Aesthetic Plastic Surgery of the East Asian Face

Hon g Ryu l Jin , MD, Ph D

Professor an d Ch air
Depar t m en t of Otorh in olar yngology–Head an d Neck Su rger y
Boram ae Medical Cen ter
Seoul Nat ion al Un iversit y College of Medicin e
Seoul, Repu blic of Korea

956 illu st rat ion s

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Nam es: Jin, Hong Ryul, editor.
Title: Aesth et ic plast ic surger y of th e East Asian face / [edited by]
Hong Ryul Jin .
Descript ion : New York : Th iem e, [2016] | In clu d es bibliograp h ical
referen ces an d in dex.
Iden t ifiers: LCCN 2015048817| ISBN 9781626231436 (h ardcover :
alk. pap er) | ISBN 9781626231443 (eISBN)
Su bject s: | MESH: Recon st ru ct ive Surgical Procedu res | Cosm et ic
Tech n iques | Surger y, Plast ic--m eth ods | Face--surger y | Asian
Con t in en t al An cest r y Group
Classificat ion : LCC RD119 | NLM WO 600 | DDC 617.9/52—d c23
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Dedicated to th ose p hysician s w h o believe th at a p h ilosophy is requ ired to ch ange even a sm all par t of th e face.

v
Contents
Forew ord ................................................................................................................................................................................................. ix
Dean M. Torium i
Forew ord .................................................................................................................................................................................................. x
Stephen S. Park
Preface ..................................................................................................................................................................................................... xi
Ack n ow ledgm en t s ..............................................................................................................................................................................xii
Con t r ib u tor s ........................................................................................................................................................................................xiii

I Intro ductio n
1. Th e Ch an gin g Face of Aest h et ic Facial Plast ic Su r ger y am on g East Asian s ........................................................................... 3
Keng Lu Tan and Hong Ryul Jin

II Rhino plasty
2. Au gm en t at ion Rh in op last y Usin g Silicon e Im p lan t s .................................................................................................................13
In-Sang Kim
3. Th e Use of Cost al Car t ilage for Dor sal Au gm en t at ion an d Tip Graft in g ...............................................................................26
Victor Chung and Dean M. Torium i
4. Nasal Tip Mod if cat ion in Asian s: Au gm en t at ion an d Rot at ion Con t rol ..............................................................................47
Hong Ryul Jin and Jong Sook Yi
5. Hu m p Resect ion ................................................................................................................................................................................... 60
Tae-Bin W on and Hong Ryul Jin
6. Cor rect ion of t h e Deviated , Tw isted Nose .....................................................................................................................................72
Hun-Jong Dhong
7. Cor rect ion of t h e Sad d le Nose .........................................................................................................................................................87
Keng Lu Tan and Chae-Seo Rhee
8. Alar Base Mod if cat ion .......................................................................................................................................................................99
Ian Loh Chi Yuan and Hong Ryul Jin
9. Aest h et ic Rh in op last y for Sou t h east Asian s...............................................................................................................................108
Eduardo C. Yap
10. Cor rect ion of t h e Sh or t , Con t racted Nose...................................................................................................................................122
Hong Ryul Jin
11. Man agem en t of Allop last -Related Com p licat ion s ....................................................................................................................135
Eunsang Dhong

III Blepharo plasty

12. Dou b le-Eyelid Su r ger y: Non in cision al Su t u re Tech n iqu es ....................................................................................................151
Jin Joo Hong and Hae W on Yang
13. Dou b le-Eyelid Su r ger y: In cision al Tech n iqu es ..........................................................................................................................162
Jae W oo Jang
14. Agin g-Related Up p er Blep h arop last y ...........................................................................................................................................173
Hok yung Choung and Nam ju Kim
15. Ep ican t h op last y an d Aest h et ic Lateral Can t h op la st y..............................................................................................................184
Yongho Shin
16. Low er Blep h arop last y ......................................................................................................................................................................196
Yoon-Duck Kim and Kyung In W oo
17. Cor rect ion of Ptosis ..........................................................................................................................................................................210
W oong Chul Choi and Juw an Park
18. Man agem en t of Dou b le-Eyelid Su r ger y Com p licat ion s ..........................................................................................................225
In-chang Cho and Aram Harijan

vii
viii Content s

IV Facial Bo ne Surge ry
19. Zygom a Red u ct ion ............................................................................................................................................................................243
Sanghoon Park and Jihyuck Lee
20. Man d ible Red u ct ion .........................................................................................................................................................................254
Sanghoon Park and Seungil Chung
21. Aest h et ic Or t h ogn at h ic Su r ger y ....................................................................................................................................................268
Seong Yik Han and Kar Su Tan
22. Gen iop last y .........................................................................................................................................................................................286
Seong Yik Han and Kar Su Tan

V Facial Skin and Hair Rejuvenatio n

23. Man agem en t St rategies for t h e Agin g Asian Face: Ph ilosop h y an d Evolu t ion .................................................................303
Sam uel M. Lam
24. Facial Fat Graft in g ..............................................................................................................................................................................311
Kyoung-Jin (Saf ) Kang
25. En d oscop ic Foreh ead an d Brow Lift .............................................................................................................................................324
Tee Sin Lee and Stephen S. Park
26. Facial Reju ven at ion Usin g En er gy Devices .................................................................................................................................339
Un-Cheol Yeo
27. Hair Tran sp lan t at ion in East Asian s .............................................................................................................................................349
Sungjoo (Tom m y) Hw ang
28. Aest h et ic Laser Hair Rem oval for t h e Asian Face ......................................................................................................................364
W ooseok Koh

VI Minim ally Invasive Facial Plastic Surgery

29. Aest h et ic Facial Use of Bot u lin u m Toxin in East Asian s..........................................................................................................377
Kyle Seo
30. Facial Con tou r in g Usin g Filler s ......................................................................................................................................................392
Jongseo Kim
31. Man agem en t of Facial Filler In ject ion Com p licat ion s .............................................................................................................405
Hyoung Jin Moon and Jong Sook Yi

