Phẫu Thuật Tạo Hình Thẩm Mỹ Khuôn Mặt Người Á Đông

VI Minimally Invasive Facial Plastic Surgery
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Bunny Lines
The target muscles are the levator labii superioris alequae
nasi and nasalis. Consideration points are as follows: Cen-
tral vertical bunny lines are caused by the nasalis, and can
be diminished completely with BTA. However, bunny lines
lateral to the dorsum of the nose, which are produced by
the levator labii superioris alaeque nasi and the medial
band of the orbicularis oculi, cannot be entirely improved,
since completely paralyzing the levator labii superioris
alaeque nasi is not recommended.
As with all subjects, keeping the IPs medial to the naso-
facial groove can avoid inadvertent complete paralysis of
the levator labii superioris alaeque nasi. Three IPs with 2 U
per IP are recommended (Fig. 29.10).
Gummy Smile
The target muscle is the levator labii superioris alaeque
nasi. Consideration points are as follows:
1. The mechanism for this indication is weakening of
hyperactivity of the elevator muscles of the upper
lip to improve excessive gingival display (“gummy
smile”).
2. It is important to inject BTA only into the levator labii
superioris alaeque nasi because paralysis of other lip
levator muscles results in a weird-looking smile.
3. Botulinum toxin injection should be performed
cautiously in Asian patients with a long philtrum
and protruding upper lip, because this may lead to
elongation of the philtrum.
Intramuscular injection is recommended at just lateral to
the ala nasi. Injection should not be too lateral, or else the
facial expression may change during smiling. Two IPs with
2 to 4 U per IP are recommended (Fig. 29.11).
Perioral Rhytides
The target muscle is the orbicularis oris. Consideration
points are as follows:
1. A lower initial dose is better for preserving the
closing action of the orbicularis oris. Several muscles
important for facial expression are located adjacent
to the orbicularis oris, and therefore care must be
taken to avoid inadvertent injection into adjacent
muscles.
2. Botulinum toxin injection should be performed
cautiously in Asian patients with a long philtrum
and protruding upper lip, because this may lead to
elongation of the philtrum.
Fig. 29.10 Injection points and dose of BTA for bunny lines. Three
IPs with 2 U per IP are recommnended. (Used with permission from
Seo KK. Botulinum Toxin for Asians [in Korean]. Seoul: Seoul Medi-
cal Books & Publishing; 2014.)
Fig. 29.11 Injection points and dose of BTA for gummy smile.
Intramuscular injection is recommended just lateral to the ala nasi
with 2 to 4 U per IP. (Used with permission from Seo KK. Botulinum
Toxin for Asians [in Korean]. Seoul: Seoul Medical Books & Publish-
ing; 2014.)

29 Aesthetic Facial Use of Botulinum Toxin in East Asians
385
botulinum toxin should be injected into the lower
part of the depressor anguli oris to avoid the
potential for inadvertent di usion into other muscles
responsible for movement of the corner of the
mouth.
Subdermal injection can be performed to avoid inadvertent
di usion into the depressor labii inferioris. One IP with a
dose of 2 to 4 U in the lower one-third of the depressor
anguli oris is recommended (Fig. 29.13).
Cobblestone Chin
The target muscle is the mentalis. Consideration points are
as follows:
1. A “cobblestone” appearance of the chin due to
chronic hyperactivity of the mentalis can worsen
with aging and can be improved by BTA injection
into the mentalis.
2. BTA should not be injected too close to the depressor
labii inferioris to avoid the risk of asymmetry caused
by inadvertent di usion of BTA into it.
Intramuscular injection with 4 U into two IPs 1 cm apart
from central line at the lower border of the chin is recom -
mended. Two more injections with 2 U per IP above these
are required subdermally (Fig. 29.14).
At least two IPs per side on the upper lip vermillion border
are recommended. Occasionally this may be extended to
include two to four points on the lower lip. A dose of 1 U
per IP is recommended (Fig. 29.12).
Mouth Corner Elevation
(Marionette Lines)
The target muscle is the depressor anguli oris. Consider-
ation points are as follows:
1. Treatment for a pre-existing marionette line is
usually managed by ller injection with botulinum
toxin instead of botulinum toxin alone. This is
because botulinum rebalancing (i.e., weakening the
depressor anguli oris with BTA) results in elevation
of the mouth corner. Hence BTA is a widely used
adjunct to ller injection.
2. The depressor anguli oris is the most super cial
muscle above the depressor labii inferioris. If the
depressor labii inferioris is a ected by botulinum
toxin, asymmetry of the lower lip during animation
or inability to lower the lip might occur.
3. The modiolus, on which many muscles around
the corner of the mouth (including the depressor
anguli oris) converge, is lower than the intercheilion
horizontal line in 58.4% of Asians.27 Therefore,
Fig. 29.12 Injection points and dose of BTA for perioral rhytides. (a) At least two IPs per side with 1 U per IP on the upper lip vermillion
border are recommended. (b) Occasionally this may be extended to include two to four points on the lower lip. (Used with permission
from Seo KK. Botulinum Toxin for Asians [in Korean]. Seoul: Seoul Medical Books & Publishing; 2014.)
a
b

VI Minimally Invasive Facial Plastic Surgery
386
Square Jaw (Masseter Hypertrophy)
The target muscle is the masseter (Fig. 29.16). Consider-
ation points are as follows:
1. The main bene t from this novel indication for BTA
injection is to enhance the shape of the lower face by
modifying the square jaw common in Asians. Anyone
can achieve a reduced facial contour to some extent
by reducing the thickness of the masseter muscle
provided they have su cient muscle volume.
2. The mechanism of action of BTA in the treatment
of square jaw is a type of disuse muscular atrophy.
Therefore, this treatment results in a time lag in
both the onset and peak of action that di ers from
conventional treatments for wrinkles, where the
onset of action begins after just 2 to 3 days and the
peak e ect is reached 1 to 2 weeks postinjection.
In clinical practice, the e ect of BTA used in the
masseter has an onset time of 2 weeks postinjection,
Platysmal Bands
The target muscle is the platysma. Consideration points are
as follows:
1. BTA injection for the platysma is used to reduce
platysmal bands. Decussation of the platysmal band
is more frequent in Asians than in Caucasians.28
Hence, the so-called gobbler neck deformity is rarely
found in Asians.
2. BTA injection to the platysma may result in a
decrease in resting muscle tone, which brings about
the pseudo-lifting e ect achieved by the mechanism
of botulinum rebalancing.
Intramuscular injection along the platysma band from the
insertion area around the jaw line to the originating area
near the clavicle is performed w ith IPs 2 cm apart. A dose
of 2 to 4 U per IP, and no more than 80 U in one session, is
recommended (Fig. 29.15).
Fig. 29.13 Injection point and dose of BTA for mouth corner ele-
vation (marionette line). One IP with a dose of 2 to 4 U in the lower
one-third of the depressor anguli oris is recommended. (Used with
permission from Seo KK. Botulinum Toxin for Asians [in Korean].
Seoul: Seoul Medical Books & Publishing; 2014.)
Fig. 29.14 Injection points and dose of BTA for cobblestone chin.
Intramuscular injection with 4 U into two IPs 1 cm apart from the
central line at the lower border of the chin is recommended. Two
more injections with 2 U per IP above these are required subder-
mally. (Used with permission from Seo KK. Botulinum Toxin for
Asians [in Korean]. Seoul: Seoul Medical Books & Publishing; 2014.)
Fig. 29.15 (a,b) Injection points and dose of BTA for platysmal band. Intramuscular injection with a dose of 2 to 4 U per IP along the
platysma band from the insertion area around the jaw line to the originating area near the clavicle is performed with IPs 2 cm apart.
a
b

29 Aesthetic Facial Use of Botulinum Toxin in East Asians
387
7. Individuals with a pre-existing sunken cheek should
be informed in advance of the risk of aggravation
of the sunken cheek with the disappearance of the
muscle volume follow ing this procedure.
8. Patients in their 40s and above with a pre-existing
sagging jowl generally show aggravation of the
sagging following this procedure.
9. Mild temporary muscle weakness, such as di culty
chewing, will occur after BTA injections in a
proportion of subjects. However, this generally
passes and chewing returns to normal forcefulness
w ithin 3 months.32
The lower central belly of the masseter muscle is the main target
when reshaping a square jaw using botulinum toxin. Deep injec-
tion su cient to touch the mandibular bone, rather than injec-
tion at a medium depth, is very important. Super cial injection
can weaken the rizorhius attached super cially to the anterior
part of masseter, causing an embarrassing change of facial
expression (e.g., an asymmetric, unnatural smile). To reduce the
risk of adverse change of facial expression when treating mas-
seteric hypertrophy, physicians should start by injecting at least
1 cm inside the anterior margin of the masseter muscle in addi-
tion to deep injection.
For the cosmetic purpose of reshaping a lower facial
contour, the lower part of the masseter muscle under the
imaginary line connecting the tragus to the mouth corner
is the main target. A safe and e ective injection zone for
square jaw can be delineated by the upper margin being
an imaginary line connecting the tragus to the mouth cor-
ner, the lower margin as the mandibular bony border, and
the anterior and posterior margins as the anterior and pos-
terior borders of each masseter muscle. IPs are located at
and the peak e ect develops at 2 to 3 months
postinjection.3,29
3. Six months later, the muscle volume will usually
have returned to some extent, and by 10 to 12
months postinjection, the muscle volume can be
approaching its previous state. This is because
muscle atrophy is reversible, with recovery occurring
after 3 to 6 months. However, the duration of the
e ect is variable and depends on the individual’s
personal habits, such as bruxism, unconscious jaw
clenching, and excessive chewing. There have also
been many reports that the e ects of BTA in the
treatment of masseteric hypertrophy can last for
more than 1 or 2 years, even after only one session of
injections.30 This extended duration of the e ect of
BTA is particularly noted in those subjects who have
the acquired form of masseteric hypertrophy, as long
as they avoid eating tough foods and do not have the
habit of jaw clenching.
4. A person with a square jaw in the front view that
is mainly due to the masseter muscle is the best
candidate for this novel indication for treatment.
5. Factors that contribute to masseteric hypertrophy
include jaw clenching and bruxism, and the habitual
chewing of gum or dried, hard food.31 One-sided
chewing can lead to asymmetric masseteric
hypertrophy.
6. Females with a prominent zygoma tend to wish
the zygoma to not appear even more prominent;
therefore, reduction of the lower part of the
masseter, rather than the whole muscle, is most
appropriate.
Fig. 29.16 Injection for square jaw (mas-
seter hypertrophy). (a) Before the injection.
(b) Three months after the injection.
a
b

VI Minimally Invasive Facial Plastic Surgery
388
Intradermal Botulinum Toxin
Consideration points are as follows:
1. Multiple intradermal injections of BTA (intradermal
BTA) have been widely adopted in Asia, under
various names such as “mesobotox,” “dermatoxin,”
and “microtoxin.” The treatment is applied with
the expectation of not only reducing dynamic facial
wrinkles but also reducing static wrinkles and pore
sizes, as well as creating the so-called perceived
lifted e ect or pseudolift— even though actual lifting
e ects have not been objectively veri ed. Therefore,
intradermal BTA can be considered to produce a full
range of anti-aging e ects.
2. The same dynamic wrinkle reduction that is
delivered by the conventional intramuscular
injection of BTA can also be achieved by di usion
of BTA into underlying facial expression muscles,
because BTA spreads in a three-dimensional
manner from the dermis and because several
facial expression muscles also have intracutaneous
insertions.
3. The hypothesized e ects of the improvement of
static wrinkles and tightening of pores, which
imparts a shine and a tighter look to the skin,
involves dermal edema resulting from the transient
least 1 cm inside from the border, to avoid unwanted di u-
sion of BTA into other facial muscles.
Four to six IPs of 5 U are recommended depending on
the muscle volume (Fig. 29.17).
Reduction of the Parotid Gland
The target is the parotid gland. Consideration points are as
follows:
1. Enlarged parotid glands can contribute to a
square-shaped lower face appearance. Because
acetylcholine, the neurotransmitter in the salivary
glands, can be blocked by BTA, injection of BTA into
the parotid gland can result in atrophy of the parotid
gland in humans.33 Indeed, injection of BTA into an
enlarged or protruding parotid gland can reduce the
w idth of the lower face.
2. Injecting BTA into the parotid gland seldom results
in a dry mouth as 71% of salivary production comes
from the submandibular gland.34
The most protruding part of the parotid gland around the
mandibular angle is the most e ective injection site. Deep
intraglandular injection is required. Five to six IPs w ith 5
U per injection site are recommended depending on the
parotid gland volume (Fig. 29.18).
Fig. 29.17 Injection points and dose of BTA for square jaw. Depending on the muscle volume, IP numbers can vary. (a) Four IPs. (b) Six
IPs. (Used with permission from Seo KK. Botulinum Toxin for Asians [in Korean]. Seoul: Seoul Medical Books & Publishing; 2014.)
a
b

29 Aesthetic Facial Use of Botulinum Toxin in East Asians
389
the skin by giving it a smooth appearance. Recently,
the reduction of sebum production and pore size
by intradermal BTA in patients with oily skin was
objectively elucidated.39
5. The pseudo-lift e ect is in fact not true lifting but a
kind of optic illusion. The e ect can be achieved by
the reduction of the lower face contour by reducing
the volume of the masseter muscle and by giving a
sharper de nition to the chin line by weakening the
mentalis and platysma muscles.
Combining multiple intradermal injections with the con-
ventional intramuscular injection is usually recommended.
Conventional intramuscular injections can be used for
supplementation in areas with deep muscles such as the
corrugator, mentalis, and masseter. Areas for intradermal
injection are the forehead, cheek, and anterior malar area
(Fig. 29.19).

■Complications and
Their Management
To date, there is no e ective antidote for BTA. Therefore,
once it is administered, there is no way to reverse an adverse
e ect of BTA for at least 2 to 3 months. Adverse e ects are
therefore best prevented. Hence, a screening assessment of
risky patients is most important, and a careful and meticu-
lous injection technique is also recommended. Complica-
tions of BTA and speci c indications for BTA treatment have
already been described in depth in the previous sections.
and mild lymphatic insu ciency induced by
underlying muscular paralysis. Dermal edema might
improve the ne static wrinkles and dilated pores.
4. In some anecdotal reports, intradermal BTA has been
described as reducing sebum production and pore
prominence.35,36,37 Acetylcholine receptors have been
reported to be present in sebaceous glands,38 and a
possible e ect of BTA is to reduce the activity of the
sebaceous gland and the pore size, thus improving
Fig. 29.18 Injection points and dose of BTA for enlarged parotid
gland. Five to six IPs with 5 U per injection site are recommended
depending on the parotid gland volume. (Used with permission
from Seo KK. Botulinum Toxin for Asians [in Korean]. Seoul: Seoul
Medical Books & Publishing; 2014.)
Fig. 29.19 Injection points and dose of BTA for intradermal BTA. The white dots indicate intradermal injection sites and the gray dots
indicate intramuscular injection sites. (a) Frontal view. (b) Lateral view. (Used with permission from Seo KK. Botulinum Toxin for Asians [in
Korean]. Seoul: Seoul Medical Books & Publishing; 2014.)
a
b

VI Minimally Invasive Facial Plastic Surgery
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16. Sattler G, Callander MJ, Grablowitz D, et al. Noninferior-
ity of incobotulinum toxinA, free from complexing pro-
teins, compared with another botulinum toxin type A
in the treatment of glabellar frown lines. Derm atol Surg
2010;36(Suppl 4):2146–2154
17. Karsai S, Raulin C. Current evidence on the unit equiva-
lence of di erent botulinum neurotoxin A form ulations
and recom mendations for clinical practice in derm atology.
Dermatol Surg 2009;35(1):1–8
18. Kane M, Donofrio L, Ascher B, et al. Expanding the use of
neurotoxins in facial aesthetics: a consensus panel’s as-
sessment and recom m endations. J Drugs Derm atol 2010;
9(1, Suppl)s7–s22, quiz s23–s25
19. Alam M, Dover JS, Arndt KA. Pain associated with injec-
tion of botulinum A exotoxin reconstituted using iso-
tonic sodium chloride with and without preservative: a
double-blind, randomized controlled trial. Arch Derm atol
2002;138(4):510–514
20. Sarifakioglu N, Sarifakioglu E. Evaluating e ects of pre-
servative-containing saline solution on pain perception
during botulinum toxin type-A injections at di erent lo-
cations: a prospective, single-blinded, randomized con-
trolled trial. Aesthetic Plast Surg 2005;29(2):113–115
21. Yang GC, Chiu RJ, Gillm an GS. Questioning the need to use
Botox within 4 hours of reconstitution: a study of fresh
vs 2-week-old Botox. Arch Facial Plast Surg 2008;10(4):
273–279
22. Hexsel DM, De Alm eida AT, Rutowitsch M, et al. Multi-
center, double-blind study of the e cacy of injections with
botulinum toxin type A reconstituted up to six consecu-
tive weeks before application. Derm atol Surg 2003;29(5):
523–529, discussion 529
23. Liu A, Carruthers A, Cohen JL, et al. Recom mendations
and current practices for the reconstitution and storage of
botulinum toxin type A. J Am Acad Dermatol 2012;67(3):
373–378
24. Huilgol SC, Carruthers A, Carruthers JD. Raising eye-
brows with botulinum toxin. Dermatol Surg 1999;25(5):
373–375, discussion 376
25. Sundaram H, Kiripolsky M. Nonsurgical rejuvenation of the up-
per eyelid and brow. Clin Plast Surg 2013;40(1):55–76
26. Sundaram H, Carruthers J, eds. The glabella and central
Brow. In: Carruthers J, Carruthers A, eds. Procedures in
Cosmetic Dermatology: Soft Tissue Augm entation. 3rd ed.
New York, NY: Elsevier Saunders; 2013:88–99
27. Hu KS, Yang SJ, Kwak HH, et al. Location of the modiolous
and the morphologic variations of the risorius and zygo-
m aticus m ajor muscle related to the facial expression in
Koreans. Korean J Phys Anthropol 2005;18:1–11
28. Kim HJ, Hu KS, Kang MK, Hwang K, Chung IH. Decussa-
tion patterns of the platysma in Koreans. Br J Plast Surg
2001;54(5):400–402
29. Yu CC, Chen PK, Chen YR. Botulinum toxin A for lower fa-
cial contouring: a prospective study. Aesthetic Plast Surg
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31. Mandel L, Tharakan M. Treatment of unilateral m asseter-
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3. Kim HJ, Yum KW, Lee SS, Heo MS, Seo K. E ects of botu-
linum toxin type A on bilateral m asseteric hypertrophy
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perhidrosis: a review. Am J Clin Dermatol 2009;10(2):
87–102
5. Carruthers A, Kane MA, Flynn TC, et al. The convergence
of m edicine and neurotoxins: a focus on botulinum toxin
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evidence-based botulinum toxin consensus education ini-
tiative: part I: botulinum toxin in clinical and cosm etic
practice. Dermatol Surg 2013;39(3 Pt 2):493–509
6. Carruthers J, Fournier N, Kerscher M, Ruiz-Avila J, Trindade
de Alm eida AR, Kaeuper G. The convergence of m edicine
and neurotoxins: a focus on botulinum toxin type A and
its application in aesthetic m edicine—a global, evidence-
based botulinum toxin consensus education initiative: part
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practice. Dermatol Surg 2013;39(3 Pt 2):510–525
7. Ascher B, Talarico S, Cassuto D, et al. International con-
sensus recomm endations on the aesthetic usage of botu-
linum toxin type A (Speywood Unit)—Part I: Upper facial
wrinkles. J Eur Acad Derm atol Venereol 2010;24(11):
1278–1284
8. Lorenc ZP, Kenkel JM, Fagien S, et al. Consensus panel’s as-
sessment and recom m endations on the use of 3 botulinum
toxin type A products in facial aesthetics. Aesthet Surg J
2013;33(1, Suppl):35S–40S
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intraderm al injection of botulinum toxin type A. Int J Der-
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392
30 Facial Contouring Using Fillers
Jongseo Kim
sues are fundam ental consideration factors for success-
ful results. When considering augm entation of certain
facial areas, the “esthetic plane” (E-plane) is an important
guideline for a pleasing facial pro le.3,4 The E-plane is a
line drawn from the tip of the nose to the tip of the chin.
To have a pleasing facial pro le for the average Caucasian
face, the lower lip should be 2 m m behind the line, and
the upper lip 4 m m behind the line, w ith variations being
norm al for patients of di erent ethnic backgrounds. Many
physicians, however, feel that the ideal E-plane of an Asian
face is quite di erent from that of a Caucasian face. For
an Asian face, the lower lip and upper lip should be near
the E-plane. The jaw is also important to complem ent the
whole face. If the jaw is pulled in or is extending too m uch,
it disrupts the overall harm ony of the aesthetic standard.
If the patient’s pro le appears very convex, the chin and
the forehead area can be augm ented by llers; for a con-
cave pro le, llers can be placed in the nose, the paranasal
area, and the anterior cheek.

■Introduction
Filler is used in the East Asian face for diverse aesthetic pur-
poses: facial contouring, including augmentation of certain
facial areas; treatment of aging lines such as wrinkles and
prominent crease1; and dermal hydration. Many Asians
have small chins, at noses, and depressed foreheads com -
pared with Caucasians.2 To augment those areas, insertion
of implants such as silicon, Gore-Tex (W. L. Gore), Medpor
(Stryker), cartilage, bone, or fat grafts is commonly used.
Because many patients want a simple and safe procedure
instead of surgeries, ller can be an alternative option to
augment those areas.
In m ost cases, the augm entation results from ller
are sim ilar to those from implant surgery except for its
longevity. Because ller injection changes the soft tis-
sue structures and not the bony structures, the size and
the shape of the facial skeleton and thickness of soft tis-
Pearls
• Contouring or augmentation of the facial skeleton
with llers is one of the most subtle but powerful
nonsurgical treatments.
• An E-plane, which is a line drawn from the tip of the
nose to the tip of the chin, is an important guideline
for contouring the lateral pro le. In the frontal view,
a heart-shaped face is the preferred facial contour.
• To treat ne wrinkles, volume replacement just
under the dermis with soft ller that has lower
elasticity is e ective.
• For structural facial contouring, a larger volume of
ller is required in most cases. Hard ller gels such
as CaHA ller, PCL ller, and particle type HA ller
are preferred.
• When a patient is not sure about the proper ller
type and its e ect at initial consultation, use of
normal saline or HA ller is recommended. If the
patient is satis ed with the results of ller injection
but wants to avoid repeated injections, long standing
ller can be applied.
• Special caution should be taken when injecting ller
into thin-skin areas such as the eyelid, periorbit, and
ne w rinkles on the cheek area because of possible
nodule formation and color change. In this case, it is
better to inject a small amount multiple times or use
soft ller by canula.
• The forehead, temple, cheek, chin, nose, nasolabial
fold, and jaw line are common ller injection sites
for facial contouring.
• For forehead contouring, 1.5 to 3.0 mL of ller is
injected under the muscle layer using the radial
fanning technique through one entry point midway
between the eyebrows.
• Commonly used llers for nasal augmentation are
CaHA ller, Restylane (Galderma), and Perlane (Merz).
Submuscular injection using the linear threading
technique and subcutaneous injection using the serial
puncture technique are usually combined.
• In aged patients, more extensive volumetric
replacement is needed and other, concomitant
lifting procedures such as ultrasound lifting or
surgical face lifting would be helpful.
• Hydro lifting, in which hyaluronic acid is directly
injected into the dermis layer of the skin, is useful in
people who have serious dry skin or who want more
elastic and hydrated skin.

30 Facial Contouring Using Fillers
393
dures. Aspirin or Coumadin (Bristol-Myers Squibb) needs
to be stopped before the procedure to prevent bleeding and
bruising. Any patients with immunologic diseases such
as lupus or scleroderma should take extra precautions as
people with facial soft tissue atrophy can have problems.
The consultation and assessment should include the
following:
1. Discussion of the patient’s expectations (duration of
llers, injection amount of llers, patient’s aim and
purpose)
2. Medical and surgical history, medical conditions, and
drug allergies
3. Radiologic assessment (computed tomography [CT]
scans or facial X-rays)
4. Preoperative and postoperative photography for
evaluation and comparison
5. Computer-assisted simulation if available
In most cases, botulinum toxin and injectable llers are
inextricably linked. Concomitant botulinum toxin injection
is bene cial as it prevents unwanted migration of injected
ller by restricting excessive muscle movement, and also
changes facial shape favorably.5 Therefore, it is essential to
help the patient understand the bene ts of combined botu-
linum toxin injection.

■Filler Materials
A wide variety of ller materials are currently avail-
able, with a seemingly endless ow of new and emerging
products. Table 30.1 shows detailed information on ller
materials currently available. Among these llers, the best
and the safest products are hyaluronic acid (HA) llers.
There are two types of HA in terms of rheology or its par-
ticle shape: One is biphasic HA ller (Restylane) and the
other is monophasic HA ller (Juvederm, Belotero). With a
monophasic HA ller such as Juvederm, it is easy to inject
without lumps or irregularity, but it is hard to use when
contouring to form a shape with a narrow base and tall
While the E-plane is a guideline for contouring the
facial pro le, a heart shape is considered the preferred
facial contour by Asians in the frontal view. It is character-
ized by higher and fuller cheeks, raised nasal pro le, and
smaller chin contributing to a smooth facial convexity. Tra-
ditionally, it is considered ideal when the ratio between the
upper, mid-, and lower face is equal or represented as 1:1:1.
Recently, however, the “baby face,” in which the lower face
part’s ratio is a little short of 0.8, has been receiving atten-
tion in the rejuvenation of the Asian face.
Dermal llers can be an option for treatment of rhytides
as well as for facial sculpting. Understanding the aging pro-
cess is crucial to attain optimal results with facial rejuvena-
tion by ller injection. Facial aging is the result of decreased
thickness and elasticity of the skin, absorption of fat, and
resorption of the bony skeleton. In addition, decreased
adherence between the skin and subcutaneous tissue, mus-
cle alteration, and sagging of soft tissues are present. Thus,
just tightly retracting the facial skin through surgical inter-
vention may be inappropriate in some patients because it
can produce an unnatural-looking appearance. Replenish-
ing facial volume and lling ne wrinkles with injectable
llers would be a better approach in these patients.
Recently, facial rejuvenation using the hydro lling
e ect of hyaluronic acid (HA) ller has been employed for
improvement of skin texture. Since the concentration of HA
in skin decreases with aging, the skin’s elasticity and ability
to hold water are decreased, leading to an increased ten-
dency toward wrinkling and skin laxity, particularly in the
facial skin. Because of their hydrophilic nature, HA llers
play a role as a dermal reservoir of hydration, by drawing
water into the extracellular matrix in the dermis, resulting
in hydration in the dermis and improvement of skin surface
roughness and ne w rinkles.

■Patient Consultation
During consultation, the patient will be informed of the
potential risks with the ller injection. A detailed medical
history should be taken, including prior injection proce-
Table 30.1 Types of llers
Action
Type
Duration
Longevity
Product(s)
Volumizer
Hyaluronic acid
6–12 months
Temporary
Restylane
Juvederm
Belotero
Calcium hydroxylapatite
> 1 year
Temporary
Radiesse
Stimulator
Poly-L-lactic acid (PLLA)
> 1 year
Temporary
Sculptra
Polycaprolactone (PCL)
1–4 years
Temporary
Ellanse (Aqtis)

VI Minimally Invasive Facial Plastic Surgery
394
Selecting Needles
Dermal llers may be injected using either a sharp needle
or a blunt-tip microcannula (Fig. 30.1). A blunt-tip micro-
cannula (also called a smooth-tip microcannula or a blunt-
needle cannula) is a small tube (18- to 30-gauge), with an
edge that is not sharp, designed for the atraumatic subder-
mal injection of llers. Depending on the inner diameter,
it can be used either for fat transfer, or for the injection of
llers such as HA, PCL, PLLA, CaHA, etc.
Each physician has speci c preferences for injection
instruments depending on the type of procedure being per-
formed. For example, needles may be preferred for delicate
correction of lines and wrinkles, while cannulas may be
preferred for volume correction. Needles have the advan-
tages of extreme precision of movement, the possibility of
deep intradermal injection, and convenience when smaller
injection volume is required. Disadvantages include pain,
bruising, and possible vessel laceration. Cannulas cause
less trauma, pain, and bruising and allow a large area to be
treated at the chosen injection depth. Speci c training is
required to master the techniques of injection, and this is
considered a disadvantage.
Usually a 50-mm-length, 27-gauge needle is used for the
injection of Restylane. The author prefers a 70-mm 23-gauge
microcannula since it can also be used to inject Ellanse,
Restylane Sub-Q (large-particle HA), and monophasic HA llers
such as Juvederm and Teosyal (Teoxane Laboratories) as well.
height. With a biphasic HA ller such as Restylane, it is easy
to lay bricks (“brickwork”) into a form with a narrow base
and tall height, but there is a high risk of lumps or irreg-
ularity. Molding is much more di cult with biphasic HA
llers but they can last longer and are more durable than
the monophasic HA llers. Over time, the injected HA gel
is slowly absorbed into the surrounding tissues and disap-
pears by a process called isovolumetric degradation.
Similar to HA-based products, calcium hydroxylapa-
tite (CaHA, Radiesse, Merz) is also relatively inert, is very
safe, and requires no skin testing prior to injection. In com -
parison to HA-based llers, however, CaHA is not recom -
mended for the treatment of very super cial wrinkles and
creases. CaHA is more commonly used to augment deep
creases and folds as well as contouring the cheek, chin,
and forehead. Approximately 9 months after an injection,
CaHA begins to undergo gradual enzymatic digestion, with
complete disappearance of the aesthetic e ect between 12
and 18 months. From the author’s experience, the volume
starts to decrease within 1 month after CaHA injection.
Poly-L-lactic acid (PLLA; Sculptra, Dermik Laboratories)
and poly-caprolactone (PCL; Ellanse, AQTIS Medical) work
by providing a delayed long-lasting volumizing e ect.6
However, multiple treatments (two or three sessions) are
needed to achieve complete correction. Actually, Sculptra is
not a volumizing ller, but a stimulator. The augmentation
or contouring e ects of Sculptra are not predictable either;
therefore, it is not recommended for contouring purposes.

■Procedural Techniques
Anesthesia
The topical anesthetic is not adequate; hence, it is recom -
mended that the surgeon block the nerve locally or use
tumescent solution for anesthesia before ller injection.
The author prefers both. Epinephrine in the anesthetic solu-
tion helps to reduce bruising and prolong the anesthetic
e ect for a few hours. Lidocaine (mixed with epinephrine)
is used for local nerve block. For a midface local block, the
needle can be placed through an intraoral approach just
above the canine around the infraorbital nerve area. The
micro–nerve block technique can be useful for an injection
of the lip area. For the micro–nerve block technique, small
aliquots of anesthetic solution are injected along the muco-
sal border of the lip near the gingival sulcus. Micro-blocks
have the advantage of not producing a deep regional anes-
thesia. However, this technique may take longer to perform
and the potential for incomplete anesthesia is greater. The
author prefers tumescent solution, which is prepared by
mixing 100 mL of normal saline with 20 mL of 2% lidocaine
and 1 mL of 1:100,000 epinephrine.
Fig. 30.1 Needles for ller injection. (a) Sharp needle with 1-mL
ller syringe. (b) Blunt-tip micro cannula.
a
b

30 Facial Contouring Using Fillers
395
Self-Pistol Technique
The injection area is drawn with a pencil and the inser-
tion points are selected in the center of the area to be aug-
mented. After bolus injection under the fascia, molding is
applied by simple compression on the injected area. This
method is commonly used in temporal depression. Assess-
ment is easy because it is not necessary to pre-inject with
lidocaine solution in this technique.
Injection Techniques
Linear Threading, or Tunneling
Linear threading is a technique in which the needle is
inserted into the skin and the ller is deposited in a linear
fashion along the track as the needle is slowly withdrawn.
Because this creates essentially a tunnel of ller, this is also
commonly called the tunneling technique. Applied w ith a
cannula, this is the most frequently used technique for the
augmentation of the nose (Fig. 30.2a).
Serial Puncture
Serial puncture involves multiple injections positioned
adjacently along the length of the wrinkle or crease. This
technique makes many “chocolate Kisses”–like structures
on the nose (Fig. 30.2b). It is imperative that these injec-
tions remain su ciently close to form a relatively smooth,
continuous line of augmentation (Fig. 30.3). In cases where
there is a noticeable separation between the injection sites,
posttreatment massage may help blend the ller.
Fanning Technique
The fanning technique is performed for augmentation of
a wide area such as the forehead, malar, and jowl regions
(Fig. 30.4). Radial fanning is an extension of the linear
threading technique.7 The ller is deposited in a linear line
as the needle is withdrawn with a fan shape movement.
Before the needle is actually removed from the skin, it
is redirected and advanced along a new radial line. Mul-
tiple strokes will be needed to prevent irregularity after
injection.
Fig. 30.2 Two techniques for nasal augmen-
tation using ller. (a) Linear threading tech-
nique. (b) Serial puncture technique (“Kisses”
technique).
Fig. 30.3 Correction of mild hump nose with ller. (a) Pro le view
shows a mild hump nose. (b) After injection of 0.5 mL of Restylane
using a 29-gauge sharp needle with serial puncture (“Kisses”) tech-
nique, the pro le became smooth.
a
b
a
b

VI Minimally Invasive Facial Plastic Surgery
396
or subcutaneous tissues because the bone can be a guide
to control the injection depth.9 For contouring of the Asian
forehead, CaHA and PCL llers are preferred and 3 mL is
used for the rst session. Molding immediately after ller
injection is easy and essential because it is hard to mold
after the ller has settled down. For molding, a roller is
used in this region.
Temple
The temporal fossa is a critical area for volume restoration
of the aging face.7 Temple contouring is also performed for
patients who have a big malar bone. The temporal fossa is
a shallow depression on the side of the skull bounded by
the temporal lines and terminating above the level of the
zygomatic arch (Fig. 30.7). To con rm injection depth dur-
ing ller injection with a cannula, a blunt needle can be
passed through the zygomatic arch. If the cannula goes
through under the zygomatic arch, it means that the can-
nula is positioned under a deep temporal fascia or muscle
layer. If the cannula is blocked against the zygomatic arch,
it is positioned between the deep and super cial tempo-
ral fasciae. To contour or augment the temporal fossa, it is
essential to inject the ller into various layers according to
Facial Contouring
Forehead
There are ve layers on the forehead, composed of skin,
subcutaneous tissue, aponeurosis, loose connective tis-
sue, and periosteum, collectively called SCALP (Fig. 30.5).8
When injecting llers to the forehead, the target layer dif-
fers according to the purpose of ller injection. To treat
wrinkles, injectable llers can be introduced to the dermal
and the subdermal layers. However, to change the forehead
contour, a deeper injection into the supraperiosteum and
submuscular layer is preferred. In ller injection, a deep
injection has a lower risk of lumps and irregularities. To
prevent migration of ller gels, botulinum toxin is injected
together with the ller in most cases.
When using a blunt needle, the entry points should
be made before an injection. The author prefers to make
one entry point midway between the eyebrows.9 Occasion-
ally, the author makes one entry point at the center of the
forehead (Fig. 30.6) since the midline approach is safer by
avoiding damage to the blood vessels. Some doctors prefer
to make two entry points on each side of the eyebrow, but
this is not safe due to risk of injury to the supraorbital nerve
and blood vessels. Also, the entry points on the eyebrow
have a high risk of bacterial contamination from hair folli-
cles of the eyebrows. For forehead contouring, 1.5 to 3.0 mL
of ller is injected using the radial fanning technique. The
fanning method is appropriate for placement of the prod-
uct in the supraperiosteal layer instead of the subdermis
Fig. 30.4 Fanning technique of ller injection.
1
2
3
4
5
1
2
3
4 5
1. Skin
2. Subcutaneous tissue
3. Musculo-aponeurotic layer
4. Retaining ligaments and space
5. Periosteum and deep fascia
Fig. 30.5 Soft tissue layer of the face. There are ve tissue layers
on the face composed of skin, subcutaneous tissue, aponeurosis,
loose connective tissue, and periosteum, which are collectively
called SCALP.

30 Facial Contouring Using Fillers
397
and bruising. After ller injection, the temporal area may
show swelling for a few days. The swelling will gradually
resolve as the tumescent solution is absorbed. It is impor-
tant to determine the proper volume of tumescent solution
needed for the temporal area contouring. Irregularity after a
subdermal injection is common with Restylane or Perfectha
(Laboratory Obvieline), and to avoid this complication Juve-
derm, Teosyal, or Belotero (Merz Aesthetics) can be used.
The self-pistol technique is commonly used in this area
also. Usually, one stroke beneath the temporalis fascia is
adequate with the deep injection technique. If the result is
not satisfactory after the initial injection and molding, an
additional injection can be made to the insu cient area.
Cheek
As aging progresses, the bony midface “collapses,”10 lead-
ing to inferior orbital rim remodeling with loss of ante-
rior projection and sagging of the soft tissue fat pads, thus
making the midface hollow and drooping. This causes the
midface to lose vertical height, and the piriform aperture
to recess posteriorly, making four crescent aging lines
(Fig. 30.8).10,11,12,13,14 The author suggests correcting these
four crescent aging lines with ller using the “Reteenage”
method (Fig. 30.9).
Volume replacement just under the subdermis is e ec-
tive in treating ne wrinkles but inadequate to change facial
contour. To change contour, deep injection with a hard ller
gel such as CaHA ller, PCL ller, and particle-type HA ller
is necessary. To determine the injection site, the patient
is asked to smile before the injection. If the volume of the
midface is not enough, injection into the supraperiosteal
layer is preferred, and in other cases injection into the sub-
cutaneous fat plane is done.
the type of ller.The author prefers to inject CaHA beneath
the deep temporal fascia or between the deep and super -
cial temporal fasciae to prevent irregularity and to ensure
e ective treatment. But the ller can be injected into the
subdermal layer also with HA and the fanning technique
for augmentation. The fanning technique in this area begins
with the injection of tumescent solution to reduce pain
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. 30.6 Forehead ller injection through
one midline entry point. (a,c) Before the pro-
cedure. (b,d) Immediately after injection.
Through one midline entry point, supra-perios-
teal injection to forehead with 3 mL of biphasic
HA (Restylane) was performed.
Fig. 30.7 Various layers and their boundaries in temporal fossa.
Temporal fossa is bounded by the temporal lines and level of the
zygomatic arch. Understanding of super cial and deep temporal
fascia is important for selection of the injection layer.
a
b
c
d

VI Minimally Invasive Facial Plastic Surgery
398
Local anesthesia begins with a bilateral infraorbital
nerve block with 0.2 to 0.4 mL of 2% lidocaine. Some physi-
cians prefer to mix the ller with a solution containing 2%
lidocaine and 1:100,000 epinephrine.
Medial and Lateral Cheek
Cheek injection is performed sequentially from medial
to lateral. The rst injection is placed medial to the infra-
orbital nerve, entering perpendicular to the skin ~ 2 cm
beneath the medial canthus. The needle is then “walked”
medially and inferiorly, depositing ller. Additional depos-
its are placed close to the orbital rim, as well as laterally
and inferiorly. The nondominant index nger is used to
establish the inferior orbital rim location so as to prevent
deposition of material into the orbital area. The second
injection is given lateral to the infraorbital nerve and the
third is at the malar eminence. Any ller to be injected
within the boundaries of the malar septum should be
placed immediately onto the periosteum, the so-called
preperiosteal bolus injection technique. For this method, a
29-gauge sharp needle is inserted at an angle of 90 degrees
to the skin surface. This technique not only results in natu-
ral and aesthetically pleasing appearance, but also causes
fewer bruises and lowers the embolic potential since the
material is placed in an avascular space.
This pre-periosteal bolus injection technique also can
be accomplished using either a transoral or transcutaneous
approach with a cannula. For a large volume injection in the
Fig. 30.8 Blue “four crescent aging lines” are
deformities that disturb a natural facial S-line.
The four crescent aging lines are the tear
trough, midcheek groove, nasolabial line, and
pre-jowl sulcus.
Fig. 30.9 The correction of the four crescent aging lines with ller
is referred to as the “Re-teenage” method by the author. (a) Before
the procedure. (b) Immediately after injection. Two milliliters of
Restylane was injected on each cheek area into a deep medial fat
pad and medial super cial fat pad, and 0.5 mL of Restylane was
injected in the nasolabial area. Additionally, 1.5 mL of the Perfecta
Subskin product was injected on each side of the prejowl sulcus. A
total of 8 mL of the HA ller was used for the whole face.
a
b

30 Facial Contouring Using Fillers
399
because it is not a particle-type HA gel. To inject Juvederm
or Teosyal, 23 gauge is recommended. The injection is done
at the supra-periosteal layer, submuscular layer, or both.
For a major augmentation, the author prefers two-layer
injections (Fig. 30.10), rst into the submuscular layer with
the linear threading technique and then into the subcuta-
neous layer with the serial puncture technique.
The author prefers the serial puncture technique
using HA ller (especially Restylane lidocaine), Ca ller
(Radiesse), and PCL ller (Ellanse) for nasal augmentation.
The usual amount of injection is ~ 0.5 mL in Asians. How-
ever, in some cases up to 1 mL is administered by adding
another 0.5 mL a month later. Avoid using more than 1 mL
in one session to prevent migration of the ller materials.
The angles of injection change according to the shape
of the nose. The author prefers to inject rst at 10 to 20
degrees along the vertical axis and then change the angle to
90 degrees. Then multiple “Kisses” injections are applied,
especially on the dorsum and the columella area.
On follow-up, molding of the nose area can be per-
formed to reduce irregularity and deviation. Molding is
done immediately after injection if a visible contour irregu-
larity is noted because it is hard to mold a few weeks later.
A gentle pinch-and-roll technique is used. A cold compress
is helpful on the rst day to minimize swelling and ecchy-
mosis. Special care should be taken to avoid undue pres-
sure that could cause unwanted displacement of the ller.
cheek, the author prefers a transcutaneous approach with
a cannula after making an entry point 1 cm lateral from the
corner of the mouth. There is less risk of infection and bio-
lm creation with transcutaneous injection. Besides, using
a cannula is technically less demanding, easier to teach,
and has less risk of infraorbital nerve injury and vascular
injury compared w ith needle injection. When performing a
transoral approach, the use of antibiotics is recommended
to prevent bio lm formation as there is a risk of contami-
nation when the cannula is moving forward and backward
through the entry point. Another approach is to place the
monophasic and less refractive HA in the subdermal plane.
Tear Trough
For treating the tear trough, the linear threading or serial
puncture technique is used with a 30-gauge sharp needle
or cannula. Temporary, long-lasting, or permanent llers
can be used e ectively to augment the underlying soft tis-
sue. In patients with thinner skin, however, ller can create
a lump or Tyndall e ect, resulting in a more aggravated tear
trough. The author prefers to use Belotero among HA llers
to treat tear trough because the Tyndall e ect is less.
Pre-injection of lidocaine, which is called the “Baiser
Voler” technique,15 is needed to control pain and ecchy-
mosis. It is often helpful to keep the patient in an upright
position during the procedure to accurately visualize the
ongoing contouring process. The needle is inserted from lat-
eral to medial just inferior to the deepest margin of the tear
trough. The plane of injection is supra-periosteal to maxi-
mize the soft tissue cushioning of the ller below the tear
trough ligament. When using a cannula, touching the tear
trough ligament can be a guide to an appropriate plane. On
average 0.5 mL of ller is placed on each side, depending on
the degree of rejuvenation desired.
Nose
Nose augmentation by ller injection can be done for cos-
metic purposes and for correction of structural abnormali-
ties. Simple dorsal augmentation, increasing tip projection,
hump or deviated nose correction, and nostril reduction
are common indications for nose contouring using ller.
Injectable llers are also quite useful in patients who have
already undergone rhinoplasty and noted persistent post-
operative contour irregularities or depressions. This simple
injection method has gained increasing popularity and is
often referred to as medical rhinoplasty.
The linear threading technique with a blunt cannula is
the most frequently used technique for nasal augmentation
to prevent embolism and blindness, although even w ith a
blunt needle, blindness can occur in rare cases. Cannulas
of 23, 25, and 27 gauge can be used. The author prefers
23-gauge for CaHA ller and 27-gauge for Restylane or Per-
lane. It is hard to inject Juvederm with a 27-gauge cannula
Fig. 30.10 Nasal dorsal augmentation using ller. (a) Before injec-
tion. After making an entry point at the nasal tip with a 23-gauge
needle, a 50-mm, 27-gauge cannula was inserted through the
entry point to the nasion (between the medial canthi) under the
muscle layer. Restylane ller (0.8 mL) was injected while withdraw-
ing the cannula in a single motion from the nasion to the tip. For
further augmentation, subcutaneous injection using the serial
puncture technique was added. (b) After injection.
a
b

VI Minimally Invasive Facial Plastic Surgery
400
layer for a ller placement is the submucosa just above the
orbicularis oris muscle. In many cases, a layered distribu-
tion helps to provide fuller, more uniform enhancement.
For increased vermillion de nition, the needle is carefully
inserted within the potential space between the red and
white lips. When done properly, injection of the ller can
be seen to plump out the vermillion border even without
advancement of the needle. If this is not the case, the nee-
dle should be repositioned until there is low resistance to
ow. Many younger patients w ill also bene t from a vol-
ume enhancement along the philtral columns. This usu-
ally involves a middermis ller injection within the base of
each column, which helps to further outline and de ne the
lips. A total of 1 to 2 mL is usually su cient to achieve the
desired size and shape.
For lip augmentation, HA gels are commonly used.
Other ller gels, such as PCL and CaHA llers, are not pre-
ferred on the lips since white nodules are visible and pal-
pable. Moreover, PCL and CaHA ller gels can migrate after
an injection on the lips by strong muscle movement. Colla-
gen ller has a risk of causing redness and immune-related
problems and is not used at present for lip contouring, but
some allo-transplantation of human dermis (such as Allo-
derm, LifeCell) is used for lip augmentation.
Chin
In Asia, contouring the chin along with nose augmentation
is a popular procedure because many Asians have small
chins. Derma llers can be a treatment option for a small
chin correction instead of surgery or graft implantation.
Injection of ller with a sharp needle is the simplest
method for chin augmentation (Fig. 30.12). This procedure
can be performed within 1 minute. For this simple injec-
Follow-up is needed on the next day to check the shape of
the nose and examine for adverse e ects, especially if the
patient feels pain on the nose. Touch-up treatments can be
administered if necessary.
Nasolabial Folds
Nasolabial folds are formed between the nose and lips,
and a dynamic fold occurs when repetitive movement of
the facial muscles creates a skin crease. Whether the ller
would be injected at the dermal, subcutaneous, or supra-
periosteal level is determined by the anatomy of the fold.
For injection, either the linear or fanning technique is used
(Fig. 30.11).
Fillers injected in the derm al layer in a lattice pattern
give persistence and a natural e ect to sm iling. For injec-
tion in the derm is layer or lower, molding is needed, but
molding is not necessary w ith injection in the supra-peri-
osteal layer. When the primary cause is the under-devel-
opm ent of the upper jaw bone, it is best to inject into the
supra-periosteal layer.16,17 In Asians, the nasolabial folds
are often created by a weakened upper jaw and the ller
is injected just above the periosteum of the upper jaw to
create volum e. When a nasolabial fold is caused by change
of location of the malar fat pad, it is recom m ended that
the injection be m ade to the subdermal layer of both the
nasolabial fold and the nasojugal groove (tear trough) to
get lift and projection.
Lips
Lip augmentation by ller is a simple procedure to improve
the appearance of the lips and to make a harmonious
relationship with the nose and the chin by increasing the
fullness of the lips. The aging patient typically requires sub-
mucosal injection along the entire length of the lip rather
than just the central portion. Some practitioners prefer to
address this by injecting the individual lines separately.
Care should be taken not to create unwanted vertical ridges
or beading due to inadvertent over correction of the der-
mis. Precise correction of these thin super cial lines is hard
to achieve by deep dermal injection. A better alternative is
to simply add more volume during the vermillion injection,
which tends to stretch the vertical lip lines as they extend
from the mucosal lip, resulting in decreased visibility.
Another option is to use only collagen-based temporary
llers for injection of the individual lines because collagen
is better suited for super cial dermal placement.
Lip enhancement in the younger population involves
straightforward volume enhancement. Most of these
patients require volume enhancement only along the cen-
tral three- fths of the lip. Injection is typically done with
the linear threading or serial puncture technique, proceed-
ing from medial to lateral. Along the red lip, the targeted
Fig. 30.11 Determination of the depth of injection in the nasola-
bial fold. The dynamic fold formed by repetitive movement of the
facial muscles is corrected by injection into the dermis layer. In case
the cause is innate under-development in the upper jaw bone, it is
best to inject into the supra-periosteal layer.

