin thins with age, the underlying muscles cause
rhytids, which generally are perpendicular to the direc­
tion of facial muscle contraction (Fig. 2.3). The amount
of skin wrinkling is variable, and relates to the skin thick­
ness and elasticity.
Layer II: Subcutaneous Tissue
The subcutaneous tissue varies in amount in relation to
the patient’s genetics, ethnicity, and body weight [2]. In a
given individual, the thickness of the subcutaneous tissue
is different based on the facial region. In the forehead
and over the mentum, the fat layer is thick and the over­
lying skin is densely adherent. However, in the eyelids,
the fat layer is almost nonexistent and the skin is loosely
adherent. In the midface, the subcutaneous fat is highly
vascularized and compartmentalized by various fibrous
septae (Fig. 2.4).
Layer III: Superficial Fascia
The superficial fascia of the face is fairly adherent to the
overlying skin and subcutaneous tissues of the face in
most regions, and therefore must be dissected sharply
from the skin in order to surgically separate these tissue
planes. This is in contradistinction with the relationship of
the superficial fascia with the underlying deep fascia [3].
In most regions, the superficial fascia is loosely attached
to the underlying deep fascia. Surgical dissection between
the superficial and deep fascia is therefore usually blunt
and easily performed.
The superficial fascia has different designations in dif­
ferent regions of the scalp, temple, face, and neck. In
the forehead, the superficial fascia is called the galea
aponeurosis. This layer envelopes the frontalis muscle
in the forehead, and splits to encompass the occipitalis
muscle at the posterior aspect of the scalp. In the temple,
the superficial fascial layer is termed the temporoparietal
fascia (TPF; see Fig. 2.1). This layer is a thin, pliable, and
vascular layer that is well suited for facial and auricu­
lar reconstruction. In the midface, the superficial fascia
is the superficial muscular aponeurotic system (SMAS).
The SMAS and TPF are contiguous structures, but are
discontinuous at the level of the zygomatic arch. In the
neck, the superficial fascia provides a fascial sleeve for
the platysma muscle (Fig. 2.5).
Layer IV: Deep Areolar Layer
In all regions of the head and neck, the superficial fascia
(III) is connected to the deep fascia (V) by a loose areolar
C H A P T E R 2 
Applied Facial Anatomy
Jonathan M. Sykes, MD, Gustavo A. Suárez, MD, Patrick Trevidic, MD, Sebastian Cotofana, MD, PhD, and
Hyoung Jin Moon, MD

2  Applied Facial Anatomy
7
layer. This connection is variable and differs by age,
genetics, and body weight. The attachments are typically
comprised of loose connective tissue, and surgical dis­
section of this plane is therefore usually blunt [4]. The
specific structures that traverse this layer vary by region,
and are covered later.
Layer V: Deep Fascia
The deep, or investing, fascia is a dense connective tissue
that is usually immobile. It is connected to the overlying
mobile superficial fascia (III) by loose connective tissue
(IV). The deep fascia of the forehead is the frontal bone
periosteum. The periosteum is densely adherent to the
frontal bone, and becomes continuous at the superior
orbital rim with the septum orbitale. The thickening at
the orbital rim is termed the arcus marginale. The deep
fascia of the temple is designated deep temporal fascia
(DTF) or temporalis muscle fascia. This fascia overlies,
and is densely adherent to, the underlying temporalis
muscle (see Fig. 2.1) [5].
The deep fascia of the lateral midface is termed the
parotidomasseteric fascia. This fascia covers the parotid
gland and the parotid duct, and includes the buccal
branches of the facial nerve. As this fascia travels towards
the temple over the zygomatic bone, it becomes con­
tinuous with the superficial lamina of the DTF. The deep
fascia of the neck is designated deep investing fascia. All
deep fascial layers (V) are relatively fixed to the structures
they overlie, and become good fixation points for repo­
sitioning of soft tissues and surgical procedures such as
rhytidectomy or browlifting.
REGIONAL CONSIDERATIONS
Forehead
The boundaries of the forehead are the frontal hairline
(superiorly), the eyebrows and the nasal root (inferiorly),
and the temples (laterally). The transition between the
forehead and the temporal regions are the superior tem­
poral lines, or the anterosuperior extent of the temporalis
muscles. In this region, the fascial planes fuse and are
termed the conjoined tendon (see Fig. 2.5B).
The layers of the forehead consist of a thick skin layer
(I) overlying a densely attached subcutaneous tissue (II).
The skin is thick, averaging almost 2400 µm [2]. Just
deep to the subcutaneous fat is the galea aponeurosis (III).
I  II
III
FP
V
VI
Figure 2.1  Layers of the temple. FP, Fat Pad.
1. Skin
2. Subcutaneous
3. Musculo-aponeurotic
4. Retaining ligaments
and space
5. Periosteum
and deep fascia
1
2
3
4
5
1
2
3
4
5
Figure 2.2  Layers of the face.
TABLE 2.1  Layers of the Face
I
Skin
II
Subcutaneous tissue/superficial areolar tissue
III
Superficial fascia
IV
Loose areolar tissue
V
Deep fascia

8
MASTER TECHNIQUES IN FACIAL REJUVENATION
This superficial fascia of the forehead envelopes the
paired frontalis muscle (Figs. 2.6–2.7). The frontalis
muscle is the only elevator of the eyebrow. Contraction
of this muscle tightens the scalp, elevates the brow, and
creates horizontal forehead rhytids. Deep to the galea
aponeurosis/frontalis muscle is loose areolar tissue (IV)
and the pericranium (V). The pericranium is the deep
fascia of the forehead and is densely attached to the
underlying frontal skull. As the frontalis muscle con­
tracts, the superficial layers of the forehead slide over
the underlying periosteum. This glide plane of layer III
sliding over layer V affects how individuals age and how
surgeons rejuvenate faces by elevating ptotic soft tissues.
The inferior extent of the frontalis muscle interdigi­
tates with the orbicularis oculi muscle (OOM) (Fig. 2.8).
The OOM is a sphincteric muscle that is supplied by the
facial (7th) nerve and acts as a protractor to the eyelids
and a depressor of the eyebrows. Multiple branches of the
facial nerve provide motor innervation to the OOM. The
medial and inferior portions of the muscle are innervated
by the zygomatic branch, and the lateral and central por­
tions of the muscle are innervated by the anterior portion
of the temporal branch of the facial nerve. The OOM is
located immediately subcutaneously. Some of this muscle
gives involuntary action to the eyelids (blink), while other
fibers provide voluntary action (squeeze or squint). The
muscles are separated into pretarsal (superficial to the
tarsal plates), preseptal (superficial to the orbital septum),
Figure 2.3  Relaxed skin tension lines of the face.
Dermis
Epidermis
Septae
Muscle
Fat
B
A. Central forehead compartment
B. Middle forehead compartment
C. Lateral temporal cheek

compartment
D. Superior orbital compartment
E. Inferior orbital compartment
A
F. Lateral orbital compartment
G. Nasolabial compartment
H. Medial cheek compartment
I. Middle cheek compartment
J. Superior jowl compartment
K. Inferior jowl compartment
A
B
C
D
E
F
G
H
I
J
K
Sup. temporal
septum
Inf. temporal
septum
Orbicularis
retaining
ligament
Sup. cheek
septum
(zygomatic
cutaneous
ligaments)
Platysma auricular
ligament
Masseteric
cutaneous
ligaments
Mandibular
septum
Mandibular
cutaneous ligament
Figure 2.4  (A) Superficial fat compartments of the face. (B) Fibrous septae. Inf., Inferior; Sup., superior.

2  Applied Facial Anatomy
9
The origins and insertions of the orbicularis muscles,
as well as its anatomical relationships with adjacent
structures, are complex. The muscle primarily travels in
the soft tissues of the eyelids, but is fixed medially and lat­
erally to the bony orbital wall by the orbicularis retaining
ligaments (ORLs). The ORL medially to the midpupillary
line is termed the tear trough ligament, and is respon­
sible in some individuals for adding to the concavity just
and orbital (more peripheral) portions (Fig. 2.9). These
designations are not true anatomic separations of muscle,
but rather names that identify the muscle location. In
fact, there are no true separations or septi distinguish­
ing these muscle segments. Injection of the OOM with
botulinum toxin can decrease dynamic lateral canthal
lines, decrease rhytids of the lower eyelid, and elevate the
lateral or tail of the brow.
Sub-galea plane
Superior
temporal septum
Inferior
temporal septum
Temporal adhesion
Lateral orbital
thickening
Zygomatic
ligament
Masseteric
ligament
Mandibular ligament
Platysma
Parotid gland
Skin
SMAS
Sub-SMAS plane
Parotidomasseteric fascia
(deep fascia)
Galea
B
A
Figure 2.5  (A) SMAS. (B) SMAS and retaining ligaments of the face. SMAS, Superficial muscular aponeurotic system.
FM
Figure 2.6  Frontalis muscle. FM, Frontalis muscle.
FM
Figure 2.7  Frontalis muscle and galea aponeurotica. Arrow, central
area of forehead where no muscle is present. FM, Frontalis muscle.

10
MASTER TECHNIQUES IN FACIAL REJUVENATION
upper eyelid crease is a horizontal indentation formed
by the attachment of the superficial levator aponeurosis
fibers into the orbicularis oris intermuscular septa and
subcutaneous tissue. The crease is located approximately
7 to 10 mm above the eyelid margin centrally in most
Caucasians. When present, the upper lid crease in Asians
is located at 4 to 6 mm [6]. In patients with dehiscence
of the levator aponeurosis, the eyelid crease is usually
elevated and the eyelid is thin.
The eyelid is covered by very thin skin, usually only
400 to 500 µm in thickness [1]. There is almost no sub­
cutaneous tissue in the eyelids. The OOM are located
just deep to the skin. The orbital septum is located just
deep to the OOM (see Fig. 2.11). The septum is a thin,
multilayered connective tissue beginning at the arcus
inferior to the convex medial orbital fat (Figs. 2.10–2.11).
The orbicularis muscles interdigitate with the corrugator
and frontalis superiorly (Fig. 2.12). Laterally, the orbicu­
laris muscles travel superficial to the temporalis fascia;
medially, the muscle covers the depressor supercilii; and
inferiorly, the muscles travel between the superficial and
deep suborbicularis oculi fat (SOOF) pads of the cheek.
The inferomedial extent of the lower eyelid orbicularis
muscles covers the levator labii superioris and the levator
labii superioris alaeque nasi muscles.
Upper Eyelid Anatomy
The upper eyelid is composed of very thin skin, structur­
ally dense fibrous tissue (tarsal plate), and muscles that
close (protractors) and open (retractors) the lids. The
Temporalis m.
Orbicularis oculi m.
Levator labii aleque nasi m.
Levator labii superioris m.
Zygomaticus minor m.
Zygomaticus major m.
Depressor anguli m.
Depressor anguli oris m.
Depressor labii inferioris m.
Frontalis m.
Corrugator m.
Procerus m.
Levator anguli oris m.
Orbicularis oris m.
Buccinator m.
Mentalis m.
Figure 2.8  Muscles of the face. m., Muscle.
B
Orbital
Preseptal
Pretarsal
Preseptal
Orbital
O
A
PS
PT
Figure 2.9  Orbicularis oculi muscle portions. (A) Cadaver photograph of orbicularis oculi muscle with skin removed. (B) Schematic drawing of
orbicularis oculi muscle. O, Orbital; PS, preseptal; PT, pretarsal.

2  Applied Facial Anatomy
11
(LPS) muscle originates from the lesser wing of the sphe­
noid just above the annulus of Zinn and superolateral to
the optic canal. The muscle travels within the orbit in a
relatively horizontal orientation in close approximation
to the superior rectus muscle. At a point just posterior
to the superior orbital rim, the LPS widens and changes
orientation to horizontal at a fascial condensation. This
fascial thickening is termed Whitnall’s ligament (supe­
rior tarsal ligament). The fascia attaches medially to the
fascia around the trochlea and laterally to the capsule of
the lacrimal gland and the frontal bone periosteum. As
the upper eyelid retracts, the fascial sheet helps elevate
marginalis along the orbital rim. The septum is a con­
tinuation of the periorbita within the orbit and contains
the eyelid fat pads, which lie just deep to the septum. The
upper eyelid has a nasal, or medial, fat pad and a central
fat pad. In the lateral portion of the upper eyelid is the
lacrimal gland. The medial and central fat pads are sepa­
rated by the superior oblique muscle and the trochlea.
The nasal fat pad is whiter and contains more fibrotic fat
than does the central pad (see Fig. 2.10).
The eyelid fat pads are termed preaponeurotic, because
they are located just superficial to the levator aponeurosis
(upper eyelid retractor). The levator palpebrae superioris
Levator muscle
Levator
aponeurosis
Medial horn
of levator
Superior tarsus
Inferior retractors
(capsulopalpebral fascia)
Whitnall’s ligament
Muscle
aponeurotic
junction
Lateral horn
of levator
Inferior tarsus
C
Interpad septum
Inferior oblique
muscle
Central fat pad
Temporal
fat pad
Preaponeurotic
fat pad
Nasal fat pad
Lacrimal gland
Interpad septum
(arcuate expansion of
Lockwood’s ligament)
B
A
Upper lid crease
Medial canthus
Nasojugal groove
Lower lid crease
Lid-cheek junction
Lateral
canthus
Canthal tilt
Upper lid fold
Figure 2.10  Orbital fat pads. Schematic drawings indicating (A) surface eyelid anatomy, (B) location of orbital fat pads and (C) retractors of
eyelid after fat pads removed.