In d ex .....................................................................................................................................................................................................415
Forew ord
Th ere is n o p op u lat ion in th e w orld th at h as a h igh er
grow th of in terest in aesth et ic su rger y th an th e East Asian
pop u lat ion . It is repor ted th at on e in five w om en in th e
Repu blic of Korea h ave u n dergon e aesth et ic facial surger y.
Th is dram at ic in crease is m u lt ifactorial an d is in p ar t
driven by local p opu lar cu lt u re an d m edia. Th is t ren d h as
been n otable over recen t years, w ith th e adven t of Korean
pop u lar cu lt u re an d th e associated d esire to look like th e
fam ed K-pop st ars. Th e look is quite ch aracterist ic of Korean
aesth et ics, w ith m any pat ien ts sh ow ing th eir su rgeon
ph otos of th e sam e Asian m edia p erson alit ies. Th is t ren d
h as becom e so fash ion able th at it is n o longer a st igm a to
un dergo cosm et ic surger y in th e Rep u blic of Korea an d
Ch in a. In fact , it m igh t n ow be con sidered a stat u s sym bol
an d reflect u pw ard m obilit y in th e eyes of m any. Th is age
of th e “selfie” an d Facebook h as m ade “looking good” even
m ore im port an t to th is grow ing populat ion . Th ese social
ch anges h ave dram at ically in creased th e dem an d for Asian
cosm et ic surger y, st im u lat ing a sign ifican t in crease in th e
n um ber of su rgeon s perform ing th e su rger y.
Th e aesth et ics of th e Asian face are con st an tly ch anging,
an d surgical tech n iqu es m u st ch ange to accom m odate
such ch anges. Today, th ere is often th e desire for a roun der
foreh ead, h igh er n asal dorsum , n arrow er n asal t ip, an d a
less roun d, m ore angu lar m an dible an d ch in . Many of th ese
ch aracterist ics m ay in dicate a desire for a m ore “Western ”
look. How ever, th ere are differen t degrees of ch ange an d th is
m ust be recogn ized by th e surgeon . Hong Ryul Jin un derstan ds
th e im por t an ce of th is varian ce from p at ien t to p at ien t . Th is
requires th e su rgeon p erform ing en ough su rgeries to h ave
acquired a n um ber of tech n iques in th eir arm am en tarium .
In th is book, Dr. Jin h as com piled an out stan ding collect ion
of ch apters w rit ten by an exper t group of surgeon s. Th e
book covers th e m ost u pdated tech n iqu es on con touring th e
Asian face covering rh in oplast y, Asian eyelid su rger y, facial
con tou ring, an d aging-face surger y. Th e book also covers
th e rapid ly ch anging field of n on su rgical t reat m en t s, su ch
as bot u lin um toxin , fillers, an d lasers.
In the section on rhinoplast y, the authors discuss
the use of im plants and autologous m aterials for Asian
augm entation rhinoplast y. The difference in these techniques
is very significant and is reflected in these w ritings. Use of
im plants continues to be the m ost com m only used m ethod
to augm ent the nose. Nuances in the techniques are discussed
in great detail and are covered by several authors. Com bined
techniques using alloplastic m aterials for dorsal augm entation
and ear cartilage for the nasal tip have becom e popular
to avoid som e of the potential com plications of extending
alloplastic im plants into the nasal tip. The use of costal
cartilage for augm entation is discussed in detail, describing
techniques used to stabilize the nasal tip and augm ent the
nasal dorsum . Also covered are the nuances of perform ing
dorsal augm entation w ith costal cartilage and how to
m inim ize the likelihood of warping. Popular techniques, such
as diced cartilage for dorsal augm entation and tip grafting,
are covered as well.
Th e m any tech n iques available for m an aging th e Asian
eyelid are covered, in cluding in cision al an d n on in cision al
su t u re tech n iqu es, as w ell as conven t ion al in cision al
tech n iques. Precision m easu rem en t an d m arking, an esth et ic
inject ion s, in cision placem en t , m an agem en t of th e fixat ion
m eth od, postoperat ive care, an d m an aging com plicat ion s
are all discussed. Also covered is th e m an agem en t of th e
ep ican th al fold.
In the sect ion on facial contouring, the chapters cover
m anagem ent of the Asian m alar region, m andible, perialar
augm entation, chin augm entation, m asseter m uscle
contouring, forehead contouring, and com plications. Also
covered are the nuances of facial contouring that provide the
surgeon w ith m any options for creating a m ore aesthetically
pleasing Asian face.
Th e sect ion on n on surgical m an agem en t covers th e
u se of bot ulin u m toxin for facial m uscle con tou ring, brow
con tou ring, an d rhyt id m an agem en t . Th is sect ion also
covers fat inject ion s an d con tou ring u sing au tologou s fat .
Laser resu rfacing is discu ssed as w ell.
Dr. Jin h as been a st rong academ ic figure in Korea for
m any years an d h as becom e w ell kn ow n arou n d th e w orld.
He h as frequ en tly lect u red in th e Un ited St ates an d all
over Asia. He is n ow con sidered an in tern at ion al expert
on Asian rh in oplast y an d Asian facial cosm et ic surger y.
His in tern at ion al in flu en ce is reflected in th e d iversit y
of th e auth ors con t ribu t ing to h is book, an d h e h as don e
a m asterful job edit ing th is w ork. Readers w ill fin d th is
book com preh en sive in it s con ten t an d det ail of surgical
descript ion s an d u se of qu alit y op erat ive ph otography an d
illu st rat ion s. Th is book is an essen t ial referen ce for th e
su rgeon in terested in p roviding th e best ou tcom es in Asian
aesth et ic facial su rger y.
Dean M. Torium i, MD
Professor
Division of Facial Plast ic and Reconst ruct ive Surgery
Departm ent of Otolaryngology–Head and Neck Surgery
Universit y of Illinois
Chicago, Illinois
ix
 Forew ord
Hon g Ryu l Jin h as le d t h e w ay in creat in g a u n iqu e book on
aest h et ic facial su rge r y for t h e East Asian p at ie n t . Th e re
are m any u n iqu e var ian ces w it h p at ie n t s from t h is region
of t h e w orld , an d t h ey h ave p u t toget h e r a colle ct ion of
ch ap t e r s t h at cove r all asp e ct s of facial aest h et ic su rge r y
as it p e r t ain s to t h e Asian face. Th e book h igh ligh t s t h e
m any n u an ces in facial aest h et ic su rge r y in t h is grou p ,
an d any su rge on w h o h as t h e occasion al Asian p at ie n t
w ill b e w ell se r ve d to h ave t h is e d it ion in h is or h e r
refe re n ce librar y.
A solid p or t ion of th is book is dedicated to th e
tech n iqu es of Asian rh in oplast y. It is n ot lim ited to st rictly
alloplast ic dorsal im plan ts, bu t covers m any subtlet ies th at
are often required w ith Asian pat ien t s. Th e th ird sect ion
is ded icated to th e p eriorbit al rejuven at ion of th e Asian
pat ien t , in clu ding ptosis an d th e dou ble eyelid procedu re.
Th ere are in t ricacies to th is p rocedu re th at dist ingu ish
x
a good from a great result , an d th is book capt ures th em
w ell. Th e rem ain ing sect ion s touch on oth er procedu res
perform ed in facial aesth et ic su rger y, in clu ding facial
bon e con tou ring, m in im ally invasive an d office based
procedu res, an d h air rejuven at ion .
Herein is a collect ion of m any au th ors w ith vast
exp erien ce in facial aesth et ic su rger y in th e Asian
pop u lat ion . It is com p reh en sive, eloqu en tly w rit ten , an d
w ill ser ve as an invaluable resource for years to com e. Dr.
Jin is to be congrat ulated for a terrific book.
Stephen S. Park , MD
Professor and Vice-Chairm an
Depart m ent of Otolaryngology
Director, Division of Facial Plast ic Surgery
Universit y of Virginia
Charlottesville, Virginia
Preface
Aesth et ic facial plast ic surger y h as com e un der th e spotligh t
in East Asian coun t ries in th e p ast t w o decades. Korea cam e
un der th e spotligh t in th is field recen tly an d in t rigued m any
from all corn ers of th e w orld to com e, learn , an d u p date
th eir tech n iqu es. It is m y h ope th at th is kn ow ledge can be
sh ared far an d w ide w ith th e English speaking crow d, w h o
h as been fin ding it difficu lt to access in form at ion th at h as
been p assed on in variou s Asian langu ages.
Th e ch apters in th is book describe m ost of w h at you
n eed to kn ow abou t aesth et ic plast ic surger y on th e face.
Th e ch apters w ere w rit ten by m y ren ow n ed colleagu es in
th eir resp ect ive sp ecialt ies, det ailing special tech n iqu es an d
poten t ial pitfalls. Th ese det ails do n ot com e from overn igh t
en ligh ten m en t , bu t rath er reflect experien ce an d learn ing
accum ulated over decades of su rgeries. Th e con ten t in th is
book is h igh ly scien t ific an d eviden ce based, w h ich m ean s
it h as proven to be safe an d efficien t . Th is book n ot on ly
focu ses on in t roducing tech n iqu es th at are n ew, but teach es
th e basic con cept s of h ow -to-do-it in a st ru ct u red m an n er
to en sure th at readers are able to clearly con cept u alize th e
tech n iqu es an d th eories beh in d ever y m an euver.
I sincerely hope and expect that this book w ill guide the
new surgeons venturing into aesthetic plastic surgery of the
Asian face, as well as provide valuable inform ation to the others.
Hong Ryul Jin
xi
 Acknow ledgments
It w as n ot an easy journ ey for th e publicat ion of th is book,
an d I w ould like to express m y m ost h ear tfelt grat it ude to
all m y colleagu es w h o h ave con t ribu ted to it .
I thank Thiem e Publishers and its people for allow ing m e to
publish this. Due to their great work, this book changed from
an ugly duckling into a swan. Doctors w ho contributed their
valuable expertise to this book need special acknow ledgm ent
xii
for their patience in allow ing and enduring my continuous
requests. I also w ish to thank my fellows, Woo-Seong Na, Hahn
Jin Jung, and Som asundran Mutusamy, for helping m e to edit
the m anuscript. Our excellent illustrator, Mrs. Hyun-Hang Lee,
w ho devoted her tim e and talents to this book, did a wonderful
job in expressing the details in every draw ing per the requests
of each contributor. I give my sincere thanks to her.
Contributors

In-chang Cho, MD Aram Harijan, MD

Bio Plast ic Surger y Clin ic Academ ic Con sultan t
Seou l, Repu blic of Korea Well Plast ic Surger y Clin ic
Seoul, Repu blic of Korea
Woo ng Chul Cho i, MD
Director of Myou ng Ocu loplast ic Su rger y Jin Jo o Ho ng, MD, PhD
Clin ical At ten ding Professor Head
Depar t m en t of Op h th alm ology JJ Medical Group
St . Mar yʼs Hospital Seoul, Repu blic of Korea
Cath olic Un iversit y of Korea
Seou l, Repu blic of Korea Sung jo o (To m m y) Hw ang, MD, PhD
Director
Ho kyung Cho ung, MD, PhD Dr. Hw angʼs Hair Tran splan tat ion Clin ic
Assistan t Professor Seoul, Repu blic of Korea
Depar t m en t of Op h th alm ology
Boram ae Medical Cen ter Jae Wo o Jang, MD, PhD
Seou l Nat ion al Un iversit y College of Medicin e Vice Presiden t
Seou l, Repu blic of Korea Oph th alm ic, Plast ic, an d Recon st r u ct ive Surger y
Kim ’s Eye Hospit al
Se ungil Chung, MD, PhD Konyang Un iversit y
Division of Facial Bon e Su rger y Seoul, Repu blic of Korea
Depar t m en t of Plast ic Surger y
ID Hospital Ho ng Ryul Jin, MD, PhD
Seou l, Repu blic of Korea Professor an d Ch air
Depart m en t of Otorh in olar yngology–Head an d
Victo r Chung, MD Neck Surger y
Director Boram ae Medical Cen ter
La Jolla Facial Plast ic Surger y Seoul Nat ion al Un iversit y College of Medicin e
San Diego, Californ ia Seoul, Repu blic of Korea

Eunsang Dho ng, MD, PhD Kyo ung-Jin (Safi) Kang, MD, PhD
Professor Director
Depar t m en t of Plast ic an d Recon st ru ct ive Su rger y Educat ion al Cen ter of KCCS
Gu ro Hospit al, Korea Un iversit y Medical Cen ter Seoul Cosm et ic Surger y Clin ic
Seou l, Repu blic of Korea Bu san , Rep ublic of Korea

Hun-Jo ng Dho ng, MD, PhD In-Sang Kim , MD

Professor Ch ief Execut ive
Depar t m en t of Otorh in olar yngology–Head an d Depart m en t of Facial Plast ic Su rger y
Neck Su rger y Doctor Be Aesth et ic Clin ic
Sam su ng Medical Cen ter Seoul, Repu blic of Korea
Seou l, Repu blic of Korea
Jo ngseo Kim , MS
Se o ng Yik Han, MD, DDS, PhD Director
Director Depart m en t of Plast ic Surger y
Facial Plast ic Surger y Kim -Jongseo Plast ic Su rger y Clin ic
Sim m ian Maxillofacial Plast ic Surger y Un it Seoul, Repu blic of Korea
Seou l, Repu blic of Korea

xiii
xiv Contributors

Nam ju Kim , MD, PhD Juw an Park, MD, PhD

Associate Professor Associate Professor
Dep ar t m en t of Oph th alm ology Depar t m en t of Oph th alm ology
Seou l Nat ion al Un iversit y Bu n dang Hosp ital Yeou ido St . Mar y’s Hosp ital
Seongn am -Si, Kyeonggi-Do, Repu blic of Korea Th e Cath olic Un iversit y of Korea
Seoul, Rep ublic of Korea
Yo o n-Duck Kim , MD, PhD
Director Sangho o n Park, MD
Oculop last ic an d Orbital Su rger y Division Ch airm an
Professor Depar t m en t of Plast ic Su rger y
Dep ar t m en t of Oph th alm ology ID Hospit al
Sam su ng Medical Cen ter Seoul, Rep ublic of Korea
Sung Kyu n Kw an Un iversit y Sch ool of Medicin e
Seou l, Repu blic of Korea Ste phe n S. Park, MD
Professor an d Vice- Ch air
Wo o se o k Ko h, MD Depar t m en t of Otolar yngology
Director Un iversit y of Virgin ia
Dep ar t m en t of Derm atology Ch arlot tesville, Virgin ia
JMO Hair Rem oval Derm atology Clin ic
Seou l, Repu blic of Korea Chae-Seo Rhee, MD, PhD
Professor
Sam uel M. Lam , MD, FACS Depar t m en t of Otorh in olar yngology–Head an d
Director Neck Su rger y
Willow Ben d Welln ess Cen ter Seoul Nat ion al Un iversit y College of Medicin e
Plan o, Texas Seoul Nat ion al Un iversit y Bu n dang Hospital
Seongn am -Si, Kyeonggi-Do, Repu blic of Korea
Jihyuck Lee, MD
Ch ief Kyle Seo, MD, PhD
Division of Facial Bon e Su rger y Clin ical Associate Professor
Dep ar t m en t of Plast ic Surger y Depar t m en t of Derm atology
ID Hospit al Seoul Nat ion al Un iversit y College of Medicin e
Seou l, Repu blic of Korea Seoul, Rep ublic of Korea

Te e Sin Le e, MBBS (S’po re), MRCS (Edin), MMed (ORL), Yo ngho Shin, MD, PhD
FAMS (ORL) Director of Bio Plast ic Surger y Clin ic
Dep ut y Director an d Con su ltan t Clin ical At ten ding Professor
Facial Plast ic an d Recon st ru ct ive Su rger y Ser vice Depar t m en t of Plast ic Su rger y
Dep ar t m en t of Otorh in olar yngology–Head an d Korea Un iversit y
Neck Su rger y Seoul, Rep ublic of Korea
Ch angi Gen eral Hosp ital
Clin ical Lect u rer Kar Su Tan, MBBS (S’po re ), MRCS (Edin), MMed (ORL),
Yong Loo Lin Sch ool of Medicin e FAMS (ORL)
Nat ion al Un iversit y of Singap ore Medical Director
Singapore Th e Rh in oplast y Clin ic ENT Facial Plast ics
Singapore
Hyo ung Jin Mo o n, MD
Presiden t Keng Lu Tan, MD, MRCS, MS (ORLHNS)
Dr. Moon Aesth et ic Su rger y Clin ic Ear, Nose, an d Th roat , Head an d Neck Surgeon
Seou l, Repu blic of Korea Facial Plast ic an d Recon st ru ct ive Surgeon
Depar t m en t of Otorh in olar yngology
Un iversit y of Malaya
Ku ala Lum p ur, Malaysia
 Contributors xv

Dean M. To rium i, MD Facial Plast ic Su rgeon

Professor Belo Medical Grou p
Dep ar t m en t of Otolar yngology–Head an d Neck Su rger y Man ila, Ph ilip pin es
Un iversit y of Illin ois at Ch icago
Ch icago, Illin ois Un-Cheo l Ye o, MD, PhD
Ch airm an
Tae-Bin Wo n, MD, PhD S an d U Derm atologic Clin ic
Associate Professor Clin ical Professor
Dep ar t m en t of Otorh in olar yngology—Head an d Depar t m en t of Derm atology
Neck Su rger y Sam su ng Medical Cen ter
Seoul Nat ion al Un iversit y Hospital Su ngkyu n kw an Un iversit y
Seoul, Repu blic of Korea Seou l, Republic of Korea

Kyung In Wo o , MD, PhD Jo ng So o k Yi, MD

Professor Assist an t Professor
Dep ar t m en t of Op h th alm ology Depar t m en t of Otorh in olar yn ology–Head an d
Sungkyu n kw an Un iversit y Sch ool of Medicin e Neck Surger y
Sam su ng Medical Cen ter Bu n dang CHA Medical Cen ter
Seoul, Repu blic of Korea Seongn am -si, Repu blic of Korea

Hae Wo n Yang, MD Ian Lo h Chi Yuan, MBBS, MRCS, MMED, FAMS

Ch ief Director
Division of Plast ic an d Recon st r u ct ive Su rger y Facial Plast ic an d Recon st r u ct ive Ser vice
JJ Medical Group Depar t m en t of Otorh in olar yngology–Head an d
Seoul, Repu blic of Korea Neck Surger y
Ch angi Gen eral Hosp ital
Eduardo C. Yap, MD Singap ore
I
Introduction
1 The Changing Face of Aesthetic Facial Plastic Surgery
among East Asians
Keng Lu Tan and Hong Ryul Jin
Pearls
• Asian s, part icularly th ose in East Asia, h ave seen
rapid developm ent in th e eld of aesth et ic facial
plast ic surger y, especially in th e re n em en t of
Asian -speci c tech n iques, over th e past t w o decades.
• Th e t ypical Asian belief in n ot altering th e physical
ap pearan ce of on e’s face, at t ribu ted to resp ect for
th e elderly an d on e’s an cestors, h as evolved w ith
globalizat ion , resu lt ing in a m ore n eu t ralized Asian
cult ure, w h ich is a cross bet w een East an d West .
More Asian s realize th at to be at th e leading edge of
societ y, an at t ract ive ap pearan ce p lays an im p ort an t
role in d eterm in ing success. Th ere h as been a sh ift
in social accept an ce of aesth et ic su rger y, an d w e see
m ore dem an d for it th an ever before.
• East Asian feat ures of th e face are discussed in detail
in th e follow ing ch apters, w ith par t icular at ten t ion
to single-eyelid, sm all palp ebral ap ert u re, at n asal
bridge and t ip, m alar prom in en ce, broad m an dible,
ret ruded prem axilla, an d m any oth er Asian -speci c
aesth et ic su rgeries.
■ Introduction
The recent surge in the n um ber of people seeking aesthet ic
facial surger y is a testam en t to th e em ph asis placed on on e’s
looks as a w ay to gain con siderable leverage in societ y. The
n ew m ovem en t also involves the con cept of etern al youth -
fuln ess; being young is con sidered at tract ive, an d looking
younger can im prove th e com pet it iven ess of a w orker.1,2
This t rend, w hich started in Western count ries around the
en d of th e t w en t ieth cen t ur y, is fast becom ing w orldw ide.
As of th is w rit ing Asia is th e m ost act ively grow ing
econ om y in th e w orld. With m ore th an h alf of th e w orld’s
popu lat ion residing on th is con t in en t , th e im pact of any
m ovem en t in Asia w ill be in u en t ial.3 With th e populat ion
get t ing m ore a u en t an d w ith th e in creasing a ordabilit y
of a h igh er st an dard of living, th e past 10 years h ave seen
m any Asian s seeking aesth et ic p rocedures to en h an ce th eir
facial feat u res or to at ten u ate th e aging p rocess. Alth ough
th e broad term Asians is gen erally used to den ote people
w h o origin ate from Asia, in t ruth various eth n icit ies an d
races w ith d i eren t facial m orp h ologies reside in Asia.
West an d Sou th Asia st retch es to Tu rkey an d In dia, w h ere
Cau casoid p eop le (i.e., Tu rks an d In dian s) are fou n d . In
• Com m on aesth et ic surgeries of East Asian s also
in clude double-eyelid surger y, ep ican th oplast y,
rh in oplast y, facial bon e con touring surger y, fat
inject ion , an d m any oth er tech n iques discu ssed in
th is book.
• New er tech n iqu es, in clu ding th e com bin at ion
of n on su rgical tech n iques in facial rejuven at ion
su ch as llers an d bot u lin u m toxin , an d laser h air
rem oval and h air t ran sp lan t at ion sp eci c to East
Asian ch aracterist ics, are discu ssed in det ail. Th e
pros an d con s of n on surgical tech n iques su ch as
laser an d ult rasoun d for facial rejuven at ion are also
th orough ly described to keep readers updated w ith
th e latest tech n ologies an d th e opt ion s available to
ach ieve desired ou tcom es.
• Most im p or tan t , th is book n ot on ly con t ain s su rgical
tech n iqu es an d pearls from surgeon s w h o are
exp er ts in th eir resp ect ive elds of aesth et ic facial
plast ic surger y, but also in corporates com m en t s on
pitfalls an d com plicat ion s, an d h ow to overcom e
th em , in detail.
East Asia, w h ere Ch in a, Korea, an d Japan are located, peo-
ple possess East Asian feat u res. Alth ough East Asian s are
grouped in th e Mongoloid st rain along w ith th e Sou th east
Asians (In don esian s, Th ai, Polyn esian s, etc.), th e facial fea-
t ures am ong th e Mongoloids are st ill quite dist in ct from
each oth er.3 Fig. 1.1 d ep icts th e average of di eren t beau t i-
fu l Asian faces as d escribed by Rh ee.4 In dian s, Ch in ese, an d
Jap an ese are all con sidered Asian s; h ow ever, th eir facial
feat u res can be qu ite di eren t .
Du e to Asia’s long-st an d ing t rade rou tes con n ect ing
East an d West , m odern Asian cit ies are often com prised
of m ult iple eth n ic groups, re ect ing th e m odern t ren ds of
in terracial m arriages an d globalizat ion . Th ere is a rapidly
t ran sform ing e ect of globalizat ion on facial feat ures as
w ell, alth ough at th is t im e w e st ill see rath er ch aracterist ic
Orien t al feat u res am ong East Asian s.
Aesth et ic facial su rger y in East Asia h as exp an ded an d
developed at an exp on en t ial rate in th e p ast t w o decades.
Su ch rap id p rogress h as en abled u s to develop su rgical
tech n iqu es suitable for Asian s an d to accum ulate a con -
siderable am ou n t of exp erien ce (Fig. 1.2). Th e n ew skill
set s an d exp erien ce h ave been t ran slated in to tech n ical
advan cem en t an d bet ter su rgical ou tcom es. Th ose exp eri-
en ces an d advan ces in aesth et ic facial su rger y m ore su ited
3
4 I Introduction

Fig. 1.1 At tractive composite faces of di erent races. At tractive famous female entertainers’ faces were morphed by sequentially mixing
photographs at the mean values to generate the composite faces. (Used with permission from Rhee et al. At tractive composite faces of
di erent races. Aesthetic Plast Surg 2010;34:800–801.)

Hair rem oval or

transplantation

Fat injection Blepharoplast y

Botox and fillers Rhinoplast y

Facial bone
contouring

Fig. 1.2 Typical surgeries and nonsurgical procedures to improve facial aesthetic appearance in East Asians. These various techniques will
be addressed throughout this textbook, with speci c modi cations for Asians.
 1 The Changing Face of Aesthetic Facial Plastic Surgery am ong East Asians
for Asian s are becom ing m ore an d m ore p opu lar, especially
am ong th e m ore a u en t Asian s living in th e Western cou n -
t ries. Au th ors of th is book believe th ere is n o bet ter t im e
th an now to h ave ou r kn ow ledge an d experien ce gath ered
an d sh ared to st im u late m ore develop m en t in th is eld.
Many years h ave p assed sin ce th e in t rodu ct ion of
speci c tech n iqu es for Asian aesth et ic su rger y. Mu ch h as
evolved over th e years, an d th e cu rren t focu s seem s to be
on re n ing th e tech n iques to address th e st igm a faced by
Asian pat ien t s. Alth ough w e st ill n d a h an dfu l of pat ien t s
com ing to th e surgeon w an t ing to look like a part icular pub -
lic gu re, m any are steering aw ay from th at t ren d. Pat ien t s
th ese days often request a n at ural-looking face an d w ish
to en h an ce th eir curren t appearan ce w h ile ret ain ing th eir
facial ch aracterist ics, an d th ey especially w an t to preven t
th eir plast ic su rgeries from being n ot iced by oth ers. W h ile
em bracing th eir exist ing facial ch aracterist ics, p at ien t s p re-
fer n ot to look th e sam e as oth ers w h o desire th e ideal com -
p osit ion of a beau t ifu l face, albeit all sim ilar looking. Th is
h as resu lted in su rgeon s reinven t ing th em selves an d m ov-
ing in to th e n ext level of aesth et ic facial su rger y, com bin ing
less invasive p rocedures w ith su rger y w h en ever possible.
Th e art of com bin ing n on surgical an d surgical tech n iqu es
to create a beaut iful face w ill n o longer be based on a gu t
feeling bu t w ill be object ively described in th is book.
■ The Change in Cultural
Beliefs and the Modernization
of Asian Thinking
Th e Asian desire for a pleasan t face is h eavily in u en ced by
facial physiogn om y in th e past . Th e com bin at ion s of pleas-
an t-looking feat u res described in th e an cien t books w ere
illu st rated w ith pict ures of faces th at dict ated th e fut ure of
a p erson , dow n to th e p osit ion of m oles on th e face an d
body.5 Th ere w as a realizat ion of th e n eed for an aesth et i-
cally pleasing face, bu t few oth er th an Sh usrat a ven t ured
in to th e aesth et ic su rgical eld. In dividuals w ith pleasan t-
looking faces w ere m ore likely to be ju dged to h ave a good
life an d a good job, an d th ose w ith u np leasan t-looking
feat u res w ere often associated w ith socially less resp ect-
able jobs or even crim in alit y. Th e lat ter t yp es of faces w ere
d eem ed in au sp iciou s an d st ill ver y m uch in uen ce h ow
a p erson is ju dged in m odern societ y. Desp ite th is, th ere
w as lit tle develop m en t in th is eld. Few w an ted to ch ange
th eir looks surgically, par tly due to the un re n ed state of
su rgical skills at th at t im e an d th e st rong in u en ce of Con -
fu cian ism all over Asia, w h ich em ph asized th e san ct it y of
th e physical body as a sacred gift from our paren t s. Altering
on e’s physical appearan ce w as con sidered disrespectful to
on e’s an cestors.1
As globalizat ion an d Western izat ion exerted m ore
in uen ce in Asian societ y via Western m edia, th e de n i-
t ion of beaut y becam e associated w ith w h ite Caucasian fea-
5
t ures, such as double eyelids an d t all, w ell-de n ed n oses.
Fair skin is seen as th e m arker of class. On e an cien t saying
in Jap an ese, Korean , an d Ch in ese societ ies goes, “A w h ite
com plexion overrides th ree appearan ce aw s,”6 em ph asiz-
ing th e long-st an ding im port an ce of ligh t-colored skin in
m u lt iple cou n t ries across Asia. Th is w as rein forced d u ring
th e Western colon izat ion period, w h en th e European s w ere
presen t in Asia an d enjoyed h igh social st at u s. In “Th e His-
tor y of W h ite People,” Neil Pain ter even argued th at Cau-
casian s produce “th e m ost beau t ifu l race of m en” an d th at
Ch in ese eyes are an “o en ce to beau t y.”7 Th e ideal beau t y
of Cau casian s w as on ce th e w ell-accepted de n it ion of
beaut y in Asia.
Recen tly, Asian coun t ries h ave becom e st ronger an d
m ore in u en t ial econ om ically. Sch olars h ave started to
debate about “Eurocen t ric” beaut y an d th e ph en om en on
in Asia w h ere it h as becom e th e n orm to alter on e’s facial
ap pearan ce u sing p last ic su rger y to be m ore Western ized.
With grow ing con den ce w ith in Asian societ y, h ow ever,
Asian s h ave started to em brace th eir ethn ic feat ures. Th e
fu sion of cert ain desirable Western feat u res w ith Asian
feat u res is n ow seen as th e id eal form of beau t y in Asia.
Th e key con cept n ow is to blen d at t ract ive feat ures rath er
th an h aving a cert ain de n ed tem plate, a con cept th at h as
been h eavily crit icized an d is rapidly falling out of favor.
Th e good-looking feat u res are, of cou rse, th ose th at suit a
person’s facial st ru ct u re, person alit y, an d th e person as a
w h ole. En h an cem en t rath er th an alteration of th e facial
feat u res h as becom e th e n ew t ren d .
Stat ist ics sh ow th at up to 58% of w om en in Korea h ave
plast ic surger y by th e age of 50.1,8 Th e percen tage is grow -
ing in th eir m ale coun terpar t s too. Th e desire to obtain
aesth et ic p last ic su rger y is often driven by th e psych oso-
cial aspirat ion of th e pat ien t . Rapid developm en t in th is
eld is largely driven by th e n eed to app ear m ore at t rac-
t ive in order to be bet ter accepted in a societ y th at places
a lot of em p h asis on beau t y an d pleasan t app earan ce.
Looking m ore beau t ifu l becom es an invest m en t to ach ieve
h igh er socioecon om ic st at u s an d to en su re on e w ill n d a
w ealthy rom an t ic p ar t n er. Th u s a n ew cu lt u re or t ren d h as
em erged, u n stop p able by past cu lt u ral beliefs an d t aboos,
an d st rongly d riven by n ovel con cept of beau t y, w ealth , an d
a good life. As th is con cept h as grow n , th e su bject s seeking
cosm et ic en h an cem en t h ave becom e younger an d younger.
As Korean dram as an d m ovies h ave becom e m ore popular
th rough ou t Asia, so h as th e in u en ce of th e Korean de n i-
t ion of beaut y spread all across Asia. Th is ph en om en on of
“Han Ryu ” (th e Korean t ren d) w as p op u lar am ong view ers
of all ages. With at t ract ive actors an d act resses port rayed
as h eroes an d h eroin es, m any fan t asized becom ing like on e
of th em , w h ich could be ach ieved by altering th eir looks.
Th is t ren d becam e a st rong driving force in th e devel-
opm en t of aesth et ic surger y in Asia, en abling surgeon s to
grow an d ach ieve a n ew level of u n d erst an ding of aesth et ic
su rgeries. How ever, it is u p to th e con scien ce of in dividu al
pract it ion ers to guard th e san ct it y of th is eld, preven t ing
6 I Introduction
th e dou ble-edged sw ord of h arm to our pat ien t s an d to th e
p ract ice of aesth et ic surger y, by prescribing on ly appro-
p riate an d scien t i cally soun d procedu res to pat ien t s an d
p roviding th e best su rgical pract ices tested by t im e an d
exp erien ce.
■ Anatomic Di erences and
Their Implications
Most East Asians share the phenot ypic features represented
by the Mongoloid pro le. It is currently the m ost w idely dis-
tributed physical t ype, constituting over a third of the hum an
species. Therefore, it is not surprising to nd that m any living
throughout Asia share the sam e facial features. Mongoloid
features are t ypically represented by epicanthal folds and
neoteny. While som e of the features, such as the single eyelid
and m axillary retrusion, are not com m on am ong Western-
ers, they are w idely encountered in Asians, w ith double-
eyelid surgery being the m ost popular plastic surgery sought
(Fig. 1.3). High cheekbones, a broad m andibular angle, and
a low nasal pro le are features in Asians that are not highly
favored, and are often associated w ith aggression or m anli-
ness. Generally, a well-projected nose is preferred.
A low n asal bridge is n ot lim ited to Mongoloids. Th e
Malay people fou n d in m ost of Sou th east Asia across
th e Ph ilippin es, Malaysia, Th ailan d, an d In don esia often
requ est ch anges to address a low n asal bridge an d w ide
aring ala (Fig. 1.4).
Becau se th e an atom y of th e eyelids, n ose, an d facial
bon es in Asian s di ers sign i can tly from th at of Caucasian s,
a u n iqu e m an agem en t st rategy is requ ired to su ccessfu lly
im p rove th e aesth et ic ou tcom e. Th e m an agem en t st rategy
sh ou ld be aim ed at h an dling an atom ic issu es speci c to th e
Asian face such as th e follow ing:
1. Th e pret arsal skin of the upper eyelid is n ot at tach ed
to th e levator palpebrae m uscle, leading to a poorly
d e n ed superior p alp ebral fold. Th e con st ruct ion of a
d ou ble eyelid th at su it s th e m orph ology of an Asian
face is di eren t from p ract ice involving Cau casian s.
2. Excessive fat is dist ributed bet w een th e orbicularis
oculi m uscle an d th e levator m uscle w ith relat ively
th ick palpebral skin an d orbicularis oculi m uscles.
3. Orbits are sm aller w ith a m ore prot ruding orbital
m argin com p ared w ith Western ers. Th erefore,
recreat ing th e feat u res of Caucasian eyelids h as
p roven u n su it able. Aesth et ic eye surger y sh ou ld be
re n ed an d subtle rath er th an dram at ic, or it can
give rise to a th ick, deep u pp er eyelid, w h ich is n ot
su itable for sm aller orbit s.
4. Th e n asal sclera t riangle is rou n ded due to th e
p rom in en t m edial epican thal fold. A variet y of
tech n iqu es (an d th eir pros an d con s) to elim in ate
th e obt un ded angle w ill be described in detail in th e
ch apter on epican th oplast y.
5. Th e n arrow an d relat ively sm all palpebral aper t ure
result s in sm all eyes. Th is h as resulted in m any
tech n iqu es inven ted an d m odi ed over th e past
decade to in crease th e palpebral apert ure by lateral
can th oplast y. Proper con siderat ion of th e an atom y
involved in lateral an d m edial epican th oplast y
sh ou ld be given before th e su rger y is don e to preven t
later com plicat ion s su ch as low er eyelid ect ropion .
6. A at n asal bridge and a poorly de n ed cart ilagin ous
st ru ct u re of th e n ose resu lts in poor p roject ion of th e
n ose.
7. Th ere is a sm aller n asal pyram id w ith sh orter
n asal bon e length in Asian s com p ared w ith oth er
eth n icit ies. A st u dy don e by Naser an d Boroujen i
con clu ded th at th e n asal bon e length st udied in
th e skulls of Korean s w as sm aller th an in Am erican
In dian s, An atolian s, Iran ian s, an d African Am erican s.9
Th e soft an d sm all n asal sept um en coun tered
som et im es p oses di cu lt y to th e su rgeon n eed ing
a cart ilage graft from th e n asal sept u m . Du e to th is,
th e use of h om ologous an d autologous rib cart ilage
graft s h as becom e popular w h en syn th et ic im plan t s
are n ot su it able or n ot preferred by p at ien t s. Pat ien t s
sh ou ld be adequ ately cou n seled , as th e likelih ood of
n eeding a rib graft is h igh er in Asian pat ien t s.
8. Th e n asal skin is th ick w ith abun dan t sebaceous
glan ds. Th is m akes m an euvering th e n asal t ip
su bst an t ially m ore tech n ically dem an ding.
9. Asian s possess di eren t skin proper t ies com pared
w ith oth er racial groups. Asian s are kn ow n to h ave
a th in n er st rat u m corn eu m , th e sm allest in term s of
p ore size an d pore n u m bers, an d th e h igh est w ater
an d lip id con ten t in th e st rat u m corn eu m com p ared
w ith oth er peoples. Th eir skin is also kn ow n
to h ave th e w eakest ch em ical barrier. All th ese
ch aracterist ics sign ify th at topical drug pen et rat ion
is th e best in Asian skin an d th at th e form at ion
of w rin kles is less in Asian s. Such an atom ical
d i eren ces in th e epiderm al layer of th e Asian skin
m ake m an agem en t of scars an d skin lesion s di eren t
in th e Asian popu lat ion .
10. Asian s h ave a h igh m alar prom in en ce due to a
p rom in en t zygom at ic body or arch .
11. Th e broad m an dibular angle is associated w ith
m asseter hyp ert rop hy.
12. Asians’ hair is th ick and coarse, is round in shape, and
grow s faster. Asian s also h ave a h igh er prevalen ce of
curly hair, but th ick and st raight hair is predom inan t
am ong East Asian s. Th ese an atom ic di eren ces in
Asian h air com pared w ith Caucasian hair require
h air t ran splan t equipm en t an d procedu res th at are
di erent from those that are convent ionally used.
To successfully address th e above issu es, on e sh ould
un derst an d th e u n ique an atom ic presen t at ion of th e Asian
face to p rop erly m odify an d m ake re n ed adju st m en t s to
th e gen eric tech n iques presen ted in earlier textbooks.
 1 The Changing Face of Aesthetic Facial Plastic Surgery am ong East Asians 7

a b c

d e f

Fig. 1.3 Typical East Asian wom an who had rhinoplast y with blepharoplast y. (a–c) Typical East Asian face, illustrating the wide mandibu-
lar angle, high cheekbones, poorly de ned upper eyelid crease, broad and low nasal dorsum, and poorly de ned nasal tip. (d–f) The same
individual after rhinoplast y and blepharoplast y. Her appearance greatly enhanced, the individual seems more approachable and attractive,
with softening of the unfavorable wide angle of the mandible.
8 I Introduction
a b
Fig. 1.4 (a–c) The face of a t ypical Southeast Asian woman, with natural double eyelid crease, wide nasal alar, broad nasal bridge and
bulbous nose with a voluminous lip. These are some of the features associated with the Southeast Asian t ype of face.
■ Modi cation and Re nement
of Surgical Techniques
To enhance existing Asian facial characteristics, re nem ent of
the techniques is often required. Such re nem ent is well illus-
trated by the various techniques of epicanthoplast y to address
a slightly di erent curve of the m edial epicanthus, suturing
techniques to m ake eyes w ith ptotic or pu y upper eyelids
appear larger and m ore relaxed, and lateral canthopexy to
achieve a m ore attractive and lively appearance of the eyes.
Th e conven t ion al m eth ods of epican th oplast y, such as
Y-V, V-W, an d W plast y, w ere n oted to give rise to u n sigh tly
scars. As su rgeon s in Asia accu m u lated m ore exp erien ce,
m any n ew tech n iqu es w ere develop ed, su ch as th e pal-
pebral m argin in cision m eth od (Ch en , m edial epican th o-
plast y), w ith oth ers com m on ly com bin ing bleph aroplast y
w ith m edial epican th oplast y by exten ding th e in cision ,
result ing in an obscured scar. With th e in creasing n um ber
of lateral can th oplast ies don e to w iden th e palpebral aper-
t ure of th e Asian eye, com plicat ion s such as hyper t roph ic
scars an d scar con t ract u re cau sing th e p alpebral ssu re to
becom e n arrow again are possible. Th e procedu re m ay also
result in asym m et rical resu lt s du e to unpredict able scar
form at ion . In cases w h ere th e lateral can th al ligam en t is
cut to ach ieve m axim al open ing of th e palpebral apert ure,
low er eyelid ect rop ion an d sagging m ay occu r in th e fu t ure
as th e soft t issu e an d m u scu lar su p p or t is w eaken ed. Th ere-
fore, su ch surgeries are n ever to be t aken ligh tly an d sh ould
be don e on ly after su cien t risk an d ben e t assessm en t .
c
Su ch re n em en t in su rgical tech n iqu es is also seen in
rh inoplast y su rgeries, w ith m ore versat ile use of alloplas-
t ic m aterials such as Gore-Tex (W.L. Gore & Associates In c.,
Flagsta , Arizon a) an d h om ologou s cart ilage in recon st ru c-
t ion of th e n ose. Nasal augm en tat ion is rarely a n eed for
th e Western pat ien t . In con t rast , alm ost ever y East Asian
pat ien t requests n asal dorsal augm en tat ion . In th e past t w o
decades, w e h ave seen th e popularit y of silicon e im plan t s
fall an d th e su bsequ en t in creased accept an ce of Gore-Tex
as a m ore versat ile im p lan t m aterial. Alth ough th e u se of
silicon e im p lan ts is declin ing d u e to th e h igh er com plica-
t ion rate an d rigid appearan ce of th e n asal dorsum , w e
see a cu rren t t ren d of su rgeon s car ving silicon e im p lan t s
m ore ju diciou sly, get t ing rid of th e L-st ru t an d com bin ing
use of th e im plan t w ith oth er soft t issu e to produce a softer
an d n at u ral look an d red u cing th e rate of im plan t ext ru -
sion . Th is allow s th e su rgeon to con t in u e u sing th e silicon e
im plan t , w h ich does h ave som e advan t ages com pared w ith
oth er ch oices of im plan t s. On th e oth er h an d , con t in u ou s
t rials using au tologous costal cart ilage for dorsal augm en -
tat ion h ave sh ow n m u ch im provem en t over th e years w ith
im proved reliabilit y an d con sisten cy. We h ave seen a sh ift
recen tly tow ard th e in creased popularit y of autologous
graft s com pared w ith syn th et ic graft s du e to th e su perior-
it y of th e au tologou s graft in resist ing in fect ion an d pre-
ven t ing long-term com p licat ion s.10,11
Re ce n t ly, t ip su rger y in ad d it ion to d orsal augm en t a-
t ion h as becom e a st an dard p roce d u re u n d er t aken d u r-
in g rh in op last y. Th e t ip h as to be p rop erly su p p or te d an d
rot ate d after d orsal augm e n t at ion to p rod u ce a n at u ral,
p leasan t -lookin g n ose. Th is is largely ach ieved by u sin g
 1 The Changing Face of Aesthetic Facial Plastic Surgery am ong East Asians
t h e op e n ap p roach . Tip rot at ion ach ieved w it h a sept al
exten sion graft an d t h e u se of m u lt ip le laye rs of au tolo -
gou s m ater ial su ch as m u scle fascia an d car t ilage cou -
p le d w it h som e su t u re tech n iqu es are t h e m ost p op u lar
opt ion s em p loye d n ow . Bot h p at ien t s an d su rge on s h ave
sh ied aw ay from syn t h et ic m ater ial for t ip w ork d u e to
t h e h igh ext r u sion rate an d t h e su bsequ e n t d isast rou s
sequ elae of an in fect ion . Au tologou s m ate r ial is t im e
tested an d sh ow n to h ave t h e least com p licat ion s an d
b est resu lt s so far. Th e ove raggressive t ip w ork associated
w it h ove ram bit iou s m an eu vers is h igh ly advised again st ,
as too m u ch of a good t h in g in any circu m st an ces w ill on ly
resu lt in t h e op p osite of t h e d esired e ect . Over p rojec-
t ion an d rot at ion of t h e t ip is associated w it h a d efor m ed
t ip in t h e lon g r u n as a cer t ain d egree of resor pt ion of
t h e car t ilage graft u sed an d scar r in g of soft t issu e w ill
cau se in st abilit y of t h e t ip con st r u cted . Th erefore, from
ou r exp er ien ce, ju d iciou s adju st m en t of t h e d orsu m w it h
a m atch in g t ip sh ou ld be t h e lim it to su ch augm en t at ion
p roced u res, alt h ough it m ay be ver y invit in g in t raop era-
t ively to ach ieve a m a xim u m e ect .
Un d e rst an d in g t h e sp eci c an atom ic d i eren ces
in Asian s h as e n abled u s to com bin e t h e u se of var iou s
adju n ct ive su rger ies an d p roced u res w it h rh in op last y to
p rod u ce a m ore favorable ou tcom e t h an is p ossible w it h
ju st rh in op last y alon e. Som e of t h ese p roce d u res in clu d e
p aran asal im p lan t , ch in im p lan t , n asal alar resect ion , an d
colu m ella-len gt h en in g ap s to ad d ress issu es like m a xil-
lar y ret r u sion , ret rogn at h ia, w id e n asal ala, an d sh or t col-
u m ella, resp ect ively, w h ich are com m on p roble m s fou n d
in Asian s. Asian su rge on s h ave also p er fe cted t h eir skills
in m alar red u ct ion , w h ich is a m ore com m on p roced u re
in t h e East com p ared w it h t h e West . Previou s exp er ien ce
h as resu lted in som e cases of facial saggin g, facial asym -
m et r y, an d d ow nw ard m ovem e n t of t h e m alar p oin t . Th e
red u ct ion of t h e an gle of t h e m an d ible is also a com m on
aest h et ic su rger y in Asia as op p osed to t h e West , as a
softe r look an d a “V-sh ap e d ” face are st ron gly favored
in Asia. Asian su rgeon s h ave su bst an t ially m ore exp e-
r ie n ce w h en it com es to t h is kin d of skelet al re d u ct ion
w ork. Ot h er skelet al alterat ion su rger ies t h at are p op u -
lar in Asia in clu d e or t h ogn at h ic su rger y su ch as bim a x-
illar y advan ce m en t /red u ct ion or m an d ibu lar red u ct ion /
ad van cem en t , w h ich can be solely for cosm et ic p u r p oses.
Th ese su rge r ies w ere or igin ally in ten d ed to cor rect con -
gen it al d efor m it ies relate d to fu n ct ion al p roblem s su ch
as m alocclu sion . As t h e ap p earan ce of a p rot r u d in g m an -
d ible or ret r u d in g m a xilla is u n at t ract ive, p at ien t s t h ese
d ays are w illin g to u n d e rgo su rger ies even w it h ou t fu n c-
t ion al p roblem s, an d even w h e n t h e r isk of associated
com p licat ion s ou t w eigh s t h e ben e t .
The grow ing popularit y of fat graft ing h as im proved
p at ien t sat isfact ion t rem en dously. Fat graft ing produces a
long-last ing e ect in facial rejuven at ion . Th is is esp ecially
t rue in th e you nger pat ien t s in w h om a su rgical face lift
9
w ou ld p rove too drast ic an d dest ru ct ive. It also plays an
im port an t role as an adjun ct to m any cosm et ic procedu res.
Fat graft ing tech n iques h ave progressed from th e use of
cru de fat lobules to m icrofat grafts, giving rise to im proved
longevit y in th e recipien t site. Th e use of fat graft s is also
ver y p op u lar to im p rove th e con tou r of facial top ograp hy,
proving to be ver y versat ile in creat ing w h atever topogra-
phy is desired. With th eir expert ise in th is eld, th e auth ors
of th is book are able to sh are m any of th eir valuable experi-
en ces in re n ing an d perfect ing th e u se of th is tech n iqu e to
im prove surgical outcom es.
Hair restorat ion h as also becom e a p opu lar procedu re
don e for aesth et ic purposes in Asia in recen t years. It is
not on ly popu lar for m ales experien cing an drogen ic h air
loss but also for fem ales w h o w ish to resh ape th e face
an d to soften th e ou tlin e of th e face by altering th e h air-
lin e. More fem ales are seeking h air t ran splan t procedures
to exten d th e h airlin e at th e tem p oral region , th u s redu c-
ing th e m uscularit y of th e face, or to ch ange th e face to a
m ore favorable “oval” sh ape. Hair t ran splan t at ion is qu ite
di eren t in Asian s. Th is is due to th eir th icker an d coarser
hair st ruct ure, a broad er base for th e follicles, an d a h igh er
in ciden ce of keloid-form ing scars com pared w ith Cau -
casian s. Th erefore, follicular un it ext ract ion an d use of a
m icropu n ch d esign ed to m in im ize scarring an d m axim ize
hair follicle ext ract ion h ave becom e m ore popular th an th e
conven t ion al single-st rip h ar vest ing tech n ique. Due to th e
th icker an d coarser h air foun d in Asian s, during follicular
un it ext ract ion th e direct ion an d depth of th e scorings
m u st be precise an d th e base h as to be broad en ough so
th at th e germ in al un it of th e h air w ill n ot be dam aged. As
curly hair is m ore com m on in Asian s th an in Caucasian s,
th e direct ion of th e im plan tat ion h as to be con sidered so as
not to h ave un n at u ral h air grow ing in di eren t d irect ion s.
Th ese an d m any oth er pearls related to h air restorat ion in
th e Asian populat ion w ill be presen ted in th e correspond-
ing ch apters.
We w ill also d eal w it h facial h air re m oval u sin g laser
for aest h et ic p u r p oses. Th e w id t h of t h e foreh ead for m s
t h e sh ap e of t h e face in t h e su p e r ior t h ird . Th e foreh ead
is also t h e locat ion of t h e “ch akra” w h ere t h e t h ird eye
or sixt h sen se resid es as p e r San skr it scr ipt u res. A n ar-
row foreh ead p u t s too m u ch em p h asis on t h e m id d le an d
low er p ar t s of t h e face an d is often associated w it h lack
of rad ian ce. A balan ced foreh ead can be created w it h p er-
m an e n t rem oval of t h e ap p rop r iate am ou n t of h air w it h
least p roblem of d ysp igm en t at ion in Asian s, w h o ge n er-
ally h ave d arker skin ton e. Nd :YAG lase r h as p roven to be
a good ch oice for h air re d u ct ion in Asian s, com p ared w it h
conven t ion al d iod e laser, an d w as fou n d to be su p er ior in
h air re d u ct ion .12 Many st u d ies are st ill bein g con d u cte d
on laser h air rem oval regard in g t h e p arad oxical e ect of
n e h air grow t h p ost rem oval. An excit in g jou r n ey lies
ah ead , w it h m ore d et ails revealed in t h e ch ap ter on lase r
h air re m oval.
10 I Introduction
■ Procedural Techniques
Facial cosm et ic procedures can n o longer rely on surger y
alon e. Many pract it ion ers can n o longer a ord to sh u n th e
u se of laser, in ten se p ulsed ligh t (IPL), an d m any oth er n on -
su rgical tech n iqu es to ach ieve bet ter ou tcom es. Alth ough
m any of th ese tech n iqu es do n ot p rovide long-term e ect s
as good as su rgical in ter ven t ion , th ey often com plem en t
th e surgical ou tcom e or delay surgical in ter ven t ion appro-
priately. Exam ples are th e use of th read lift ing for younger
pat ien t s w h ere a surgical face lift is too drast ic an d un n at u-
ral, laser or h igh -frequ en cy focu sed u lt rasoun d (HIFU) in
face lift ing for m ild soft t issu e sagging, laser an d /or IPL in
resurfacing various t ypes of scars an d recon st ructed aps,
an d ller inject ion for sp eci c facial con tou r augm en t a-
t ion in lim ited areas. Various t ypes of ller inject ion , rang-
ing from collagen , hyalu ron ic acid, an d calcium hydroxyl
ap at ite to p oly-L-lact ic acid an d platelet-rich plasm a, are
becom ing m ore an d m ore accessible to pat ien t s as th ey are
n on invasive, are tech n ically easier to ap ply, an d provide
a reason able ou tcom e for a n on su rgical p rocedu re. At th e
t im e th is book is being prepared, hyaluron ic acid rem ain s
th e m ost w idely used ller due to it s longevit y an d it s safet y
pro le com pared w ith th e oth er t ypes of llers. It is im por-
tan t , h ow ever, th at th e reader be able to discern th e ben -
e t of th e ller inject ion an d verify th at it ou t w eigh s th e
risks of its u sage, w h ich in clu de, in th e w orst-case scen ario,
blin dn ess due to em bolism of th e ret in al vessels.13 Alth ough
n ot as severe as blin dn ess, oth er com p licat ion s, such as skin
n ecrosis of th e injected area, sh ou ld n ot be overlooked as
recon st ru ct ion of th e a ected area can be ver y t roublesom e
if it involves a large area requ iring com plex reconst ru ct ive
tech n iqu es. Th e rst sign of th e grievous com plicat ion s ju st
m en t ion ed (p ain in th e pat ien t post inject ion ) sh ou ld n ot
be sim ply disregarded, an d prom pt usage of hyaluron idase
w ith or w ith out hyperbaric oxygen is called for.
Non surgical facial rejuven at ion is often overlooked by
m any su rgeon s du e to its relat ively brief h istor y. How ever,
w ith th e grow ing num ber of clients preferring non surgical
in ter ven t ion to surgical in ter ven tion and its de nite role in
com plem ent ing surgical outcom es, nonsurgical in ter ven-
t ion has sur vived and is rapidly being reinvented and diver-
si ed in providing solu tion s to facial rejuven ation . Alth ough
these techn iques need to be further proven w ith m ore st ud-
ies an d research , surgeons shou ld be aw are of the n on su r-
gical tech n iqu es available in th e m arket because ultim ately
patients w ho need surger y m ay be those w ho h ave expe-
rien ced com plicat ion s from th ese n on surgical tech n iqu es.
In certain circum stan ces, th ese n on su rgical tech niqu es can
also be e ect ively com bin ed w ith th e u se of su rgical tech -
n iques to ach ieve bet ter results.
■ Conclusion
New t ren ds, con cept s, an d tech n iqu es are rap idly ap pearing
in Asia for aesth et ic facial plast ic surger y. Th is t ren d can -
n ot be ign ored an d w ill becom e our st rength as experien ce
grow s. Many of th e n ew tech n iqu es sh ou ld be review ed
judiciously an d m et iculously an d u sed carefully. Th erefore,
th is n ew book is open ing up a w h ole n ew ch apter in aes-
th et ic facial surger y for East Asian s.
References
1. Holliday R, Joan n a EH. Gen der, globalizat ion an d aesth et ic
surger y in South Korea. Body Soc 2012;18(2):58–81
2. Weeks DM, Th om as JR. Beaut y in a m ult icult ural w orld. Fa-
cial Plast Surg Clin North Am 2014;22(3):337–341
3. Raw lings AV. Eth n ic skin t ypes: are there di eren ces in
skin st ruct ure an d fu nct ion ? In t J Cosm et Sci 2006;28(2):
79–93
4. Rh ee SC, Lee SH. At t ract ive com posite faces of di eren t
races. Aesth et ic Plast Su rg 2010;34(6):800–801
5. Tem park T, Shwayder T. Chinese fortune-telling based on face
and body m ole positions: a hidden agenda regarding m ole
rem oval. Arch Derm atol 2012;148(6):772–773
6. Wagat sum a H. Color an d race: th e social percept ion of skin
color in Japan . Daedalu s 96(2);1967:407–443
7. Zh ang L. Eurocen t ric Beaut y Ideals as a Form of St ru ct ural
Violen ce: Origin s an d E ects on East Asian Wom en , in Vio-
len ce an d Su ering in th e Con tem p orar y World (Sp ring
2013). 4–11
8. 90% of Korean w om en w ould h ave plast ic su rger y, poll
show s. Ch osun Ilbo 2009 (October 26): 11
9. Asieh ZN, Mariyya PB. CBCT evaluat ion of bony n asal pyra-
m ic dim en sion s in Iran ian p opulat ion : a com parat ive st udy
w ith eth n ic groups. Intern at ion al Sch olarly Research No-
t ices 2014:1–5
10. Jin HR, Won TB. Nasal t ip augm en tat ion in Asian s u s-
ing au togen ou s cart ilage. Otolar yngol Head Neck Su rg
2009;140(4):526–530
11. Park JH, Jin HR. Use of au tologou s cost al cart ilage in Asian
rh in oplast y. Plast Recon st r Surg 2012;130(6):1338–1348
12. Wan it p h akd eedech a R, Th an om kit t i K, Seth abu t ra P, Eim -
pun th S, Man uskiat t i W. A split axilla com parison st udy
of axillar y h air rem oval w ith low u en ce h igh repet it ion
rate 810 n m diode laser vs. h igh u en ce low repet it ion
rate 1064 n m Nd:YAG laser. J Eu r Acad Derm atol Ven ereol
2012;26(9):1133–1136
13. Carru th ers JD, Fagien S, Roh rich RJ, Wein kle S, Carru th ers
A. Blin dn ess caused by cosm et ic ller inject ion : a review
of cause an d th erapy. Plast Recon st r Surg 2014;134(6):
1197–1201
II
Rhinoplasty
2 Augmentation Rhinoplasty Using Silicone Implants
In-Sang Kim
Pearls
• For East Asian noses, m ajor augm entation is
frequen tly required for th e n asal dorsu m an d th e t ip.
• Th e silicon e im plan t is w idely used in Asian
coun t ries becau se it is easy to use, lim itless in
volu m e, cost-e ect ive, an d su p erior to th e au to- or
h om ograft from th e aesth et ic view poin t .
• Th ere are t w o sources of problem s related to th e
allop last ic im p lan t . On e is th e problem s in h eren t
in th e m aterial itself, w h ich can be m in im ized. Th e
oth er is p roblem s from tech n ical or ju dgm en t al
errors, w h ich are m ore com m on an d m u st be
avoided.
• In fect ion is a seriou s p roblem th ough u n com m on .
Th orough san it izat ion of th e operat ion eld,
in clu ding th e n asal vest ibule an d an terior n asal
cavit y, is im por tan t . Care sh ould be t aken n ot to tear
th e m ucosal barrier using at raum at ic tech n iques.
Operat ion t im e sh ou ld be redu ced to decrease
th e ch an ce of in fect ion . Th e im plan t m ust be
im m ersed in an t isept ic solu t ion before an d after any
m an ip u lat ion .
• Design ing an im p lan t m u st be in d ivid u alized . Th e
su rgeon sh ou ld h ave in m in d th e desired sh ape of
th e n ose. In dividu al an atom ic ch aracterist ics m ust
be con sidered such as th e n asofron t al angle, dorsal
con tour, an d t ip project ion .
■ Introduction
Th e n oses of East Asian people are di eren t in m any
asp ects from Cau casian n oses. Augm en t at ion rh in op last y
is on e of th e m ost com m on aesth et ic p rocedures in Asian
coun t ries because of th e relat ively at an d w ide Asian n ose.
How ever, augm en t at ion rh in op last y sh ou ld be con ser va-
t ive, preser ving th e eth n icit y to m ake th e n ose appear ver y
n at u ral an d h arm onious w ith oth er facial un it s. In Asian
coun t ries, augm en t at ion rh in oplast y is n ot a m ajor recon -
st ru ct ive op erat ion . It is regard ed as on e of th e u n com pli-
cated com m on cosm et ic procedures. It is often regarded as
a t ren dy op erat ion , an d th e aesth et ic st an dard of p at ien t s
is gen erally h igh . People w an t sh ort recover y t im es an d a
quick ret urn to th e job, alth ough m ajor augm en tat ion is
frequ en tly requ ired.
In th is sit u at ion , a pract ical an d cost-e ect ive opt ion
for a surgeon is rh in oplast y u sing an alloplast ic im plan t .
• Proper select ion of a t ip tech n ique is im port an t .
Accord ing to th e t ip tech n iqu e, th e design of an
im plan t varies. Th e im plan t sh ould be con n ected to
th e augm en ted t ip sm ooth ly an d seam lessly.
• Do n ot t r y to augm en t th e t ip w ith th e im plan t .
Un like th e relat ively im m obile dorsum , th e t ip
is h igh ly m obile. Th erefore, on ly au tologou s
cart ilage m ust be used for th e t ip, w ith appropriate
tech n iqu es to preven t ext rusion an d skin problem s.
An im plan t p laced on th e t ip is aesth et ically
u npleasing because it alw ays leads to a rot ated t ip
w ith an u n n at urally th ick in frat ip lobule.
• With th e u se of on ly au tologou s cart ilage for th e
t ip, skin problem s are preven ted and m ore n at ural
outcom es are en sured.
• Stacking of m ult iple layers of on lay graft s is
com m on ly required for su cien t t ip project ion
in Asian s. Th e w ing graft sh ou ld be used in
com bin at ion w ith th e st acked on lay graft to preven t
n ot iceabilit y of th e on lay graft an d pin ch ing
deform it y.
• Com plicat ion rates of alloplast ic im plan t s are
m edically accept able. Com p licat ion s are m ore
frequ en tly th e resu lt of th e su rgeon’s tech n ical an d
judgm en t al errors, rath er th an th e fault of in h eren t
ch aracterist ics of th e m aterial it self.
Am oun t s of autologou s m aterials except for costal car t ilage
are lim ited for th e u su al large-volu m e augm en t at ion . How -
ever, w ith th e u se of costal car t ilage, econ om ic an d p sych o-
logical burden s are h eavy for pat ien ts. Oth er disadvan t ages
in clude postoperat ive scarring on th e ch est , rigidit y of th e
t ip, prolonged operat ion t im e, an d a long recover y period.
In addit ion , th e u se of cost al car t ilage is n ot free of com -
plicat ion s. Problem s of w arping an d resorpt ion are w ell
kn ow n . In fect ion is rare but is possible. Th erefore, cost al
cart ilage is reser ved as a last resor t by m any surgeon s.
On th e oth er h an d , allop last ic im p lan t s are ready to
u se, easy to car ve, varied in size, an d su p erior to au tolo-
gou s m aterials from an aesth et ic view p oin t . Also, th ey are
n ot su bject to resorpt ion or w arping. Am ong th e m ost com -
m on ly u sed allop last ic m aterials are silicon e, exp an ded
polytet ra u oroethylen e (Gore-Tex), an d porous h igh -den -
sit y polyethylen e (Medp or, St r yker, Kalam azoo, Mich igan ).
Silicon e is th e m ost frequen tly used m aterial in Asian
count ries. It is n onporous, in con t rast to th e oth er t w o
13
14 II Rhinoplast y

m aterials, w ith n o t issu e ingrow th or vascu larizat ion
seen after im p lan t at ion . Becau se of it s n onp orou s n at u re,
it is n on ad h esive to su rroun ding t issue an d en closed in a
brou s cap su le. Also, it is free from deform at ion , easy to
sterilize, an d easy to rem ove w h en n ecessar y. It is relat ively
ch eap an d available in a range of soft n ess values.
Expan ded polytet ra uoroethylen e (ePTFE) is com -
p osed of n od ules of Te on in tercon n ected by brils of
p olytet ra u oroethylen e an d h as a m icrop orous arch itec-
t ure, w ith pore sizes ranging from 10 to 30 m m . It s poros-
it y m akes it easily m alleable an d su scept ible to long-term
com pression , result ing in volum e decrease or deform at ion
of th e im plan t . Its hydroph obic an d porou s n at ure m akes
th e sterilizat ion process using an an t isept ic or an t ibiot ic
solu t ion di cu lt . Relat ively h igh cost is an oth er disadvan -
t age. For th e revision cases, som et im es it is ver y di cult
to rem ove th e previou s ePTFE im plan t , especially w h en th e
im plan t is th in , an d th e durat ion of im p lan t at ion is long.
W h en th e surroun ding soft t issue is rem oved togeth er
w ith th e im plan t , th e result ing soft t issue irregularit y is
ext rem ely d i cu lt to repair.
Porous polyethylen e (Medpor) con sists of a con t in uous
system of in tercon n ect ing p ores of size 125 to 250 m m . Th e
vascu lar an d brou s ingrow th leads to in tegrat ion an d st a-
bilizat ion of th e im plan t . Th e ten sile st rength of th e m ate-
rial is ver y h igh , con t rar y to th e case for ePTFE. Becau se of
it s st i n at u re, it sh ou ld be used w ith ut m ost caut ion in
m obile areas su ch as th e m em bran ou s sept u m or t ip.
Syn th et ic im plan ts in rh in oplast y h ave been a topic of
great con t roversy. In part icular, silicon e, w h ich is th e single
m ost com m on ly u sed im p lan t m aterial in Asian cou n t ries,
is a poin t of w orldw ide con ten t ion .1 Asian n oses are con sid-
ered m ore recept ive to allop last ic im p lan ts becau se of th eir
th ick skin .2 Th is is t rue to som e exten t , but even th icker
skin can n ot resist long-term th in n ing, ext ru sion , in am -
m at ion , an d in fect ion . Th erefore, p roper tech n iqu es u sing
an adequ ately design ed im plan t m u st be execu ted .
W h en an experien ced surgeon uses proper tech n iques,
th e com plicat ion rate for alloplast ic im plan t s is su rpris-
ingly low and in a m edically accept able range. Recen t st ud-
ies about th e com plicat ion rates of alloplast ic im plan t s for
augm en tat ion rh in op last y sh ow th at th ey are m u ch low er
th an th ose in st udies from th e 1960s an d 1970s.3 Th ese
ch anges are due to im provem en t s in im plan t design, con -
ser vat ive su rgical tech n iqu es, su rgeon s h aving m ore exp e-
rien ce, an d th e u se of softer silicon e.
Profession al recom m en dat ion s sh ould be given to th e
pat ien t after a th orough an alysis of th e face. Th e relat ion -
sh ip of th e n asal dorsu m , t ip , p h ilt ru m , lips, an d m en t u m
w ith th e ver t ical facial axis sh ou ld be invest igated. In an a-
lyzing the face, any facial asym m et r y m ust be n oted an d
revealed to th e pat ien t before th e surger y, because th e
augm en tat ion rh in op last y m ay w orsen or accen t u ate a
pre-exist ing facial asym m et r y. W h en th e vert ical facial
axis is skew ed or de ected, th e augm en ted n ose can n ot
be absolutely ver t ical an d st raigh t . In pat ien t s w ith sign i -
can t facial asym m et r y, it is bet ter to augm en t th e n ose in a
di eren t ver t ical axis from th e an atom ic dorsum . In th ese
pat ien t s, n asal bon es on th e t w o sides are frequen tly asym -
m etric in term s of th e w id th an d th e slope. W h en th e bony
asym m et r y is sign i can t , th e bot tom of th e im p lan t is bet-
ter car ved asym m et rically accordingly.
Facial asym m et r y com m on ly accom pan ies asym m et-
ric n asal alae. Pre-exist ing alar asym m et r y m akes th e n ose
look deviated even after augm en tat ion to th e correct axis.
Asym m et ric alar resect ion in th ese pat ien t s m ay n ot cor-
rect th e problem sat isfactorily. Alar asym m et r y relat ing to
facial asym m et r y is d i cu lt to correct becau se of it s m u lt i-
dim en sion al n at ure.
A system ic exam in at ion of th e n ose is p erform ed from
top to bot tom (Fig. 2.1). Th e relat ion sh ip of th e foreh ead
w ith th e n asal root is im port an t for a su ccessful dorsal aug-
m en t at ion . Th e Asian foreh ead is relat ively at an d less p ro-
t ruding. Gen erally, Cau casian s are m ore dolich oceph alic

■ Patient Evaluation
Th e sh ape an d pro le of th e n ose requ ested by th e pat ient ,
an d th eir feasibilit y or desirabilit y are discu ssed in th is
sect ion . Advan t ages an d disadvan t ages of u sing allop last ic Fig. 2.1 Key areas that should be considered for successful aug-
im p lan t s an d p ossible altern at ives to alloplast ic m aterials mentation rhinoplast y: forehead slope, nasofrontal transition, pro-
are also discu ssed . jections of the nasal tip, prem axilla, and chin.
 2 Augm ent ation Rhinoplast y Using Silicone Im plant s 15

an d Asian s are m ore brach iocep h alic. Brow ridges in Asian s

are also n ot as prom in en t as in Cau casian s. As a resu lt ,
th e n asofron tal angle in Asian s is like a gen tle an d grace-
fu l cu r ve rath er th an an angle. Augm en t at ion rh in op last y
in Asian s m u st preser ve th is gen tle cur vaceous t ran sit ion
from th e foreh ead to th e n asal dorsu m . An d th e augm en ted
n ose m u st h arm on ize w ith th e relat ively at foreh ead .
Th erefore, excessive augm ent at ion of th e radix area sh ould
be avoided in pat ien t s w ith a at foreh ead. Th e proxim al
en d of th e im p lan t sh ou ld be carefu lly tap ered to accom -
m odate to th is area an d n ot be visible or p alpable. Desp ite
th e ret ruded foreh ead, if th e pat ien t w an t s a subst an t ial
am ou n t of dorsal augm en tat ion , com bin ed foreh ead aug-
m en t at ion sh ou ld be con sid ered. Foreh ead augm en t a-
t ion surger y is rarely perform ed in th e West; h ow ever, it
is a com m on su rger y in Asian cou n t ries, u sing alloplast ic
im p lan t s or m icrofat inject ion .
In p at ien ts w ith excessive skin an d soft t issu e crow ding
in th e glabellar an d n asal root area, th e brow lift sh ou ld be
con sidered. Th at is because augm en t at ion rh in oplast y m ay
m ake th is area look h eavier an d th icker an d m ay w orsen
th e m ascu lin e look in th ese pat ien ts, leading to u n sat isfac-
tor y outcom es. Aged pat ien t s ten d to h ave brow ptosis an d
a th ick soft t issu e load in th e glabellar area. Th erefore, a
com bin ed brow lift surger y sh ould be con sidered in aged
p at ien t s an d augm en t at ion of th e radix area sh ou ld be
Fig. 2.2 A preoperative X-ray helps in planning by visualizing the
m in im ized, focu sing m ore on t ip augm en tat ion . How ever,
bone and soft tissue anatomy of the nose.
even in you ng p at ien ts h aving a sh ort dist an ce from gla-
bellar area to n asion , dorsal augm en t at ion m ay fu rth er
sh orten th e dist an ce, m aking th e n asal root area u n n at u ral
an d at ten ed. Th erefore, a com bin ed brow lift su rger y m ay
be con sidered in th ese young pat ien ts also. Th e en doscopic w ith th e pat ien t , becau se it is u n realist ic to t r y to m ake th e
brow lift is th e best opt ion for young pat ien ts con sidering sides of th e alae com pletely sym m et ric. In p at ien ts w ith
th e e ect on th e m edial brow an d m in im izing postopera- un derdevelopm en t of th e m axilla or prem axilla, paran asal
t ive scarring. or prem axillar y augm en tat ion m ay be con sidered as an cil-
Th e glabellar an d n asal root region sh ow s a w ide range lar y p rocedures of th e augm en tat ion rh in oplast y.
of variat ion even in Asians. Th erefore, th e proxim al im plan t How ever, it sh ou ld be taken in to con siderat ion th at
sh ou ld be car ved carefu lly according to in dividu al an atom y acu te n asolabial angle is n ot u n com m on in Asian s. Som e
to t in th is area. Preoperat ive X-ray m ay be h elpful for Asian n oses are beaut ifu l en ough even w ith th e acute n aso-
visualizat ion of th e bon e an d soft t issue an atom y of th is labial angle, an d in som e p at ien t s acute n asolabial angle is
area (Fig. 2.2). Exam in at ion by m an u al palp at ion of th is not a con cern at all.
area before or d u ring th e operat ion is also ver y im p ort an t . Pat ien t s w ith prot ruding lips can ben e t from th e com -
Carefu l dorsal exam in at ion p reced es th e design of an bin at ion of rh in oplast y, m axillar y augm en tat ion , an d ch in
im plan t . Th e n asal bon e is exam in ed for it s length , w idth , augm en tat ion . Th is com bin at ion of su rgeries w ill dram at i-
an d asym m et r y. Man u al p alpat ion along th e dorsu m is cally en h an ce th e facial pro le in selected pat ien ts.
h elpfu l in revealing soft t issu e th ickn ess, presen ce of h u m p ,
or dorsal irregu larit y.
Skin th ickn ess of n asal t ips is qu ite variable in Asian s.
For th e th in -skin n ed pat ien ts, visibilit y of graft s or th e ■ Surgical Techniques
im plan t m igh t be problem at ic. On th e oth er h an d, for th e
th ick-skin n ed pat ien t s w ith bulbou s t ips, it is ver y di cult Skin Marking
to obt ain a n e de n it ion of th e t ip.
Wide alae are com m on in Asian s. For th e en h an ced Skin m arking for th e augm en tat ion m u st be don e in th e
outcom e of dorsal augm en t at ion , alar resect ion m ay be sit t ing p osit ion . Marking a vert ical lin e for th e dorsal aug-
requ ired in som e p at ien ts. If alar asym m et r y an d asym m et- m en t at ion is im p or t an t , becau se frequ en tly th e glabella,
ric m axillar y develop m en t are p resen t , th ey are d iscu ssed nasal dorsu m , an d n asal t ip are o th e sam e vert ical axis,
16 II Rhinoplast y
an d augm en t at ion rh in op last y m ay accen t u ate th e devi-
ated look of th e n ose.
Th erefore, th e surgeon m ust set a ver t ical lin e for th e
augm en tat ion . Th e lin e th at looks th e st raigh test is care-
fu lly ch osen for th e lin e of augm en tat ion (Fig. 2.3). W h en
th e dorsu m an d t ip are ver t ically m isalign ed, u sually a ver-
t ical lin e exten ded upw ard from th e t ip is m ore appropriate
for th e lin e of augm en tat ion , rath er th an th e lin e along th e
d orsu m , alth ough th is is n ot alw ays th e case.
Th e n asal start ing poin t is set an d a h orizon t al lin e is
m arked, u su ally at th e h eigh t of th e ciliar y m argin s. In gen -
eral, w h en th e p at ien t w an t s a h igh er dorsu m , th e lin e m ay
be draw n at th e h eigh t of th e su prat arsal crease. W h en th e
p at ien t w an t s a m ore n at ural look, th en th e lin e is draw n
bet w een th e ciliar y m argin an d th e pupil. How ever, it is
in dividualized according to th e pat ien t’s facial ch aracter-
ist ics. Th is h orizon t al lin e also provides a lan dm ark for th e
ceph alic exten t of th e subperiosteal dissect ion .
Anesthesia and Positioning
Th e pat ien t is put un der an esth esia in a supin e posit ion
an d drap ing is don e. Augm en tat ion rh in oplast y u sing allo-
plast ic im plan ts is don e un der gen eral an esth esia or in t ra-
ven ou s an esth esia w ith sedat ion . W h en it is don e u n der
in t raven ou s an esth esia, close m on itoring of th e respirat ion
is cru cial. Main t ain ing th e oral air w ay du ring th e surger y
Fig. 2.3 Skin marking is done in a sit ting position using a straight
wooden stick. A vertical line is drawn. The nasal starting point,
rhinion, and nasal tip are marked.
is required. Any blood or secret ion in th e oral an d ph ar yn -
geal cavit y is su cked ou t rep eatedly u sing a su ct ion cath eter
th rough th e oral air w ay during th e operat ion . To redu ce th e
secret ion , in t raven ou s inject ion of glycopyrrolate before
th e surger y is recom m en ded. Oxygen supplem en t at ion
th rough th e oral air w ay also can be h elpful.
Preparation of the Implant
Before local an esth et ic inject ion , an im plan t is prep ared
an d t ried on th e d orsu m (Fig. 2.4). Th e su rgeon m u st ch eck
w h eth er it is suit able for th e desired h eigh t an d desired
n asal pro le, w h eth er it is w ell t ted for th e n asofron t al
angle, an d th e d orsal con gu rat ion . Th en in it ial car ving is
perform ed using a n o. 15 surgical blade before th e surger y.
A correctly design ed im plan t is crucial for a su ccessful
outcom e. Any single im plan t m ust be custom ized accord-
ing to in dividu al an atom y. Th e th ickn ess of th e im plan t is
decided rst . Im plan t s w ith 4 to 5 m m of th ickn ess are m ost
frequ en tly ch osen am ong th e 2 to 10 m m th ickn ess range.
How ever th e th ickn ess is n ot u n iform an d varies along th e
dorsu m after car ving according to th e in dividual’s an a-
tom ic ch aracterist ics. In gen eral, w h en th e n ose is low in
radix an d th e t ip is w ell projected, the im plan t is car ved
proxim ally th ick an d dist ally th in . On th e con t rar y, w h en
th e n ose is adequ ately h igh in radix an d th e t ip is low, th e
im plan t is car ved proxim ally th in an d dist ally th ick. W h en
a h u m p is p resen t , th e im plan t is often car ved th in n er in
th e rh in ion area (Fig. 2.5).
Th e im plan t’s sh ape, especially th e distal por t ion , is
also variable according to th e preferred t ip augm en t at ion
tech n iqu e.
Th e in it ially car ved im plan t is im m ersed in an t isept ic
solu t ion su ch as hyp och lorou s acid u n t il it s later u se. