Tái Tạo Thể Tích Khuôn Mặt Bằng Filler – Kyle K. Seo (2021)

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Ấn phẩm xuất sắc năm 2021 của Tiến sĩ Kyle K. Seo về kỹ thuật sử dụng chất làm đầy (Filler) đặc thù cho người châu Á. Sách hướng dẫn cách tạo hình V-line, làm đầy thái dương, rãnh mũi má và nâng cằm dựa trên sự khác biệt về cấu trúc xương người Á Đông.

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123
Facial
Volumization
with Fillers
Kyle K. Seo

Facial Volumization with Fillers

Kyle K. Seo
Facial Volumization
with Fillers

ISBN 978-981-33-6211-6 ISBN 978-981-33-6212-3 (eBook)

© Springer Nature Singapore Pte Ltd. 2021
This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or
part of the material is concerned, specifically the rights of translation, reprinting, reuse of
illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way,
and transmission or information storage and retrieval, electronic adaptation, computer software,
or by similar or dissimilar methodology now known or hereafter developed.
The use of general descriptive names, registered names, trademarks, service marks, etc. in this
publication does not imply, even in the absence of a specific statement, that such names are
exempt from the relevant protective laws and regulations and therefore free for general use.
The publisher, the authors, and the editors are safe to assume that the advice and information in
this book are believed to be true and accurate at the date of publication. Neither the publisher nor
the authors or the editors give a warranty, expressed or implied, with respect to the material
contained herein or for any errors or omissions that may have been made. The publisher remains
neutral with regard to jurisdictional claims in published maps and institutional affiliations.
This Springer imprint is published by the registered company Springer Nature Singapore Pte Ltd.
The registered company address is: 152 Beach Road, #21-01/04 Gateway East, Singapore
189721, Singapore
Kyle K. Seo
Modelo Clinic
Seoul
Korea (Republic of)

This book is dedicated to my children, Seongwon, Hyejune, and
Yejin, who give me hope and motivation in life.

vii
Aging of the face is not merely the result of wrinkling of the skin from age-
related loss of dermal elasticity but more significantly due to the loss of con-
tinuity in the facial contour caused by the sinking and sagging of the face with
age. Injectable fillers are youth-restoring in this respect as they serve not only
to fill etched-in grooves and creases but also to plump up facial volume
depressions and thus help restore the convexity and fullness of the face seen
in youth. Indeed, injectable fillers together with botulinum toxin injections
represent the two most essential tools in the esthetic practitioner’s armamen-
tarium of facial rejuvenation treatments. Today, injectable fillers have evolved
beyond a rejuvenation tool for recapturing youth and have become a signifi-
cant beautification tool for unlocking facial beauty. Based on the multifaceted
three-dimensional assessment of the face, injectable fillers serve not only to
reshape the facial contour when placed in the receded chin, sunken cheeks,
and areas of facial asymmetry but also to enhance and beautify individual
facial features, for example, by projecting the nose and plumping the lips.
While soft tissue fillers have been customarily referred to as dermal fillers
ever since collagen fillers first made their debut back in the 1980s, it might be
high time they were referred to instead as volume fillers in light of their
increasingly larger role and versatility as volume enhancers.
In these pages, I have attempted to provide a comprehensive A to Z guide
to filler injection techniques for facial volumization which have been honed
and refined over my 20 years of clinical experience with soft tissue fillers.
The Asian face is inherently rounder and flatter compared to the Caucasian
face. Within the Asian demographic, this has created a desire for and popular-
ity of various volumizing filler applications for adding definition and projec-
tion to the face, with augmentations of the forehead, nose, and chin being
among some of the most highly requested indications. Notably, the cheeks
are a common area for volumization in Korean patients, who aspire to have a
baby-like face with full, chubby cheeks—a hallmark of the ideal Korean look,
which a Caucasian patient may happen to find less appealing.
On top of this robust demand for facial volumization with soft tissue fill-
ers, the Korean market for HA fillers is capable of supplying HA fillers at
prices more affordable than anywhere else in the world due to the fierce com-
petition among different brands. It is thus reasonable to conclude that this
interplay between the supply- and demand-side factors puts Asia ahead of
Western countries in terms of the sheer number of facial volumization
treatments performed. As a testament to this buoyant trend, I have had the
Preface

viii
pleasure of being recognized as “Asia’s Top BeloteroⓇ Injector” by Merz,
Germany, for three consecutive years from 2018 to 2020. In 2019 alone, as it
turns out, I used over 7000ml of BeloteroⓇ HA fillers in my practice. Besides
Belotero, I also regularly use RestylaneⓇ and other local HA filler brands for
treating between 20 and 30 patients per day, which translates into more than
5000 cases performed annually. The ten thousand hour rule popularized by
Malcolm Gladwell famously dictates that it takes four hours of practice per
day for ten years to achieve mastery in a given field. By this standard, I sup-
pose I qualify as a master injector, considering I have been practicing inject-
able filler procedures for over 20 years, the recent ten years of which I have
dedicated exclusively to botulinum toxin and filler treatments,
However, to reach this stage in my career, I admit numerous trials and
errors have been made along the way. Several episodes come to mind. Back
in 2000 when I had first started injecting fillers, fillers had yet to be used for
facial volume replacement. Thus, when an elderly patient in her 70s pre-
sented for treatment of her severe nasojugal grooves, I applied the same
approach I had typically used for treating the glabella frown lines, injecting
only minimal amounts of HA filler superficially in the dermis and sub-dermis
of the anterior malar, and was left to wonder why nothing was happening.
Indeed I had my moments of highs and lows and everything in between dur-
ing my years of practice with filler treatments. I recall how I almost leaped
with elation upon learning hyaluronidase could be used to melt away irregu-
larities from HA fillers and, conversely, how I agonized over the unexpected
allergic reactions suffered by a patient after her hyaluronidase injections.
There were also times when, for lack of knowledge, I resorted to antibiotics
for treating a delayed-type hypersensitivity reaction related to BDDE or HA
impurities, misunderstanding it to be an infection-related inflammation. Of
course, as a practitioner I have also had my fair share of vascular complica-
tions from inadvertent intravascular injections of HA filler, though fortu-
nately, none of these events ever escalated to disastrous skin necrosis. In fact,
most of the HA filler- related complications described in this book are based
on my own clinical experience. It is against this backdrop that this book was
written, in the hope of providing fellow practitioners who are either just start-
ing out on their practice with injectable fillers or who still lack the confidence
in performing this procedure with the equivalent of a Drivers Manual, and lay
out the safe and effective treatment practices drawing on the trials and errors
I confess to have committed in my practice while learning things from scratch.
The three key factors physicians typically consider when selecting a filler
product are safety, longevity, and price. Among those, safety takes first prior-
ity as injectable fillers represent an extraneous substance introduced into the
human body. While collagen stimulators or semipermanent fillers provide a
better, more prolonged duration of effect, HA outperforms all other types of
soft tissue fillers currently on the market in terms of its excellent safety pro-
file. Not only does HA consist of the same substance naturally occurring in
the human body, but it represents the only type of injectable filler reversible
with the injection of hyaluronidase should problems occur. It is for this reason
that I almost exclusively use HA fillers in my practice and why this book also
primarily describes the use of HA fillers.
Preface

ix
Meanwhile, Asians and Caucasians differ both in their structural facial
anatomy and the respective facial beauty standards they pursue, which should
be appreciated when undertaking filler treatments. For example, the Asian
face is wider and flatter compared with the more dimensional and narrower
Caucasian face. This explains why a prominent zygoma and well-defined
jaws are regarded as desirable beauty traits within the Western culture, while
square jaw reduction with botulinum toxin are so popular among Asians who
wish to slim down their broad faces. In the same context, while a midface
augmentation in a Caucasian patient typically consists of increasing the lat-
eral cheek projection to accentuate the coveted Ogee curve, such an approach
is rarely practiced in Koreans as they tend to disfavor having a prominent
zygoma. Conversely, whereas Koreans generally aspire to have a baby face
with full plump cheeks, Caucasians tend to find such soft rounded features
less appealing.
Such differences in ethnic esthetic standards are a constant theme run-
ning through many of the discussions contained in this book. I do accept,
however, that a relatively larger portion of the book has been dedicated to
strategies relevant to Asian patients, for which I seek the reader’s kind
understanding. That said, given that most of the available literature or pub-
lications dealing with the use of injectable fillers are written solely with the
Caucasian patient in mind, this book may perhaps offer more balanced
guidance, reflecting the facial aesthetic standards of both Asian and
Caucasians and allowing practitioners to deliver adequately customized
treatments tailored to the aesthetic needs of different ethnic patients. Driven
by the strong influence of the Korean wave throughout many parts of the
world via K-pop and K-drama, the Korean look has been established as a
distinct and dominant feature of the Asian aesthetic standard. In some
respects, therefore, the strategies laid out in the book may generally reso-
nate with the broader Asian demographic who also favor the prevailing
Korean beauty standard.
The injection techniques prescribed in this book are based not on the
Consensus Data but instead on the specific approaches I actually employ in
my own practice. In fairness, different doctors may hold different views on
some of the points I cover. That notwithstanding, the effectiveness of the
injection techniques presented in this book has been established based upon
the extensive patient cases I have performed over the past 20 years and will
be of relevance for those seeking some practical pointers in performing facial
volumization with fillers. To the extent no single method can be upheld as
absolute, however, I am more than happy to entertain any further input and
constructive critique from respected colleagues reading this book,
While my primary motivation for writing this book was to put together
an equivalent of a Drivers Manual to help other physicians navigate a safer
and more pleasant journey through the complexities of volumizing filler
treatments, part of the reason was also to give myself an opportunity to look
back and take stock of the past 20 years of my career built mostly around
injectable filler treatments. If my previous book “Botulinum Toxin for
Asians (Springer, 2017)” published four years ago represented my first
child, this work represents the second child I bring into this world, for
Preface

x
which I have both high expectations and corresponding concerns. Finally, it
is my sincere hope that “Facial Volumization with Fillers” and, hopefully,
its future 2nd and 3rd editions with updated and expanded information will
continue to serve as a valuable and relevant source of current knowledge
and insight on filler injection procedures for interested readers all over the
world.
Kyle K. Seo
Seoul, Korea
March, 2021
Preface

xi
Acknowledgment
There are plenty of people who helped in bringing this book to fruition, whom
I wish to recognize and acknowledge.
Words cannot express my feelings of gratitude for Ms. Sanhyo Kim, who
was responsible for translating this book into the English language. As a con-
ference interpreter, Ms. Kim has worked closely with me during the past 10
years as my English teacher, based on which she was able to accurately con-
vey the subtlest of nuances in my original manuscript with exceptional flair.
It was also her occasional prodding that helped keep my progress on sched-
ule. I especially appreciate how she put this work before all her other commit-
ments during the final weeks to allow timely completion of this book.
As always, I am eternally grateful to my dear friend professor Hee-Jin
Kim of Yonsei University for lending his rich and invaluable insight into the
discipline of facial anatomy for this work and for graciously providing me
with the brilliant selection of photographic images. Without his experiences
and support, this book would not have the robust and rigorous anatomical
foundation upon which it stands
A very special thanks indeed to Ms. Hye Won Hur, one of the greatest
illustrators I could ever imagine working with, who truly took this book to the
next level by enriching it with her beautiful and super accurate anatomic
illustrations. Ms. Hur is a student of Prof. Kwan-Hyun Yoon of Incheon
University and Representative of Mediart, who had been responsible for pro-
viding the illustrations contained in Botulinum toxin for Asians (Springer,
2017). Having obtained her degree as a Bachelor of Fine Arts, she is currently
studying anatomy as a Ph.D. student at the Department of Orthodontics,
Yonsei University. Judging from the phenomenal energy and brilliant ingenu-
ity she demonstrated throughout the course of this project, I have no doubt in
my mind that she is indeed a master in the making in the field of medical art
illustration. The student has become the master, as the saying goes.
I would also like to express my sincere gratitude to Dr. Per Winlof of
Galderma and Mr. Sin-Gu Lee (head of R&D center, JETEMA) for their
invaluable insight and advice regarding HA filler manufacturing and filler
rheology, topics on which the author cannot claim to be an expert. Their expe-
rience and support has been indispensable to preparing Chap. 2 Volumizing
Fillers of this book, and any credit for the level of detail and perfection
embodied in the said chapter should go to them.

