Geoffrey 2 C. Gurtner, Peter C. Neligan, Daniel Z. Liu – Plastic Surgery Principles. 2-Elsevier (2018)

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Fig. 10.9  (A) Patient who underwent cosmetic blepharoplasty with inadvertent disinsertion of the right levator aponeurosis during orbicularis oculi and retroseptal fat
removal resulting in a right upper eyelid ptosis. (B) Patient following cosmetic blepharoplasty with a left upper eyelid ptosis from inadvertent levator aponeurosis
detachment. (C,D) Patients with left upper eyelid cicatricial ptosis due to adhesions between the levator aponeurosis, orbital septum, and skin. (From Jelks GW, Jelks EB.
Blepharoplasty. In: Peck GC (ed). Complications and Problems in Aesthetic Plastic Surgery. New York, NY: Gower Medical Publishing; 1992.)
A
B
C
D
Fig. 10.10  The Fasanella–Servat technique. (A) The eyelid is everted. (B) Two thin, curved hemostatic forceps are placed on the lower edge of the everted lid ≤3 mm from
the upper border of the tarsus. The first of the interrupted incisions is made. The interrupted incisions are extended in steps of 4–5 mm. A mattress suture is placed after
each incision. (C) The sutures are tied so as to hold the tissues firmly yet allow the lid to be returned to its normal position at the end of the procedure. (D) Fasanella’s
alternative method of suturing a running continuous or “serpentine” fashion. (E) The running continuous or “serpentine” suture is returned, and the suture is tied on the
temporal side. (Modified from Jelks GW, Smith BC. Reconstruction of the eyelids and associated structures. In: McCarthy JG (ed). Plastic Surgery. Philadelphia, PA: WB
Saunders; 1990:1671.)
A
B
C
D
E

335
Upper eyelid
Fig. 10.11  (A) Patient with excessive skin removal from the upper eyelid and lagophthalmos. Bell’s reflex is fair. (B) Patient with upper eyelid retraction, lid margin
eversion, and exposure keratopathy due to excessive upper eyelid skin excision. Note the surgical marking for the proposed incision to release the scar and establish a wide
defect. (C) Retroauricular full-thickness skin graft sutured to the defect. (D) Patient 9 months postoperatively. (From Jelks GW, Jelks EB. Blepharoplasty. In: Peck GC (ed).
Complications and Problems in Aesthetic Plastic Surgery. New York, NY: Gower Medical Publishing; 1992.)
A
B
C
D
Fig. 10.12  (A) Patient 2 months postoperatively with right upper eyelid cicatricial retraction of the midlamellar structures (tarsus, orbital septum, and levator aponeurosis).
(B) Patient 6 months after the release of lid adhesions and a levator recession of the right upper eyelid. Minimal ptosis of the right upper eyelid was deliberately produced.
(C) Patient 6 months after ptosis correction by tarso-mullerectomy. (From Jelks GW, Jelks EB. Blepharoplasty. In: Peck GC (ed). Complications and Problems in Aesthetic
Plastic Surgery. New York, NY: Gower Medical Publishing; 1992.)
A
B
C
Fig. 10.13  (A) Patient presents with left upper lid retraction and right lid ptosis secondary to purulent granulation tissue in the right upper eyelid. (B) By covering the right
ptotic eye, the retracted eye exhibits a normal lid level due to Hering’s law of equal innervation. (C) Following excision of granulation tissue and correction of ptosis, the
patient exhibits normal lid levels bilaterally.
A
B
C

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CHAPTER 10 • Secondary blepharoplasty: Techniques
Fig. 10.14  (A) The lateral palpebral raphe. (B) The lateral canthal tendon and the
anatomy of the structures of the lateral canthus. (Modified from Jelks GW, Smith
BC. Reconstruction of the eyelids and associated structures. In: McCarthy JG (ed).
Plastic Surgery. Philadelphia, PA: WB Saunders; 1990:1671.)
A
Orbital
Upper preseptal
Upper pretarsal
Lateral palpebral raphe
B
Upper tarsus
Upper preseptal
Upper
pretarsal
Lower preseptal
Lower
pretarsal
Lateral horn of levator
Lateral canthal
tendon
Fig. 10.15  The lateral extension or horn of the levator aponeurosis (upper arrow)
splits the lacrimal gland into its orbital (O) and palpebral (P) lobes and extends
inferolaterally to join the lateral retinaculum. The lateral portion of Whitnall’s
ligament (W) inserts into the orbital lobe of the gland by way of the interglandular
fascial septa. The inferolateral pole of the palpebral lobe of the lacrimal gland
usually rests at the level of the lateral retinaculum (lower arrow). The lateral
retinaculum is a confluence of the lateral horn of the levator, the lateral canthal
tendon, Lockwood’s suspensory ligament of the globe, and check ligaments from
the lateral retinaculus muscle. (Modified from Jelks GW, Smith BC. Reconstruction
of the eyelids and associated structures. In: McCarthy JG (ed). Plastic Surgery.
Philadelphia, PA: WB Saunders; 1990:1671.)
Upper
preseptal
Upper
pretarsal
Lower
preseptal
Lower
pretarsal
Levator palpebrae superioris
Superior rectus
Lateral rectus
Lateral horn
of levator
Lateral canthal
tendon
Anatomical analysis, especially of the lateral canthal region,
and a thorough understanding of lower eyelid malposition
etiology are required to choose and perform the appropriate,
corrective secondary blepharoplasty procedure in the lower
lid (Tables 10.2 & 10.3). Predisposing factors for post-
blepharoplasty eyelid malposition include: hypotonicity/
involutional changes, malar hypoplasia, shallow orbit, thyroid
ophthalmopathy, unilateral high myopia, and patients under-
going secondary blepharoplasty.3,23
A thorough clinical assessment should include evaluation
of: (1) pretarsal orbicularis oculi muscle function; (2) presence
of vertical midlamellar cicatricial lid retraction/excessive skin
resection; (3) morphology: vector analysis and soft-tissue–
bone distance; (4) tarsoligamentous integrity; (5) presence of
Table 10.2  Secondary blepharoplasty candidate evaluation: lower eyelid
Anterior lamella
Pretarsal orbicularis oculi function
Absent
Present
Scars
Absent
Present
Position
Severity
Skin
Normal
Abnormal
Over-resection
Excess
Lid margin eversion
Absent
Present
LME I
LME II (w/scleral show)
LME III (w/lash rotation)
Ectropion
Lagophthalmos
Absent
Present
Middle lamella
Vertical cicatricial midlamellar retraction
Present
Absent
Fat
Normal
Abnormal
Excess removal
Retention
Posterior lamella
Palpebral conjunctiva
Normal
Abnormal

337
Lower eyelid
above. When midlamellar retraction is present, the eyelid will
have restricted upward mobility (Fig. 10.17).
The lateral view reveals the vector relationship of the (1)
ocular globe to (2) the lower lid and (3) the malar eminence
(Fig. 10.18).23,49–51 A positive vector relationship is when the
most anterior projection of the globe lies behind the lower
eyelid margin, which lies behind the anterior projection of the
malar eminence. It is a favorable anatomic situation because
there is good bony, eyelid, and tarsoligamentous support with
normal eyelid contours and levels. A neutral vector relation-
ship is when the most anterior projection of the globe is in a
vertical relationship with the lower lid and malar eminence.
Like the positive vector relationship, it has minimal risk for
lower eyelid malposition following aesthetic blepharoplasty.
The negative vector relationship is when the most anterior
projection of the globe lies anterior to the lower lid and malar
eminence These patients often have scleral show. They have
a hypoplastic malar relationship, which increases the risk for
an unfavorable result and requires alteration in the aesthetic
blepharoplastic procedure to prevent postoperative lower
eyelid malposition (Fig. 10.19).
The soft tissue–bone distance is measured from the lateral
canthus to orbital rim (Fig. 10.20). This distance is important
for determining what type of lower lid support procedure is
necessary to deliver acceptable results. If the distance is <1 cm,
the patient usually presents with deep set eyes (i.e., positive/
neutral vector). Tarsal strip lateral canthoplasty and inferior
retinacular lateral canthoplasty/canthopexy are effective
procedures to address this problem. If the distance is >1 cm
and the patient presents with prominent eyes (i.e., negative
vector), inferior retinacular lateral canthoplasty, dermal-
orbicular pennant lateral canthoplasty, and midfacial eleva-
tion are effective procedures in the surgical armamentarium
to correct lower lid malposition in these patients.
The tarsoligamentous integrity is determined by three
components: lower lid laxity, medial canthal laxity, and lateral
canthal laxity. Horizontal lower lid laxity is diagnosed by
“distraction” and “snap” test (Fig. 10.21).3,23,39 In the distrac-
tion test, the lower lid is grasped with the thumb and index
finger and displaced anteriorly. In the post-blepharoplasty
patient, when the lower lid can be distracted laterally >8 mm,
lower margin eversion; (6) posterior lamellar integrity; and (7)
presence of malar fat pad descent.
Significant deformities may occur when excess skin and
muscle are excised during a blepharoplasty procedure. Scar-
ring of the pretarsal orbicularis oculi muscle to the middle
lamella can result in lower lid malposition and scleral show.
Denervation of the orbicularis oculi muscle leads to flattening
of this area resulting in an aged, unnatural look. More impor-
tantly, denervation or damage to orbicularis oculi muscle can
lead to an incomplete blink mechanism, lack of tone, laxity of
the lower lid, and scleral show.
During the evaluation of the patient with lower eyelid
malposition, it is important to determine if there is any
element of midlamellar (tarsus, capsulopalpebral fascia,
orbital septum) cicatricial retraction (Fig. 10.16). If lid retrac-
tion is present, then surgical management may require lysis
of the adhesions, interpositional grafts (cartilage, palatal
mucosal), and other grafts, flaps, and procedures for correc-
tion. Ordinarily, when upward traction is placed on the lower
eyelid, it is easily displaced to the level of the midpupil or
Table 10.3  Lateral canthal zone evaluation
Anatomical morphology
Vector analysis
Positive
Neutral
Negative
Soft tissue: bone
distance
<1 cm
<1 cm
>1 cm
Tarsoligamentous integrity
Distraction test
Normal
Abnormal
(>8 mm)
Snap test
Normal
Abnormal
Lateral canthal laxity
No
Yes
Medial canthal laxity
No
Yes
Other
Medial to lateral
canthal position
Equal
Abnormal
High
Palpebral aperture
Symmetric
Asymmetric
Fig. 10.16  Midlamellar cicatricial retraction is one of
the most common indications for secondary
blepharoplasty. Correction requires lysis of adhesions in
conjunction with lateral canthoplasty with or without
spacer grafts.
Tarsus
Midlamellar cicatrix
Lower pretarsal
obicularis oculi
Lower preseptal
obicularis oculi
Orbital septum
Lateral canthal tendon
Conjunctiva
Orbital rim
Inferior oblique

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CHAPTER 10 • Secondary blepharoplasty: Techniques
Fig. 10.17  (A) Patient with vertical displacement of the right lower eyelid demonstrates movement of the eyelid to the midpupillary level. (B) Same patient with
displacement of the left lower eyelid demonstrating midlamellar cicatricial changes preventing movement of the lid (lid retraction). (From Jelks GW, Jelks EB.
Blepharoplasty. In: Peck GC (ed). Complications and Problems in Aesthetic Plastic Surgery. New York, NY: Gower Medical Publishing; 1992.)
A
B
Fig. 10.18  Comparison of the variable anatomic relationships of the orbital region that influence the palpebral aperture. (1) Ocular globe; (2) lower lid; (3) malar
eminence. Cosmetic blepharoplasty may have to be combined with other surgical procedures to prevent complications. (A,B) Young woman with high lid folds, deep-set
eyes (large, bony orbital volume with small ocular globes), and well-developed malar eminences. The most anterior projection of the ocular globe lies behind the lower
eyelid margin and the malar eminence. This positive vector relationship is a favorable anatomic situation as there is good eyelid and tarsoligamentous integrity with normal
eyelid contours and levels. (C,D) Woman presenting for cosmetic blepharoplasty with prominent ocular globes and increased periorbital skin and fat. The most anterior
projection of her ocular globes are posterior to the lower eyelid margin and inferior orbital margin (malar eminence). This is a neutral vector relationship with a minimum
risk for lower eyelid malposition. (E,F) Woman with prominent ocular globes, slight scleral show, and malar hypoplasia. The lateral view demonstrates the influence of the
globe on the lower eyelid position and the lack of eyelid support from the inferior orbital rim. This patient has a negative vector relationship with the most anterior portion of
portion of the globe anterior to the lower lid and malar eminence. This negative vector relationship requires alterations in the cosmetic blepharoplastic procedure to prevent
lower eyelid malposition. (G,H) Middle-aged woman with excess eyelid skin and fat, normal ocular globe position, marked inferior scleral show, lower eyelid laxity, and
malar hypoplasia. This woman has a negative vector relationship and is at risk for an unfavorable result from lower eyelid surgery. A lower eyelid and lateral canthal
tightening with repositioning (lateral canthalplasty) should be combined with the cosmetic blepharoplasty. (From Jelks GW, Jelks EB. Blepharoplasty. In: Peck GC (ed).
Complications and Problems in Aesthetic Plastic Surgery. New York, NY: Gower Medical Publishing; 1992.)
A
1
2
3
B
C
1
2
3
D
E
1
2
3
F
G
1
2
3
H

339
Lower eyelid
Fig. 10.19  Eyelid malpositions following lower eyelid blepharoplasty. (A) Patient with bilateral lid margin eversion, round of the lateral canthi, and scleral show. (B) Patient
with lower eyelid horizontal laxity as well as the findings shown in (A). Note the malar hypoplasia. (C,D) Patient with marked lower eyelid malpositions and corneal
exposure. Note the malar hypoplasia with inadequate bony support to the lower eyelid and ocular globe. (From Jelks GW, Jelks EB. Blepharoplasty. In: Peck GC (ed).
Complications and Problems in Aesthetic Plastic Surgery. New York, NY: Gower Medical Publishing; 1992.)
A
B
C
D
Fig. 10.20  Lateral bone to canthus
relationship. (A) Patients with <1 cm
distance exhibit a positive/neutral vector.
(B) Patients with >1 cm exhibit an negative
vector.
A
B

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CHAPTER 10 • Secondary blepharoplasty: Techniques
divided into four subtypes. The four types of lower lid ever-
sion are as follows: (I) lid margin eversion (LME) with scleral
show; (II) LME with scleral show and horizontal lid laxity;
(III) LME with lash rotation; and (IV) ectropion – involutional
or cicatricial (Fig. 10.23). The term “ectropion” denotes an
outward turning or eversion of the eyelid. Ectropion may be
classified as either involutional or cicatricial.5,23,39 A common
factor in all forms of ectropion is conjunctival hyperemia or
keratinization, punctual occlusion, and inflammatory changes
that become progressively worse. Involutional ectropion (also
called senile ectropion) is caused by horizontal lid laxity of the
eyelid supportive structures and usually begins with scleral
show (Fig. 10.24). Cicatricial ectropion is caused by a defi-
ciency of the skin or skin and muscle of the lid. In secondary
there should be concern for compromised tarsoligamentous
integrity. The snap test is performed by pulling the eyelid
inferiorly to the level of the inferior orbital margin and then
releasing it to judge the speed at which it returns to a normal
level. A lid with a slow snap-back or a persistent eversion may
have eyelid and canthal laxity requiring correction (Fig. 10.22).
If the lateral canthus is higher than or equal to the level of the
medial canthus, one may elect to perform horizontal lid
shortening with a wedge resection alone or in combination
with lateral canthoplasty. If, however, the lateral canthus is
lower than the medial canthus, a lateral canthoplasty proce-
dure is necessary for optimal correction.
Another component in the evaluation of the secondary
blepharoplasty patient involves lower lid eversion, which is
Fig. 10.21  Distraction and snap test.
(A) In the distraction test, the lower lid is
grasped with the thumb and index finger
and displaced anteriorly. In the post-
blepharoplasty patient, when the lower lid
can be distracted laterally >8 mm there
should be concern for compromised
tarsoligamentous integrity. (B) The snap
test is performed by pulling the eyelid
inferiorly to the level of the inferior orbital
margin and then releasing it to judge the
speed at which it returns to a normal level.
A lid with a slow snap-back or a persistent
eversion may have eyelid and canthal laxity.
A
B
Fig. 10.22  Medial canthus to lateral canthus relationship. (A) If the lateral canthus is higher than or equal to the level of the medial canthus, one may elect to perform
horizontal lid shortening with a wedge resection alone or in combination with lateral canthoplasty. (B) If, however, the lateral canthus is lower than the medial canthus, a
lateral canthoplasty procedure is necessary for optimal correction.
A
B

341
Lower eyelid
Finally, examination of the inner component of the poste-
rior lamella should be conducted to determine if fibrosis,
infection, inadequate blood supply, etc., is present.
Management
Several surgical procedures are available to provide excellent
lower eyelid function and contour in the secondary blepharo-
plasty patient requiring correction of lower lid derformi-
ties.2,3,8,9,16,53–62 As mentioned previously, careful evaluation of
the etiology of the lower eyelid defect as well as a thorough
morphological anatomical examination will assist the surgeon
in determining the optimal procedure(s) to perform to best
address the defect or defects (Fig. 10.25 & Table 10.4).
blepharoplasty patients, cicatricial ectropion is seen following
excess skin removal and/or multiple previous blepharoplasty
procedures and resultant scarring (see Fig. 10.24).
Patients with lower lid retraction often have a descent of
the malar fat pad.7,9 A procedure such as a subperiosteal
midface suspension techniques may be required to elevate the
malar fat pad to a position that will assist in supporting the
lower eyelids. A transblepharoplasty subperiosteal midface
elevation in conjunction with lateral canthoplasty (with or
without a spacer graft) may be required in patients who
present with lagophthalmos from multiple procedures and
excessive skin resection to obviate or reduce a full-thickness
skin grafting requirement. This is partially covered in Chapter
6.2.23,52
Fig. 10.23  Lower lid eversion divided into four types subtypes: (A) lid margin eversion (LME) with scleral show; (B) LME with scleral show and horizontal lid laxity;
(C) LME with lash rotation; (D) ectropion – involutional or cicatricial.
A
B
C
D
A
B
Fig. 10.24  Classification of ectropion: (A) cicatricial or (B) involutional. (Modified
from Jelks GW, Smith BC. Reconstruction of the eyelids and associated structures.
In: McCarthy JG (ed). Plastic Surgery. Philadelphia, PA: WB Saunders; 1990:1671.)
Fig. 10.25  Etiology of the lower eyelid defect versus the optimal procedure to
address the defect.
Increasing technical complexity
We already know the trends
Mild lid margin eversion
Horizontal lid laxity
Severe horizontal lid
laxity & retraction
Severe lid malposition with
midface decent
Pexy alone
Plasty +/- tarsal strip
Plasty + vertical
spacer graft
Plasty + spacer +
cheek suspension
Increasing severity of defect

342
SECTION I
CHAPTER 10 • Secondary blepharoplasty: Techniques
portion of lateral retinaculum, the lid is elevated far enough
to cover 1–2 mm of the inferior limbus (Fig. 10.26B). The level
of fixation to the inner aspect of the orbital rim should cor-
respond to a point level with the superior aspect of the pupil
in primary position (Fig. 10.26C). Finally, upon closure of the
lateral canthal skin incisions, the angle of the divergence from
the original horizontal orientation must be equal and sym-
metric from one side to the other to ensure lateral canthal and
lower eyelid symmetry (Fig. 10.26D).
It is not advisable to rely on horizontal lid shortening with
simple wedge resections for lower lid support or to preserve
the lateral canthal anatomy. Pentagonal resection of the lower
eyelid only addresses one aspect of the lower lid malposition,
namely, excess horizontal length. Optimal correction should
address all aspects of the pathology, in particular the
restoration/preservation of canthal anatomy to maximize
postoperative success.
Fixation of a lateral canthoplasty or canthopexy may be
accomplished by directly suturing the lateral canthus to the
lateral orbital rim periosteum. However, in some patients, the
soft, connective tissue of the periosteum has lost its integrity
due to damage from scarring or trauma. In patients with
minimal damage, the fixation may be supplemented with a
local periosteal flap63–65 or a fascial graft.66 However, patients
who have undergone multiple procedures with extensive
damage to the orbital rim periosteum may require drill hole
fixation.57,67 Drill hole fixation of the lateral canthus is accom-
plished by determining the desired point of fixation in the
lateral orbital rim. The point of fixation is determined by
tucking the lateral canthus against the orbital rim until it
corresponds with the vertical level of the superior aspect of
the pupil. This position is marked with surgical ink, and a
single drill hole is made no less than 1 mm and generally
Table 10.4  Canthoplasty techniques and indications
Canthoplasty technique
Indications
Tarsal strip lateral canthoplasty
Lower lid canthal malposition
without lid laxity or ectropion
Tarsal strip lateral canthoplasty
with horizontal lid shortening
Lid laxity or ectropion
Dermal-orbicular pennant
lateral canthoplasty
Bone to soft tissue distance of
>1 cm
Inferior retinacular lateral
canthoplasty
Bone to soft tissue distance of
<1 cm
Inferior retinacular lateral
canthopexy
Bone to soft tissue distance of
<1 cm, minimal distraction,
+ snap test
Vertical spacer graft
Vertical deficiency from
release of midlamellar
cicatrix or skin deficiency
Subperiosteal midface
elevation
Multiple previous procedures
– recruitment of skin and
tissue
Fig. 10.26  Key points to achieve symmetric lateral canthal repositioning. (A) The lateral canthal and lower eyelid incision should be horizontal. (B) The lid is elevated to
cover 1–2 mm of the inferior limbus. (C) The level of fixation to the lateral orbital periosteum is at a level corresponding to the superior aspect of the pupil in primary
position. (D) On closure of the lateral canthal skin incisions, the angle of divergence from the original horizontal orientation must be equal and symmetric to ensure lateral
canthal and lower eyelid symmetry. (Modified from Jelks GW, Smith BC. Reconstruction of the eyelids and associated structures. In: McCarthy JG (ed). Plastic Surgery.
Philadelphia, PA: WB Saunders; 1990:1671.)
Horizontal incision
A
Lid elevation
B
Level of fixation
C
Symmetry of closures
D
The lateral canthoplasty and its various modifications are
useful in addressing lower eyelid malposition.53–62 The proce-
dures described in the following text require a precise knowl-
edge of the orbital anatomy and the desire to preserve the
external commissure. There are key surgical points that should
be kept in mind when performing a lateral canthoplasty to
achieve symmetric lateral canthal repositioning. The lateral
canthal and lower eyelid incision should be horizontal (Fig.
10.26A). After selective release of the lower eyelid with its

343
Lower eyelid
Fig. 10.27  Drill hole fixation of a lateral canthopexy. Following determination of
the proper point of fixation, a single drill hole is made no less than 1 mm and
generally approximately 4 mm posterior to the lateral orbital rim. A double-armed
4-0 Mersilene (ME-2) suture is used for fixation. In a canthopexy procedure (no
lysis of the lateral canthus) the suture is double-looped into the canthal tissue and
both suture arms are brought through the single hole. (From Aston SJ, Steinbrech
DS, Walden JL (eds). Aesthetic Plastic Surgery. Philadelphia, PA: Saunders Elsevier;
2009.)
Fig. 10.28  Tarsal strip lateral canthoplasty. The lower portion of the lateral
retinaculum is divided and development of a tarsal element for fixation is formed by
excising the temporal lid margin, cilia, conjunctiva, and skin. The tarsal strip is then
fixed in position to the lateral orbital periosteum with sutures. (Modified from Jelks
GW, Smith BC. Reconstruction of the eyelids and associated structures. In: McCarthy
JG (ed). Plastic Surgery. Philadelphia, PA: WB Saunders; 1990:1671.)
Lateral canthal tendon
approximately 4 mm posterior to the lateral orbital rim. A
double-armed 4–0 Mersilene (ME-2) suture is used for fixa-
tion. In a canthopexy procedure (no lysis of the lateral canthus)
the suture is double-looped into the canthal tissue and both
suture arms are brought through the single hole (Fig. 10.27).
In a canthoplasty procedure (lysis of the lateral canthus) a
single loop of suture is brought through the canthal edges of
the lids, and the arms are brought out through the single hole.
Both arms of the suture are secured to the deep temporal
fascia.67
Tarsal strip lateral canthoplasty and vertical spacer grafts
Early in the senior author’s experience, the procedure of
choice for post-blepharoplasty lower lid malposition was the
tarsal strip lateral canthoplasty53–56,59 combined with horizon-
tal lid shortening and lateral support with or without vertical
spacer grafts of skin, cartilage, or mucosa (Fig. 10.28). The
tarsal strip lateral canthoplasty procedure divides the lateral
palpebral commissure and selectively releases the lower lid.
The amount of horizontal lid shortening can be varied with
the suture placement and fixation in the orbital periosteum.
The tarsal strip procedure, and its many variations, is useful
for secondary correction of the lax lower eyelid; however, this
technique produces a decrease in the horizontal dimension of
the palpebral aperture that may cause deformities of the lower
lid and a rounding of the external commissure (Fig. 10.29).
If midlamellar cicatricial retraction is present, then surgical
correction may only require incising the midlamellar cicatri-
cial adhesion. However, if the vertical lid defect is excessive,
an interpositional graft composed of palatal mucosa, cartilage,
or a flap of de-epithelialized lateral canthal dermis (dermal
pennant flap) may be required (Fig. 10.30).3,58,59 The preferred
graft is palatal mucosa.3,29,39 The graft donor site is between
the gingival and the midline, which is a location of well-
defined submucosa for easy separation of the graft from the
fat and periosteum. When performing bilateral retraction
repair, it is preferable to take two grafts from both sides of the
mouth rather than one large graft; this will encourage more
rapid healing. Once the graft has been thinned and all remain-
ing fatty tissue excised, it is sutured into the lower eyelid. A
6-0 mild chromic suture is used to attach the graft(s) to the
inferior tarsal edge and the recessed conjunctiva and capsu-
lopalpebral fascia.
Dermal-orbicular pennant lateral canthoplasty
The dermal-orbicular pennant lateral canthoplasty (DOPLC) was
developed to reduce the incidence of tarsal strip lateral can-
thoplasty contour complications (Fig. 10.31).3,59 This procedure
uses an extension of the lower lid in the form of a
de-epithelialized pennant of skin and underlying orbicularis
muscle, but it does not divide the lateral palpebral commis-
sure (Fig. 10.32). This method maintains the horizontal dimen-
sion of the palpebral aperture while allowing for tightening
of the lower lid as well as lateral suspension (Fig. 10.33).
The DOPLC is useful in post-blepharoplasty patients with
lower lid malposition, especially in patients with a bone–soft-
tissue relationship (see Fig. 10.20) of >1 cm. However, because
the incision between the upper and lower lids has a very
narrow skin bridge, persistent edema between the upper and
lower lids may occur laterally with this technique.

344
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CHAPTER 10 • Secondary blepharoplasty: Techniques
Fig. 10.29  (A) Patient exhibiting post-blepharoplasty complications of scleral show, temporal bowing, and mild ectropion that is greater on the right side than on the left.
(B) The tarsal strip ready for periosteal fixation. (C) At 6 months after bilateral tarsal strip procedures. (From Jelks GW, Jelks EB. Blepharoplasty. In: Peck GC (ed).
Complications and Problems in Aesthetic Plastic Surgery. New York, NY: Gower Medical Publishing; 1992.)
A
B
C
Fig. 10.30  Lower eyelid spacer grafts. (A) A spacer graft of autogenous palatal mucosal or auricular cartilage, or a (B) vascularized, de-epithelialized lateral canthal dermal
pennant flap may be used to increase vertical height of the retracted or deficient lower eyelid in conjunction with a lateral canthoplasty. Spacer grafts are useful in
enhancing the results in post-blepharoplasty patients with defects secondary to cicatricial retraction or excessive skin resection.
A
Spacer graft
B
Dermal pennant as spacer graft
Inferior retinacular lateral canthoplasty/canthopexy
and midface elevation
The inferior retinacular lateral canthoplasty/canthopexy
(IRLC) was developed for secondary blepharoplasty patients
requiring correction of lower lid malposition and lateral
canthal deformities without the problems associated with the
tarsal strip lateral canthoplasty and DOPLC (Fig. 10.34).60 The
IRLC is indicated in the secondary or primary blepharoplasty
patient with a negative vector analysis, but with a favorable
bone–soft-tissue relationship (<1 cm discrepancy) (see Figs.
10.18 & 10.20).3,59–62
The IRLC is performed through the lateral aspect of the
upper eyelid blepharoplasty incision. A skin–muscle flap is
elevated along the lateral orbit extending onto the lateral
aspect of the inferior orbital rim. This maneuver exposes the
lower lid lateral fat pad that lies behind the orbital septum.
The inferior aspect of the lateral retinaculum lies immediately
superior to this fat. The lateral fat pad can be removed to
better expose the lateral retinaculum. Following removal of
the fat pad, the suborbicularis plane will be elevated to the
level of the lateral retinaculum. The lower lid component of
the lateral retinaculum may then be identified.
In the canthoplasty procedure, the lateral retinaculum is
released completely from all lateral attachments to the orbit
and allows free movement of the lower orbit. A canthopexy
procedure is a non-lysis canthoplasty in which the lower lid
component of the lateral retinaculum is plicated and anchored
to the lateral orbital rim. A canthopexy is only appropriate for
those patients with minimal distensibility and a firm snap
test.
Both needles of a 4-0 Polydek suture are then passed into
a hitching stitch. The suture is passed through the lateral
orbital rim periosteum at a level corresponding to the superior
edge of the pupil with the globe in primary gaze. The Polydek
suture is adjusted and tightened so that the lower lid covers
1–2 mm of the inferior cornea. The lower lid component of
the lateral retinaculum is fixed in its newly elevated position
on the lateral orbital rim. The position of the lateral canthus
will appear overcorrected, and there may be some initial
bunching of the soft tissue at the lateral canthal region. This
relaxes to a normal contour over 2–4 weeks postoperatively
as the lateral canthus settles inferiorly.
Midface elevation and fixation
Transblepharoplasty subperiosteal midface elevation is useful
in conjunction with lateral canthoplasty with or without
spacer grafts for patients who have undergone multiple cos-
metic procedures who present with lower eyelid and midface
malposition with a deficiency of lower lid skin.9,52,61,68 Proper
midface fixation and canthoplasty prevent lower lid descent
in the first critical weeks of postoperative healing.