12
MASTER TECHNIQUES IN FACIAL REJUVENATION
The tarsal plates are dense fibrous tissue that give
structural integrity and form to the upper eyelid. The
upper lid tarsal plate measures 8 to 12 mm centrally and
tapers medially and laterally to 2 to 3 mm as the plate
inserts into the canthal tendons. The levator apparatus
attaches to the tarsal plate on its superficial and superior
surfaces. The palpebral conjunctiva is densely attached
and bound to the undersurface of the tarsal plate.
Lower Eyelids
The lower eyelid is composed of very thin skin, a small
tarsal plate, and muscles that close (protractors) and open
(retractors) the lid. The shape of the lower eyelid is deter­
mined by the attachment of the medial and lateral canthal
tendons as well as the tone and contraction of the OOM.
The lateral canthal angle is usually positioned 1 to 2 mm
above the medial canthal angle. The infratarsal crease of
the lower eyelid is variable, but is often most noticeable at
the inferior border of the short lower eyelid tarsal plate.
The lower eyelid is also covered by very thin skin with
almost no subcutaneous tissue being present. The OOM
is located just deep to the skin, with the pretarsal OOM
contributing to the tone and shape of the lower eyelid.
The septum orbitale of the lower eyelid is located just
deep to the lower OOM. This septum covers and con­
tains the three fat pads of the lower eyelid. Herniation of
these fat pads is associated with unsightly bulges of the
lower eyelid. The medial (nasal) and central lower lid fat
pads are separated by the inferior oblique muscle. The
central and lateral (temporal) fat pads are separated by
the arcuate extension of the oblique muscle. The inferior
oblique muscle is the most superficial extraocular muscle,
and injury to this should be avoided during lower blepha­
roplasty (see Fig. 2.10).
The retractors of the lower eyelid arise from fibers
of the inferior rectus and inferior oblique muscles. The
retractors begin as a fibrous sheet and emanate from the
superior tarsal ligament (Lockwood’s ligament) and fuse
with fibers from the orbital septum approximately 5 mm
below the inferior border of the tarsal plate. These con­
joined fibers insert onto the inferior border of the tarsal
plate (see Fig. 2.11).
The lower lid tarsal plate is shorter than the upper
tarsal plate, and measures approximately 4 mm centrally
and tapers medially and laterally to 2 mm as the plate
inserts into the canthal tendons. Again, the palpebral
conjunctiva of the lower eyelid is densely adherent to the
deep surface of the lower eyelid tarsal plate.
Midface
The skin (layer I) of the midface is variable in thickness
and adherence to the underlying subcutaneous fat. The
skin of the lower eyelid is thin and loosely attached to
the underlying tissue, while the skin of the midface is
moderately bound to the deeper tissues. The skin of the
perioral complex (medial and inferior to the melolabial
fold and medial to the marionette fold) is densely bound
to and not easily separated from the immediate subcuta­
neous tissues.
The subcutaneous fat compartments of the midface
(layer II) are separated by fibrous septae that connect
the upper eyelid fat pockets, preventing unsightly eyelid
bulging.
At the level of Whitnall’s ligament, the levator muscle
separates into anterior (superficial) aponeurosis and pos­
terior (deep) muscle components. The retractor complex
also changes from a horizontal orientation to a vertical
one. The deep muscle is termed Müller’s muscle and
is innervated by sympathetic nerve fibers. These fibers
course with the third (oculomotor) cranial nerve. Müller’s
muscle attaches to the superior border of the tarsal plate,
while the majority of aponeurotic fibers insert onto the
lower one-third of the anterior surface of the tarsal plate
(see Fig. 2.11) [7].
Orbital septum
Orbicularis m.
Levator apononeurosis
Müller’s m.
Tarsus
Tarsus
Capsulopalpebral
fascia
Septum
Figure 2.11  Upper and lower eyelid. m., Muscle.
FM
CSM
Figure 2.12  Corrugator and frontalis muscle relation. Arrow, point­
ing to supraorbital neurovascular bundle. CSM, Corrugator supercilii
muscle; FM, frontalis muscle.

2  Applied Facial Anatomy
13
vermillion border. The orbicularis oris muscle contributes
to the form and shape of the lips. Contraction of this
muscle closes and protracts the lips (Fig. 2.13).
The position and movement of the lips is acted upon
by several mimetic muscles that elevate and depress the
lips. These muscles attach to a connective tissue thicken­
ing at the oral commissures referred to as the modiolus.
Elevators of the upper lip include the levator labii supe­
rioris and the levator labii superioris alequae nasi muscle.
Levator muscles attach to the lower lip at or near the
modiolus to elevate the lips or oral commissure.
Various depressors of the lower lip attach to the modi­
olus and the skin of the lip. These include the platysma
muscle, which is a flat muscle originating from the neck
and inserting into the chin at the commissures of the
mouth and into the anterior one-third of the oblique line
of the mandible. Other lower lip depressors include the
depressor anguli oris (DAO), depressor labii inferioris
(DLI), and the mentalis muscles. The zygomaticus major
and risorius muscles elevate the angle of the mouth.
Injection of botulinum toxin in perioral muscles can
help diminish upper lip rhytids, lessen the hyperdynamic
function of muscles, and create symmetry in patients with
perioral asymmetry. The DAO is a triangular muscle that
arises from the inferior border of the mandible and inserts
into and depresses the corner of the mouth. It is overlaid
by the more medial and triangular DLI, which depresses
the lower lip (see Fig. 2.13). Injection of muscles that
depress the corner of the mouth and the lower lip (DAO)
with botulinum toxin can elevate the corner of the mouth.
When injecting toxin into the DAO, the DLI should be
circumvented in order to avoid creating an asymmetric
smile [9].
the overlying skin with the underlying superficial fascia
of the midface. The fat compartments are well vascular­
ized with small vessels, which course within these septae
(see Fig. 2.4).
As stated earlier, the superficial fascia of the midface
(layer III) is SMAS. The SMAS envelopes the facial mus­
culature and has connections to the overlying subcutane­
ous fat and the deep fascia of the face (layer V) beneath.
The SMAS of the midface is continuous with the nasal
SMAS medially and continuous with the platysma muscle
of the neck. The SMAS is contiguous with the superficial
fascia of the temple (TPF). This discontinuity occurs at
the zygomatic arch.
The layer between the superficial and deep fascia of
the face is the deep areolar layer (layer IV). This layer
envelopes and covers the deep fat compartments of the
face. The central deep fat compartments are termed the
medial and lateral SOOF. The deep lateral fat compart­
ment lies just inferior to the two SOOF fat compart­
ments. These three fat compartments are bounded by
the facial vein (medially) and the zygomatic ligament
(laterally). Another deep fat compartment is termed the
deep medial fat of the face. This compartment lies just
medial to the facial vein. Injection of soft tissue fillers
or autologous fat is usually performed in these deep fat
compartments.
The attachment of the superficial (III) and deep fascia
(V) of the face is variable in different individuals and in
different portions of the face. The connections between
these layers contain distal branches of the facial nerve
(CN VII) and are points of fixation of the suspensory liga­
ments (e.g., zygomatic ligament, ORL) of the face. Layers
III and V are densely attached in the lateral midface
(preauricular region). The connections of these layers is
a blunt dissection plane where looser attachments are
found (see Fig. 2.5B). In the region anterior to the parotid
gland, the premasseteric space is found. The floor of
this space is the parotidomasseteric fascia and the roof
is the SMAS.
Layer V of the midface is the parotidomasseteric
fascia, or deep fascia, of the face. This fascia covers the
parotid gland and the parotid duct, and includes the
buccal branches of the facial nerve. This fascia continues
towards the temple over the zygomatic bone, where it
is referred to as the superficial lamina of the DTF. The
masseteric ligaments connect the buccinator muscle to
layer III. These ligaments form the anterior boundary
of the premasseteric space. The parotid duct exits the
anterior border of the parotid gland and courses within
the parotidomasseteric fascia and traverses the premas­
seteric space. The duct then pierces the buccinator muscle
to enter the oral cavity opposite the upper second molar
tooth [8].
Lips and Perioral Region
The skin covering the perioral region is moderately thick
and is densely bound to the underlying soft tissue. The
upper and lower lips are comprised of the sphincteric
orbicularis oris muscle, which is covered externally by
skin and internally by mucosa. The junction between
the mucous membrane and the cutaneous skin is the
MM
Figure 2.13  Orbicularis oris muscle. Black arrow, facial artery, red
arrow, depressor anguli oris muscle, blue arrow, orbicularis oris muscle.
MM, Masseter muscle.

14
MASTER TECHNIQUES IN FACIAL REJUVENATION
efficiency of facial injections and surgery, and helps avoid
complications.
R E F E R E N C E S
1. Bennett R. Anatomy and physiology of the skin. In: Papel ID. Facial
plastic and reconstructive surgery. New York: Thieme; 2009.
2. Frohm ML, Durham AB, Bichakjian CK, et al. Anatomy of the skin.
In: Baker Shan. Local flaps in facial reconstruction. Philadelphia:
Elsevier; 2014.
3. Stuzin JM, Baker TJ, Gordon HL. The relationship of the superficial
and deep facial fascias: relevance to rhytidectomy and aging. Plast
Reconstr Surg 1992;89(3):441–9, discussion 450–1.
4. Baker SR. Deep plane rhytidectomy and variations. Facial Plast Surg
Clin North Am 2009;17(4):557–73, vi.
5. Sykes JM, Cotofana S, Trevidic P, et al. Upper face: clinical anatomy
and regional approaches with injectable fillers. Plast Reconstr Surg
2015;136:204S–18S.
6. Jeong S, Lemke BN, Dortzbach RK, et al. The Asian upper eyelid:
an anatomical study with comparison to the Caucasian. Arch Oph­
thalmol 1999;117(7):907–12.
7. Knize DM. An anatomically based study of the mechanism of
eyebrow ptosis. Plast Reconstr Surg 1996;97(7):1321–33.
8. Cotofana S, Schenck TL, Trevidic P, et al. Midface: clinical anatomy
and regional approaches with injectable fillers. Plast Reconstr Surg
2015;136:219S–34S.
9. Braz A, Humphrey S, Weinkle S, et al. Lower face: clinical anatomy
and regional approaches with injectable fillers. Plast Reconstr Surg
2015;136:235S–57S.
Facial Artery and Vein
The facial artery is a branch of the external carotid artery
and crosses the mandible just anterior to the masseter
muscle at a depression in the mandible termed the ante­
gonial notch. The artery is located just anterior to the
facial vein. After crossing the mandibular border, the
artery and vein separate and the artery becomes very
tortuous as it travels toward the oral commissure. It gives
off the superior and inferior labial arteries and usually
becomes the angular artery travelling in the nasofacial
crease. The artery and vein are located at the anterior
border of the masseter muscle and just posterior to the
posterior border of the DAO muscle (see Fig. 2.13). Injec­
tion of toxin or fillers in this region should avoid injury
to the facial vessels.
SUMMARY
To evaluate and treat facial aging, a thorough knowl­
edge of facial anatomy is required. Understanding facial
anatomy enhances the practitioner’s ability to diagnose
facial deformities and to create procedures to rejuve­
nate the face. Knowledge of anatomy maximizes the

15
HISTORY AND INTRODUCTION
As noted by Pessa, “there are many arbitrary definitions
of what constitutes a youthful face but the appearance of
youth is not arbitrary; it is simply difficult to define” [1].
In an effort to solve any problem, one must first define
the problem, come up with a solution, and then suc­
cessfully execute the solution. The progression of facial
shape with aging is the subject of many theories and
hypotheses, but much remains to be understood. Current
understanding of the facial aging process remains largely
empirical, given that it has traditionally been based on
the effectiveness of various treatments aimed at rejuve­
nation, some resulting in an odd or “done” appearance.
Defining the problem has proved challenging, as facial
aging is a complex process that is the cumulative effect
of simultaneous changes of the many components of the
face, as well as the interaction of these components with
each other.
A growing understanding of this complex process has
been ongoing in the world of surgery and surgical tech­
niques since its inception, and has informed and driven
the change from an empiric approach to an anatomic one,
enabling improved and more natural-appearing results.
Fig. 3.1, adapted from an article on facial aging from
Cotofana et al., provides an impressive illustration of
how innovation and advances in technology, which have
given us newer and faster ways to both gather and share
information, are accelerating our understanding of facial
anatomy [2]. As a result our understanding of the ana­
tomic changes observed in the aging face has progressed
considerably over the last couple of decades, leading to a
paradigm shift in the way we both perceive and approach
these changes. The answer to the question of whether we
sink or we sag has become a “yes” to both, as we begin
to see aging as a complex and interdependent interplay
between all structural layers culminating in the collapse
of a three-dimensional (3D) construct. Newer under­
standing of volume loss as a critical component of facial
aging and the integration of volume replacement into the
surgical and nonsurgical therapeutic algorithm is argu­
ably the most significant recent development in the field
of facial rejuvenation. The ability to accurately recognize
where volume has been lost (or sometimes lacking in the
first place) in each individual at a given point in time
will greatly enhance our ability to address the loss with
site-specific corrections in order to achieve optimal and
natural-looking results. However, most of us would agree
with Glasgold that the recent rapid and widespread adop­
tion of “off the shelf” volume replacement has outpaced
a sophisticated understanding of its goals, resulting in a
new and different, but equally undesirable category of
“looking done” [3].
So the problem can be defined as the attainment of
natural-looking results in the rejuvenation of the aging
face, and the solution to that problem, as well as its
execution, lies in understanding its pathogenesis, which
is anatomic. Recent insights and gains in our anatomic
understanding enhance our current ability to come closer
to this goal. For this reason, this chapter is not written
on the various types of fillers or techniques of filler injec­
tion, about which much has been written, but rather
on how to decide where to use it and why in differ­
ent faces, using anatomy as a guide. This approach is
rational, practical, teachable, and reproducible, as it is
simply the result of the recognition, and targeted correc­
tion, of currently recognized specific anatomic deficien­
cies. Using this approach has improved my results and
resulted in much higher patient satisfaction. That said, it
is not the only way. Many other approaches have been
employed successfully (using specific landmarks or masks
or phi ratios, for example), in order to obtain pleasing
results; however, some aspects of these approaches also
use anatomy. The purpose of this chapter is to provide
an introduction and brief summary of some of the recent
literature concerning facial anatomy and the anatomy of
facial aging, which serve as the basis and foundation for
predictable, specific, reproducible, and natural-appearing
results with the use of injectables. This summary of current
concepts will be presented along with clinical examples
C H A P T E R 3 
Addressing Facial Shape and
Proportions With Injectable Agents
in Youth and Age
Rebecca Fitzgerald, MD
If I had an hour to solve a problem, I’d spend 55 minutes thinking about the problem
and 5 minutes thinking about the solutions.
ALBERT EINSTEIN

16
MASTER TECHNIQUES IN FACIAL REJUVENATION
exhibiting primarily congenital absence or aging changes
in the tissue layer discussed in order to better illustrate
the discussion. The practical use of these concepts in
injectable treatment of the face will then be illustrated
using a number of case reports of patients of different
ages, gender, and ethnic backgrounds along with a short
description of where each face was treated and why, using
both a layered anatomic (tissue structures) and regional
approach (upper, mid, and lower face, shape, propor­
tions). In order to look at a number of cases, as well as
to compare and contrast different faces, these cases are
presented in a “composite” format. This smaller format
additionally makes it easier to recognize facial shape and
proportions, and to determine what is present or missing
that may be moving the face away from the ideal shape
and proportions, which will be discussed below.
Finally, as aging is a complex multimodal process,
multimodal therapy must be used to address it. Despite
the widespread popularity of injectable treatments as an
“immediate gratification no downtime option,” they have
their limitations and risks like everything else, and are not
a panacea (or stand alone) treatment of the aging face.
PERSONAL PHILOSOPHY
Although a new patient may present pointing to a wrinkle,
line, or fold they have noticed seemingly overnight, as
stated above, we are now increasingly aware that these
first obvious signs of aging noted by the patient are in
fact downstream markers of a slow progressive change
taking place in all structures of the face. This represents
a paradigm shift in our current approach to facial reju­
venation. This concept will be addressed, discussed, and
illustrated in this chapter.
Facial beauty and attractiveness are important cross-
cultural social concepts as they tend to dictate how
individuals are judged and treated [4]. Research has
shown that facial beauty is perceived and processed
rapidly by the brain, and this perception biases subse­
quent cognitive processes [5]. A recent extensive review
of research on facial beauty determined that four charac­
teristics emerge as the most statistically significant deter­
minants of attractiveness: averageness (prototypicality),
sexual dimorphism, youthfulness, and symmetry [6].
Not surprisingly, all of these have something to do with
optimizing mate selection. Youth and sexual dimorphism
are obvious. Prototypicality likely signifies a good mix of
genes (avoiding autosomal recessive disease), while sym­
metry may indicate a history of maternal stability and
health during development. Additionally, changes seen
with aging may lead to an unintended and undesirable
misinterpretation of mood by others that is unwelcome to
most all of us as we age and is one of the most common
presenting complaints, i.e., “I don’t mind getting older
I just don’t want to look mad, sad, and tired.” This
can often be remedied with glabellar neuromodulators as
well as fillers infraorbitally as well as around the mouth,
resulting in a surprisingly different first impression of a
face, as seen in Fig. 3.2. Looks matter because they can
have a great impact on quality of life.
FACIAL ANATOMY: INTRODUCTION AND OVERVIEW
The traditional approach to assessing the face is to con­
sider the upper, middle, and lower thirds, regionally.
Other newer useful approaches using structural layers
or functional differences reflect our recognition that the
pathogenesis of facial aging is a multifactorial process
that can be explained on an anatomic basis, and likely
accounts for the variations in the onset and outcome of
aging seen in different individuals. We will look at the
face with these different approaches in the next section.
1800
1801
Buccal fat pad
X Bichat
1959
Zygomatic lig- (McGregor’s patch)
M.McGregor
1976
SMAS
V.Mitz
2000
LOT
J.Moss
1995
SOOF
A.Aiache
2002
Prezygomatic space
B.Mendelson
2007
Subcutaneous fat compartments
R. Rohrich
2008
Premasseter space
B. Mendelson
2012
Tear trough lig-
CH.Wong
2013
Premaxillary space
CH.Wong
2012
DLCF
M.Gierloff
2009
Deep chin fat
R.Rohrich
2008
Mandibular septum
jowl fat
E.Reece
2002
Orbicularis retaining lig
AZ.Muzaffar
1945
Buccal space
J.Kostrubala
1912
Modiolus
P.Eisler
1951
Intra-orbital fat pads
S.Castanares
1885
Juxtaoral organ
J.Chievitz
1992
Masseteric lig-
JM.Stuzin
1989
Mandibular lig-
Platysma-cutaneus lig-
DW.Fumas
2008
DMCF
Ristow space
R.Rohrich
1973
Lorés fascia
J.Lore
1909
ROOF (Charpy’s fat pad)
M.Charpy
1900
1910
1920
1930
1940
1950
1960
1970
1980
1990
2000
2010
Figure 3.1  Timeline from 1800 to present, showing the date of the first description of important structures in the human face. DLCF, Deep lateral
cheek fat; DMCF, deep medial cheek fat; LOT, lateral orbital thickening; ROOF, retro-orbicularis oculi fat; SMAS, superficial musculoaponeurotic
system; SOOF, suborbicularis oculi fat. (Reproduced with permission from Cotofana S, Fratila AA, Schenck TL, Redka-Swoboda W, Zilinsky I,
Pavicic T. The anatomy of the aging face: a review. Facial Plast Surg 2016;32(3):253–60.)

3  Addressing Facial Shape and Proportions With Injectable Agents in Youth and Age
17
Regardless of approach, cumulative changes in all struc­
tural tissue layers of the face with time lead to a change
in the morphology of the entire face in terms of its shape,
proportions, and topography. Morphologic changes seen
in women from different decades of life (30s to 60s) are
illustrated in Fig. 3.3. Although these types of figures were
initially used to visualize the differences in the depth of
a tear trough (TT), nasolabial fold (NLF), or marionette
line with advancing age, they can now be appreciated
as evidence that these folds and lines are downstream
markers of a global change rather than isolated entities.
This figure also illustrates how changes in facial topog­
raphy seen with aging sharpen the once smooth transi­
tion between anatomic units, by greatly magnifying light
reflection and/or shadow. This concept is critical to our
understanding, as seemingly subtle changes in light and
shadow over time can have an enormous impact on our
Figure 3.2  Changes commonly seen with aging may also communicate an unintended message of anger, sadness, or fatigue. Removing this negative
message results in a surprisingly different first impression of the same aged face. Photographs courtesy of Rebecca Fitzgerald MD.
Figure 3.3  Individuals from several decades of life arranged in chronological progression are traditionally used to illustrate the deepening of indi­
vidual folds and lines seen with aging. However, these same images also illustrate how all structural tissue layers are affected by aging, leading to
morphological changes seen in the topography, shape, and proportions of the entire face, showing these lines and folds to be downstream markers
of the collapse of the entire 3D structure. (Reproduced with permission from Fitzgerald R, Vleggaar D. Facial volume restoration of the aging face
with poly-L-lactic acid. Dermatol Ther 2011;24:2–27.)
perception of a face in an almost indiscernible way. The
rationale behind restoring 3D contours to the face as it
ages, whether by lifting, tightening, or volume restora­
tion, is easy to appreciate when looking at photographs
illustrating how aging takes us from 3D to 2D, as shown
in the woman in Fig. 3.4 shown at college graduation and
30 years later, both before and after injectable treatment.
The youthful oval face dramatically flattens with age,
and restoration of previous arcs and convexities restore
youthful light and shadow patterns.
Although the sequence of events observed in aging is
somewhat predictable, its pace among individuals is vari­
able and progresses in each person from a unique start­
ing point. Additionally, changes in different tissue layers
within a single individual occur interdependently. The
lack of, or loss, of structural integrity in one area may
worsen the appearance of a neighboring area. Conversely,

18
MASTER TECHNIQUES IN FACIAL REJUVENATION
not—one area seems to blend seamlessly with another,
reflecting light uninterrupted by the shadows seen on
the right. Note that the amount of volume loss with
aging on the initially smaller right side has now resulted
in an outer skin envelope slightly too large for its now
“smaller” face, and contributes to a more pronounced
ptosis and loss of jawline contour on this side earlier than
on the left side (which commonly has more solar elastosis
because its the driver’s side window). Less bony support
and soft tissue leads to a lower brow position, leading
to lid lag laterally and an early hollowing “A-frame”
deformity somewhat camouflaged by a slackened upper
the presence, or restoration, of structural integrity in
one area may improve the appearance of a neighboring
area [7].
We know that almost all faces develop with slight
asymmetry following development of the neural tube
embryologically, and the aforementioned concept can be
readily appreciated when looking at the facial asymmetry
in the woman in Fig. 3.5 who appears more aged on her
right, “sunken,” side compared with her fuller left side.
Note that the less volumized side (right) of her face shows
a clear delineation of her temple, lid, and cheek as sepa­
rate entities, while the more volumized side (left) does
Figure 3.4  The rationale behind restoring three-dimensional contours to the face as it ages, whether by lifting, tightening, or volume restora­
tion, is easy to appreciate when looking at photographs illustrating how aging takes us from three-dimensional to two-dimensional, as seen in
this 51-year-old woman shown at college graduation, and again 30 years later both before and after injectable treatment. Photographs courtesy of
Rebecca Fitzgerald MD.
Figure 3.5  The less volumized side of the face in this patient with mild asymmetry simulates the effects of volume loss in all layers seen with
aging. (Reproduced with permission from Fitzgerald R, Vleggar D. Using Poly-L-lactic acid (PLLA) to mimic volume in multiple tissue layers. J
Drugs Dermatol 2009;8:s5–s14.)

3  Addressing Facial Shape and Proportions With Injectable Agents in Youth and Age
19
lid. A TT and lid-cheek junction are seen only on the
less volumized side. There is also less anterior and lateral
cheek projection, a slightly deeper nasal sulcus, a longer
upper lip, and an increased mental hollowing on the less
volumized side, whereas no such demarcation is visible
on the more volumized side. This combines to make the
perioral proportions in the lower third of her face look
slightly less youthful on the less volumized side. Finally,
the peripheral contours on the less volumized side of
her face are more abrupt than those on the fuller side.
The convexity of the temple and the preauricular volume
on the full side lends an overall oval shape to that side
of her face that is lost due to the atrophy on the right.
Compare this with the ideal proportions of a youthful
face, as shown in Fig. 3.6, depicting a width of five eyes
across in vertical fifths and an equal volume in the upper,
mid, and lower face when measured in horizontal thirds.
Additionally, this schematic depicts the golden phi ratio
of 1:1.6 in the perioral region of the lower third of the
face. Note that the fuller side of the face in Fig. 3.5 is
closer to these ideal proportions, providing a “roadmap”
of where to revolumize the other side.
Over a decade ago, in an effort to visualize the aging
face in linear examples, Lambros used computer anima­
tion to compare current photographs of patients matched
1⁄3
1⁄3
1⁄3
2⁄3
1⁄3
B
1⁄5
1⁄5
1⁄5
1⁄5
1⁄5
A
Figure 3.6  Facial proportions. The vertical proportions are generally broken down into fifths based on the width of an eye (A). The horizontal
facial proportions are divided into thirds as measured from the hairline to the glabella, from the glabella to the subnasale, and from the subnasale
to the menton (B). The lower third can be further broken down to the upper one-third, from the subnasale to the junction of the lips, and the lower
two-thirds, from the junction of the lips to the menton.
for light and position with photographs taken 10 to 50
years previously to gain insight into midfacial aging,
showing that deflation can mimic descent [8]. Recent
work by Lambros and Amos now provides an invaluable
tool to visualize the facial aging process using 3D facial
averaging [9]. They have published animations made
from 3D facial images amassed over the past 10 years,
using a 3D camera system (Vectra; Canfield Scientific,
NJ, USA). These are shown as static images in Fig. 3.7.
The image on the left shows the average of the 3D facial
surfaces of 116 female subjects aged 20 to 30 years, and
the image on the right shows the average of the 3D facial
surfaces of 100 female subjects aged 68 to 91 years. The
static images illustrate the differences seen in the mor­
phology of the younger and older averages well; however,
this image may be viewed in animation online at http://
links.lww.com/PRS/B922. It is interesting to compare the
similarities between the youngest and oldest women in
Fig. 3.3 to the 3D-averaged image of similar age. Look
at the shape of the orbits, the bony support under the
brow and the nose, the flattening of the midface and
lateral cheeks, and the change in proportions in the lower
third of the face. Note how the TT and NLF deepen as
the craniofacial support changes and the cheek flattens.
Look at the eversion versus inversion of the lips. Look at

20
MASTER TECHNIQUES IN FACIAL REJUVENATION
summarized here, paraphrasing the (“can’t be improved
upon”) descriptions published by Glasgold, Glasgold,
and Lam. Compare characteristics of younger and older
faces as you read through these by looking again at the
women pictured in Figs. 3.3, 3.4, and 3.5 and the aver­
ages of the 3D facial surfaces in Fig. 3.7.
Upper Face
In the upper face the young eye appears full, the bony
orbit is not visible, the skin is elastic and thick, and most
of the upper lid is concealed by the full brow, with only
a few millimeters of upper lid show. The youthful upper
lid sulcus lacks a shadow, and the eye has an overall
“almond” configuration, with the lid margin, lid crease,
and eyebrow all parallel. As the upper lid deflates, a fold
of skin develops where there was once fullness, and the
shadow of the upper lid sulcus emerges. With increasing
age, this fold of upper lid skin often droops and may
encroach on the lash line, completely effacing any vis­
ibility of the upper lid (“hooding”). The eyelid skin may
also slip into the lid crease, revealing the upper lid veiled
in youth by the full brow. Often this is initially most pro­
nounced medially, resulting in the so-called “A-frame”
deformity [11]. With aging, shadows also develop in the
temple and upper orbit. A deep shadow of the temple sets
off the lateral orbital rim and zygomatic arch. Filling the
temple and lateral brow will affect the appearance of the
tail of the brow as well as the upper lid. The temple addi­
tionally relates to the entire lateral face contour including
the zygoma, buccal regions, and lateral mandible.
Midface
The manifestations of midfacial aging are largely due
to changes in facial volume that transition the midface
from a youthful convex platform dominated by highlights
to an aged flattened platform segmented by shadows
(concavities) [12]. Younger midfaces have an unbroken
convexity running from the lower eyelid to the NLF,
creating a dominant cheek highlight. Soft tissue covers
the bony skeletal components of the midface, providing
a softer appearance; the inferior orbital rim is masked,
minimizing any delineation between the lower eyelid and
cheek [13]. The zygomatic arch, providing the founda­
tion of lateral cheek volume, is adequately covered by
soft tissue to hide the shadows that delineate its superior
and inferior margins [14]. Advancing age is associated
with a generalized deflation of the midface, particularly
in the upper aspects. The combination of volume loss
and the effect of underlying facial retaining ligaments
contribute to the hallmarks of midface aging. As we will
see in the next section, the most relevant ligaments in
the midface are the orbicularis retaining ligament (ORL),
malar septum (zygomaticocutaneous ligament), and the
McGregor patch (zygomatic ligament) [15]. Volume loss
at the inferior orbital rim creates a concavity and over­
lying shadow, separating the lower eyelid from the cheek.
Volume loss in the anterior cheek converts the youthful
convexity into a concavity with its base tethered by the
malar septum (zygomaticocutaneous ligament). Lateral
cheek volume loss diminishes the dominance of midface
volume and skeletonizes the zygomatic arch, creating a
light and shadow, and how it plays off areas of depression
and prominence (convexities and concavities) in both the
younger and older face. Do not focus on just “lines and
folds,” but consider all the structural changes in the face.
Consider the interdependency between them by treating
the whole face as a 3D interlocking puzzle where losing
or correcting one component may have a negative or
positive impact on another.
FACIAL ANATOMY AND AGING: REGIONAL
THIRDS OF THE FACE
The traditional regional approach to assessing the face is
to consider the upper, middle, and lower thirds (as shown
in Fig. 3.6B). Glasgold, Glasgold, and Lam have greatly
increased our appreciation that a detailed examination
of the shadows and shadow patterns that develop in all
areas of the face with volumetric facial aging will lead to
a better understanding of how to apply volumetric tech­
niques to create a natural-appearing result. Although they
have worked mostly with fat augmentation, the same
concepts apply to filler (although filler may not be a cost-
effective option for those needing a lot of volume) [10].
Although every face is unique, the shadows that develop
as we age are consistent. Not everyone develops every
shadow, but the typical shadows of aging are universal.
Glasgold notes the ease with which an artist can depict
an aging face with a few shadow strokes makes this con­
cept easy to grasp. Studies documenting the consistent
patterns of volume loss in the aging face are reviewed in
the following sections. The skin of the face has consistent
attachment points to the underlying structures through
the facial retaining ligaments, and as the volume of the
face deflates, these attachment points will define most of
the shadows that develop with age [3]. Advancing age
accounts for specific areas of volume loss in all thirds
of the face. These changes in each third of the face are
Figure 3.7  (Left) The average of the facial surfaces of 116 female
subjects aged 20 to 30 years. (Right) The average of the facial surfaces
of 100 female subjects aged 68 to 91 years (average, 76 years). (Repro­
duced with permission from Lambros V, Amos G. Three-dimensional
facial averaging: a tool for understanding facial aging. Plast Reconstruct
Surg 2016;138.6:980e–982e.) This image may be viewed in animation
online at

3  Addressing Facial Shape and Proportions With Injectable Agents in Youth and Age
21
approach to the eyes has been of volume and tissue
removal, typically leaving the eye offset in deep shadows
looking aged and unhealthy. Volume replacement to the
upper eye, particularly the medial orbit A-frame shadow,
is, in the opinion of Glasgold, one of the most effective
uses of volume in the face, as it eliminates these aging
shadows. In the perioral region the natural aging process
invariably creates a ring of shadow around the lips and
mouth, which contribute to an aged appearance. The
effect of creating a frame of light in as many of the small
subunits of the perioral region as possible will enhance
the beauty of the mouth. Conversely, adding volume to
the lips without addressing the surrounding area serves
to deepen the shadows and further disconnect the lip and
mouth from the perioral region, resulting in one of the
odd appearances that patients fear [3]. Many of these
changes have been described earlier on the smaller, more
aged-appearing side of the patient pictured in Fig. 3.5.
FACIAL ANATOMY AND AGING: FUNCTIONAL
AND STRUCTURAL
Despite the recent advances revealing the aging changes
seen in facial soft tissue anatomy, and it’s underlying skel­
etal support, our understanding of this complex process
is still in its infancy. Mendelson and Wong suggest that
in addition to the traditional assessment of facial thirds, a
more global understanding is facilitated by distinguishing
between the different functional regions of the face, as
well as by considering the anatomy in terms of a layered
construct. They consider the face can be divided into
the highly mobile anterior face, which is functionally
adapted for facial expressions and the fixed lateral face,
which overlies masticatory structures [15]. A vertical line
of retaining ligaments separates the anterior and lateral
face (Fig. 3.8). These ligaments are, from above: tempo­
ral, lateral orbital, zygomatic, masseteric, and mandibu­
lar ligaments. The orbicularis retaining ligament is seen
running along the inferior orbital rim, and the zygomati­
cocutaneous ligament along the inferior zygoma. In the
anterior face, the midcheek is split obliquely into two
separate functional parts by the midcheek groove (which
runs along the inferior zygoma correlating to the zygo­
maticocutaneous ligament) related to two cavities: the
periorbital part above and the perioral part below. The
transitions between these areas, while not seen in youth,
become increasingly evident with aging. This is illustrated
in Fig. 3.9, where the ligaments themselves can be seen in
the parotidomasseteric area in an emaciated face in Fig.
3.9A, and the pull on the skin from the various ligaments
can be appreciated in both a thin and a full face in Fig.
3.9B and C. These transitions (or their lack) can also be
appreciated in the faces in Figs. 3.3, 3.4, 3.5, and 3.7.
These authors conceptualize the soft tissues of the
face as arranged concentrically into five basic layers that
are bound together by a system of facial retaining liga­
ments, as first hypothesized by Stuzin et al. [18]. The
layers are pictured in Fig. 3.10 and consist of (1) skin;
(2) subcutaneous fat; (3) the musculoaponeurotic layer;
(4) areolar tissue, including facial retaining ligaments and
harsh submalar shadow [16]. In the midface, augmenta­
tion of the cheek alone will worsen the separation from
the eye, upper lip, buccal area, and temple, often con­
tributing to an unnatural appearance. Addressing the
shadow group of the midface as a whole will allow the
creation of a unified cheek highlight with no separation
between the cheek, the eye, and the upper perioral unit.
Adding volume in the inferior orbital rim will reunify
the lower eyelid and cheek segments. Filling the cheek,
with a focus on the malar septal (zygomaticocutaneous
ligament) depression, will recreate a convex cheek with
a strong highlight. Volume may need to be added to the
lateral cheek when there is deficient lateral projection,
but most important is filling around the zygomatic arch
to restore youthful soft contours. The buccal region tran­
sitions the lateral facial contour of the zygoma into the
lateral mandible [12].
Lower Face
The lower face has two distinct components, the jawline
and the perioral region. The hallmarks of a youthful
lower face include a smooth transition from the cheek
to chin, devoid of shadowing at the labiomandibular
fold. The jawline is well defined by a curvilinear shadow
coursing from the mandibular angle to the anterior chin;
on oblique view the shadow framing the jawline has
a “hockey stick” shape. This youthful jawline shape is
dependent on an adequate bony foundation providing
sufficient volume at the prejowl sulcus and angle of man­
dible. In the perioral area the labiomental hollow creates
an upside down U-shaped shadow that separates the
lower lip from the chin and the labiomental fold creates
a distinct shadow that typifies the frown. The prejowl
sulcus appears as volume loss progresses at the inferior
portion of the mandible, anterior to the jowl, and cor­
responds to the attachment of the mandibular ligament
causing a shadow in front of the jowl. The typical jowl
can be thought of as a highlight that exists between the
shadows of the prejowl sulcus and (if present) shadowing
of the lateral mandible. Congenital lower face volume
deficiencies are most common in the chin and mandibular
angle. Deficiencies in the anterior chin and prejowl sulcus
create a relative middle jawline dominance, which mani­
fests in an appearance of early jowl formation. These
patients tend to present at an earlier age for lower face
rejuvenation as even early volume changes more easily
highlight their skeletal deficiencies [17].
Finally, Glasgold et al. have introduced an additional
regional concept they term the “three dominant frames in
the face” [10]. The first is the global facial frame, which
extends along the jawline to offset the face from the neck
and then flows up the lateral contour of the face from the
angle of the mandible along the contour of the buccal,
zygomatic, and temple line. The global facial frame
strongly affects our perception of a face on many levels:
aging, gender, and attractiveness. A sharp, uninterrupted
shadow separating the face from the neck is desirable. A
soft inverted egg-shaped lateral contour suggests youth­
ful femininity, while a more angular/rectangular line is
more masculine. The other two frames highlight the eyes
and the mouth. As noted earlier, the traditional surgical

22
MASTER TECHNIQUES IN FACIAL REJUVENATION
A
B
C
Figure 3.9  A vertical line of retaining ligaments separates the anterior and lateral face. The transitions between these areas, while not seen in
youth, become increasingly evident with aging as illustrated in the following examples. The ligaments themselves can be seen in the parotidomas­
seteric area in an emaciated face in (A), and the pull on the skin from the various ligaments can be appreciated in both a thin and a full face in (B
and C). Photographs courtesy of Rebecca Fitzgerald MD.
facial spaces; and (5) periosteum and deep fascia [19]. As
noted earlier, to secure the superficial fascia (defined as
the composite flap of layers 1–3) to the facial skeleton,
a system of retaining ligaments binds the skeleton to the
dermis, and the components of this system pass through
all layers, as illustrated in Fig. 3.11. Like a tree, these
ligaments start as a thicker trunk, and subsequently fan
out in a series of thinner branches as they insert into the
subcutaneous fat and the dermis. At different levels of
dissection, the ligament system is given different names,
such as the retinacula cutis in the subcutaneous layer
and ligaments under the superficial musculoaponeurotic
system (SMAS) level, as seen in Fig. 3.12. The density
of these branches determine the difficulty encountered
when dissecting the tissue and accounts for the fact that
it is easier to dissect in the deep subcutaneous layer than
the dermis. The nerves and vessels are always located
in close proximity to the retaining ligaments, as these
vital structures are protected by traveling through other
layers in concert with these structures. The retinacula
cutis fibers are not uniform across the face, but vary
in orientation and density according to the anatomy of
the underlying deeper structures. As will be apparent
when the anatomy of the underlying layer 4 is described,
at the location of the retaining ligaments, the vertically
orientated retinacula cutis fibers are the most dense and
are the most effective in supporting the overlying soft
tissues, and in so doing, form the anatomic boundaries
that compartmentalize the subcutaneous fat [15]. Addi­
tionally, Mendelson and Wong’s extensive work support
that a large part of the sub-SMAS layer 4 consists of
soft tissue “spaces” that have defined boundaries that
are strategically reinforced by retaining ligaments. As
the roof of each space is the least supported part, it is
more prone to developing laxity with aging, compared
with the ligament-reinforced boundaries. This differential
laxity accounts for much of the characteristic changes
that occur with aging of the face.
Figure 3.8  Regions of the face. The mobile anterior face is function­
ally adapted for facial expressions and is separated from the relatively
fixed lateral face (shaded), which overlies masticatory structures. A
vertical line of retaining ligaments (red) separates the anterior and
lateral face. These ligaments are, from above: temporal, lateral orbital,
zygomatic, masseteric, and mandibular ligaments. In the anterior face,
the midcheek is split obliquely into two separate functional parts by
the midcheek groove (dotted line) related to two cavities: the periorbital
part above (blue) and the perioral part below (yellow). (Reproduced
with permission from Mendelson B, Wong C. Anatomy of the aging
face. Section I, Chap 6. Aesthetic Surgery of the Face. Elsevier; 2013.)

3  Addressing Facial Shape and Proportions With Injectable Agents in Youth and Age
23
Each of the aforementioned layers will be discussed
in more detail (with an emphasis on fat and bone as it
relates to injectable treatments) in the sections here.
PREPROCEDURAL ASSESSMENT
As all structural tissues play a role in the aging face,
restoring youthful characteristics (or establishing them
where they are congenitally absent) starts from the skel­
etal framework and builds progressively to the canvas of
the face. Therefore, current literature pertaining to the
morphological changes of the facial skeletal framework,
retaining ligaments, facial muscles, fat compartments,
and skin envelope will be presented in the next section.
All contribute to facial aging in variable degrees, some
of it primary, some secondary, and what is known about
which is which, as well as the relative contributions of
1. Skin
2. Subcutaneous
3. Musculoaponeurotic
4. Retaining ligaments
and space
5. Periosteum
and deep fascia
1
2
3
4
5
1
2
3
4
5
Figure 3.10  The face is constructed of five basic layers. This five-
layered construct is most evident in the scalp but exists in the rest of
the face, with significant modification and compaction for functional
adaptation. Layer 4 is the most significantly modified layer, with alter­
nating facial soft tissue spaces and retaining ligaments. Facial nerve
branches also transition from deep to superficial in association with the
retaining ligaments through layer 4. (Adapted from Mendelson B, Wong
C. Anatomy of the aging face. Section I, Chap 6. Aesthetic Surgery of
the Face. Elsevier; 2013.)
Figure 3.11  To secure the superficial fascia to the facial skeleton, a
system of retaining ligaments binds the dermis to the skeleton, and
the components of this system pass through all layers. There are three
morphological forms of retaining ligaments of the face. SMAS, Super­
ficial musculoaponeurotic system. (Reproduce with permission from
Mendelson B, Wong C. Anatomy of the aging face. Section I, Chap 6.
Aesthetic Surgery of the Face. Elsevier; 2013.)
Dermis
Retinacula
cutis
SMAS
Retaining
ligament
Periosteum
Bone
Figure 3.12  The retaining ligaments of the face can be likened to a
tree. The ligaments attach the soft tissues to the facial skeleton or deep
muscle fascia, passing through all five layers of the soft tissues. It fans
out in a series of branches and inserts into the dermis. At different levels
of dissection, it is given different names, such as the retinacula cutis in
the subcutaneous layer and ligaments in the sub-SMAS level. SMAS,
Superficial musculoaponeurotic system. (Adapted from Mendelson B,
Wong C. Anatomy of the aging face. Section I, Chap 6. Aesthetic
Surgery of the Face. Elsevier; 2013.)

24
MASTER TECHNIQUES IN FACIAL REJUVENATION
another. Figuring out what you want to treat is a process
of observation and palpation/provocation that allows us
to determine the nature and extent of the structural tissue
changes affecting the face in front of us at that particular
point in time, as well as how those structural changes
have affected the shape, proportions, topography, and
frames of the entire face. It is, of course, more of a “read”
than a “recipe,” as there is no one algorithm that fits
all faces. It is useful to think of what is deviating that
face from the ideal proportions shown in Fig. 3.6, which
shows an ovalized “upside down egg” shape, an anterior
convexity, an oval frame, youthful proportions of “five
eyes across” and three relatively equal thirds of the face.
What you choose to address depends on the extent of the
changes seen in each structural layer or region, and the
parity of these changes between layers or regions. Try to
figure out “which tissue is the biggest issue” or, if region­
ally, “one of these things is not like the other.” If there is
just a little change in all layers, almost any interventional
approach will work. If there is regional disparity, try to
blend them all back to a more similar place. The most
common disparities are creating young lips or cheeks that
“stick out” rather than blend in to an otherwise aging
face, or placing too much filler too high under the eyes,
which looks odd.
Figs. 3.13 and 3.14 may help clarify this approach.
The faces pictured in Fig. 3.13 all have a clear-cut “one
tissue issue” (see figure legend), while the face in Fig. 3.14
has a discrepancy in the size of her upper, mid and lower
face. The lack of volume in the lower two-thirds of her
face make her forehead seem too large in the before
picture, while it looks quite normal following treatment
of the cheeks and chin in the after photo.
This kind of optical illusion is not uncommon in the
face. It is termed a “perspective illusion” and is illustrated
well in the classic three cars example seen in Fig. 3.15. If
there is a lot of loss of integrity in multiple layers, then
multiple interventions and a great deal of product may
be needed to obtain optimal results, as seen in Fig. 3.16.
It is interesting to note on the cropped close-up view of
this face shown in Fig. 3.17 how treatment of the areas
of skeletal remodeling and fat loss in this patient affected
the overall shape, topography, and proportions of this
face towards the ideal proportions pictured in Fig. 3.6.
Recognize that a patient’s final outcome, and the
amount of product and work it will take to get there,
is a reflection of the quality of tissues with which they
start. Wasted faces (associated with HIV or endurance
exercise) are harder to fill, and it is harder to sustain
the fill. Older faces with advanced craniofacial remodel­
ing, fat loss, and very poor skin quality can be treated
successfully; however, fillers of any kind may not be the
most cost-effective choice in a patient who would best
benefit from fat augmentation and a face lift. Discussing
this and setting realistic expectations before treatment
will decrease frustration for both the patient and the
practitioner. Conversely, fuller and younger faces “bring
in their own volume” and are therefore easily reshaped
with a conservative amount of filler of any kind. This is,
of course, an issue of patient selection and not product
selection. For these reasons, for the novice, I strongly
each, is in a constant state of evolution and refinement.
Even with those limitations in mind, with careful evalua­
tion some specific age-related changes or congenital defi­
ciencies can now be addressed in a site-specific manner
to achieve natural-looking results.
This section on assessment will discuss the importance
of patient selection and introduce an approach to evalu­
ating the face. As noted by Pessa, although anatomy is
remarkably consistent between individuals, the variable
sizes and shapes of the different structures in each individ­
ual gives everyone their own unique appearance and has
tremendous influence on the variations in the onset and
outcome of aging seen in different individuals [20]. This
is made more complex by the recognition that although
the sequence of events as we age is somewhat predictable,
its pace is variable between individuals and even between
tissue layers in one individual. Subsequently, there is no
one algorithm to address facial aging. As mentioned
earlier four characteristics emerge as the most significant
determinants of attractiveness: prototypicality (average­
ness), sexual dimorphism, symmetry, and youthfulness
[6]. Averageness requires harmony of all regions of the
face. Sexual dimorphism requires recognition of gender
differences. A detailed discussion of gender differences is
out of the scope of this chapter, but a few well-accepted
norms are worth mentioning here. Males often have a
stronger forehead and straighter brow, a cheek apex that
is lower and more medial, and a stronger chin and jawline
than females. Conversely, female faces have a higher,
more lateral cheek apex and a more tapered lower face
than males. Obviously, you do not want to feminize a
male face with high lateral cheekbones, or fail to treat a
masculinizing masseter hypertrophy in a female. Regard­
ing symmetry, after the neural tube develops early in
our embryologic development, the two sides of the body
develop like siblings, not twins, and the vast majority of
us have a shorter fuller side and a thinner longer side. The
discrepancy between these sides becomes more apparent
with aging. The contribution of symmetry to beauty is
often maligned by showing a photograph of a face next
to photographs made using the two right and two left
sides of that face, often showing a bizarre looking thin
face and fat face. However, this results from comparing
the two sides of an asymmetric face. If the original face
photographed is truly symmetric, then all three photo­
graphs would be identical. It is interesting to note that
the fuller shorter side is usually the more attractive side
in youth, and the younger appearing side with age. Look
back at Fig. 3.5. In my experience, augmenting volume
around the temple, brow, orbit, and zygomatic arch just
enough to restore more symmetrical light reflection from
both sides can make a surprising difference in our percep­
tion of that face.
In relatively young faces with early aging changes
(including the face pictured in Fig. 3.5), addressing a
TT, NLF, or marionette line as an isolated entity will
often yield good results. However, as these folds represent
downstream markers of global changes, in those individ­
uals with congenital deficiencies, and those further along
in the aging process, this approach may yield suboptimal
results by taking one area of the face out of harmony with

3  Addressing Facial Shape and Proportions With Injectable Agents in Youth and Age
25
with any procedure, the patient must demonstrate suf­
ficient “psychosocial maturity” to weather any potential
complications. The patient should be educated and a
true informed consent obtained. Manage expectations.
Anxious, demanding, or unhappy patients are poor can­
didates. Although there are no absolute contraindica­
tions, patients with active autoimmune disease, poor
dental hygiene, or a history of previous permanent filler
(especially if done outside the USA) may be at increased
risk for complications.
CURRENT CONCEPTS IN THE ANATOMY OF AGING
Skin: Layer 1
Skin appearance (including elasticity, the absence of
wrinkles, a smooth texture, and clarity and evenness of
color) is a primary indicator of age. The epidermis is a
cell-rich layer composed mainly of differentiating keratin­
ocytes and a smaller number of pigment-producing mela­
nocytes and antigen-presenting Langerhans cells. The
dermis comprises predominantly the extracellular matrix
secreted by fibroblasts. Type I collagen is the most abun­
dant protein. Other collagen types (III, V, VII), elastin,
proteoglycans, and fibronectins are present in smaller
quantities. A rich vascular plexus is an important compo­
nent of the dermis and it provides support and nutrients
to the epidermis. The thickness of the dermis relates to
its function and tends to be inversely proportionate to
its mobility. The dermis is thinnest in the eyelids and
thickest over the forehead and the nasal tip. The thinner
the dermis, the more susceptible it is to qualitative dete­
rioration aging changes [15]. The vast majority of skin
aging is photoaging from exposure to ultraviolet (UV)
light [21]. The shorter UVB rays cause a pathognomonic
lesion (thymine dimers) in the epidermal keratinocytes,
which may lead to the development of skin cancers. The
longer UVA ray exposure causes oxidative damage in the
dermis, leading to the elaboration of collagenase (matrix
metalloproteinases [MMPs]), which fragments existing
A
B
C
Figure 3.13  Individual variations in the onset and outcome of aging are commonplace. While many of us age with relative parity in all structural
tissue layers, some individuals are a mostly “one tissue issue.” (A) Shows a young man with good bone structure and good skin, but extreme loss
of fat. (B) Shows a young woman with good skin and soft tissue volume, but a congenital lack of craniofacial support. (C) Shows an elderly woman
who has good bone structure and ample soft tissue, but very elastotic skin. Photographs courtesy of Rebecca Fitzgerald MD.
Figure 3.14  Although on first glance you notice this young woman’s
large forehead, it seems proportional after augmenting the suboptimal
cheekbone and chin in the lower two-thirds of the face. Photographs
courtesy of Rebecca Fitzgerald MD.
recommend starting with younger patients with mild-to-
moderate volume changes.
Finally, as with any procedure, there is no guaran­
tee of a specific or perfect result, and serious complica­
tions such as delayed nodules, ischemia and necrosis, or
even blindness, although extremely rare, can occur. As