xii
Finally, I wish to give a big shout out to my amazing staff for their hard
work in compiling the copious amounts of material and images accompany-
ing the manuscript as well as contributing their photographs for inclusion in
the book. I am forever in their debt.
My heartfelt appreciation also goes to Galderma and Merz for their gener-
osity in providing me with the numerous invaluable photos that significantly
helped to enrich the content of this book.
March, 2021
Kyle K. Seo
Acknowledgment

xiii
1 Pretreatment Assessment�� 1
1.1 Introduction�� 1
1.2 Individualized Assessment�� 1
1.2.1 Subjective Factors�� 1
1.2.2 Objective Factors�� 4
1.2.3 Facial Assessment Flow Chart�� 4
1.2.4 Sociocultural Aspects�� 12
1.2.5 Gender-Specific Differences�� 14
1.2.6 Past Medical History of Aesthetic Procedures�� 15
1.2.7 Financial Aspects�� 16
1.3 Consideration of Ethnic Differences in Filler Procedures�� 17
1.3.1 Definition of the Asian Population and Asian
Facial Morphotypes�� 18
1.3.2 Differences in the Skull Shape Between
Caucasians and Asians�� 19
1.3.3 Differences in Facial Beauty Standards
Between Caucasians and Asians�� 20
1.3.4 Different Filler Treatment Strategies for
Caucasians and Asians�� 23
References�� 28
2 Volumizing Fillers�� 29
2.1 Types of Injectable Fillers�� 29
2.2 Hyaluronic Acid Fillers�� 31
2.2.1 Characteristics of HA�� 32
2.2.2 Hyaluronic Acid Filler Manufacturing Process�� 33
2.2.3 Choice of HA Filler�� 45
2.2.4 Rheological Properties of HA Filler �� 48
2.3 Major HA Filler Products �� 58
2.3.1 Restylane®: The Golden Standard of HA Fillers�� 58
2.3.2 Juvéderm®: The First Original Soft HA Filler�� 60
2.3.3 Belotero®: HA Filler with a Reputation
for Safety�� 63
2.3.4 YVOIRE®: Korea’s First HA Filler�� 65
2.3.5 Neuramis®: Representative Korean Soft HA Filler�� 67
2.3.6 e.p.t.q.®: HA Filler with a Top Priority on Safety�� 69
Contents

xiv
2.4 Other Types of Injectable Fillers�� 70
2.4.1 Collagen Fillers�� 70
2.4.2 Permanent Injectables�� 71
2.4.3 Collagen-Stimulating Fillers�� 72
References�� 81
3 Hyaluronic Acid (HA) Filler Injection Procedure�� 85
3.1 Preparation Prior to the Injection�� 85
3.1.1 Preparation of Tray �� 85
3.1.2 Dispensing�� 85
3.1.3 Dilution of HA Filler�� 85
3.1.4 Disinfection�� 85
3.1.5 Anesthesia�� 86
3.2 Injection Method�� 90
3.2.1 Needle vs. Cannula �� 90
3.2.2 Linear Thread Technique�� 94
3.2.3 Tower Technique�� 94
3.2.4 Fern Pattern Technique
(Multiple Intradermal Injection) �� 95
3.2.5 Subcision Technique �� 96
3.2.6 Double-Layering Technique �� 96
3.2.7 Injection Technique for Deep Static Grooves�� 97
3.2.8 Volumizing Injection Technique �� 99
3.2.9 The Role of the Nondominant Hand��100
3.3 HA Filler Injection Training Employing the
Use of Pig Trotters��102
References��103
4 Regional Particulars��105
4.1 Forehead Augmentation��105
4.1.1 Anatomical Considerations��108
4.1.2 Pretreatment Assessment��108
4.1.3 Injection Technique for Forehead Concavity
and Forehead Sloping ��110
4.1.4 Combination Treatment��113
4.1.5 Complications ��114
4.2 Temple Augmentation��115
4.2.1 Anatomical Considerations��115
4.2.2 Pretreatment Assessment��119
4.2.3 Injection Technique��119
4.2.4 Complications ��120
4.3 Deep Glabella Furrow��123
4.3.1 Anatomical Considerations��123
4.3.2 Pretreatment Assessment��124
4.3.3 Injection Technique��125
4.3.4 Complications ��127
4.4 Sunken Eyes Volumization��127
4.4.1 Anatomical Considerations��128
4.4.2 Pretreatment Assessment��128
Contents

xv
4.4.3 Injection Technique��130
4.4.4 Complications ��130
4.5 Pretarsal Roll Augmentation��132
4.5.1 Anatomical Considerations��133
4.5.2 Pretreatment Assessment��133
4.5.3 Injection Technique��135
4.5.4 Complications ��136
4.6 Inferior Orbital Hollow, Tear Trough, and
Palpebromalar Groove��138
4.6.1 Anatomical Considerations��139
4.6.2 Pretreatment Assessment��139
4.6.3 Injection Technique��140
4.6.4 Complications ��143
4.7 Nasojugal Groove ��144
4.7.1 Anatomical Considerations��145
4.7.2 Pretreatment Assessment��148
4.7.3 Injection Technique��150
4.7.4 Complications ��154
4.8 Malar Eminence��155
4.8.1 Anatomical Considerations��156
4.8.2 Pretreatment Assessment��156
4.8.3 Injection Technique ��158
4.8.4 Complications ��160
4.9 Nose��160
4.9.1 Anthropometry of the Nose��161
4.9.2 Ethnic Differences��164
4.9.3 Anatomical Considerations��165
4.9.4 Pretreatment Assessment��166
4.9.5 Injection Technique��168
4.9.6 Nasal Dorsum Augmentation��170
4.9.7 Glabella Correction��170
4.9.8 Nasal Tip Correction��173
4.9.9 Columella Correction��175
4.9.10 Nasolabial Angle Correction��175
4.9.11 Injection Techniques for Special Indications��177
4.9.12 Combination Treatment��180
4.9.13 Complications ��182
4.10 Sunken Cheek Augmentation��186
4.10.1 Anatomical Considerations��186
4.10.2 Pretreatment Assessment��188
4.10.3 Injection Technique��189
4.10.4 Complications ��191
4.11 Nasolabial Folds��192
4.11.1 Anatomical Considerations��193
4.11.2 Pretreatment Assessment��194
4.11.3 Injection Method��194
4.11.4 Complications ��197
Contents

xvi
4.12 Lip Filler ��198
4.12.1 Anthropometry of the Lips��199
4.12.2 Anatomical Considerations��202
4.12.3 Pretreatment Assessment��204
4.12.4 Injection Technique��205
4.12.5 Complications ��207
4.13 Marionette Lines��211
4.13.1 Anatomical Considerations��211
4.13.2 Pretreatment Assessment��213
4.13.3 Injection Technique��214
4.13.4 Complications ��216
4.14 Chin Augmentation��216
4.14.1 Anthropometry of the Chin��216
4.14.2 Anatomical Considerations��219
4.14.3 Pretreatment Assessment��219
4.14.4 Injection Technique��220
4.14.5 Improvement of Anterior Projection ��220
4.14.6 Lengthening of Chin Height
(Elongation of the Chin) ��222
4.14.7 Widening of the Chin Width ��222
4.14.8 Correction of Chin Asymmetry��224
4.14.9 Combination Treatment��225
4.14.10 Complications ��226
4.15 Jawline Filler��226
4.15.1 Anatomical Considerations��227
4.15.2 Pretreatment Assessment��229
4.15.3 Injection Technique��229
4.15.4 Complications ��231
4.16 Earlobe Filler��231
4.16.1 Anatomy of the Outer Ear��231
4.16.2 Injection Technique��231
4.17 Atrophic Scar volumization for Soft Tissue
Depressions from Autoimmune Diseases ��235
4.17.1 Pretreatment Assessment��236
4.17.2 Injection Technique��236
4.17.3 Complications ��237
4.18 Facial Asymmetry Correction��237
4.18.1 Pretreatment Assessment��239
4.18.2 Principles and Injection Technique for
Facial Asymmetry Correction��241
4.18.3 Combination Treatment��241
4.19 Neckline Treatment with HA Filler��244
4.19.1 Pretreatment Assessment��244
4.19.2 Injection Technique ��244
4.20 Hydrolifting (Multiple Intradermal Injections of
HA Filler)��247
4.20.1 Pretreatment Assessment��248
Contents

xvii
4.20.2 Injection Technique ��249
4.20.3 Use of Injectors��251
4.20.4 Laser-Assisted Needleless Injector��252
4.20.5 Cocktail Therapy��253
4.20.6 Wrinkles Above the Knee ��254
4.20.7 Complications ��254
References��255
5 Complications��257
5.1 Vascular Complication��257
5.1.1 Symptoms ��257
5.1.2 Prevention ��257
5.1.3 Treatment��259
5.1.4 Cause and Treatment of Blindness Following
HA Filler Injection��261
5.2 Inflammation from Delayed-Type Hypersensitivity to
HA Filler��264
5.2.1 Cause of Delayed-Type Hypersensitivity
Following HA Injection��264
5.2.2 Symptoms ��265
5.2.3 Differential Diagnosis��267
5.2.4 Treatment��268
5.2.5 Summary��268
5.3 Posttreatment Contour Irregularity ��269
5.3.1 Inadequate Placement ��269
5.3.2 Inadequate Balance��271
5.3.3 Delayed Irregularity��271
5.3.4 Solution: Administration of Hyaluronidase ��273
5.4 The Adequate Use of Hyaluronidase��274
5.4.1 Pharmacological Characteristics��274
5.4.2 Products��274
5.4.3 Use of Hyaluronidase in the Correction of
HA Filler Placement ��276
5.4.4 Use of Hyaluronidase for Managing Inflammation
from Delayed-type Hypersensitivity to HA or
Bacterial Infection��278
5.4.5 Use of Hyaluronidase in the Treatment of
Vascular Complications from HA Filler Injection��278
5.4.6 Allergic Reaction to Hyaluronidase and
Allergy Testing��279
5.4.7 Skin Atrophy��280
5.4.8 Use of Ultrasonic Imaging to Establish the
Presence of HA in the Tissue��281
References��282
Contents