30 Facial Contouring Using Fillers
401
Jaw
Age-associated volume loss is known to play an important
role in the structural changes of the lower face line. In the
lower face, this manifests as drooping of the corners of
the mouth and jowl, leading to a loss of the oval jaw line
of youth. Jaw line reshaping by volume replacement has
therefore become an indispensable component of modern
facial rejuvenation and contouring.
Jowl Contouring
CaHA, PCL gel, or hard HA gels can be injected into the fol-
lowing locations.21 To correct the round shape of the lower
jaw line, CaHA or PCL ller should be placed at the deep
dermis using a 70-mm, 23-gauge cannula. Injections can
be delivered using the fanning technique (Fig. 30.14). The
choice of injection depth will depend on whether a needle
or cannula is used and also on the thickness of the der-
mis. Recommended insertion points are at the mandibular
angle and prejowl sulcus. Patients who have severe sag-
ging on the lower face line may not achieve the bene ts
with dermal ller procedures only. The majority of doc-
tors advocate use of injectable llers in subjects who are
waiting for surgery, or in those who do not want surgery
or in whom surgery is contraindicated, and as a powerful
adjunct in augmenting or complementing a surgical result.
Cogged thread insertion or high-intensity focused ultra-
sound (HIFU) can be performed for contouring the lower
face for these individuals instead of using injection llers. It
is better to combine ller injection with these procedures.
Marionette Lines
Volume enhancement of marionette lines is usually done
with one of the three injection techniques mentioned pre-
viously. Nearly all categories of llers can be safely used
tion, Restylane mixed with lidocaine can be used with a
29-gauge needle. This sharp needle is included in the box
with the ller. Juvederm also can be used for chin con-
touring using the same method. These HA llers can be
injected into the subdermal layer, although supra-perios-
teal or submuscular injection is preferred. Intramuscular
injection should be avoided because of discomfort in the
mentalis muscle during facial expression. When making a
heart line chin, the procedure must be done evenly from
the upper layer of the periosteum to the subdermal layer
between the chin’s central line and the mentalis mus-
cle.18,19,20 The injected product can easily move to the lower
part of the chin because there is no barrier tissue within
the subcutaneous fat layer below the chin. To be success-
ful, the noninjecting hand should be used as a barrier or
guide when injecting to ensure the product remains where
it is intended. The blunt needle technique is preferred for
injection of CaHA and PCL ller. For a cannula method, two
entry points are used in the pre-jowl sulcus area of the
lower border (Fig. 30.13).
Prior to marking the entry points, a small amount of
lidocaine is injected, followed by the insertion of a sharp
23-gauge needle or a 70-mm, 23-gauge cannula. To reduce
pain during the procedure, tumescent solution can be
injected prior to CaHA and PCL ller injection through the
same cannula. Patients should be noti ed that the amount
of augmentation by CaHA and PCL ller will be reduced 1
month after the injection. Muscle relaxants such as Botox
(Allergan), Dysport (Galderma), and Xeomin (Merz) are
also used concomitantly to soften the chin (preventing a
cobblestone appearance) and to improve the contour.
Fig. 30.12 Chin augmentation using ller. (a) Before the proce-
dure. (b) Immediately after injection of 1.5 mL of Radiesse.
Fig. 30.13 Contouring of the lower face line by llers. Entry points
and fanning technique of injection for rejuvenation of jaw lines.
a
b

VI Minimally Invasive Facial Plastic Surgery
402
llers.22 Particle-type S-HA can improve skin texture as
well as skin roughness.
Before the treatment, a 9% lidocaine topical anesthetic
cream is applied to the injection area and covered with
plastic wrap for 40 minutes. Patients can be injected with
1mL of S-HA (Restylane Vital, Belotero Soft, Belotero Basic,
Juvederm Vobella) that is divided into 1,000 shots using
the injector (DermaQueen, Woorhi Medical Group or Vital
Injector). This device has ve needles and the distribution
of the microdroplet injections provides a more regular area
of coverage than manual injection. Particle-type S-HA or
biphasic (Restylane Vital), monophasic (Juvederm Vobella),
or polyphasic (Belotero Basic) llers can be injected into the
dermis. The injection depth can be controlled by a touch
panel on the injector (0–2 mm). The recommended injec-
tion depth is about 1 mm. This method was invented by the
author and was named the “Reteenage method.”23 Because
there is a bevel in the tip of the needle, the actual depth
of the injection w ill be less than 1 mm. During this proce-
dure, the injection depth should be reduced if substantial
bleeding is noted, which means the injection penetrated
the subdermal plexus. After the injections, cold compres-
sion is performed to spread the S-HA and to reduce pain
and ecchymosis.

■Key Technical Points
1. For contouring a wide area, a cannula is preferred to
a needle to reduce complications during injection.
2. In changing the forehead contour, a deeper injection
such as at the supra-periosteal and submuscular
layers is preferred to reduce irregularity.
for this purpose. The injection layer is a combination of
the deep dermal and subcutaneous planes. In many cases,
there is not only a deep line extending from the commis-
sure, but also a loss of volume in the surrounding area. In
these cases, a cross-hatching technique can be used to add
more volume. Distribution of the ller often ends up follow-
ing the shape of an inverted triangle with the lateral mar-
gin based on the deepest marionette line. Prejowl sulcus
enhancement by extending the ller injection down to the
lower mandibular border is often an adjunct to marionette
line correction. In thin-skinned patients, longer-lasting and
permanent llers can be placed over the periosteum with
a higher safety margin. Due to displacement of the jowl
when supine, it is recommended that patients be injected
in the upright position for more accurate correction. The
ller is distributed along the lower margin of the mandible
and in some cases just below the mandibular border if the
jowling is severe. This injection extends from the anterior
margin of the jowl toward the midline of the chin to help
restore a more youthful transition between these points.
Between the marionette lines and prejowl sulcus, a total
volume of 2 to 3 mL of ller is commonly used to achieve
adequate correction.
Dermal Hydration Using
Hyaluronic Acid
Skin texture is a very important factor from the perspec-
tive of beauty and anti-aging. A stabilized hyaluronic acid
(S-HA) ller gel has been mainly used to treat folds and
wrinkles associated with facial aging since it can be main-
tained for a longer time and yields better e ects than other
Fig. 30.14 Lower face contouring using ller. (a) Before the procedure. Sagging skin and underlying bone resorption contribute to forma-
tion of the jowl with aging. (b) Immediately after an injection to the lower jawline with Ellanse M. (c) One month after injection. (d) After
two sessions of injections for the lower jawline.
a
b
c
d

30 Facial Contouring Using Fillers
403
To prevent intra-arterial ller injection, the needle tip
should always be kept in the midline and never placed paral-
lel to the dorsal nasal artery. If side wall injection is inevitable
due to correction of a deviated nose, the needle tip should be
moved obliquely after midline injection. Severe pain during
the procedure and geographic pale skin color change are clues
of arterial injection. But skin necrosis by venous congestion
is more common and occurs when a large volume of ller is
injected into the supratip area. To avoid this, a small amount of
ller should be injected to the deep layer. If a vascular problem
is suspected, stop the injection and aspirate the injected ller
to reduce volume. Hyaluronidase injection and hyperbaric
oxygen therapy must be applied as soon as possible. Antibiot-
ics should be administrated to prevent secondary infection.24
The midface region has a relatively loose subcutane-
ous fat plane, and there can be pressure-induced migra-
tion of the ller. The author does not recommend rm
massages within 3 weeks after injection, and it is better
to inject ller with higher cohesiveness to prevent migra-
tions. Malar edema can arise from injections with HA, Juve-
deram, or Restylane Vital, as these llers have the power
to attract water. Malar edema can persist as long as a few
months after an injection. Lower eyelid edema also can
develop after cheek contouring. During contouring of the
cheek or tear trough correction, a ller can be incidentally
injected into the orbital fat through the orbital septum,
which causes a prolonged edema on the lower eyelid. A
large amount of ller into the subdermal layer of the lower
eyelid can also make a prolonged edema. Therefore, when
injecting the subdermal layer on the lower eyelid to treat
3. Because tumescent solution can interfere with the
determination of the proper volume of ller to be
injected into the subdermal temple region, the
volume e ect of tumescent solution should always
be considered.
4. Intramuscular injection during chin augmentation
should be avoided because of mentalis muscle
discomfort during facial expression.
5. The linear threading technique with a cannula is the
most frequently used technique for nasal augmentation
to prevent arterial embolism and blindness.
6. HA gels are commonly preferred for lip
augmentation. Other ller gels, such as PCL and
CaHA ller, are not appropriate in most cases due to
visible and palpable white nodules.
7. Due to displacement of the jowl when supine, the
physician is advised to inject patients in the upright
position for more accurate correction.

■Complications and
Their Management
Irregularity, asymmetry, and uneven shape are common
complications after ller injection regardless of region.
These complications can be prevented by choosing the
appropriate type of ller according to injection layers and
postoperative molding. Retouching is recommended 1 to 3
months after the rst injection if these complications occur.
Region-related speci c complications are mentioned later.
Supraorbital nerve damage can be avoided by using
the midline one-entry-point technique. Injecting CaHA and
PCL with tumescent solution to reduce pain has the pos-
sibility of undergoing sudden volume loss after 1 month,
which should be explained to patients before the proce-
dure. Bruising or skin necrosis by arterial embolism is rela-
tively rare in the forehead region.
In contouring of the temple, irregularity is the most com-
mon after a fanning technique injection into a subdermal
layer and migration may occur after the self-pistol technique
into a deep layer. Pain and hematoma are common complica-
tions after an intramuscular injection (self-pistol technique).
To prevent intra-arterial injection, a negative pressure test
(regurgitation) should be done before injecting ller.
In contouring of the nose, blindness is the most seri-
ous and irreversible complication, although it is rare. It can
occur when ller is injected into the dorsal nasal artery,
supratrochlear artery, or angular artery around the nasal
and periorbital region. These arteries anastomose with the
ophthalmic artery. To prevent this, the needle should be
kept in the midline and moved back and forth continuously
during injection. Skin necrosis is the second most serious
complication (Fig. 30.15). Intra-arterial embolization or
venous congestion can lead to this problem.
Fig. 30.15 Skin necrosis after nasal ller injection. Nasal skin
necrosis with crust formation developed in a 25-year-old woman
who had a nasal HA ller injection 1 month previously. She was
treated with hyaluronidase and hyperbaric oxygen therapy, but the
necrosis progressed.

VI Minimally Invasive Facial Plastic Surgery
404
15. Kim JA, Van Abel D. Neocollagenesis in human tissue in-
jected with a polycaprolactone-based dermal ller. J Cos-
m et Laser Ther 2015;17(2):99–101
16. Emre IE, Cakm ak O. Ageing face, an overview—aetiol-
ogy, assessm ent and managem ent. Otorhinolaryngologist.
2013;6(1):160–166
17. Zim bler MS, Kokoska MS, Thom as JR. Anatomy and patho-
physiology of facial aging. Facial Plast Surg Clin North Am
2001;9(2):179–187, vii
18. Colem an SR, Grover R. The anatomy of the aging face: vol-
um e loss and changes in 3-dim ensional topography. Aes-
thet Surg J 2006;26(1S):S4–S9
19. Rohrich RJ, Pessa JE. The fat compartments of the face:
anatomy and clinical implications for cosmetic surgery.
Plast Reconstr Surg 2007;119(7):2219–2227, discussion
2228–2231
20. Hur MS, Kim HJ, Choi BY, Hu KS, Kim HJ, Lee KS. Morphol-
ogy of the m entalis m uscle and its relationship with the
orbicularis oris and incisivus labii inferioris m uscles. J Cra-
niofac Surg 2013;24(2):602–604
21. Dallara JM, Baspeyras M, Bui P, Cartier H, Charavel MH,
Dumas L. Calcium hydroxylapatite for jawline rejuvena-
tion: consensus recom mendations. J Cosm et Dermatol
2014;13(1):3–14
22. Matarasso SL, Carruthers JD, Jewell ML; Restylane Con-
sensus Group. Consensus recom mendations for soft-tis-
sue augm entation with nonanimal stabilized hyaluronic
acid (Restylane). Plast Reconstr Surg 2006;117(3 Suppl):
3S–34S; discussion 35S–43S
23. Kim AJ. E ect of injection depth and volume of stabilized
hyaluronic acid in human dermis on skin texture, hydration,
and thickness. Arch Aesthet Plast Surg 2014;20(2):97–103
24. Coleman SR. Avoidance of arterial occlusion from injection of
soft tissue llers. Aesthet Surg J 2002;22(6):555–557
25. Rohrich RJ, Rios JL, Fagien S. Role of new llers in facial
rejuvenation: a cautious outlook. Plast Reconstr Surg
2003;112(7):1899–1902
ne wrinkles, injecting a small amount of ller over two or
three sessions is recommended over a single large-volume
injection. In addition, a soft-type ller is chosen to prevent
lumpy hardness at the infraorbital area.
For contouring of the nasolabial fold, it is important to
avoid injecting into the lateral nasal artery. Because the lat-
eral nasal artery runs 4 mm above the supra-alar groove,
avoid injecting above the groove (Fig. 30.16). Inject slowly
and carefully and pay attention to any change of skin color.
A small amount of injection (~ 0.05 mL per injection) is rec-
ommended to prevent vascular complications.25
References
1. Brandt FS, Cazzaniga A. Hyaluronic acid gel llers in the
m anagem ent of facial aging. Clin Interv Aging 2008;
3(1):153–159
2. McCurdy JA, Lam SM, eds. Cosm etic Surgery of the Asian
Face. New York, NY: Thiem e Medical Publishing; 2011
3. Ricketts RM, ed. Orthodontic Diagnosis and Planning:
Their Roles in Preventive and Rehabilitative Dentistry. Vol.
2. Denver, CO: Rocky Mountain/Orthodontics; 1982
4. Ricketts RM. Esthetics, environment, and the law of lip re-
lation. Am J Orthod 1968;54(4):272–289
5. Carruthers JD, Glogau RG, Blitzer A; Facial Aesthetics Con-
sensus Group Faculty. Advances in facial rejuvenation:
botulinum toxin type a, hyaluronic acid derm al llers,
and combination therapies—consensus recom menda-
tions. Plast Reconstr Surg 2008;121(5, Suppl):5S–30S, quiz
31S–36S
6. Mikos AG, Thorsen AJ, Czerwonka LA, et al. Preparation
and characterization of poly (L-lactic acid) foam s. Polym er
1994;35(5):1068–1077
7. Buck DW II, Alam M, Kim JY. Injectable llers for fa-
cial rejuvenation: a review. J Plast Reconstr Aesthet Surg
2009;62(1):11–18
8. Mendelson BC, Muza ar AR, Adam s WP Jr. Surgical anat-
omy of the midcheek and m alar m ounds. Plast Reconstr
Surg 2002;110(3):885–896, discussion 897–911
9. Kim JA. Clinical experience with Ca ller in o -label use in
forehead, neck fold, nose and tear trough. Paper presented
at: 2014 joint m eeting of Aesthetics Asia and the 1st Aes-
thetic and Anti-Aging Medicine Asian Congress; Septem -
ber 25–27, 2014; Singpore, Marina Bay Sands
10. Shaw RB Jr, Katzel EB, Koltz PF, et al. Aging of the facial skel-
eton: aesthetic implications and rejuvenation strategies.
Plast Reconstr Surg 2011;127(1):374–383
11. Richard MJ, Morris C, Deen BF, Gray L, Woodward JA. Anal-
ysis of the anatom ic changes of the aging facial skeleton us-
ing computer-assisted tom ography. Ophthal Plast Reconstr
Surg 2009;25(5):382–386
12. Zadoo VP, Pessa JE. Biological arches and changes to the
curvilinear form of the aging m axilla. Plast Reconstr Surg
2000;106(2):460–466, discussion 467–468
13. Pessa JE, Desvigne LD, Lambros VS, Nimerick J, Sugunan B, Za-
doo VP. Changes in ocular globe-to-orbital rim position with
age: implications for aesthetic blepharoplasty of the lower
eyelids. Aesthetic Plast Surg 1999;23(5):337–342
14. Doual JM, Ferri J, Laude M. The in uence of senescence on
craniofacial and cervical m orphology in hum ans. Surg Ra-
diol Anat 1997;19(3):175–183
Fig. 30.16 Course of lateral nasal artery at the alar groove. To
prevent intra-arterial injection in nasolabial fold correction, avoid
injecting above the alar groove because the lateral nasal artery runs
4 mm above the alar groove.

405
31 Management of Facial Filler Injection
Complications
Hyoung Jin Moon and Jong Sook Yi
calcium hydroxyapatite and poly-L-lactic acid are excellent
for their volumetric e ect.2
An understanding of facial anatomy, especially skin
thickness and vessels, is also crucial to reduce complica-
tions. Skin thickness varies among di erent anatomic
regions, and requires di erent techniques depending on
ller type. Generally, human collagen should be placed
in the middermis, and medium -length hyaluronic acid
products should be placed in the deep dermis. Calcium
hydroxyapatite is injected at the dermal subcutaneous bor-
der, while poly-L-lactic acid and fat are injected into the
subcutis.2 Since the eyelids, periorbita, and nasal dorsum
are known to have a very thin dermis, special care should
be taken when injecting into these regions not to intro-
duce lumpiness, nodules, or potential granulomas. For the
novice, sometimes it is better to err on the side of ller
placement that is too deep rather than too super cial even
though the augmentation e ect may not be as apparent.2,3
The rich network of blood vessel in the face is by and
large a blessing, but it can increase the chances of bruising,
hematoma, or embolism-related complications. The glabellar
and nasolabial regions are regarded as high-risk facial units

■Introduction
A ller is any material that can augment volume when
injected into the body, and is usually available in an inject-
able form. Well-known llers include hyaluronic acid prod-
ucts, collagen, para n, and liquid silicone. Although most
of the llers in the market are known to have a good safety
pro le, complications can occur occasionally since they
are arti cial implants that can induce a foreign-body reac-
tion. Because injection is a blind procedure, the physician
is unable to see exactly where the ller is placed. Accord-
ing to a study of 286 patients injected with hyaluronic acid
gel, there was a complication rate of ~ 5%.1 However, most
complications can be prevented by selecting safe products
and performing the procedure in an appropriate manner.
Although llers can be injected into any region of the body
theoretically, each ller has a speci c niche in terms of its
purpose. For instance, human collagens and the medium
hyaluronic acid products such as Restylane (Galderma) and
Juvederm Ultra (Allergan) are appropriate for correcting
ne rhytides in thin-skin areas while heavier llers such as
Pearls
• Skin thickness varies across di erent anatomic
regions. Since the eyelids, periorbital area, and
nasal dorsum are known to have a very thin dermis,
special care should be taken while injecting into
these regions not to create lumpiness, nodules, or
granulomas.
• The glabellar and nasolabial regions are regarded as
high-risk facial units in which surgery can lead to
serious vascular complications.
• Fillers should be placed in the appropriate layer of
skin. Too super cially injected llers can result in
unevenness and visibility. Too deeply injected llers
can be under e ective at changing shapes.
• Given that most faces are slightly asymmetric, it is
important to visually check whether the two sides of
the face are symmetric during injection.
• Massage is generally su cient to atten and
disperse excessive, super cial, or unaesthetically
placed ller causing visibility.
• Bilateral compression and releasing of the superior
nasal corner of the orbital rims during injection is a
new maneuver that can reduce orbital complications
by increasing intraluminal pressure.
• Severe pain and blanching of the skin are warning
signs of intravascular injection of ller and require
emergent measures. These include stopping
injection, aspirating as much injected ller as
possible, and injecting a high dose of hyaluronidase
in case of hyaluronic acid ller.
• Low-molecular-weight heparin, hot packs and soft
massage, 2% nitroglycerin paste patch, and injection
of prostaglandin E1 are additional measures to
enhance vasodilation and inhibition of platelet
aggregation in case of vascular occlusion by ller.
• Once eschar has formed, appropriate wet dressing
is required with antibiotics to prevent secondary
infection. Starting hyperbaric oxygen therapy also
helps to improve healing.
• When addressing an intervention to complicated
cases such as skin necrosis, more conservative and
less invasive treatment should be attempted before
recommending a radical solution.

VI Minimally Invasive Facial Plastic Surgery
406
situation, it is best to attempt an alternative treatment or
product, or simply not to treat at all. To set up an accurate
treatment plan, the physician should ask about the onset
and progress of symptoms and signs. Generally, transient
swelling or tenderness can be seen 24 to 72 hours after
injection because of the physical imposition and subse-
quent volume displacement on the skin from an implant.2
These adverse e ects will diminish over a relatively short
period of time. But if there is an irregularity due to a semi-
permanent or permanent ller, it will require some form of
intervention. When the physician determines it is neces-
sary to do some kind of intervention, the patient needs to
be informed that the treatment plan may require multiple
sessions, whether it is a small complication or a devastat-
ing one. A discussion regarding the potential for any per-
manent scars from these interventions should be included
in the initial consultation. This step is really important in
maintaining a good doctor-patient relationship since the
patient is usually in a very anxious state. More conserva-
tive and less invasive treatment is often recommended as a
rst attempt for a complicated patient rather than a radical
solution.

