Phẫu Thuật Tạo Hình Thẩm Mỹ Khuôn Mặt Người Á Đông

IV Facial Bone Surgery
284
Fig. 21.15 Case 2. Mandibular prognathism with long face. (a,b) Preoperative photo-
graphs. (c,d) Preoperative cephalometry and panoramic view.
Fig. 21.16 Case 2. (a,b) Three years postoperative photographs. (c,d) Three years post-
operative cephalometry and panoramic view.
a
b
c
d
a
b
c
d

21 Aesthetic Orthognathic Surgery
285
13. Bell WH. Le Forte I osteotomy for correction of m axillary
deform ities. J Oral Surg 1975;33(6):412–426
14. Morris DE, Lo LJ, Margulis A. Pitfalls in orthognathic sur-
gery: avoidance and managem ent of complications. Clin
Plast Surg 2007;34(3):e17–e29
15. Lanigan DT, West RA. Managem ent of postoperative hem -
orrhage following the Le Fort I m axillary osteotomy. J Oral
Maxillofac Surg 1984;42(6):367–375
16. Ruggles JE, Hann JR. Antibiotic prophylaxis in intra-
oral orthognathic surgery. J Oral Maxillofac Surg 1984;
42(12):797–801
17. Gallagher DM, Epker BN. Infection following intraoral sur-
gical correction of dentofacial deformities: a review of 140
consecutive cases. J Oral Surg 1980;38(2):117–120
18. Posnick JC, Al-Qattan MM, Stepner NM. Alteration in fa-
cial sensibility in adolescents following sagittal split and
chin osteotom ies of the m andible. Plast Reconstr Surg
1996;97(5):920–927
19. Lindquist CC, Obeid G. Complications of genioplasty done
alone or in combination with sagittal split-ramus osteotomy.
Oral Surg Oral Med Oral Pathol 1988;66(1):13–16
20. Van de Perre JP, Stoelinga PJ, Blijdorp PA, Brouns JJ, Hop-
penreijs TJ. Perioperative m orbidity in maxillofacial ortho-
paedic surgery: a retrospective study. J Craniomaxillofac
Surg 1996;24(5):263–270
21. van Merkesteyn JPR, Groot RH, van Leeuwaarden R,
Kroon FH. Intra-operative complications in sagittal and
vertical ram us osteotomies. Int J Oral Maxillofac Surg
1987;16(6):665–670
22. Merkx MA, Van Dam m e PA. Condylar resorption after or-
thognathic surgery. Evaluation of treatm ent in 8 patients. J
Craniom axillofac Surg 1994;22(1):53–58
23. Bell WH, Fonseca RJ, Kenneky JW, Levy BM. Bone healing
and revascularization after total m axillary osteotomy. J
Oral Surg 1975;33(4):253–260
References
1. Raym ond GV. Craniofacial genetics and dysm orphology. In:
Kolk CAV, Wilkins EG, eds. Plastic Surgery Indications, Op-
erations, and Outcom es. Mosby; 2000:613–617
2. Steinhäuser EW. Historical development of orthognathic sur-
gery. J Craniomaxillofac Surg 1996;24(4):195–204
3. Reuther J. [Orthognathic surgery: corrective bone op-
erations.] Mund Kiefer Gesichtschir 2000;4(Suppl 1):
S237–S248
4. Angle EH. Classi cation of m alocclusion. Dental Cosmos
1899;41:248–264
5. Blair VP. Operations on the jaw-bone and face. Surg Gyne-
col Obstet 1907;4:67–78
6. Owens EG, Goodacre CJ, Loh PL, et al. A multicenter in-
terracial study of facial appearance. Part 2: A comparison
of intraoral parameters. Int J Prosthodont 2002;15(3):
283–288
7. Owens EG, Goodacre CJ, Loh PL, et al. A multicenter in-
terracial study of facial appearance. Part 1: A comparison
of extraoral parameters. Int J Prosthodont 2002;15(3):
273–282
8. Ahn SN. Kephalometrische Vergleichstudie von skelettalen
und Weichteil Param etern zweier ethnischer Gruppen.
Doctoral dissertation. Kieferorthopaedie, ZMK Klinik, Uni-
versitat Ham burg; 1995
9. Obwegeser HL, ed. Mandibular Grow th Anom alies. Berlin,
Heidelberg, Germ any: Springer-Verlag; 2001
10. Kaduk WM, Podm elle F, Louis PJ. Revisiting the suprafo-
ram inal horizontal oblique osteotomy of the m andible. J
Oral Maxillofac Surg 2012;70(2):421–428
11. Scheuer HA, Höltje WJ. [Stability of the mandible after high
sagittal supraforaminal osteotomy. Roentgen cephalometric
study.] Mund Kiefer Gesichtschir 2001;5(5):283–292
12. LeFort R. Etude experimentale sur les fractures de la m a-
choire superieure. Rev Chir 1901;23:208–227

286
22 Genioplasty
Seong Yik Han and Kar Su Tan
can safely assume that this trend will continue to evolve,
and surgeons will have to stay current with the times and
modify their techniques to suit the requirements of the
contemporary aesthetic preference.
Genioplasty, while seemingly a relatively straightfor-
ward procedure, has a signi cant impact on overall facial
harmony and attractiveness. This surgery is generally con-
sidered an adjuvant surgery, performed to enhance and
complement other facial bone surgeries such as sagittal
split ram us osteotom y (SSRO), anterior segm ental osteotomy
(ASO), m andibular angle reduction surgery, and m alarplasty.
The most common indications for genioplasty are (1)
small chin with class II malocclusions (with or without open
bite or bimaxillary protrusion) and (2) big chin with class III
malocclusion and an excessively long face. These problems are
often a result of congenital syndromes (e.g., Treacher-Collins
syndrome) or hereditary malocclusion, chin hypoplasia sec-
ondary to childhood osteomyelitis, chin deviation due to soft
tissue contractures (e.g., burns), and anterior chin or temporo-
mandibular joint growth center disruptions from trauma.

■Introduction
The chin is vital in creating a sense of symmetry and pro-
portion of the face. The features of importance in the chin
include (1) the curvature from the inferior vermillion to
the chin tip, (2) the volume of the chin bone, and (3) the
position of the chin tip. Interestingly, the chin has a sig-
ni cant impact on the patient socially. Many patients with
micrognathia or mandibular hypoplasia reveal a lack of
con dence, introversion, and an inferiority complex. In this
sense, the role of aesthetic surgeons extends beyond simple
aesthetic enhancements and augmentations.
The concept of beauty borrows heavily on the indi-
vidual’s cultural background and exposure. In East Asian
traditions, a round and voluminous chin was preferred as
the ideal. Nowadays, however, many female patients want a
small face with a V-shaped chin instead of the big U-shaped
chin of previous times. Most male patients also prefer a nar-
rower, slightly longer and moderately prominent chin. We
Pearls
• Genioplasty has no e ect on occlusion and can thus
be considered a wholly aesthetic procedure aimed
at modifying the form and appearance of the bony
mentum.
• Genioplasty is most commonly done as an
adjunctive procedure of anterior segmental
osteotomy, angle reduction surgery, mandibular
shaving, zygomatic surgery, and rhinoplasty to
yield synergistic e ects in making an aesthetically
pleasing face.
• Proper evaluation and documentation in the form
of facial photography, simulation modeling, and
radiographic investigations (panoramic view, lateral
and posterior-anterior [PA] cephalogram, and/or 3D
computed tomography [CT] scan) are imperative
prior to surgery.
• The objective is to achieve facial harmony through
surgically modifying the mentum and mandibular
symphyseal areas, recreating appropriate facial
proportions and symmetry of the lower third of
the face.
• The ideal chin position varies among individuals,
and is determined by taking into consideration both
the hard and soft tissue cephalometry reference
points.
• Genioplasty can be performed in two ways:
(1) osseous genioplasty and (2) augmentation
genioplasty using implants. The authors prefer
osseous genioplasty because it provides a more
reliable outcome.
• Osseous genioplasty is done intraorally under
general anesthesia. Horizontal bone cuts are made
bicortically with an oscillating saw, taking care
not to injure the mental nerve, and the mobilized
segment is xed with pre-bent miniplates.
• Although genioplasty is a relatively safe operation
with very low complication rates, mental nerve
injury, malunion/nonunion, irregularity of bone
surface, lip drooping or skin dimpling, chin ptosis,
and asymmetry may develop.

22 Genioplasty
287
tion of the xation method, this technique is still w idely
used today. Further advances in the osteotomy designs
in the horizontal, vertical, and sagittal planes resulted in
greater control over the nal appearance of the chin.

■Essential Cephalometric Data
for Genioplasty
The important norms for chin position in cephalometric
analysis are summarized in Table 22.1. The di erences in
cephalometric norms among various ethnic groups have
been well documented through various comparative stud-
ies.4,5,6 The major di erence in chin cephalometric param -
eters is the length of the lower face. In Koreans, Sp′–Gn
(mm) is longer than it is, for example, in Germans (65.91
mm versus 63.27 mm, respectively). Thus, the ratio N–ANS/
ANS–Me (79.5%) is lower in Koreans. This value is a useful
guide for the calculation of the ideal vertical length of the
chin. Other variables also showed signi cant di erences
(see Chapter 21, Fig. 21.4 and Fig. 21.5).

■Patient Evaluation
Patient Consultation
It is important to inquire about the patient’s medical and
family history. Sometimes patients may withhold signi -
cant details, such as previous ller injection or chin implant
surgery, only to be revealed during routine preoperative
radiologic examinations. This highlights the importance
of a complete preoperative assessment including X-rays. It
is also important to listen attentively and take note of the

■Historic Background of
Genioplasty
Historically, genioplasty is performed in one of two ways:
the use of onlay augmentation over the mentum sur-
face, and the repositioning of the chin via osteotomies. G.
Aufricht in 1934 described the use of the excised nasal
hump as an autograft material “recycled” from rhino-
plasty.1 In 1948, K. H. Thoma described the use of titanium
mesh for genioplasty. Numerous materials had been exper-
imented with throughout history with varying success, but
as implant technologies advanced, so did the outcomes.
Some examples of these include acrylic, wax, silastic chin
implant (Brown et al 1953), expanded polytetra uoroeth-
ylene (e-PTFE, or Gore-Tex [W. L. Gore]) synthetic implants,
ceramics and hydroxyapatite, and demineralized granu-
lated tooth (Auto BT) with BMP.
The concept of osseous genioplasty was rst presented
by O. Hofer in 1942. He utilized a three-step technique:
segmental osteotomy, relocation, and xation of the chin
bone to the new position.2 Hofer described rst creating
a horizontal osteotomy of the anterior part (mentum) of
the mandible via an extraoral submental incision to correct
prognathism and micrognathia (Fig. 22.1a). H. Obwegeser
(1957) later described advancement sliding genioplasty
via an intraoral approach to avoid visible chin scars
(Fig. 22.1b).3
After osteotomizing the lower portion of the anterior
mandible, this segment was pulled forward, pedicled on the
geniohyoid muscle. He xed the segment using periman-
dibular Supramid (S. Jackson) thread over the acrylic splint.
Later Obwegeser switched to direct bone wiring. He also
described modi cations of his technique for asymmetric
chins, by modifying the arc of the segment. With the excep-
Fig. 22.1 Early genioplasty techniques. (a) Anterior sliding advancement genioplasty was rst described by O. Hofer in 1942. It was
performed via an extraoral submental approach. (b) Genioplasty surgery described by Obwegeser. This sliding advancement genioplasty
was performed intraorally, xed with perimandibular Supramid thread on each side over an acrylic dental splint.
a
b

IV Facial Bone Surgery
288
menton (see Chapter 21, Fig. 21.5), and (4) the concept of
the “zero-meridian” (Gonzalez-Uloa, 1962).
The “esthetic” line, or E-line, can be drawn from the
nasal tip (pronasale) to the soft tissue pogonion (Pog′)
to evaluate lip position (Fig. 22.2). The mean distance of
the upper lip to the E-line is 0.41 mm in Asians and 4.72
mm in Caucasians; while the mean distances for the lower
lip are 1.27 mm and 3.14 mm for Asians and Caucasians,
respectively.4 Using these measurements, the position of
the pogonion can be extrapolated. One pitfall to note is that
this method relies heavily on the patient’s having a nor-
mally projected pronasale (nasal tip). Usually the pronasale
is inadequately projected in Asians; thus, using this point as
a reference in such patients can lead to an erroneous con-
clusion in identifying a retruded pogonion position.
The rule of thirds is also applied in the analysis of facial
proportions. The face is divided into three equal vertical
sections: The portion from the trichion (Tr) to the glabella
forms the upper third, from the glabella to the subnasale
the middle third, and from the subnasale to the menton the
lower third (see Chapter 21, Fig. 21.3a). Asians are known
to have a longer lower third than Caucasians by ~ 2 to 3%.
This method of proportional analysis may be used to deter-
mine the ideal position of the soft tissue menton (Me′)
(Fig. 22.3a). In addition, further analysis of the lower third
can be made by studying the positions of the subnasale
(Sn), stomion (St), lower lip (LL), and soft tissue menton.
The ratio of the distances Sn–St:St–Me′ is 1:2, and that of
the distances Sn–LL:LL–Me′ is 1:1 (Fig. 22.3b). In patients
w ith small chins, the Sn–LL:LL–Me′ ratio will be more than
1. Using these ratios of the lower facial third, the optimal
position of the soft tissue menton can be calculated.
The concept of zero-meridian was described by Gon-
zalez-Ulloa in 1962.8 From the soft tissue N point, a line
perpendicular to the Frankfort horizontal line (FH line), the
patient’s desires and expectations. The parameters dis-
cussed usually include (1) the volume and shape of the chin
(small/large, broad/narrow, sharp/oval), (2) positioning of
the chin tip on the sagittal plane (protrusion or retrusion),
(3) vertical height of the chin (lengthening/shortening),
and (4) symmetry (in all three planes).
Occasionally, the surgeon may encounter a patient hav-
ing good chin shape, position, height, and symmetry but
who requests surgery. In this situation, the surgeon needs
to consider the patient judiciously.
The patient’s occlusion is also examined during the
consultation. This is especially crucial in patients who have
had previous orthodontic treatment or jaw surgeries. Gen-
erally, simple genioplasty alone is su cient for a patient
with normal class I occlusion. However, it will not su ce
for proper aesthetic correction for patients with class II or
III occlusions. In this case, orthodontic treatment or sur-
gery (such as anterior segmental osteotomy or sagittal split
ramus osteotomy) should precede genioplasty to correct
malocclusion.

■Patient Assessment
For preoperative assessment, analysis of facial photo-
graphs, including frontal, 45 degrees oblique, lateral, basal,
and helicopter views, and smiling and pouting views, is the
rst step. It is crucial to obtain smiling and pouting photo-
graphs since some problems, such as skin dimpling, may
appear only during pouting or smiling.
To determine the ideal soft tissue vertical dimension of
the lower third of the face, various references may be used,
such as (1) the Ricketts line (E-line), (2) the rule of thirds,
(3) soft tissue divisions from the subnasale (Sn) to the soft
tissue menton (Me′) and from the glabella to the soft tissue
Table 22.1 Important norms of chin position by cephalometric analysis (adapted from Dr. SN Ahn4)
Variablesa
Norms (Asian)
Norms (Caucasian)
N–Me (mm)
118.8 ±4.5
115.7 ±4.5
N–ANS (mm)
52.9 ±2.7 (45% from N–Me)
52.4 ±3.0 (45% from N–Me)
ANS–Me (mm)
65.9 ±4.5 (55–56% from N–Me)
63.3 ±5.5 (54–55% from N–Me)
N–ANS/ANS–Me (%)
80.5 ±5.7
83.2 ±6.2
S–N–A (°)
82.0 ±3.9
81.1 ±4.1
S–N–B (°)
79.4 ±3.5
79.0 ±3.5
G–Sn:Sn–Me′
1:1
Sn–St:St–Me′
1:2
a See Chapter 21, Table 21.1 for a guide to variables.

22 Genioplasty
289
line from the upper rim of the external auditory canal to
the lower rim of the orbit, is drawn. This is known as the
zero-meridian. The soft tissue pogonion is located along
the zero-meridian (Fig. 22.3c).
Imaging analysis including X-ray (panoramic view,
Cephalo PA, Cephalo Lat) or 3D CT scan is also a necessity.
In the planning of the ideal position of the chin tip (Me or
Pog), it is useful to bear in mind that proportion is more
important than the actual length. Lateral cephalometry
is perhaps the single most informative tool in assessing
and determining the position of the chin. The anterior-
posterior chin projection (Pog) is determined on the sag-
ittal plane by locating it between the SNA and SNB lines.
The nasion (N)–anterior nasal spine (ANS)/anterior nasal
spine (ANS)–menton (Me) ratio is the most frequently used
parameter to assess the adequacy of the vertical height of
the chin (Fig. 22.4). These parameters are the norms for
reference; however, depending on the patient’s preference,
the nal chin position may be adjusted to within 6% of this
reference gure safely.
Pn
UL to E line
LL to E line
Pog'
Fig. 22.2 Esthetic line (E-line,
Ricketts’ line). The “esthetic” line,
or “E-line,” is drawn from the nasal
tip (pronasale, Pn) to the soft tis-
sue pogonion (Pog′) to evaluate lip
position.
G
Sn
St
Li
Me'
1/2
1/2
1/2
1/2
1/3
2/3
N
Frankfort line
Pg
0-Meridian
Fig. 22.3 Proportional analysis by
facial thirds to determine the vertical
dimension of the chin. (a) Normal ver-
tical dimension (left); vertical de ciency
of lower third (middle); vertical excess of
lower third (right). (b) Distance ratio Sn–
St:St–Me′ is 1:2, and the distance ratio
Sn–LL:LL–Me′ is 1:1. (c) Zero-meridian
line: from N′ (soft tissue nasion) perpen-
dicular to the Frankfort horizontal line
(upper rim of the external auditory canal
to lower rim of the orbit). Pog′ (soft tis-
sue pogonion) should be located along
this line. Otherwise the chin is retruded
or protruded.
a
b
c

IV Facial Bone Surgery
290
2. Subperiosteal in ltration of local anesthesia with
1:100,000 epinephrine from the rst premolar to the
contralateral side will not only provide hemostasis
but also ease hydrodissection for periosteal elevation
over the chin. In ltration into the labial mucosa is
also helpful in reducing mucosal bleeding.
3. The intraoral approach is preferred, especially in
Asians, since the incisional scar on the skin tends to
be more prominent than in Caucasians. There are
two ways of making the intraoral incision, via either
a labial mucosal incision or a marginal gingival
incision (Fig. 22.6).
a.
Labial m ucosal incision: The midline is hatched
with a scalpel for reference. Then a labial incision
is made 5 mm away from the labiogingival
groove, leaving an edge for easier suturing
during closure. It extends from the rst premolar
of one side to that of the other. From the
super cial mucosa, the incision is made to the
periosteum with diathermy. Take note to avoid
excessive disruption of the mentalis muscle
bers to prevent chin ptosis.
b. Marginal gingival incision: An incision is made
along the gingival margin from the second
premolar of one side to that of the contralateral
side with a no. 12 or no. 15 scalpel down to
the bony alveolar crest. Next the periosteum
is directly lifted and the mucogingival ap is
developed to expose the bony surface of the chin.
The advantages of this incision include sparing
of the mentalis muscle and the absence of a
mucosal scar.
4. The dissection should extend to the inferior margin
of the mandible on the labial mandibular surface,
and should be wide enough for the osteotomy.
Unnecessarily wide dissection around the symphysis
area should be avoided. The ap should not extend
to the lingual surface; this is necessary to prevent
chin ptosis, dimpling, and uneasiness of lower lip
movement after surgery. Bleeding from nutrient
vessels encountered during dissection may be
easily controlled with bone wax. Identifying the
mental nerve is not mandatory, but it will be safer.
If genioplasty is to be combined with mandibular
shaving or angle reduction surgery, it is more
convenient to skeletonize the mental nerve to allow
more space for operation.
5. The midline of the chin is marked with a small
round bur, normally from the line between the lower
central incisors to the midline of the chin tip. This
marking is used for approximation of the midline of
the chin segment later. The horizontal cutting line is
marked as designed (Fig. 22.7).