xix
Kyle K. Seo is a dermatologist based in Seoul. He received his M.D. and
Ph.D. from Seoul National University College of Medicine, Seoul, South
Korea. He became a Clinical Professor in the Department of Dermatology of
Seoul National University College of Medicine as a chief of the Botox Clinic.
Presently, he is also the Director of Modelo Clinic in Seoul, South Korea. He
also leads the Korean Dermatology Society as a President of the Korean Society
for Dermatologic Surgery.
He has worldwide reputation as an authority in the field of botulinum toxin
and fillers. He was the first doctor in Korea to have launched a hands-on train-
ing course on botulinum toxin and fillers, namely the “Modelo Academy,”
open since 2002. He has also published extensively on the areas of botulinum
toxin and filler treatments including “Botulinum Toxin for Asians (Springer
2017)” and “Clinical Anatomy of Face for Botulinum Toxin and Filler
Injection (Springer, 2016).” His extensive experience provided him many
opportunities to lecture internationally on the subject of botulinum toxin and
filler. In recognition of his exceptional dedication and prominent academic
achievements, he was ultimately selected as the sole keynote speaker to rep-
About the Author

xx
resent the entire global cosmetic field at the plenary session of the 23rd World
Congress of Dermatology (Vancouver 2015) and also chaired the botulinum
toxin and filler session of the 24th World Congress of Dermatology (Milan
2019).
He also dedicated himself to promoting global academic activity in the
dermatology society as the Vice President of the local organizing committee
for the 22nd World Congress of Dermatology (WCD) (Seoul, 2011) and the
Secretary-General of the local organizing committee for the 36th annual
meeting of the International Society for Dermatologic Surgery (ISDS) (Seoul,
2015).
About the Author

1
© Springer Nature Singapore Pte Ltd. 2021
K. K. Seo, Facial Volumization with Fillers,
Pretreatment Assessment
1.1
Introduction
As with all other aesthetic procedures, the
value of an individual approach cannot be
emphasized enough in facial filler procedures.
Delivering elaborately tailored treatment out-
comes starts with a detailed assessment of the
individual face, based on which a customized
treatment strategy catering to the unique needs
of each patient should be established. Factors
to be considered during this assessment consist
largely of subjective and objective appraisal of
the face. Other relevant aspects including the
sociocultural environment of the patient, eth-
nic aesthetic preferences, and gender-specific
characteristics should also be broadly taken
into consideration. This chapter outlines the
approaches for identifying the patient’s sub-
jective aesthetic desires and expectations and
covers the steps for undertaking an objec-
tive evaluation of a patient’s face, including
the assessment of facial shape, aging-related
changes, facial symmetry, overall balance
of proportions, profile view of the face, and
dynamic expressions during facial animation.
On this basis, the following pages explain how
to formulate an individualized treatment plan
which also comprehensively considers such
other relevant factors as past medical history
of cosmetic interventions, socioeconomic con-
ditions, ethnic aesthetic ideals, gender-based
differences, and budgetary considerations of
the patient.
1.2
Individualized Assessment
During pretreatment consultations, it is impor-
tant to establish the relevant patient factors
that may potentially affect treatment outcomes.
These include subjective, objective, sociocultural,
and financial conditions as well as past medical his-
tory of aesthetic procedures. Individualized treat-
ment in the truest sense can be delivered only by a
treatment strategy that caters to the unique needs of
the individual patient across each of these aspects.
1.2.1
Subjective Factors
Given the subjective nature of beauty, it is vital first
and foremost to establish precisely what the indi-
vidual patient perceives as a key aesthetic concern
in his or her face. In order words, it is necessary
to clarify the patient’s main treatment goal and to
make sure both the patient and practitioner are on
the same page regarding this aesthetic goal. While
some patients may be more concrete in articulating
their exact aesthetic concerns down to the specific
type of wrinkle they wish to have addressed, others
may be more vague in their request and ask sim-
ply to have, for example, a more youthful look or a
softer appearance. In this case, the practitioner is
advised to dig deeper into the question and encour-
age the patient to specify their treatment priorities
in more precise terms. This is because patients will
not be pleased with the treatment outcome at the
end of the day unless their initial presenting com-
1

2
plaints have been satisfactorily resolved even if
positive improvements have been made in other
respects. To this end, in my practice, I usually
hold a mirror to the patient and ask them to pin-
point what it is exactly that bothers them about their
faces (Fig. 1.1a). Such “mirror consultation” has
the advantage not only of allowing the perceived
defect(s) to be appreciated and expressed in richer
detail but also of allowing the patient to realize any
other issues that they may have previously failed or
neglected to notice and inspire them to seek solu-
tions for those as well. Moreover, applying the
spreading test or the compression test at this stage
can further help the patient visualize the expected
outcome post-treatment (Fig. 1.1b).
Having nailed down the treatment priorities,
the next step is to manage patient expectations
regarding the treatment outcomes. This is cru-
cial to optimum patient outcome as patients
who have unrealistic expectations or the strict-
est standards are most likely to be dissatisfied
with the result no matter how good it may in
fact turn out to be. Indeed, ‘expectation manage-
ment’ is an established field of study within the
discipline of business administration, according
to which the customer’s satisfaction with a prod-
uct or service is said to be inversely proportion-
ate to their level of expectation. This implies,
assuming the goods or services concerned meet
required quality standards, it becomes impracti-
cal to satisfy a customer whose expectation level
is set too high. In aesthetic procedures such as
injectable filler treatments, accurate communi-
cation of expected outcomes is absolutely key
to managing patients’ expectations at levels
achievable by the practitioner. In this regard, it
is essential first and foremost, to lay down what
the practitioner may or may not reasonably
be expected to achieve with injectable fillers,
so patients with unrealistic expectations may
be guided in the right direction. For example,
patients should be counseled beforehand that
filling the tear troughs may not be of much ben-
efit in case puffy eye bags are also present above
the tear troughs. In this respect, visual represen-
tation is by far the most effective method for
managing patient expectations. While sophisti-
cated 3D imaging devices such as Vectra can be
used to help patients visualize what they might
look like after their treatment, in its absence,
a mirror can be used as a simple method for
simulating the postoperative results. A few use-
ful tests or manoeuvers can be done during the
mirror consultation to help patients foresee the
results, such as the “spreading test” for deep
glabella grooves or by pushing up the anterior
malar fat to see if it corrects the tear troughs.
a
b
Fig. 1.1 (a) Mirror consultation, (b) An 72-year-old sub-
ject with bulging eyebags and tear trough is shown the simu-
lated result after filler injection through mirror consultation
1 Pretreatment Assessment

3
Episode: The Light in Your Eyes
If you assumed botox and fillers were simply
the preserve of old people, given how they
are used as near synonyms of “wrinkle treat-
ment” you’d be surprised to learn how over
the years, there has been a steady and nota-
ble growth of young people in their 20s and
30s opting for these treatments. Originally
developed as anti-wrinkle treatments, botox
and fillers have now evolved beyond their
initial indication and have emerged as via-
ble tools for purposes of facial beautifica-
tion. Typical examples include masseter
reduction with botox for facial slimming
and the use of fillers for reshaping and
recontouring the nose, lips, and chin. Rather
than aimed at counteracting signs of aging,
these treatments are focused on aesthetically
enhancing and optimizing the congenital
structural deficits of the face and body, for
which, I suppose, there exists a ready market
across demographics of all ages.
Obviously, the fact that the threshold
age at which wrinkle-prevention starts has
been lowered to the late 20s or early 30s
also explains why the market for botox
and filler is getting increasingly younger.
As regards botox injections, they serve not
merely as a quick fix for expression lines
but upon repeat use offer the long-term
benefit of keeping the face less wrinkle
prone, as was already established world-
wide some 10 years ago. As a matter of
fact, when it comes to botox treatments, the
younger you start, the better. Since young
skin is naturally high in elasticity, wrin-
kles on a young face can be successfully
tackled with botox alone. By the time you
get to your 60s and 70s however, expres-
sion lines left neglected end up becoming
deep static wrinkles permanently etched
on the face like scars; the aging face also
undergoes volume depletion and soft tis-
sue ptosis, none of which can be satisfacto-
rily addressed with the use of botox alone.
Nonetheless, every now and then, I meet
patients in their 40s and 50s who come
in for anti-wrinkle consultations and even
after hearing out my explanation in full,
decline to get botox until much later in life.
Understandably, undergoing an aesthetic
procedure can be unnerving the first time
around. After all, the image of having toxin,
that is, botox, or a foreign material, that is,
fillers, shot in the face is perhaps not the
most comforting thought one can imagine.
Some might feel uneasy about the prospect
of having to rely on botox and fillers for the
rest of their lives, given the temporary nature
of these injectables and fret whether they
might not be starting too early on. However,
for those who refuse botox for reasons fall-
ing outside these vague concerns if not for
financial considerations, I simply smile
benignly and advise them to “Get started
while you’re still young and pretty. Why
hold out until you’ve become a granny?”
Personally speaking, I am at that stage in
my life where I’m not getting any younger
or fitter. If I’m getting any wiser though,
I’ve come to realize the value of living for
today. As the old Korean adage goes, the
reddest flower cannot last beyond 10 days
and even a grasshopper has its own sea-
son. It is a simple fact of life, just as the
moon waxes and wanes and flowers bloom
and wilt that nothing lasts forever includ-
ing our transient youth and beauty. For all
the euphemism about wrinkles being “the
medals of our passage of life,” let’s face it;
it is a basic human desire to stay forever
young and beautiful if possible. Though we
may never regain the vitality of fresh green
spring leaves we once embodied as teens
or recover the lusciousness of a blooming
flower we radiated in our twenties, advances
in modern medicine however have brought
us the next best thing; the ability to continue
looking our best and remaining elegantly
beautiful even in our 40s and 50s, with
proper maintenance and upkeep.
This year’s Baeksang Arts Awards for
Best Korean TV Drama was awarded to Kim
Hye Ja in honor of her overwhelming and
1.2 Individualized Assessment