■Complications and
Their Management
The best way to manage complications is to prevent them
by choosing the appropriate technique and ller type.
Attaining a consistently excellent outcome and avoiding
poor results begin before the actual injection. Marking the
injection points prior to the actual injections considering
adjacent anatomy is helpful to reach these goals.
that can be associated with serious complications, includ-
ing emboli and resulting necrosis because their main arter-
ies, the supratrochlear artery and the angular lateral nasal
artery, respectively, are vulnerable to embolism by ller
(Fig. 31.1).2,3,4 Augmenting the chin with heavy llers can
potentially lead to vascular compromise if too much of the
product is injected at once by compressing the blood vessels.
It is not clear which type of injection technique, the
multiple serial puncture or the linear threading technique,
causes fewer complications. The multiple puncture tech-
nique makes it easier to control placement but can lead
to unevenness. The linear threading technique tends to
require more experience, and can result in over-injection
to a given area. The fanning technique has been reported
to increase the likelihood of bleeding even in experienced
hands.2,5 Ultimately, the practitioner can utilize these tech-
niques to supplement the weaknesses of one another.

■Patient Evaluation
The patient with complications after ller injection should
be interviewed thoroughly about previous medical proce-
dures. If the patient is in an immunosuppressed state, it
is not a contraindication, but the higher risk of infection
should be discussed. In those patients with immunologic
diseases such as lupus or scleroderma, it is best to consult
with the dermatologist or rheumatologist before proceed-
ing with any additive procedures. Previous ller-related
issues, including type and dose of llers, number of injec-
tions, and injected areas, should be evaluated.
If a patient is dissatis ed with a previous ller type,
the physician should not re-administer that product. In this
Fig. 31.1 Dermal necrosis after ller injec-
tion at glabellar and nasolabial regions.
The glabellar and nasolabial regions are
regarded as high-risk facial units. Embo-
lism of the supratrochlear artery and lateral
nasal artery caused skin necrosis of the
(a) glabella and (b) nasal tip, respectively.
a
b

31 Management of Facial Filler Injection Complications
407
The facial artery takes a tortuous course along the naso-
labial crease (Fig. 31.3), where it becomes endangered by
an injection intended to soften and reduce the prominent
nasolabial fold. The frontal branch of the super cial tem-
poral artery gives o descending branches to anastomoses
with the supraorbital and the supratrochlear arteries from
the ophthalmic artery. To prevent complications, a small-
bore needle tip is recommended with smaller syringes,
preferably 0.5 to 1 mL, so that less pressure is required on
Early Onset
Minor Form
Bruising is a common complication of ller injections, and
it is caused by vascular damage from a needle. All patients
should be informed not to take blood thinners such as aspirin
1 week before the procedure. During the procedure, pierc-
ing of muscular layers must be minimized. The injection
site should be cleaned with an alcohol swab, and the pro-
cedure should be performed in a room with adequate light-
ing. Immediately applying an ice pack to the injection site
may help to minimize bruising. Special needles or cannulae
can be used to minimize vascular injury as well (Fig. 31.2).
If bleeding occurs during the procedure, the injection site
should be covered with gauze and pressed for several min-
utes to prevent hematoma formation. Usually bruising is
only temporary and does not a ect the nal therapeutic
e ect. It can darken in the days following the injection, but
will gradually disappear after 10 days in most cases.6
Occasionally, there may be hypersensitivity to the ller
ingredients. The main symptoms are pain and erythema,
accompanied by pruritus and fever.7 In the vast majority
of patients, fortunately, these symptoms resolve in 2 to 3
days as the causative substance disappears. In severe cases,
administering corticosteroid products and warm compres-
sion may help alleviate the symptoms. V-beam laser treat-
ment can be used for persistent erythema.8
Major Form
The serious complications that occur after ller injection
are blindness and dermal necrosis. Vascular compromise
can be largely divided into intra- and extravascular causes.
Intra-arterial injection of ller is rare but can be disastrous.
Extravascular causes include external venous compres-
sion due to excessive volume of injection, and edema and
in ammatory response caused by a component of the ller.
Intra-arterial Embolism
Intra-arterial embolism has a relatively low incidence,
but its consequences are devastating. Blindness following
cosmetic ller injection is the most serious complication.
Most cases of ocular complications occur during multiple-
site injections, but some facial units distinguished by the
fat compartments and the retaining ligaments may have a
higher risk compared with others.9,10,11 The nasolabial and
the frontotemporal units are known to be danger zones
due to large-core cutaneous arteries susceptible to acci-
dental cannulation, the facial and the super cial temporal
arteries.12 Young patients may have higher risk of blind-
ness because healthy skin has abundant cutaneous arterial
anastomoses.
Fig. 31.2 Cannula for ller injection. For safety reasons, facial ller
injection is best done using a thin, blunt cannula instead of a sharp
needle.
Fig. 31.3 The tortuous course of the facial artery. The facial
artery runs along the nasolabial crease and anastomoses with the
descending nasal artery. The two facial arteries communicate with
each other in the nasal supratip region.

VI Minimally Invasive Facial Plastic Surgery
408
If the patient complains of sudden ocular pain or visual
loss, however, injection must cease immediately. An oph-
thalmologist should be contacted for measurement of
visual acuity and fundoscopy.
The goal of treatment is rapid restoration of perfusion
to the retina and optic nerve head. Retrobulbar injection
of 2 to 4 mL (150 to 200 U/mL) of hyaluronidase is recom -
mended within 60 to 90 minutes.13 This might be the single
most e ective option to dissolve the intraorbital intravas-
cular hyaluronan in a time-sensitive manner.14 Ocular mas-
sage (repeated, increasing pressure applied to the globe for
10- to 15-second intervals over 3 to 5 minutes) may lower
intraocular pressure and increase arteriolar ow, poten-
tially moving the retinal vascular embolus peripherally.15
Intravenous mannitol and diuretics (500 mg of acetazol-
amide) may increase retinal blood ow and rapidly reduce
intraocular pressure. Topical and intravenous antibiot-
ics and subsequent administration of high-dose cortico-
steroid (methylprednisolone 1 g/day intravenously for 3
days, and dose tapering with oral administration) can be
attempted.15,16 In fact, no safe, feasible, and reliable treat-
ment exists for iatrogenic retinal embolism. Nonetheless,
therapy should theoretically be applied as soon as possible
to increase the chance of recovery.
Injection rhinoplasty is also the main procedure that
can induce intra-arterial embolism by injecting the dorsal
nasal artery directly. The dorsal nasal artery, as its name
suggests, runs along the dorsum of the nose, ~ 3 mm away
from the midline (Fig. 31.5). It is a fairly immobile blood
vessel xed to the surrounding tissue, and the needle tip
can be inserted safely if it is inserted in parallel with the
the plunger. The needle tip should be moved back and forth
continuously during injection since most complications
occur while injecting ller materials in the static state with
high pressure. Previously traumatized areas, such as a blunt
trauma site or blepharoplasty site, should be avoided. Dur-
ing ller injection at the temple area, the needle tip can be
deviated super cially from the deep injection plane by a
bony curve of the frontal bone and encounter the frontal
branch of the super cial temporal artery. Thus, special care
should be taken not to lose the appropriate plane. Recently,
evidence has emerged of persistent anastomoses between
the ophthalmic artery and the facial arterial system at the
superior nasal corner of the orbital rim.12 Based on this
knowledge, the author has introduced an e ective safety
maneuver that bilaterally compresses the superior nasal
corners of the orbital rims during the injection moment
and releases them soon afterward. This technique creates a
temporary collapse of the anastomotic pathways using the
hand of an assistant (Fig. 31.4).
When an assistant is unavailable, an alternative method
is to compress the tissue on the course of the core artery
between the injection site and the eye while stretching
the skin for an injection procedure using the nondominant
hand. This method could increase the luminal pressure
enough to block any ller that was accidentally injected
into the main artery underneath from traveling to the globe.
The target areas for compression are the oral commissure,
upper nasolabial fold, alar crease, side of the nose, medial
canthus, superior nasal orbital rim, and glabella. With the
index and long ngers counteracting with the thumb, the
injection areas can be stretched and immobilized.
Fig. 31.4 Anastomotic channel blockage by compression. Blocking the anastomotic channel between the ophthalmic artery and the
other facial arterial system prevents blindness by embolism. Orbital rims at the superior nasal corners are compressed using the index and
long ngers during ller injection at the (a) nasolabial area and (b) superciliary ridge.
a
b

31 Management of Facial Filler Injection Complications
409
the needle tip should move to the side. Because the dor-
sal nasal artery is located in the super cial fatty layer and
SMAS, the injection should be into the deep fatty layer to
prevent embolization to the dorsal nasal artery. Aspirat-
ing the needle before injection and injecting ller while
withdrawing the needle are tips for safe injection. Using a
blunt cannula also helps to prevent incidental puncture of
the vessel and is recommended to physicians who are not
familiar with the injection technique.
If the patient complains of severe pain and blanching of
the skin is observed along the area of the blood vessel dur-
ing the ller procedure, the injection should immediately
stop and as much ller should be aspirated as possible. If
hyaluronic ller has been injected, injection of hyaluronidase
to the lesion is recommended (Fig. 31.8). The optimal time
of hyaluronidase injection in case of vascular complications
has not been determined yet, but it is wise to use high doses
of hyaluronidase (at least 200 U) as early as possible. Some
experts recommend dilution with saline to increase disper-
sion or lidocaine to aid vasodilation. Additional hyaluronidase
should be injected if improvement is not seen within 60 min-
utes.17 According to an experimental study, the degradation
ratio of cross-linked HA with 100 IU of hyaluronidase after
24 hours was 50%, and it depended on the amount of hyal-
uronidase.18,19 Recently, there has been some evidence that if
hyaluronidase is injected subcutaneously, it will di use into
the obstructed vessels and degrade the HA ller to prevent
blood vessel. The dorsal nasal artery anastomoses with
the ophthalmic, infratrochlear, and angular arteries, and a
widespread embolism through the connected blood vessels
manifests as skin necrosis in a geographic pattern.
If arterial injection is suspected, however, prompt
management should be done according to the treatment
protocol of intra-arterial embolism. Once ller is injected
into the arterial bloodstream, the patient experiences
severe pain immediately, and may complain of a sensa-
tion of something spreading out from the injection site.
The area supplied by the blood vessel where ller embo-
lism has occurred becomes pale due to ischemia. The isch-
emic area develops edema within several hours, and soon
appears mottled and purplish due to venous congestion as
a rebound phenomenon. After ~ 24 hours, multiple ulcer-
ative lesions accompanied by eschar and erythema, wors-
ening over time, result in desquamation of the tissue within
several days (Fig. 31.6).3,4 These large areas of necrosis heal
and reduce over time, eventually leading to scar formation
w ith contraction of tissue (Fig. 31.7).
To prevent this complication during nasal augmenta-
tion with llers, the needle tip must always be located in
the midline to avoid injecting into the dorsal nasal artery.
If ller has to be injected into the side of the nasal dorsum,
for example, for correction of a deviated nose, the needle
should never move in parallel with the direction of the
blood vessel. After inserting the needle into the midline,
Supratrochlear a.
Dorsal nasal a.
External nasal branch
of anterior ethmoidal a.
Columellar branch
Septal branch
Supraorbital a.
Infraorbital a.
Lateral nasal a.
Angular a.
Superior labial a.
Facial a.
Fig. 31.5 Arterial supply of the external nose.
The dorsal nasal artery runs along the dorsum
of the nose, ~ 3 mm away from the midline. The
dorsal nasal artery anastomoses with the ophthal-
mic, infratrochlear, and angular arteries, causing
the spread of embolism through the connected
blood vessels, manifesting as skin necrosis in a
geographic pattern.

VI Minimally Invasive Facial Plastic Surgery
410
e ective by the action of vasodilation and inhibition of plate-
let aggregation. A regimen of 10 mg a day for 3 to 7 days is
recommended. Appropriate dressing should be applied once
desquamation and pustule formation occur after a day. The
physician should administer appropriate antibiotics to pre-
vent secondary infection, apply wet dressing for faster wound
healing, and continue to administer antibiotics.2,3,4
impending necrosis caused by intra-arterially injected HA
ller.17 Low-molecular-weight heparin therapy can decrease
thrombosis and embolism, but it may be di cult to obtain
and administer in an outpatient clinic setting. It is very impor-
tant to supply enough oxygen to the area of ischemia. For this
purpose, hot packs, soft massage, and 2% nitroglycerin paste
can be applied for vasodilation. Injection of prostaglandin E1 is
Fig. 31.6 Intra-arterial embolism by ller injection. The ischemic area develops edema within several hours, and soon a purplish, mottled
area appears due to venous congestion occurring as a rebound phenomenon. After ~ 24 hours, multiple ulcerative lesions accompanied by
eschar and erythema appear and worsen over time, resulting in desquamation and ulceration of the tissue within several days. (a) Before
injection. (b) Four hours after injection. (c) One day after injection. (d) Three days after injection.
Fig. 31.7 Skin contracture after nasal ller injection. (a) Treatment was delayed after intra-arterial ller injection, and necrosis pro-
gressed even with hyperbaric oxygen chamber treatment. (b,c) Two months later, the size of the necrotic area has decreased, but her right
alar area shows slight contracture.
a
b
c
d
a
b
c

31 Management of Facial Filler Injection Complications
411
pack should be applied to the a ected area. The skin should
be punctured at the site of ller injection and squeezed to
remove ller. If hyaluronic acid–type ller was used, inject
hyaluronidase rst and then try removing injected ller.
Administer antibiotics and prostaglandin E1 as mentioned
previously. Two percent nitroglycerin paste can be applied
for vasodilation. Hyperbaric oxygen therapy is also recom -
mended. Unlike intra-arterial embolism, venous compres-
sion can be resolved without sequelae if treated properly
initially. However, if the initial treatment was not provided
or was inappropriate, it progresses to dermal necrosis due
to venous congestion, and after a day the skin turns dark
violet. When this happens, the physician should apply
a wet dressing for faster wound healing and continue to
administer antibiotics.4,6
After the active wound stage, necrotic areas change
into chronic stage w ith rem aining scars. Scars w ill never
disappear but can be reduced. The Fraxel Xena laser
(Solta Medical), platelet-rich plasm a (PRP), stem cell fat
grafting, diam ond peeling, and carboxy therapy can be
addressed w hen the scars becom e perm anent. Surgical
treatm ent of scar tissue can be attem pted if severe skin
deform ity rem ains regardless of these m easures. Since
surgical treatm ent has the risk of m aking a new scar, a
thorough discussion should take place w ith the patient
before the surgery. According to the size and location
of the wound and the preference of the surgeon, a local
rotational flap, nasolabial flap, or forehead flap can be
used.
Starting hyperbaric oxygen therapy is also helpful. It
is known to improve neovascularization and postischemic
tissue survival by elevating cellular oxygen levels. The pro-
tocol di ers among practitioners, but the authors recom -
mend 90 minutes of treatment twice per day for 7 to 30
days with 100% oxygen at 0.2 MPa. This yields a more than
20% increase in arterial blood oxygen content.20
Venous Congestion
Dermal necrosis due to venous compression from exces-
sive ller volume is more common than dermal necrosis
by direct intra-arterial injection. Initially, both the vein and
artery supplying the injected site are compressed by the
excess ller volume, so the patient feels severe pain and the
skin in that area becomes pale. Unlike arterial compression,
which can be reperfused by high lling pressure and col-
lateral circulation, venous congestion often persists. In this
case, the patient continues to feel dull pain and the skin
darkens w ith time. The skin turns dark violet after 24 hours
and desquamation or pustules can be observed. De nitive
signs of dermal necrosis such as eschar formation occur
gradually, and the skin recovers through the wound heal-
ing process (Fig. 31.9).1–4
The skin color and pain should be closely monitored
while injecting a small amount at a time.
If vascular compression is suspected from blanching of
the injected area right after injection, the injection should
be stopped immediately, and su cient massage and a hot
Fig. 31.8 Hyaluronidase treatment of ller
embolization. A woman had hyaluronic acid
ller injection on both nasolabial folds.
Immediately after injection, she felt a burn-
ing sensation and pain. Treatment with
ller aspiration and hyaluronidase injection
started 1 day after injection. (a) She devel-
oped redness on the right cheek and nasal
dorsum. (b) Within a week, redness on the
cheek and nasal dorsum decreased.
a
b

VI Minimally Invasive Facial Plastic Surgery
412
Asymmetry is the most common complication of ller
injection, especially after injection rhinoplasty. But many
patients have asymmetry at the baseline already. If the
quality of facial asymmetry seems unlikely to be corrected
with ller injection, this should be discussed before any
procedure and the patient should be made aware of the
limitations of the procedure.1,2,3,4
To prevent asymmetry during injection rhinoplasty,
the needle tip must be placed precisely in the midline, and
the direction of the bevel should be toward the median
plane. When injecting ller into a patient with a deviated
nose, it is prudent to watch the shape of the nose closely
while slowly injecting small amounts of ller. Maintenance
of symmetry is important regardless of the amount of
material delivered. There are two ways to maintain sym -
metry: measuring the amount of injection and visible
correction. When using the traditional 1-mL syringe, the
injector should ensure that approximately equal amounts
are delivered to corresponding structures, such as the lips
or the nasolabial folds on the two sides of the face. Given
that most faces are often slightly asymmetrical, it is more
important to visually check that the sides of the face are
symmetric. Alternating small aliquot injections between
the sides may permit the achievement of symmetry.
Delayed Onset
Mild Form
In ammatory response and edema can occur due to a pro-
tein component such as endotoxin contained in the ller,
resulting in injury to the skin. This is caused mostly by
hyaluronic acid ller, and symptoms such as erythematous
edema, dermal hypertrophy, and pustules appear several
days after injection. Symptoms can occur at all sites of ller
injection and usually can be treated well with appropriate
antibiotic treatment and dressing.9,21
Injecting ller too super cially (close to the skin sur-
face) may result in unevenness of the injected site or visi-
bility of the ller. Particularly when semi-permanent llers
are injected too super cially, the lumpiness may remain
for several months.1,2,3 Gross unevenness after soft tissue
augmentation is certainly not acceptable. To avoid this, the
ller should be injected into the appropriate layer accord-
ing to its characteristics. If ller visibility or unevenness of
the skin occurs, massaging the ller into the deeper layer
may improve the appearance. If a bluish ridge develops
due to the Tyndall e ect (Fig. 31.10), hyaluronidase can be
injected and excessive ller can be replaced.22
4 Hrs
24 Hrs
48 Hrs
72 Hrs
5 Days
3 Wks
Fig. 31.9 Venous congestion by ller injec-
tion. As the process of venous congestion con-
tinues, the skin darkens with time, such that it
turns dark violet after ~ 24 hours and desqua-
mation or pustules can be observed. As time
passes, de nitive ndings of dermal necrosis
such as eschar formation occur gradually, and
then the skin recovers through the wound heal-
ing process.

31 Management of Facial Filler Injection Complications
413
References
1. McCracken MS, Khan JA, Wulc AE, et al. Hyaluronic acid gel
(Restylane) ller for facial rhytids: lessons learned from
American Society of Ophthalm ic Plastic and Reconstruc-
tive Surgery m em ber treatm ent of 286 patients. Ophthal
Plast Reconstr Surg 2006;22(3):188–191
2. Gladstone HB, Cohen JL. Adverse e ects when injecting facial
llers. Semin Cutan Med Surg 2007;26(1):34–39
3. Andre P, Lowe NJ, Parc A, Clerici TH, Zimmermann U. Ad-
verse reactions to dermal llers: a review of European expe-
riences. J Cosmet Laser Ther 2005;7(3-4):171–176
4. Lowe NJ, Maxwell CA, Patnaik R. Adverse reactions to
derm al llers: review. Derm atol Surg 2005;31(11 Pt 2):
1616–1625
5. Dayan SH, Bassichis BA. Facial dermal llers: selection
of appropriate products and techniques. Aesthet Surg J
2008;28(3):335–347
6. Glaich AS, Cohen JL, Goldberg LH. Injection necrosis of the
glabella: protocol for prevention and treatment after use of
dermal llers. Dermatol Surg 2006;32(2):276–281
7. Matarasso SL, Herwick R. Hypersensitivity reaction to no-
nanim al stabilized hyaluronic acid. J Am Acad Derm atol
2006;55(1):128–131
8. Lupton JR, Alster TS. Cutaneous hypersensitivity reaction
to injectable hyaluronic acid gel. Derm atol Surg 2000;
26(2):135–137
9. Alam M, Dover JS. Managem ent of complications and se-
quelae with temporary injectable llers. Plast Reconstr
Surg 2007;120(6, Suppl):98S–105S
10. Gierlo M, Stöhring C, Buder T, Wiltfang J. The subcutane-
ous fat compartm ents in relation to aesthetically impor-
tant facial folds and rhytides. J Plast Reconstr Aesthet Surg
2012;65(10):1292–1297
Major Form
Bumps can be formed after any type of ller injection;
these can be due to either granuloma or nodule forma-
tion, although the etiology is not clear. A granuloma is
an immune response to an injected foreign body and is
formed by accumulation of immune response–related cells
such as lymphocytes to eliminate the foreign body.23,24,25 It
is very rare and usually results from the injection of semi-
permanent or permanent ller. Treatment options include
corticosteroid injection and surgical removal. Although the
intralesional steroid injection is e ective, it should be used
judiciously in a weak concentration (no greater than 10
mg/mL) since it can result in adjacent skin atrophy.2 Nod-
ules are round and solid, and they are essentially collec-
tions of injected ller without an in ammatory response.
The treatment is hyaluronidase injection, if the used ller
is hyaluronic acid, or surgical removal.4,5
Late-onset infection is usually caused by less com -
mon bacteria, such as mycobacteria.22 Fluctuant nodules
with erythema, warmth, and tenderness are the key signs
of infection in contrast to granuloma. Limited incision
and drainage or dressing changes usually fail to eradicate
these infections, even when accompanied by appropriate
antibiotic therapy. Successful treatment requires aggres-
sive debridement of all infected subcutaneous tissues and
skin.26 Large defects can be covered with split-thickness
skin grafting.
Migration of llers can occur up to several years after
the injection. Semi-permanent and permanent implants
are both prone to migrate. It is known that an infection or
delayed granuloma may trigger migration.27 If the underly-
ing condition is controlled, hyaluronidase injection or sur-
gical removal are treatment options for migrated llers.
Fig. 31.10 Visibility of ller due to super-
cial injection. (a) Too super cial injection
of ller caused a bluish discoloration of the
nasal dorsum by the Tyndall e ect. (b) After
7 months, the ller resorbed and the nasal
dorsum looks normal.
a
b