With a micromotor drill, two or three very small
holes are made along the planned osteotomy line,
In practice, it is important to remember that the soft
tissue does not move at the same magnitude as its underly-
ing repositioned bone. For example, a 5-mm advancement
of the chin bone usually results in soft tissue advancement
of ~ 75% of that. In vertical lengthening and shortening of
the chin, however, soft tissue follows bone more closely, on
the order of ~ 90%.

■Surgical Techniques
There are essentially ve kinds of genioplasty, depending
on the direction of chin mobilization: (1) sagittal augmen-
tation, (2) sagittal reduction, (3) vertical augmentation, (4)
vertical reduction, and (5) transverse correction (Fig. 22.5).
Although osseous genioplasty is a relatively simple
operation, it is better to perform it using general anesthesia
as the noise and vibration of the bony work can be unset-
tling and distressing to the patient. Nasal intubation is the
method of choice for securing the airway. This also allows
the chin shape and position to be checked in closed occlu-
sion during surgery. Recently, osseous genioplasty using an
ultrasonic bone cutter has become feasible with local anes-
thesia under IV sedation (Fig. 22.8).
1. The midline of the face (running through the dorsum
of the nose and philtrum, between the two medial
incisors to the midpoint of the chin) is drawn with
a marking pen preoperatively. This serves as an
intraoperative guide.
S

N

NSL
N-ANS
ANS
NL
ANS-Me
Go
Me
ML
Fig. 22.4 Cephalometric analysis of chin position. The ratio N–
ANS/ANS–Me is the best parameter for determining the ideal ver-
tical chin length. The N–ANS/ANS–Me index is 80% ± 6 in Asians
as opposed to 83% ± 6 in Caucasians. The N–ANS length averages
51 to 53 mm in every ethnic group. However, the ANS–Me length
is signi cantly di erent, averaging 66 mm in Asians and 63 mm
in Caucasians. ANS, anterior nasal spine; S, sella; N, nasion; NSL,
nasion-sella line; NL, nasal line; Go, gonion; Me, menton; ML, man-
dibular line. (See Fig. 21.4 and Table 21.1 for the de nition of ref-
erence points.)

22 Genioplasty
291
and local anesthetic with epinephrine is in ltrated
into the medulla via these ports to reduce bleeding
during the mental osteotomy. A 5-mm -long groove
is created at the two ends of the planned osteotomy
with a 1.8-mm bur, to create a leading groove for
the saw blade to prevent slippage during sawing.
The osteotomy line should be at least 5 mm away
from the mental foramina inferiorly. A reciprocating
saw with a round-tip blade is used to make the
horizontal osteotomy. The rst cut is from one lateral
edge to the midline, and this is repeated on the
contralateral side. During the osteotomy, the mental
nerves should always be protected with instruments
to prevent inadvertent injuries to the nerves. Bear in
mind that it is often easier to create a more natural-
looking mandibular line when the osteotomy line
starts more posteriorly.


The progress of the cutting can be felt as the saw
cuts through the outer cortex and medulla to engage
the inner lingual cortex. Once both cortices have
been engaged, it may be more expeditious to cut
bicortically. Perisymphyseal bleeding can be reduced
if prior intramedullary in ltration was performed
as described earlier. Due to its atraumatic nature,
Fig. 22.5 Five types of genioplasty. (a) Sagittal augmentation
(anterior advancement). (b) Sagittal reduction (posterior reduc-
tion). (c) Vertical augmentation with bone graft. (d) Vertical reduc-
tion. (e) Transverse correction in facial asymmetry.
Fig. 22.6 Operative incisions for osseous genioplasty. (a) Labial
mucosal incision. (b) Marginal gingival incision.
Fig. 22.7 Bony marking for genioplasty. The midline of the chin
is marked with a small round bur or saw. Marking the horizontal
cutting line is done with a pencil or marking pen as designed. A
long groove is created at the two ends of the planned osteotomy to
prevent slippage during sawing.
a
b
c
d
e
a
b

IV Facial Bone Surgery
292
the ultrasonic bone cutter reduces trauma to the
tissue, bony hemorrhage, and postoperative swelling
(Fig. 22.8). However, it extends the operation time by
30 to 40%. This technique is particularly useful when
employed near the mental nerve or facial artery.
6. Once the osteotomy is completed and hemostasis
secured, the distal osteotomized mentum segment is
mobilized. The anterior belly of the digastric muscle
is attached to the digastric fossa on the lingual
surface of this segment, and it is not necessary to
detach this structure. However, in cases of vertical
reduction, the muscle attachment to the reducing
bone should be removed with an electric cautery.
7. The mobilized segment is then xed in the new
position according to preoperative plans with
two pieces of two- or three-hole miniplate and
screws. Pre-bent protrusion/retrusion miniplates
are available (Fig. 22.9). During xation, always
refer to the marked midline to ensure the central
position of the chin. In vertical shortening of the
chin, a bony step is formed at each end of the chin
segment where the original mandibular line has
been disrupted. Utmost care should be taken when
trimming the step to restore a smooth mandibular
line, as the mental nerve is often in close proximity.
8. The mucosa is then closed with interrupted 4–0
Vicryl (Ethicon) or silk. The midline is rst identi ed
and opposed using the previously hatched mucosal
points, and the rest of the incision is closed from
lateral to medial. The importance of proper closure
cannot be overemphasized since poorly matched
closure can result in facial asymmetry, discomfort,
and functional disturbance postoperatively, despite
perfect bony alignment and xation. For this reason,
marginal gingival incision is more convenient,
as it can be returned to its original position
without mucosal or muscular mismatch. Closing
of the marginal gingival incision can be done with
interdental papillary mattress sutures. Silastic drains
3 to 4 cm in length are inserted prior to putting in
the nal stitches on both sides.
9. After nishing the sutures, compressive dressing is
applied with elastic taping to the chin, giving it a
mild lift. Genioplasty is always done as a day surgery,
and hospitalization is not necessary in most cases.
Patients are prescribed antibiotics and analgesics.
Fig. 22.8 The ultrasonic bone cutter is e ective for sensitive
areas. (a) Equipment. (b) Bone cutting with ultrasonic bone cutter
during genioplasty.
Fig. 22.9 The mobilized segment is xed in the new position
according to preoperative plans with pre-bent four-hole miniplate
and screws.
a
b

22 Genioplasty
293

■Complications and
Their Management
General Complications
Genioplasty is a relatively safe operation with very low
complication rates. General complications include hemor-
rhage, infection, swelling, and pain. Most of the postopera-
tive bleeding is from the marrow of the osteotomized bone
and can be controlled intraoperatively w ith hemostatic
products such as hemostatic collagen (CollaTape, Zimmer
Dental, or Helistat, Moore Medical), gelatin agents (Gel-
foam, P zer), bone wax, or cellulose materials (Surgicel,
Ethicon). Mucosal bleeding can be controlled with an elec-
tric cautery. Infection risks are mitigated w ith judicious
intra- and postoperative antibiotic use, ensuring sterile
operative procedures and environment and meticulous
hemostasis. Fortunately, infection rates in genioplasty are
very low. Postoperative edema is thought to be related to
the degree of surgical trauma sustained intraoperatively.
The atraumatic nature of the ultrasonic bone cutter has
reduced postoperative swelling signi cantly. Edema usu-
ally peaks on postoperative days 3 and 4 before subsiding.
Genioplasty is a relatively painless surgery. Postoperative
pain can usually be easily controlled with acetaminophen.
Mental Nerve Injury
Injury to the mental nerve presents with lower lip pares-
thesia, especially at the corners of the mouth. This is pre-
vented with careful protection of the nerve during surgery.
In cases where a wide operative eld is required, the nerve
should be dissected and mobilized to avoid excessive trac-
tion on it. If the nerve is severed during surgery, re-anas-
tomosis should be attempted with a 9–0 or 10–0 suture.
The nerve function can be assessed postoperatively with a
pinch test at the corner of the mouth. Traction injuries on
the nerve often recover within 1 to 3 weeks. Small branches
may be cut during labial mucosa incision. The loss of lip
sensation is more prominent at the median area rather
than the corners of the mouth. In such cases, sensation usu-
ally returns within a month.
Bony Malunion or Nonunion
The risk of mal- or nonunion is higher with wire xation.
The development of the miniplate osteosynthesis system
enabled rigid xation of the segments. Malunion or non-
union is very rare in genioplasty as long as there is con-
tact between the bone segments. Two miniplates with four
screws are often su cient to obtain rigid xation in the
symphyseal region.

■Key Technical Points
1. A preoperatively drawn midline of the face from the
dorsum of the nose to the midpoint of the chin will
serve as a very useful intraoperative guide.
2. In ltration of subperiosteal local anesthesia from
the rst premolar to the contralateral side provides
hydrodissection as well as hemostasis to ease lifting
of the periosteum over the chin later.
3. An intraoral incision is preferred over the external
approach in Asians since the incisional scar on the
skin tends to be easily noticeable compared with
Caucasian.
4. A labial incision is made 5 mm away from the
labiogingival groove, leaving an edge for suturing
during closure. Marginal gingival incision has the
advantages of sparing the mentalis muscle and the
absence of a mucosal scar.
5. While making an incision, care should be taken to
avoid detachment of mentalis muscle bers, which
can lead to chin ptosis.
6. The extent of subperiosteal ap dissection should be
limited to the inferior margin of the mandible on the
labial mandibular surface since unnecessarily wide
dissection around the symphysis area can result in
inadvertent chin ptosis or dimpling and uneasiness
of lower lip movement after surgery.
7. Identifying the mental nerve is not always necessary,
but it is more convenient to skeletonize it when
genioplasty is to be combined with mandibular
shaving or angle reduction surgery.
8. With a micromotor drill, two or three very small
holes are made along the line of the planned
osteotomy to in ltrate epinephrine into the medulla,
which can help reduce bleeding during the mental
osteotomy.
9. Osteotomy cuts are made from lateral to midline.
Grooves may be made on the bone with a small
bur to prevent saw slippage when performing the
osteotomy.
10. It is better to make a horizontal osteotomy line
more posteriorly to create a more natural-looking
mandibular line.

IV Facial Bone Surgery
294
and its proper re-attachment during surgery are essential.
When it is used, revision surgery is aimed at re-anchoring
the mentalis muscle to the incisive fossa, and to repose the
dragged periosteum and chin pad superiorly.
Asymmetry
Asymmetry most frequently results from errors in plan-
ning and/or surgical execution. Corrective genioplasty for
asymmetric chins should be planned meticulously. Failure
to mark the midline prior to performing the osteotomy will
lead to asymmetry. Also, it must be kept in mind that the
magnitude of soft tissue movement corresponds to only 75
to 90% of the magnitude of bony translations. For example,
if the bone segment is moved 5 mm transversely, the cor-
responding soft tissue position will only move between
3.75 and 4.75 mm. Therefore, in correction of the asym -
metric chin, over-correction of the bone is often required
to achieve soft tissue symmetry. Once it is established that
there is postoperative asymmetry as a result of malposi-
tioning, revision is advised within 2 weeks.
Allograft-Related Complications:
Chin Drooping, Distortion,
Irregular Skin
Chin drooping and distortion occur after implantation of
an allograft such as silicone or Gore-Tex. There is invari-
ably erosion of the cortical chin bone by inserted implants,
and in some patients this is coupled with an osteophytic
reaction along the perimeter of the implant, creating a cra-
ter-like bony defect (Fig. 22.11). Occasionally this erosion
can extend through the anterior alveolar bone to reach the
roots of the frontal teeth.
A peau d’orange appearance of the chin is another
frequently encountered problem following chin implants,
Irregularity of Bone Surface
Irregularity of the inferior border of the mandible is a
common complication, particularly in vertical chin height
reduction surgeries. After making parallel horizontal oste-
otomies, the middle segment is removed; the caudal seg-
ment is then placed to the main mandibular body. At the
lateral ends of the bone edges, a triangular bony protuber-
ance will be produced due to the misaligned mandibular
line (Fig. 22.10).
If this protuberance is not shaved o during the surgery,
patients will complain of irregularity and sometimes pain
at the mandibular border. It may also be seen in aggressive
narrowing of the chin tip. In this case using arti cial bone
with BMP can help smooth out the steps.
Lip Drooping, Chin Ptosis, and
Skin Dimpling
Chin ptosis is de ned as the drooping of chin soft tissue
over the inferior border of the mandible. Lip drooping is
de ned as lower-positioned lip with dimpled skin during
lip closure. Chin ptosis and lip drooping are due to prob-
lems with the mentalis and depressor muscles of the lower
lip. The mentalis muscle originates from the incisive fossa
of the mandible and inserts into the dermis of the chin skin.
It has two functions: (1) to support, elevate, and protrude
the lower lip; and (2) elevation and wrinkling of the skin
of the chin. Failure to re-attach the mentalis muscle after
division and muscular brosis after infection or removal of
a large implant are known to be the main causes of this
phenomenon.9 Patients having a history of chin implant
surgery have a higher risk of exacerbation of chin ptosis
after revision osseous genioplasty for this reason. Thus, it
is important to obtain preoperative photographs for docu-
mentation. To prevent the aesthetic and functional compli-
cations mentioned previously, preservation of the mentalis
Fig. 22.10 (a,b) Treatment of bony irregularity after osseous genioplasty. Triangular bony irregularities at both lateral ends following
vertical or sagittal reduction genioplasty. This bony edge needs to be removed to prevent postoperative inconvenience. It is usually located
near the mental foramen, and thus extra caution should be taken during the removal.
a
b

22 Genioplasty
295
f.
Lower and upper lip protrusion: upper lip to
E-line, 3.7 mm (mean –1.02); lower lip to E-line,
7.2 mm (mean 2.03)
Treatment Plan
1. Conservative temporomandibular joint (TMJ)
treatment with an occlusal stabilizing appliance.
The aim is to set up the optimal and stable condylar
position
2. Orthodontic treatment: teeth alignment for anterior
crowding, leveling of dental arches, intrusion of
upper posterior molars.
3. Operation: anterior segmental osteotomy (ASO) of
maxilla, sagittal split ramus osteotomy (SSRO) of
mandible, genioplasty.
Notes
1. The rst aim of this operation was TMJ stabilization
and then normalization of the occlusion.
2. For aesthetic improvement, advancing genioplasty
alone could not ful ll these goals; therefore,
maxillary anterior segmental osteotomy (ASO) was
applied in combination.
3. After surgery, upper and lower anterior teeth
inclination, the zero-meridian and Pog′ relationship,
and the E-line to upper and lower lip distances were
normalized. Lip muscle strain and gummy smile
were also improved.
4. Most important, the patient’s con dence and smile
were restored, and she recovered from the inferiority
complex and depression she had experienced before
treatment.
especially Gore-Tex. This may be due to disrupted muscle
bers failing to re-align and re-attach to the cortical bone
surface due to the presence of the interpositioned implant.
Another possibility may be implant migration. These allo-
plastic implants have also been found to adhere to over-
lying muscle bers and dermis, resulting in skin thinning
over time. Care should be taken in performing revision
surgery in such cases, as perforation of the skin can occur
during implant removal.