4
transformative performance in the drama
series The Light in Your Eyes in which she
played the role of a young woman in her
20s who suddenly finds herself bumped up
to old age. Kim’s exceptional performance
which transcends generation to capture
both the sweet innocence of a 20 something
and the calm poise of an elderly woman,
combined with a brilliant screenplay carry-
ing a massive surprise ending, led the series
to become a smashing hit with a peak rating
of 9.7%. The series purports to be a fan-
tasy drama about a young woman who is
suddenly transformed into an elder due to
some inexplicable circumstances which rob
her of all her time; but it turns out—spoiler
alert!—that the whole narrative all along
had been one told by the old woman who
in fact was suffering Alzheimer’s disease.
The drama shed light on the precious-
ness of time and life, and a line from the
final episode resonated in particular with
many; “Don’t let the regrets of yesterday or
uncertainties tomorrow spoil your present.
Live for today. Let the light into your eyes.
This is your moment to shine. You deserve
nothing less” And that is exactly what I
remind myself at this very moment. May
those dazzling words of wisdom guide us
both in our lives and in removing our wrin-
kles. Carpe diem (May, 2019).
1.2.2
Objective Factors
An objective evaluation of a patient’s face consists
of a comprehensive assessment of the patient’s
biological factors such as gender and age, as well
as the extent of facial aging as manifested by the
lack of continuity in facial contour, characteristic
of facial lines and wrinkles, visibility of pores,
facial volume depression and sagging, and skin
thickness and elasticity, among others. As with
all other medical treatments, it is essential to
define the problem correctly before finding the
right solution, as an accurate diagnosis is the first
step toward achieving a successful postoperative
aesthetic result.
As such, prior to an injectable filler procedure,
each face should be assessed individually to iden-
tify the characteristics and aging changes specific
to the patient’s face. On this basis, it should be
determined whether the patient is the right can-
didate for the filler treatment, whether the pro-
cedure may not disrupt balance with the rest of
the face, and whether combination with other
treatment modalities should be considered. For
example, deep glabella furrows cannot be satis-
factorily erased with HA fillers alone but instead
requires the adjunctive use of BoNT-A. Likewise,
the sunken cheeks lateral to the nasolabial fold
need to be filled concurrently during a nasolabial
fold correction in patients with severely sunken
cheeks, to create a confluent transition between
these adjacent anatomical units.
1.2.3
Facial Assessment Flow Chart
As illustrated, a thorough and accurate assess-
ment of the patient’s face guides the artistry of
injectable filler injections and represents the
starting point for delivering elaborately tailored
treatment outcomes. To this end, a step-by-step
guide for analyzing the face can help ensure
that all necessary objective factors are considered
in a sequential manner. The flow chart in Fig. 1.2
has been drawn up to provide a visual illustra-
tion of the relevant steps to be performed. The
first step of a customized facial assessment con-
sists of facial shape analysis. With the oval facial
shape defined as the aesthetic ideal, the other
facial shapes are stylized into seven categories,
including round, oval, square, pentagon, oblong,
rectangular (or slender), and inverted triangle
shapes (Fig. 1.3). After placing the face into the
relevant category, the next step is to formulate the
aesthetic strategy for bringing the face closer to
the ideal oval shape. In square, pentagonal, rect-
angular, and round faces where the prominence
of the masseter m. or temporalis m. is the under-
lying cause, combination treatment with BoNT-A
is recommended for reducing the facial width.
Meanwhile, in faces featuring a pronounced
1 Pretreatment Assessment

5
Fig. 1.2 Facial analysis flow chart
zygoma, while the bony zygoma itself cannot be
reduced via injectable fillers, volume restoration
simultaneously in the temporal and lateral cheek
hollows can visually diminish the zygomatic
emphasis by blending its superior and inferior
borders with the lateral facial contour (Fig. 1.4).
Volumizing the zygomatic arch and sunken
cheeks in slender or inverted triangle faces not
only helps to ovalize the face but also creates the
illusion of a shorter facial length by adding facial
width. Conversely, chin augmentation in round or
square faces has the effect of slimming the face
and bringing it closer to the ideal oval shape by
adding the facial length (Fig. 1.5). While assess-
ing the facial shape, it is also essential to consider
the size of the face. It bears reminding in this
regard that patients with a naturally large, volu-
minous face should be injected with conserva-
tive amounts only as injectable filler procedures
serve primarily to add volume to the face.
The second step involves assessment of the
aging changes present in the patient’s face, includ-
ing the appearance and extent of facial wrin-
kling, sagging, and depression, and clumping of
facial fat (Fig. 1.6). Depending on the severity of
such symptoms, combination with other adjunct
procedures may be explored. For example, in
patients presenting with pronounced jowl fat and
jowl descent, volume correction of the sunken
cheeks alone may exacerbate the heaviness of the
jowls. In this case, the adjunct use of thread lifts
or energy devices such as high-intensity focused
ultrasound (HIFU) or fat-reducing injections
should be considered for lifting and tightening
the sagging face (Table 1.1). By the same token,
patients with under-eye bags presenting for tear
trough correction should be advised to also seek
surgical removal of the herniated infraorbital fat
for optimum results.
In the third step, facial symmetry should be
considered. Slight asymmetry is common in
most people and may even contribute to a more
natural-looking facial appearance. That said, those
with more pronounced forms of facial asymmetry
require adequate medical treatment, as such dis-
crepancy can be aesthetically displeasing. While
a definitive correction requires an orthodontic or
even surgical interventions including upper and
lower jaw surgery in severe cases, patients can also
benefit from moderate cosmetic improvements
with injectable fillers. Here, injectable fillers can
be placed strategically to augment the weaker side
of the face and to realign the canted maxilla/man-
dible to lie closer to the facial midline (Fig. 1.7).
The fourth step concerns facial balance. When
it comes to facial aesthetics, the whole is greater
than the sum of its parts. A face with the most
stunning and prominent eyes, nose, and mouth
may detract from beauty if each feature is not
congruent with each other. It is for this reason
that assessments should be performed regarding
the relative size and position of individual facial
features and the proportionality of the facial con-
tour to determine the overall balance and propor-
1.2 Individualized Assessment

6
Oval
Round
Square
Pentagon
Fig. 1.3 The facial shape analysis. Oval, round, square, pentagon, oblong, rectangular, and inverted triangle shapes
1 Pretreatment Assessment

7
Oblong
Inverted Triangle
Slender
Fig. 1.3 (continued)
1.2 Individualized Assessment

8
Fig. 1.5 Chin elongation with filler injection can bring about a slimmer V line in U-shaped face
Fig. 1.4 A pronounced zygoma can be camouflaged by volume restoration simultaneously in the temporal and lateral
cheek hollows leveraging optical illusion
1 Pretreatment Assessment

9
tion of the face. For example, a face that has a
disproportionately small mouth, as shown in the
composite image, tends to looks odd and out of
balance (Fig. 1.8). Further, even where the size
and shape of individual features remain attrac-
tively adequate, if one were to tip the balance of
their relative positions by, for instance, narrow-
ing the distance between the eyes or elongating
the length of the philtrum, this can also diminish
facial attractiveness (Fig. 1.9). Balance of pro-
portions is also important in assessing the facial
contour. Altering the proportions of the facial
contour by narrowing the width of the forehead
or chin, or widening the facial width can distort
the face and cause it to lose its proportional qual-
ity, even where the size and location of individual
features remain intact (Fig. 1.10).
In the fifth step, the face must be assessed
from the profile view. A side view of the face is
particularly important prior to the augmentation
Table 1.1 Treatment recommendation for square shape face depending on the aging pattern
Depression
Sagging
Fat accumulation
Recommended treatment
Square
None
None
None
FC_BoNT_A
Square
None
None
Yes
FC_BoNT_A, FRI or liposuction
Square
None
Yes
None
FC_BoNT_A, HIFU or thread lifting
Square
None
Yes
Yes
FC_BoNT_A, FRI, HIFU or thread lifting
Square
Yes
None
None
FC_BoNT_A, filler
Square
Yes
None
Yes
FC_BoNT_A, filler, FRI, (HIFU or thread lifting)
Square
Yes
Yes
None
FC_BoNT_A, filler, HIFU or thread lifting
Square
Yes
Yes
Yes
FC_BoNT_A, filler, FRI, HIFU, thread lifting
FC_BoNT_A facial contouring using botulinum toxin, FRI fat reduction injection, HIFU high-intensity focused
ultrasound
a
b
Fig. 1.6 Aging pattern (a) in oval shape and (b) in pentagon shape
1.2 Individualized Assessment

10
Fig. 1.8 A face that has a disproportionately small mouth, as shown in the composite image, tends to looks odd and out
of balance
a
b
Fig. 1.7 Facial asymmetry can benefit from cosmetic improvements using injectable fillers. (a) Before and (b) after
filler volumization
1 Pretreatment Assessment

11
of the forehead, nose, lips, and chin, as it gives
the best view of the incline of the sloping fore-
head, presence of a nasal hump, protruded lips,
receded chin, or protruded jaw, none of which
may be immediately apparent on the frontal
view (Fig. 1.11). This assessment should form
part of the decision-making process and inform,
for example, that a chin filler is not indicated
in a patient with a prognathia (protruding lower
jaws).
Fig. 1.9 Imbalance of relative positions between individual facial features can diminish facial attractiveness
Fig. 1.10 Balance of proportions is also important in the
facial contour. Altering the proportions of the facial con-
tour by narrowing the width of the forehead or chin, or
widening the bizygomatic distance, can distort the face
and cause it to lose its proportional quality, even where the
size and location of individual features remain intact
1.2 Individualized Assessment

12
The sixth step is to assess the face in animation
and to observe the movement of facial muscles
and the patient’s dynamic expressions in action.
It bears noting that in patients with a hypertro-
phic medial band of the orbicularis oculi m.,
the contraction of this band during smiling will
cause the orbicularis oculi to protrudes forward
and become visible. In these patients, volume
addition in the anterior malar may exacerbate the
bulging of this band due to the bunching of the
injected filler on muscle contraction. Such risks
should be clearly communicated to the patient in
advance or addressed with concurrent BoNT-A
injection into the band (Fig. 1.12). Also, patients
presenting with cheek dimples or whose cheeks
tend to project laterally on smiling due to the
partial insertion of the zygomaticus major m.
into the skin (Fig. 1.13) may end up with cheeks
that become puffy when they smile and stick
sideways like the cartoon character Mr. Bogus
(Fig. 1.14), as the injected filler is pushed out-
ward by the facial musculature. While it is impor-
tant for practitioners to tactfully pick up on these
features during patient consultation by observing
the patient’s dynamic expression during normal
talking and smiling, it is also useful to ask the
patient, where necessary, to animate their faces
for a direct assessment.
1.2.4
Sociocultural Aspects
It is useful to gain insight into the sociocultural
aspects of the patient, including their occupa-
tion, marital status, amount of downtime they
can afford to set aside for a bruise or edema to
subside, nationality, ethnic aesthetic ideals, and
gender-based characteristics, all of which should
form part of the treatment strategy. Appreciation
of such factors would guide the practitioner,
for example, that lower injection volumes are
appropriate for a patient whose profession com-
a
b
Fig. 1.11 Recessed chin can be more accurately diagnosed by (a) front view and (b) profile view
1 Pretreatment Assessment

13
pels them to stand in front of the camera, such
as news anchors, celebrities, and professional
models, as slightly less facial volume makes for
a more photogenic appearance. When counsel-
ing a male business executive in his late 40s, the
practitioner can recommend strategies for rejuve-
nating the face without making it look too obvi-
ous, for example, through the strategic placement
of injectable fillers mostly in the glabella frown
lines or infraorbital hollows.
Meanwhile, when approaching patients of dif-
ferent ethnicities, it is relevant to consider their
a
b
Fig. 1.12 The hypertrophic medial band of the orbicu-
laris oris m. (a) Contraction of the hypertrophic medial
band of the orbicularis oris m. (b) Anatomy of the medial
band of the orbicularis oris m
Fig. 1.13 Assessment of the face in animation
Fig. 1.14 Mr. Bogus
1.2 Individualized Assessment