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19. Lam bros V. The use of hyaluronidase to reverse the e ects
of hyaluronic acid ller. Plast Reconstr Surg 2004;114(1):
277
20. Klein KC, Guha SC. Cutaneous wound healing: current
concepts and advances in wound care. Indian J Plast Surg
2014;47(3):303–317
21. Sha r R, Am ir A, Gur E. Long-term complications of facial
injections with Restylane (injectable hyaluronic acid). Plast
Reconstr Surg 2000;106(5):1215–1216
22. Hirsch RJ, Narurkar V, Carruthers J. Management of in-
jected hyaluronic acid induced Tyndall e ects. Lasers Surg
Med 2006;38(3):202–204
23. Fernández-Aceñero MJ, Zamora E, Borbujo J. Granulo-
m atous foreign body reaction against hyaluronic acid:
report of a case after lip augm entation. Derm atol Surg
2003;29(12):1225–1226
24. Raulin C, Greve B, Hartschuh W, Soegding K. Exudative
granulom atous reaction to hyaluronic acid (Hylaform ).
Contact Derm at 2000;43(3):178–179
25. Sidwell RU, Dhillon AP, Butler PE, Rustin MH. Localized
granulom atous reaction to a semi-perm anent hyaluronic
acid and acrylic hydrogel cosm etic ller. Clin Exp Derm atol
2004;29(6):630–632
26. Plaus WJ, Hermann G. The surgical m anagement of super-
cial infections caused by atypical mycobacteria. Surgery
1991;110(1):99–103
27. Jordan DR, Stoica B. Filler m igration: a num ber of
m echanism s to consider. Ophthal Plast Reconstr Surg
2015;31(4):257–262
11. Alghoul M, Codner MA. Retaining ligam ents of the face: re-
view of anatomy and clinical applications. Aesthet Surg J
2013;33(6):769–782
12. Tansatit T, Moon HJ, Apinuntrum P, Phetudom T. Veri ca-
tion of embolic channel causing blindness following ller
injection. Aesthetic Plast Surg 2015;39(1):154–161
13. Carruthers JD, Fagien S, Rohrich RJ, Weinkle S, Carruthers
A. Blindness caused by cosm etic ller injection: a review
of cause and therapy. Plast Reconstr Surg 2014;134(6):
1197–1201
14. Fagien S. Paper presented at: 2013 Allergan ALFA executive
consultants meeting; Novem ber 23, 2013; New York, NY
15. Lazzeri D, Agostini T, Figus M, Nardi M, Pantaloni M, La-
zzeri S. Blindness following cosmetic injections of the face.
Plast Reconstr Surg 2012;129(4):995–1012
16. Sung MS, Kim HG, Woo KI, Kim YD. Ocular ischem ia and
ischem ic oculom otor nerve palsy after vascular emboliza-
tion of injectable calcium hydroxylapatite ller. Ophthal
Plast Reconstr Surg 2010;26(4):289–291
17. Cohen JL, Biesman BS, Dayan SH, et al. Treatm ent of Hy-
aluronic acid ller-induced impending necrosis with hy-
aluronidase: Consensus recomm endations. Aesthet Surg J
2015;35(7):844–849
18. Kim DW, Yoon ES, Ji YH, Park SH, Lee BI, Dhong ES. Vascular
complications of hyaluronic acid llers and the role of hy-
aluronidase in m anagem ent. J Plast Reconstr Aesthet Surg
2011;64(12):1590–1595

415
Index
Note: Page numbers followed by f and t indicate gures and tables, respectively.
A
ablative rejuvenation, 339
– lasers for, 340, 343, 344f
– principles of, 340
abscess, facial fat grafting and,
320, 320f
ACell. See MatriStem
acne, facial, improvem ent, laser
hair removal and, 369, 369f
acneiform eruption, facial fat
grafting and, 320
adenosine triphosphate (ATP), in
hair transplant procedures,
306
adipose-derived stem cells, in fat
grafting, 318
ADSC. See adipose-derived stem
cells
aesthetic facial plastic surgery, in
East Asians
– pearls, 3
– trends in, 3–10
aging. See also blepharoplasty,
aging-related
– of Asian face, managem ent of,
303–310
–– pearls, 303
– lower eyelid, 196–197, 197f
– periocular, 196–197, 197f
– periorbital changes related
to, 174
– skin, solar exposure and,
303–304
ala (pl., alae)
– asym m etric, 14, 15
– East Asian, ideal shape of, 100,
100f
– aring of, 99, 101, 101f
– hanging, 100, 101, 103
–– sail excision for, 109–110,
110f–111f
– hooding, 101
– physical examination of,
99–100, 100f
– resection, 9, 15
– w ide, 9
alar base
– de nition of, 99
– of East asian nose, 99
– ethnic variations in, 99
– illusions and, 100
– m odi cation
–– indications for, 99
–– patient evaluation for, 99–101
–– pearls, 99
– poor harmony w ith nasal
dorsum and tip, after alar base
surgery, 105
– skin of, 101
– skin quality and, 100
– surgery
–– in aesthetic rhinoplasty for
Southeast Asians, 116
–– case studies, 105–106, 106f,
107f
–– for cleft nose, 103, 104f
–– complications of, 104–105,
105f
–– excision design, 102, 102f
–– key technical points in,
103–104
–– nasal obstruction after, 105
–– pearls, 99
–– poor harm ony of alar base
w ith nasal dorsum and tip
after, 105
–– scarring after, 104–105, 105f
–– techniques for, 101–103
–– types of, 102, 102f
– surgical anatomy of, 101, 101f
– width of, 99, 100
alar batten grafts, 39
alar-colum ellar disproportion,
correction of, 53–54, 54f
alar facial groove, 101
alar lift, sail excision for, 109–110,
110f–111f
alar rim
– excessively thick, 99
– hanging, 99
alar rim graft(s), 39, 54–55
– in corrective rhinoplasty for
short contracted nose, 128,
128f
alar wedge resection, 102, 102f
– large, V-Y advancem ent for, 103
– and sill excision, combined, 102,
102f, 103f, 105–106, 106f, 107f
AlloDerm , in rhinoplasty, 135
– complications of, 138, 138f, 140
allograft, in genioplasty,
complications of, 294–295,
295f
alloplastic implants. See also
Gore-Tex; Medpor; silicone
implants
– advantages of, 13
– in Asian aesthetic surgery, 14
– calci cation of, 22
– capsule form ation w ith, 22
– for chin
–– complications of, 294–295,
295f
–– in facial rejuvenation, 309
– complications of, 13, 14, 22–23,
28, 28f
– infection with, 23, 24, 25f
– inherent physical characteristics
of, problem s caused by, 22–23
– in rhinoplasty
–– calci cation, secondary
rhinoplasty for, 139, 140f
–– complications of, 135–148
–– deviated, secondary
rhinoplasty for, 138–139
–– infectious complications of, 141
–– in am m ation caused by, 140
–– m obile, secondary rhinoplasty
for, 139
–– patient evaluation, 136–138
–– pearls, 135
–– protrusion, secondary
rhinoplasty for, 139
–– visible, secondary rhinoplasty
for, 139
– in septorhinoplasty, 135–136,
143
–– pearls, 135
– and short nose deform ity, 122
– skin and m ucosal dam age
caused by, 22
alopecia. See also hair loss
– endoscopic forehead and brow
lift and, 337
– temporary, after hair
transplantation, 359
anatomy
– of alar base, 101, 101f
– of Asian eyelid, 6, 211
– of Asian face, 6, 7f, 8f
– of Asian nose, 6, 26, 27f, 61–62
– of East Asian eyelid, 162–163,
163f
– of facial artery, 407, 407f
– of facial bones, 6
– of forehead, 324–326,
325f–327f, 331–332, 332f
– of glabella, 324–326, 325f–327f,
331–332, 332f
– of internal nasal valve, 87
– of lateral nasal artery, 404f
– negative vector, 197f, 198, 207,
207f
– positive vector, 198
– of temporal region, 324–326,
325f–327f
– of upper eyelid, 152–153, 153f,
162
anesthesia
– for augm entation rhinoplasty,
16, 28
– for blepharoplasty, 178
– for double-eyelid surgery, 166
– for endoscopic forehead and
brow lift, 330
– for facial fat grafting, 312, 313
– for ller injection in facial
contouring, 394
– for genioplasty, 290
– for ptosis surgery, 216, 216f
– for zygom a reduction, 247
Angle classi cation, of
malocclusion, 269, 270f
anterior segm ental osteotomy, for
bim axillary protrusion, 274t,
277–279, 279f
– and genioplasty, 286, 295,
296f–297f, 298, 299f
Aquam id. See polyacrylam ide gel
arcus m arginalis, 326, 331
arteriovenous stula, hair
transplantation and, 360
Artesense. See polym ethyl
m ethacrylate
Asian(s)
– de nition of, 3
– facial aesthetic procedures used
in, 3, 4f
ASO. See anterior segm ental
osteotomy
ATP. See adenosine triphosphate
(ATP)
augm entation rhinoplasty. See
also nasal dorsal augm entation
– alar batten grafts in, 39
– alar rim grafts in, 39
– anesthesia for, 16, 28
– and base reduction, 39
– brow lift with, 15
– case studies, 40–43, 40f–45f
– caudal septal extension graft in,
34, 34f, 40, 41f
– closure for, 21, 39
– complications of, 22–23
– defatting for, 18, 18f
– and glabellar augm entation, 39
– incisions for, 17, 21
– key technical points, 21–22, 40
– and low nasal bridge, 21
– open, incisions for, 17
– opening nose for, 28
– osteotomy in, 19
– patient evaluation for, 14–15,
14f, 15f
– pearls, 13
– positioning for, 16
– postoperative care, 39–40
– principles of, 13
– release of ligam entous
attachm ents in, 18
– septal cartilage harvest in,
18–19, 19f
– silicone implants for, 13–25
–– case studies, 23–24, 24f, 25f
–– closure technique for, 21
–– complications of, 22–23
–– derm al fat graft with, 22, 23f
–– displacem ent and movem ent
of, 23

Index
416
– evaluation, 175, 176f
– involutional
–– clinical presentation of, 175,
175f
–– and deep superior sulcus,
175, 175f
– patient evaluation, 211–214
– versus ptosis, 174, 175f
– upper eyelid function in, 153
blindness
– fat graft em bolization and, 320
– after ller injection, 10, 403
–– prevention of, 407–408, 408f
blood, as ller, properties of, 393t
botulinum toxin
– as adjunct to endoscopic
forehead and brow lift, 336
– aesthetic facial use of, 377–391
–– injection levels, 379
–– landm arks for, 379
–– patient evaluation for, 378
–– pearls, 377
– for brow lifting and shaping,
336, 381–382
– for bunny lines, 384, 384f
– for cobblestone chin, 385, 386f
– com m ercial form ulations, 378
– complications of, 389
– for crow’s-feet, 380–381, 381f,
382f
– dilution of, 378–379
– dosage of, 378
– for forehead and glabellar
rhytidosis, 328
– for forehead horizontal lines,
379, 379f, 380f
– for glabellar frown lines,
379–380, 380f
– for gum my sm ile, 384, 384f
– for infraorbital eye opening,
382–383, 383f
– for infraorbital wrinkles, 382,
382f
– intraderm al injection, 388–389,
389f
– for m arionette lines, 385, 386f
– for m asseter m uscle
hypertrophy, 386–388, 387f,
388f
– for m outh corner elevation,
385, 386f
– for nasal tip lifting, 383, 383f
– for parotid gland reduction,
388, 389f
– for perioral rhytids, 384–385,
385f
– for platysm al bands, 386, 386f
– for square jaw, 386–388, 387f,
388f
– storage of, 378–379
breast augm entation, and costal
cartilage harvest, 28–29, 29f
brow lift. See also endoscopic
forehead and brow lift
– with augm entation rhinoplasty,
15
– and blepharoplasty, 176
– botulinum toxin for, 336, 381–382
– fat transposition, 199, 202–203
–– complications of, 206
–– subperiosteal, 202–203
–– supraperiosteal, 203, 203f
– goals of, 173–174
– lower, 196–209
–– in Asian patients, surgical
considerations, 199
–– asym metry after, 205
–– case studies, 206–207, 207f
–– complications of, 205–206
–– conjunctival chem osis after,
206
–– diplopia after, 206
–– ectropion after, 205, 205f
–– eyelid retraction after, 205
–– globe position and, 198
–– horizontal laxity correction
procedures, 204
–– inferior orbital rim and, 197f,
198
–– key technical points in, 204
–– and lateral tarsal strip
procedure, 204
–– lower eyelid laxity and,
198–199
–– and minim ally invasive lateral
canthoplasty, 204
–– negative vector anatomy and,
197f, 198, 207, 207f
–– and orbicularis oculi
suspension, 204, 206, 207f
–– orbicularis-retaining ligam ent
release and orbitom alar
suspension in, 203
–– and orbital hem orrhage, 206
–– patient evaluation for,
197–199
–– pearls, 196
–– w ith pinch skin excision, 199,
201, 201f
–– positive vector anatomy and,
198
–– postoperative care, 201
–– and prom inent lateral fat
pad, 205
–– and SOOF lift, 198, 199, 203,
207, 207f
–– surgical techniques for,
199–204
–– transconjunctival approach,
197, 199
–– transconjunctival fat excision
procedure, 199–201, 199f,
200f
–– transcutaneous approach, 197,
199, 201, 202f
– upper
–– and endoscopic forehead and
brow lift, 336
–– skin-only, 304f
blepharoptosis, 162, 174, 174f
– causes of, 210
– correction, 153, 154
– versus derm atochalasis, 175,
176f
– after double-eyelid surgery,
236–237, 237f
blepharoplasty, 7f, 307, 307f. See
also double-eyelid surgery
– aging-related (upper), 173–183,
328
–– anesthesia for, 178
–– asym metry after, 181
–– blepharoptosis and, 175, 176f
–– brow position and, 175–176
–– case studies, 182–183,
182f–183f
–– complications of, 180–181
–– corneal protection m echanism
and, 177
–– deep superior sulcus and,
175, 175f
–– derm atochalasis and, 175,
176f
–– eyelid crease design in, 178
–– eyelid crease form ation in,
179, 180f
–– eyelid wrinkles and, 177
–– fat rem oval in, 179, 179f, 181
–– goals of, 173–174
–– key technical points in, 180
–– lacrim al gland injury in, 181
–– lacrim al gland position and,
177
–– lagophthalm os after, 181
–– levator function and, 175,
175f, 176f
–– and natural eyelid crease
creation, 182, 182f
–– and noticeable eyelid crease
creation, 183, 183f
–– orbital fat prolapse and, 177
–– and orbital hem orrhage, 181
–– patient dissatisfaction with,
180
–– patient evaluation for,
175–178
–– pearls, 173
–– postoperative care, 180
–– skin closure, 179, 180f
–– skin excision in, 178, 178f, 181
–– skin texture and thickness
and, 178
–– and superior sulcus, 181
–– tear secretion and, 177
–– techniques for, 178–179
–– too-high double-lid fold after,
181
–– trends in, 173–174
–– under-correction in, 180
–– unnatural eyelid contour
after, 181
–– upper eyelid crease and, 177
–– without eyelid crease creation,
182, 182f
– Asian, 162. See also double-
eyelid surgery
– complications of, 225–239
– dem and for, among East asians,
196
– and epicanthoplasty, com bined,
8
– fat preservation method,
197–198, 202–203
–– indications for, 198
augm entation rhinoplasty
(continued)
– silicone implants for (continued)
–– extrusion of, 23
–– infection with, 23, 24, 25f
–– insertion of, 19, 19f
–– key technical points in, 21–22
–– pearls, 13
–– periosteal pocket for, 17–18,
18f
–– preparation of, 16–17, 16f,
17f
–– splinting, 21
– skin ap elevation, 17, 17f
– skin m arking for, 15–16, 16f
– spreader graft placem ent in,
32–33, 33f, 40, 41f
– stacked onlay graft for, 19–20,
20f
– surgical techniques for, 28–39
– tip contouring in, 37–39, 38f
– and tip-to-septum height
di erence with lateral crural
inclination, variant technique
for, 21, 21f
– uni ed graft and implant hybrid
insertion in, 20
– variant techniques for, 20–21
– vertical line for, 16, 16f
– wing graft placement in, 20, 20f
autoim mune disease, and saddle
nose, 89
autologous grafts, 8–9
B
backstop graft, in aesthetic
rhinoplasty for Southeast
Asians, 113
beauty
– Asian ideal of, 5
– cultural beliefs about, 5
– Eurocentric, 5
– Korean de nition of, in uence
of, 5
Bell’s phenomenon, preoperative
evaluation, 177, 181, 214, 329
Belotero. See hyaluronic acid
bigonial distance, 254, 270, 271f
– increased, 255–256
– reduction of, 255
bilateral vertical sagittal ram us
osteotomy, m andibular, 274t
bimaxillary advancem ent/
reduction, 9, 295, 296f–297f,
298, 299f
bimaxillary protrusion, anterior
segm ental osteotomy for, 274t,
277–279, 279f
– and genioplasty, 286, 295,
296f–297f, 298, 299f
bimaxillary surgery. See anterior
segm ental osteotomy; double
jaw surgery
bitemporal width, 270, 271f
bizygom atic width, 244–246
Blaskovics’ m ethod, for aesthetic
lateral canthoplasty, 190–191,
191f

Index
417
– harvest of, 125–126, 125f
–– anatomical considerations in,
29, 29f
–– incision for, 28–29, 29f
–– and pneum othorax, 130
–– and scar, 28, 29f, 31
–– technique for, 28–31, 30f, 40,
41f, 43, 44f
– for nasal dorsal augm entation,
8, 26–46, 30f, 41f, 43, 44f
–– pearls, 26
– nasal dorsal onlay graft
–– m ovability of, 130–131
–– warping of, 130, 131f
– for nasal tip grafting, 26–46,
30f, 41f
–– pearls, 26
– problem s with, 13
counseling, preoperative, for
rhinoplasty, 27–28
CPT. See Comfort Pulse
Technology
Crohn’s disease, and saddle
nose, 89
crow’s-feet
– botulinum toxin for, 380–381,
381f, 382f
– preoperative evaluation, 177
cucum ber face, 246
D
deep temporalis fascia, 325, 325f,
326f
dental m odel, 272
depigm entation, after laser facial
hair removal, 370
derm al hydration, using
hyaluronic acid, 402
derm atochalasis, 174, 174f, 210,
328
– versus blepharoptosis, 175,
176f
– brow ptosis with, 176
– evaluation, 175
digital im aging
– m orphing with, 27
– in rhinoplasty planning, 27, 40,
40f, 43, 43f
diplopia, after lower
blepharoplasty, 206
distraction test (forward traction
test), for eyelid laxity,
198–199
dorsal nasal artery, ller injection
in, prevention of, 403,
408–409, 409f
double eyelid, 151–152, 152f, 162,
163, 174
– form ation
–– external-incision technique,
153
–– nonincision suture ligation
for, 153
– height for, 165, 166f
– opening phase, 153f
– resting phase, 153f
– too-high, after aging-related
(upper) blepharoplasty, 181
– edem a after
–– late (persistent), 81
–– m anagem ent of, 81
– endonasal approach for, 75
– external approach for, 75
– key technical points in, 80–81
– nasal septal straightening in,
77–78, 78f
– osteotomy in, 76–77
– patient selection, 74–75
– pearls, 72
– postoperative m anagem ent, 80
– preoperative patient interview
for, 74
– for saddle nose, 87–98
–– pearls, 87
– septal extension graft in, 79–80,
80f
– for short contracted nose,
122–134, 141–142, 142f
–– case studies, 131–133,
132f–133f
–– closure, 129
–– complications of, 130–131
–– composite graft for, 124f, 125,
129, 130f
–– dorsal augm entation in, 129,
129f
–– elongation of fram ework in,
127, 128f
–– graft carving for, 126, 126f,
127f
–– graft m aterial harvesting for,
125–126, 125f
–– key technical points in, 130
–– m ovability of costal cartilage
graft after, 130–131
–– nasal obstruction after, 131
–– patient evaluation, 122–123,
123f
–– pearls, 122
–– pneum othorax due to, 130
–– skin dam age in, 130
–– skin underm ining, 127
–– strategies for, 123–125, 124f
–– techniques for, 123–129
–– tip grafts in, 127–128, 128f
–– tip problem s after, 131
–– tip repositioning in, 127–128,
128f
–– warping of costal cartilage
graft after, 130, 131f
– spreader graft in, 78–79, 79f
– surgical planning, 74
– techniques for, 75–80
corrugator supercilii m uscle,
326–327
costal cartilage
– advantages of, 27–28
– age and, 28
– carving
–– for augm entation rhinoplasty,
31, 43, 44f
–– for dorsal onlay graft, 126,
126f, 127f
–– for at straight piece, 126, 127f
– disadvantages of, 13
– graft splinting technique, 31, 32f
– de nition of, 257
– drooping/distortion, after
genioplasty, 294
– ideal, characteristics of, 286
– onlay augm entation, historical
perspective on, 287
– peau d’orange on, after
genioplasty, 294–295
– in planning for lower facial
contouring, 257
– position, cephalometric analysis
of, 287, 288t, 289, 290f, 295,
297f
– psychosocial signi cance of, 286
– ptosis, after genioplasty, 294
– resection, in lower facial
contouring, 257
chin implant, 9
cobblestone chin, botulinum toxin
for, 385, 386f
cocaine abuse, and saddle nose,
89–90
collagen, injection, depth of, 405
colum ella
– Asian, 26, 27f
– lengthening aps for, 9
– retraction of, 100
– retrusion of, 99
– short, 9
– wide base of, 99
colum ellar base, too-wide,
correction of (narrowing of),
103, 104f
Comfort Pulse Technology
(Thermage), 344
computed tom ography
– cone beam , 272
– preoperative
–– for genioplasty, 289
–– for mandibular reduction, 256
–– for secondary rhinoplasty, 136
conjoint fascia, 326, 327f, 331
conjoint tendon, 331
conjunctival chemosis, after lower
blepharoplasty, 206
conjunctival prolapse, after ptosis
correction, 221
conjunctival tarsal Müllerectomy,
211
conjunctivo-Müllerectomy. See
Müller muscle conjunctiva
resection (MMCR)
contact lens–induced ptosis,
214, 214f
contraction, nasal, postoperative,
24, 25f
corneal protection m echanism ,
preoperative evaluation, 177
corneal ulcer, 177
corrective rhinoplasty, 72–86
– approach for, selection of, 75
– bleeding/hem atoma after, 81
– case studies, 81–83, 82f–85f
– closure, 80
– complications of, 81
– dorsal irregularity/deviation
after, 81
– dressing, 80
– incisions for, 329, 330f
– indications for, 15
brow tip aesthetic line, 72–73, 73f
bruising
– facial fat grafting and, 319
– ller injection and, 407
bunny lines, botulinum toxin for,
384, 384f
BVSRO. See bilateral vertical
sagittal ram us osteotomy
C
calci cation, of alloplastic
implants, 22
calcium hydroxylapatite, 394, 405
– properties of, 393t
cartilage
– auricular, advantages of, 24
– autologous, for nasal tip
augmentation, 13
– conchal
–– in corrective rhinoplasty for
short contracted nose, 124f, 125
–– harvest of, 17, 109
– costal. See costal cartilage
– as dorsal implant, 114
– septal, harvest of, 18–19, 19f, 62
cartilage grafts, 6
– in rhinoplasty, 8
caruncle. See lacrim al caruncle
Caucasians, as beauty ideal,
historical perspective on, 5
Caucasoids, 3
cephalom etry
– ethnic di erences and,
270–272, 272f, 290f
– for genioplasty, 287, 288t, 289,
290f, 295, 297f, 298
– param etric values, disparity
among Asians and Caucasians,
270–272, 272f
– preoperative, in orthognathic
surgery, 282f–284f
– reference points in, 270, 271f,
272f, 273t
charming roll, 378, 383
cheek
– ller injection in, 397–399, 398f
– four crescent aging lines,
397–399, 398f
cheekbones
– Asian, 6, 7f
– prominent (high), 243, 244
chemical peeling, in facial
rejuvenation, 340
chemosis, conjunctival, after
lower blepharoplasty, 206
chin
– aesthetics of, 286
– alloplastic implant for, 309
– asym m etry, and lower facial
contouring, 257
– augm entation, 40–43, 42f
–– in facial rejuvenation, 309
–– ller injection for, 400–401,
401f
– cobblestone, botulinum toxin
for, 385, 386f