■Case Studies
Case 1
A 23-year-old woman presents with a bimaxillary protrusion
and a severely retruded small chin (Fig. 22.12 and Fig. 22.13).
Problem List
1. Aesthetic: unfavorable facial aesthetics, highly
convex facial pro le, retruded chin, beak-like lip
shape, fullness of mouth with gummy smile
2. Functional: internal TMJ derangement, muscle strain
around lips, crowding of lower anterior teeth
3. Cephalometric analysis:
a.
Severe proclination of lower anterior teeth (L1
inclination): 37.3 degrees (mean 25 degrees ± 2)
b. Extremely small interincisal angle: 99.8 degrees
(mean 124.0 degrees ± 8.3)
c.
Position of Pog too posterior from N-perpendicular
(Pog to N-perp): –12.5 mm (mean, –5 mm ± 1)
d. High degree of facial convexity: 16.5 degrees
(mean 3.6 degrees ± 4.6)
e.
Short mandibular body length: 66.7 mm (mean
78 mm ± 4.3)
Fig. 22.11 Osteolytic crater on chin bone by alloplastic chin implant. (a) Identi cation of previously inserted Gore-Tex chin implant. (b)
Crater-like erosion of the chin bone near the root of anterior teeth is observed during removal of the chin implant.
a
b

IV Facial Bone Surgery
296
Fig. 22.12 Case 1. Pre- and postoperative
photos. Frontal and lateral views show-
ing improvement of chin projection. (a,b)
Before the surgery; (c,d) After the surgery.
a
b
c
d

22 Genioplasty
297
Fig. 22.13 Case 1. Cephalogram. (a) Measure-
ments of angles and lengths were marked on the
cephalogram and lateral photograph. (b) Measure-
ment drawings overlapped on lateral photograph. (c)
Postoperative cephalogram showing bone cuts and
miniplates.
a
b
c

IV Facial Bone Surgery
298

– LIE to facial plane: 12.6 mm (mean, 4.6 mm ±
1.7)

– FMIA (angle FH line): 32.1 degrees (mean,
59.8 degrees ± 6.4)
e.
Shorter mandibular body length: 65.7 mm
(mean, 78.0 mm ± 4.3)
Treatment Plan
1. Orthodontic treatment: teeth alignment for anterior
crowding, leveling of dental arches.
2. Operation: (1) anterior segmental osteotomy (ASO)
of maxilla and mandible; (2) genioplasty.
Notes
1. The main objectives of the surgery were (1) to
correct the proclination of the upper and lower
anterior teeth, and (2) to restore the position of the
chin and soft tissue pogonion.
2. The correction of upper and lower anterior teeth
proclination can be easily achieved. But for more
aesthetically pleasing results, the osteotomized
maxillary segment is mobilized upward and the
mandibular segment downward. Otherwise the
orthodontist may have di culties postoperatively
trying to achieve adequate impaction of the anterior
teeth.
3. Generally, the mandibular body can be lengthened
via body osteotomy in class II patients. In this
case, the patient had class I occlusion; hence,
advancement of the chin with sliding genioplasty
alone was su cient.
4. All surgeries were performed in a single stage as a
day surgery.
Case 2
A 26-year-old woman presented with typical bimaxillary
protrusion and a retruded chin (Fig. 22.14).
Problem List
1. Aesthetic: unsatisfactory facial contour, convex facial
pro le, upper lip protrusion with excessive upper
anterior teeth labioversion, small chin, nonideal
cervical curvature
2. Functional: muscle strain surrounding lips,
hypertonic mentalis muscle, lip incompetence
3. Cephalometric analysis:
a.
Bimaxillary protrusion (Angle’s class I occlusion)
b. Chin retrusion:

– Pog to N-perp: –40.9 mm (mean, –5 mm ± 1)

– SNB: 69.4 degrees (mean, 79.1 degrees ± 3)

– Y-axis to SN (angle N–S–Gn): 80.2 degrees
(mean 70.3 degrees ± 2.4)

– Pog′ to A′B′: –6.91 mm (mean 3.0 mm ± 2.0)
c.
Proclination of upper and lower lips:

– Nasolabial angle: 89.9 degrees (mean, 100
degrees ± 2)

– Upper lip to E-line: 3.7 mm (mean, –1.0 mm
± 2.0)

– Lower lip to E-line: 7.17 mm (mean, 2.0 mm
± 3.0)
d. Protrusion and proclination of upper and lower
anterior teeth:

– Inter-incisal angle: 110.4 degrees (mean,
124.0 degrees ± 8.3)

– UIE to facial plane: 16.61 mm (mean, 6.0 mm
± 1.5)

22 Genioplasty
299
Fig. 22.14 Case 2. Pre- and postoperative photos and cephalogram. (a,b) Preoperative facial photographs show slightly protruding lips
with retruded chin. (d,e) Postoperative photographs show increased chin projection and improved lip position. (c,f) Pre- and postopera-
tive lateral cephalograms.
a
b
c
d
e
f

IV Facial Bone Surgery
300
5. Hwang HS, Kim WS, McNamara JA Jr. Ethnic di erences in
the soft tissue pro le of Korean and European-Am erican
adults with norm al occlusions and well-balanced faces.
Angle Orthod 2002;72(1):72–80
6. Ioi H, Nakata S, Nakasim a A, Counts AL. Comparison of
cephalom etric norms between Japanese and Caucasian
adults in antero-posterior and vertical dimension. Eur J
Orthod 2007;29(5):493–499
7. Ricketts RM. Esthetics, environment, and the law of lip re-
lation. Am J Orthod 1968;54(4):272–289
8. Gonzalez-Ulloa M. Quantitative principles in cosm etic sur-
gery of the face (pro leplasty). Plast Reconstr Surg Trans-
plant Bull 1962;29:186–198
9. Zide BM, McCarthy J. The mentalis m uscle: an essential
component of chin and lower lip position. Plast Reconstr
Surg 1989;83(3):413–420
References
1. Aufricht G. Com bined nasal plastic and chin plastic: correc-
tion of m icrogenia by osteocartilaginous transplant from
large hump nose. Am J Surg 1934;25:292
2. Hofer O. Operation del Prognathie und Microgenie: Die
Operative Behandlung der alveolaren Retraktion des Un-
terkiefers und ihre Anwendungsmoglichkeit fur Prog-
nathie und Mikrgenie. Dtsch Zahn Mund Kieferheilk
1942;9:121–132
3. Obwegeser H. Surgical procedures to correct m andibu-
lar prognathism and reshaping of the chin. In: Trauner R,
Obwegeser H, eds. The surgical correction of m andibular
prognathism and retrognathia with consideration of genio-
plasty. Oral Surg Oral Med Oral Pathol 1957;10:677–689
4. Ahn SN. Kephalometrische Vergleichstudie von skelettalen
und Weichteil Param etern zweier ethnischer Gruppen.
Doctoral Dissertation. Kieferorthopaedie, ZMK Klinik, Uni-
versitat Ham burg; 1995

V
Facial Skin and Hair Rejuvenation

(Trang không có chữ)

303
23 Management Strategies for the Aging Asian Face:
Philosophy and Evolution
Samuel M. Lam

■Introduction
The aging East Asian face bears remarkable similarities to
the aging faces of other peoples, but also has distinct attri-
butes that separate it from the rest of the world. This chap-
ter will explain both the similarities and di erences of the
Asian face regarding the aging process and how to approach
it in a culturally sensitive, e ective, and safe manner. The
focus of the chapter will be heavily biased through the l-
tered lens of my worldview, which I hope will increase the
pragmatism of the content rather than be considered overly
simplistic or prejudiced.1,2,3 The major topics that will be
covered include hair restoration, facial volumization, Asian
blepharoplasty,4 and facelifting. To cover each of these top-
ics surgically would take a textbook to do the subject mat-
ter justice. Instead, this chapter will focus on the relevant
aging process of the Asian face on a global scale and touch
on the philosophy of what ages the Asian face and how in
general terms to manage this problem. I believe that this
chapter will be helpful both for the surgeon who is new to
working with the East Asian face and for the surgeon who
has great experience in this eld.

■Patient Assessment and
Philosophy of Aging
The Asian face has been considered relatively resistant to
the aging process, at least compared with the fairer races,
who are more subject to the weathering e ects of solar
exposure. The unique nature of the Asian’s skin stands as
a barrier to the detrimental e ects of solar rays and helps
keep the face from the accelerated aging that is a common
and early feature of many Caucasian faces.5 Nevertheless,
aging does occur both subtly and profoundly but perhaps
not so aggressively as in the Caucasian. Part of this pro-
tracted youthfulness in the Asian can be attributed to the
cultural proclivity to avoid the sun for two principal rea-
sons. First, sunspots and freckles that may be considered
charming in the Occident are often deemed unattractive
in Asia. Second, the darker skin that an Asian bears may
relegate the individual to a lesser societal status, whether
overtly or subconsciously. This bias toward fairer complex-
ion reigns in many cultures throughout Europe, Africa, and
many other sectors of the world. I believe that sun expo-
Pearls
• The principal manifestation of aging for most
East Asians (and all other peoples for that matter)
is volume loss. Judicious volumization using fat
grafting and/or llers can provide wonderful
rejuvenation that is natural and impactful.
• Hair restoration can be a vital component to global
facial rejuvenation and can provide an important
frame to the upper face to make it appear more
youthful and attractive.
• The aging Asian eyelid is a complicated subject.
The treatment algorithm is based on which type of
eyelid a patient possesses: a natural eyelid crease,
an eyelid without a crease, or an eyelid with a
previously surgically created crease.
• Typically, lower facial rejuvenation for the East
Asian is not necessary until much later in life when
compared with the Caucasian. Neuromodulators can
be used in the platysma to reverse early aging and
to delay the need for a facelift. A chin implant can
be an important adjunct to improve the shape of
the Asian face as well as to enhance a facelift result.
Lipocontouring of the neck should be done sharply
with scissors in a conservative fashion under direct
vision rather than with a suction cannula.
• Management of the skin should be an integral
part of every consultation and strategy for global
rejuvenation. However, it is advisable to always
be more conservative when it comes to ablative
techniques owing to the increased risk and time of
convalescence for the Asian patient.

V Facial Skin and Hair Rejuvenation
304
when lling an Asian face not to do so as robustly in many
cases as for the very gaunt faces that are often seen in other
races. In fact, lling areas around the periorbital and chin
regions can make a face actually appear slimmer if done in
a judicious fashion (Fig. 23.1). A further word of caution is
that in many Korean faces, lling the malar region can be
deemed masculinizing since it can square o a wide face;
in fact, many Koreans pay to have their malar bones sur-
gically reduced and collapsed inward. This cultural sensi-
tivity should be verbally addressed and heeded to avoid a
miscalculated outcome.
There are two principal mechanisms for volumizing a
face, fat grafting (a surgical modality) and injectable ll-
ers (an in-o ce procedure). Fat grafting is very e ective
as a durable, long-lasting result but su ers from a few
drawbacks. First, absorption is relatively unpredictable.
There can be variable loss of the transplanted fat, though
in general there should be a large percentage that remains.
Accordingly, I do not like to use fat grafting to try to x one
area of the face since the absorption rate may compro-
mise the intended outcome. Conversely, if the entire face is
treated, su cient fat grafting can survive so that the entire
face appears better. Such an instance, when enough of the
transplanted fat is left to contribute to an improved look of
the face, may be called an improvement in one’s “blink”;
that is one looks better in the blink of an eye to an onlooker
even though the minutiae of the face may not be entirely
corrected in every way. I use llers to touch up almost any
fat graft to achieve improved outcomes.
sure can actually be worse for aging than smoking or other
nicotine use, and that sun and nicotine together can be neg-
atively synergistic. Further, Asians who remain in Asia typi-
cally have healthier diets than those Asians who migrate to
the West, which can further maintain their youthful mien.
All bets are o when the Asian decides to travel to the West
to settle and then adopts Western habits of sunbathing
and consumption of processed and heavily adipose-laden
foods. Nevertheless, the genetic nature of the Asian skin
type can provide relative protection against aging despite
the adoption of such adverse lifestyle changes.

■Volume Loss and
Volume Restoration
Even though Asians age relatively less than their fairer-
skinned counterparts, there are still unmistakable signs of
aging in the Asian face. It would be quite rare to look at a
70-year-old Asian and unwittingly assume that she is only
30 years old. If her skin (like that of many of my octogenarian
aunts) is relatively white, unblemished, and almost wrinkle
free, why is it so obvious that she is indeed much older? To
me, the answer is readily apparent. It is the universal sign
of volume loss that a ects all races in relative degrees but is
the predominant feature of the aging Asian face.6
Volume loss is observed as a linear loss of fat from birth
until death. A 1-year-old has considerably more facial fat
than a 5-year-old. Similarly, a 5-year-old’s face has more
fat than a 10-year-old’s. In an adult if body weight is held
the same, every 5 years represents ineluctable, progressive
volume loss and skeletonization of the face. Accordingly,
the senescent shadows that develop across the face and the
loss of glorious, youthful highlights should be the principal
targets in revolumizing the face. Further, there is an imme-
diate “blink” e ect: We pretty much know who is young
and who is old in a nanosecond, based on facial shape. A
young face is very round, which we have a special term for:
baby fat. Baby fat is nothing special. It just represents the
exuberant fat of youth that gradually dissipates. As youth
regresses, the shape of the face becomes a more angelic
oval by 30 years of age, which is cherished by many women
who fear looking fat as the ideal age of beauty. By 40 years of
age, as the fat continues to skeletonize and the malar bones
begin to be partially exposed, the face becomes squared
o in appearance. Further volume loss and possibly some
weight gain contribute to an inversion of the facial features,
where the lower face increasingly becomes the dominant
attribute. Accordingly, a primary focus for the aging Asian
face is to restore balance and shape to the face to make it
look more youthful. I believe that lling the temple, perior-
bital region, malar area, and perioral area can be as helpful
for the Asian face as it is for other ethnic and nonethnic
faces, with a few caveats.
First, Asian faces in general tend to be fuller to begin
with than many white faces. Therefore, it is important
Fig. 23.1 A Chinese patient who underwent single facial fat graft-
ing procedure along with a conservative skin-only upper blepharo-
plasty. (a) Before the procedure. (b) One year after the surgery. The
patient’s face appears narrower by selective targeting of the peri-
orbital and perioral regions for volumization and by avoiding the
buccal area. The upper blepharoplasty was helpful since the eyelid
skin had de ated near the ciliary margin. However, the principal
method of rejuvenation of the eyelid was facial fat grafting.
a
b

23 Management Strategies for the Aging Asian Face: Philosophy and Evolution
305
will frame the back of the head. All of these elements can
provide improvement for the Asian patient. Even women
lose their facial frame and can bene t from hair restoration
as part of a global strategy of rejuvenation (Fig. 23.5).
Today, hair transplant surgery can produce results as
incredibly natural as any other type of facial procedure.
Many surgeons still recall the unnatural appearance of plug
If llers can be so accurate in rejuvenating the face, why
is this method not preferred over fat grafting? The simple
reason is cost. Fat is free; it can be harvested without paying
for each syringe except for the labor that is involved. Fill-
ers, especially durable llers like poly methyl methacrylate,
can be costly when multiple syringes are used to contour
every detail of the face. Today, with the advent of dispos-
able microcannulas, I have had an exponential increase in
the use of llers because many patients do not prefer the
up-front cost, the nature and time of the recovery process,
and the variable absorption of fat grafting. When approach-
ing a face with either llers or fat grafting, I prefer to target
a little bit of ller or fat at almost every small area of the
face, including the temple, brow/upper eyelid, lower eyelid,
nasojugal groove, anterior cheek, lateral cheek, subzygo-
matic recess, buccal area (as deemed appropriate), canine
fossa and nasolabial groove, prejowl sulcus, anterior chin,
and lateral mandible (as deemed appropriate). By lling all
of these areas, the face appears balanced and rejuvenated.
The degree and distribution of the ller are based on art-
istry, judgment, and experience and lie beyond the scope of
this philosophically based chapter.

■Hair Loss and Hair Restoration
Hair restoration occupies a large part of my clinical prac-
tice, and I have extensive experience working with the
Asian patient. I will speak here again in terms that are spe-
ci c to the Asian, and also present some universal concepts
that can be helpful for anyone who is contemplating enter-
ing the eld of hair transplant surgery. Further, to elaborate
on every technical aspect of how to perform hair restora-
tion would be nearly impossible in a span of a few pages,
and any cursory treatment of the procedure would not do it
justice. Nevertheless, the artistic and philosophical points
are well worth exploring even in the format of this chapter.
First of all, what is the end objective of performing hair
transplant surgery? I would like to state that goal at the
outset, which is to provide a strong aesthetic frame to the
upper face. Similarly, fat grafting around the eyes can help
with providing an eye frame, lling the temple and outer
cheek can provide an outer facial frame, and facelifting/
chin implants/volumization can provide a lower face frame.
When the hairline has been re-established for either a man
or a woman, the face looks more attractive and youthful
instantly. The frame of the upper face is comprised of two
components: the central hairline and the temple hairline.
Not every person needs both horizontal (central) and verti-
cal (temple) hairlines improved, but it is worthwhile for the
reader to understand the importance of considering these
options (Fig. 23.2).
Other examples of facial framing with hair restoration
include an eyebrow hair transplant (Fig. 23.3) that will
frame the eye, and a crown hair transplant (Fig. 23.4) that
Fig. 23.2 A Chinese patient who underwent hair restoration.
(a) Before the procedure. (b) After the procedure. Hair restoration
provides a stronger frame to his face.
Fig. 23.3 An Indian patient who underwent eyebrow hair trans-
plant. (a) Before the procedure. (b) After the procedure. An eye-
brow hair transplant brightens the eyes and provides an improved
frame to the eyes.
a
b
a
b