26
MASTER TECHNIQUES IN FACIAL REJUVENATION
Figure 3.16  Older female with a “multiple tissue issue,” that is, relative parity of loss of integrity in multiple tissue structural layers is seen here
before and after nonsurgical panfacial treatment. Older faces with advanced craniofacial remodeling, fat loss, and very poor skin quality can be
treated successfully; however, fillers of any kind may not be the most cost-effective choice in a cosmetic patient who would best benefit from fat aug­
mentation and a face lift. (Reproduced with permission from Jones DH. Injectable Fillers: Principles and Practice. Wiley-Blackwell, London 2010.)
Figure 3.15  Optical illusions are defined as something that deceives the eye by appearing to be other than it is. A change in perspective, such as
that seen in the classic 3 parked cars example pictured above, can make an object appear smaller or larger than it actually is. This type of illusion
may be seen in the face.

3  Addressing Facial Shape and Proportions With Injectable Agents in Youth and Age
27
[25] and speculation on whether the collagen-stimulating
fillers or stem cells from fat augmentation may play a
similar role, leading to the skin improvement commonly
seen after these procedures.
Be aware that it is very difficult to fill an elastotic
outer skin envelope with volume augmentation of any
kind, and these patients will require surgical intervention
to both lift and fill. On the other hand, if the under­
lying craniofacial support and fat volume is good, and
the skin still has a fair amount of collagen, any procedure
that can effectively tighten skin will make an enormous
difference, as seen in the patient in Fig. 3.19 who under­
went a nonfractionated CO2 laser resurfacing procedure
as monotherapy.
Fat: Layer 2
The recent description of the superficial and deep fat
compartments of the face by Rohrich and Pessa (utiliz­
ing dye sequestration in cadaveric dissections) [26] and
radiological confirmation by Gierloff et al. (utilizing radi­
opaque dye and computed tomography [CT]) [27,28] has
provoked great interest in both the role that these com­
partments play in the layered and spatial relationships
existing in the face, as well as to what role this might
contribute to the theory of facial deflation with aging.
It should be noted that the theory of facial deflation is
not universally accepted. It has been observed that inver­
sion photographs of aging patients (either in a supine
or Trendelenburg position) demonstrate an appearance
consistent with that of photographs taken approximately
10 to 15 years prior [29]. These authors feel that aging
must, therefore, be partially gravitational: much of the
volume in the face must be retained and not lost, because
volumes drift back into position when the supine position
is assumed.
The 3D technique employed by Gierloff et al. [27,28]
allowed these compartments to be simultaneously
collagen [22]. Research now reveals that collagen deficit
in both photoaged and chronologically aged human skin
derives primarily from altered mechanical properties of
the fragmented collagenous extracellular matrix of the
dermis rather than from time and/or UV irradiation-
derived genetic damage to fibroblasts [23].
Intact type I collagen fibrils in the dermis provide
mechanical stability and attachment sites for fibroblasts,
which is critical for normal, balanced production of
collagen and collagen-degrading enzymes. Without this
attachment the fibroblasts collapse, and collapsed fibro­
blasts exacerbate the situation by producing more MMPs,
advancing the aging process into a self-perpetuating, del­
eterious cycle. This phenomenon is well illustrated in Fig.
3.18, showing both sun-protected and sun-exposed skin in
an elderly female. Sunscreen, antioxidants, and retinoids
help mitigate collagen loss [24]. Microneedling, peels,
and various energy devices work by inducing new col­
lagen formation. There is some evidence that hyaluronic
acid fillers may provide a “stretch effect” on fibroblasts
Figure 3.17  Note on this cropped close-up view how treatment of the areas of skeletal remodeling and fat loss in this patient affected the overall
shape, topography, and proportions of this face toward the ideal proportions pictured in Fig. 3.6. Photographs courtesy of Rebecca Fitzgerald MD.
Figure 3.18  The vast majority of skin aging is photoaging from expo­
sure to ultraviolet light, which is well illustrated in the photograph
above showing both sun-protected and sun-exposed skin in an elderly
female. Photographs courtesy of Rebecca Fitzgerald MD.

28
MASTER TECHNIQUES IN FACIAL REJUVENATION
Superior orbital fat
Sub-orbicularis oculi fat
Lateral part
Medial part
Deep medial cheek fat
Lateral part
Ristow’s space
Medial part
Inferior orbital fat
Lateral orbital fat
Medial orbital fat
Middle cheek fat
Nasolabial fat
Lateral
temporal-cheek fat
Figure 3.20  Schematic of the superficial and deep fat compartments.
The superficial layer is composed of the nasolabial, the medial cheek,
the middle cheek, and the lateral temporal cheek compartments, as well
as the three orbital compartments. The deep layer is composed of the
suborbicularis oculi fat (medial and lateral parts) and the deep medial
cheek fat (medial and lateral parts). A deep compartment termed Ris­
tow’s space is located posterior to the most medial aspect of the deep
medial cheek fat and lateral to the pyriform aperature.
identified and measured, as well as viewed from several
angles. This allowed the investigators to further define the
deep subcutaneous fat of the midcheek into a medial and
lateral compartment, as well as define the isolated buccal
extension of the buccal fat pad. This finding—the discrete
nature of buccal fat lobes—is of tremendous importance
clinically to avoid a potential complication of augmenta­
tion of deep medial cheek fat (DMCF). Although injec­
tion of filler into the central lobe of buccal fat specifically
augments that region alone, inadvertent injection of filler
into the inferior lobe of buccal fat may lead to the cre­
ation of a more prominent jowl, and should therefore
be avoided.
Schematics of the superficial and deep fat compart­
ments of the midface (adapted from this first radiologic
study) are shown in Fig. 3.20.
Gierloff et al. additionally concluded from their study
(albeit with a small sample size) that aging leads to an
inferior migration of the midfacial fat compartments and
an inferior volume shift within the compartments [27].
They also noted that a deflation of the compartmental­
ized buccal extension of the buccal fat aggravates the
inferior migration of the fat compartments superior to
it—the medial cheek fat, middle cheek fat, and subor­
bicularis oculi fat (SOOF).
Clinical observation suggests that these compartments
may age variably, both between individuals and between
compartments in one individual. The reasons behind this
are not yet understood and it is thought that many factors
may play a role here, including vascular patterns or endo­
crine functions of fat. Recall that certain disease states
(such as diabetes, human immunodeficiency virus, and
progeria) have a pathognomonic distribution of fat. An
example of two patients aging with changes in different
fat compartments is illustrated in Fig. 3.21. The first is of
a patient with congenital lipoatrophy, who despite a lack
of superficial fat, has retained a good deal of her deep
fat (in the pattern illustrated in the previous schematic)
and therefore has good anterior projection of her midface
A
B
Figure 3.19  Older woman with minimal aging changes noted in her craniofacial skeletal support or soft tissue volume, shown (A) before and
(B) after a nonfractionated CO2 laser skin-tightening procedure. (Reproduced with permission from Obagi S. Specific techniques for fat transfer.
Clin Facial Plastic Surg 2008;16(4):401–7.)

3  Addressing Facial Shape and Proportions With Injectable Agents in Youth and Age
29
with no NLF or TT, despite an otherwise hollow and
skeletonized appearance. This can be treated using the
superficial fat compartments as a guide to placement. In
the next example, we see an endurance exercise patient
who does not have the skeletonized appearance the pre­
vious patient has in her temples and lateral cheek, but
instead has lost a good deal of deep midfacial fat, leading
to a lack of anterior projection in the midface, with a
visible TT and NLF. Her TT is not really the problem—
the problem is that it has been revealed because she no
longer has midfacial projection. This can be resolved with
the use of filler in the area of the deep midfacial compart­
ments. Likewise, the NLF is a secondary phenomenon
that will soften as the midfacial fat is filled.
Rohrich and colleagues have defined many superficial
and deep fat compartments of the face and described and
demonstrated their clinical importance [30–35]. They
observed that superficial adipose tissue is compartmental­
ized by vascularized membranes arising from superficial
fascia, but deep fat is compartmentalized by nonvascular­
ized fascial boundaries that most likely represent fusion
zones of various fascias.
The superficial compartments of the midface are
shown in the cadaveric dissection with dye sequestration
from the original study in Fig. 3.22. The preauricular
compartments are shown in the schematic superimposed
on a cadaveric specimen in Fig. 3.23. These superficial
fat compartments offer a roadmap for achieving spe­
cific results using site-specific techniques. This is illus­
trated with a few clinical examples accompanying a
A
B
Figure 3.21  Clinical correlation of superficial and deep midfacial
facial fat compartments. In the face pictured in (A), deep midfacial fat
is visible clinically. There is no visible undereye hollowing or nasolabial
fold, and there is a convex contour to her midface. However, due to a
congenital lipodystrophy, there is a striking lack of superficial fat. This is
most obvious in her lateral temporal cheek compartment and her upper
periorbital area; however, on closer observation the lack of superficial
fat in her midface is causing a good deal of shadowing in her lower
lateral cheeks. Compare this face with ample deep midfacial fat, and an
extreme lack of superficial fat to the face (B). This endurance exercise
patient has a normal amount of superficial fat, without shadowing in
her temples and lateral cheeks, but appears to have lost a good deal of
fat in her deep midfacial compartments, leading to a lack of midfacial
projection and a very visible lid-cheek junction. Photographs courtesy
of Rebecca Fitzgerald MD.
ORL
ORL
SCS
SOOF
ZM
Nasalabial
Medial cheek
Middle cheek
Temporal & lateral cheek
A
B
C
D
Figure 3.22  Superficial fat compartments. Rohrich and Pessa have performed multiple cadaver studies supporting the concept that subcutaneous
fat is compartmentalized, specifically by fascial extensions that travel from superficial fascia to dermis. These fascial extensions form a framework
that provides a “retaining system” for the human face. Implicit in this concept is the suggestion that the face ages three dimensionally, with sepa­
rate compartments changing relative to one another by both position and volume. (A) The nasolabial fat compartment is the most medial of the
major cheek compartments. Blue dye has stained this region. The ORL is the superior boundary (black arrow). Additional black arrows point
to the SOOF and the ZM muscle. (B) The medial cheek fat compartment lies adjacent to the nasolabial fat. The superior boundary is again the
ORL. The red area designates a zone of fixation where this fat compartment intersects with the inferior orbital fat compartment. (C) The middle
cheek fat compartment is found anterior and superficial to the parotid gland. This compartment is lateral to the medial fat compartment, medial
to the lateral temporal cheek fat, and inferior to the SCS. The red arrow designates a zone of fixation between adjacent compartments. The lateral
temporal cheek compartment is the most lateral compartment of cheek fat and connects the temporal fat to the cervical subcutaneous fat (D). The
STS and ITS represent the superior boundaries, and it has an identifiable septal barrier medially called the LCS. ITS, Inferior temporal septa; LCS,
lateral cheek septum; ORL, orbicularis retaining ligament; SCS, superior cheek septum; SOOF, suborbicularis oculi fat; STS, superior temporal
septa; ZM, zygomaticus major (Reproduced with permission from Rohrich RJ, Pessa JE. The fat compartments of the face: anatomy and clinical
implications for cosmetic surgery. Plast Reconstr Surg 2007;119:2219–27 [discussion: 2228–31].)