345
Lower eyelid
Fig. 10.31  Dermal-orbicular pennant lateral canthoplasty (DOPLC). (A) Patient is illustrated with a protective,
colored contact lens in place. The dermal-orbicular flap is outlined at the lateral canthus. Note the horizontal
alignment and the maintenance of the external commissure. An incision is made through the superficial
layers. (B) The flap is de-epithelialized preserving the underlying dermis. The superficial border of the flap is
incised to the suborbicularis muscle plane. (C) The inferior border of the dermal-orbicular pennant is elevated
to the external commissure, which remains intact. The lower lid component of the lateral retinaculum is
divided by “strumming” the structure with a Colorado needle. (D) The fixation of the suture is to the lateral
orbital rim corresponding to the upper level of the pupil with the patient in primary gaze. (E) A spacer graft
can be added as necessary. (Modifed from Jelks GW, Jelks EB. Repair of lower lid deformities. Clin Plast
Surg. 1993; 20:417–421.)
Scratch through dermis
De-epithelialized dermal flap
Protective contact lens
A
Dermis
Cut to fascia
Canthal angle remains intact
B
Mobilize flap to pretarsal muscle
Orbicularis muscle
Periorbital fascia
C
Strumming inferior retinaculum
with Colorado needle to release lower lid
Suture fixation is to lateral rim corresponding to the upper
level of the pupil with the patient in the primary gaze
D
Spacer graft
E

346
SECTION I
CHAPTER 10 • Secondary blepharoplasty: Techniques
Fig. 10.32  Dermal-orbicular pennant lateral canthoplasty (DOPLC) fixation and
closure. (A) Both arms of an ME-2 4-0 Polydek suture are passed through
periosteum from the inner to the outer aspect of the orbital rim. The needles are
passed through the loop, and cinched tightly down, hugging the inner aspect of the
orbital rim. (B) Most commonly, periosteal fixation is to the lateral edge of the
tarsus. Fixation of the lower lid to the orbital rim should result in an overcorrection
such that the lower lid covers 1–2 mm of the inferior cornea. (C) Upon closure,
elevation causes inferior angulation of the original horizontal incision. (D) When
bilateral procedures are performed, care is taken to obtain symmetry of closure.
(Modifed from Jelks GW, Jelks EB. Repair of lower lid deformities. Clin Plast Surg.
1993; 20:417–422.)
ME-2 needles
Fixation suture inside periosteum of orbital rim
A
Suture into tarsus
Alternate suture placement
B
Closure
C
Bilaterally symmetrical angles
D
Fig. 10.33  (A) Patient with bilateral lower eyelid malposition after blepharoplasty.
(B) The patient is seen 9 months following bilateral dermal-orbicular pennant
lateral canthoplasties. (From Jelks GW, Jelks EB. Blepharoplasty. In: Peck GC (ed).
Complications and Problems in Aesthetic Plastic Surgery. New York, NY: Gower
Medical Publishing; 1992.)
A
B
Subperiosteal midface elevation is achieved through a
lower blepharoplasty incision. A skin–muscle flap is dissected
down to the infraorbital rim. Periosteum at the anterior
margin of the infraorbital rim is elevated with a subperiosteal
pocket. The periosteum is released laterally over the inferior
lateral rim followed by release of the entire subperiosteal flap
so it can be mobilized superiorly. The midfacial flap is sus-
pended with using two 4-0 Vicryl sutures on half-circle cutting
needles that are used to purchase the suborbicularis oculi fat
and the malar fat pad. The sutures are then tied to a titanium
screw placed on the anterior surface of the lateral orbital bone
(zygomatic bone) (Fig. 10.35). The screw is tightened until the
head is flush with the bone surface. Alternative methods that
can be used to elevate the midface include a preperiosteal
dissection from the lower lid,69 the concentric malar lift,70 and
the endoscopic, subperiosteal approach from the temple
(covered further in Chapter 6.8).
The elevated and stabilized structures support the reposi-
tioned lower lid, and the recruited and elevated cheek skin
and tissue help replace deficient posterior lamella.
Choosing the appropriate technique(s)
Careful evaluation of specific indications in regard to the
patient’s anatomy, as well as their specific defect, enable
the surgeon to choose the optimal lateral canthoplasty pro-
cedure (see Table 10.4). In patients with a bony–soft tissue
(i.e., lateral orbital rim–external commissure) distance of
≥1 cm, the dermal-orbicular pennant lateral canthoplasty has
become the procedure of choice for correction of lower lid
malposition. The DOPLC allows for correction of the lateral

347
Lower eyelid
Fig. 10.34  Inferior retinacular lateral canthoplasty (IRLC) technique. (A) The IRLC is performed through the lateral aspect of an upper eyelid blepharoplasty incision. A
skin–muscle flap is elevated along the lateral orbit exposing the lower lid lateral fat pad. The inferior aspect of the lateral retinaculum lies immediately superior to this fat.
The lateral fat pad can be removed to better expose the lateral retinaculum. Inset: following removal of the fat pad, a “cave” is revealed superior to the lateral retinaculum.
The illustration reveals this area as it would be visualized from inside the orbit. (B) Canthoplasty procedure with lysis of the lateral retinaculum. Inset: canthopexy, or
non-lysis procedure in which the lower lid component of the lateral retinaculum is plicated and anchored to the lateral orbital rim. (C) Both needles of 4-0 Polydek suture
have been passed into a hitching stitch. The suture has been passed through the lateral orbital rim periosteum (as denoted by the arrow) at a level corresponding to the
superior edge of the pupil with the globe in primary gaze. (D) The Polydek suture is adjusted and tightened so the lower lid covers 1–2 mm of the inferior cornea. The
lower lid component of the lateral retinaculum is then fixed in its elevated position to the lateral orbital rim. (Modifed from Jelks GW, Glat PM, Jelks EB, et al. The inferior
retinacular lateral canthoplasty: a new technique. Plast Reconstr Surg. 1997;100:1262–1270.)
Removal of fat pad to reveal ‘cave’
Cave from inside orbit
A
Canthopexy
Canthoplasty
B
C
D
Fig. 10.35  Mitek screw fixation in subperiosteal midface
elevation. Following elevation of the subperiosteal midface flap,
fixation is achieved by suspending the flap using two 4-0 Vicryl
sutures on half-circle cutting needles. The sutures are then tied
to a titanium screw placed on the anterior surface of the lateral
orbital bone (zygomatic bone). The screw is tightened until the
head is flush with the bone surface. The elevated and stabilized
structures support the repositioned lower lid and the recruited
and elevated cheek skin and tissue help replace deficient
posterior lamella. (From Aston SJ, Steinbrech DS, Walden JL
(eds). Aesthetic Plastic Surgery. Philadelphia, PA: Saunders
Elsevier; 2009.)
Mitek screw
Screw locations
X
X
X
X
Cutting edge
on outside of curve
Cutting edge
on outside

348
SECTION I
CHAPTER 10 • Secondary blepharoplasty: Techniques
Fig. 10.36  (A) Patient with excessive lower lid fat resection with associated lower eyelid malposition. (B) The supplementary submental autogenous fat grafts are shown
before their placement into a retroseptal position through a lateral canthal incision. Lateral canthoplasties were also performed. (C) Patient seen one year postoperatively.
(From Jelks GW, Jelks EB. Blepharoplasty. In: Peck GC (ed). Complications and Problems in Aesthetic Plastic Surgery. New York, NY: Gower Medical Publishing; 1992.)
A
B
C
canthal angle, while preserving the external commissure.59
Lid laxity or ectropion are indications for canthoplasty;
however, it is still preferable to utilize some form of horizontal
lid shortening (usually with a tarsal strip). This maneuver
allows for correction of the laxity while allowing for canthal
resuspension.
In patients with lid retraction, a DOPLC may be sufficient
to correct the problem if there is associated soft-tissue–bony
disparity. If release of midlamellar (orbital septum, lid retrac-
tors) cicatricial retraction is the cause of the vertical deficiency,
the use of autogenous palatal mucosal or auricular cartilage
as a spacer graft is recommended. Spacer grafts should also
be utilized when release of the posterior lamella (conjunctiva)
produces a vertical deficit. In patients with multiple previous
procedures presenting with deficient lower eyelid skin and
tissue, midface elevation techniques may also be necessary
for an optimal result. Finally, for secondary or primary
blepharoplasty patients with negative vectors and favorable
bony–soft-tissue relationships (<1 cm), the IRLC is recom-
mended.23,49,50,59–62 The IRLC procedure avoids the pitfalls
Fig. 10.37  (A) Blepharoplastic patient preoperatively. (B) At 2 months postoperatively with evidence of inadequate resection of fat from the right lower eyelid medial
compartment. (C) The fat is removed via a small stab incision through skin, muscle, and orbital septum. (From Jelks GW, Jelks EB. Blepharoplasty. In: Peck GC (ed).
Complications and Problems in Aesthetic Plastic Surgery. New York, NY: Gower Medical Publishing; 1992.)
A
B
C
Fig. 10.38  (A) Patient seen following blepharoplasty with persistent malar excess skin. (B) Immediately after direct excision. (C) A satisfied patient seen 9 months
postoperatively. (From Jelks, GW, Jelks EB. Blepharoplasty. In: Peck GC (ed). Complications and Problems in Aesthetic Plastic Surgery. New York, NY: Gower Medical
Publishing; 1992.)
A
B
C
of horizontal lid shortening and the edema associated with
DOPLC.
Miscellaneous complications
Excessive fat resection is a most disturbing problem, especially
when associated with lower eyelid malposition. Autogenous
fat pad sliding, fat grafting (Fig. 10.36), and fat injection have
been utilized to correct this deformity with variable results.71–77
A lateral canthoplasty should be performed at the time of fat
augmentation.
Inadequate fat resection most commonly occurs in the upper
and lower medial and lower lateral compartments. A small
stab incision through the skin, muscle, and septum can be
utilized to deliver the residual fat for excision (Fig. 10.37).29 In
the lower lid, the transconjunctival approach may also be
used.
Persistent malar bags, or excess skin that presents without
lower lid cicatricial retraction can be directly excised and
carefully closed to produce acceptable results (Fig. 10.38).29

349
Lower eyelid
Fig. 10.39  Patient with persistent chemosis.
3. Jelks GW, Jelks EB. Repair of lower lid deformities. Clin Plast Surg.
1993;20:417–425.
5. Jelks GW, Jelks EB. Preoperative evaluation and treatment of lower
lid ectropion following blepharoplasty. Plast Reconstr Surg.
1990;85:971–981. Preoperative identification of a predisposition to
ectropion is the first step in preventing this complication after
blepharoplasty. The authors discuss surgical techniques to avoid this
common adverse outcome and address procedures designed to reverse
ectropion if it does occur.
7. Patipa M. The evaluation and management of lower eyelid
retraction following cosmetic surgery. Plast Reconstr Surg.
2000;106:438–453. Causes of lower eyelid retraction are discussed from an
anatomical perspective. The author then presents etiology-based corrective
procedures.
12. Lisman RD, Hyde K, Smith B. Complications of blepharoplasty. Clin
Plast Surg. 1988;15:309–335.
25. Zide BM, Jelks GW. Surgical anatomy of the orbit. Plast Reconstr
Surg. 1984;74:301–305.
46. Carraway JH. The impact of Herring’s law on blepharoplasty and
ptosis surgery. Aesthetic Surg J. 2004;24:275–276.
50. Pessa JE, Desvigne LD, Lambros VS, et al. Changes in ocular
globe-to-orbital rim position with age: implications for aesthetic
blepharoplasty of the lower eyelids. Aesthetic Plast Surg.
1999;23:337–342. The authors present findings from computed
tomography scans assessing the relationship of the globe to surrounding
anatomy throughout the aging process. Their findings inform
recommendations for lower lid blepharoplasty and are incorporated into a
model of craniofacial aging.
56. Rees TD. Prevention of ectropion by horizontal shortening of the
lower lid during blepharoplasty. Ann Plast Surg. 1983;11:17–23.
62. Fagien S. Algorithm for canthoplasty: the lateral retinacular
suspension: a simplified suture canthopexy. Plast Reconstr Surg.
1999;103:2042–2053. Methods to provide canthal support and avoid lower
lid malposition in midface/lower eyelid rejuvenation are presented. The
author describes his novel transpalpebral lateral retinacular suspension in
this context.
66. McCord CD Jr, Ellis DS. The correction of lower lid malposition
following lower lid blepharoplasty. Plast Reconstr Surg.
1993;92:1068–1072. Methods to correct lower lid malposition are
presented based on the underlying anatomical pathology.
Access the complete reference list online at

Chemosis is a milky edema of the subconjunctival tissues. It
results from obstruction of the lymphatic drainage channels
of the periorbital area (Fig. 10.39). Repositioning the eyelids
over the chemotic conjunctiva and patching usually resolve
the situation. If the chemosis becomes more marked or there
is actual incarceration by the eyelids, temporary suture tarsor-
rhaphy may be required.3,29,39

349.e1
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72. Silkiss RZ, Baylis HI. Autogeneous fat grafting by injection. Ophthal
Plast Reconstr Surg. 1987;3:71–75.
73. Coleman SR. Structural fat grafts: the ideal filler? Clin Plast Surg.
2001;28:111–119.
74. Coleman SR. Facial recontouring with lipostructure. Clin Plast Surg.
1997;24:347–367.
75. Coleman SR. Long-term survival of fat transplants: controlled
demonstrations. Aesthetic Plast Surg. 1995;195:421–425.
76. Kanchwala SK, Bucky LP. Facial fat grafting: the search for
predictable results. Facial Plast Surg. 2003;19:137–146.
77. Ellenbogen R. Free autogenous pearl fat grafts in the face – a
preliminary report of a rediscovered technique. Ann Plast Surg.
1986;16:179–194.