V Facial Skin and Hair Rejuvenation
306
many Asian faces. A very narrow hairline often will not look
quite right on an Asian patient because the hairline shape
will not match the face or will not match a hairline that
exists in this race. Studying natural, nonbalding hairlines in
Asians can be a good guide to training one’s aesthetic eye
with real-world examples before beginning to operate on
these individuals.
There are two types of donor harvesting that are cur-
rently o ered. The traditional method of graft harvesting is
known as follicular unit transplant, or FUT, which involves
a linear strip from the back of the head. The newer method,
which involves small punches and avoids the linear inci-
sion, is known as follicular unit extraction, or FUE. FUT still
plays a very signi cant role for many of my patients for
several reasons. First, grafts that are taken through a linear
harvest and then dissected are unquestionably healthier
and thereby have an increased survival rate after transplan-
tation. Even the very best FUE grafts are more fragile and,
even with the most assiduous handling and transplantation
of them, are still less viable relative to FUT. Second, FUE
may not be the best way to optimize the use of the donor
hair region, in that grafts must be taken very broadly across
the entire expanse of the back of the head, and that may
cause several problems. First, there can be donor deple-
tion if you take more than 20% of the grafts, leading to a
moth-eaten appearance or diminished density in the donor
area. Second, FUE is not a scarless procedure and can lead
to punctate white dots correlating with where the punches
have taken the grafts. Third, because harvesting must occur
in a wide expanse, the harvest can approach or exceed the
de ned safe donor area; that is, future hair loss can prog-
ress into the areas where harvesting occurred, leading to
loss of transplanted grafts in a haphazard fashion. FUE
scars are more visible as well in patients with greater pig-
mentation since the scars are typically hypopigmented in
nature. FUT, however, is not without risk either, particularly
in the Asian. Because Asians tend to create more exuberant
grafts that transformed a patient into a doll’s head. How-
ever, no longer is that the case. Using naturally occurring
clusters of hair known as follicular units, transplants can
be performed and bring incredible naturalness. What gives
me absolute pleasure in working with hair transplantation
is the artistry that can be exercised during any procedure,
from designing a hairline or eyebrow to allocating grafts
with the density gradient that is optimal for a particular
patient. The tedium that many surgeons associate with
the surgical procedure lies in their ignorance of how much
enjoyment can be had when performing it.
The Asian patient has a few very salient di erences
from other races that should be considered before perform -
ing a procedure on him or her. First, the hairs typically are
very dark, very coarse, and very straight and are set against
a paler to moderately dark skin. This is perhaps the worst
combination of characteristics to have when one wants
to achieve naturalness. The darker, coarser, and straighter
hair, especially when set against a scalp that is fairer in
complexion, can make a graft look unnatural if not per-
fectly executed. It is, however, extremely easy for the tech-
nician team to dissect and transplant these grafts because
they are so dark, coarse, and straight. The surgical team
must take steps to ensure that the result appears absolutely
natural in every way. To ensure this outcome, I almost
always perform an increased number of single-hair grafts
along the frontal hairline so that the hairline looks natural.
For example, I may use only 150 to 200 single-hair grafts in
a light-skinned, light-colored, ne- and curly-haired indi-
vidual. In contrast, I may use twice that number of single-
hair grafts for an Asian patient before I even contemplate
starting with two-hair grafts because I want the hairline to
appear very soft in nature. The recipient sites that are made
to accommodate these grafts form what is known as the
“micro” hairline. The “macro” hairline refers to the actual
initial line drawn on the scalp into which these recipient
sites will be placed. The macro hairline drawn on the typi-
cal Asian also can look quite di erent from that in the Cau-
casian patient. The macro hairline is typically rounder in
shape with less suppression or concavity along the lateral
extent of the hairline, which matches the rounder shape of
Fig. 23.4 A Vietnamese patient who underwent crown hair trans-
plant. (a) Before the procedure. (b) After the procedure.
Fig. 23.5 A Filipina patient who underwent hair transplant.
(a) Before the procedure. (b) After the procedure. A hair transplant
improves the frontal frame to her face.
a
b
a
b

23 Management Strategies for the Aging Asian Face: Philosophy and Evolution
307
the crease to be too high and thereby render the appear-
ance unnatural in my opinion. Similarly, brow lifting can
make a supratarsal crease too high in an Asian, especially
if performed in conjunction with eyelid skin removal. Con-
versely, fat grafting and llers maintain or lower the eyelid
crease. Accordingly, if skin is removed or a brow lift per-
formed, I almost always use some level of lling to bring
the eyelid crease height back down as needed (Fig. 23.6).
One other point that should be stressed is that an eye-
lid crease, unfortunately, is not an all-or-none proposi-
tion. There are partial creases, and a patient can have a full
crease on one side and a partial crease on the other side.
Typically, the side with the partial crease has a narrower
palpebral aperture that resembles true ptosis. When I
speak of an Asian born with an eyelid crease, I am speaking
only of Asians who have 100% complete full creases bilater-
ally. Partial creases of any degree really behave about the
same as no creases at all and should be placed into that cat-
egory, which I will discuss next.
The temptation with the Asian who is born w ithout a
crease is simply to perform a standard blepharoplasty in
which eyelid skin is removed and no xation is performed
to create a crease. Since there is no crease, where does the
surgeon make the incision? There is no good answer. I have
noticed that when one simply removes the skin in these
patients, there is no discernible result, that is, no improve-
ment. Instead, a visible scar may become apparent since
the skin cannot fold over a crease that doesn’t exist. If the
surgeon concurrently tries to remove fat from the postsep-
scar formation than Caucasians, at times a thicker scar may
develop in the donor area. Further, because the donor hair
is very dark black and very straight, the white line of a scar
can be more visible than in many other races. These consid-
erations are meant to serve only as guidelines for a physi-
cian who is interested in performing a hair transplant in an
Asian patient, and are not intended to frighten or mislead
either a prospective surgeon or patient.
Recently, there has been a rise in the use of regenera-
tive medicine techniques that I like to refer to as “fertilizers”
since these adjunctive measures help transplanted hairs
grow much better, faster, and more consistently. The donor
scar can be helped w ith these products as well. The three
major products that we use are MatriStem (ACell), platelet-
rich plasma (PRP), and adenosine triphosphate (ATP). It lies
beyond the scope of this chapter to discuss how and why
each of these products is used. Su ce it to say that I believe
these products are indispensable for every hair transplant
procedure that I perform and can be very helpful to achieve
better outcomes whether the patient is Asian or not.

■Aging Asian Eyelids and
Brows, and Eyelid Rejuvenation
I have written about this topic before in other textbooks,
and I believe I have come to a good understanding of how
to help a surgeon trying to manage the complex topic of
the aging Asian eyelid. I have divided the aging Asian eye-
lid into three categories: Asians born with a natural supra-
tarsal eyelid crease, Asians who do not have a crease, and
Asians who have had a previously surgically created crease.
By approaching an Asian patient in this fashion, the sur-
geon should be able to navigate this issue safely to develop
the best outcomes for a particular individual.
Let us begin w ith Asians who are born with a natural
eyelid crease. These individuals are perhaps the easiest
category to manage. Because of the crease, their eyelid
behaves almost identically to a Caucasian one, and accord-
ingly the same options are available. If the eyelid skin hangs
over the ciliary margin, I recommend a conservative upper
blepharoplasty, removing skin only. I almost always recom -
mend adding some kind of volume to the upper eyelid and
brow simultaneously or in a staged procedure. As I have
thoroughly discussed, de ation of the brow and upper eye-
lid is the principal mechanism by which aging occurs in all
races. Therefore, I believe that eyelid skin removal is only
a support to re-in ation of the eyelid and brow. Further,
I believe that brow lifting is unnecessary and detrimen-
tal. One caveat is worth issuing here: I remove skin only
when it appears to be hanging at or over the ciliary mar-
gin. If there is still a very visible distance of 1 to 3 mm of
exposed supratarsal crease when the patient has his or her
eyes open on forward gaze, then I do not recommend any
additional skin removal because such removal would cause
Fig. 23.6 A Chinese patient who has ptosis on her right side and
what appears to be too high a supratarsal crease even though she
has never had a previous eyelid surgery. The height of her crease
is high most likely from volume loss as well as acquired ptosis. She
had full facial fat grafting that improved her eyelid position and
contour, thereby rejuvenating her upper eyelid. She also underwent
a transconjunctival blepharoplasty. (a) Before the surgery. (b) After
the surgery.
a
b

V Facial Skin and Hair Rejuvenation
308
a partial crease, that crease should be considered nonexis-
tent and treated accordingly.
A great option is to perform both a supratarsal crease
and volumization of the brow. However, I typically do not
like performing both procedures at the same time, as I am
always concerned that the fat will disrupt the security of
the crease xation. Also, I generally do not like to do the
fat graft rst and later the crease xation because this may
interfere with the crease xation at a later date. Accord-
ingly, if I were to perform both procedures, in an ideal
world I would perform the supratarsal crease xation rst
followed 4 to 6 months later with fat grafting or llers.
tal tissue without crease xation sutures, then the eyelid
aperture unfortunately still looks narrow, without substan-
tive change. Even worse, there can be variable xation in
which creases are only partially xed but not uniformly or
evenly so. In my opinion it is inadvisable in an Asian patient
who does not have a crease (or who has a partial crease) to
simply remove skin. It w ill not work and will lead to poor
outcomes.
So, then, what can be done for an Asian without a
crease? In my opinion, there are two options: create a
crease and/or use llers or fat grafting in the upper-eyelid/
brow region (Fig. 23.7 and Fig. 23.8). To create a supratar-
sal crease is an apparently straightforward process but
carries with it some important limitations that should be
conveyed to the patient before surgery is contemplated.
First, a crease does change the look of an individual, mak-
ing the eyelid shape rounder and more open. This is usually
not a big issue for a teenager or young adult who comes to
the physician for the express purpose of creating a crease.
However, it can be more of an issue for someone who has
lived, say, 50 or 60 years and now would like to have a reju-
venative procedure. This point should be communicated
to a prospective patient expressly and clearly. Further, the
method that I prefer to use to create a crease is the full-inci-
sion method that I learned from my late mentor, Dr. John
A. McCurdy. The technique o ers the most durable results
but su ers from a protracted recovery time. The crease
can look very abnormal at a week and can appear slightly
unnatural even for a few months follow ing the procedure.
This is much more di cult for men because they cannot
wear camou aging eye makeup and can therefore look
more unnatural with a higher crease than women do. This
higher crease will eventually become smaller and smaller
until it becomes completely natural in appearance several
months to a year down the road. I also recommend the use
of thicker-framed rectangular glasses that can rest approxi-
mately at the supratarsal crease or slightly above to distract
an onlooker’s eyes from the temporarily elevated crease
height. If the individual does not wear glasses normally,
I recommend that he or she start wearing such glasses
before the surgery to habituate onlookers to the presence
of eyeglasses on the face.
For the individual without a natural crease, the other
suggested alternative is lling the upper-eyelid/brow com -
plex with llers or fat grafting. Although this technique
may appear not to make much sense since the brow often
already looks too full, recall that in fact the eyelid is de ated
and only appears to be dependent and hanging. If there is
any question as to the patient’s perspective on whether
this would be a suitable option, I recommend a test using
a temporary, reversible procedure like administration of
hyaluronic acid to determine if the aesthetic is in align-
ment with the patient’s goals. If so, then a more permanent
option can be undertaken. Also, recall that if the person has
Fig. 23.8 A Vietnamese woman who had fat grafting to her eye-
lids and face. She has a partial eyelid crease and accordingly has
two options only: create a supratarsal crease and/or volumize the
brow. I performed only a single session of fat grafting to her eye-
lids. (a) Before the procedure. (b) One year after the procedure.
The de ated brow appears lifted only because it has been lled out.
Fig. 23.7 This 53-year-old Korean man wanted eyelid rejuvena-
tion and he is shown in the “before” photograph without a true
supratarsal crease. He underwent a formal Asian blepharoplasty
to create a supratarsal crease and seems more rejuvenated in his
appearance. (a) Before the procedure. (b) After the procedure.
a
b
a
b

23 Management Strategies for the Aging Asian Face: Philosophy and Evolution
309
as a preventive measure against recurrence and as a rst
attempt to see how much improvement can be had short
of surgery. There really is no di erence in my facelift tech-
niques for an Asian neck and a Caucasian neck. I typically
use short incisions that only circumscribe the ears and do
not extend into the hair-bearing area, along with an inci-
sion in the submental region, which I believe can be univer-
sally acceptable no matter the race. Because the Asian skin
is thicker and more elastic than that of many fairer-skinned
races, often I do not remove a lot of skin during the surgery,
but that is not the point of a facelift anyway.
Another procedure that can be very helpful for many
Asians, whether a facelift is performed or not, is an allo-
plastic chin implant. (I use the extended anatomic Con-
form implant manufactured by Implantech.) Many Asians
have a retruded chin along the inferior border as well as
premaxillary de ciency. Adding a chin implant can provide
improved skeletal projection and render the face less full
and round in aspect. In addition, I believe a chin implant
in an Asian can be helpful in improving a facelift result for
three reasons. First, the neck length is increased, making
the neck appear improved without the need to perform a
lifting procedure in many cases of early tissue descent. Sec-
ond, the chin implant can provide a fulcrum around which
the lifting of the tissues is improved, as would be the case
in any individual w ith weaker skeletal support. Finally, the
chin implant can disrupt the mandibular ligament, a retain-
ing structure that limits the ability to lift the tissues e ec-
tively. William Binder, who lectures on the subject, believes
that the permanent interposition of the chin implant will
better maintain the position of the jaw line since the man-
dibular ligament never re-adheres.
As far as neck adiposity is concerned, for the younger or
older patient I prefer to open the neck tissues sharply with
scissors and then selectively remove just the right amount of
adipose tissue, taking care to leave enough fat on top of the
platysma that platysmal dehiscence does not show up after-
ward if a facelift is not being simultaneously performed. I
believe that judicious and selective removal of pre-platys-
mal adipose tissue without a concurrent rhytidectomy can
be undertaken in some Asians even into their 50s, unlike in
fair-skinned individuals, in whom I generally am concerned
about doing so after ~ 40 to 45 years of age for fear that the
platysmal bands will become more evident if no concurrent
tightening procedure is undertaken. I almost never perform
liposuction using a cannula anymore because I believe that
it overskeletonizes a neck that can already be skeletonized
in appearance from aging. Accordingly, my liposuction
machine generally sits in the corner of my operating room
collecting dust. A combination of judicious lipocontouring,
chin augmentation, and rhytidectomy often can provide far
better results than any one procedure alone, but obviously
must be undertaken in the right candidate who would ben-
e t from all three of these treatment strategies.
The nal category is the Asian patient who has had a pre-
viously surgically created crease. You could potentially treat
this patient just like an individual born with a natural crease.
However, the reason this is a separate category has a lot to
do with how high the previous crease was made and how
long ago. Back in the 1980s, a procedure known as West-
ernization was in vogue, in which a lot of skin and fat was
removed and a high crease created. Over time, as the patient
ages, the skin around the crease continues to de ate, making
the crease look much smaller than it was originally. How-
ever, this lower crease cannot be treated as a normally low
crease. The reason for this is that if skin is further removed
from this patient, the previously abnormally high crease will
return and the patient may experience lagophthalmos. The
way that the physician can determine if the crease was made
too high is simply to lift up the eyelid skin and look at where
the crease was fashioned. Just by doing this simple maneu-
ver during the consultation, the surgeon can easily deter-
mine if the crease was made very high and the eyelid tissue
excavated (i.e., already excessively removed). Another option
is just to look at the patient. With previous surgery the eyelid
will look somewhat unnatural but it may not be apparent
why to the surgeon since the crease height can be relatively
low. The reason for this is that the crease primarily consists
of thick brow skin that has been folded over, making the eye-
lid look deep set and bizarre. I believe that the only way to
improve this situation is with volumization using either fat
grafting or llers. I would contend that any other method
would compromise the desired outcome by returning the
patient to the more unnatural state of many years ago.

■Lower Facial Aging and
Rejuvenation
Fortunately, for many Asians the lower face does not age
as much as in Caucasians. Their thicker and solar-resistant
skin helps them to keep their neck position better for a
much longer period than for Caucasians. However, aging
still will show up in the Asian, even though it may do so
a decade or two later than in other races. A preventative
maneuver that I use in all races to delay the need for a face-
lift is routine application of neurotoxin to the platysmal
bands (using ~ 10 to 15 units of botulinum toxin). Patrick
Trevidic, from Paris, France, has presented convincing evi-
dence that individuals who had strokes many years prior
su er no neck aging on the a ected/stroked side. I have
seen clinical evidence of ongoing improvement in the neck
with continuous neurotoxin used to return the neck to a
more youthful state. Obviously, if the neck has already
considerably advanced in aging, it will be di cult to ele-
vate the neck tissue without a formal rhytidectomy. Even
in these cases, I like o ering neuromodulator treatments

V Facial Skin and Hair Rejuvenation
310
I perform far fewer lower facial rejuvenations in Asians
than I do in Caucasians, even though for the mid- and upper
face I perform almost the same frequencies of intervention.
I believe that Asians simply do not su er as much from
lower facial descent and should not be needlessly subjected
to rejuvenation in this area. As stressed earlier in the chap-
ter, I believe that neuromodulators and chin implants are
very e ective adjuncts to management of the lower face,
particularly in the Asian patient who may bene t from
these interventions.
The complicated subject of the aging Asian eyelid is
presented in an algorithmic fashion that I believe can help
almost any physician steer clear of problems, especially
the surgeon who has limited experience working with the
Asian patient or who does not perform Asian eyelid sur-
gery in general. Breaking down patients into the broad
categories of those born with a natural crease, those who
do not have a crease, and those who have previously had a
surgically created crease can be very helpful in designing a
proper treatment plan that is both e ective and safe.
Although I have only brie y mentioned the manage-
ment of the Asian skin and the fact that I do not often per-
form aggressive skin therapy, I believe that in most Asians
skin therapy can be highly e ective as part of a global
strategy. I have almost every aging Asian patient on neu-
romodulator therapy and on a comprehensive topical skin
regimen. Helping the skin look more polished can make
anyone look better and should not be overlooked in any
individual of any race.
References
1. Lam SM, Glasgold MJ, Glasgold RA, eds. Complem entary Fat
Grafting. Philadelphia, PA: Lippincott, Williams & Wilkins;
2006
2. Glasgold MJ, Glasgold RA, Lam SM. Volum e restoration
and facial aesthetics. Facial Plast Surg Clin North Am
2008;16(4):435–442, vi
3. Lam SM, Glasgold RA, Glasgold MJ. Limitations, complica-
tions, and long-term sequelae of fat transfer. Facial Plast
Surg Clin North Am 2008;16(4):391–399, v
4. Karam AM, Lam SM. Management of the Asian upper eyelid.
Facial Plast Surg Clin North Am 2010;18(3):419–426
5. McCurdy JA Jr, Lam SM, eds. Cosm etic Surgery of the Asian
Face. New York, NY: Thiem e Medical Publishers; 2005
6. Lam SM. A new paradigm for the aging face. Facial Plast
Surg Clin North Am 2010;18(1):1–6

■Skin Aging and
Rejuvenation Methods
I am con dent that Asian skin therapy is far better treated
elsewhere in the book than I have done here. I have a great
reluctance to perform ablative resurfacing, whether frac-
tional or otherwise, in an Asian due to the pigmentary
risks—both hyper- and hypopigmentation—and the pro-
longed recovery times that ensue. Accordingly, I prefer to
use topical therapies such as grow th factors, anti-oxidants,
and brighteners to help patients, and limited nonablative
phototherapies like erbium and photofacial treatments to
improve skin quality. I know that my more experienced col-
leagues achieve excellent outcomes by means of aggressive
skin resurfacing w ith limited morbidity, so I humbly defer
a more comprehensive discussion of the subject to them.