14
ethnic aesthetic differences, as the preferred facial
shape and treatment goals vary widely between
Caucasians and Asians (see Sect 1.3). For exam-
ple, Koreans do not desire the Ogee curve coveted
by Caucasians as the aesthetic ideal, as they feel it
serves only to accentuate their prominent zygoma.
In contrast, Caucasians are less inclined to have
the characteristic baby face with full plump cheeks
most Koreans find appealing. That said, the per-
sonal preference of each patient should always be
enquired as well, as the patient’s personal beauty
standards may not always agree with that pursued
by his or her ethnic group. For example, a Korean
female based in Los Angeles working as a profes-
sional model or married to a Caucasian spouse
may elect to espouse the Caucasian standard of
beauty that prevails in her profession or her circle
of relationship. As an aside, it is worthwhile to
note that when treating temporal recessions in a
Chinese female patient, larger doses are preferred,
as full, rounded temples are considered an auspi-
cious trait that may potentially bring a woman a
perfect husband in the Chinese culture.
1.2.5
Gender-Specific Differences
Gender-specific differences must also be incorpo-
rated into the treatment plan. As portrayed in the
Composite Image of Attractive Korean Male and
Female Faces made from 10 input faces of Korean
celebrities (Fig. 1.15), men ideally have smaller
eyes and a larger nose compared to women. Also,
the zygomatic bone is ideally more prominent and
cheeks more flatter, if not slightly depressed, on a
man. The male chin is more extended and broader
than that of a female, which is smaller and pointier
in shape [1]. Concerning the ideal facial shape,
whereas a smooth oval face is desirable for females,
a strong, angular contour built on a well-defined
mandibular angle and robust masseter m. is con-
sidered more manly and charismatic in men. It is
thus vital to respect these sexual dimorphic traits
and vary the approach for male and female patients
accordingly. For example, when treating the infra-
orbital hollowness or sunken cheeks, injection of
discreet amounts is advised in men—just enough to
mitigate the severely gaunt, hollowed-out appear-
Fig. 1.15 Attractive composite faces of Korean males and females made from 10 input faces of Korean celebrities
1 Pretreatment Assessment

15
ance, whereas larger volumes to create a fuller, a
more voluminous contour is acceptable in females.
Too much volume in the male cheeks serves to
feminize a male face by taking the edge off the
desirably chiseled masculine contour. Regardless, it
is always appropriate to confirm with each patient
regarding his specific aesthetic preferences, as more
men in recent times opt to favor an androgynous or
effeminate appearance than before.
1.2.6
Past Medical History
of Aesthetic Procedures
While some patients would be undergoing the
injectable filler treatment for the very first time,
many have experiences with various different
cosmetic treatments ranging from BoNT-A injec-
tions, injectable fillers, liposculpture, and thread
lifts to surgical facelifts. In patients with a history
of past filler treatments, it is relevant to ask when
they had the procedure done and where, using
which product. Also, it is useful to review their
level of satisfaction from those procedures and
the occurrence of complications, if any.
While the results of these previous procedures
may appear to be favorable on the surface, they
typically leave tissue adhesions and scars in the
underlying subcutaneous tissue due to neocol-
lagenesis, which can be very hard and painful
to penetrate with a cannula during a subsequent
HA filler procedure. Further, the blood vessels
trapped within the substance of the scar tissue
present a greater risk of inadvertent intravascu-
lar injection of HA filler and extensive bruising
due to vessel rupture. Where tissue adhesions
are present, injecting HA fillers under the tis-
sue can be a challenge, as the tightly bound scar
tissues prevent the even deposition of HA filler
and cause surface irregularities. This can be par-
ticularly problematic when treating the forehead,
where only limited space is available for filler
placement. Here, tissue adhesions dotted across
multiple areas of the forehead may conspire to
restrict the creation of a smooth, even surface
contour. The situation is worse for patients pre-
senting with lumps and bumps in the forehead
left from an inadequately performed previous
procedure, be it implantation of injectable fillers,
autologous fat, or thread lift sutures. In the case
the previously implanted material consists of HA,
hyaluronidase injections can be administered to
remove existing irregularities before the proce-
dure; however, in the case of collagen stimulators
such as Sculptra® or El Ellansé™ or autologous
fat, irregularities are harder to treat since they
are the result of scar tissue adhesions created by
neocollagenesis. In such cases, it is necessary to
bring this to the patient’s attention prior to any
treatment, to prevent the patient from wrongly
attributing the less favorable outcome to the pres-
ent HA filler procedure.
To some extent, the patient’s past medi-
cal history of cosmetic interventions can lend
precious insight into their attitude toward the
filler treatment. First-time filler patients with no
prior experience of aesthetic procedures natu-
rally tend to be more concerned about the treat-
ment and the associated social downtime from
bruising and swelling. On the other hand, a few
pokes of a needle is hardly an issue for a patient
who has previously undergone more invasive
procedures such as mandibular angle resection
or a surgical facelift. This is particularly the
case for patients who have previously received
autologous fat transfers. Note, however, that,
unless asked directly, aesthetic patients would
rarely volunteer information regarding their past
cosmetic interventions. This is particularly true
of patients who received facial bone surgeries
performed intraorally, such as mandibular angle
resection or malar and zygoma reduction sur-
gery, as those surgeries would leave no appar-
ent scars on the exterior of the face. However,
it may be of value for the practitioner to ask
directly if the patient had any work done if the
patient happens to present an unnatural “step”
below the zygomatic arch (indicative of a pre-
vious zygoma reduction surgery) or an overly
linear jawline extending from the ear to the
chin (undoubtedly from an aggressive mandibu-
lar angle resection) as HA filler can be used to
restore the surgically removed volume in each
of those cases (see Sect 4.14).
1.2 Individualized Assessment

16
1.2.7
Financial Aspects
Costs represent an important, yet often neglected,
part of the conversation with the patient. It would
serve no purpose for the practitioner to extol the
benefits of a procedure that the patient could not
afford anyway, other than to leave the patient
feeling alienated. Ideally, it would be best if the
practitioner could make an educated guess of the
patients’ budget based on their age, profession,
reaction to suggestions of available treatment
options, as well as the practitioner’s pure intu-
ition. Otherwise, however, it might be a good idea
to ask the patient upfront what their budget is. For
patients who appear to be looking to stay within
a defined budget, the practitioner and patient can
work together to set priorities and determine the
best fit between what the patient perceives as
their biggest aesthetic concern and what, in the
practitioner’s professional judgment, can provide
the most visible results for the money spent.
When fillers are used for facial rejuvenation as
opposed to beautification of individual features
such as the lips or nose, a full facial approach is
commonly used to produce the optimum balance
of proportions among various facial features and
prevent regional disparity. However, as desirable
as this approach may be, adding volume across
multiple areas of the face requires the use of mul-
tiple filler syringes, which admittedly imposes
a financial burden on the patient. In this case, a
more preferable approach to give patients better
value for money is to charge not by the number
of syringes used or individual regions treated but
based on a package deal where reduced prices are
offered for 5–10 mL of filler used across the full
face.
Episode: On Being a Dad of Miss Korea
While being an MD specializing in der-
matology, I am also an aesthetic practi-
tioner whose work involves rejuvenating
or beautifying the facial appearance of
clients using injectables such as botox or
fillers. Helping people look younger and
more beautiful can be just as enjoyable
and gratifying as providing medical care to
patients with illnesses. Besides, since most
of the people visiting my clinic consist of
good-looking people seeking to improve
their already fairly good appearances, I get
to enjoy the extra perk of meeting a lot of
attractive faces in my daily practice.
I happened to come across one such
patient a few years ago; a glamour-
ous healthy-looking female patient in her
20s who introduced herself as the previ-
ous year’s Miss Korea winner and came
in to consult whether she could possibly
beautify what she described as her “plain
face” with the use of nonsurgical proce-
dures. Unfortunately, I couldn’t be of much
assistance to her since she presented with
relatively large zygoma and a wide nasal
base, features which made her a bad can-
didate for filler volumization. Since fillers
are indicated to literally fill out areas of
volume deficit on the face such as grooves,
creases, or sunken cheeks, if not to aug-
ment a flat nose or enhance small lips, it is
not applicable to reducing a wide nose or a
prominent zygoma. Perhaps, it was due to
the fact that she was wearing no makeup,
but I had to agree that she had more of a
casual, modest girl-next-door quality to
her face rather than being a case of divine
beauty. The patient happened to be of simi-
lar age with my youngest daughter. Perhaps
for that reason, just as the owl might think
her own young fairest, I soon found myself
entertaining the idea of having my own
girl, who in the eyes of her doting dad was
by no means less beautiful, enter the Miss
Korea contest of that year, which she even-
tually did and won.
Sure enough, defining facial beauty
remains a widely debated topic, and yet I
am a strong proponent of facial proportion-
ality which, I believe, trumps most other
factors of facial attractiveness such as hav-
ing fair skin, large eyes, tall nose, full lips,
or a sharp jaw line. While I am no fan of
1 Pretreatment Assessment

17
any blind, across-the-board application of
the golden ratio that does not respect each
patient’s individuality and character, with-
out there being some sense of proportional-
ity among individual features, the face can
appear bizarrely distorted and unattractive.
To illustrate this point in my lectures
and seminars, I often use multiple manip-
ulated images of Angelina Jollie’s face.
Reducing the size of the eyes, nose, and
mouth on Angelina Jollie’s face alone
does not significantly affect her facial
attractiveness. However, when her facial
proportions are altered by way of reduc-
ing the intercanthal distance or by elon-
gating the philtrum, the face immediately
becomes distorted and weird looking. The
same happens when her eyes, nose, and
mouth are left intact, but the facial shape or
contour is distorted out of proportion, by
narrowing the forehead, reducing the chin,
or augmenting the malars. This demon-
strates how balance among facial features
rather than the aesthetics of individual
elements play a bigger role in determining
facial attractiveness. To her credit, while
my youngest daughter does not exactly
fit the profile of a classic beauty featur-
ing big eyes and tall nose, she is nonethe-
less endowed with a small oval face with
a harmonious balance between individual
structures, which combine to create a
sublime oriental allure. I guess this gives
me some vindication when I say, in her
father’s trained eyes, she’s worthy of the
title Korean Beauty Queen by all means.
Beauty is not the only area where bal-
ance matters. For almost all things in life,
there can be too much of a good thing,
and you need to know how to strike the
right balance. Korean voters have demon-
strated an amazing, almost uncanny sense
of balance in this regard by allowing the
transition of power from the left-wing gov-
ernment to the right and back to the left at
exactly 10-year intervals. Yet, the beauty of
such harmony seems to be lost on the cur-
rent government, caught up with “liquidat-
ing deep-rooted corruption” while leaving
the economy to languish under the ambigu-
ous and unproven policy of ‘income-driven
growth’. To borrow from the Korean movie
Friend, “Give it a break pal. I’ve had
enough already” (Nov 2018).
1.3
Consideration of Ethnic
Differences in Filler
Procedures
Attempts to define a perfectly ideal face have led
some to advocate using a single universal stan-
dard such as the golden ratio or the phi mask
for describing facial attractiveness. However,
the qualities of a beautiful face can rarely be
distilled down to a single or uniform formula.
On the contrary, the standard for facial beauty
constantly evolves with time and varies among
different ethnic groups. While attending filler
training sessions given by western practitioners
many years ago as a novice injector, it was never
quite clear to me how the inverted triangle drawn
over Brigitte Bardot’s face connecting her bilat-
eral zygoma with the pogonion, or the triangle
of beauty as it was called, purported to represent
the gold standard for an aesthetic face. Likewise,
I struggled to fathom how the prominent lateral
zygoma set against the slightly concave temples
and subzygomatic regions was meant to create
the purported hallmark of all youthfully beauti-
ful faces referred to as the Ogee curve [2]. This
is because a prominent zygoma contrasted with
sunken cheeks is considered an aesthetically dis-
pleasing trait by an average Korean female whose
concept of facial beauty consists of an oval baby-
ish face with full plump cheeks. As such, accen-
tuating the triangle of beauty by augmenting the
lateral cheekbones and brows would hardly trans-
late well onto an Asian face already endowed
with a congenitally wide frame and prominent
cheekbones. Eventually, I came to learn how
such incompatibilities arose from the differences
1.3 Consideration of Ethnic Differences in Filler Procedures