SECTION I • Aesthetic Surgery of the Face
11 
Asian facial cosmetic surgery
Kyung S. Koh, Jong Woo Choi, and Clyde H. Ishii
SYNOPSIS
■ There has been tremendous growth of cosmetic surgery in the Asian
population over the past several decades.
■ Currently most Asians want to improve their appearance while
preserving their ethnic identity.
■ Asian cosmetic surgery is not simply Western cosmetic surgery
applied to Asians. Rather cosmetic surgery in Asians must take into
account the underlying differences in anatomy and aesthetic
proportions among various Asian ethnic groups as well as those
between Asians and Caucasians.
■ Asian blepharoplasty and rhinoplasty are two of the most popular
facial cosmetic procedures in Asia today.
■ Facial bone contouring and aesthetic orthognathic surgery are also
becoming more popular.
■ There is no perfect way to define facial beauty, and facial
attractiveness varies according to race. Therefore, one must use both
subjective and objective tools for analyzing facial profiles according to
ethnic standards.
Asians, including people from Japan, South Korea, China, and
Taiwan.1 Asia is the largest continent and has numerous ethnic
groups.1,2 Southern Asians have darker, thicker skin, larger
eyes with double folds and smaller, narrower facial skeletons
compared to northern Asians, whereas western Asians have
quite different facial features from other Asians. Although
there are some constants, the standard of beauty varies among
countries. Anatomic characteristics and cultural differences,
including trends in each ethnic group, should be considered
before performing facial cosmetic surgery.
Much controversy surrounds the concept of universal
beauty. Symmetry, balanced facial proportions and youth-
fulness make a face more attractive, regardless of ethnic
background.3 In Caucasian women, high cheekbones are an
important factor, whereas Asian women with round or oval-
shaped faces are considered more beautiful. When Asians see
facial photographs of themselves alongside Caucasians, they,
especially younger individuals, are sometimes disappointed
with their appearances. In general, Asian faces tend to look
broader with a flatter contour to their eyes, nose, and face. We
live in a three-dimensional world, and the faces we observe
directly are three-dimensional. Facial cosmetic surgery is a
three dimensional procedure, and more emphasis is being
placed on facial contour changes given the fact that there are
differences in terms of the facial skeleton as well as the soft
tissue proportions (Fig. 11.1A, B, C).
Young female Asians have become acutely interested
in their appearance, creating a boom in cosmetic surgery.
Females in East Asia seek larger eyes, a higher nose, and a
smaller face, which are not traditional to “Asian” beauty but
have been influenced by Western countries. It is incorrect to
simply assume that Asians seek to “Westernize” their faces.
Although Westernization of the Asian face seemed to be a goal
in the past, most patients now want to preserve their ethnic
identity, while at the same time improving their appearance
(Fig. 11.1).1-3
Modern concepts of facial cosmetic surgery, including
double eyelid plasty and augmentation rhinoplasty, began
and were developed in Japan in the late 19th and 20th
Everything is in the face.
Cicero
Access the Historical Perspective sections online at

Introduction
The face, while only a single part of the body, is the icon of
self-identity and can be easily recognized among hundreds of
thousands of faces. Asian and Caucasian faces each have
unique features. It is generally accepted that Asians have
small, puffy eyes with an epicanthal fold, shallow orbits, a
low-profile nasal dorsum with thick skin, flat faces with large
cheekbones and broad width. This is especially true for East
  Access video and video lecture content for this chapter online at expertconsult.com

351
Asian blepharoplasty
Fig. 11.1  The differences between the facial skeletons of Western and Oriental people are shown. Generally speaking, the Western skull is dolicocephalic, while the
Oriental skull is brachycephalic. The frontal bar, nose, and maxillomandibular complex show the differences. (A) There exist various differences between Western and
Oriental people with regard to the face. Therefore, the norm should be different in order to get the ideal aesthetic face. (B) Caucasian facial skeleton. (C) Oriental facial
skeleton.
A
B
C
centuries. In South Korea, facial cosmetic surgery flourished
following the Seoul Olympics in 1988. With economic devel-
opment, cosmetic surgery in China has grown rapidly. Due to
the increased scientific knowledge and training of board-
certified plastic surgeons in East Asia, facial cosmetic surgery
has advanced rapidly. These plastic surgeons have also played
a key role in introducing new ideas and techniques about
Asian facial plastic surgery.
Some Asians have attractive facial traits, including large
eyes, a well-balanced nose with a good profile, and small
lower faces.4,5 Individuals who regard their facial features as
falling short of the mainstream ideals of beauty are willing to
undergo facial cosmetic surgery. Younger individuals, for
example, wish to undergo facial bone contouring to make
their faces smaller. These individuals do not have “below
average faces”.1 Rather, they want to look above average,
sometimes chic and stylish, not merely natural. Most patients
who want facial cosmetic procedures like double eyelid plasty
and augmentation rhinoplasty are women, but these cosmetic
procedures are also requested by men.
Asian blepharoplasty
Introduction
Blepharoplasty does not appear to be the most commonly
performed cosmetic operation in North American and Euro-
pean countries, whereas it is the most popular plastic surgery
procedure in East Asian countries – with estimates suggesting
that 30–60% of Asian women from metropolitan areas undergo
this procedure.6 The patient demographic is significantly dif-
ferent as well, with older patients wanting a rejuvenative
blepharoplasty in Western countries and younger patients
wanting an aesthetic operation in East Asia.
Historically, plastic surgery literature from Western coun-
tries have described Asian individuals as having puffy crease-
less eyelids and epicanthal folds, both of which obscure the
view of the eye itself. This stereotypic generalization has
received scrutiny in the past four decades, and we now
understand that about half of the women in East Asian popu-
lations have clear supratarsal folds without strongly conspicu-
ous epicanthal fold.1,2 The post-World War II surgeons from
the US and Europe reported that Asian patients wanted to
have the “round eyes” of Caucasian visitors.7 In the ensuing
decades, however, this perception of Asian patients wanting
to look more “Western” has either shifted or has been rejected
as an aesthetic norm in East Asian countries. It is a fact that
the majority of contemporary Asian patients do not want to
have Western or Caucasian eyelids.1,2,8 Large deep-set eyelids
with high creases do not compliment the overall harmony of
the Asian face. Blepharoplasty should compliment – not alter
or diminish – ethnic identity for this reason (Fig. 11.2A).
Surgically created supratarsal fold or “double eyelid”
was first described by Mikamo in 1896, for a patient who
lacked a fold in one of the upper eyelids.6 Shirakabe et al.
made a historical review of 32 surgical techniques reported
in Japan.9 Sayoc was one of the first surgeons to consider
anatomic differences in upper eyelids between Caucasians
and East Asians within the context of blepharoplasty.10 Hawaii
served as the first testing ground for these ideas, where
surgeons such as Fernandez and Flowers began to publish
a series of studies and essays on blepharoplasty in Asian
patients.11,12 Subsequent developments in blepharoplasty
include further aesthetic refinements and minimally invasive
approaches.13
Anatomic considerations (Fig. 11.2B)
Multiple theories exist regarding the formation of supratarsal
crease or fold. Sayoc was one of the first surgeons to discuss
the connection between levator palpebrae superioris muscle
and the dermis as the anatomic basis for the appearance of
supratarsal fold and how this connection was absent in Asian
patients without supratarsal fold (see Fig. 11.2).13 The pres-
ence of this connection was confirmed by Cheng and Xu

352
SECTION I
CHAPTER 11 • Asian facial cosmetic surgery
(caruncle and lacrimal lake) and increase the interepicanthal
distance. In East Asian populations, conspicuous epicanthal
folds are present in at least 50% of adults. If minor skin bridges
are included in the definition, epicanthal folds are present in
virtually all East Asian people.1
through scanning electron microscopy studies.84 Similarly, the
fibrous septa forms an adhesive layer between the tarsal plate
and pretarsal skin, and the dense adhesions between the tarsal
plate and skin is associated with supratarsal crease.3,15 Both of
these prevailing explanations try to account for a connection
that transmits the force vector of levator mechanism to the
eyelid skin.
In addition, supratarsal crease formation appears to be
dependent on the level at which orbital septum and levator
aponeurosis are fused. From this confluence, fibrous con-
nections can insert into the dermis and create a supratarsal
crease.13 In most Caucasian eyelids, upper eyelid crease is
defined at the level of this adhesion between septum and
aponeurosis.16 However, the septum and aponeurosis fuses
at a more inferior level in Asian patients, which results in
a low-lying or absent crease (see Fig. 11.2B). Asian patients
with naturally occurring superior palpebral folds have a
relatively higher fusion of septum and aponeurosis.17 The
preaponeurotic orbital fat within the pretarsal space elimi-
nates the formation of double fold in Asians. Among Asians,
it is not unusual for the upper lids to vary, being double and
single in the same individual, depending on such variables
as fatigue, diurnal variations of eyelid swelling, and weight
change.
In addition to variations in supratarsal crease, the epican-
thal fold is a characteristic feature of the Asian upper eyelid
(Fig. 11.3). Epicanthal folds veil the medial corner of eye
Fig. 11.2  (A) The differences in skeleton
and levator attachment make Oriental eyes
looks different. (B) Multiple theories exist
regarding the formation of the supratarsal
crease or fold. First theory: Expansions of the
levator palpebrae superioris muscle
penetrating through the septum and
orbicularis oculi muscle to the overlying
dermis were thought to be present in
Caucasian eyelids and less so in Asians.
Second theory: Supratarsal crease formation
is the level of fusion of the orbital septum
and the levator apponeurosis. The level of
adhesion between the orbital septum and
levator aponeurosis defines the superior
palpebral crease in most Caucasian eyelids,
whereas lower fusion of the orbital septum to
levator aponeurosis results in a low-lying or
absent crease in the Asian eyelid. Third
theory: The skeletal differences make the
eyelid look different.
A
B
Asian eyelid
Preseptal fat
Müller muscle
Levator aponeurosis
Orbicularis Oculi Muscle
Orbitale septum
Orbital fat pad
Caucasian eyelid
Fig. 11.3  The epicanthal fold is also a characteristic feature of Asian upper lid. It
hides the medial part of eye, including the caruncle and lacrimal lake, and
increases the intercanthal distance. In East Asians, at least 50% of adults have
epicanthal fold. (A) Oriental eyelid. (B) Caucasian eyelid.
A
B

353
Asian blepharoplasty
of fold is called the double eyelid line, and the distance
between this line and the margin of the lid at primary gaze is
pretarsal exposure or “show”. In young Caucasian adults, the
superior tarsal fold is not as deep as in Asian patients, and
this pretarsal skin show is commensurate with the height of
superior palpebral crease.17 In contrast, the Asian lid crease is
generally 2–3 mm lower than that of Caucasian eyelid with a
greater amount of superior palpebral fold hanging over the
pretarsal skin.8 Because of this, lesser of the pretarsal skin is
visible in the Asian eyelid. Blepharoplasty alters the extent of
pretarsal exposure by several means, such as incision height,
the amount of skin excision, fixation height, and changes to
levator mechanism.17 While geographical variations do exist,
most Asian patients seem to prefer a pretarsal show of less
than 3 mm and as little as 1 mm.8 Older patients tend to prefer
a lesser amount of pretarsal exposure, and this is especially
true for elderly male patients.
The shaped of desired crease is yet another significant
consideration. Typically, the Caucasian eyelid crease is char-
acterized by a semilunar shape, by which the central third of
crease is farther away from the lash line than are medial and
There has been a recent trend to eliminate or loosen the
epicanthal fold as part of the double eyelid operation. This
medial epicanthoplasty will decrease the wide intercanthal
distance and increase the horizontal width of the palpebral
apertures. However, surgeons should be very cautious about
total elimination of epicanthal folds, because this can leave a
noticeable scar and result in loss of ethnic identity.
Preoperative considerations and diagnosis
Blepharoplasty should be performed while respecting the
anatomic differences between Asian and Caucasian eyelids.
Decades ago, Asian patients wanting to undergo blepharo-
plasty wished only for double fold formation. More recently,
Asian blepharoplasty has evolved to reduce the puffiness of
eyelids, create the supratarsal fold, and to increase the width
of palpebral fissure.17 It is important to note that the reduction
of eyelid puffiness does not equate to sunken or deflated
upper eyelid.3
The height of supratarsal crease is an important issue (Fig.
11.4A). In Asian blepharoplasty vernacular, the lower border
Fig. 11.4  Non-incisional
double eyelidplasty.
(A) Preoperative puffiness
of Asian eyelid. (B) This
method creates a
mechanical connection
between the dermis and
levator mechanism. The
stitch is simply inserted
through the skin at the level
of the preferred lid crease,
traversing the full thickness
of the lid tissues down to
and including either the
levator aponeurosis or the
tarsal plate. (C) Single-stitch
non-incisional double
eyelidplasty. (D) Multiple
stitch non-incisional
methods utilize 3-5 stitches.
A
a
b
d
c
B
C
Skin
1
2
3
4
5
Conjunctiva
D

354
SECTION I
CHAPTER 11 • Asian facial cosmetic surgery
lateral thirds.18 This semilunar shape of the crease appears
unnatural to Asian patients, who prefer a crease that is paral-
lel to the lid margin. Laterally, the ideal crease has slightly less
curvature such that the crease is farther away from the lash
line compared to the central third. This lateral flare gives an
uplifted appearance of the upper eyelid and tends to minimize
the bunching of skin flaps that commonly occurs over the
lateral canthus. Medially, the crease may taper toward the
medial canthus (i.e., “inside fold”) or run outside the epican-
thus (i.e., “outside fold”).19
Treatment/surgical technique
Asian blepharoplasty encompasses a spectrum of operative
techniques developed in the context of the eyelid anatomy
and aesthetics of East Asian patients. Although principles of
blepharoplasty are similar for both Asian and Caucasian
patients, it is important to recognize that upper blepharoplasty
is not a Westernization procedure. Generally, surgical tech-
niques for double fold formation can be categorized into
incisional and non-incisional methods, with partial-incisional
methods somewhere in-between.
Non-incisional methods (Figs. 11.4 and 11.5)
Numerous non-incisional methods have been described and
are used primarily for younger patients without dermatocha-
lasis and for patients with relatively pliable upper eyelid
surface (i.e., thin eyelid skin without overabundance of peri-
orbital fat).20–25 Compared to incisional methods, these mini-
mally invasive approaches are associated with a lesser degree
of postoperative edema. However, this advantage must be
balanced against the knowledge that an incisionless fixation
may not be as durable as fixations with incisional methods
(Video 11.2
).
Non-incision methods create a mechanical connection
between the dermis and levator mechanism (e.g., tarsal plate
or aponeurosis) using a suture introduced through pinpoint
access created by needles or scalpel tips. Fixation to the levator
aponeurosis can result in a more natural appearance with
minimal postoperative edema but is associated with higher
rates of failure (i.e., disappearance of crease). Fixation through
the upper portion of the tarsal plate can result in a defined
eyelid crease with minimal relapse, but postoperative edema
can occur more frequently compared to levator fixation
methods.
Upon surgical preparation and local anesthesia, the suture
is inserted through the dermis and across the thickness of the
lid tissue, incorporating either the levator aponeurosis or the
tarsal plate. The sutured are tied with the knots buried. Non-
incisional methods can be categorized as single-stitch and
multiple-stitch methods, both of which have advantages and
disadvantages.
■ Single-stitch non-incisional methods have many
modifications (Fig. 11.4C).20
■ Multiple-stitch non-incisional methods utilize 3–5 stitches
for each eyelid (Fig. 11.4D).
Partial-incisional methods
Partial-incisional methods are being used more frequently
and have evolved to overcome disadvantages of both inci-
sional and non-incisional methods.26,27,83 Compared to non-
incisional methods, partial-incisional methods can induce
moderate degrees of tissue adhesion, which is helpful in
decreasing the rate of failure in the early postoperative
period.85 Partial incisions break up the continuity of incisional
scar and results in postoperative eyelids with an appearance
that is more natural than that of a full-width incision. Also,
partial-incisional approaches allow removal of preaponeurotic
fat for reducing puffiness of eyelids.
In this method, one or more small stab incisions are made
along the crease design. The preaponeurotic fat is removed
via dissection windows through the orbicularis. A non-
absorbable suture is used to fix the underlying aponeurosis
or superior edge of the tarsal plate to the skin edges. The lid
should be everted to confirm that the suture has not pierced
the conjunctiva.
Full-incisional methods
Tarsodermal fixation through open blepharoplasty incision
has been the traditional method and is still considered the
standard for creating double fold.28 Furthermore, this approach
is the only viable option for patients requiring excision of
redundant eyelid skin.
Preoperatively, the crease height and shape is demon-
strated using a probe to the satisfaction of the patient. The
incision line is designed, beginning from the middle of eyelid
at the desired height away from the upper eyelid margin.
The line is extended medially, while tapering closer to the
lash line towards the epicanthal fold. Whether the crease
design converges with or continues outside the epican-
thal fold is a matter of patient preference. If skin excision
is necessary, it is important to recognize that most of the
redundancy is in the lateral portion of the eyelid and, as
such, the excision strip must be narrower medially and wider
laterally.
Upon surgical preparation, the upper eyelid skin is opened
along the incision design and excess skin is removed at this
time. The orbicularis oculi is then removed in order to allow
Fig. 11.5  Non-incisional double eyelidplasty with subclinical ptosis correction and medial epicanthoplasty using skin redraping method.
A
B