■Conclusion
The aging process in the Asian, albeit delayed and less
profoundly evident than in the fairer-skinned races, nev-
ertheless does occur and must be treated for optimal out-
comes. For me, the principal approach to help rejuvenate
most Asians lies in understanding volume restoration. For
Asians with limited volume loss, I prefer in-o ce inject-
able llers because they do not need very much volume
and allow more accuracy in accomplishing the right level
of volumization. Fat grafting still has a signi cant role in
my practice toward achieving these goals, but I reserve this
intervention for someone who has a greater degree of vol-
ume loss due to more advanced aging.
I believe that hair restoration can be a very important
aspect to rejuvenation for both the Asian male and female
patient but is overlooked because many surgeons do not
perform this procedure. When an individual has a weak
hairline but has been rejuvenated throughout the rest of
the face and neck area, I contend that the overall result is
compromised and the patient should consider having hair
restoration if it is applicable to and bene cial for him or
her. Even if surgery is not an option for whatever reason,
there are many potent and e ective medical solutions such
as nasteride, minoxidil, and low-level laser therapy that
can partially counteract early to moderate hair loss. Even
topical camou aging products can be used to temporarily
restore the hair for social events or even on a daily basis if
the individual forgoes a surgical option.

311
24 Facial Fat Grafting
Kyoung-Jin (Saf ) Kang
peri-ligamental fat. Eventually, the soft tissue foundations
become weak and laxity of face ensues. Autologous fat
can be injected into the intra- and peri-ligamental space,
thereby strengthening the attenuated ligamentous xation
to provide solid soft tissue foundations.
Thus, to achieve a successful outcome in fat injection,
a systematic approach considering the roles of various
structures related to facial contour, the structural changes
imposed by the aging process, and the in uence of gravity
is necessary. Considering all these factors, the whole face is
divided into several zones, and the autologous fat is grafted
according to a speci c sequence of injections.

■Patient Evaluation
The physician should evaluate the facial proportions,
degree of aging, and the facial shape of the patient (oval,
round, heart, square, rectangle, inverted triangle, triangle,
and diamond shapes). According to the facial shape and
degree of aging, the physician can recommend the best
approach for fat grafting that can make the patient’s face
look younger, smaller, and more beautiful. For example, fat
grafting for anterior projection is recommended in a broad
and at face. Volumetric lifting using fat grafting is rec-
ommended in a sagged, triangular, or rectangular face. An
asymmetric face or facial expression should be evaluated

■Introduction
Autologous fat transfer has been widely used to improve
wrinkles, folds, and depressions caused by aging and to
treat partial congenital facial hypoplasia. In 2000, Fournier
introduced a lipo- lling technique as a good solution for
reversing the aging process via volume surgery. Also, he
was the rst user of the syringe-needle unit or syringe-can-
nula unit to completely block contact with air.1 Since then,
complementary fat grafting has been frequently used as
an adjunctive treatment to restore volume de ciency that
cannot be improved by conventional rhytidectomy.2
At present, fat grafting is done not only for volume
recovery, but for facial contour improvement as well.
Despite the surgeon’s attempts to achieve successful fat
grafting, an unnatural facial contour such as a at, broad,
and sagged appearance can occur when the fat is injected
only for the correction of volume depletion, with no con-
sideration of the structural and functional relationship of
the aging and soft tissue foundations.3 Special structures
that maintain soft tissue contours by restricting or xing
the movement of facial soft tissue are classi ed according
to three morphologic forms: retaining ligament, septum,
and adhesion. However, with aging as well as after years
of muscular activities and the pull of gravity, the ligamen-
tous xations become distended, elongated, and thinned
due to the decrease of collagen ber and loss of intra- and
Pearls
• Reducing the initial excessive expectations of the
patient by adequate counseling is important.
• The structural and functional relationship of
the aging and soft tissue foundations under the
in uence of gravity should be considered to avoid an
unnatural facial contour after fat grafting.
• Fat grafting achieves volumetric lifting by
strengthening soft tissue foundations and restoring
volume de ciency.
• Common fat harvesting sites are the abdomen and
lateral thigh, followed by the medial thigh and ank.
• Fat grafting of the face should be performed
sequentially from the postero-superior to the
antero-inferior area and from the deep layer to the
super cial layer.
• Pressing or massaging after fat injection must be
avoided since it can damage mature adipocytes.
• Using an ideal grip technique is important in
increasing survival and reducing the complications
of fat grafting.
• Fat injections must always be performed as the
syringe or cannula is being drawn back to prevent
vascular occlusion.
• When injecting fat into the forehead area, the
surgeon is strongly recommended to inject
botulinum toxin before the procedure for better fat
survival, with the exception of patients who have
eyelid ptosis.
• Fat injection is not a procedure without
complications. Serious complications such as
infection and vascular occlusion always need both
the surgeon’s and the patient’s attention.

V Facial Skin and Hair Rejuvenation
312
tion cannula (Coleman Type I, Mentor, 1.2 mm × 7.0 cm;
Type II, 1.0 mm × 7.0 cm), and syringe (Luer slip disposable
syringe, 1.0 mL) (Fig. 24.1).
For local injection, lidocaine (1,000 mg/L) contain-
ing epinephrine (1.0 mg/L) is mixed with bicarbonate (10
mEq/L). Modi ed Klein solutions for donor and recipient
sites are as follows: lidocaine (2,400 mg/L) containing epi-
nephrine (2.0 mg/L) is mixed with bicarbonate (15 mEq/L).
Anesthesia
For fat grafting, local anesthesia combined with oral pre-
operative medications (cephalexin, acetaminophen, and
diazepam) or intravascular sedation (propofol) is usually
applied. The author prefers to do fat grafting under seda-
tion, but general anesthesia can also be applied according
to the demand of the patient and the anesthetic physician’s
requirement according to the medical status of the patient.
A nonsteroidal, long-lasting anti-in ammatory drug such
as diclofenac sodium can be given before surgery for pre-
emptive analgesia.
Preparation of Fat for Injection
Liposuction
In donor site selection, the rst preference is the abdomen
and lateral thigh. The second is the medial thigh and ank.
The third is the supra-pubic, anterior thigh, and supra-knee
region. However, any body area that is possible for liposuc-
tion can be a donor site for fat grafting.
For harvesting fat, the entry site is anesthetized by
modi ed Klein solution for regional anesthesia using an
in ltrator attached to a 10-mL Luer lock syringe, and a
3- to 4-mm -long incision is made at the entry site with
prior to the procedure. According to the degree of asymme-
try, the amount of fat and level of placement should di er.
To predict the total amount of fat to be injected, it is
necessary to identify the areas where the patient wants
grafting, and to con rm other areas necessary to create
natural contour without sagging, even if the patient does
not want to perform fat grafting in those areas. Addition-
ally, the thickness and elasticity of the skin and subcutane-
ous tissue should be checked to adjust the amount of fat
and level of placement.
During the consultation, the importance of environ-
mental factors that can decrease the survival rate and lon-
gevity of grafted fat should be explained to the patient.
The physician must precisely check the patient’s surgical
history, including all facelifting procedures, previous fat
grafting, allograft implantation, and any injections of arti-
cial llers including foreign bodies (silicone or para n).
Other checking points include the hemorrhagic tenden-
cies of currently taken drugs, health foods, and nutritional
supplements, such as aspirin, ibuprofen, deer antler, red
ginseng, licorice, ephedra, garlic, onion liquid, vitamin
E (α-tocopherol), and omega-3 fatty acids. Smoking and
drinking should be stopped 1 or 2 weeks prior to the proce-
dure and at least 2 weeks to a maximum of 3 months after
the procedure because they increase the incidence of hem-
orrhage, edema, in ammation, and delayed wound healing.
Generally, the turnover of grafted fat occurs within 2 to 3
months after the procedure due to transient reperfusion
ischemia, but it can occur after up to 6 months.4 Therefore,
it would be good to maintain the patient’s body weight
until 6 months after the procedure. It is advisable to inform
the patient in advance that if there is a need for additional
fat grafting, it should be done within 3 months after the
rst procedure, as such timing is safer and is associated
w ith better e ects. When the patient has asymmetric facial
movement, botulinum toxin can be injected 2 weeks prior
to the planned procedure.
Because facial fat grafting brings dramatic changes in
facial appearance as time passes, pre- and postoperative
photographing is very important to evaluate the e ects.
A sky-blue background is preferred because skin color is
expressed better and it can have shadow thinning e ects.
A strobe ash is a good light source since it is close to natu-
ral light. Use of a standard lens that has a 50-mm distance
between the camera and the lens is recommended.

■Procedural Techniques
Instruments and Solutions
Instruments for harvesting fat include a tumescent in ltra-
tor (1.8 mm [diameter] × 25.0 cm [length]), standard suc-
tion cannula (3.0 mm × 25.0 cm), and syringe (Luer lock
disposable syringe, 10.0 mL). Instruments for fat injection
include a tumescent in ltrator (0.9 mm × 15.0 cm), injec-
Fig. 24.1 Cannulas of various sizes for (a) fat harvesting and
(b) injection.
a
b

24 Facial Fat Grafting
313
a surgical blade. The appropriate in ltrated volume of
tumescent solution is in a ratio of 1 to 2 mL for each 1 mL
of the expected fat harvest.5 A standard suction cannula
connected to a Luer lock syringe is introduced for manual
liposuction. For this procedure, the plunger of the syringe
should be gently handled to provide ~ 1 or 2 mL of nega-
tive pressure space in the barrel of the syringe while the
cannula is pushed through the harvest site. A high vacuum
(more than 2 mL) may damage fat cells during the proce-
dure. The application of skin protector or the patient’s own
oil from the fat aspirates to the incision site is helpful in
preventing friction burn and hypertrophic scar. All incision
sites should be closed with nylon 6.0 interrupted sutures.
Separation of Aspirates
After harvesting, the fat aspirate is centrifuged at 1,200 g
for 3 minutes.6 Free oil should be removed by holding the
syringe diagonally and pouring the oil out. The contaminated
portion can be absorbed or wiped by moist gauze with ster-
ile saline. After eliminating the free oil, the lower fraction,
which contains blood and tumescent solution, is discharged
and the puri ed fat is then transferred from the 10-mL Luer
lock syringe to a 1.0-mL disposable syringe (Fig. 24.2).
Fat Injection
Regional in ltration of anesthesia with a 1% lidocaine with
epinephrine (1:100,000) mixture is injected into the entry
site of fat injection for sensory nerve block. The supraor-
bital, supratrochlear, infraorbital, mental, buccal, zygo-
maticotemporal, zygomaticofacial, greater auricular, and
auriculotemporal nerves are targets of sensory nerve block.
Tumescent in ltration can be used for prevention of bleed-
ing, pain, and vascular embolization in the temple, orbital,
buccal, and pre-auricular area.
To achieve a successful outcome in fat injection, appro-
priate design and sequential injection are important. The
author introduced the sequential autologous fat injection
(SAFI) technique, which was developed to apply fat using a
systemic approach.
Face (Temporal, Midface, and
Lower Face Regions)
For SAFI, four lines divide the lateral face into ve zones
(Fig. 24.3). Each zone has several areas for fat grafting. The
areas numbered 1, 3, 6, 9, 11, 13, 14, 15, 17, 18, 19, and 21
are the areas where most of the patients want fat grafting.
The other numbered areas are the sites where the physi-
cian should inject fat for providing strong skeletal support,
strengthening the soft tissue foundation, and preventing
gravitational descent. The placement and injectable vol-
ume of each SAFI area are described in Table 24.1.
Fig. 24.2 Separation and transfer of fat. (a) Lipo-aspirate before
the centrifugation (left), fractionated lipo-aspirate after centrifuga-
tion, separated into three layers (supranatant oil layer, middle real
fat layer, and infranatant layer, which is composed of blood, tissue
uid, tumescent solution, and puri ed fat after removing suprana-
tant and infranatant layers (right). (b) Direction of fat transfer from
10-mL Luer lock syringe to 1.0-mL Luer slip disposable syringe.
Line 3
Line 4
21
20
18
19
17
16
15
14
13
9
10
11
7
4
6
5
3
2
Line 2
Line 1
8
Zone I
Zone II
Zone III
Zone IV
Zone V
12
Dire ct io n o f skin
d ro o p in g w it h a g in g
Inject ion Se quence
1
Fig. 24.3 Four SAFI lines and possible areas for injection. The four
SAFI lines that divide the face into ve zones are (1) Line 1, con-
necting the temporal hairline and the anterior auricular border; (2)
Line 2, connecting the orbital ligament, the posterior border of the
orbital process of the zygoma, the zygomatic retaining ligament,
and the posterior border of the super cial masseter muscle; (3)
Line 3, connecting the zygomatico-maxillary suture, the anterior
inferior prominence of the maxilla, and the anterior border of the
super cial masseter muscle; (4) Line 4, connecting the nasolabial
fold and the labio-mandibular fold.
a
b

V Facial Skin and Hair Rejuvenation
314
Fat injection is performed in a systematic manner: (1) in
the sequence of zones I, II, III, IV, and V; (2) from the postero-
superior area to the antero-inferior area within the same
zone (Fig. 24.3); and (3) in the sequence of deep, middle,
and super cial layer within an area or its subarea (Fig. 24.5).
For example, the submalar hollow is divided into two
subareas (anterior and lateral) because this area is relatively
Fig. 24.4 shows the location of entry sites, injectable
areas, and advancing directions for the cannula in perform -
ing SAFI. The arrows from each entry site indicate the direc-
tions and approachable areas for the cannula. However, the
selection of the entry sites depends on the status of the
patients and the preferred posture or convenience of the
physician.
Table 24.1 Areas, placement, and volume of fat grafting in the face
Zone
Area
Area and subarea
Purpose
Placement
Volume*
I
1
Temporal scalp area within
5 cm from the hairline
Augment and strengthen
soft tissue foundations
The space between super cial
temporal fascia (STF) and
deep temporal fascia (DTF),
subcutaneous super cial fat layer,
and inferior temporal septum
2.0–3.0
2
Sideburn and its posterior
temporal area
1.0–2.0
II
3
Temporal hollow
Strengthen soft tissue
foundations
Orbital ligament and inferior
temporal septum
2.0–4.0
Augmentation
Subcutaneous super cial fat layer,
and the space between STF and DTF
4
Pre-auricular area
Augmentation
Sub-SMAS and super cial fat layer
(Super cial temporal fat pad)
2.0–3.0
5
Zygomatic arch
Strengthen soft tissue
foundations
Zygomatic retaining ligament
0.5–1.5
Augmentation
Subcutaneous super cial fat layer
6
Lateral cheek depression
Augmentation
Deep lateral cheek fat, SMAS, and
subcutaneous super cial fat layer
1.0–2.0
7
Parotid gland area
Augmentation
Subcutaneous super cial fat layer
1.0–2.0
III
8
Lateral canthal area
Augmentation
On the periosteum and under the
orbicularis oculi muscle
0.5–1.0
9
Palpebro-malar groove
(lateral trough deformity)
Strong skeletal support
and augmentation
Under the orbital retaining
ligament, on the periosteum of
anterior area to arcuate marginalis,
above the orbital retaining
ligament, and SOOF
0.5–1.5
10
Malar emimence
(hypoplasia or at mala)
Strong skeletal support
and augmentation
Supra-periosteal layer(pre-
zygomatic space), SOOF, and
super cial fat layer
1.0–4.0
Strengthen soft tissue
foundations
Zygomatic ligaments and bucco-
maxillary retaining ligament
11
Lateral subarea of
submalar hollow
Augmentation
Deep lateral fat, intermediate
lobe of buccal fat pad, SMAS,
and super cial fat layer
2.0–4.0
Strengthen soft tissue
foundations
Masseteric cutaneous ligament
12
Lower part of the
masseter muscle
Augmentation
Masseter muscle and
subcutaneous fat layer
1.0–2.5

24 Facial Fat Grafting
315
sion, injection into the whole layer of the depressed area
is necessary.
Forehead Region
The forehead also can be divided into ve zones based on
the structures related to the morphology and aging of the
forehead. Fat is injected in the sequence of zones I, II, III,
IV, and V as shown in Fig. 24.7. When performing forehead
fat grafting, fat should be rst injected into area above the
wide and has a high risk of sagging due to the weak soft tis-
sue foundation. Fat is sequentially injected into the supra-
periosteal layer of the zygoma and maxilla for increasing
skeletal support, into the masseteric cutaneous ligament
for strengthening the soft tissue foundation, and into the
atrophied buccal fat pad for increasing fullness (Fig. 24.6).
The nasolabial fold consists of two parts: the lateral
bulging caused by volume-depleted pseudo-ptosis and the
medial depression caused by the loss of volume. To correct
the lateral bulging, fat is injected to the malar, midcheek
furrow, and submalar area. To correct the medial depres-
IV
13
Tear trough deformity
Strong skeletal support
and augmentation
On the periosteum of the inferior
orbital rim, under orbital retaining
and bucco-maxillary ligament,
SOOF, and preorbital subcutaneous
super cial fat layer
1.0–2.0
14
Midcheek furrow
Strong skeletal support
and augmentation
Bucco-maxillary ligaments, above
the periosteum and under the lip
levator muscles (deep medial cheek
fat, a part of SOOF), and super cial
medial cheek fat.
2.0–4.0
15
Anterior subarea of
submalar hollow
Strong skeletal support,
strengthen soft tissue
foundations, and fullness
On the periosteum of zygoma
and maxilla, masseteric cutaneous
ligament, and atrophied buccal fat
pad
2.0–6.0
Augmentation
Peripheral of buccal fat pad, under
the bucco-maxillary ligament
and lip elevator muscles, and the
subcutaneous super cial fat layer
16
Jowl (hypoplasia)
Deep and super cial fat layer
1.0–2.0
V
17
Nasolabial fold
Augmentation
Whole layer of depressed part
1.0–2.0
18
Labio-mandibular fold
(marionette line)
Augmentation
Whole layer of depressed part
1.0–2.0
19
Pre-jowl sulcus
Augmentation
On the periosteum of mandibular
bone, and deep and super cial fat
1.0–2.0
20
Pre-maxillary and upper
lip area
Strong skeletal support
and augmentation
On the periosteum of the piriform
area and deep fat
1.0–2.0
21
Small chin
Strong skeletal support
and augmentation
On the periosteum of mandible,
deep and submental fat layer, and
super cial fat layer
2.0–5.0
Total injectable volume
26.5 to
57.5
Abbreviations: DTF, deep temporal fascia; SMAS, super cial musculoaponeurotic system; SOOF, suborbicularis oculi fat; STF, super cial
temporal fascia.
*Volume: Injectable fat (mL/one side of face)

V Facial Skin and Hair Rejuvenation
316
Possible entry sites ( ) and directions ( ) of injection
B
o
n
e
B
o
n
e
B
o
n
e
B
o
n
e
B
o
n
e
Skin

Skin

Skin
Skin
Skin
1
2
3
4
5
6
7
8
9
10
1
2
3
4
5
6
7
8
9
10
Retaining ligament
Muscle
Lower
depressed
area
Upper
depressed
area
Skin
Fig. 24.4 Possible entry sites and directions of injection. The
arrows from each entry site indicate the directions of injection and
approachable areas for the cannula.
Fig. 24.5 Sequential depth of fat injection. (a) As the fat is
injected closer to the underlying skeleton, the e ect of the sup-
porting skeleton is stronger and the chance of gravitational descent
is less. (b) As the fat is injected more into the deep level, the pos-
sibility of injected fat descending inferiorly becomes less.
Fig. 24.6 Sequential fat injection in two abutting areas of the face. When
injecting two depressed areas that are abutting (a), fat should be injected into
the upper depressed area rst followed by the lower area, including soft tissue
and retaining ligament (b). This technique helps to decrease the volume of
injected fat in lower areas and skin becomes more tense. Eventually, it can also
prevent soft tissue sagging induced by gravitational descent. Injecting fat in
the reverse order (c) is not recommended.
a
b
a
b
c

24 Facial Fat Grafting
317
areas. Approaching zones I to III is also easy from entry site
B. Zone IV includes the most depressed area in the fore-
head. If deep horizontal forehead wrinkles are present in
zone IV, entry at site C along the wrinkles is selected.
Irregularities and lumps occur frequently in forehead
fat grafting. Molding the irregular areas is often performed
for a smooth and even surface, but it is not usually recom -
mended. Additionally, it is strongly recommended to inject
botulinum toxin before the procedure for better fat sur-
vival, except in patients who have eyelid ptosis. The bound-
aries of the zones and the amounts of fat to be injected are
described in Table 24.2.
Baton Grip Technique
Syringe grip and injection methods are important factors
in the success rate and prevention of complications in fat
grafting procedures. Bene ts from ideal syringe grip are
nesse, accuracy, easy adjustment of the fat volume, and
less trauma. The proper grip is called “baton grip” because
it is similar to the grip of the baton used by the conductor
of an orchestra. The positions of the ngers for this tech-
nique are shown in detail in Fig. 24.8. The tip of the can-
nula is pushed into the target area with thumb and index
nger extended. The grafting fat volume is nely adjusted
with thumb and index nger while the cannula is drawn
back with constant speed by using the hand and the entire
arm. The force is passed down to the thumb resting on
the plunger supported by the hypothenar eminence. Fat
is passed through the cannula by pulling the barrel of the
syringe and comes out of the cannula in a thread-like shape
(Fig. 24.9).
frontal hair line (zone I) beneath the galea aponeurosis
and frontalis muscle for tightening the frontalis muscle to
reduce physical stress on the grafted fat. Although entry
site A is a good choice for grafting zones II and III, it is dif-
cult to move the cannula and inject fat evenly because the
subcutaneous layers of zones II and III are relatively thin,
dense, and sti . Care is needed to avoid unexpected com -
plications such as lump and irregularity in these zones.
Koreans tend to prefer a more projected and round
midforehead (zone III). Sequential fat grafting from zones
I to III tightens soft tissues with volumetric lifting in these
Zone I
Zone II
Zone III
Zone IV
Zone V
Fig. 24.7 The ve zones, possible entry sites, and directions of
injection for forehead fat grafting. The two blue lines indicate the
superior temporal line. The two black dotted circles show the fron-
tal eminences. The blue circles (A, B, C) are the possible entry sites,
and the white arrows show the directions of injection.
Table 24.2 The boundary of SAFI zones, purposes, placement, and volume of fat grafting in the forehead
Zone
Boundary
Purpose
Placement
Volume*
I
Area to 7 cm above the
frontal hairline
Tightening of frontalis
muscle
Subgaleal space
3–5
II
Upper third of forehead
Anterior projection and
natural lateral contour
Subgaleal space, super cial fat layer
1–2
III
Middle third of forehead
Anterior projection and
natural frontal eminence
Subgaleal space, super cial fat layer
1–3
IV
Lower third of forehead
Strong skeletal support
Supraperiosteal layer or subgaleal space,
intramuscular, galeal fat pad, super cial fat layer
2–4
V
Brow area below zone IV
Volume recovery and
strong skeletal support
Supraperiosteal layer or subgaleal space,
glabella fat pad, brow fat pad (ROOF),
super cial fat layer
1–2
Total injectable volume
8 to 16
Abbreviation: ROOF, retro-orbicularis oculi fat.
*Volume: Injectable fat (mL/one side of face).

V Facial Skin and Hair Rejuvenation
318
the in ltrated area. Light exercise is allowed, but strenuous
exercise should be avoided for a month as it may have a
negative impact on the early survival rate of the injected
fat.9 Additional fat grafting can always be performed.
The optimal time for an additional procedure is at least 3
months after the rst fat grafting. However, if the patient
strongly demands it, the procedure may be performed at
least 1 month after the rst one using fresh or frozen fat.

■Key Technical Points
1. Fat injection is performed in a systematic manner: (1)
in the sequence of zones I, II, III, IV, and V; (2) from the
postero-superior area to the antero-inferior area within
the same zone; (3) in the sequence of deep, middle,
and super cial layers within an area or subarea.
2. Application of a skin protector or patient’s own oil
from the fat aspirates to the incision site is helpful in
preventing friction burn and hypertrophic scarring.
Application of Platelet-Rich Plasma
and Adipose-Derived Stem Cells
Various attempts have been made to increase the survival rate
and longevity of grafted fat. Among them, the application of
platelet-rich plasma (PRP)7,8 and adipose-derived stem cells
(ADSC)4 are the most popular, and positive research results
have been published on these applications. However, more
research is still required for more evidence in improvement
of fat survival and longevity by these applications.
Postoperative Care and Treatment
Immediately after fat grafting, Microfoam (3M) tape should be
placed on the in ltrated area and left in place with application
of an ice pack for 3 or 4 days. This is for minimizing the forma-
tion of edema, and for preventing migration of in ltrated fat
and protecting the skin. The entry site sutures are removed
after 3 days, and then Steri-Strip (3M) is applied for 2 days
more. Facial muscle movement should be restricted, and liq-
uid food such as porridge is recommended over this period of
time. Three days after the procedure, it is better to replace ice
packs with hot packs to eliminate edema and bruising.
Particular attention should be paid to avoid pressure on
the in ltrated area during sleep until 3 months after the
procedure. Patients should also be instructed to keep their
face above their heart during sleep. Warn patients to make
sure that they and others do not touch or put pressure on
Fig. 24.8 Baton grip technique for fat grafting. The barrel of the
syringe is positioned between the tip of the thumb and the distal
interphalangeal joint of the index nger. The rest of the plunger is
positioned in the junction between the hypothenar eminence and
the medial side of the palm. Other ngers hold the barrel of syringe
as if they were grabbing an egg. (a) Lateral view of the exion state.
(b) Lateral view of the extension state.
Fig. 24.9 Fineness of baton grip technique. The thread-like fats
extruded from two kinds of cannulas, with inner diameters of (a) 15
mm and (b) 12 mm, using the baton grip technique.
a
b
a
b

24 Facial Fat Grafting
319
any lump and bump still exists, excision is recom m ended.
These complications can be prevented if an adequate vol-
um e of fat is placed at the optim al layer using a precision
syringe grip technique.
Asymmetry and Hyper- and
Hypo-Correction
Occasionally, some patients complain of asymmetry imme-
diately after fat grafting. Edema or inappropriate correc-
tion is the most common cause of asymmetry. This can be
improved with adjustment of volume by performing either
liposuction or additional fat grafting at least 1 month after
the procedure.
Migration and Gravitational Descent
Early migration is mainly caused by direct pressure on the
in ltrated site or active movement of the mimic muscle. It
might be improved by molding with gentle digital pressure
or prevented by pretreatment w ith botulinum toxin. Late
migration usually occurs in the areas of the nasolabial folds,
cheeks, and jowls and is caused by gravitational descent
due to the weight of the injected fat. The principle of correc-
tion is to do proper liposuction of the descent area rst and
then do volumetric fat grafting into the depressed area. But
sometimes facelift surgery is necessary for patients who
have severe laxity of skin. It is suggested that application of
the SAFI technique and pretreatment with botulinum toxin
are reliable approaches to prevent these complications.
Resorption of Fat
Resorption of grafted fat is the most serious common com -
plaint by patients. Many environmental and technical fac-
tors are related to the survival rate of injected fat. To reduce
this complication, applying ADSC, pretreatment with bot-
ulinum toxin, even placement of fat using the baton grip,
cessation of smoking, postoperative limitation of facial ani-
mation, and one or two sessions of additional fat grafting
are required.
Hyperpigmentation and Scar
Hyperpigmentation is frequently found in the orbital and
periorbital area with bruising after fat grafting. The sur-
geon should apply sunblock cream and prescribe 2 to 4%
hydroquinone cream one or two times per day if it becomes
worse. In the patient with sensitive skin, half-strength
hydroquinone cream is applied. The application of intense
pulsed light and Q-sw itch Nd: YAG laser might also be
helpful to improve hyperpigmentation. Damage of approxi-
3. Tumescent solution should not be injected suddenly
in a huge volume with high pressure; this could
cause the development of a lake in the tissue, which
could lead to insu cient and uneven liposuction.
4. The baton grip technique of using the syringe in fat
injection helps to increase the survival of grafted fat
and to decrease complications.
5. When correcting tear trough deformity, the end
point of fat grafting is a status that is slightly under-
corrected in the supine position.
6. In forehead fat grafting, fat is injected into the
area above the frontal hairline beneath the galea
aponeurosis and frontalis muscle to tighten the
frontalis muscle and thus help to reduce physical
stress on the grafted fat.
7. Injecting botulinum toxin before grafting increases
the survival of grafted fat in the forehead.

■Complications and
Their Management
Edema, Bruising, or Hematoma
Edema or persistent edema (longer than 2 weeks) may
occur due to tissue damage during pre-tunneling and injec-
tion, hypo-osmolarity due to the tumescent uid, and sev-
eral other systemic diseases. To avoid or minimize edema,
adequate taping is most important. Prolonged edema
should not be confused w ith hyper-correction, hematoma,
in ammation, or factors due to systemic diseases. Gener-
ally, a medical device that accelerates lymphatic circulation
can be helpful to reduce edema.
The major cause of bruising or hematoma is vascular or
muscular damage caused by the cannula during injection. A
precise injection grip technique should be applied, and the
bleeding tendency of the patient should be checked before
the procedure.
Irregularity, Lump, and Bump
The occurrence of irregularity, lump, and bump usually
depends on the physician’s grip technique, experience,
and aesthetic sense. Molding of the irregular areas is
often perform ed for a sm ooth and even surface during
the procedure, although its e ect is lim ited. If the lump is
seen or felt during or w ithin 2 weeks after the procedure,
it should be rem oved properly w ith lipolysis-assisted or
m anual liposuction. Also, if any irregularity is seen after
rem oval of the lump, it is advisable to correct it im m e-
diately w ith additional fat grafting. Som etim es, two or
three injections of catabolic steroid solution can help to
reduce the size of lump and bump. Despite all attempts, if

V Facial Skin and Hair Rejuvenation
320
mated epithelium caused by some friction of the cannula is
the main cause of scar formation. It is helpful to treat scars
with the application of antiscar ointment, steroid ointment
or injection, and laser resurfacing. The author recommends
that entry be made with an 18-gauge needle and that the
site is sutured for prevention of scar.
Acneiform Eruption
Acneiform eruption is caused by excessive oil formation
from destroyed fat cells after fat grafting. It frequently
develops in patients with oily skin and previous acne his-
tory. It can be improved by adequate cleansing of the face
and administration of drugs for ~ 7 days.
In ammation and Abscess Formation
Bacterial infection after fat grafting is accompanied by pain,
swelling, and erythematous induration, which lasts 2 or 3
days to several weeks after the procedure. Abscess com -
monly forms if the infection is not controlled at an early
stage (Fig. 24.10).10,11 Once it occurs, an aggressive treat-
ment such as incision and drainage is needed since it can
spread to the surrounding tissue, causing severe complica-
tions such as cellulitis.10,12 The main causes of infection are
inadequate sterilization of surgical instruments, contami-
nated frozen fat, intraoperative contamination of fat and
cannula, and infection through the entry site. Attention
should be given to the patient’s history since an immune-
compromised patient has a much higher possibility of
infection. To prevent infection, washing the inside of the
cannula thoroughly and complete sterilization of surgical
instruments are mandatory. All uids including tumescent
solutions should be sterile, and strict hygiene control dur-
ing harvesting, separating, and recharging of the fat is nec-
essary. The perioral area and nasal cavity should be avoided
as entry sites of injection, and adequate pre- and postop-
erative antibiotics should be administrated. Continuous
application of ice packs may prevent spreading of infection
to the surrounding area in the early stages. The basic goal of
surgical treatment is to remove contaminated fat and sur-
rounding tissue. Additional fat grafting is possible at least
6 months after complete recovery from the infection, and
only fresh fat should be used.
Vascular Embolization
Although the occurrences of vascular occlusion from fat
grafting have signi cantly decreased with the use of the
blunt cannula, it still exists. It is known to occur frequently
after facial fat grafting at the regions of the glabella, nasola-
bial folds, nose, and temporal area (Fig. 24.11).
Regional complications such as skin necrosis13 and
blindness14,15 can be caused by occlusion of an end branch
Fig. 24.10 Abscess formation after fat injection. (a) A female
patient who developed left cheek swelling after whole face fat
injection. (b) About 30 mL of pus was aspirated from her left cheek.
Fig. 24.11 Skin necrosis of the nasolabial area after fat injection.
or surrounding branches of an artery when fat is accidently
injected into the artery. If a large amount of fat is injected
into the artery with high pressure, the fat can be re uxed
into the internal carotid artery. Eventually, a serious com -
plication such as stroke may occur.15,16 Blindness occurs
concurrently with sudden orbital or periorbital pain during
or immediately after the fat grafting. No instances of visual
restoration have been reported after fat grafting–induced
a
b

24 Facial Fat Grafting
321
accompanied by volume reduction of the temporal, malar
and submalar areas, and the lateral cheek. Six months after
fat grafting, the overall facial contour changed to an oval
or reversed triangle shape, and asymmetry signi cantly
improved in the frontal view (Fig. 24.13). This successful
volume redistribution made the face look lifted naturally in
the postero-superior direction also. The most remarkable
change is the ogee curve in the midface. The completely
isolated ogee curve became connected and round by the
anterior projection through fat grafting.
blindness, but symptoms of brain infarction have partly
resolved in a few cases as time passed.14,15,16,17
On the other hand, if the fat is injected into the vein,
it goes through the heart and then blocks the pulmonary
artery. Sudden sweating, dyspnea, and tachypnea can be
manifested as typical symptoms of nonthrombotic pulmo-
nary embolism during fat grafting.18
It appears that the mobility of the vessel is signi cantly
reduced after the rst fat grafting due to brosis and full-
ness of the in ltrated area. Thus, in spite of using the blunt
cannula, the vessels may have a much higher chance of
being penetrated with re-injection of the previous in ltra-
tion site than with the primary fat injection. Even when
the fat is injected for the rst time, fullness due to over-
correction can also reduce the mobility of the vessels, thus
increasing the possibility of penetration.
These serious complications can be prevented by avoid-
ing over-correction and using a cautious approach in the
second and third sessions of fat grafting. It is important to
inject fat not when the cannula is pushed ahead, but when
the cannula is being drawn back. Avoid injecting fat parallel
to the course of a vessel and use epinephrine for constrict-
ing vessels. Additionally, emergency care must always be
ready and the patient must be transferred immediately to
the secondary or tertiary care center for further appropri-
ate treatment when vascular occlusion occurs.
Complications of the Donor Site
Severe complications from liposuction occur rarely since
only a relatively small amount of fat is needed for facial
fat grafting. The possible complications from liposuction
include depression or irregularity, bleeding and hematoma,
brosis, hyperpigmentation, paresthesia and pain, in am -
mation, seroma, scar, necrosis, fat embolism, thromboem -
bolism, and toxic shock syndrome.