30
MASTER TECHNIQUES IN FACIAL REJUVENATION
A
B
C
D
E
Figure 3.23  The periauricular fat compartments abut one another
and form an interlocking group of adipose regions, as pictured previ­
ously. The superior auricular compartment is the largest adipose region,
spanning the region above the auricularis muscle and the superficial
temporal fascia. (Reproduced with permission from Rohrich RJ, Taylor
NS, Ahmad J, Lu A, Pessa JE. Great auricular nerve injury, the “sub­
auricular band” phenomenon, and the periauricular adipose compart­
ments. Plast Reconstr Surg 2011;127.2:835–43.)
dissection or CT showing the boundaries of the specific
compartment(s) to be filled, and can be seen in Figs. 3.22
through 3.30. Product used as well as choice of a cannula
or needle is included in the figure legends. Note that the
patients pictured in Fig. 3.24 have varying degrees of loss
in the temporal fat as well as the preauricular fat, which
has a pronounced effect on their facial shape, remedied
by specific focal treatment in these areas (see figure legend
for details). Although the patient in Fig. 3.25 has lost
some temporal fat, it is the loss of her superficial lateral
fat that is most affecting her facial shape. Without a
strong jawline, patients with loss in this area assume a
“horse-like” facial shape—something seen not uncom­
monly in thin faces after face lifting. Here, because of her
strong lower face, her facial shape is more like a figure
8. Note that without this lateral fat, the tragus can be
seen in anterior view, and disappears after treatment in
this area. The prominent brow ridge seen in Fig. 3.26, is
actually made visible by the shadow created by loss of
central forehead fat in this male patient, which resolves
with replacement of the volume in this area. The woman
pictured in Fig. 3.27 has a short flat forehead which can
be lengthened and rounded by replacement of fat in the
middle forehead compartments. Jowl fat is pictured in
Fig. 3.28, and clinical correction in that area is seen in
Fig. 3.29. Fig. 3.30 shows several views of the 50-year-old
female with good craniofacial support, good skin tone,
and global severe lipoatrophy shown in Fig. 3.21. On
close observation she is missing superficial fat in all areas
pictured in Fig. 3.22, which has been replaced with filler.
Again note that the absence of lateral cheek fat leaves the
tragus visible in anterior view and has a great effect on
the facial shape. The facial frame is optimized, and the
tragus is no longer visible in anterior view, with treatment
of this area. Also note the position of the deep midfacial
fat seen in this patient as we review the next several slides.
As noted earlier, the deep fat of the midface exists in
four compartments. Inflation of the DMCF with saline in
cadavers has been shown to eliminate the V deformity,
reduce the size of the NLF, and diminish the appearance
of the TT, as seen in Fig. 3.31. (Note in this cadaver that
the emptiness of the lateral SOOF becomes obvious only
after the DMCF has been filled.) Look at the shape. It
is a natural-appearing, nicely shaped cheek. Note that
this cheek looks good because it is taking the shape of
the compartment into which it was placed (here likely
placed in both the medial and lateral deep cheek fat).
Now look at the patient in the lower half of the figure.
Again, a natural-appearing attractive cheek can be seen
because it is the shape of the cheek compartment into
which the filler was placed. This patient was treated in
all four deep midfacial fat pads—the medial and lateral
SOOF, as well as the DMCF and the deep lateral cheek fat
(DLCF). Fig. 3.32 shows a younger patient with earlier
volume loss, again in the area of deep midfacial fat shown
in the CT image. In the CT scan, note the triangular
shape of the DMCF, which extends down around the
nasal ala and lip cheek area, and extends all the way up
to the orbital rim. The DLCF is not pictured here, but
would lie just lateral to the DMCF. The medial and lateral
SOOF are also pictured here. Interestingly, this particular
CT image is likely of an older patient, as you can see
an inferior shift of the compartments from the orbital
rim, as well as an inferior shift of the compartment con­
tents. The young woman in the figure was treated in
all four deep midfacial compartments. The result under
her eyes can be better appreciated on her right in this
three-quarter view.
Rohrich and Pessa, proposed that volume loss in the
deep midfacial fat compartments may be one of the
primary determinants of the morphologic appearance of
the aging midface—specifically that volume loss in this
deep compartment can lead to the loss of midfacial pro­
jection, which worsens the NLF and under-eye bag. They
proposed the name “pseudoptosis” for this concept.
Some authors suggest that selective atrophy of deep
fat compartments and relative hypertrophy of superficial
fat compartments occurs in the aging face. Recent work
suggests that this may correspond to a larger adipocyte
size in superficial fat compared with deep fat [36–38].
This concept of pseudoptosis has led a group of authors
to investigate the 3D relationships of these compart­
ments to their neighboring areas, as well as to advocate
for deep volumization techniques in the midcheek area
[39,40].
It has also provided the impetus for a recent study
using advances in 3D photography and computer analysis
to highlight the topographical changes that occur with
volumetric changes in the DMCF compartment [41]. This
study represents a concept the authors have named the
“augmentation zone,” showing how volume augmenta­
tion of a specific compartment alters the topography of
the overlying soft tissue in the targeted region. Fig. 3.33
illustrates how this method allows the investigators to see
how much volume it takes to fill the diameter and perim­
eter of a compartment, as well as how much it needs
for anterior projection. Although this project focused on

3  Addressing Facial Shape and Proportions With Injectable Agents in Youth and Age
31
Fig. 3.36 shows more views of the patient seen in Figure
3.21, the 38-year-old female endurance exercise patient
who has lost a good deal of deep midfacial fat. This
patient has good craniofacial support (although zygo­
matic prominence is a little flattened), and very good skin
elasticity. Treatment in the four deep fat compartments
of her midface resulted in a very natural result, camou­
flaging her undereye hollows and providing a slight lift
to her oral commissures. Glabellar neuromodulator was
also done, as well as a small amount of volume under the
mentalis muscle, as will be discussed later in this section.
In both of these cases, replacement of volume in the deep
midface compartments provided some anterior projection
of the midface.
This anterior projection from replenishing deep fat
can be seen in other areas, as illustrated by this patient
the deep medial cheek, ongoing work will help to eluci­
date how other fat compartments behave in response to
volumization.
Fig. 3.34 shows a dissection outlining the borders of
the deep lateral fat compartment. The medial border is
the DMCF, and the lateral border is the zygomaticus
major muscle [42].
Fig. 3.35 shows an older woman with loss of some
midfacial bone and fat, but still with good skin elastic­
ity that was filled in the midface deep fat compartments
(DMCF, DLCF, medial and lateral SOOF) to blend in and
camouflage her mildly herniated orbital fat. Whether or
not a treatment like this will work is contingent upon
how much orbital fat needs to be camouflaged and how
well the patient’s skin can hold the fill. This patient could
have used additional treatment in the lateral SOOF area.
A
B
C
Figure 3.24  (A) The patient pictured here has lost temporal fat as well as superior preauricular fat area posterior to her hairline. Note that this
affects the shape of her face, changing it to a sort of “peanut” shape, which is restored to an oval with volume augmentation in this area. Poly-l-
lactic was used with a 25 gauge needle. (B) The patient here has lost temporal fat at the superior temporal septum, resulting in a somewhat harsh,
skeletonized appearance, which softens with volume augmentation in that area. (C) This patient has lost volume in all of the above mentioned
areas. Hyaluronic acid was used with a 26 gauge needle in B and C. Photographs courtesy of Rebecca Fitzgerald MD.

32
MASTER TECHNIQUES IN FACIAL REJUVENATION
Figure 3.25  This patient has some shadowing in her temples; however, the striking loss of lateral cheek fat is what gives the lateral area of her
midface a concave appearance. Treatment in this area restores an oval facial frame. Note that the tragus is visible in an anterior view in a patient
without lateral cheek fat and is less visible when this area is full. This is not uncommonly seen in thin patients after face lifting, and often gives
the face an almost “horse-like” appearance (not seen in this patient due to her strong mandible, looking instead like a figure 8). Hyaluronic acid
was used with a 25 gauge cannula. Photographs courtesy of Rebecca Fitzgerald MD.
Figure 3.26  Computed tomography image of the subcutaneous central forehead compartment. The yellow line indicates the position of the gla­
bellar fold that is located superficially to the inferior portion of the compartment. Note that site-specific augmentation of this particular fat pad
reduces the perceived look of anger in this patient. (Reproduced with permission from Gierloff M, Stohring C, Buder T, et al. The subcutaneous
fat compartments in relation to aesthetically important facial folds and rhytides. J Plast Reconstr Aesthet Surg 2012;65(10):1292–7.) Hyaluronic
acid was used with a 27 gauge cannula. Reproduced with permission from Fitzgerald R, Rubin A. Filler Placement and the Fat Compartments
Dermatol Clin 32 (2014) 37–50.
in her 40s in Fig. 3.37, who was treated along her upper
lid and brow, as well as her temples. The after picture
shows an anterior projection of the brows and lid after
placement of product in the retro-orbicularis oculi fat,
giving her eye the youthful feature of a parallel brow,
lid sulcus, lid, and lash line. The photograph of the
patient frowning is included here to demonstrate that this
effect is not from the use of a neuromodulater. A more
detailed description is available in the reference provided
here [43].
Finally, we focus on the fat compartments of the peri­
oral region. Deep to the orbicularis oris muscle, may
the fat serve to evert the lips, as shown in Fig. 3.38.
The superficial labiomandibular fat compartments of the
chin are pictured in a CT image in Fig. 3.39. This par­
ticular study imaged and quantified this fat compartment
and (although limited by a small sample) found that
those cadavers with more labiomandibular fat pushing
up against the posterior border of the compartment clini­
cally showed less of a marionette fold [28].

3  Addressing Facial Shape and Proportions With Injectable Agents in Youth and Age
33
STS
Figure 3.27  The middle forehead fat compartments are situated on either side of the central fat and are located medially to the STS. The inferior
border is the orbicularis retaining ligament of the superior orbit. The lateral temporal cheek fat has already been described and is the third of the
forehead fat compartments. STS, Superior temporal septum. Volume replacement in this middle forehead fat compartment recontours the convexity
of the forehead as illustrated in the before and after photograph above. Hyaluronic acid was used with a 25 gauge cannula. Photographs courtesy
of Rebecca Fitzgerald MD.
ZM
Buccal
fat
Superior jowl
Superior jowl
Inferior jowl
Figure 3.28  Superficial fat compartments. Rohrich and Pessa have performed multiple cadaver studies supporting the concept that subcutaneous fat
is compartmentalized. Here the superior and inferior jowl fat are dyed blue, and the buccal fat is dyed red. ZM is the zygomaticus magor muscle.
Reproduced with permission from Rohrich RJ, Pessa JE. The fat compartments of the face: anatomy and clinical implications for cosmetic surgery.
Plast Reconstr Surg 2007: 119: 2219–2227. Discussion 2228–2231.
Fig. 3.40 shows a patient in her 60s following a suc­
cessful face lift, but with filler in her lips that appears
unnatural. This is a good example of how adding volume
to the lips without addressing the surrounding area serves
to deepen the shadows and further disconnect the lip and
mouth from the perioral region, resulting in one of the
odd appearances patients fear. Removing suboptimally
placed filler in the vermillion border and body of the lip
(with hyaluronidase) followed by placement of filler in
a submuscular location in the mucosal and cutaneous
portion of the patient’s upper and lower lip, as well as
in her lateral (labiomandibular fat compartment) and
anterior (submental fat compartment discussed below)
chin, provide more support for her lips and a more
natural-appearing result. This patient was also treated
in the pyriform fossa and the prejowl sulcus as discussed
in the next section, which improves the phi ratio in the
lower third of the face. The patient pictured in Fig. 3.41
presented with no antecedent treatment and was treated
in all the same areas. A small amount of volume was also
placed in the body of the lips in this patient.
Figs. 3.42 and 3.43 show a CT/radiopaque dye image
and a cadaver dissection image of the submental fat deep
to the mentalis muscle. The CT image shows that the

34
MASTER TECHNIQUES IN FACIAL REJUVENATION
Figure 3.29  Treatment in the isolated extension of the buccal fat and the superior and inferior jowl compartments soften the hollow midface
shadow and further define the jawline. Poly-l-lactic acid was used here with a 25 gauge needle. This patient was also treated in the area of the
lateral cheek fat and the submental fat compartment.
Figure 3.30  This patient with congenital lipodystrophy was shown in Figure 3.21. The volume present in the deep midfacial fat pads give some
anterior projection to her face, with no visible undereye hollowing or nasolabial fold. However, the lack of superficial fat (as pictured in Figure
3.22) contributes to a skeletonized appearance which is softened by treatment in these areas. Poly-l-lactic acid was used with a 25 gauge needle.
It can be predicted that a patient with this amount of volume loss will need a lot of product and a few sessions to correct. Photographs courtesy
of Rebecca Fitzgerald MD.

3  Addressing Facial Shape and Proportions With Injectable Agents in Youth and Age
35
C
D
A
B
Figure 3.31  (A) Photograph of a deflated midface. (B) Saline injected specifically into the deep medial cheek fat restores anterior projection, dimin­
ishes the nasolabial fold, and effaces the nasojugal trough. Note that the cheek has a natural appearance. Recognize that this is because the fascial
boundaries of the deep medial cheek compartment determine and define its shape. This means that filler placed specifically into this fat compart­
ment will reflect this shape and have a natural appearance. (C, D) Reinflation of the deep medial cheek fat pad effaces of the lid-cheek junction
and the nasolabial fold. (A and B: Reproduced with permission from Rohrich RJ, Pessa JE, Ristow B. Plast Reconstr Surg 2008;121(6):2107–12;
C) before and D) after reinflation of the deep midfacial fat compartments using poly-l-lactic acid. Note that this treatment indirectly effaces the
lid cheek junction and the nasolabial fold. C and D: Reproduced with permission from Jones DH. Injectable fillers: principles and practice. Wiley
Blackwell: London; 2010.)
superficial fat pad over the mentalis does not sit beneath
the labiomental crease (therefore filling superficially
under this crease is unlikely to eradicate the crease). It
does show, however, that the submentalis fat does sit
beneath this crease. For this reason, placement of filler
deep to this muscle under this crease straightens and elon­
gates the chin, elevating the area between the lower lip
and the chin, and minimizing the labiomental crease [28].
This can be seen in the patients in Figs. 3.40, 3.41,
and 3.44.
Facial Muscles: Layer 3
The SMAS was initially described by Mitz and Peyronie
in 1976 [44], and has been further detailed by Rohrich
and colleagues [26,30–33].
The mimetic muscles of the face are located in the
superficial fascia of the anterior face, made up of the
skin, fat, and the SMAS. The SMAS is described as a
midlevel fibromuscular layer separating the deep facial fat
from the superficial facial fat. The role of the SMAS in

36
MASTER TECHNIQUES IN FACIAL REJUVENATION
DMC
MS
LS
Figure 3.32  (Top) The deep midfacial fat compartments. The deep medial cheek fat is composed of a medial part (DMC) and a lateral part (not
shown). The medial part extends medially almost to the lateral incisor tooth. Augmentation of the deep medial cheek fat will consequently elevate
and efface the nasolabial fold. The suborbicularis oculi fat is composed of a medial part (MS) and a lateral part (LS). With aging, an inferior
migration of these compartments occurs, as well as an inferior volume shift within the compartments. as seen in this CT image. (Reproduced from:
Gierloff M, Stohring C, Buder T, et al. Aging changes of the midfacial fat compartments: a computed tomographic study. Plast Reconstr Surg
2012;129(1):263–73). Before and after Hyaluronic acid filler was placed in the fat compartments shown in the CT image above using a 25 guage
cannula. Note the improvement on the right side of her face in the three-quarter view. (Reproduced with permission from Fitzgerald R, Rubin A.
Filler Placement and the Fat Compartments Dermatol Clin 2014;32:37–50.)
AP Projection
Injected volume
6 mm
3.5 mm
1 mm
1cc
2cc
3cc
4cc
Figure 3.33  Augmentation zone for deep medial cheek compartment. Surface change resulting from deep medial cheek augmentation from 1- to
4-cc injection of fat analogue. Color scale demonstrates range of surface change from 1 mm (red) to a maximum of 6 mm (blue). Note the superior
boundary of the augmentation zone at the nasojugal groove. AP, Anteroposterior. (From: Stern CS, Schreiber JE, Surek CC, et al. Three-dimensional
topographic surface changes in response to compartmental volumization of the medial cheek: defining a malar augmentation zone. Plast Reconstr
Surg 2016;137.5:1401–8.)
facial aging and surgical procedures has been elucidated
in multiple studies, a detailed discussion of this is out of
the scope of the present chapter.
The relatively fixed lateral face overlies the mastica­
tory structures—the temporalis, masseter, and parotid
gland and duct—which are all located deep to the deep
fascia. The only superficial muscle in the lateral face is
the platysma (located in the lower third), which extends
to the level of the oral commissure [16].
The muscles of mastication are variable in size between
individuals and are often larger in some ethnicities (Asian
faces), as well as in gum chewers and tooth grinders. This
can masculinize the lower face in a female and distort the
shape of a male face when very large. Hypertrophic mas­
seters are fairly common and easy to recognize; however,
hypertrophy of the temporalis muscle may also be present
as a defined focal convexity just inferior to the insertion
of the superior temporalis fascia, sometimes large enough
in the hairline to interrupt an oval facial frame. Treat­
ing the masseters with neuromodulator can refeminize a
female face, as seen in Fig. 3.45. A very large temporalis
muscle appears odd in either sex, and is also amenable
to treatment with neuromodulator.
The question of whether facial mimetic muscles age
histologically or physiologically in response to the aging
process or secondary to the changes occurring with aging

3  Addressing Facial Shape and Proportions With Injectable Agents in Youth and Age
37
BB
BB
LS
MS
PZ
DLCF
#
#
DLCF
OOM
Figure 3.34  View onto the right and left infraorbital region of layer 4 (deep to the OOM) in a female (left) and male (right) fresh-frozen speci­
men. (Left) The PZ and the lateral part of the DMCF (DLCF) are circled. The hash symbol (left) indicates the zygomaticus major muscle with its
broadly based fibrous origin. This long attachment represents the lateral-inferior boundary of the DLCF. The facial vein is marked by the arrows
and represents the medial-inferior boundary of the DLCF. The OOM is flipped towards the nose to expose the BB where this muscle attaches on the
orbital rim. (Right) Dye has been injected into the prezygomatic space (red and blue) and into the lateral part of the DMCF (DLCF, green). Note
that the injection was performed with constant contact to the bone during application in all three locations. The red and blue areas correspond to
the medial SOOF (MS) and to the lateral SOOF (LS). The hash symbol (right) indicates zygomaticus major muscle with its broadly based fibrous
origin; BB, bare bone area after sharp removal of the OOM from its attachment on the orbital rim. The asterisk marks the levator labii superioris
alaeque nasi muscle. The arrows point to the facial vein. BB, Bare bone; DLCF, deep lateral cheek fat; DMCF, deep medial cheek fat; LS, lateral
suborbicularis oculi fat; MS, medial suborbicularis oculi fat; OOM, orbicularis oculi muscle; PZ, prezygomatic space; SOOF, suborbicularis oculi
fat. (From: Cotofana S, Schenck TL, Trevidic P, et al. Midface: clinical anatomy and regional approaches with injectable fillers. Plast Reconstr Surg
2015;136.5S:219S–234S.)
Figure 3.35  Softening of the nasojugal and nasolabial folds following volume augmentation of the medial and lateral SOOF (using hyaluronic
acid and a 25 gauge cannula), and the DMCF and DLCF (using calcium hydroxylapatite and a 25 gauge cannula). This result is possible in this
patient because she has strong midfacial bone structure, her orbital fat herniation does not exceed the volume loss in her deep cheek fat, and her
skin has good elasticity. Photographs courtesy of Rebecca Fitzgerald MD.
of neighboring structures is not yet clear. It is interesting
to note that patients with Bell’s palsy do not develop the
same lines and folds as a face with normal innervation.
Gosain et al., utilizing magnetic resonance imaging of the
midface, found that although some facial soft tissues show
ptosis over time, the mimetic musculature was unchanged
in volume and length [45]. LeLouarn et al. analyzed mag­
netic resonance images from patients of varying ages and
found that the muscles of facial expression may adjust
to shifts in underlying volume by adjusting their resting
tone and progressively shortening and straightening [46].
Pessa’s algorithm of aging considers skeletal remodel­
ing as one among four components of facial aging (skin
aging, subdermal fat loss, skeletal remodeling, and fat
deposition). According to the algorithm, increased facial
muscle tone and soft tissue repositioning are a direct and
unique result of skeletal remodeling [47].
What is currently clear is that clinically these mimetic
muscles appear to tighten in the face and neck with age,
and that this can be mitigated with neuromodulating

38
MASTER TECHNIQUES IN FACIAL REJUVENATION
potential for successful treatment in this area [48]. The
osseous attachments of the platysma muscle along the
mandibular septum likely play a role here. Note that this
treatment in the patient pictured in Fig. 3.46 has served
to re-ovalize her lower face.
Ligaments and Facial Spaces: Layer 4
Furnas first characterized the ligaments of the face. He
noted that fibrous condensations encountered in face lift
dissections were osseocutaneous and musculocutaneous
supporting structures [49,50]. Mendelson and others
agents. We see this commonly with treatment in the gla­
bella and crow’s feet. This can be seen in the platysma
bands, which stretch from the chin to the collarbone
area and become more pronounced with age. The results
of the so-called “Nefertiti lift” of the neck are shown in
the patient pictured in Fig. 3.46. This neuromodulator
neck lift was described by Levy as a minimally inva­
sive (albeit shorter lived) alternative for patients seeking
an effective way to delay surgery. Disappearance of the
mandibular border with a forceful downward pull on
the platysma at the corners of the mouth indicates the
Figure 3.36  This endurance exercise patient was shown in Figure 3.21. She has a fairly normal amount of superficial fat, without much shadowing
in her temples and lateral cheeks, but appears to have lost a good deal of fat in her deep midfacial compartments, leading to a lack of midfacial
projection, a very visible lid-cheek junction, and an early nasolabial fold. Because she is young and has good craniofacial skeletal support and elastic
skin you can predict that she will get a nice result from volume augmentation of her deep midfacial fat. However, if you glance back at Figure 3.33
you can also see that she will require a good amount of volume in order to achieve her desired result (which was the case). The lateral and medial
SOOF were treated with hyaluronic acid and the deep cheek fat was treated with both hyaluronic acid and calcium hydroxyapatite. A cannula was
used in all locations. Photographs courtesy of Rebecca Fitzgerald MD.

3  Addressing Facial Shape and Proportions With Injectable Agents in Youth and Age
39
Figure 3.37  This patient in her 40’s was treated along her upper lid
and brow as well as her temples. The after picture shows an anterior
projection of the brows and lid after placement of product in the retro-
orbicularis oculi fat (using hyaluronic acid and a 25 gauge cannula)
which gives her eye the youthful feature of a parallel brow, lid sulcus,
and lash line. The patient is shown here frowning to demonstrate that
this effect is not from a neuromodulator. Photographs courtesy of
Rebecca Fitzgerald MD.
C
B
A
Figure 3.38  Just as there is suborbicularis fat around the eye, there
is suborbicularis fat of the perioral region. Histologic examination
confirms the macroscopic finding that the orbicularis insertion defines
the wet-dry border of the lip. (A) Vertical sectioning of the upper lip
reveals fat deep to the orbicularis oris muscle (arrow) and superficial
to the buccal mucosa. (B) The clinical impression from this research is
that the volume of deep lip fat contributes significantly to the appear­
ance of the youthful lip. (C) Vertical sectioning of the lower lip again
shows deep submuscular fat (arrow). Of particular note, this specimen’s
lower lip showed anterior projection and eversion similar to that seen
in a much younger individual. (From Rohrich RJ, Pessa JE, Ristow
BR. The youthful cheek and the deep medial fat compartment. Plast
Reconstr Surg 2008;121:2107–12; Rohrich R, Pessa J. The anatomy
and clinical implications of perioral submuscular fat. Plast Reconstr
Surg 2009;124(1):266–71; with permission.)
have extensively detailed the ligaments, septae, and adhe­
sion zones of the brow, periocular region, and midface
[51–57].
Mendelson and Wong have more recently defined the
anatomy of the three soft tissue spaces of the midcheek
(preseptal, prezygomatic, and premaxillary) and their
relationship to the retaining ligaments of the midface [58].
As noted in a previous section, layer 4 contains the
facial ligaments that attach the superficial fascia to the
underlying deep muscle or skeleton, and the soft tissue
spaces allow the superficial fascia to glide over the deep
muscular fascia or periosteum (layer 5). The simplified
anatomy over the scalp gives the basic prototype of layer
4. There are not any structures crossing this plane in
the area of the scalp, which is essentially an avascular
potential space. In the face proper, while the principles
of construction remain the same, there is considerably
greater complexity [15].
Functionally, these soft tissue spaces exist in layer 4
to allow independent movement of different areas of
the face. The retaining ligaments of the face are strategi­
cally placed within the boundaries between the soft tissue
spaces and function to reinforce the boundaries. In the
lateral face, immediately in front of the ear, extending 25
to 30 mm forward of the ear cartilage to the posterior
border of the platysma, is a diffuse area of ligamentous
attachment, described by Furnas as the platysma auricu­
lar fascia [49]. As no facial expression occurs here, the
dermis, subcutaneous tissue, SMAS, and the underlying