18
in the underlying craniofacial anatomy between
Caucasians and Asians, whereby Caucasians
generally have an anteroposteriorly long and
transversely narrow dolichocephalic head in
contrast to the transversely wide brachycephalic
facial bone structure presented by Asians. This
chapter details the ethnic differences to consider
when undertaking volumizing filler procedures
on ethnic patients, with a focus on the treatment
of Asians.
1.3.1
Definition of the Asian
Population and Asian Facial
Morphotypes
The Asian continent represents a vast territory
spanning from the Middle East to Northeast
Asia, encompassing highly diverse and hetero-
geneous ethnics groups who cannot be described
as a uniform population. Thus, for the sake of
consistency, the term Asia as it appears in this
chapter is defined narrowly, referring only to the
East Asians including the Chinese, Korean, and
Japanese as well as the Southeast Asian popu-
lations, and does not extend to cover ethnici-
ties from India and Arabic nations whose faces
bear a closer resemblance to that of Caucasians.
Even under this narrow definition, the Asian face
can be categorized into three different morpho-
types based on geographic regions, that is, the
northern, intermediate, and southern facial types
(Fig. 1.16). The northern facial type is commonly
seen in the populations of Mongolia, Northern
China, and Korea, while the southern facial type
is typical of those from the Philippines, Thailand,
and Vietnam, and the intermediate facial type is
common among those from Hong Kong, Taiwan,
and Southern China (Fig. 1.17) [3].
Concerning the specific morphological fea-
tures, the northern facial type manifests promi-
nent a mandible and zygoma, which conspire to
produce a square facial frame; it also features
narrow palpebral fissures without any supratar-
sal crease and a high nasal dorsum with small,
narrow nasal ala (Table 1.2). The skin is usually
fair, corresponding to Fitzpatrick skin types 2 or
3. The southern facial type is defined by a small
oval face framed by a less prominent mandibu-
lar angle and zygoma, wide palpebral fissures
with a distinct supratarsal crease, and a flat nasal
dorsum with wide, round nasal ala. The skin
tends to be darker and more pigmented than the
northern type (Fitzpatrick skin type 4 or 5). The
intermediate facial type is defined by a round
face owing to a relatively small chin. The facial
components of the intermediate face (eyes, nose,
and mouth) represent a blend of the other two
face types. Of course, this classification does not
purport to be the absolute standard against which
Fig. 1.16 Asian facial morphotypes of northern, intermediate, and southern facial types (from left to right)
1 Pretreatment Assessment

19
to identify and discern Asian faces. Different
facial morphotypes may be found within a sin-
gle geographic region, while a single individual
may manifest different morphotypical features
across distinct parts of the face (Fig. 1.18) [4].
Nonetheless, the classification lends valuable
guidance for providing individualized treatments
to Asian patients of varying facial types and aes-
thetic desires.
1.3.2
Differences in the Skull Shape
Between Caucasians
and Asians
A glaring distinction between the Asian and
Caucasian faces lies in their skull shape.
The Asian face is characteristically wider and
flatter than that of Caucasians. Whereas the
dolichocephalic Caucasian head is anteroposte-
Table 1.2 Characteristics of different Asian facial morphotypes
Northern
Intermediate
Southern
Regions
Mongolia, Northern
China, Korea, etc.
Hong Kong, Taiwan,
Southern China
The Philippines, Thailand, Vietnam, and
other Southeast Asian countries
Facial shape
Square
Round
Narrow, oval
Zygoma
Prominent
Intermediate
Not prominent
Mandibular
angle
Prominent
Intermediate
Less prominent
Palpebral
fissure
Narrow
Intermediate
Wide
Supratarsal
crease
Absent
Intermediate
Present
Nasal dorsum
High
Intermediate
Low
Ala nasi
Small narrow
Intermediate
Wide round
Fig. 1.17 Asian facial morphotypes based on geographic regions
1.3 Consideration of Ethnic Differences in Filler Procedures

20
riorly long and transversely narrow, the brachy-
cephalic Asian cranium is transversely wide and
anteroposteriorly short (Fig. 1.19). Furthermore,
the Asian head is hypsicranic, that is, with a high
cranial vault, where the vertical height of the head
is long relative to its anteroposterior length, while
the lower face and chin tend to be relatively small
[5]. Another salient feature that distinguishes the
Asian face from the Caucasian is the prominence
of the zygoma and mandibular angle. The relative
lack of nasal dorsal projection observed in Asians
further contributes to the flattened appearance of
the face.
1.3.3
Differences in Facial Beauty
Standards Between
Caucasians and Asians
Regardless of ethnicity, a distinction is drawn
between the average and the ideal faces of that
ethnic group. The features mentioned earlier,
which make up the average Asian face, do not
represent the ideals of facial beauty Asians
aspire to. In the following section, we explore
the distinct features of facial beauty pursued,
respectively, by the average Caucasian vs. Asian
so that tailored aesthetic treatments may be pro-
vided according to each group’s different aes-
thetic goals [6].
As illustrated in Fig. 1.20, an attractive
Caucasian face tends to demonstrate the follow-
ing characteristics: narrow distance between the
eye and brow, deep-set eyes, and high arched
brows; large, open eyes with a tall, distinct supra-
tarsal crease; and absence of lower pretarsal
fullness. The nose is tall with a sharp bridge, nar-
row ala nasi and sidewalls, and a well-projected
pointed tip. The preferred facial features also
include large, voluminous lips, a well-defined
mandibular angle, and pronounced cheekbones
highlighted by subtle concavities in the submalar
cheek and temples. On the contrary, an attractive
Asian face is characterized by the following fea-
tures: straight, horizontal brows sitting relatively
far above the eyes; a flat upper eyelid devoid of
hollowness; small relatively large eyes without
a distinct supratarsal crease; and the presence of
lower pretarsal fullness. A beautiful Asian face is
also correlated with a slightly rounded nasal tip
and a moderately projected nasal dorsum, as well
as moderately voluminous lips, all of which are
framed by an oval face with full cheeks without
zygomatic or mandibular prominence (Table 1.3).
Such ethnic differences in facial beauty stan-
dards have been well-established in a study
whereby attractive composite faces of differ-
ent ethnicities were produced for comparative
Fig. 1.18 A single individual may manifest different
morphotypical features in distinct parts of the face. This
beautiful Korean woman demonstrates certain southern
type features such as the supratarsal crease and wide pal-
pebral fissure but also displays distinct northern type char-
acteristics such as the prominent zygoma, a wide face, and
narrow nasal base
1 Pretreatment Assessment

21
Fig. 1.19 The dolichocephalic Caucasian head (left) and the brachycephalic Asian head (right). (Photo: courtesy of Dr.
Tommy S. Hwang)
Fig. 1.20 Comparison between the attractive Caucasian vs. Asian faces (Cited from Ref. [6])
1.3 Consideration of Ethnic Differences in Filler Procedures

22
analysis based on the images of popular female
celebrities representing the relevant ethnic
groups [7, 8]. Specifically, if we compare the
Caucasian composite face morphed from input
faces of beautiful Caucasian actresses includ-
ing Angelina Jolie and Hillary Duff against the
Asian composite face generated using the faces
of Korean celebrities including Lee Young-Ae,
Kim Tae-Hee, and Song Hae-Kyo, certain salient
differences can be found (Fig. 1.21). The ideal
Caucasian female face tends to have a nar-
row palpebral height, large well-defined facial
components (eyes, nose, and mouth), relatively
hollow cheeks, prominent zygoma, and a more
chiseled mandible, which altogether gives a more
masculine appearance compared with the ideal-
ized Asian face (Fig. 1.16).
Even within the East Asian population, subtle
differences exist among the attractive Chinese,
Japanese, and Korean faces, with the Chinese
face demonstrating the narrowest facial width
and slimmest cheeks while the Japanese face dis-
Fig. 1.21 Comparison of attractive composite faces between Caucasians vs. Asians made from 10 input faces of celeb-
rities belonging to each ethnicity
Table 1.3 Differences between Asian and Caucasian
attractive faces
Caucasian
Asian
Eyebrows
Arched
Straight
Distance
between the
eye and brow
Narrow with
hollow upper
eyelid
Wide with flat
upper eyelid
Facial shape
Triangle of
beauty
Oval
Zygoma
Prominent
Less prominent
Mandibular
angle
Well-defined
Less prominent
Cheeks
Slightly
concave
Full, chubby
Eyes
Wide
Relatively large
Supratarsal
crease
Present
Absent or narrow
Lower
pretarsal roll
Absent
Present
Nasal tip
Pointed
Relatively Rounded
Nasal
dorsum
Tall, sharp
Moderately
projected
Ala nasi
Small, narrow
Relatively wide
Lips
Full, large
Moderately
voluminous
1 Pretreatment Assessment