■Case Studies
Case 1: Whole Face Fat Grafting
A 30-year-old woman wanted to improve her angular face
(Fig. 24.12). She had dark circles with infraorbital hollows,
deep nasolabial folds, volume de ciencies of the lateral
cheek, temporal hollows, and a at forehead. A total of
65 mL of puri ed fat was used for injection into the face
and forehead. A preoperative view shows a long, rectan-
gular, asymmetric face with a sagging appearance due to
the development of nasolabial folds and jowls, which is
Fig. 24.12 Case 1. Whole face volume recovery with fat grafting.
(a,b) The patient before the procedure (unpowdered state).
Fig. 24.13 Case 1. (a,b) Six months after the procedure (unpow-
dered state).
a
b
a
b

V Facial Skin and Hair Rejuvenation
322
the malar, palpebro-malar groove, tear trough deformity,
and midcheek furrow to increase skeletal support and to
restore volume de ciency. Postoperatively, the lid-cheek
junction was signi cantly shortened, and infraorbital hol-
lowness and deep midcheek furrow improved remarkably
(Fig. 24.15). Increased skeletal support and restoration of
soft tissue made the fat protrusion less prominent.
Case 2: Lower Lid Rejuvenation Using
Fat Graft
A 33-year-old woman complained of orbital fat protrusion
and tear trough deformity (Fig. 24.14). Using the baton
grip technique, ~ 15 mL of puri ed fat was injected to
Fig. 24.14 Case 2. Skeletal supporting and volume recovering e ect
of SAFI on lower lid rejuvenation. The patient before the procedure.
Fig. 24.15 Case 2. The patient 18 months after the procedure.
The lid-cheek junction was signi cantly shortened and infraorbital
hollowness and deep midcheek furrow remarkably improved after
fat injection.
Case 3: Forehead Fat Grafting
A 24-year-old woman wanted to have a round and con-
vex forehead (Fig. 24.16). In two sessions of fat grafting
5 months apart, 18 mL and 10 mL of puri ed fat were
injected, respectively. Twenty units of botulinum toxin
were injected into the frontalis and corrugator muscle 10
days before the procedures (Fig. 24.17).
Fig. 24.16 Case 3. Forehead fat grafting and pretreatment with bot-
ulinum toxin. The patient before the procedure (unpowdered state).
Fig. 24.17 Case 3. (a) Five months after the rst procedure (unpowdered state). A second procedure was performed at this time. (b) Five
years after the rst procedure, and 4 years and 7 months after the second procedure (powdered state).
a
b

24 Facial Fat Grafting
323
10. Beeson WH, Slama TG, Beeler RT, Rachel JD, Picerno NA.
Group A streptococcal fasciitis after submental tumescent
liposuction. Arch Facial Plast Surg 2001;3(4):277–279
11. Galea LA, Nicklin S. Mycobacterium abscessus infection
complicating hand rejuvenation with structural fat grafting.
J Plast Reconstr Aesthet Surg 2009;62(2):e15–e16
12. Villani F, Caviggioli F, Giannasi S, Klinger M, Klinger F. Cur-
rent applications and safety of autologous fat grafts: a re-
port of the ASPS Fat Graft Task Force. Plast Reconstr Surg
2010;125(2):758–759, author reply 759
13. Danesh-Meyer HV, Savino PJ, Sergott RC. Case reports and
small case series: ocular and cerebral ischemia following
facial injection of autologous fat. Arch Ophthalmol 2001;
119(5):777–778
14. Teim ourian B. Blindness following fat injections. Plast Re-
constr Surg 1988;82(2):361
15. Dreizen NG, Fram m L. Sudden unilateral visual loss after
autologous fat injection into the glabellar area. Am J Oph-
thalmol 1989;107(1):85–87
16. Thaunat O, Thaler F, Loirat P, Decroix JP, Boulin A. Cerebral
fat em bolism induced by facial fat injection. Plast Reconstr
Surg 2004;113(7):2235–2236
17. Yoon SS, Chang DI, Chung KC. Acute fatal stroke imm edi-
ately following autologous fat injection into the face. Neu-
rology 2003;61(8):1151–1152
18. Jiang X, Liu DL, Chen B. Middle temporal vein: a fatal haz-
ard in injection cosm etic surgery for temple augm entation.
JAMA Facial Plast Surg 2014;16(3):227–229
References
1. Fournier PF. Fat grafting: my technique. Dermatol Surg
2000;26(12):1117–1128 Com ment in Derm atol Surg
2003;29:898
2. Amar RE. [Adipocyte microin ltration in the face or tissue
restructuration with fat tissue graft.] Ann Chir Plast Esthet
1999;44(6):593–608
3. LaTrenta GS. Atlas of Aesthetic Face and Neck Surgery. 1st
ed. Philadelphia, PA: Saunders, Elsevier; 2004:52–59
4. Yoshimura K, Sato K, Aoi N, Kurita M, Hirohi T, Harii K. Cell-
assisted lipotransfer for cosmetic breast augmentation: sup-
portive use of adipose-derived stem/stromal cells. Aesthetic
Plast Surg 2008;32(1):48–55, discussion 56–57
5. Kuhbier JW, Weyand B, Radtke C, Vogt PM, Kasper C, Re-
im ers K. Isolation, characterization, di erentiation, and ap-
plication of adipose-derived stem cells. Adv Biochem Eng
Biotechnol 2010;123:55–105
6. Colem an SR. Structural Fat Grafting. St Louis, MO: Quality
Medical Publishing; 2004:55–73
7. Cervelli V, Palla L, Pascali M, De Angelis B, Curcio BC, Gen-
tile P. Autologous platelet-rich plasm a m ixed with puri ed
fat graft in aesthetic plastic surgery. Aesthetic Plast Surg
2009;33(5):716–721
8. Abuzeni PZ, Alexander RW. Enhancem ent of autologous
fat transplantation with platelet rich plasma. Am J Cosm et
Surg 2001;18:59–70
9. Niechajev I. Lip enhancem ent: surgical alternatives and
histologic aspects. Plast Reconstr Surg 2000;105(3):
1173–1183, discussion 1184–1187

324
25 Endoscopic Forehead and Brow Lift
Tee Sin Lee and Stephen S. Park
ere2 compared the results of open approaches versus EFBL.
They found no statistical di erence in the measurable
results between these procedures. In a systematic review
of open versus endoscopic techniques published in 2011,
there is no clear evidence to indicate that open methods
are inferior to the endoscopic approaches.3 However, EFBL
does o er some advantages over the open techniques. The
incisions are smaller and well hidden within the hairline.
It results in less blood loss and also reduced scalp hypo-
esthesia. Disadvantages include the increased cost for the
more sophisticated instruments and also a learning curve
to overcome. The ideal xation method is still controversial
but many di erent techniques seem to work well.

■Relevant Anatomy
Facial proportions are divided into horizontal thirds and
vertical fths. The upper face occupies the upper third and
starts from the trichion to the glabella. The temporal region
is also important when dealing with the lateral brow posi-
tion. Hence, knowing the anatomy of the forehead and tem -
poral region is of paramount importance to ensure a safe
and complication-free forehead and brow lift.

■Introduction
Forehead and brow lift is an important component of upper
face rejuvenation. This often complements the results of
upper blepharoplasty, and the reverse is also true. Fore-
head lift results in a smoother contour with resolution or
improvement of forehead and glabellar rhytids, while brow
lift aims to elevate the brows to an aesthetically pleasing
position and also to sculpt an aesthetically pleasing shape.
In the process of achieving this, incisions have to be made
in the forehead and scalp or along the hairline, where they
may be too conspicuous for patients to accept. Hence, the
concept of the minimally invasive procedure was devel-
oped. and the endoscopic forehead and brow lift (EFBL) was
popularized.
This was rst described by Vasconez et al1 in 1994 in the
United States, where they detailed the use of endoscopes to
guide the release of the supraorbital and glabellar tissues.
The dissection was in the subgaleal plane, but the xation
was not well described. Subsequently, multiple variations
in dissection and xation techniques have been reported.
In general, EFBL has been shown to produce excellent
results; however, it has not been proven to be superior to
the open techniques. A study in 2002 by Puig and LaFerri-
Pearls
• The aging upper one-third of the face is assessed as a
unit, and all aesthetic units are interrelated.
• The aging brow can have a dramatic impact on
general facial expression, creating a tired or fatigued
appearance.
• Ptosis of the aging brow can simulate
dermatochalasis of the upper eyelid.
• The approaches to forehead and brow lift can be
divided into open and endoscopic. Open approaches
include trans-blepharoplasty, direct, midforehead,
trichophytic, and coronal.
• The principles of endoscopic forehead and brow lift
(EFBL) are the making of smaller, well-camou aged
incisions; maximal release of muscular and
periosteal attachments; cephalic rotation of the
scalp, forehead, and brow complex; and xation of
the complex at the desired height.
• When a combined approach to dealing with the
brows and eyelids is planned, EFBL is done rst to
set the height of the eyebrows and determine the
amount of skin to be excised.
• The advantages of EFBL over the coronal approach
are camou aged incisions, shorter recovery time,
and less risk of alopecia and scalp numbness.
• The disadvantages of EFBL are that the hairline
can be raised, redundant forehead skin cannot
be excised, less control in asymmetrical brows,
increased cost due to more sophisticated
instruments being used, and learning curve.
• EFBL has been shown to be e ective with lasting
outcomes. Di erent xation methods are available.

25 Endoscopic Forehead and Brow Lift
325
The forehead is made up of ve layers. From super cial
to deep, they are skin; subcutaneous fat; galea aponeuro-
tica, which splits to envelop the frontalis muscle; loose are-
olar tissue; and periosteum. At the brow area is the subbrow
fat pad or the retro-orbicularis fat pad, found just below the
orbicularis oculi muscle but above the periosteum. As for
the temporal region, the layers are skin, subcutaneous fat,
temporoparietal fascia, deep temporalis fascia, and nally
the temporalis muscle. The deep temporalis fascia splits
into super cial and deep layers to envelop the super cial
temporal fat pad ~ 2 cm above the zygomatic arch. The
super cial layer attaches to the super cial superior margin
of the zygomatic arch, and the deep layer attaches to the
deep superior margin. Deep to the deep layer lies the deep
temporal fat pad, which represents a superior extension of
the buccal fat pad.
The frontal branch of the facial nerve courses within
the temporoparietal fascia (Fig. 25.1) along the Pitanguy
line.4 This is a line that runs from 0.5 cm below the tragus
to 1.5 cm above the lateral eyebrow (Fig. 25.2).
A loose areolar plane separates the temporoparietal
fascia from the deep temporalis fascia. This is a relatively
avascular plane, and it is deep to the frontal branch of the
facial nerve, and hence is an ideal plane of dissection dur-
ing EFBL (Fig. 25.3). However, the medial zygomatico-tem -
poral vein or the sentinel vein can be found traversing this
plane (Fig. 25.4). The vein can be found ~ 1 cm lateral to
the frontozygomatic suture line, and the frontal branch is
usually found just cephalad to it. Trinei et al5 mapped out
a zone of caution based on the location of this vein and its
proximity to the frontal branch, and found that the nerve
was always within a 10-mm radius of this vessel. A more
recent study by Sabini et al found this radius to be much
closer, within 0 to 2 mm.6 Extreme care should be taken in
this area since a disruption of the vein can lead to bleeding,
impaired visualization, electrocautery, and then injury to
the facial nerve.
The supraorbital notch or foramen transmits the supra-
orbital nerve, a branch of the ophthalmic nerve. This can be
located ~ 27 mm lateral to the glabellar midline, or typically
within 1 mm of a line drawn in a sagittal plane tangential
to the medial limbus (Fig. 25.5). As it emerges from the
foramen or notch, it divides into a deep and a super cial
branch. The deep branch runs superolaterally, parallel and
~ 0.5 to 1.5 cm medial to the superior temporal line in the
loose areolar tissue between the galea and periosteum. The
super cial branch usually divides into multiple branches,
piercing the frontalis muscle and running super cial to it.
The deep lateral branch supplies sensation to the lateral
posterior forehead and scalp while the super cial medial
branch supplies sensation to the forehead along the mid-
line and frontal scalp.
The supratrochlear nerve, also a branch of the oph-
thalmic nerve, can be found ~ 17 mm lateral to the gla-
bellar midline or at an average of 9 mm medial to the exit
Deep temporalis fascia
Plane of dissection
Temporoparietal
fascia
Superficial fat pad
Superficial
temporal vessels
Frontal branch
of facial nerve
SMAS
Deep fat pad
Zygomatic
arch
Fig. 25.1 The frontal branch of the facial nerve courses within the
temporoparietal fascia. SMAS, super cial musculoaponeurotic system.
1.5 cm
0.5 cm
Fig. 25.2 The frontal branch of the facial nerve follows the Pitan-
guy line.

V Facial Skin and Hair Rejuvenation
326
the frontal and zygomatic branches of the facial nerve. The
depressors of the brow need to be adequately dealt with
to achieve an e ective lift. They are usually in a balanced
state maintaining the position of the brow. Any over- or
under-activity of either will cause the brows to be raised
or lowered.
of the supraorbital nerve through a notch (Fig. 25.5). The
nerve penetrates the corrugator and frontalis muscles as it
courses superiorly along a line tangential to the medial end
of the brow. It supplies sensation to a central vertical strip
of forehead and the medial upper eyelid. The infratrochlear
nerve exits just below the supratrochlear nerve around the
medial orbital rim, and it provides sensation to the upper
nose and medial orbit.
It is important to know that there is brous ligamen-
tous thickening around the orbital rim and temporal area
that xates the brow and forehead complex. These rm
attachments need to be released for the brow and forehead
to be adequately and e ectively lifted. The arcus marginalis
is an area of localized thickening of the aponeurosis at the
superior orbital rim where the orbital septum attaches to
the orbital bone. Another area of this thickening is the con-
joint tendon or the zone of xation at the temporal fusion
line (Fig. 25.6). This is an area of fusion between the galea,
temporoparietal fascia, and deep temporalis fascia and the
periosteum of the frontal bone. It also marks the transition
between forehead and temple. Finally, there is the orbital
retaining ligament centered over the frontozygomatic
suture that holds the lateral part of the brow down.
The musculature also plays an important role in the
position and shape of the brow. This is divided into the
brow elevators and depressors. The elevators are the fron-
talis muscle and are supplied by the frontal branch of the
facial nerve. The depressors are the procerus, corrugator
supercilii, and the orbicularis oculi muscles, supplied by
*
Fig. 25.3 Cadaveric dissection demonstrating temporal anatomy.
A: Temporoparietal fascia on the ap side. B: Deep temporalis fascia
demonstrating the glistening white fascia. C: A small window cre-
ated in the deep temporalis fascia to demonstrate the temporalis
muscle. Between A and B: loose areolar tissue and plane of surgical
dissection.
Fig. 25.4 Intraoperative endoscopic view of the sentinel vein
(asterisk) seen traversing between the temporoparietal fascia
(above) and deep temporalis fascia (below).
Fig. 25.5 Supraorbital and supratrochlear neurovascular bundles.
On the right side of the skull, the supraorbital neurovascular bundle
is seen exiting ~ 27 mm from the midline. The deep branch runs
superolaterally while the super cial branch situates medially. On
the left side of skull, the supratrochlear neurovascular bundle is
seen exiting ~ 17 mm from the midline.

25 Endoscopic Forehead and Brow Lift
327
For males, the brows should be positioned at or near
the supraorbital rim with minimal arching and be more
horizontal. Creating the arch in a man will be unattractive.
For females, the brows should be positioned slightly supe-
rior to the supraorbital rim with a subtle arch as described
previously.
Aging Process
As we age, the brow undergoes descent due to gravitational
forces and loss of skin elasticity. The medial brow height
is maintained by the balance between brow elevator (fron-
talis) and depressors (corrugator supercilii and procerus).
However, as the frontalis stops at the temporal fusion line,
the lateral brow receives unopposed depression from the
lateral part of the orbicularis oculi due to lack of frontalis
action. Hence, the lateral brow descends earlier and more
severely than the medial brow.
As the lateral brow descends, it creates hooding of the
lateral part of the eyelid, which m ay cause obstruction of
the visual eld. Ptotic brows can portray the appearance of
anger, sadness, worry, and weariness despite the absence
of em otional intent or causative physical condition.
Forehead and glabellar rhytids develop as a result of
repeated muscular contraction during facial expression
and also the process of aging, which produces skin thinning
and loss in elasticity.

■Considerations
Brow Aesthetics
Before assessing the patient, the surgeon needs to know
what the ideal brow position and shape are, and also to
understand the problem that is being addressed. The ideal
brow position and shape vary with sex, age, race, culture,
and fashion trends. Hence, it is important to understand
the patient’s needs and concerns before embarking on sur-
gery. There is no one standard surgery for all patients.
The brow can be analyzed in terms of its shape, posi-
tion, mobility, and symmetry with the contralateral side.
The medial brow should begin at a vertical line drawn from
the alar facial crease to the medial canthus, and at ~ 1 cm
above the medial canthus (Fig. 25.7). It should progress
laterally in a club-like con guration, gradually tapering
toward its lateral end. It should ascend superiorly to the
apex and then turn inferiorly. The lateral brow should end
at an oblique line from the alar facial crease to the base of
the lateral canthus. The highest point, or apex, of the brow
should be at the lateral limbus. However, some believe that
this high point should be more lateral than the lateral lim -
bus and closer to the lateral canthus. Finally, the medial and
lateral ends should lie at about the same horizontal plane.
The shape of the brow can be described as at, arching,
downward slanting, or upward slanting. Most important,
the brows on the two sides should be in symmetry.
Fig. 25.6 Conjoint fascia and brow muscles. A: Conjoint fascia. B:
Orbital retaining ligament. The conjoint fascia requires complete
transection from the vertex to the orbit. This is approached from
lateral to medial (direction shown in C), and then released anterior
to posterior (as in direction D).
a b
Fig. 25.7 Ideal brow position. The medial brow should begin at a
vertical line drawn from the alar facial crease to the medial canthus.
The lateral brow should end at an oblique line from the alar facial
crease to the base of the lateral canthus. The highest point of the
brow should be at the lateral limbus (a) or some believe that it should
be more lateral, closer to the lateral canthus (b). Finally, the medial
and lateral ends should lie at about the same horizontal plane.

V Facial Skin and Hair Rejuvenation
328
Special Considerations in
East Asian Patients
In general, the distance between the brow and lashes of
the upper eyelid is greater in Asians than in Caucasians. In
addition, Asians tend to have a shallower superior orbital
sulcus compared with Caucasians.
Horizontal forehead rhytids are also less common in
Asians because of increased dermal thickness as well as the
presence of more abundant adipose tissue in the supraga-
leal plane. This holds true for glabellar rhytidosis as well.
Eyebrow tattooing or micropigmentation is very pop-
ular in Asia and must be recognized at the preoperative
evaluation; it is important to locate the position of the
actual brow, which may have been plucked or removed.
Subsequent tattooing can be utilized for scar camou aging
if necessary.

■Patient Evaluation
History and Examination
It is uncommon for patients to present with complaints of
droopy brows and speci cally request a brow elevation.
More frequently, their general complaint is looking tired,
fatigued, solemn, or older, while their energy and mood do
not correlate. It is not uncommon for them to ask to “have
their eyes done” as they pinch the hooded skin of the upper
lids. In more severe cases, they may complain of superior
visual eld obstruction due to the hooding or frontal ten-
sion headache secondary to frontalis over-activity in an
attempt to raise the upper lid to see better. Deep static fore-
head rhytids frequently co-exist after many years of fron-
talis hyperactivity. If the medial brow drops, the patient
may complain that it creates the impression of sternness
or anger.
It is important to identify the speci c etiology of the
unwanted appearance and demonstrate this to the patient.
This leads to the most direct surgical treatment. One
must distinguish between dermatochalasis, brow ptosis,
dehiscence of the levator aponeurosis, hyperfunctioning
frontalis, facial nerve injury, and other esoteric variables.
Frequently a combination of maneuvers provides the best
option, with EFBL being a central staple in upper facial
rejuvenation.
As with all cosmetic patients, it is important to identify
those with hidden agendas or psychiatric issues during the
consultation process. If their expectations are unreason-
able or if they have unrealistic demands, it may be better
not to operate on them.
After understanding a patient’s needs and concerns,
the next part of the consultation is to establish the pathol-
ogy and severity. The whole face has to be examined for
Relationship with the Eyelid
Analysis of the brow would not be complete without the
analysis of the eyelid, as they both contribute to the upper
face aesthetics and undergo a similar aging process. Very
often, brow ptosis and dermatochalasis contribute to lat-
eral hooding. Hence, performing a brow lift or blepharo-
plasty alone may not adequately deal with the problem.
Combining a brow lift with a blepharoplasty allows a more
conservative resection of the upper eyelid skin and is a
common procedure.
When assessing a patient for a blepharoplasty, it is
imperative to assess the brow position as well. If the brows
are ptotic to begin with, performing a blepharoplasty may
exacerbate this and create an unnatural appearance. In
this scenario, it is best to rst raise and stabilize the brows
before an upper blepharoplasty.
Another situation is when a patient presents with an
asymmetric brow position secondary to over-activity of
the frontalis on one side. This can occur from unilateral
upper eyelid ptosis where the patient habitually raises one
brow in an attempt to improve the visual eld. Hence, the
brows need to be assessed w ith the frontalis at rest to avoid
intervention in what is a physiologic condition rather than
an anatomic one. The correct management in this situation
would be to correct the ptosis rather than the brow posi-
tion. With over-activity of the frontalis due to brow ptosis,
eyelid ptosis, or dermatochalasis, dynamic forehead rhytids
will gradually become static, requiring a forehead lift.
Indications
The three main indications to lift the forehead and brow are
forehead and glabellar rhytidosis, brow ptosis, and brow
asymmetry.
Forehead and glabellar rhytidosis can be occasionally
treated with botulinum toxin injection into the depres-
sor muscles, a chemical brow lift. Botulinum toxin may
have a stronger indication in a prophylactic role. Deeper
rhytids can be addressed with soft tissue llers, occasion-
ally in combination w ith botulinum toxin. However, these
methods are temporary and require repeated treatments to
maintain the desired outcome.
In a surgical forehead lift, the wrinkles are mechani-
cally pulled upward and attened. The muscular elevator
and depressors can be resected, separated, or weakened
surgically to achieve similar e ects. These results are
deemed more permanent than the use of botulinum toxin
and injectable llers. However, the longevity is question-
able as the muscle bers tend to regenerate and re-estab-
lish the connection, resulting in some return of muscle
function and hence the rhytids. Some argue that the return
of function is minimal and the need for botulinum toxin is
overstated.

25 Endoscopic Forehead and Brow Lift
329
amount of redundant upper lid skin is determined by
pinching and then marking with a skin marker. The
amount of skin to be resected should be just enough
to evert the lid lashes to 90 degrees but not cause
lagophthalmos.
6. Presence of eyelid ptosis: It is extremely important
to assess for eyelid ptosis, as it can be the major
contributor to the tired appearance and visual eld
de cit. The marginal re ex distance can be used. The
ptosis may secondarily give rise to an asymmetric,
relative, unilateral brow ptosis as the ipsilateral
frontalis attempts to compensate and elevates the
brow. Moreover, a standard brow lift w ill not correct
the compensatory brow asymmetry.
7. Absence of Bell’s phenom enon and lagophthalm os:
Any baseline lagophthalmos should be detected
as it will likely be exacerbated following EFBL and
upper blepharoplasty. Bell’s phenomenon is a
normal protective mechanism for the cornea and
should be present, especially if a small amount of
lagophthalmos occurs postoperatively.
8. Lower two-thirds of the face: Again, the rest of the
face should be assessed to ensure facial harmony. If
signi cant aging co-exists in this region of the face,
the discrepancy can be more dramatic following
surgery.
Methods and Patient Selection
There are many methods to elevate the forehead and brow;
these can be divided into open and endoscopic approaches.
The various incisions available for di erent types of brow
lift are shown in Fig. 25.8. The open approaches include
1. Coronal approach
2. Modi ed coronal approach
a.
Trichophytic
b. Pretrichophytic
3. Direct brow lift
4. Indirect brow lift or midforehead brow lift
5. Trans-blepharoplasty brow lift
The main disadvantage of the open technique is the prob-
lem with the surgical scar and numbness from transection
of the supraorbital and supratrochlear nerves. The scar
can be too visible or result in alopecia along the incision.
Going across the skull or hairline causes scalp hypoesthe-
sia, which can be disconcerting to some patients. Although
the trans-blepharoplasty approach avoids the major issue
of the surgical scar, it does not allow a great deal of lift and
should be regarded more as a brow stabilizer than as an
elevator. The endoscopic approach remedied these issues
and has become the technique of choice for most surgeons.
proportion and harmony, including the aging process of the
lower face. After rejuvenation of the upper face, the lower
jowls and marionette lines will appear more dramatic in
contrast. The face can be in disharmony.
It is critical to give patients a mirror during the con-
sultation for them to point out their exact concerns. You
can then use the mirror to con rm what they desire and
also to demonstrate what you can achieve for them. It is
important for the surgeon and patient to have similar goals
and expectations.
The examination should start from top to bottom.
1. Hairline: The hairline is important as it determ ines
the starting point of the upper face and can be
altered during a brow lift. If the hairline is high,
it m akes the forehead appear longer, and further
elevation m ay be undesirable. Conversely, a low
hairline lends itself well to a brow lift procedure. A
receding hairline is a m ajor factor in determ ining
the proper surgical option since scar exposure in
the future is clearly a problem . Even wom en, as
they age, can show signs of thinning hair in the
frontal area.
2. Height and shape of forehead: The height and shape
of the forehead determines if the EFBL method can
be used. If the forehead is too long and convex, the
endoscopic instruments may not be able to reach the
supraorbital rim and arcus marginalis adequately,
making the procedure technically very di cult. A
atter forehead with a relatively low hairline is ideal
for EFBL.
3. Forehead and glabellar rhytids: Forehead and
glabellar rhytids are assessed to determine if they
are dynamic or static. Muscular hyperactivity is not
uncommon, and e orts to relax the muscles are
required to bring the brows back to their natural
position. This is an important step before assessing
the actual position of the brows and the amount of
redundant upper lid skin.
4. Position, shape, and sym m etry of eyebrow s: The
desired height and shape of the brow is determ ined
w ith the patient in front of a m irror. It can be
discussed in only general term s, or a precise
calculation can be m easured. The forehead is rst
relaxed and brows are elevated to the desired
position and shape. A skin m arker is then placed
at the apex of the brow at the desired height.
Next, the brow is released and the skin m arker is
allowed to slide up onto the skin of the forehead.
The distance m arked is the am ount of brow
elevation required. The sam e is then done on the
contralateral side. Any baseline asym m etry should
also be pointed out.
5. Am ount of redundant upper eyelid skin: With the
brows held at the desired height by an assistant, the

V Facial Skin and Hair Rejuvenation
330
The incisions of the endoscopic approach are smaller and
run parallel to the nerves, thus sparing them. This approach
raises the hairline superiorly and should not be performed
for someone with a high hairline to begin with. Another fac-
tor to consider is the convexity of the forehead. If the fore-
head is high and very convex, the EFBL instruments will not
reach the inferior margin of dissection; the forehead con-
vexity inhibits the rigid instruments. Finally, this approach
is not feasible for patients with a receding hairline or bald-
ness, as the frontal incisions will not be well camou aged.

■Surgical Techniques
Instruments
The instruments fundamental to EFBL are shown in Fig. 25.9.
Preoperative Preparation
Preoperative photographs should be taken w ith the patient
in the upright position and without any makeup. Skin
markings should also be done in the upright position and
the amount of brow elevation recorded. The course of the
frontal branch of the facial nerve, the supraorbital notch/
foramen, and supratrochlear notch can be marked out on
the skin.
Incisions
EFBL can be done under either general anesthesia or con-
scious sedation. One percent xylocaine with 1:100,000
epinephrine is used to in ltrate the planned incisions.
Tumescence solution can be used to inject in the sub-
periosteal plane at the forehead and scalp to facilitate the
dissection.
Scalp incisions can vary. Generally, ve or six incisions
are used (Fig. 25.10). One (or two) midline and two more
The endoscopic approach does have some disadvan-
tages and limitations, and hence patient selection is impor-
tant. Its advantages include
• Reduction in length of incisions
• Well-camou aged incisions
• Less edema and swelling
• Less blood loss and surgical trauma
• Faster recovery
• Less scalp paresthesia
Disadvantages include
• Learning curve
• Raised hairline
• Increased cost due to instruments and monitor
• Potential complications from implants
a
b
c
d
e
f
Fig. 25.8 Incisions available for di erent types of brow lift. a, cor-
onal; b, trichophytic; c, pre-trichophytic; d, indirect brow or mid-
forehead; e, direct brow; f, trans-blepharoplasty.
Fig. 25.9 Endoscopic forehead and brow lift instruments.

25 Endoscopic Forehead and Brow Lift
331
supratrochlear nerves. Lateral dissection is made up to the
conjoint tendon or the linea temporalis.
Through the temporal incisions, dissection is made
through the temporoparietal fascia down to the deep tem -
poralis fascia. The deep temporalis fascia can be identi ed
by its glistening white fascia that is strong and striated.
A small cut through this fascia to reveal the underlying
temporalis muscle can be used to con rm the right layer
(Fig. 25.3). Blind dissection along this plane can be done
superior to the course of the frontal branch of the facial
nerve and to the conjoint tendon.
The conjoint tendon can be dissected through to con-
nect the center and temporal pockets from lateral to medial
using a periosteal elevator in a sweeping manner (Fig. 25.6).
As this is dense and adherent fascia, a reasonable amount
of force is required. Going from lateral to medial ensures
that the correct plane is achieved and can be done under
direct visualization from the central pocket.
Release of Muscular and
Ligamentous Attachment
The rest of the dissection should be done with the aid of
a 30-degree endoscope to visualize the neurovascular
bundles. The endoscope with a retraction arm is inserted
through the midline incision and a curve periosteal eleva-
tor through the lateral incision on the side of dissection.
The subperiosteal dissection is recommended, as the white
of the skull bone o ers excellent optics with the endoscope.
With the help of the retraction arm, an optical cavity is
maintained for visualization.
The objective of the remaining dissection is to free up
periosteal and muscular attachments to allow cephalic rota-
tion of the forehead and brow. The rst structure is the con-
joint tendon, which has already been freed as mentioned
previously. The second structure is the arcus marginalis, in
which the dissection is done under endoscopic guidance. If
the supraorbital neurovascular bundle exits from a notch,
it can be freed by pushing it inferiorly into the orbital cav-
ity. The arcus marginalis can then be released entirely. If the
supraorbital bundle exits from a foramen, it will be encoun-
tered earlier in the dissection and care has to be taken not
to transect or overly stretch the nerve. In this circumstance,
dissection is performed circumferentially around the fora-
men. Once the arcus marginalis is completely dissected, the
instrument can enter the upper eyelid.
The third structure is the orbital retaining ligam ent
found at the frontozygom atic suture. It lim its lateral brow
m ovem ent by indirectly attaching the lateral brow skin
to the lateral orbital rim . This is usually approached from
the temporal incision w ith the endoscope through the lat-
eral incision. Extrem e caution m ust be exercised during
dissection at the area lateral to the lateral orbital rim and
frontozygom atic suture region, as the sentinel vein and
the frontal branch of the facial nerve can be vulnerable.
The sentinel vein can be identi ed by tenting the tem -
lateral vertical incisions are placed ~ 2 cm behind the hair-
line. Each incision should be ~ 2 cm. The lateral incisions
should be placed at the apex of the brows or where the
maximal elevation should be. This is usually centered on
the lateral canthus. Vertical incisions are used as they are
parallel to the course of the supraorbital and supratroch-
lear nerves and thus reduce the risk of scalp paresthesia.
The direction of closure also minimizes skin tension and
hence reduces the risk of alopecia. Two coronal tempo-
ral incisions are made 2 cm behind the hairline, over the
temporalis fascia. These incisions are made parallel to the
temporal hairline with the center of the incisions perpen-
dicular to a line drawn from the alar facial crease to the
lateral canthus. It can be converted to an elliptical excision,
allowing some skin excision to aid in the lateral brow lift.
These incisions are intentionally beveled in the direction of
the hair so as to maximize the preservation of hair follicles
and reduce the risk of alopecia.
Dissection
Once the midline and lateral incisions are made, sharp dis-
section is taken down directly to the skull bone to enter
the subperiosteal plane. Blind dissection is rst made pos-
teriorly to the vertex and then anteriorly to 2 cm above
the supraorbital rim to protect the neurovascular bundles.
Centrally the dissection can be made to the nasofrontal
suture at the nasal radix, as this area lies in between the
Fig. 25.10 Incisions used in the endoscopic forehead and brow
lift approach. The rst incision is placed in the midline; the second
incision is more lateral, usually centered at the apex of the brow
or the lateral canthus; the third incision is the most lateral and is
placed perpendicular to a line traversing the alar-facial groove and
the lateral canthus over the temporalis fascia. These incisions are
placed ~ 1.5 to 2.0 cm posterior to the hairline.

V Facial Skin and Hair Rejuvenation
332
Fixation Method
Once the forehead and brow complex is maximally released
and mobilized, it has to be surgically stabilized in the
desired position while waiting for the natural healing and
xation process to take place. Permanent xation of the
brow is achieved by re-adherence of the periosteum to the
skull bone at the desired position. Romo et al8 and Scla-
fani et al9 found that this adherence took 6 to 12 weeks to
occur. More recently, there are studies reporting that the
re-adherence is complete within 2 weeks.10,11 Hence, a xa-
tion method that can last long enough for the natural re-
adherence to take place is necessary to hold the brows in
the desired position.
Temporal Fixation
In the temporal area, the lateral part of the brow is raised and
xated by securing the undersurface of the ap to the tempo-
roparietal fascia, and then to the deep temporalis fascia, with
a 2–0 polypropylene or polydioxanone suture (Fig. 25.12).
Alternatively, the suture can be placed through the
temporal incision and brought out through the skin near
the brow but just anterior to the hairline. This is to reduce
the possible tension from the incision line to decrease the
risk of alopecia. A stab incision is then made with a no. 15
blade through the epidermis at the exit point of the suture.
The suture is then passed back through the stab incision
and anchored to the deep temporalis fascia to achieve the
desired temporal lift.12
Forehead and Brow Fixation
As for the central forehead area, the dissection is subperios-
teal and hence there is absence of soft tissue for sutures to
anchor to. This leads to a wide variety of xation methods
poroparietal fascia up (Fig. 25.4) up, and it can be seen
traversing this space ~ 1 cm lateral to the frontozygom atic
suture. Inadvertent injury to this vein m ay cause unnec-
essary bleeding that obscures your surgical eld. It can
also be di cult to control the hem ostasis endoscopically
and m ay put the frontal branch of the facial nerve at risk
if excessive cautery is used. It is unnecessary to routinely
cauterize the vein if it is not breached, as som e studies
have show n that this results in the developm ent of super-
cial reticular veins at the temple area.7 The dense fascia
at the lateral orbital rim can then be dissected free, tak-
ing care not to disrupt the lateral canthal tendon. It is not
necessary to dissect the zygom atic arch unless there is a
plan for a m idface lift.
Next, the periosteum is released across the superior
orbital rims and across the nasal radix. This will provide
additional mobility and release of the forehead and brow
complex to facilitate elevation. As the periosteum is incised,
the galeal fat pad may be exposed (Fig. 25.11). Additional
horizontal periosteal incisions made more superiorly
under the frontalis muscle can be done if the patient has
deep horizontal forehead rhytids. This maneuver can jeop-
ardize the nerves and diminish brow elevation.
The fourth structure to be released is the brow depres-
sor. Releasing the brow depressors can also deal w ith the
horizontal and oblique glabellar rhytids caused by the
procerus and corrugator supercilii m uscles, respectively.
Myectomy, complete mytotomy, or partial disruption of
m uscle bers can be done, and the preferred m ethod
rem ains controversial. Once the corrugator m uscle is
encountered and isolated, it can be excised and rem oved
to the extent possible. However, excessive rem oval m ay
result in a visible depression in the glabellar area, splay-
ing of the m edial brows, and an unnatural anim ation. In
this situation, a glabellar implant or autologous fat m ay
be required to ll in the defect. Alternatively, the m uscle
can be partially disrupted by incising it or by blunt dis-
section w ith endoscopic forceps. Care is needed to pro-
tect the supraorbital and supratrochlear neurovascular
bundles w hile doing so. The supraorbital vessels and
nerves can be seen behind the transverse head of the cor-
rugator at the superior orbital rim level. Medially w here
the oblique head of the corrugator is, the supratrochlear
vessels and nerves traverse through the substance of the
m uscle and should be adequately preserved. The procerus
can be dealt w ith in a sim ilar m anner. Whichever m ethod
is used, there m ay be a tendency for the cut ends of the
m uscle to adhere to one another, resulting in unnatural
glabellar m ovem ents.
An alternative treatm ent for the brow depressors is the
use of a neurotoxin given preoperatively. Paralysis of the
depressors can achieve two objectives. It results in further
mobilization of the brows and hence allows m ore com -
plete elevation. Second, the lack of m ovem ent from the
depressors postoperatively facilitates the xation of the
forehead and brow complex to the bone, optim izing the
results of EFBL.
Fig. 25.11 Illustration of the forehead and glabellar anatomy
under endoscopic view.