Index
418
– m edial, 8, 165
– m odi cation and re nem ent for
Asians, 8
– m odi ed Uchida method, 187,
188f
– palpebral m argin incision
m ethod, 8
– Park’s Z-plasty m ethod, 187,
188f
– patient evaluation for, 185
– pearls, 184
– reconstructive, 189, 189f, 190f
–– back-cut design in, 189, 189f
–– rotation ap in, 189, 190f
–– V-Y advancement ap for, 189,
189f, 190f
– reverse Fuente’s design, 186f,
187
– Roveda m ethod, 186
– scar after, 187–189
– simple skin excision method, 186
– skin excision in, 185
– skin redraping method, 187, 188f
– surgical techniques for,
186–187
– V-Y advancem ent m ethods,
186–187, 187f
– W-plasty method, 186
– Wu’s square- ap method, 188f
– Yoon’s one-arm ed jumping m an
m ethod, 188f
– Z-plasty ap method, 186–187,
188f
epicanthus inversus, 184, 185f
– iatrogenic, 187–189
– prevention of, 189, 189f, 190f
epicanthus palpebralis, 184, 185f
epicanthus supraciliaris, 184,
185f
epicanthus tarsalis, 184, 185, 185f
E-plane. See esthetic plane
(E-plane)
ePTFE. See Gore-Tex
erythm a
– after ller injection, 407
– after laser facial hair rem oval,
370
esthetic line (E-line), 272, 272f,
288, 289f
esthetic plane (E-plane), 392
exophthalm os, double-eyelid
surgery and, 154
expanded
polytetra uoroethylene. See
Gore-Tex
exposure keratitis, 177, 181
external nasal valve
– collapse, 100–101
– stenosis, after alar base surgery,
100
eyebrow(s). See also brow lift;
endoscopic forehead and brow
lift; ptosis
– aesthetics of, 327, 327f
– age-related changes in, 174,
175–176, 327
– asym m etry of, 328
– depressor m uscles, 326, 332
– edem a after, 337
– exam ination for, 328–329
– xation method, 332–336
–– with cortical bone tunnels,
334, 335f
–– with Endotine Forehead
device, 334–336, 336f
–– with brin glue, 333
–– with m onocortical screws,
333–334, 334f
– forehead and brow xation in,
332–333
– granulom a form ation after, 337
– hairline elevation after, 337
– hematom a caused by, 337
– historical perspective on, 324
– history-taking for, 328–329
– and implant problem s, 337
– incisions for, 330–331, 331f
– indications for, 328
– and infection, 337
– instrum ents for, 330, 330f
– and intracranial injury, 337
– key technical points in, 336–337
– nerve injury in, 337
– no xation in, 333
– and open techniques,
comparison of, 324, 329
– over- and under-correction
in, 337
– patient evaluation for, 328–330
– pearls, 324
– plane of dissection for, 325,
325f, 326f, 331
– postoperative care, 336
– preparation for, 330
– relaps after, 337
– release of m uscular and
ligam entous attachm ent in,
331–332, 332f
– seroma after, 337
– suture extrusion after, 337
– techniques for, 330–336
– temporal xation in, 332, 333f
– and wound problem s, 337
Endotine Forehead device,
334–336, 336f
entropion, 162
– correction of, 168
– after ptosis correction, 221
epicanthal fold(s), 164–165,
173, 184
– reconstruction, 194, 194f
– thirds of, 185
– types of, 184–185, 185f
– under-corrected, 188–189
epicanthoplasty, 184–189
– anatom ical considerations in, 6
– complications of, 187–189
– and dog-ear, 185–186
– double-fold operation and,
185–186, 186f, 187f
– Fuente’s transposition ap for,
187, 188f
– Jordan’s deep tissue approach
m ethod, 188f
– Matsunaga’s m odi ed M-plasty
m ethod, 188f
–– procedures for, 156–157,
156f–158f
–– and relapse, 158–159
–– and scar, 159, 160f
–– and stitch abscess, 160
–– and strangulation, 160
–– suture material, 155–156
– partial incisional technique, 163
– patient evaluation for, 154
– pretarsal fullness after,
232–233, 233f
– ptosis after, 238, 238f
– and pu y eyelid, 154
– removal of surgically created
eyelid fold after, 237
– revision case, 154–155
– scar after, 226, 226f, 227f
– shallow fold after, 227–228, 228f
– simple suture technique, 163
– sunken eyelid after, 236, 236f
– transconjunctival Müller
tucking in, 158, 159f, 161, 161f
– triple fold caused by, 166, 167,
168f, 232, 233–236, 234f, 235f,
238, 238f
– and weak levator function, 154
double jaw surgery, 274t, 279
dry eye syndrome, 177, 181, 214
E
East Asians, 3
– facial aesthetic procedures used
in, 3, 4f
– phenotypic features of, 6
ecchym osis, after endoscopic
forehead and brow lift, 337
ectropion, 8, 198
– after double-eyelid surgery,
228, 230f
– after lower blepharoplasty,
205, 205f
– after ptosis correction, 221
eczem a, lateral canthal, 174
edem a
– after endoscopic forehead and
brow lift, 337
– facial fat grafting and, 319
– after ller injection, 403, 412
EFBL. See endoscopic forehead
and brow lift
E-line. See esthetic line (E-line)
endoscopic forehead and brow
lift, 324–338
– advantages and disadvantages
of, 324, 330
– alopecia caused by, 337
– anatom ical considerations in,
324–326, 325f–327f, 331–332,
332f
– anesthesia for, 330
– and botulinum toxin, 336
– closure, 336
– com bined approach, sequence
of, 336
– complications of, 337
– dissection, 331
– dressing, 336
– ecchym osis after, 337
double-eyelid surgery, 162
– asym metry after, 233
– blepharoptosis after, 236–237,
237f
– complications of, 158–160, 170,
225–239
–– case studies, 238, 238f
–– key technical points for, 237
–– patient evaluation, 225
–– pearls, 225
–– surgical techniques for,
226–237
– deep fold after, 228
– ectropion after, 228, 230f
– and epicanthoplasty, 185–186,
186f
– and exophthalmos, 154
– incisional, 162–172
–– anesthesia for, 166
–– asymmetry after, 170
–– case studies, 170–171, 171f
–– closure, 169, 169f
–– complications of, 170
–– for correction of high crease to
low crease, 171, 171f
–– for correction of short inside
crease to outside crease, 170,
171f
–– crease design, 165–166, 166f
–– crease disappearance after,
170
–– disadvantages of, 163
–– xation suture of eyelid crease
in, 168, 168f
–– indications for, 163, 163f
–– key technical points in, 169
–– and levator advancem ent,
169, 169f
–– multiple folds caused by, 166,
167, 168f
–– orbicularis muscle rem oval in,
166–167, 167f
–– orbital fat removal in, 167,
167f
–– patient evaluation for,
163–164
–– pearls, 162
–– postoperative care, 170
–– ROOF rem oval in, 167, 167f
–– skin bulging after, 168, 169f
–– skin excision in, 165, 166–167,
166f, 167f
–– skin incision in, 166, 167f
–– skin suture in, 169, 169f
–– techniques for, 165–169
– inclusion cyst after, 226, 227f
– multiple folds caused by, 166,
167, 168f, 233–236, 234f, 235
– nonincisional suture techniques
–– case studies, 161, 161f
–– complications of, 158–160
–– and irregular fold, 159
–– key technical points in, 158
–– and knot exposure, 160
–– and lid m argin tension
eversion, 160, 160f
–– needle choice, 156
–– pearls, 151

Index
419
– laser in, 10
facial analysis, 14, 14f, 74, 75f,
244–246, 255–256, 270
– for endoscopic forehead and
brow lift, 329
– for fat grafting, 311–312
– for genioplasty, 288–290
facial artery, anatomy of, 407,
407f
facial asym m etry
– causes of, 73
– and fat grafting, 311–312
– after ller injection, 412
– after genioplasty, 294
– and lower facial contouring,
257
– preoperative, 14, 73
– transverse correction
genioplasty for, 290, 291f
facial bones
– age-related changes in, 174,
178
– Asian, anatomy of, 6
facial bone surgery. See
also m andible; m axilla;
orthognathic surgery
– complications of, 280–281
facial contouring
– llers for, 392–404
–– pearls, 392
– surgery for, 243. See also
m andible, reduction
(contouring)
–– planning for, 256–257, 256f
facial contour line(s)
– anterior, 244f
– posterior, 244f
facial hair
– in m en, 364–365
– in wom en, 364–365
facial harm ony, evaluation, 246,
246f
facial m idline, 72–73, 73f
facial nerve
– frontal branch of, 325, 325f,
326, 331
–– injury in endoscopic forehead
and brow lift, 337
– palsy, and unilateral ptosis, 174,
175f, 176
– zygom atic branch, 326
facial rejuvenation, 9. See also
endoscopic forehead and
brow lift
– hyaluronic acid for, 393
– light devices for, 340–344
– nonsurgical, 10
– using energy devices,
339–348
–– devices com monly used in,
340
–– pearls, 339
– volum e restoration in, 304–305,
304f
facial swelling, after hair
transplantation, 359
facial symm etry, analysis of, 270
Fasanella-Servat procedure, 211
– in/out (neutral), 154, 155f, 156
– inside, 154, 155f, 156
– irregular, nonincisional double-
eyelid surgery and, 159
– m ultiple, caused by double-
eyelid surgery, 166, 167, 168f,
233–236, 234f, 235
– outside, 154, 155f, 156
– shallow, after double-eyelid
surgery, 227–228, 228f
– surgically created, rem oval
of, 237
– triple
–– after double-eyelid surgery,
166, 167, 168f, 232, 233–236,
234f, 235f, 238, 238f
–– prim ary, correction, 236,
236f
eye surgery, aesthetic. See also
blepharoplasty
– anatom ical considerations in, 6
F
face(s)
– Asian, 243, 244f
–– aesthetic ideals and, 378,
392–393
–– aging, m anagem ent of,
303–310, 311
–– anatom ical considerations, 6,
7f, 8f, 378
–– characteristics of, 272, 272f
– brachycephalic, 243, 244f, 254
– Caucasian, 243, 244f
– cultural beliefs about, 5
– dolichocephalic, 243, 244f
– fem ale, attractive composites,
3, 4f
– at, adding dim ension to, 255,
255f, 311
– frontal plane, vertical divisions
( fths), 270, 271f, 324
– frontal view, aesthetic divisions
in, 270, 271f
– ideally shaped, creation of, 255,
255f, 256f
– lower
–– aging of, 309
–– rejuvenation of, 309
–– shape, classi cation of, 256,
256f
–– width
classi cation of, 256, 256f
narrowing, 255
– m esocephalic, 254
– shape
–– cultural factors a ecting, 257
–– ethnicity and, 257
–– and fat grafting, 311
– thirds of (rule of thirds), 270,
271f, 288, 289f, 324
– volum e loss in, 304–305, 304f,
311
– volum e restoration in, 304–305,
304f, 311–312
facelift, 309
– high-frequency focused
ultrasound in, 10
–– m iddle lam ella, 152
–– opening process of, 152–153,
153f
–– orbital fat of, 164
–– posterior lam ella, 152–153
–– pu y, 177
double-eyelid surgery and, 154
–– retractors, 210
–– structure-function
relationships, 151
– wrinkles
–– correction, 177
–– preoperative evaluation, 177
eyelid crease. See also eyelid
fold(s)
– aging and, 307–308, 307f, 308f
– deep, after double-eyelid
surgery, 228
– design
–– in aging-related (upper)
blepharoplasty, 178
–– in double-eyelid surgery,
165–166, 166f
– duplicated, 177
– evaluation, 177
– xation suture of, in double-
eyelid surgery, 168, 168f
– formation, in aging-related
(upper) blepharoplasty, 179,
180f, 182, 182f, 183, 183f
– height, 165, 166f, 177, 213
–– ideal, 163
–– preoperative simulation, 163
– high
–– correction of, 229–232,
231f–233f
–– after double-eyelid surgery,
170, 229–232, 230f
– inside, 164, 164f
– low, after double-eyelid
surgery, 170, 228–229, 228f,
229f
– nasally tapered, 164
– outside, 164, 164f
–– fan-parallel type, 164
–– fan type, 164, 164f
–– higher, 164, 165f
–– parallel type, 164, 164f
– parallel, 164
– partially high, after double-
eyelid surgery, 232
– postoperative disappearance,
after double-eyelid surgery,
170, 226–227
– sem ilunar, 164
– shallow, after double-eyelid
surgery, 227–228, 228f
– shape of, 164
– surgically created, 308
–– age-related changes and, 177
–– aging and, 309
– too-high, after aging-related
(upper) blepharoplasty, 181
– webbing of, 165, 165f
eyelid fold(s). See also eyelid
crease
– deep, after double-eyelid
surgery, 228, 238, 238f
– elevation, in compensation for
blepharoptosis, 174, 174f, 175,
175f, 210, 211, 212f, 221, 222f
– elevator muscles, 326
– hair transplant for, 305, 305f
– ideal position of, 327, 327f
– position of, evaluation,
175–176, 329
– rejuvenation of, 307–308, 307f,
308f
– shape, evaluation, 329
– shaping, botulinum toxin for,
336, 381–382
– symmetry, evaluation, 329
– tattooing, 328
– volumization of, 308, 308f
eyelash(es)
– direction of, 215, 215f
– upper, downward angulation,
164
eyelash ptosis, 162, 215, 215f
– correction of, 168, 218–219
– evaluation of, 164
eyelid(s). See also lid lag; lid
m argin
– age-related changes in, 174, 328
–– management of, 307–309, 307f
– Asian
–– anatomy of, 6, 162–163, 163f,
211
–– characteristics of, 173, 196
– asym metry
–– after double-eyelid surgery,
233
–– preoperative, 233
– Caucasian, anatomy of, 163f
– East Asian, anatomy of,
162–163, 163f
– lower
–– age-related changes in,
196–197, 197f
–– Asian, characteristics of, 196
–– asym metry, after lower
blepharoplasty, 205
–– fat grafting for, 322, 322f
–– uid accumulation in, 198
–– horizontal laxity correction
procedures for, 204
–– laxity, 198–199
–– loss of skin elasticity, 198
–– retraction, after lower
blepharoplasty, 205
– ptosis, 328
–– evaluation, 329
– redundant skin of, evaluation,
329
– rejuvenation of, 307–308, 307f,
308f
– skin of, 164
– sunken, 236, 236f
– upper. See also double eyelid;
single eyelid
–– anatomy of, 152–153, 153f, 162
–– anterior lamella, 152–153
–– ethnic variations, 152
–– fat pockets in, 177
–– lower-positioned transverse
ligament in, 167, 168f

Index
420
– sling, 211, 215, 219–220, 220f
FUE. See follicular unit extraction
FUT. See follicular unit transplant
G
galeal fat pad, 332, 332f
genioplasty, 274, 274t, 282–283,
282f–284f, 286–300
– advancem ent sliding via
intraoral approach, historical
perspective on, 287, 287f
– anesthesia for, 290
– anterior sliding advancem ent,
historical perspective on,
287, 287f
– asym m etry after, 294
– bleeding and, 293
– and bony m alunion/nonunion,
293
– bony m arking for, 290, 291f
– case studies, 295, 296f–297f,
298, 299f
– cephalom etry for, 287, 288t,
289, 290f, 295, 297f, 298
– chin ptosis after, 294
– closure, 292
– complications of, 293–295
–– allograft-related, 294–295,
295f
– dressing for, 292
– xation in, 292, 292f
– historical perspective on, 287,
287f
– history-taking for, 287
– incision for, 290, 291f
– indications for, 286
– infection after, 293
– intraoral approach for, 290, 291f
– key technical points in, 293
– labial m ucosal incision for,
290, 291f
– lip drooping after, 294
– m andibular bony irregularity
after, 294, 294f
– m arginal gingival incision for,
290, 291f
– m ental nerve injury in, 293
– narrow ing, 255, 255f, 256f
–– com bined with m andible
reduction (contouring), 260,
260f
– pain after, 293
– patient evaluation for, 287–288
– pearls, 286
– preoperative assessm ent for,
288–290
– sagittal augm entation (anterior
advancem ent) technique,
290, 291f
– sagittal reduction (posterior
reduction) technique, 290, 291f
– skin dimpling after, 294
– techniques for, 290–292, 291f
– transverse correction technique,
290, 291f
– ultrasonic bone cutter for, 292,
292f, 293
– vertical augmentation
technique, 290, 291f
– in nasolabial folds, 400, 400f
– pain after, 407
– self-pistol technique, 395
– serial puncture (“kisses”)
technique, 395, 395f, 406
– skin necrosis after, 403, 403f,
406, 406f, 409, 410f, 411, 412f
– skin thickness and, 405
– for sunken eyelid, 236, 236f
– super cial, ller visibility after,
412, 413f
– in tear trough, 399
– for tear trough depression, 197
– techniques for, 395
– in upper-eyelid/brow complex,
308, 308f
– venous congestion caused by,
411, 412f
nasteride, 351
follicular unit extraction, for hair
restoration, 306, 354–355,
355f
follicular unit transplant, for hair
restoration, 306, 350, 354, 355
folliculitis
– facial, improvem ent, laser hair
rem oval and, 369, 369f
– in hair transplantation, 355,
356f, 359–360
– after laser facial hair removal,
370
forehead. See also endoscopic
forehead and brow lift
– age-related changes in, 327
– anatomy of, 324–326,
325f–327f, 331–332, 332f
– augm entation, 15
– ller injection in, 396, 397f
– hair rem oval from , 9, 365, 369,
369f, 371–372, 371f, 372f
– height, evaluation, 329
– horizontal lines in, botulinum
toxin for, 379, 379f, 380f
– layers of, 325, 396, 396f
– preoperative exam ination of,
14–15, 14f
– reshaping, by hair reduction,
9, 365, 369, 369f, 371–372,
371f, 372f
– rhytidosis, 328
–– evaluation, 329
– shape, evaluation, 329
– size, cultural beliefs about, 365
– widening, laser hair rem oval
for, 365, 369, 369f, 371–372,
371f, 372f
four crescent aging lines,
397–399, 398f
Fox’s m ethod, for aesthetic lateral
canthoplasty, 191, 191f
Frankfort horizontal line,
288–289, 289f
frontalis m uscle, 210, 326
– intraderm al botulinum toxin
injection and, 388–389, 389f
– overactivity of, 328
–– unilateral, 328
– ptosis surgery and, 210, 211,
215, 219–220, 220f
–– vascular em bolization of fat
after, 320–321, 320f
–– volume used, 313–317,
314t–315t
–– whole face, 321, 321f
– for sunken eyelid, 236, 236f
– in upper-eyelid/brow complex,
308, 308f
ller injection, 10
– aesthetic uses of, 392
– bruising after, 407
– bumps caused by, 413
– in chin, 400–401, 401f
– complications of, 10
–– delayed onset, 412–413
–– early onset, 407–411
–– patient evaluation, 406
– danger zones, 407
– depth of, 405
– edema after, 412
– erythm a after, 407
– facial contouring using,
392–404
–– anesthesia for, 394
–– cannulas for, 407, 407f
–– in cheek, 397–399, 398f
–– complications of, 403–404,
403f, 405–414
–– in forehead, 396, 397f
–– key technical points in,
402–403
–– m aterials for, 393–394, 393t
–– needles for, 394, 394f, 407,
407f
–– patient assessm ent for, 393
–– patient consultation for, 393
–– pearls, 392
–– Reteenage m ethod, 397–399,
398f
–– techniques for, 394–402
–– in temple, 396–397, 397f
– in facial volume restoration,
304–305, 393t, 405
– fanning technique, 395, 396f,
406
– ller m igration after, 413
– llers for, 10, 393t
– for forehead and glabellar
rhytidosis, 328
– granulom a after, 413
– high-risk areas, 405–406
– hypersensitivity reaction to,
407
– infection after, 413
– in amm ation after, 412
– intra-arterial, 403, 409, 410f
–– m anagem ent of, 409
–– prevention of, 407–408, 408f
– for jaw line reshaping, 401, 402f
– for jowl contouring, 401, 402f
– linear threading (tunneling)
technique, 395, 395f, 406
– in lips, 400
– for lower face contouring,
400–401, 401f, 402f
– lumpiness after, 412, 413
– for m arionette lines, 401–402
– for nasal augm entation, 395,
395f, 399–400, 399f
fat grafting, 9
– facial, 304–305, 304f, 311–323
–– and abscess formation, 320,
320f
–– and acneiform eruption, 320
–– additional procedures, 318
–– anesthesia for, 312, 313
–– areas, 313–317, 313f,
314t–315t
–– asymmetry after, 319
–– baton grip technique, 317,
318f
–– bruising after, 319
–– cannulas for, 312, 312f
–– case studies, 321–322, 321f,
322f
–– complications of, 319–321
–– direction of injection, 314,
316f
–– donor-site complications, 321
–– edem a after, 319
–– entry sites for, 314, 316f
–– fat preparation for, 312–313,
313f
–– fat resorption in, 319
–– in forehead region, 315–317,
317f, 317t, 322, 322f
–– graft gravitational descent
in, 319
–– graft harvest for, 312–313
–– graft m igration in, 319
–– hem atoma caused by, 319
–– history-taking for, 312
–– hyperpigm entation after, 319
–– hypo- and hyper-correction
in, 319
–– and in am mation, 320
–– injection techniques, 313–317
–– instruments for, 312, 312f
–– irregularity after, 319
–– key technical points in,
318–319
–– in lower face, 313–315, 313f,
314t
–– for lower lid rejuvenation,
322, 322f
–– lump/bump caused by, 319
–– in midface, 313–315, 313f,
314t
–– patient evaluation for,
311–312
–– pearls, 311
–– placem ent, 313–317,
314t–315t
–– postoperative care, 318
–– preparation for, 312
–– scar after, 319–320
–– sequential autologous fat
injection (SAFI) technique for,
313, 313f, 314t–315t, 316f,
317t
–– sequential depth of injection,
314, 316f
–– sequential injection in
abutting areas, 314–315, 316f
–– and skin necrosis, 320, 320f
–– techniques for, 312–318
–– in temporal region, 313–315,
313f, 314t