355
Asian blepharoplasty
is thought to create a more static and defined upper lid
crease.
Aesthetic correction of subclinical ptosis
Many patients who wish for more attractive-looking eyelids
are not satisfied with the creation of an upper eyelid crease
alone.29 These patients may have an upper eyelid margin that
is slightly low at resting position, which can be corrected to
increase the height of palpebral fissure.30 This tendency for
upper eyelid ptosis is defined as “subclinical ptosis” in Asian
blepharoplasty literature (Fig. 11.6A).
Patients with mild subclinical ptosis may be candidates for
procedures used to correct mild ptosis, such as Müllerectomy,
levator aponeurosis plication, or aponeurosis advancement
(Fig. 11.6B,C).31–34 A recent trend in Korea has been to address
both mild blepharoptosis as well as the lack of upper eyelid
crease. Examples of such approaches include partial-incision
for a sharp lid crease, and this should be performed such that
a wider strip of muscle is excised than skin. Leaving excess
orbicularis can result in a puffy appearance.
Beyond the muscular plane, the septum is carefully opened.
A variable amount of retroseptal fat may be either excised or
released. Any released fat globules are allowed to be pulled
superiorly with muscle movement. The levator aponeurosis
is exposed near the tarsal plate, which is typically 6–7 mm in
height among Asian patients.
With all soft tissue dissections complete, the upper crease
is created. Various methods have been described for suture
fixation between the superficial soft tissue to the deep levator
mechanism. One method is to create 3–7 fixations between
the aponeurosis and the dermis–muscle of the inferior skin
edge. The skin is thus anchored to the levator mechanism
and will be hidden by the overhanging skin fold (i.e., the
upper skin flap). Alternatively, the dermis–muscle can be
fixed to the superior edge of tarsal plate – a procedure that
Fig. 11.6  Subclinical ptosis
correction using levator aponeurosis-
Müller muscle complex
advancement with incisional
methods.
B
Orbital septum
and underlying
(preaponeurotic) fat
Levator aponeurosis
C
A
D

356
SECTION I
CHAPTER 11 • Asian facial cosmetic surgery
subclinical ptosis correction as well as incisional levator
plication.105-108
The partial-incisional method is appropriate for patients
without redundant eyelid skin. It uses a combination of five- or
six-point dermotarsal fixation and one- or two-loop Müller
tucking sutures (Fig. 11.7). The double eyelid crease is made
using triangular single-knot sutures through five small slit
punctures on the eyelid. The blepharoptosis is addressed via
tucking of Müller’s muscle, which is performed through one
or two of the central slits. The tucking suture is passed through
the conjunctiva and passed through the posterior wall of con-
junctiva and is elevated 8–10 mm cephalad. After purchasing a
bite of the check ligament, the suture is brought back down
caudally. With the Müller’s muscle tucked, the suture is passed
through the skin (Fig. 11.7). Incisional blepharoptosis correction
is done as per conventional ptosis correction (Video 11.4
).
Medial epicanthoplasty
Medial epicanthoplasty is a very important component of
Asian eyelid surgery (Fig. 11.8).35 The techniques were origi-
nally developed for correction of blepharophimosis in Western
countries and were later adopted for changing the epicanthal
folds in Asian patients.
Traditional methods such as the Mustarde technique have
been used for epicanthoplasty, but such techniques have
Fig. 11.7  Subclinical ptosis correction using sustentation of levator aponeurosis-
Müller muscle complex advancement with non-incisional methods. This procedure
assures the sustentation to prevent bursting levator aponeurosis-Müller muscle
complex.
Leavator aponeurosis
Müller’s muscle
Tarsus
Conjoint fascial sheath
(check ligament of
superior fornix)
Fig. 11.8  (A) Medial epicanthoplasty with skin
redraping method. These skin redraping methods,
which have become very popular in Asia, include a
medial subciliary incision on the lower eyelid, which
makes a non-visible scar and resection/release of
medial epicanthal adhesions, procedures that can
minimized medial epicanthal scars and correct medial
epicanthus quite well. (B,C) Full incisional double
eyelidplasty and medial epicanthoplasty with skin
redraping method. For double fold formation in the
upper lid, traditional tarsodermal fixation through
incisional methdos has been an effective standard
method. In patient with redundant eyelid skin, the
incisional approach is unavoidable.
A
C
B
D
2
C
A
D
1
B
A
5
4
C
A
B
D
C
A
B
D
3
B
C

357
Asian blepharoplasty
Fig. 11.9  Lateral canthoplasty. (A) Lateral
canthoplasty to lengthen the lateral
canthal angle and correct the outer tail of
the eye.110 (B) Lateral canthoplasty using
Shin’s cosmetic lateral canthoplasty.111
(C) Lateral canthal lengthening with
triangular rotation flap.112
A
B
C
fallen out of favor because of the visibility of postoperative
scars.36,37 Such problems may be overcome by the half Z-plasty
technique, but the downside is limited release of the epican-
thal fold.36,38,39
Newer methods have therefore been developed to address
the visibility of scarring and incomplete release of the band.35,40
The skin redraping methods are representative of the newer
techniques and are very popular in Asia. These include a
medial subciliary incision on the lower eyelid to decrease
visibility of scars, and resection or release of medial epicanthal
adhesions (Fig. 11.8A,B). The disadvantage of skin redraping
methods is unnatural dimpling at the releasing point of
medial epicanthal adhesions (Video 11.1
).
Lateral canthoplasty
In Asian patients, the lateral canthus is around 8 mm higher
than the medial canthus and the palpebral fissure is not as
wide as it is in Caucasian patients. Lateral canthoplasty serves
to lower the lateral canthus and to increase the width of pal-
pebral fissure (Fig. 11.9).41 The Von Ammon local flap tech-
nique carries the risk of scar contracture, which may result in
an obtuse lateral canthal angle. Transpositional flaps may
be effective but can result in lower eyelid eversion in less
experienced hands. The combination of canthotomy and
canthopexy can be effective while minimizing complications
such as grayline defect, recurrence, or canthal deformity.
Lateral canthoplasty with lowering of lateral canthus is
becoming popular but remains controversial for the time
being.109
Postoperative care
Postoperative care for Asian blepharoplasty patients is similar
to that for blepharoplasty in Caucasians. Scarring is generally
not a problem, although excessive swelling can result in a
higher crease height than is desired. Postoperative instruc-
tions are as follows:
1. Cold compresses, as tolerated, for 24 h
2. Antibiotic ointment along the suture lines
3. Wound cleaning with water
4. Avoid use of cosmetics to upper eyelid for 7–10 days
5. Skin sutures may be removed in 4–5 days.
Outcomes, prognosis, and complications
Complications are similar to those observed during routine
blepharoplasty procedures and consist of asymmetry, pro-
longed swelling, loss of folds, multiple folds, milia, suture
granuloma, infection, and hematoma.
Asymmetry is the most common patient complaint from
Asian blepharoplasty, especially when combined with levator

358
SECTION I
CHAPTER 11 • Asian facial cosmetic surgery
plication or advancement. During the preoperative interview,
patients should be informed of the possibility that operative
revisions may be required for significant and persistent
asymmetry.
Characteristics of eyelid plasty in East Asians
East Asians have small eyes with an epicanthal fold, shallow
orbits, a low-profile nose with thick skin, flat faces with large
cheekbones and broad facial width.
The connection between the levator palpebrae superioris
muscle and the dermis, that transmits the force vector of
levator mechanism to the upper eyelid skin, is absent in Asian
patients without supratarsal fold.
The epicantholds fold exist in at least 50% of Asian adults.
Asian lid crease is generally 2-3 mm lower than that of
Caucasian eyelid. Less of the pretarsal skin is visible.
Inside folded eyelid crease that is parallel in lateral two
thirds would be mostly preferable.
Asian rhinoplasty
Introduction
Rhinoplasty ranks second only to blepharoplasty in terms of
popular aesthetic operations performed in East Asian coun-
tries. The rhinoplasty literature originating from Western
countries is based on nasal anatomy of Caucasian population,
with reduction and corrective rhinoplasty as commonly
discussed interventions. In contrast, there is a significant
anatomic variation between the “Western norm” and local
aesthetics in Asian populations. As such, augmentation of
nasal dorsum and tip is a primary concern for those surgeons
practicing in Asia, for whom the textbook anatomy does not
exactly mirror everyday clinical experience.42 The general
principle behind rhinoplasty is to enhance the harmony
between the nose and the rest of the face. While this principle
applies to all rhinoplasty patients, the technical and aesthetic
emphases can significantly vary, depending on the anatomy
of each patient and the cultural context within which the
patient presents to the clinic.
Differences in nasal anatomy between
Asian and Caucasian patients
Relative to the Caucasian counterpart, the Asian nose is
characterized by less height and length, less tip projection,
and a wider nasal base.86 The nasal septum is usually smaller
and thinner in Asian patients, and this anatomic difference
places significant limits on donor cartilage availability, espe-
cially in the context of septal extension graft. The overlapping
area between the nasal bones and upper lateral cartilages is
less than the typical 10-mm overlap observed in Caucasian
patients. Manipulation of the septal tissue is more hazardous
in Asian patients because of this reason. Another clinically
meaningful anatomic difference can be found in the soft-tissue
envelope over the nasal framework, which consists of a denser
fibromuscular layer along with thicker fatty layer. This is
especially true over the alar lobules.
Although variations exist across Asian populations, nasal
skeletons are generally smaller and more delicate in Asian
patients than in Caucasian patients (Fig. 11.10).43 Contrary to
the widespread preconception, the alar cartilage in Asian
patients is not markedly smaller than in Caucasian patients,
although there are morphological differences such as the
configuration and thickness of the cartilage or the length of
the footplate of the medial crus.87 Finally, the nasolabial angle
tends to be more acute in Asian patients due to a retracted
columella and premaxillary hypoplasia.44
Recently, four anatomic structures have been receiving
significant attention within the Asian rhinoplasty community.
These are the transverse nasal sling, scroll ligament, nasal
hinge complex, and dermocartilaginous ligament (Fig. 11.11).
The transverse nasal sling consists of the transverse nasalis
muscle aponeurosis, which provides adhesion from the nasal
envelope to the nasal bone and upper lateral cartilages (Fig.
11.11A). This sling should be released from the skeletal frame-
work in a meticulous manner, for sufficient development of
implant pocket and for surgical management of the contracted
or short nose (Fig. 11.11B). The scroll ligament refers to the
muscular fascial condensation between upper and lower
lateral cartilages. Release of the scroll ligament is vital for a
more complete alar mobilization (Fig. 11.11C,D). The nasal
hinge complex consists of the pyriform aperture, accessory
cartilage, connective tissue, and sesamoid cartilages. Release
of the nasal hinge may be necessary for alar pivot motion or
advancement. The lateral nasal artery passes along the nasal
hinge and, as such, caution is needed during the release of
nasal hinge complex. The dermocartilaginous ligament origi-
nates from the upper orbicularis oris muscle and inserts into
the nasal musculo-aponeurotic system (SMAS). Manipulation
of this ligament is necessary when correcting animation-
dependent nasal tip drooping.
Diagnosis
Patient interview and physical examination of the nose should
not vary across ethnicity. Nasal analysis is the same between
Asian and Caucasian patients.
Nasal dorsum
Most Asian patients wishing to undergo rhinoplasty have a
relatively low nasal dorsum. In recent years, patients have
been requesting augmentation of dorsal contour with simul-
taneous increase in tip projection. Height of the nasal dorsum
in such patients must be assessed in the context of the entire
lateral profile from the forehead to the lip and chin. The thick-
ness of nasal skin must also be considered, especially if the
augmentation will require alloplastic material. The thick soft-
tissue envelope offers a robust separation between the implant
material and the outside world. However, the thickness of
skin envelope correlates with resistance to tissue expansion,
and patients should be counseled on the limitation that thick
skin places on implant size and, subsequently, on dorsal
profile augmentation.
Nasal tip
The cartilaginous framework is extremely delicate in most
Asian patients, and this is universal in patients with an under-
projected nasal tip and can be assessed in a number of ways.49
The goal of examination should be to find a balancing point
between patient wishes and anatomic constraints of both the

358.e1
Historical perspective
Historical perspective
Rhinoplasty in Asian patients was first reported in 1964 by
Khoo Boo-Chai.44 Following this, Furukawa summarized the
important aspects of Asian rhinoplasty in 1974.14 He reported
anthropometric data for the Japanese population, identified the
optimal nasal profile for Asian patients, and described unique
Asian rhinoplasty techniques. Moreover, he introduced a mor-
phologically diverse set of silicone dorsal implants. In 1986,
McCurdy put a convincing argument for aesthetic goals of
rhinoplasty that applied to both non-Caucasian and Caucasian
noses.45 Parsa reported nasal augmentation with split calvarial
grafts in Asian patients in 1991.64 Columella lengthening for
nasal tip remodeling was reported by Shin and Lee in 1993,88
and Watanabe studied the alar anatomy of Asian patients
in 1994.89 In 1996, Han and Kang reported prefabrication of
nasal implants via curing of silicone adhesive, with satisfac-
tory results in Asian patients.46 These advancements in nasal
anatomy and surgical techniques specific to Asian patients
allowed for an ever-expanding list of rhinoplasty techniques
in the ensuing decades. Many of the mainstream techniques
have been fine-tuned to further improve aesthetic outcomes
and decrease complication rates. Management of complicated
and/or difficult rhinoplasty cases are now finding consensus
among a larger group of rhinoplasty surgeons practicing in
developed East Asian countries.

359
Asian rhinoplasty
of the Asian nose frequently necessitates dorsal augmenta-
tion. When provided with the option between alloplastic and
autogenous graft operations, patients will usually choose
the simpler procedure that does not require an additional
scar. While the issue of alloplastic graft complications is con-
troversial, proponents of alloplastic graft rhinoplasty have
reported low complication rates with careful patient selection
and technical modifications.
Autogenous augmentations are not without inherent
disadvantages (limited donor material, increased operative
time, resorption, and warping).47 The radix can be aug-
mented with a variety of tissues including fascia, conchal
cartilage, and diced cartilage. However, one needs to first
assess the nasofrontal angle and determine the correct loca-
tion for nasion, since operating on the radix may affect the
nasion.
Alloplastic materials
Alloplastic implants must be readily available, not associated
with donor site morbidity, easy to sculpt, and have smooth
contour. These requirements have lead to the introduction
of nasal implants based on materials such as silicone, nylon
(Supramid mesh); PTFE (polytetrafluoroethylene: Teflon,
Gore-Tex, Proplast), polyester (Mersilene), polyethylene
nasal tip and its relationship to remainder of the face. Dento-
alveolar protrusion can be found with some frequency in
Asian patients. If this contributes significantly to the percep-
tion of tip underprojection, rhinoplasty alone will not solve
the patient’s problem.
Surgical techniques and treatment
Low-profile nasal dorsum augmentation
(Video 11.3 )
Dorsal augmentation is performed widely in Asian countries.
However, the method of augmentation is not readily agreed
upon and appears to have a geographical pattern.47 In the
West, most surgeons prefer autogenous augmentation and
shun the use of alloplastic materials to avoid the associated
complications (infection, displacement, extrusion, and capsu-
lar contracture).
In East Asian countries, alloplastic materials are used
frequently, especially the case in South Korea. This difference
in alloplastic implant use reflects the anatomic difference
between Asian and Caucasian patients, as well as the cultural
norms between these two groups of patients. The low dorsum
Fig. 11.10  Although there are racial variations among Asians, nasal skeletons are generally smaller and weaker in Asians than in Caucasians.
A
B
C
D
E
F

360
SECTION I
CHAPTER 11 • Asian facial cosmetic surgery
Fig. 11.11  Recently, four anatomic structures have been emphasized to achieve a
successful Asian rhinoplasty. These include the transverse nasal sling, scroll
ligament, nasal hinge complex, and dermocartilaginous ligament. Contrary to popular
thought, the alar cartilage in Asians is not markedly smaller than in Caucasians,
although there are differences in the configuration and thickness of the cartilage and
the length of the footplate of the medial crus.
A
Nasalis
(transverse part)
B
C
D
E
(Medpor), and hydroxyapatite.48 Despite complications such
as extrusion, translucency, displacement, and infection, sili-
cone continues to be the most widely used type of rhinoplasty
implant material in Asia, where the specific risks have been
mitigated by following the basic tenets of alloplastic graft
implantation.
One such principle is to “replace like with like”. Silicone
implants have mechanical properties similar to that of the
cartilaginous vault. However, this similarity does not extend
into the nasal tip, and silicone implants in the nasal tip carry
a high risk of extrusion, infection, and deformation. For this
reason, silicone-based implants should be trimmed short
of the nasal tip. Additionally, the implant pocket must be
dissected symmetrically to prevent implant deviation from
the midline. The underside of implant should be prepared to
fit the contour of underlying skeletal framework, and the
implant surface can be scored or perforated to allow tissue
ingrowth. Finally, the cephalic end of the implant should be
placed halfway between the eyebrows and the intercanthal
line (Fig. 11.12).

361
Asian rhinoplasty
reluctant to choose this option because of the additional scar
and other issues specific to costal cartilage grafts. Even if
patients are willing, the surgeon must take into account the
additional operative time and carving techniques. Despite
concentric carving or lamination, the graft can still warp and
may require the use of internal K-wires to stabilize the graft.52,57
Temporalis fascia and the fascia lata have also been used
for minimal dorsal augmentation and for salvage rhinoplasty
following failed alloplastic graft augmentation.49 In recent
years, diced cartilage has be incorporated into temporalis
fascia for dorsal augmentation.54,58–60 In this technique, autolo-
gous cartilage (septal, conchal, or costal) is diced into 1-mm
cubes and rolled into a cylindrical fascia graft, which is then
used as a dorsal onlay graft.61 Histologic studies have con-
firmed the long-term survival of diced cartilage.60,62 Diced
cartilage can also be used without fascia to fill in smaller
defects and for minor dorsal augmentations.60,63 Split calvarial
bone and bone grafts from other anatomic regions have also
been used to augment the nose.64 Although bone graft aug-
mentations do not undergo significant resorption, donor site
morbidities in harvesting bone grafts have made these less
than popular. Dermofat grafting is another useful alternative.
While it is associated with unpredictable rates of resorption,
this soft-tissue graft is versatile, in that it allows a sizeable
graft to be harvested and it can be used in both primary and
secondary operations.
Each type of implant/graft source has specific limitations,
advantages, and disadvantages (Table 11.1). Plastic surgical
history is full of lessons on how patients are much more likely
to suffer from complications when large alloplastic implants,
of any type, are placed under a thin or very tight overlying
tissue envelope. This holds true for the dorsal augmentation
rhinoplasty, and the primary determining factor for type
of graft is the amount of nasal profile that needs to be
augmented.
The offset between the nasal bridge and the line between
lash line to the supratip is a highly objective method of assess-
ing dorsal deficiency.63,65 Dorsal augmentation of less than
3 mm can be accomplished with septal cartilage, diced carti-
lage alone, or rolled fascia grafts. Alloplastic materials, diced
cartilage in fascia, or costal cartilage are indicated for augmen-
tations between 3 and 5 mm. Autogenous costal cartilage is
preferred for augmentations greater than 5 mm. All other
things being equal, autografts are preferable for patients with
thin skin, in all secondary cases, and for failed implant-based
augmentations.
Nasal tip plasty
The nasal tip is a significant challenge for Asian rhinoplasty
surgeons, as the majority of patients present with a relatively
underprojected nasal tip. Surgical techniques designed to
improve nasal tip projection in Caucasian patients have been
found to be far less effective in Asian patients, due to the deli-
cate cartilaginous structure and the thicker overlying soft
tissue.
First and foremost, nasal tip remodeling begins with a solid
structural foundation, which is usually addressed by a com-
bination of autologous cartilage grafts and/or suture tip
techniques. One potential side effect of increasing projection
is cephalic rotation of the tip, with resultant nostril show
and nasal shortening.49 This highly undesirable side effect of
Homografts
Cadaveric costal cartilage for dorsal augmentation is an
attractive alternative to alloplastic materials, as it is also
readily available, without donor site morbidity or additional
operative steps.49,50 However, graft warpage is a problem,
even with the use of balanced cross-sections.51 Also, graft
resorption creates a significant issue for patients and surgeons
because of the unpredictable postoperative results beyond the
first few months.49–53 For this reason, homografts are used in
specific revision rhinoplasty operations where patients are
reluctant to use their own costal cartilage.
Autografts
For dorsal nasal augmentation, many surgeons feel that
autografts hold distinct advantages over other types of grafts,
provided that one takes into account tissue availability, donor
site morbidity, increased operative time, and operator experi-
ence. Autografts are well tolerated by the body and have been
shown to survive long term. When compared with other
materials, autografts have the lowest risk of infection.49,54
Septal cartilage can be sufficient for minor dorsal augmenta-
tion. However, this is a significant limitation in most Asian
patients due to the difference in septal anatomy.43 The use of
septal cartilage is not an option in a patient who had already
undergone a primary rhinoplasty operation using septal car-
tilage as a graft.49,55
As an alternative, the conchal cartilage may be used for
minor dorsal augmentation.56 The curved conchal cartilage
must be modified to fit the nasal dorsum and is more appro-
priate for remodeling the nasal tip.
For most Asian patients, the tissue requirements for dorsal
augmentation often exceed the volume and strength provided
by either septal or conchal cartilage. When autogenous graft
must be used in a patient with significant dorsal deficiency,
costal cartilage is the only significant source of cartilaginous
graft. Despite this, a significant proportion of patients are
Fig. 11.12  The most popular nasal tip plasty methods with cartilage graft in Asian.
Alloplasts may be used for dorsal augmentation but should not extend to the nasal
tip. It is well known that alloplastic materials extending to the nasal tip carry a high
risk of extrusion, infection and deformation of the nasal tip. The implant pocket
must be symmetrically dissected to prevent implant deviation from the midline.
Columella strut graft
Septal
extension graft
Shield graft
Tip graft
Derotation graft
Tip extension suture
Alloplastic material for dorsal
augmentation
(mainly with silicone implant)

362
SECTION I
CHAPTER 11 • Asian facial cosmetic surgery
various tip suture techniques, including transdomal and
interdomal sutures.90 The tip-extension suture method can
also be helpful.66,70 Following release of the alar cartilages, the
dorsal portion of alar cartilages is sutured to the septum to
provide stability to nasal tip projection (Fig. 11.14).
Strut graft
Two types of strut grafts are possible. The floating type of
strut graft has been reported to yield 1–2 mm of tip projection
in Caucasians.56 However, floating strut grafts do not seem as
effective in Asian patients with thicker nasal skin and more
delicate alar cartilages. Because of this, strut grafts are usually
fixed to the anterior nasal spine, while accepting the trade-off
in stiffer nasal tip (Fig. 11.15). Sources for strut grafts include
the septum, concha, rib cartilage, and homologous rib carti-
lage. Care must be taken to avoid asymmetry from cartilage
warping. Alloplastic materials should be avoided at all costs
in this area.
Onlay graft
Onlay grafts provide an additive method of increasing projec-
tion. The grafts should be morselized and be free of sharp
edges to avoid graft visibility, especially in patients with
thinner skin.
Septal extension graft
Septal extension grafts (Fig. 11.16) were originally developed
to address the contracted nose.66,93,94 Rhinoplasty surgeons in
Asian countries have adopted this graft to increase nasal tip
projection without cephalic rotation of the nasal tip and to
derotate of short noses.59,68,92 Since Asians patients often have
thin septal cartilages, septal extension may require additional
support from batten type grafts. In South Korea, septal exten-
sion grafts are categorized into three types: direct extension,
tip projection has prompted a number of techniques that
simultaneously increase nasal tip projection and control
cephalic rotation. In the most contemporary procedures,
Asian rhinoplasty often includes the division between the
upper and lower lateral cartilages – a maneuver that allows
separation of projection and rotation of the lower unit. The
projected and caudally rotated tip is fixed in the new position
and orientation with the use of septal extension graft and
derotational conchal cartilage graft (Fig. 11.13A–E).
Current trends in nasal tip remodeling in Asian countries
are at odds with the classical understanding of nasal tip bio-
mechanics. The tripod theory was first suggested by Anderson
in 1969 and is based on the three legs of the paired lateral crus
on pyriform apertures and conjoined medial crus on columella
base (Fig. 11.14A). However, the use of septal extension graft
and/or derotation grafts suggests that a fourth tensor-stress
vector might be at play in determining the position and ori-
entation of the nasal tip. This additional element was discussed
in detail by Lamson, who reasoned that the caudal septum
provides major mechincal support to the nasal tip. As rhino-
plasty is currently practiced in Asian countries, an increasing
number of rhinoplasty surgeons appear to be following the
“quadripod” concept of the nasal tip, with the anterior caudal
septum as the fourth leg (Fig. 11.14B).103 In other words, I
would rather call it ‘septum based nasal tip plasty’. The data
for long-term stability of these nasal tip techniques should
become available for review within this decade.
Tip suture methods for nasal tip projection
Suture methods based on the tripod principle can be applied
to Asian patients, but in most situations, a suture technique
by itself will not be adequate and result in an upturned nose.
To prevent cephalic rotation of the nasal tip, the alar cartilages
must first be released and reoriented prior to suture fixation.
The mobilized nasal tip can then be projected effectively with
Table 11.1  Advantages and disadvantages of different graft materials for nasal dorsum augmentation
Autogenous material
Alloplastic material
Materials
Dermofat graft
Rib cartilage
Diced cartilage
Silicone
Goretex
Silitex
Composition
Dermis and
subcutaneous
fat
Cartilage
Cartilage
Polydimethlysiloxane
Expanded PTFE
(polytetrafluoroethlylene)
with 10–30 µm pore
structure
Silicone
covered
by e-PTFE
Advantage
No foreign body
reaction
No capsule
formation
No calcification
No foreign
body
reaction
No capsule
formation
No calcification
No foreign
body
reaction
No capsule
formation
No calcification
Predictability in
dorsal height
Immobilization
Minimal capsule formation
Predictability
in dorsal
height
Minimal
capsule
formation
Less mobility
Disadvantage
Decreased
predictability
of contour
owing to
absorption
Warping
Donor site
morbidity
Increased
surgical time
Donor site
morbidity
Increased
surgical time
Foreign body
reaction
Capsule formation
Calcification
Infection
Decreased predictability in
contour
Difficulty in removal owing
to adhesion
Infection
Difficulty in
carving
Difficulty in
removal
owing to
adhesion
Infection

363
Fig. 11.13  The modern Asian rhinoplasty often includes separation of the upper and lower lateral cartilages, a maneuver that allows mobilization of the lower lateral
cartilages and improves tip projection with various maneuvers while minimizing the risk of unwanted tip movement. After freeing the cartilage complex, fixation is achieved
with a septal extension graft and derotational conchal cartilage graft. These techniques are gaining acceptance as standards in Asian rhinoplasty although controversy still
exists regarding the long-term stability of these grafts and their effect on nasal tip projection.
A
C
D
E
B
Fig. 11.14  (A) Anderson’s nasal tip tripod
concept. (B) Quadripod concept including septal
support.
A
B

364
SECTION I
CHAPTER 11 • Asian facial cosmetic surgery
paired spreader, and paired batten grafts.91 Complete release
of soft-tissue constraints and secure fixation of the extension
graft provide long-term stability of nasal tip projection and
derotation (Video 11.5
).
Derotation graft
The derotation graft lengthens and projects the nasal tip
complex at the same time. Prior to the introduction of derota-
tion graft by Paik, cephalic rotation was most commonly
addressed by rigid fixation of the mobilized alar cartilage
complex. This technique was developed to allow a secure
connection between the middle vault and lower cartilages
while allowing cephalocaudal flexibility. The graft itself is
usually fashioned from conchal cartilage and interposed
between the upper lateral cartilages and the mobilized alar
cartilage complex (Fig. 11.16). Mechanically, this graft serves
as a hinge between the rigid upper frame and pliable lower
complex.69
When the ear cartilage is harvested for this purpose, the
cymba concha is used for columellar struts and derotation
graft, whereas the cavum concha is utilized as onlay graft.71
The operation is not technically demanding and provides
stable result. However, supratip bulging is a known issue for
this procedure.
Rib cartilage graft
Rib cartilage grafts were originally used to reconstruct saddle
nose deformities but have found applications for septal exten-
sion and fixed struts. Rib cartilage grafts also serve as the
salvage material for secondary correction of contracted noses,
for which there are no other options.63 While some advocate
the use of rib cartilage graft for primary operation, this is
considered a controversial approach.
Outcomes, prognosis, and complications
Compared to Caucasian counterparts, Asian patients are more
prone to experience hyperpigmentation, hypertrophic scar-
ring, and prolonged edema. As such, patients should be
properly informed of these risks during the preoperative
process. Other complications include asymmetry of the
dorsum, ala, or nostrils. Graft visibility does occur but is not
as common a problem because of the thick nasal skin in Asian
patients.
Implant deviation
Implant deviation is the most common complication after
augmentation rhinoplasty in Asian patients. This complication
typically occurs when alloplastic materials have been placed
into an asymmetric pocket through a unilateral vestibular
incision via closed approach. This can be prevented by bilateral
incisions when creating the pocket in the closed approach. In
the open approach, midline fixation of the implant to the
cartilaginous framework may prevent implant movement. For
both closed and open approaches, the most critical factor in
preventing implant deviation is precise pocket dissection.
Exposure and infection of alloplastic implant
Visibility, redness, infection, and skin thinning may indicate
inevitable exposure of implant. Infected alloplastic materials
should be removed, with revision rhinoplasty performed after
a minimum delay of 3 months. Removal of the implant alone
does not prevent subsequent implant failure, and the result-
ing volume defect should be addressed using autogenous
tissue. In Korea, dermal–fat grafts are most frequently used
in such patients. Other types of autogenous grafts include rib
cartilage, bone, and diced cartilage.
Capsular contracture
Capsular contractures may occur around any alloplastic
implant and become a cause for deformity and/or implant
extrusion. Capsular contracture is managed with removal of
the fibrous capsule, release of the scar adhesion and nasal
envelope, and reconstruction of the deformed cartilage
framework.
Secondary procedures
Forehead augmentation
Augmentation rhinoplasty addresses the lateral profile of the
midface. Simultaneous forehead augmentation can further
Fig. 11.15  A 22-year old Asian female patient who underwent the septum based nasal tip plasty based on the quadripod concept accompanied by the mild humpectomy.
A
B
C

365
Asian rhinoplasty
Fig. 11.16  Derotation grafting involves placement of conchal cartilage grafts on
midline scroll area in order to prevent the cephalic rotation of the alar cartilage
complex. These grafts lengthen and project the nasal tip complex at the same time
in the long term. Cymba concha is used for columellar struts and derotation grafts,
whereas cavum concha is used for onlay grafts.
A
B
C
D
E
F

366
SECTION I
CHAPTER 11 • Asian facial cosmetic surgery
enhance the lateral profile for patients with flat forehead and
low dorsum. Traditionally, custom-made silicone or PTFE
implants have been used for forehead augmentation, despite
the possibility of seroma and implant-related complications.95
Microfat grafting or augmentation with various cements may
also be used to improve the forehead profile in patients
undergoing rhinoplasty.
Paranasal augmentation
Asian patients presenting with low dorsum or contracted nose
frequently have simultaneous hypoplasia of the paranasal or
premaxillary area. As such, concomitant augmentation of both
the nose and paranasal areas has become quite popular in Asia.
Paranasal augmentation can be performed using PTFE,
silicone, or polyethylene implants. This procedure is associ-
ated with higher rates of inflammation or chronic infection,
when compared with alloplastic implants in the nose, and
patients should be properly informed of this. Microfat grafts
may also be used for paranasal augmentation.
Alar base surgery
Many patients presenting to Asian rhinoplasty surgeons are
also concerned with the width of the nasal base. The biggest
concern with this operation is the very real risk of visible
scarring, and patients must be completely aware of this fact
prior to consenting to the operation. Careful patient selection
is an important responsibility of the surgeon. When a clear
indication exists, alar base surgery should be performed only
after completion of dorsal augmentation and/or tip remodel-
ing. In some instances, nasal tip augmentation may narrow or
give the appearance of a narrower nasal base, and the patient
may no longer need an alar base operation.
Genioplasty
As in Caucasian patients, chin projection should always be
considered in relation to nasal tip projection and overall
profile of the face. Both osseous genioplasty and augmenta-
tion genioplasty with alloplastic materials can yield highly
satisfactory results. In the long run, however, osseous genio-
plasty is recommended because genioplasty with alloplastic
materials is associated with high rates of complications
such as contracture, infection, bony erosion, and implant
displacement.
Characteristics of rhinoplasty in East Asians
Asian nose is characterized by less height and length of the
nose, less tip projection and a wider nasal base. The septum
is usually smaller and thinner. Soft tissue envelope over the
nasal framework consists of a denser fibromuscular layer
along with thicker fatty layer.
The management of the four anatomic structures such as
the transverse nasal sling, scroll ligament, nasal hinge complex
and dermocartilaginous ligament are crucial in modern Asian
rhinoplasty.
Nasal dorsum and nasal tip should be managed separately.
Modern Asian nasal tip plasty seems like based on the
septum based nasal tip plasty such as the septal extension
graft, derotation graft or tip extension suture as well as the
onlay graft and columellar strut.
Asian facial bone surgery
Introduction
Although the standards of facial beauty have changed over
time, certain features remain constant. Many studies have
shown that symmetry and averageness could be the overall
standards for beauty profiles.72 Throughout history, humans
have attempted to define beauty objectively. Beauty can be
measured by various methods, including artistic standards,
cephalometric standards, and anthropometric analysis.72,73
There is no perfect way to define beauty. Therefore, it would
be wise to use both subjective and objective tools for analysis
of facial profiles according to ethnic standards.
Facial bone contouring surgery has strong roots in local-
ized mandibular angle and malar reductions, and has evolved
to address the whole facial profile. Profiloplasty is a popular
term in contemporary aesthetic facial bone surgery, and it
deals with whole profiles from both frontal and lateral per-
spectives of the face. In order to get the ideal facial proportions
and shape, surgeons need to change each portion based on
the ideal proportions of the face.
Diagnosis and indications
Total facial profiles
The facial profile is largely divided into the upper, middle,
and lower thirds. Aesthetic facial contouring surgery is based
on the premise that ideal facial proportions do exist and that
this ideal can be achieved through a combination of forehead
plasty, rhinoplasty, malarplasty, mandibuloplasty, and/or
genioplasty.96 Orthognathic surgery can markedly correct
mid- and lower facial profiles. Based on occlusion, the facial
profile in three dimensions should be evaluated as a whole
for the successful total facial profiloplasty.
Prominent mandible
Mandibular prominence occurs in both frontal and lateral
profiles. On frontal view, prominent mandibular angle con-
tributes to the masculine appearance of a square jaw, which
is an issue for female patients. On lateral view, prognathism
is characterized by acute gonial angle and mandibular protru-
sion. Evaluation of the mandible, however, should not be
limited to reduction of the prominence in just these two pro-
files. Instead, the overall shape of entire mandible is to be
considered in the context of whole facial contour.
Prominent zygoma
Prominent cheekbones are considered attractive by both
Western and Eastern standards of beauty, but the discrepancy
lies in its interpretation. Where it is a sign of youthfulness and
considered a feminine facial feature in Western countries,
prominent cheekbones are associated with assertiveness and
masculinity in the East.
Horizontal dimensions, including bitemporal width, are
helpful in assessing the lateral component of the zygomatic
protrusion, especially that of the arch. Though anterior projec-
tion is also considered, this component of the zygoma should
be preserved as much as possible to retain the youthful

366.e1
Historical perspective
Historical perspective
Malarplasty
Reduction malarplasty, first reported in 1983 by Onizuka and
colleagues, is based on underpositioning of the osteotomized
zygoma through an intraoral approach.73 In 1988, Baek et al.
reported 94 cases of reduction malarplasty using a coronal
approach. In that series, the malar prominence was reduced
via an in situ transposition osteoplasty or via the extraction,
ex vivo contouring, and implantation of the malar complex.74
In 1993, Satoh and Watanabe reported outcomes following
tripod osteotomy and simultaneous frontoperiorbital lifting
through coronal approach in Japanese patients.105 Cho com-
pared the results of the intraoral and bicoronal approaches.76
Subsequently, Baek and Lee reported that intraoral malar
reduction could result in cheek drooping and recommended
a combination of reposition malarplasty and facelift to address
this issue.74
Mandibuloplasty
Baek et al. had first reported the mandible angle ostectomy of
42 Asian patients in 1984, and subsequently in 1994, reported
technical refinements based on anatomic classifications of the
mandible.3,75 The gonial angle stripper, by Kyutoku et al., was
also introduced in 1994.97 Satoh reported a combined approach
to mandibular contouring operation, by which both the
gonion and mandibular angle were remodeled simultane-
ously.77 Significant volume changes in osseous mandible and
masseter muscle were reported by Lo et al. in patients who
had undergone mandibular contouring operations.78 In Korea,
long-curved osteotomy was recently introduced to reduce the
body and angle of the mandible.
Orthognathic surgery and anterior
segmental ostectomy
Orthognathic method of addressing dentofacial deformity
was first reported by Obwegeser in 1957.79 Following this, the
Baek brothers reported advancement of central portions of
maxillary and mandibular bones via anterior segmental
osteotomies.80 Taiwanese plastic surgeons Yuray Chen, Philip
Chen, and Lunjou Lo have played important roles in develop-
ing orthognathic surgery suitable for Asian patients. Recently
in Korea, orthognathic surgery is being performed for aes-
thetic reasons. Entirely new concepts such as clockwise rota-
tion of the maxillomandibular complex and surgery-first
orthognathic surgery have been developed and accepted as
standard methods in South Korea.

367
Asian facial bone surgery
occlusal plane and overall facial ratios. In addition, the subjec-
tive expectation of the patient should be explored during
consultation and preoperative planning phase.
Mandibuloplasty is usually performed with an oscillating
saw via intraoral approach. Meticulous subperiosteal dissec-
tion is important to minimize bleeding and postoperative
edema. Critical anatomic structures must be respected, and
these include the inferior alveolar nerve, the facial artery, and
the retromandibular vein. In women, the average distances of
the inferior alveolar nerve from the mandibular angle are
23.69 mm for square faces versus 20.66 mm for normal faces.
In men, the respective distances are 27.30 mm and 23.28 mm.81
Ostectomy is divided into three different patterns:
■ Curved ostectomy accompanied by narrowing
genioplasty. This procedure deals with the mandibular
angle, body and the chin.
■ Long-curved ostectomy: This procedure is indicated in
patients with a prominent mandible angle with wide
mandibular body and chin. Simultaneous reduction of
the mandibular angle and body can result in a much
smaller lower facial contour (Fig. 11.18).
■ External cortextomy with a reciprocating saw: This tangential
ostectomy of the external cortex of mandibular ramus is
performed to narrow the bigonial distance in mandibles
with lateral flaring in frontal view. This procedure alone,
however, may not be sufficient in creating a smooth
lateral contour.82
Following ostectomy, the secondary angle is smoothed out by
burring or by multiple smaller ostectomies.
appearance of midface and to minimize postoperative droop-
ing. In modern malarplasty, the overall shape and position of
the malar bone is emphasized to a higher degree than mere
size of cheekbones.
Chin
Genioplasty in Asian patients, either for reduction or advance-
ment, is a similar to those performed for Caucasian patients.
Park reported the narrowing genioplasty, which makes the
lower face appear slender and therefore makes the chin appear
more feminine. This procedure is appropriate for trapezoid or
broad chin morphology.
Dentoalveolar protrusion
Anterior segmental setback ostectomy (ASO) is indicated in
the case of bimaxillary protrusion. Dentoalveolar protrusion
is a common tendency in Asian patients and may require
orthodontic treatment or ASO. Mild dentoalveolar protrusion
might be better treated with orthodontic treatment alone, with
ostectomy reserved for patients with significant protrusions.
Surgical techniques and treatments
Mandibuloplasty (Fig. 11.17)
Mandibuloplasty is a modern term and implies reshaping of
the whole mandibular contour (i.e., angle, body, and chin).
The mandible should be examined for factors such as man-
dibular width, length, height, and curvature – along with the
Fig. 11.17  Mandibuloplasty. “Mandibuloplasty” is a modern term and implies the reshaping of
the whole mandibular contour including angle, body, and chin. (A) Long curved mandibuloplsty.
(B) Narrowing genioplasty with mandibuloplasty. (C) External corticotomy.
A
B
External corticotomy
C

368
SECTION I
CHAPTER 11 • Asian facial cosmetic surgery
Fig. 11.18  Long-curved mandibuloplasty. In order to get the ideal mandibular shape, the various factors should be considered such as mandibular width, length, height,
and curvature, along with the occlusal plane and overall facial profiles.
A
B
Fig. 11.19  Malarplasty. Modern malarplasty involves
repositioning of the malar bone onto the ideal location using
reduction, setback, or upward movement of the malar bone.
The protrusion of malar can be categorized into one of three
types, such as anteroposterior, oblique, and lateral
protrusions. Based on the movement vector, there are the
simple reduction, setback, and rotational malarplasties.
A
B
Malarplasty (Fig. 11.19)
The older concept of malar reduction had reducing the bizy-
gomatic width in a single coronal dimension as the primary
goal. In contrast, modern malarplasty aims for complete
three-dimensional repositioning of the malar bone into the
desired location (i.e., reduction for lateral, setback for antero-
posterior, and upward movement for oblique displacements).
Each movement vector can be accomplished by simple reduc-
tion, setback, or rotational malarplasty. For example, the
conventional simple zygomatic arch reduction is sufficient for
patients who have lateral protrusion of the zygoma with
conspicuous zygomatic arch. However, patients with promi-
nent zygoma often have a significant anterior protruding
component, and this requires posterior setback of the malar
bone in addition to simple arch reduction. Currently, most
Asian plastic surgeons prefer linear osteotomy without bony
removal, while maximizing the stability of malar bone using
plate fixations (Fig. 11.20).
Intraoral infracture technique with incomplete osteotomy
To overcome the limits of intraoral malar reduction, this
procedure may be useful (Fig. 11.19). Infracture of the malar
bone is helpful in decreasing the risk of postoperative soft-
tissue ptosis and malar reunion. Additionally, the bony step
in the malar area often requires burring for smoother contour.
This method may require secure zygomatic arch fixation.
Bicoronal approach
A bicoronal incision is deemed too morbid, aesthetically
speaking, for simple cases of malar reduction. However, the

369
Asian facial bone surgery
Fig. 11.20  Malarplasty with mandibuloplasty. Most Asian plastic surgeons prefer the linear osteotomy without bony removal, while maximizing the stability of malar bone
using plate fixations.
A
B
A
approach allows enough exposure of the malar comlex for
precise multi-vector mobilization. This approach may be
advantageous in middle-aged and elderly patients because it
allows simultaneous lifting of the forehead.
Narrowing genioplasty
Various operative techniques have been introduced to alter
the chin shape: (1) narrowing genioplasty decreases the trans-
verse width of the chin; (2) long-curved ostectomy including
symphyseal or parasymphyseal; and (3) modified reduction
genioplasty. For all techniques involving chin contouring, care
should be taken to avoid injury to the mental nerve.
Narrowing genioplasty, either as a single procedure or
in combination with mandible reduction or orthognathic
surgery, makes the lower face appear slender and produces
a more feminine chin contour (Fig. 11.21). Soft-tissue attach-
ment of the chin is maintained to produce a maximum
narrowing effect and maintain the blood flow to bony seg-
ments. Horizontal osteotomy and two vertical osteotomies
are designed as shown in Fig. 11.21. The amount of resec-
tion in the central segment is determined preoperatively,
depending on the width of chin and patient preference. The
two segments are approximated centrally and fixed with
microplates and screws. These segments can be projected
anteriorly as necessary to correct the profile from lateral view.
Aesthetic Orthognathic surgery
Surgical treatment objectives for aesthetic orthognathic surgery
differ for Caucasian and Asian patients in that dentoalveolar
Fig. 11.21  (A) Narrowing
genioplasty.
Continued

370
SECTION I
CHAPTER 11 • Asian facial cosmetic surgery
B
C
protrusion is more common in the latter group. For example,
most cases of class III prognathism are addressed by maxil-
lary advancement and mandibular setback procedures in
Western countries. However, this conventional maxillary
advancement results in undesirable aesthetic outcomes in
Asian patients because the orientation of the occlusal plane
is not addressed. For this reason, clockwise movement of the
maxillomandibular complex is more appropriate for the Asian
patients with prognathism.
The maxillomandibular complex is moved in a clockwise
manner by posterior impaction of the maxilla and auto-
rotation of the mandible (Fig. 11.22).102 Modern aesthetic
orthognathic surgery has been focusing on the maximal use
of the change of occlusal plane-altering orthognathic surgery
is one example where the power of a change in the occlusal
plane is used to improve facial proportions (Fig. 11.23A,B).
Alteration of the occlusal plane using clockwise rotation or
counter-clockwise rotation is useful for improving the aes-
thetic proportions and posterior pharyngeal airway.101,102 In
addition, counter-clockwise rotation of the maxillomandibu-
lar complex is also useful in patients with obstructive sleep
apnea.
Surgery-first orthognathic approach (Fig. 11.24)
The surgery-first approach to orthognathic management is a
relatively new concept and represents a major paradigm shift
in orthognathic surgery.100,101 The standard management of
dentofacial deformity using orthognathic surgery consists of
the following sequence: pre-surgical orthodontic treatment,
orthognathic surgery, and post-surgical orthodontic treat-
ment. The aim of pre-surgical orthodontic treatment is mobi-
lization of dentition in the correct position within the basal
bone during the dental decompensation process. However,
complete decompensation may not be possible because of
mastication forces and spontaneous dental compensation
in opposition to the decompensating force. Therefore, post-
surgical orthodontic treatment is generally suggested.
The characteristics of the surgery-first approach are as
follows: (1) The post-surgical orthodontic treatment directs
the decompensation process in line with spontaneous dental
compensation and muscular forces following orthognathic
surgery. This alignment of forces decreases time required
for full decompensation.104 (2) Inevitable aggravation of
facial aesthetics during the pre-surgical orthodontic treat-
ments is avoided in the surgery-first approach. (3) It is a
Fig. 11.21, cont’d
(B) Reduction genioplasty.
(C) T-shaped osteotomy of
genioplasty.

371
Asian facial bone surgery
Fig. 11.22  (A),(B) The clockwise maxillomandibular
complex movement can be done by posterior impaction
of the maxilla and autorotation of the mandible. Currently,
this clockwise rotational orthognathic surgery in
prognathic patients is becoming quite popular in Asia.
(C) Clockwise rotation of the maxillomandibular complex
around a point at the A point. (D) Counter clock-wise
maxillomandibular rotation for the Class II dentofacial
deformity at the A point.
A
B
C
D
taken to preserve the palatal mucosa. Preoperative and post-
operative orthodontic treatments are mandatory for predict-
able results.
Combined ASO, orthognathic surgery with
facial contouring surgery
In order to maximize aesthetic outcomes, Asian plastic sur-
geons have been trying various combinations of orthognathic
surgery, ASO, and facial bone contouring operations.98 In
patients with severe dentoalveolar protrusion, the orthogna-
thic surgery with ASO is a good alternative to the traditional
option of orthognathic surgery with premolar teeth extrac-
tion. Today, orthognathic surgery is often combined with
mandibuloplasty and/or malarplasty in Korea since it can
restore the patient’s profile dramatically. However, this repre-
sents extensive remodeling of the facial bone and may
surgeon-oriented approach. (4) For the skeletal-first and
dentition late-correction approaches, an accurate preoperative
dental model is mandatory to simulate immediate postopera-
tive dental occlusal status, which is important for stability of
the actual postoperative occlusion (Fig. 11.25).
Bimaxillary protrusion: anterior
segmental setback ostectomy
In this procedure, the anterior portions of LeFort I segment
and mandible are osteotomized and set back. To accommodate
for this posterior movement, the first or second molar needs
to be extracted prior to or at the time of operation. For anterior
segmental ostectomy of the maxilla, two different pedicles can
be used. The palatal pedicle is commonly used for the buccal
approach, which provides improved exposure and is techni-
cally less demanding. During these procedures, care must be

372
SECTION I
CHAPTER 11 • Asian facial cosmetic surgery
Fig. 11.23  Aesthetic occlusal plane altering
orthognathic surgery accompanied by the mandibular
contouring surgery. Alteration of the occlusal plane using
clockwise rotation or counter clockwise rotation is a very
useful tool for correcting aesthetic disproportions and
posterior pharyngeal airway function. Modern aesthetic
orthognathic surgery has been focusing on the maximal
use of the change of occlusal plane in order to get the
ideal facial proportions.
A
B
C
D
adversely affect various functions of the face. As such, such
combination procedures require proper preoperative simula-
tion and planning (Fig. 11.26A–C).
Outcomes, prognosis, and complications
Malarplasty
Intraoperative complications are rare for malarplasty. Long-
term complications include drooping of cheek tissues and
malar bone nonunion. Excessively wide dissection can release
the zygomatico-cutaneous ligaments, which is the anatomic
basis for soft-tissue ptosis. Poor fixation of the osteotomy can
lead to nonunion. Unfortunately, fixation of the malar complex
in the superior–medial direction is not easy via the intraoral
approach. The bicoronal approach can solve this problem by
providing access for secure fixation. An alternative method of
reducing the risk of malunion is the infracture technique with
a green-stick fracture. Less invasive approaches with minimal
dissection are being introduced to further reduce the incidence
of complications associated with open approaches.
Mandibuloplasty
Mandible angle reduction is associated with various compli-
cations.75 The most critical complications are condyle fracture
caused by a wayward osteotomy, massive bleeding from the
retromandibular vein or facial vessels, and damage to the
mental nerve. Condylar fracture must be avoided by precise
ostectomy around the posterior border of the mandible, which

373
Asian facial bone surgery
Fig. 11.24  The surgery-first orthognathic approach is a new concept and major paradigm shift in
orthognathic surgery. However, a simulation surgery using a dental model is performed before surgery to
create the appropriate wafer and estimate the extent of post-surgical orthodontic treatment. This pre-surgical
procedure is a critical step in our surgery-first approach. The overall procedure is carried out as follows.
(A) Preoperatively, the standard model mounting process is performed to assess the patient’s occlusion.
(B) In the model setup, teeth that are already adapted into the skeletal discrepancy are simulated and
reorganized into their predicted location. Then simulation of actual orthognathic surgery similar to that of the
standard approach is done. (C) At this time, if we revert the position of the teeth to before pre-surgical
orthodontic treatment on the dental model using the original teeth model, we could get a model reflecting
the condition of orthognathic surgery without pre-surgical orthodontics. Based on the simulated model
surgery, intermediate and final wafers for orthognathic surgery without pre-surgical orthodontics are made.
A
B
C
Fig. 11.25  Surgery-first orthognathic approach (A) preoperative, (B) immediate postoperative, and (C) long-term postoperative lateral cephalometry. The characteristics of
the surgery-first approach are as follows. (1) The direction of the post-surgical treatment is in line with the natural direction of spontaneous dental compensation and
muscular forces following orthognathic surgery, thereby decreasing the time to full decompensation. (2) Inevitable aggravation of facial aesthetics during the pre-surgical
orthodontic treatments is avoided in the surgery-first approach. (3) Surgeon-oriented approach. (4) Skeletal first and dentition late correction approach.
A
B
C
is facilitated by adequate periosteal dissection and visualiza-
tion of the posterior border.99 The retromandibular vein cannot
be accessed easily through the intraoral approach. Direct
coagulation or other means of hemostatic control is not always
easy, and failure to control the bleeding must be addressed by
manual compression for a duration greater than 30 min. The
facial artery is sometimes injured during periosteal dissec-
tions, which can be addressed by manual compression or
direct ligation of vessel. Fortunately, facial nerve injury is rare
in mandibuloplasty.

374
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CHAPTER 11 • Asian facial cosmetic surgery
11. Romm S. The changing face of beauty. Aesthetic plastic surgery.
1989;13:91–8.
19. Baek SM, Kim SS, Tokunaga S, et al. Oriental blepharoplasty:
single-stitch, nonincision technique. Plast Reconstr Surg.
1989;83:236–242. The pioneer article for Asian mandible angle ostectomy.
40. Oh YW, Seul CH, Yoo WM. Medial epicanthoplasty using the skin
redraping method. Plast Reconstr Surg. 2007;119:703–710. This
technique has changed the concept of medial canthoplasty.
80. Baek SM, Baek RM. Profiloplasty of the lower face by maxillary and
mandibular anterior segmental osteotomies. Aesthetic Plast Surg.
1993;17:129–137. First article for Asian profiloplasty.
81. Jin H, Park SH, Kim BH. Sagittal split ramus osteotomy with
mandible reduction. Plast Reconstr Surg. 2007;119:662–669. New
concept of mandible angle ostectomy.
Access the complete reference list online at

Fig. 11.26  Surgery-first orthognathic approach combined with facial contouring surgeries. (A,B) Preoperative view without pre-surgical orthodontic treatment.
(C,D) Postoperative view with postoperative orthodontic treatment only.
A
B
C
D
Characteristics of aesthetic facial bone surgery
in East Asians
As the Asian facial skeleton is generally known to be wider
and less projected, the anterior-posterior projection and the
reduction in width are generally pursuing goal. However, in
order to get the ideal facial proportions and shapes, surgeons
need to change each portions based on the individual prefer-
ences and standards.
Occlusal plane altering orthognathic surgery is a powerful
tool in changing facial profile.
Surgery first orthognathic surgery is a new paradigm shift
in traditional orthognathic surgery.
Although the ASO(anterior segmental ostectomy) would be
a powerful tool in correcting the dentoalveolar protrusion, the
indications should be limited given the long-term outcomes.
Acknowlegement
I appreciate the help of Dr. Woo-Shik Jeong and Dr. Sung-Chan Kim.

374.e1
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combined use of a gull-wing concha composite graft and a rib
costochondral dorsal onlay graft. Plast Reconstr Surg.
2000;105:2190–2201.
72. Honn M, Goz G. [The ideal of facial beauty: a review]. J Orofac
Orthop. 2007;68:6–16.
73. Onizuka T, Watanabe K, Takasu K, et al. Reduction malar plasty.
Aesthetic Plast Surg. 1983;7:121–125.
74. Baek RM, Lee SW. Face lift with reposition malarplasty. Plast
Reconstr Surg. 2009;123:701–708.
75. Baek SM, Kim SS, Bindiger A. The prominent mandibular angle:
preoperative management, operative technique, and results in 42
patients. Plast Reconstr Surg. 1989;83:272–280.
76. Cho BC. Reduction malarplasty using osteotomy and repositioning
of the malar complex: clinical review and comparison of two
techniques. J Craniofac Surg. 2003;14:383–392.
77. Satoh K. Mandibular contouring surgery by angular contouring
combined with genioplasty in orientals. Plast Reconstr Surg.
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78. Lo LJ, Mardini S, Chen YR. Volumetric change of the muscles of
mastication following resection of mandibular angles: a long-term
follow-up. Ann Plast Surg. 2005;54:615–622.
79. Obwegeser HL. Surgical procedures to correct mandibular
prognathism and reshaping of the chin. Oral Surg Oral Med Oral
Pathol. 1957;10:677–689.
80. Baek SM, Baek RM. Profiloplasty of the lower face by maxillary
and mandibular anterior segmental osteotomies. Aesthetic Plast
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81. Jin H, Park SH, Kim BH. Sagittal split ramus osteotomy with
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concept of mandible angle ostectomy.
82. Choi JW, Lee JY, Koh KS, et al. Frontal soft tissue analysis using a
3 dimensional camera following two-jaw rotational orthognathic
surgery in skeletal class III patients. J Craniomaxillofac Surg.
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83. Cho BC, Byun JS. New technique combined with suture and
incision method for creating a more physiologically natural
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84. Cheng J, Xu FZ. Anatomic microstructure of the upper eyelid in
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85. Lam SM, Kim YK. Partial-incision technique for creation of the
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86. Toriumi DM, Swartout B. Asian rhinoplasty. Facial Plast Surg Clin
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87. Abdelkader M, Leong S, White PS. Aesthetic proportions of the
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88. Shin KS, Lee CH. Columella lengthening in nasal tip plasty of
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89. Watanabe K. New ideas to improve the shape of the ala of the
Oriental nose. Aesthetic Plast Surg. 1994;18:337–344.
90. Gunter JP, Rohrich RJ. Lengthening the aesthetically short nose.
Plast Reconstr Surg. 1989;83:793–800.
91. Han K, Jin HS, Choi TH, et al. A biomechanical comparison of
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92. Kim JS, Han KH, Choi TH, et al. Correction of the nasal tip and
columella in Koreans by a complete septal extension graft using an
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2007;60:163–170.
93. Byrd HS, Salomon J, Flood J. Correction of the crooked nose. Plast
Reconstr Surg. 1998;102:2148–2157.
94. Baek MH. Correction of the short nose. Arch Plast Surg. 2005;11:
22–28.
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Plast Surg Clin North Am. 2010;18:71–77.
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averageness and symmetry in non-western cultures: in search of
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97. Kyutoku S, Yanagida A, Kusumoto K, et al. The gonial angle
stripper: an instrument for the treatment of prominent gonial
angle. Ann Plast Surg. 1994;33:672–676.
98. Jin H, Kim BH, Woo YJ. Three-dimensional mandible reduction:
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Plast Surg. 2006;30:553–559.
99. Hwang K, Han JY, Kil MS, et al. Treatment of condyle fracture
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100. Choi JW. Comparison of long-term outcomes between surgery-first
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374.e3
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SECTION I • Aesthetic Surgery of the Face
12 
Neck rejuvenation
James E. Zins, Joshua T. Waltzman, and Rafael A. Couto
SYNOPSIS
■ Aging affects the face globally. Therefore, the neck is an important
component of any facelift procedure.
■ Improvement in neck contour is predicated upon skin release from
retaining ligaments, appropriate removal of fat from the subcutaneous
and subplatysmal plane, and alteration of the medial platysma.
■ In selected instances, the neck can be treated as an isolated entity
including submental approach only (anterior lipectomy and
platysmaplasty) and direct excision of neck skin.
■ For best results, skeletal developmental abnormalities are treated at the
time of face/necklift.
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Introduction
Neck laxity is one of the earliest signs of facial aging and is,
therefore, most often present when the patient presents with
other signs of facial aging. It is best integrated into a global
approach to cervicofacial rejuvenation. However, under
appropriate circumstances as detailed in this chapter, it can
be treated as an isolated entity.
Improvement in the neck contour is predicated upon (1) skin
release from retaining ligaments and septae; (2) appropriate fat
removal from the subcutaneous (superficial) and subplatysmal
(deep) plane; (3) alteration of the platysma and on occasion the
digastric muscles; and (4) submandibular gland alteration.
Skin tension should generally be avoided in facelift/
necklift procedures, as it results in poor scar quality at best
and skin slough at worst. Skin tension adds little to further
neck improvement.
When corrected by skin and platysmaplasty techniques,
neck surgery results are long-lasting. In fact, neck correction
when performed as described, is generally the longest-lasting
component of the face/necklift procedure.
Anatomy and the effect of aging
The critical anatomical areas in the neck are the cervicomental
angle, the submental/submandibular triangles, and the gonial
angles. The paired anterior bellies of the digastric muscles
extend from the lesser cornu of the hyoid bone to the posterior
surface of the mandible on each side of the symphysis. The
motor innervation of the anterior belly of the digastric muscle
is the mandibular division of the trigeminal nerve. The
muscles act as weak depressors of the mandible. Excision
produces no noticeable functional deficit but does cause retro-
positioning of the hyoid bone and, therefore, a favorable
deepening of the cervicomental angle.1
The borders of the submandibular triangles are formed by
the digastric muscles and the inferior border of the body of
the mandible. These bilateral triangles each contain the sub-
mandibular salivary gland, facial artery and vein, lingual
nerve, and the marginal mandibular branch of the facial
nerve. The submandibular gland may produce a bulge in the
submandibular triangle if it is hypertrophied and/or ptotic.
In the lower face, the marginal mandibular nerve exits from
under the anterior–inferior portion of the parotid gland. In
this location, the course is deep to the parotid masseteric
fascia. It runs horizontally along the lower border of the
mandible passing from deep to the parotid masseteric fascia
into the subSMAS (SMAS = superficial musculo-aponeurotic
system) cleavage plane and continuing superficial to the facial
vessels to innervate the depressor anguli oris and mentalis
muscles.2 This is the area most prone to marginal mandibular
nerve injury during facelift surgery, and recovery after com-
plete transection is unlikely due to its infrequent cross-
innervation with buccal branches of the facial nerve (Fig.
12.1).3 Huettner demonstrated in a cadaveric study the man-
dibular cutaneous ligament is located in the parasymphyseal
region 67.8 ± 3.3 mm from the horizontal line constructed
from the gonial angle along the inferior border of the mandible
(Fig. 12.2). The marginal mandibular nerve passes 9.7 ±
1.2 mm superior to the mandibular cutaneous ligament in the
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