23
plays the most robust chin projection (Fig. 1.22)
[8]. From these composite faces, we can con-
clude that while certain similarities may exist
among the most beautiful women, the perception
of facial attractiveness is never uniform across
ethnicities and may not be captured solely by
means of a uniform formula such as the golden
ratio, but is described more as a function of the
intricate interplay between various biological,
cultural, and cognitive factors. Therefore, it is
vitally important for practitioners to develop a
keen appreciation for such distinct ethnic aes-
thetic preferences and provide nuanced treatment
catering to the concept of beauty pursued by each
ethnicity.
1.3.4
Different Filler Treatment
Strategies for Caucasians
and Asians
1.3.4.1 Different Strategies for Facial
Contouring Based
on Underlying Anatomical
Differences
As mentioned earlier, due to the varying underly-
ing structural facial anatomy between Caucasians
and Asians, the ideal face shape pursued by the
two groups is different, which must be respected
when undertaking filler treatments. For example,
since Caucasians tend to have a long, narrow dol-
ichocephalic head, midface augmentation pro-
cedure in a Caucasian patient typically consists
of volumizing the lateral zygoma to accentuate
the triangle of beauty coveted by Caucasians.
However, replicating this same approach, that
is, horizontal midface augmentation, in a north-
ern facial type Asian with a brachycephalic head
would produce deleterious results, serving only
to make their broad faces appear bigger and
wider. Instead, a vertical midface augmentation
which aims to project forward the midline facial
features of the forehead, nose, medial malar, and
chin, etc., and deemphasizing the lateral aspects
is more advisable in Asians, as the anterior pro-
jection and three dimensionality added to the
face serves to produce a visually slimming effect
(Table 1.4; Fig. 1.23).
Likewise, while lateral brow elevation or jaw-
line contouring with fillers (i.e., enhancing the
lateral borders of the mandibular angle to give
the face a squarer shape) may be suitable for
accentuating and defining a narrow Caucasian
face, such indications are hardly ever practiced
Korea
China
Japan
Fig. 1.22 Comparison of the attractive composite faces of Korean, Chinese, and Japanese females made from 10 input
faces of celebrities belonging to each country (from left to right)
1.3 Consideration of Ethnic Differences in Filler Procedures

24
in Asians since laterally expanding the already
broad Asian face would only serve to make the
face appear wider and more rugged. On the con-
trary, to achieve the Asian aesthetic goal of a soft
oval face, a popular indication among Asians is
to volumize the sunken temples and submalar
hollows to subdue the prominence of the lateral
zygoma and smoothen the lateral facial contour
extending from the temples toward the jawline
(Fig. 1.24). However, when performing this
indication in a Caucasian face, volume should be
added more conservatively only to the extent of
reducing the severity of the temporal and subzy-
gomatic recesses to preserve the integrity of the
Ogee curve considered aesthetically desirable
by Caucasians. Chin augmentation or chin tip
enhancement is also a highly requested indica-
tion among Asians to sculpt the jawline into the
desired V-shape and add vertical height to the
face, making it appear slimmer overall in rela-
Fig. 1.23 Different
strategies for midface
augmentation between
Caucasians vs. Asians
Table 1.4 Difference in filler indication between Caucasians and Asians by facial region
Caucasian
Asian
Forehead augmentation
Reported mainly on forehead concavity
Popular/Adds dimension and
convexity to flat Asian faces
Lateral eyebrow augmentation
Achieves brow arching via lateral
enhancement of the brow
Seldom practiced
Temple augmentation
Only to the extent of improving the
severity of the depression
Popular
Malar augmentation
Lateral malar enhancement
Infraorbital medial malar
enhancement
Mandibular angle augmentation
Adds definition and volume support to
a thin narrow face
Seldom practiced
Cheek augmentation (sunken
cheek)
Only to the extent of improving the
severity of the depression
Popular/creates fullness in the
cheeks to resemble a baby face
Sunken eye volumization
Only to the extent of improving the
severity of the hollowness
Recent gain in interest
Pretarsal roll augmentation
Rarely practiced
Popular
Nose augmentation
Confined mostly to nasal hump
correction
Popular
Lip augmentation
Popular
Recently popular
Chin augmentation for receded
chin/V-shaped jawline
Primarily for receded chin correction
Both indications popularly
requested
1 Pretreatment Assessment

25
tion to the facial width. Other procedures com-
monly used in Asians to add dimensionality and
projection include forehead augmentation, filler
rhinoplasty, and receded chin augmentation
(Fig. 1.18).
1.3.4.2 Different Strategies for Shaping
Facial Features (Table 1.5)
Nose augmentation represents one of the most
popular and well-established filler procedures
among Asians who have a relatively low set
nasal dorsum compared with Caucasians. This
is in contrast to Caucasians for whom filler rhi-
noplasty is practiced more sparingly, primarily
for correcting a nasal hump or bifid nose tips.
Though among the Asian facial morphotypes, the
northern facial type tends to feature a relatively
taller nasal dorsum, nose fillers are routinely used
even in this group for nasal hump correction or
for the partial augmentation of the upper dorsum.
This is relevant for patients with a narrow naso-
frontal angle as it helps to smoothen the transi-
tion between the superciliary arch and the nasal
dorsum. In southern facial type Asians who char-
acteristically have a flat nose with a wide nasal
base, filler rhinoplasty is applied not only for
elevating the nasal dorsum but also for projecting
and cephalically rotating the nasal tip by placing
fillers in the columella and the subnasale region
to open the nasolabial angle. It should be noted
that Asians generally tend to have a rounded
nasal tip, and therefore, direct injection in the tip
is best avoided as it is likely to create a bulbous
appearance. Hence, only a tiny judicious amount
of filler is advised in the nasal tip just enough to
provide slight accentuation.
Table 1.5 Filler indication for different Asian facial morphotypes by facial region
Northern
Intermediate
Southern
Pretarsal roll
augmentation
Popular
Popular
Only when favored by the patient
Malar
augmentation
Confined to infraorbital
medial malar enhancement
Confined to infraorbital
medial malar
enhancement
May optionally combine lateral
malar augmentation in those
with a thin narrow face
Mandibular angle
augmentation
Not indicated
Not indicated
May be indicated for thin narrow
face
Chin augmentation
Primarily for receded chin
correction
For both V-shaped
jawline and receded chin
correction
Primarily for receded chin
correction
Nasal dorsum
augmentation
Nasal hump correction/nasal
dorsum augmentation
preferred
In both nasal dorsum and
the subnasale
In both nasal dorsum and the
subnasale
Fig. 1.24 Different
strategies for achieving
the ideal facial shape for
Caucasians vs. Asians
1.3 Consideration of Ethnic Differences in Filler Procedures

26
Meanwhile, whereas high arched eyebrows
with lateral peaks are considered a favorable
feature in a Caucasian female, and thus eyebrow
augmentation with fillers is commonly performed
in Caucasians to gently lift the lateral brow, eye-
brow arching is seldom practiced in Asians who
much prefer to have straight horizontal brows.
On the other hand, the use of fillers for sunken
upper eyelid treatment is an indication that has
recently gained popularity among Asians as it
gives the eyes a more youthful and rested appear-
ance. In Asians for whom fullness in the upper
lid is the norm, the appearance of hollowness in
the eyes tends to be more strongly correlated with
the perception of tiredness and aging compared
with Caucasians for whom deep-set eyes with
narrow distance between the eye and brow is a
more common facial feature.
Caucasians and Asians also differ in their
aesthetic preference for lower pretarsal fullness.
Pretarsal hypertrophic roll a.k.a. charming roll
is a structure generated or accentuated by the
contraction of the palpebral portion of the orbi-
cularis oculi m. while smiling. For this reason,
the constant presence of pretarsal fullness at rest
imparts a soft, friendly smiling impression as
well as framing the eye fissures in such a way to
give the illusion of enlarged eyes. For this rea-
son, they are called the ‘supratarsal crease’ for
the lower lid. Among Koreans, augmenting the
pretarsal roll with fillers is a particularly popu-
lar indication (Fig. 1.25). From the Caucasian
viewpoint, however, the pretarsal roll may serve
as a factor that makes the small Asian eye appear
even smaller. In fact, this motivated the devel-
opment of a novel BoNT-A indication for the
removal of the pretarsal roll for widening the eye
fissures [9].
Removing the lower pretarsal roll with this
method, however, inhibits the contraction of eye
fissures during a smile, which prevents the eyes
from smiling along with the rest of the face, cre-
ating a rather uncanny disparity (Fig. 1.26). At
rest, it results in lower white sclera show, creat-
a
b
Fig. 1.25 (a) Before and (b) after pretarsal roll augmentation combined with filler volumization for sunken eyes and
tear trough
1 Pretreatment Assessment

27
ing a rather negative macabre image. For this rea-
son, this procedure is absolutely contraindicated
in Koreans. Instead, most Asians, especially the
northern facial types, appreciate the benefits of
filler injection to their lower pretarsal roll. That
said, southern facial types who tend to share
the Caucasian aesthetic ideal of large, round,
almond-shaped eyes may occasionally elect to
have their lower pretarsal fullness removed with
BoNT-A treatment. As such, the pretarsal roll
treatment should be determined based on the
patient’s expressed preference.
Lip augmentation has traditionally been a
popular aesthetic indication among Caucasians
who find large, voluminous lips appealing. On
the other hand, the explosion in enthusiasm for lip
fillers is a relatively recent phenomenon in Asia,
which has taken hold over the past few years.
Attesting to this new trend, there is now even an
aesthetic dermatology clinic in Seoul practicing
only lip volumization procedures to the exclusion
of all other aesthetic treatments. Finally, chin
augmentation in Caucasians is performed primar-
ily to restore a receded chin as opposed to defin-
ing the chin tip (a.k.a. “V-line filler”) since their
already long, narrow faces do not require further
elongation. In contrast, a combination of receded
chin correction and V-line filler is routinely used
in Asians, particularly in intermediate face types,
to add both volume and vertical length to the chin
since the face often demonstrates not only a weak
chin but also a rounded facial shape due to lack
of facial length.
1.3.4.3 Summary
Knowledge of the different facial aesthetic goals
between Caucasians and Asians for the ideal
facial shape and facial attractiveness is the start-
ing point for delivering the right aesthetic treat-
ment for the right ethnic population. The same
applies when undertaking volumizing filler pro-
cedures. As previously noted, the average Asian
face tends to be wide and flat, presenting with
enlarged zygoma and a relatively small lower
facial third. For this reason, vertical midface
augmentation accentuating the midline features
of the forehead, nose, and chin, etc., to increase
anterior projection and create the perception of
a slimmer face is preferred for volumizing an
Asian face and thus achieving the aesthetic ideal
of an oval baby-like face. Similarly, augment-
ing the sunken temples and submalar hollows to
obscure the appearance of the prominent zygoma
is commonly used in Asians to smoothen the
lateral facial contour and achieve a softer taper
toward the lower face. Finally, the Asian face
a
b
c
d
Fig. 1.26 (a, c) Before and (b, d) after removing the lower pretarsal roll with botulinum toxin injection
1.3 Consideration of Ethnic Differences in Filler Procedures

28
can be classified into three distinct morphotypes,
namely, the northern, intermediate, and southern
facial types, and differentiated solutions should
be provided consistent with the aesthetic goals of
each group.
References
1. Hu KS, Koh KS, Han SH, Shin KJ, Kim HJ. Sex deter-
mination using non-metric traits of the mandible in
Koreans. J Forensic Sci. 2006;51(6):1376–82.
2. Goodman GJ. Facial attractiveness and the central role
of volume. In: Carruthers J, Carruthers A, editors. Soft
tissue augmentation. Philadelphia: Elsevier; 2018.
p. 7–15.
3. Sundaram H, Huang PH, Hsu NJ, Huh CH, Wu W,
Wu Y, Cassuto D, Kerscher MJ, Seo KI, Pan-Asian
Aesthetics Toxin Consensus Group. Aesthetic applica-
tions of botulinum toxin A in Asians: an international,
multidisciplinary, pan-asian consensus. Plast Reconstr
Surg Glob Open. 2016;4(12):e872.
4. Seo KK. Aesthetic use of botulinum toxin in Asians.
In: Benedetto AV, editor. Botulinum toxins in clini-
cal aesthetic practice, Functional anatomy and injec-
tion techniques, vol. 2. 3rd ed. Boca Raton, FL: CRC
Press/Taylor and Francis Group; 2018. p. 299–309.
5. Kim HJ, Seo KI, Lee HK, Kim JS. Clinical anatomy
of face for botulinum toxin and filler injection. Berlin:
Springer; 2016. p. 45–8.
6. Seo KK. Botulinum toxin for Asians. Singapore:
Springer Nature Ltd.; 2017. p. 37–43.
7. Rhee SC, Lee SH. Attractive composite faces of dif-
ferent races. Aesthet Plast Surg. 2010;34:800–1.
8. Rhee SC. The average Korean attractive face. Aesthet
Plast Surg. 2006;30(6):729–30.
9. Flynn TC, Carruthers JDA, Carruthers JA. Botulinum
toxin treatment of the lower eyelid improves infra-
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2001;27(8):703–8.
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29
© Springer Nature Singapore Pte Ltd. 2021
K. K. Seo, Facial Volumization with Fillers,
Volumizing Fillers
2.1
Types of Injectable Fillers
By definition, fillers refer to all materials added
to provide filling efficacy in areas of volume defi-
cit. In facial aesthetic procedures, these include
materials placed in the face to lift etched-in
grooves or to revolumize facial depressions. In
this sense, a broader definition of the term may
include autologous fat used in fat graft proce-
dures or, for that matter, encompass even paraffin
or silicon previously used widely in illicit cos-
metic treatments. That said, the first injectable
filler recognized as a legitimate medical device
was based on collagen—a structural component
of the skin matrix. In the early 1980s, bovine-
derived ZYDERM® (Allergan. the US) was intro-
duced to the market, representing the very first
modern-day injectable filler to be approved by
the US FDA (Fig. 2.1). However, due to their ani-
mal origin, the use of bovine collagen-based fill-
ers was constrained by the inherent risk of
immunogenic reactions and their short duration
of effect. Accordingly, with the subsequent
advent and dominance of HA fillers, bovine col-
lagen fillers soon fell out of favor globally.
Today, injectable fillers are still commonly
referred to as “dermal fillers”, maybe due to the
fact that the first fillers ever to be used was
collagen-based. Granted, collagen does represent
an essential building block of the dermal archi-
tecture, and indeed collagen fillers had originally
been injected directly in the dermis to improve
skin elasticity and wrinkles. However, the use of
injectable fillers has since evolved significantly
and today they are utilized not simply for refining
lines and wrinkles but in an exciting array of new
and minimally invasive cosmetic procedures that
leverage the volumizing effect of injectable fillers
(Fig. 2.2) [1]. Examples include enhancing a flat
nose or plumping thin lips, if not reshaping the
facial contour. Moreover, whereas the term “der-
mal filler” implies they are injected into the der-
mis, the depth of injection required for these
volumization procedures is much deeper than
that, that is, in the deep subcutaneous or even
down onto the supraperiosteal plane. On this
basis, it may be fair to suggest the term “dermal
filler” has become a misnomer, and that it is high
time the modifier “dermal” was duly removed.
After collagen fillers, HA came to dominate
the world market for injectable fillers. The key
drivers of its success were its excellent safety
profile consisting of the same constituents that
make up the dermis, causing minimal immuno-
genic responses in the body, and its unique ability
to be reversible, whereby results could be dis-
solved away if so desired using a reversal agent.
On top of its unmatched safety, HA fillers have
also proven to show an excellent duration of
effect. While initially HA fillers were understood
to last between 6 months and 1 year in the tissue
when first introduced in the early 2000s, it is now
widely accepted that their longevity can last for
up to several years if injected in boluses or given
in repeat maintenance dosages. This is because
when the HA filler is injected in the form of a
2

30
bolus, it limits the per unit surface area of the HA
filler that comes into contact with the body’s
hyaluronidase, inhibiting degradation by the
enzyme. Notably, HA filler placed in the fore-
head, nasal dorsum, and the pretarsal roll regions
tends to show longevity lasting for as long as
5–10 years.
While the first HA filler to come to market
was Hylaform® (Hylan B gel) (Genzyme
Biosurgery) extracted from rooster combs, the
product was driven out of use due to problems
associated with protein impurities from avian
sources and subsequently, HA fillers have been
made using purified HA from bacterial sources
such as streptococcus, which remain to this day
to be the most dominant product on the market.
Whereas collagen-based or HA fillers are
designed primarily to replace and restore lost vol-
ume (“replacement filler”), collagen-stimulating
fillers, also known as biostimulating fillers, con-
sist of biodegradable polymers that induce colla-
gen biostimulation in the injected area while they
themselves slowly degrade in the body. Prime
examples of these collagen-stimulating fillers
include Radiesse® for calcium hydroxylapatite
(CaHA) and Sculptra® for poly-l-lactic acid
(PLLA) (see the Sect. 2.4.3). In general, these
collagen-stimulating fillers are known to provide
better longevity compared with HA fillers. The
drawback to these fillers, however, is that they do
not allow customization of volume correction, as
results are subject to individual variability in col-
lagen production; and that it takes 4–12 weeks for
the new collagen to build whereas the initial vol-
ume replenishment from the carrier substance, be
it CMC (carboxymethylcellulose) or saline, dis-
sipates shortly after the treatment. Moreover, the
results of collagen-stimulating fillers are hard to
Fig. 2.1 ZYDERM®1
2 Volumizing Fillers

31
reverse in the event of any nodules or irregulari-
ties arising from uneven placement of the
product.
Meanwhile, products such as PAAG (poly-
acrylamide gel)-based Aquamid® or PMMA
(polymethyl methacrylate)-based Bellafill® were
developed to provide prolonged longevity based
on the use of permanent synthetic substances (see
the Sect. 2.4.2). However, whether these perma-
nent fillers are necessarily a good option remains
open to question, considering that the underlying
facial structure is not permanent. With aging, the
face loses its youthful definition due to the pro-
gressive sagging and clumping of facial tissue,
which continues well after these permanent fill-
ers are placed. Consequently, this can result in a
disharmonious appearance between the injected
area and the rest of the aging face. Moreover, the
permanency of fillers also implies that potential
complications arising from such permanent or
semipermanent solutions are also permanent, for
which surgical removal remains the only option.
2.2
Hyaluronic Acid Fillers
Hyaluronic acid (“HA”) represents the most
widely used type of injectable filler in the world,
with its excellent biocompatibility, low immuno-
genicity, and reversibility putting it far ahead of
other types of injectable fillers (Fig. 2.3). While
commercial HA filler products are more or less
similar to each other in appearance, there exist
slight distinctions in terms of their HA concen-
tration, cross-linking technology, degree of cross-
links, viscosity, gel hardness, cohesivity, etc.
Differences exist even among products within the
same brand of HA filler, and knowledge of such
characteristics is critical for customizing the use
of each product for its intended use.
Fig. 2.2 The use of injectable fillers for three-
dimensionality and volumizing effect. A 31-year-old
female patient showed marked changes after receiving
volumization filler injection for sunken cheeks, nose,
chin, and anterior medial malar area
2.2 Hyaluronic Acid Fillers

32
2.2.1
Characteristics of HA
Hyaluronic acid is a high-molecular-weight poly-
mer comprised of repeating disaccharides first
discovered in 1934 by Karl Meyer and John
Palmer in the vitreous body of bovine eyes [2].
Hyaluronic acid is said to derive its name from
hyaloid (meaning vitreous) and uronic acid, a
component of repeating dissacharide units. In the
natural state, hyaluronic acid exists in the salt
form, mostly as sodium hyaluronate bound to
sodium (Na), a cation most widely found in the
human body. In 1986, the term “hyaluronan” was
adopted in accordance with the international
nomenclature
of
polysaccharides
[3].
Correspondingly, the terms hyaluronic acid,
sodium hyaluronate and hyaluronan are all used
interchangeably to refer to the same HA.
Hyaluronic acid constitutes a glycosamino-
glycan (GAGs) molecule consisting of polysac-
charide
chains
made
up
of
alternating
d-glucuronic acid and N-acetyl-d-glucosamine
units combined together in a repetitive manner
(Fig. 2.4) [2]. GAGs refer collectively to the
group of long, unbranched linear polysaccharides
containing amino acids that are made up of
repeating disaccharide units. Representing a cru-
cial component of the extracellular matrix, GAGs
are classified into six classes based on the under-
lying mono-saccharide structures, namely, HA,
chondroitin sulfate, keratin sulfate, dermatan sul-
fate, heparin, and heparin sulfate. Of the GAGs,
HA is found most commonly in the skin [2].
However, unlike other classes of GAGs, it is not
modified with sulfate groups and is not cova-
lently bound to a protein core.
Further, it represents the only class of GAG
that is present in both animal- and bacterial-
sources. As a highly hydrophilic molecule, HA is
also capable of retaining water up to1000 times
its molecular weight [2]. In aqueous solution, the
abundance of negative charges in HA’s chemical
structure generally causes the negative charges to
repel each other. This allows HA to occupy a
larger space, as the entire molecular network
expands and is surrounded by water molecules.
In addition, while HA molecules decrease in vol-
ume when subject to an increase in external pres-
sure, they mostly recover their original volume
once the external force is removed, due to the
mutual repulsion between the negative charges.
These characteristics allow HA to exist in a gel
form when mixed with water, demonstrating the
properties of both viscosity and elasticity. In a
normal physiological pH environment, the
carboxyl groups (–COOH) comprising the
d-glucuronic acid of the HA is converted to
sodium salt. HA possesses four hydroxyl groups
(–OH) and one sodium salt group in each disac-
charide unit [2]. The hydroxyl groups of HA
form hydrogen bonds with water molecules and
thus become readily soluble in water.
Each disaccharide unit of HA consisting of
d-glucuronic acid and N-acetyl-d-glucosamine
represents a monomer with a molecular weight of
400 Da, with each monomer linked together
via β-1,4 glycosidic bonds to form the HA poly-
mer. The HA polymers present in the human
synovial fluid are known to consist of 20,000
monomers or a molecular mass of seven million
Da. As a major component of the body’s extracel-
lular matrix, HA is responsible for absorbing
moisture and keeping the tissues lubricated and
hydrated while providing necessary structural
support. Furthermore, it is also responsible for
the modulation of cellular migration and prolif-
eration, as well as regulating inflammation con-
trol and wound repair/regeneration. The total HA
content in an adult weighing 70 kg is estimated to
be approximately 15 g [4], with roughly half of
this amount known to be located in the skin.
Hyaluronic acid is also found in high concentra-
Fig. 2.3 Hyaluronic acid gel (Photo: Courtesy of
Galderma)
2 Volumizing Fillers