Index
421
– orthognathic surgery and, 280
– rhinoplasty and, 143
– and saddle nose, 89
– septoplasty and, 143
– septorhinoplasty and, 141, 143
inferior alveolar nerve injury,
in m andible reduction
(contouring), 261
in am m ation
– facial fat grafting and, 320
– ller injection and, 412
– with m andible reduction
(contouring), 261
– with nasal alloplastic implants,
140
infraorbital eye opening, botulinum
toxin for, 382–383, 383f
infraorbital nerve, injury
– in orthognathic surgery, 281
– in zygom a reduction, 249
infraorbital w rinkles, botulinum
toxin for, 382, 382f
intense pulsed light
– in facial rejuvenation, 340,
341–342, 341f, 342f
–– complications of, 342, 342f
– for nonablative rejuvenation,
339–340
intercanthal distance, 185f
interepicanthal distance, 184,
185, 185f, 189
internal nasal valve
– anatomy of, 87
– collapse of, 87–88
interpalpebral ssure, 212, 213f
intracranial injury, in endoscopic
forehead and brow lift, 337
intraoral vertical ramus osteotomy,
mandibular, 276, 277f
IPL. See intense pulsed light
IVRO. See intraoral vertical ram us
osteotomy
J
jaw line, reshaping, ller injection
for, 401, 402f
jowl contouring, ller injection
for, 401, 402f
Juvederm . See hyaluronic acid
K
keloids, 9, 100
– hair transplantation and, 351,
359
keratitis, after ptosis correction, 221
Korea, plastic surgery in, 5
L
lacrimal caruncle
– bilateral size discrepancy, 185
– exposure
–– epicanthal fold and, 184, 185
–– excessive, 189
– hook-shaped, 184, 185f
– round, 184, 185f
– shape of, 184, 185f
– triangular, 184, 185f
– visible size of, after
epicanthoplasty, 184
– with m andible reduction
(contouring), 261
– in m andibular sagittal split
ram us osteotomy, 280
Hering’s law, 214–215
hiccups, hair transplantation
and, 360
HIFU. See ultrasound, high-
intensity focused
high-frequency focused ultrasound
(HIFU), in face lift, 10
high sagittal supraforaminal
osteotomy, m andibular, 274,
276, 276f, 281
Hinderer analysis, of m axim al
m alar projection, 245, 245f
horizontal line, in lower eyelid, 198
HSSO. See high sagittal
supraforam inal osteotomy
humpectomy. See nasal hump
surgery
hump nose(s). See also nasal
hump
– Asian, 60–71
–– characteristics of, 60–61,
87, 88f
– preoperative exam ination of,
60–61
hyaluronic acid, 10, 393–394, 405
– biphasic, 393–394
– derm al hydration using, 402
– em bolization, treatm ent of,
409–410, 411f
– for facial rejuvenation, 393
– m onophasic, 394
– properties of, 393t
hyaluronidase, treatm ent of ller
embolization, 409–410, 411f
hyperbaric oxygen treatm ent, for
ller embolization, 410f, 411
hyperesthesia, after hair
transplantation, 359
hyperpigm entation
– facial, reduction, laser hair
removal and, 368, 368f
– facial fat grafting and, 319
– after laser facial hair rem oval,
370
– post-in am m atory, 100, 196
hypochlorous acid, 16–17
hypoesthesia, after hair
transplantation, 358–359
I
inclusion cyst, after eyelid
surgery, 226, 227f
infection
– alloplastic implants and, 23, 24,
25f, 141
– augm entation rhinoplasty
and, 13
– endoscopic forehead and brow
lift and, 337
– ller injection and, 413
– genioplasty and, 293
– m andible reduction
(contouring) and, 261
– nasal alloplastic implants and,
141
hair transplantation, 349–363. See
also hair restoration
– and arteriovenous stula, 360
– in Asians, 349
– case studies, 360–361, 361f
– complications of, 358–360
– and dehiscence, 358
– density gradient and layering
e ect in, 357, 357f, 358
– depth-controlled technique for,
355–356, 356f, 358
– donor harvesting for, 353–355.
See also follicular unit
extraction
–– strip surgery method,
353–354, 354f
– facial swelling after, 359
– folliculitis with, 355, 356f,
359–360
– graft dissection, 355–356, 355f,
356f
– graft preservation, 356
– gray hair follicles and, 355,
355f, 358
– hairline design in, 352–353,
353f
– and hiccups, 360
– hyperesthesia after, 359
– hypoesthesia after, 358–359
– implanters for, 356, 356f
– key technical points in, 358
– and loss of transplant, 360
– and necrosis, 358
– neuralgia after, 359
– num bness after, 358–359
– optim al density for, 358
– pain after, 358
– patient evaluation for, 351–352
– pearls, 349
– pitting after, 360
– poor graft survival after, 360
– postoperative care, 358
– preparation for, on day of
surgery, 352
– recipient site, 356–358, 357f
– scalp pruritus after, 359
– and scars, 351, 352, 358, 359
– and syncope, 360
– techniques for, 352–358
– temporary hair loss after, 359
– unnatural hairline due to, 359
– and W-plasty for scar revision,
358, 359, 359f
Han Ryu, 5
hem atom a
– after endoscopic forehead and
brow lift, 337
– facial fat grafting and, 319
– after ller injection, 403
– with m andible reduction
(contouring), 261
– preseptal, lower blepharoplasty
and, 206
– retrobulbar, lower
blepharoplasty and, 206
hem orrhage. See also orbital
hem orrhage
– genioplasty and, 293
– in Le Fort I osteotomy, 280
– vertical reduction technique,
290, 291f
glabella
– anatomy of, 324–326,
325f–327f, 331–332, 332f
– augm entation, 39
– preoperative evaluation, 15
glabellar frown lines, botulinum
toxin for, 379–380, 380f, 381f
glabellar rhytidosis, 328
– evaluation, 329
glycopyrrolate, 16
gonial angle, ideal, 256
Gore-Tex, 13, 113
– advantages of, 14
– chin implant, complications of,
294, 295f
– disadvantages of, 14
– dorsal nasal graft, 43, 43f
– preform ed nasal dorsal implant,
114, 114f, 115f
– rem oval rate for, 135
– in rhinoplasty, 8, 135
–– complications of, 135
– sheet, nasal dorsal implant, 116
granuloma
– after endoscopic forehead and
brow lift, 337
– after ller injection, 413
granulomatous disease(s), and
saddle nose, 89
gummy smile, botulinum toxin
for, 384, 384f
H
hair, Asian, 6, 9, 350
hair density, in Asians, 350
hairline
– Asian, 349–350, 350f
– correction, laser hair rem oval
for, 365
– design
–– in hair transplantation,
352–353, 353f, 360–361,
361f
–– laser hair rem oval and, 369,
369f
– elevation, after endoscopic
forehead and brow lift, 337
– evaluation of, 329
– unnatural, after hair
transplantation, 359
hair loss, 305–307, 305f, 306f. See
also alopecia
– male pattern, 349
– prevention, m edications for,
351
– temporary, after hair
transplantation, 359
hair rem oval/reduction, 9
– facial, using laser, 364–374. See
also laser hair removal
hair restoration, 9, 305–307,
305f, 306f. See also hair
transplantation
– follicular unit extraction for,
306, 354–355, 355f
– follicular unit transplant for,
306, 354, 355

Index
422
–– types of, 258, 258f
– protrusion, orthognathic
surgery for, 274t
– reduction (contouring),
254–267
–– asym m etry and, 257
–– case studies, 261, 262f, 263,
263f–264f, 265, 265f–267f
–– chin and, 257
–– complications of, 261
–– condylar fracture in, 261
–– ethnicity and, 257
–– fracture in, 261
–– frontal plane analysis for,
256, 256f
–– general procedure for,
258–260, 259f
–– hem orrhage w ith, 261
–– infection with, 261
–– in amm ation with, 261
–– intraoral versus external
approach for, 258
–– key technical points in, 260
–– m andible-m axilla relationship
and, 257
–– and narrowing genioplasty,
com bined, 260, 260f
–– nerve injury in, 261
–– patient evaluation for, 255–256
–– pearls, 254
–– postoperative care, 260
–– preoperative im aging for, 256,
256f
–– sagittal plane analysis for, 256
–– soft tissue and, 257
–– surgical planning, 256
–– surgical techniques for,
258–260, 259f
–– transverse plane analysis for,
256, 256f
–– and unfavorable aesthetic
outcom e, 261
–– and zygom a reduction,
com bined, 246, 252, 252f,
253f, 263–265, 263f–267f
– retrusion, orthognathic surgery
for, 274t
– sagittal split ram us osteotomy,
274–275, 274t
–– bleeding during, 280
–– case studies, 282–283,
282f–284f
–– and genioplasty, 286
–– infection after, 280
– vertical de ciency, orthognathic
surgery for, 274t
– vertical excess, orthognathic
surgery for, 274t
m andibular angle
– Asian, 6, 7f, 254
– prom inent, 254
– reduction, 9
–– and genioplasty, 286
– resection of, 255
– secondary (postoperative),
259, 260
m andibular plane–sellar nasion
(MP-SN) angle, 256
lid m argin
– closed, 154, 155f
– de nition of, 154
– double-eyelid surgery and,
154, 155f
– in/out (neutral) fold, 154, 155f,
156
– inside fold, 154, 155f, 156
– open, 154, 155f
– outside fold, 154, 155f, 156
– shapes of, 154, 155f
– tension eversion, 160, 160f
lip(s)
– Asian, characteristics of, 270
– drooping, after genioplasty, 294
– ller injection in, 400
– position of, evaluation, 272,
272f, 288, 289f
– projection of, 270
liposuction, for fat graft harvest,
312–313
– complications of, 321
lower eyelid, sagging, 8
lower-positioned transverse
ligam ent (LPTL), in upper
eyelid, 167, 168f
M
m alarplasty, and genioplasty, 286
m alar prom inence, 6
m alar reduction, 9
m ale pattern hair loss, 349
m alignancy, and saddle nose, 89
m alocclusion, 9
– classi cation of, 269, 270f
– inter-arch problem s and, 269
– intra-arch problems and, 269
– after orthognathic surgery, 281
m andible. See also orthognathic
surgery
– asym m etry, and lower facial
contouring, 257
– bilateral vertical sagittal ram us
osteotomy, 274t
– fracture, intraoperative, 261
– high sagittal supraforam inal
osteotomy, 274, 276, 276f, 281
– hypoplasia, psychosocial e ects
of, 286
– instability, after orthognathic
surgery, 281
– intraoral vertical ramus
osteotomy, 276, 277f
– and m axilla, abnorm al skeletal
relationship between, 257
– orthognathic surgery of,
274–275, 274t
–– case studies, 282–283,
282f–284f
–– complications of, 281, 282f
–– fracture in, 281
–– incomplete osteotomy in, 281
– ostectomy
–– curved, with oscillating saw,
258, 258f, 259, 259f
–– tangential, with reciprocating
saw (lateral cortex ostectomy),
258, 258f
–– technique for, 368
– mechanism s of, 365, 365f
– patient evaluation for, 366
– pearls, 364
– targets for, 365, 365f
– techniques for, 366–369
lateral canthal rhytids. See
crow’s-feet
lateral canthoplasty, 6
– aesthetic, 189–192
–– Blaskovics’ method for,
190–191, 191f
–– candidates for, 190
–– case studies, 194, 194f
–– Fox’s m ethod for, 191, 191f
–– patient evaluation for, 189–190
–– pearls, 184
–– principles of, 189
–– Shin’s m ethod for, 191, 192f
–– surgical techniques for,
190–192
–– Von Am m on’s m ethod for,
190, 190f
– clinical applications of, 189
– com bined with Mongolian
slant lowering, 191–192, 193f,
194, 194f
– contraindications to, 190
– minim ally invasive, 204
– modi cation and re nem ent for
Asians, 8
– postoperative care, 192
lateral crural graft
– in corrective rhinoplasty
for short contracted nose,
123–125, 124f
– for nasal tip contouring, 53–54,
53f, 54f
– onlay, 53–54, 53f
– strut, 53–54, 54f
lateral nasal artery
– anatomy of, 404f
– ller injection in, prevention of,
404, 406
lateral tarsal strip procedure, 204
Le Fort I osteotomy. See also
double jaw surgery
– maxillary, 274t, 276–277, 278f
–– bleeding in, 280
leprosy, and saddle nose, 89
levator palpebralis, 210
– age-related changes in, 174
– aponeurosis
–– advancem ent, 169, 169f, 177
–– dehiscence, 175, 212–213, 328
–– plication, in double-eyelid
surgery, 169
–– ptosis surgery and, 210, 211
–– stretching or disinsertion, 177,
212–213, 213f
– and congenital ptosis, 211, 212f
– function, evaluation, 175, 176f,
212, 213f
– malfunction, in aponeurotic
ptosis, 213, 213f
– ptosis surgery and, 210, 211
– resection, in ptosis correction, 219
lid lag, after ptosis correction, 221
lacrim al gland
– injury, in blepharoplasty, 181
– position, preoperative
evaluation, 177
lagophthalm os
– with congenital ptosis, 214
– evaluation, 177, 329
– iatrogenic postoperative, 176,
181
– after ptosis correction, 214, 221
laser(s)
– for ablative rejuvenation, 340,
343, 344f
– Accusculpt, 344
– Aram is, in facial rejuvenation,
342–343, 343f
– carbon dioxide (CO_{2sub>), in facial rejuvenation,
340, 343
– chromophores for, 339–340,
342, 342f
– CoolTouch, in facial
rejuvenation, 342–343
– dye, in facial rejuvenation,
339, 340
– Edge, in facial rejuvenation, 344f
– in face lift, 10
– for facial hair rem oval, 364–374
–– pearls, 364
– in facial rejuvenation, 340–344
– fractional, in facial rejuvenation,
340, 343–344, 344f
–– ablative, 343, 344f
–– nonablative, 343
– Fraxel, in facial rejuvenation,
343
– interstitial, in facial
rejuvenation, 344, 344f, 345f
– midinfrared, in facial
rejuvenation, 339, 342–343,
342f, 343f
– Nd:YAG, in facial rejuvenation,
339, 340, 342
– for nonablative rejuvenation,
339–340
– Q-switched, in facial
rejuvenation, 340
– Sm artlipo, 344
– Sm oothbeam, in facial
rejuvenation, 342–343
– thulium, in facial rejuvenation,
343–344
laser hair rem oval, 9, 364–374
– case studies, 370–372, 371f,
372f
– complications of, 370, 370f
– e cacy of, factors a ecting,
365–366
– for fem ale East Asians, 366–367,
367f
– hairline design for, 369, 369f
– historical perspective on, 364
– key technical points in, 370
– lasers used for, 364
– for male East Asians, 367–369
–– aesthetic e ects of, 368, 368f
–– goals of, 367
–– motivations for, 364–365}

Index
423
– dissection, in aesthetic
rhinoplasty for Southeast
Asians, 111, 112f
– ischem ia, and saddle nose,
89–90
– L-strut, fabrication of, 92–93,
93f
– perforation
–– Medpor implant and, 137, 138f
–– and saddle nose, 89–90
– subtotal reconstruction, for
class 3 saddling, 92–93, 93f
nasal skin, 6, 15, 26, 27f, 61, 62f,
100
– exam ination of, 74
nasal tip, 6, 7f, 8f, 26, 27f
– and appearance of nasal base,
100, 105
– asym m etry, 55
– augm entation, 13
–– case studies, 56–57, 56f–58f
–– with endonasal onlay graft, 56,
56f–57f
– boxy, cephalic resection of
lower lateral cartilage lateral
crus for, 52–53, 53f
– bulbous, cephalic resection of
lower lateral cartilage lateral
crus for, 52–53, 53f
– cap graft via endonasal
approach, 48–49, 49f
– colum ellar strut, interdom al
suture, and onlay graft via
endonasal approach, 49, 50f
– contouring, 37–39, 38f
–– case studies, 40–43, 40f–45f,
56–57, 56f–58f
–– graft showing after, 55
–– key technical points, 40, 55
–– lateral crural strut grafts for,
37–38, 38f
–– and nasal obstruction, 55
–– pain/discom fort after, 55
–– patient evaluation for, 48, 48f
–– shield graft versus horizontal
onlay graft for, 38, 38f, 40, 41f,
43, 44f
– costal cartilage graft for, 26–46,
30f, 41f
–– pearls, 26
– deviation, 55
– evaluation of, 48, 48f
– lateral crural graft for, 53–54,
53f, 54f
– lifting, botulinum toxin for,
383, 383f
– m odi cation
–– in corrective rhinoplasty
for short contracted nose,
123–125, 124f, 127–128,
128f, 131
–– using open approach, 57,
57f–58f
– over-rotation, 55
– pain in, after corrective
rhinoplasty for short
contracted nose, 131
– preoperative evaluation, 15
– m anagem ent of nasal base in,
34, 34f
– osteotomy in, 32
– patient evaluation for, 26–28,
27f
– postoperative care, 39–40
– preoperative counseling for,
27–28
– silicone implants for, 13–25
– spreader graft placem ent in,
32–33, 33f, 40, 41f
– surgical techniques for, 28–37
nasal dorsum
– and appearance of nasal base,
100, 105
– Asian, 26, 27f
– bony and cartilaginous,
relationship of, 61–62, 62f
– preoperative evaluation, 15
nasal hump
– characteristics of, 60–61, 87, 88f
– generalized, 61
– localized, 61
– versus pseudo hump, 61, 61f
nasal hump surgery, 60–71
– anatom ical considerations in,
61–62, 62f
– case studies, 68, 68f–69f, 70,
70f–71f
– complications of, 67, 138, 139f,
140, 141f
– component hump reduction,
63, 64f
– conservative humpectomy,
65, 66f
– dissection and septal cartilage
harvest in, 62
– dorsal augm entation and tip
re nem ent with, 65–67, 66f
– functional problem s after, 67
– and internal valve collapse, 67
– inverted-V deform ity after, 67
– key technical points in, 67
– in large-hump nose, 63, 64f
– nasal dorsal irregularity after,
67
– open versus closed approach
for, 62
– pearls, 60
– and residual convexity, 67
– sequence of surgery and tip-
plasty in, 62–63, 63f
– in sm all-hump nose, 65, 66f
– spreader grafts in, 65, 65f
– techniques for, 61–67
nasal obstruction
– after alar base surgery, 105
– assessment for, 73–74
– after corrective rhinoplasty for
short contracted nose, 131
– after nasal tip surgery, 55
nasal pro le, 6, 7f
nasal pyram id, 6
nasal root, preoperative
evaluation, 15
nasal septum , 6
– deviated, straightening, 77–78,
78f
m idface
– age-related changes in, 174
– four crescent aging lines,
397–399, 398f
m idpupillary horizontal line, 27f,
60, 61f
m inoxidil, 351
MMCR. See Müller m uscle
conjunctiva resection (MMCR)
Mongolian slant, lowering,
191–192, 193f, 194, 194f
Mongoloids, 3
– phenotypic features of, 6
m outh corner elevation,
botulinum toxin for, 385, 386f
MP-SN angle. See m andibular
plane–sellar nasion (MP-SN)
angle
MRD. See m argin-re ex distance
m ucocele, with nasal alloplastic
implant, 138, 139f, 140, 141f
Müller m uscle, 210
– ptosis surgery and, 210, 211,
214
Müller m uscle conjunctiva
resection (MMCR), 211, 214,
215, 219
myasthenia gravis, 164
N
NAR. See nonablative rejuvenation
nasal ala (pl., alae). See ala (pl.,
alae)
nasal base, reduction, 39
nasal bones, 6
nasal bridge, low, 6, 7f, 8f
nasal dorsal augmentation, 8–9,
21, 135, 136f
– with alloplastic implant, and
short nose deform ity, 122
– alloplastic implants for, 135. See
also alloplastic implants
–– pearls, 135
– and base reduction, 39
– case studies, 40–43, 40f–45f
– closure for, 39
– in corrective rhinoplasty for
short contracted nose, 129,
129f
– costal cartilage for, 8, 26–46,
30f, 41f, 43, 44f
–– pearls, 26
– dorsal graft placem ent and
xation in, 35–37, 35f, 36f, 37f
– ller injection for, 395, 395f,
399–400, 399f
–– complications of, 408–409,
410f
– and glabellar augmentation, 39
– graft, w ithout osteotomy,
31–32, 32f
– with hump resection, 65–67,
66f
– key technical points, 40
– m anagem ent of bony vault in,
31–32, 32f
– m anagem ent of m iddle third in,
32–33, 33f
m andibular prognathism , w ith
long face, case studies,
282–283, 282f–284f
m andibular ramus osteotomy,
technique for, developm ent
of, 269f
m andibular reduction/
advancem ent, 9
m argin-re ex distance
– clinical signi cance of, 175,
176f, 212
– measurem ent of, 175, 175f,
212, 213f
m argin-re ex distance 1, 164,
210, 212, 213f
m argin-re ex distance 2, 198,
212, 213f
m arionette lines
– botulinum toxin for, 385, 386f
– ller injection for, 401–402
m asseter m uscle, hypertrophy
– botulinum toxin for, 386–388,
387f, 388f
– and lower facial contouring, 257
MatriStem, in hair transplant
procedures, 306
m axilla. See also bim axillary
protrusion; orthognathic
surgery
– down-fracture, in orthognathic
surgery, 281
– instability, after orthognathic
surgery, 281
– Le Fort I osteotomy, 274t,
276–277, 278f
–– bleeding in, 280
– and m andible, abnorm al
skeletal relationship between,
257
– orthognathic surgery for, 274t,
276–277
–– complications of, 281, 282f
–– incomplete osteotomy in, 281
– preoperative evaluation, 15
– protrusion, orthognathic
surgery for, 274t
– vertical excess, orthognathic
surgery for, 274t
m axillary retrusion, 9
m axim al m alar projection, 245,
245f
m edial epicanthoplasty, 8, 165,
194, 194f
– with ptosis surgery, 212
m edical skin care, in facial
rejuvenation, 340
Medpor, 13, 113
– advantages of, 14
– rem oval rate for, 135
– in rhinoplasty, 135
–– complications of, 135
m elanin index, 366, 367f
m ental nerve injury, in
genioplasty, 293
m icrognathia, psychosocial e ects
of, 286
m icrojet injection, in skin
rejuvenation, 340, 347, 347f

Index
424
orbital hem orrhage
– aging-related (upper)
blepharoplasty and, 181
– lower blepharoplasty and, 206
orbital retaining ligam ent, 326,
327f, 331
orthognathic surgery, 9
– aesthetic, 268–285
–– patient evaluation for,
269–272
–– pearls, 268
–– psychological considerations
in, 269–270
– case studies, 282–283,
282f–284f
– classi cation of, by diagnosis,
274, 274t
– complications of, 280–281
– condylar resorption after, 281
– de nition of, 268
– developm ent of, 268, 269f
– functional relapse after, 281
– and functional restoration, 268
– incomplete osteotom ies in, 281
– infection after, 280
– key technical points in, 280
– m andibular, 274–275, 274t
–– case studies, 282–283,
282f–284f
–– complications of, 281, 282f
– m axillary, 274t, 276–277
–– complications of, 281, 282f
– nerve injury in, 281
– pain after, 280
– partial necrosis of bone
segm ent and m ucosa after,
281, 282f
– postoperative care, 279–280
– psychosocial bene ts of, 268
– techniques for, 274–279
– technological advances and, 268
– unfavorable osteotom ies in, 281
osteotomy
– in aesthetic rhinoplasty for
Southeast Asians, 113
– anterior segm ental, for
bim axillary protrusion, 274t,
277–279, 279f
–– and genioplasty, 286, 295,
296f–297f, 298, 299f
– in augm entation rhinoplasty, 19
– bilateral vertical sagittal ramus,
m andibular, 274t
– in corrective rhinoplasty, 76–77
– high sagittal supraforaminal,
m andibular, 274, 276, 276f,
281
– intraoral vertical ram us,
m andibular, 276, 277f
– Le Fort I. See also double jaw
surgery
–– m axillary, 274t, 276–277, 278f
––– bleeding in, 280
– m andibular ram us, technique
for, developm ent of, 269f
– in nasal dorsal augm entation,
32
– in rhinoplasty, 76–77
–– correction, 122–134
–– pathogenesis of, 122
–– postoperative, 122, 123f
– skin-soft tissue envelope,
exam ination of, 74
– Southeast Asian, characteristics
of, 108
– starting point of, in Asians,
60, 61f
– twisted
–– physical exam ination of,
72–73, 73f, 74f
–– surgical correction of, 72–86.
See also corrective rhinoplasty
– upper lateral cartilages, 87–88
–– destruction, with alloplastic
implant complications, 136
nostril(s)
– asym m etry of, 99
–– after alar base surgery, 105, 105f
–– after corrective rhinoplasty for
short contracted nose, 131
– large, 99
– teardrop, after alar base
surgery, 105, 105f
num bness, after hair
transplantation, 358
O
oblique line, in lower eyelid,
197f, 198
Obwegeser-Dal Pont m ethod. See
sagittal split ram us osteotomy
(SSRO)
occlusion
– ideal, 269
– norm al, 268–269
– preoperative evaluation, in
genioplasty, 288
ocular m otility, preoperative
evaluation, 177
open bite, orthognathic surgery
for, 274t
orbicularis oculi, 326–327
– prom inence of, 197f, 198
– suspension procedure, 198, 199,
204, 206, 207f
– tightening procedure, 199
orbiculus oculi m uscle, 6
orbit, 6
– age-related changes in, 174
orbital fat
– age-related changes in, 198
– central, 164, 177, 198
– herniation, 164
– lateral, 198
– m edial, 164, 177, 198
– prolapse, 177, 197f, 198
– protrusion, and lower eyelid
appearance, 196
– pseudoherniation of, 197f
– rem oval
–– aesthetic e ects of, 197
–– in aging-related (upper)
blepharoplasty, 179, 179f
–– in double-eyelid surgery, 167,
167f
–– indications for, 198
neuralgia, after hair
transplantation, 359
neurotoxin injection. See also
botulinum toxin
– for brow depressors, 332
– for platysm al bands, 309
nonablative rejuvenation
– physiologic e ects of, 340
– principles of, 339–340
nonsurgical intervention, 10
nose. See also nasal entries;
saddle nose
– alar base, 99
–– m odi cation of, 99–107
– arterial supply to, and ller
injection, 403, 404, 406,
408–409, 409f
– Asian, anatomy of, 6, 26, 27f,
61–62
– basal view of, 100, 100f
– bird’s-eye view of, 73, 73f,
82f, 84f
– bony asym metry, 14
– bony pyramid
–– late deviation after corrective
rhinoplasty, 81
–– and saddle nose, 87, 88f
– cleft, 103, 104f
– contracted, postsurgical, 122
– crooked
–– physical examination of,
72–73, 73f, 74f
–– surgical correction of, 72–86.
See also corrective rhinoplasty
– deformity. See also saddle nose
–– oblique lighting of, 74f
–– surgical correction of, 72–86.
See also corrective rhinoplasty
– deviation
–– lower third, 79–80, 80f
–– m iddle third, 78–79, 79f
–– m idvault, 77
–– physical examination of,
72–73, 73f, 74f
–– surgical correction of, 72–86.
See also corrective rhinoplasty
–– tip, 77
–– upper-third, 75–77
– external, physical exam ination
of, 72–73, 73f, 74f
– internal, exam ination of, 73–74
– inverted-V deform ity, 67, 87,
88f
– keystone area, 87, 88f
– lateral crura, m alpositioned, 54
– lower lateral cartilages, 88
–– destruction, w ith alloplastic
implant complications, 136
– physical exam ination of, 72–74
– preoperative examination of,
14–15, 14f, 26–28, 27f, 60–61
– preoperative X-ray of, 15, 15f
– quadrangular cartilage, and
saddle nose, 87, 88f
– short. See also corrective
rhinoplasty, for short
contracted nose
–– congenital, 122
nasal tip (continued)
– projection and counter-rotation,
in aesthetic rhinoplasty for
Southeast Asians, 112–113, 113f
– projection of, 47–48, 48f, 60
–– augmentation via endonasal
approach, 48–49, 49f, 50f
–– loss of, 55
–– septal extension graft for,
49–51, 51f
– re nement
–– w ith hump resection, 65–67,
66f
–– preoperative counseling for,
27–28
–– surgical techniques for, 37–39
– revision surgery, 136, 138, 138f
– rigid, with AlloDerm implant,
secondary rhinoplasty for, 140
– rotation, 9, 60
–– septal extension graft for,
49–51, 51f
– rotation of, 47–48, 48f
– septal extension graft for,
49–51, 51f
–– end-to-end, 50, 52f
–– overlapping, 50, 51f
–– technique for, 50–51, 51f, 52f
–– types of, 50, 51f
– shape, evaluation of, 48, 48f
– shield graft for, 51, 53f
– silicone implant and, 13–25
– skin thinning on, augm entation
rhinoplasty with silicone
implant and, 23
– stacked onlay graft for, 13
– support, evaluation of, 48, 48f
– surgery
–– in Asians, 47
–– complications of, 55
–– in hump resection, 62–63, 63f
–– key technical points, 55
–– modi cation and re nem ent
for Asians, 8–9
–– pearls, 47
–– principles of, 47
–– techniques for, 47, 48–55
– volum e of, 47
–– reduction, cephalic resection
of lower lateral cartilage
lateral crus for, 52–53, 53f
– w idth of, 47
– w ing graft for, 13
nasion, level of, in Asians, 60, 61f
nasion (N)–anterior nasal spine
(ANS)/anterior nasal spine
(ANS)–menton (Me) ratio, 272,
272f, 287, 288t, 289, 290f
nasofrontal angle, 60
nasofrontal transition, 14f, 15
nasolabial angle, 60, 272, 272f
– acute, 15
– in Asians, 15
– obtuse, 122, 123f
nasolabial fold(s), ller injection
in, 400, 400f
neck. See also platysm al bands
– adiposity, m anagement of, 309

Index
425
– aesthetic, for Southeast Asians,
108–121
–– alar lift via sail excision in,
109–110, 110f–111f
–– case studies, 117, 118f, 119,
119f–121f
–– closure, 116
–– complications of, 117
–– conchal cartilage harvest for,
109
–– dorsal implant for, 113–116
–– key technical points in, 116
–– m em branous septum
dissection in, 111, 112f
–– osteotomy in, 113
–– patient counseling before, 109
–– patient evaluation for,
108–109
–– pearls, 108
–– septal extension graft in, 112,
112f, 113f
–– techniques for, 109–116
–– tip projection and counter-
rotation in, 112–113, 113f
– alloplastic implants in. See also
alloplastic implants
–– complications of, 135–148
–– pearls, 135
– augm entation. See
augm entation rhinoplasty
– corrective. See corrective
rhinoplasty
– for deviated/twisted nose,
72–86. See also corrective
rhinoplasty
–– pearls, 72
– edem a after
–– late (persistent), 81
–– m anagem ent of, 81, 140
– infections in, 143
– injection, asym m etry caused
by, 412
– m odi cation and re nem ent for
Asians, 8
– osteotomy in, 76–77
–– lateral, 76–77, 76f, 77f
–– m edial, 76f, 77
–– tips for perform ing, 77
–– types of, 76, 76f
– patient evaluation for, 14–15,
14f, 15f, 72–75
– planning for, 27
– preoperative counseling for,
27–28
– preoperative evaluation for, 27,
60–61
– secondary
–– for alloplast-related
complications, 135–148
–– case studies, 143, 144f, 145,
145f–147f
–– and capsule around silicone
implant, 136, 137f
–– for deviated implant, 138–139
–– for dorsal skin redness, 139
–– and Gore-Tex implant
complications, 137
–– for hard nasal tip, 140
–– historical perspective on,
210–211
–– incision for, 216, 217f
–– instruments for, 215, 216f
–– keratitis after, 221
–– key technical points in, 220
–– lagophthalm os after, 221
–– and levator resection, 219
–– levator surgery for, 215
–– lid lag after, 221
–– m ethod, selection of, 215
–– Müller m uscle conjunctiva
resection (MMCR) for, 211,
214, 215, 219
–– patient evaluation for,
211–214
–– pearls, 210
–– photographs in sitting position
during, 218, 219f
–– postoperative care, 220
–– preoperative considerations,
214–215
–– preparation for, 215–216, 216f
–– techniques for, 215–220
–– unilateral versus bilateral, 215
–– visual eld test before, 214
– diagnosis of, 212–214
– after double-eyelid surgery,
238, 238f
– evaluation of, 164, 210
– functional e ects of, 174
– Hering’s test and, 214–215
– history-taking for, 211–212
– latent, 214–215
– m asked, 211
– over-correction of, 220
– physical examination for, 211–212
– under-correction of, 220, 221f
– unilateral, 174, 175f, 176, 210,
215
pug nose, 87
pulm onary em bolism , fat graft
and, 321
R
Radiesse. See calcium
hydroxylapatite
radiofrequency devices, in facial
rejuvenation, 340, 344–346
– bipolar, 344, 345
–– with light, 345
– in ltrative fractional, 345–346,
346f
– m onopolar, 344, 345
reduction rhinoplasty, 60
– pearls, 60
relapsing polychondritis, and
saddle nose, 89
Restylane. See hyaluronic acid
retrognathia, 9
retro-orbicularis orbital fat
(ROOF), 164
– rem oval, in double-eyelid
surgery, 167, 167f
revision rhinoplasty, 24, 25f
rhinoplasty, 7f
– adjunctive surgeries and
procedures w ith, 9
polyacrylam ide gel, properties
of, 393t
poly-caprolactone, 394
poly-L-lactic acid, 394, 405
– properties of, 393t
polym ethyl methacrylate,
properties of, 393t
pore size, intraderm al botulinum
toxin injection and, 388–389,
389f
porous high-density polyethylene.
See Medpor
prem axilla, preoperative
evaluation, 14f, 15
prem axillary augm entation, 15
prem axillary graft, 54
pretarsal area
– fullness, after double-eyelid
surgery, 232–233, 233f
– height-volum e relationship in,
232–233, 233f
pretarsal bulge, 378, 383
pretarsal show, 165, 166f
procerus m uscle, 326–327
pro loplasty, 60–71
– pearls, 60
PRP. See platelet-rich plasm a
pseudo hump, 61, 61f
pseudolift, intradermal
botulinum toxin injection and,
388–389, 389f
pseudoptosis, 162
– causes of, 210
ptosis, 162, 176, 307, 307f. See
also chin, ptosis; eyelash ptosis
– aesthetic e ects of, 174, 327
– aging-related, 212–213, 327,
328
– aponeurotic, 211, 212–213,
212f, 213f
– asym metric, 214–215
– versus blepharoptosis, 174, 175f
– congenital, 211, 212f, 213–214,
222, 222f
– contact lens–induced,
214– 214f
– correction of, 169, 169f,
210–224
–– anesthesia for, 216, 216f
–– case studies, 221–222, 222f
–– complications of, 220–221
–– conjunctival prolapse after,
221
–– contour deformity after, 221
–– dissection in, 216–217, 217f,
218f
–– and early postoperative
revision, 221, 221f
–– ectropion after, 221
–– entropion after, 221
–– eyelid crease design for,
215–216, 216f
–– and eye protective function, 214
–– xation of levator-Müller
m uscle ap in, 217–218, 218f,
219f
–– frontalis sling for, 210, 211,
215, 219–220, 220f
–– lateral, 76–77, 76f, 77f
–– medial, 76f, 77
–– tips for perform ing, 77
–– types of, 76, 76f
– sagittal split ramus, m andibular,
274–275, 274t
–– bleeding during, 280
–– case studies, 282–283,
282f–284f
–– and genioplasty, 286
–– infection after, 280
– in zygom a reduction
–– anterior, 247, 247f
–– I-shaped, 248
–– L-shaped, 246–247, 247f, 248
–– ostectomy versus, 248
–– posterior, 247, 247f
P
pain
– after ller injection, 403, 407
– after genioplasty, 293
– after hair transplantation, 358
– after nasal tip surgery, 55
– after orthognathic surgery, 280
Painter, Neil, 5
palpebral aperture, widening
of, 378
palpebrom alar groove, 197f,
198, 199
paranasal augmentation, 15
paranasal implant, 9
paresthesia, after zygom a
reduction, 249
parotid gland, reduction,
botulinum toxin for, 388, 389f
peau d’orange, on chin, after
genioplasty, 294–295
periorbital fat, 164
phenylephrine test, 214, 215
photodocumentation
– for facial fat grafting, 312
– postoperative, with ptosis
correction, 212
– preoperative, 27, 74, 101
–– for blepharoplasty, 164
–– for endoscopic forehead and
brow lift, 330
–– for hair transplantation, 352
–– for lower blepharoplasty, 199
–– for m andibular reduction, 256
–– for ptosis correction, 212
– during ptosis correction, 218,
219f
piriform ligam ents, release of, in
augm entation rhinoplasty, 18
Pitanguy line, 325, 325f
platelet-rich plasma
– in fat grafting, 318
– in hair transplant procedures, 306
platysmal bands
– botulinum toxin for, 386, 386f
– neurotoxin injection for, 309
PLLA. See poly-L-lactic acid
pneum atic compression, in skin
rejuvenation, 340, 347, 347f
pneum othorax, costal cartilage
harvest and, 130

Index
426
skin rejuvenation
– ablative, 339–340. See also
ablative rejuvenation
– nonablative, 339. See also
nonablative rejuvenation
– type I, 339, 340
–– with intense pulsed light,
341–342, 341f
– type II, 339, 340
–– with intense pulsed light, 342
skull, Asian, characteristics of,
349–350, 350f
snap-back test, for eyelid laxity,
198–199
snub nose, postoperative, 122,
123f
soft tissue, lifting, in lower facial
contouring, 257
SOOF. See suborbicularis orbital
fat (SOOF)
Southeast Asians, 3, 8f
– aesthetic rhinoplasty for,
108–121
–– pearls, 108
square jaw, botulinum toxin for,
386–388, 387f, 388f
SSRO. See sagittal split ram us
osteotomy (SSRO)
stereophotogram m etry,
preoperative, 27
steroid injection, after corrective
rhinoplasty, 81
stim ulator(s) ( ller), properties
of, 393t
subnasale–labialis inferior:labialis
inferior–soft tissue m enton
(Sn–Li:Li–Me´) ratio, 272f,
288, 289f
subnasale–stomion:stomion–soft
tissue m enton (Sn–St:St–Me´)
ratio, 272f, 288, 289f
suborbicularis orbital fat (SOOF)
– elevation (lift), 198, 199, 203,
207, 207f
– in fat repositioning
blepharoplasty, 203, 203f
sun exposure
– avoidance, after laser facial hair
rem oval, 370
– and skin aging, 303–304
superior palpebral fold, 6, 7f
superior sulcus
– deepening
–– age-related, 175, 175f
–– with ptosis, 211, 212f
– m anagem ent in aging-related
(upper) blepharoplasty, 181
supraorbital nerve, injury, in ller
injection, 403
supraorbital neurovascular
bundle, 325, 326f
supratrochlear neurovascular
bundle, 325–326, 326f
suptratrochlear artery, ller
injection in, prevention of,
404, 406
surgical techniques, modi cation
and re nem ent for Asians, 8–9
– advantages of, 13–14
– for augm entation rhinoplasty,
13–25
–– capsule around, 136, 137f
–– pearls, 13
– chin, complications of, 294
– complications of, 22–23, 28,
28f, 135
– dermal fat graft with, 22, 23f
– popularity of, 13–14
– rem oval rate for, 135
– in rhinoplasty, 135
–– complications of, 135, 136,
137f
–– and m ucocele form ation, 138,
139f, 140, 141f
–– pearls, 135
Silskin. See silicone, liquid
single eyelid, 152, 152f, 162–163,
173
– anatomy of, 153
– opening phase, 153f
– resting phase, 153f
skeletal reduction surgery, 9
skin, Asian, 6
– age-related changes in, 174,
178, 310
–– sun exposure and, 303–304
– of alar base, 101
– characteristics of, 196
– chin
–– dimpling, after genioplasty,
294
–– peau d’orange appearance,
after genioplasty, 294–295
– in epicanthal area, 185
– of eyelid, 164
– facial, laser hair rem oval and,
368, 368f
– lifting, in lower facial
contouring, 257
– lower eyelid, loss of elasticity,
198
– nasal, 15, 26, 27f, 61, 62f, 100
–– damage in corrective
rhinoplasty for short
contracted nose, 130
–– dorsal redness, secondary
rhinoplasty for, 139
–– exam ination of, 74
–– m obility, evaluation, 123,
123f
– necrosis
–– with fat graft em bolization,
320, 320f
–– after ller injection, 403, 403f,
406, 406f, 409, 410f, 411, 412f
–– after hair transplantation, 358
– palpebral, 6
– rejuvenation, 310
– resistance to aging, 303–304,
378
– resurfacing, 310
– topical therapy for, 310
skin color
– cultural beliefs about, 5,
303–304
– and hair transplantation, 350
SAFI. See sequential autologous fat
injection (SAFI) technique
sagittal split ramus osteotomy
(SSRO), mandibular, 274–275,
274t
– bleeding during, 280
– case studies, 282–283,
282f–284f
– and genioplasty, 286
– infection after, 280
Sam urai eyebrow, 382
sarcoidosis, and saddle nose, 89
sausage eyelid, 232
scalp, pruritus, after hair
transplantation, 359
SCALP m nem onic, 396, 396f
scar(s), 8. See also keloids
– after alar base surgery,
104–105, 105f
– with epicanthoplasty, 187–189
– after eyelid surgery, 226, 226f,
227f
– facial fat grafting and, 319–320
– after ller injection, 411
– hair transplantation and, 351,
352, 358, 359
– hypertrophic, 100, 185, 196
–– with epicanthoplasty, 189
–– after eyelid surgery, 226
–– hair transplantation and,
351, 359
–– treatment of, 189
– with nonincisional suture
technique for double-eyelid
surgery, 159, 160f
– resurfacing, 10
Sculptra. See poly-L-lactic acid
seborrheic dermatitis, after laser
facial hair removal, 370, 370f
sentinel vein, in forehead, 325,
326f, 331–332
Sephyl. See blood, as ller
septal extension graft, 135, 136f
– in aesthetic rhinoplasty for
Southeast Asians, 112, 112f,
113f
– in corrective rhinoplasty
for short contracted nose,
123–125, 124f
septoplasty, infections in, 143
septorhinoplasty, 135
– complicated, 135, 143
–– alloplastic implants for, 135
–– pearls, 135
– infections in, 143
sequential autologous fat
injection (SAFI) technique,
313, 313f, 314t–315t, 316f,
317t
serom a, after endoscopic
forehead and brow lift, 337
shield graft, in aesthetic
rhinoplasty for Southeast
Asians, 113
Shin’s m ethod, for aesthetic
lateral canthoplasty, 191, 192f
silicone, liquid, properties of, 393t
silicone implants, 8, 113
rhinoplasty (continued)
– secondary (continued)
–– for implant calci cation, 139,
140f
–– for implant protrusion, 139
–– for infectious conditions,
140–141
–– key technical points in,
142–143, 142f
–– and Medpor implant
complications, 137, 138f
–– for m obile implant, 139
–– for noninfectious conditions,
138–140
–– patient evaluation for,
136–138
–– for short nose deform ity,
141–142, 142f
–– techniques for, 138–142
–– for visible implant, 139
rhytidectomy, 309
rhytids
– forehead, 327
– glabellar, 327
– lateral canthal. See crow’s-feet
– perioral, botulinum toxin for,
384–385, 385f
Ricketts line. See esthetic line
(E-line)
ROOF. See retro-orbicularis orbital
fat (ROOF)
rule of fths, 270, 271f, 324
rule of thirds, 270, 271f, 288,
289f, 324
S
saddle nose (deform ity)
– aesthetic e ects of, 87, 88f, 89f
– anatom ic considerations, 87–88,
88f, 89f
– case studies, 94, 95f, 96, 96f–98f
– characteristics of, 87, 88f
– class 1, 90–91, 91f
– class 2, 90, 91–92, 91f, 92f
– class 3, 90, 91f, 92–93, 93f
– class 4, 90, 91f, 93, 94f
– classi cation of, 90, 91f
– correction of, 87–98
–– pearls, 87
– disease and, 89
– etiology of, 88–90
– extended spreader graft for,
92, 92f
– functional e ects of, 87
– iatrogenic causes, 89
– m alignancy and, 89
– patient evaluation, 90
– versus pseudo saddle, 87, 88f
– septal extension graft for, 92,
92f
– spreader graft for, 92, 92f, 93
– surgical techniques for, 90–93,
91f–94f
–– key technical points, 93
– system ic disease and, 89
– total dorsal reconstruction for,
93, 94f
– trauma-related, 89

Index
427
– complications of, 249–250
– xation in, 247, 248f, 249
– goals of, 243–244
– infraorbital nerve injury and
paresthesia after, 249
– intraoral approach for, 246–247
– I-shaped osteotomy in, 248
– key technical points in, 248–249
– L-shaped osteotomy in,
246–247, 247f, 248
– and mandible reduction
(contouring), com bined, 246,
252, 252f, 253f, 263–265,
263f–267f
– nonunion after, 249
– ostectomy versus osteotomy
in, 248
– patient evaluation for, 244–246
– pearls, 243
– posterior osteotomy in, 247,
247f
– soft tissue sagging after, 249
– surgical techniques for, 246–247
– trism us after, 249
– and under-correction, 250
– vector of transposition in, 248
zygom atic arch, 6
zygom atic body, 6
– position of, 244–245
– volum e of, 244
zygom atico-temporal vein,
m edial, 325, 326f
vitam in c iontophoresis, in facial
rejuvenation, 340
V-line surgery, 255, 255f
volum izer(s), properties of, 393t,
405
Von Am m on’s m ethod, for
aesthetic lateral canthoplasty,
190, 190f
W
Wegener’s granulom atosis, and
saddle nose, 89
West Asians, 3
Whitnall’s ligam ent, 167
Wilkinson analysis, of m aximal
m alar projection, 245, 245f
X
X-ray, preoperative
– for genioplasty, 287, 289
– for m andibular reduction, 256
– of nose, 15, 15f
– for secondary rhinoplasty, 136
Z
zero-m eridian, 288–289, 289f
zygom a reduction, 243–253
– anesthesia for, 247
– anterior osteotomy in, 247, 247f
– approach for, 246–247
– asym m etry after, 249
– case study, 250, 250f, 251f
thum bprint sign, 32
TMJ. See temporom andibular
joint (TMJ)
Tranilast, 188
transconjunctival Müller tucking,
158, 159f, 161, 161f
trauma, and saddle nose
deform ity, 89
triam cinolone acetate, injection
– after corrective rhinoplasty, 81
– for hypertrophic scar, 189
triangular m alar m ound, 198
trism us, after zygom a reduction,
249
two-jaw surgery, 268. See also
double jaw surgery
U
ultrasound
– in facial rejuvenation, 340
– high-intensity focused, in facial
rejuvenation, 340, 346, 346t
upper eyelid crease, 6, 7f, 162
– low, 163
V
visual eld(s)
– improvement, after aging-related
(upper) blepharoplasty, 180
– ptosis and, 174
– testing, w ith ptosis correction,
214
syncope, hair transplantation
and, 360
syphilis, and saddle nose, 89
T
tear breakup tim e, 177, 181
tear secretion, preoperative
evaluation, 177, 181
tear trough, ller injection in, 399
tear trough depression, 197–198,
197f, 199
– fat grafting for, 322, 322f
teeth, exposure, and facial
aesthetics, 270
temple, ller injection in,
396–397, 397f
temporal fossa
– ller injection in, 396–397, 397f
– layers of, 396, 397f
temporal region, anatomy of,
324–326, 325f–327f
temporom andibular joint (TMJ)
– dysfunction, preoperative
docum entation of, 270
– instability, after orthognathic
surgery, 281
– pain, after orthognathic surgery,
280
temporoparietal fascia, 325, 325f,
326f
Thermage, 344
thread lifting, 10

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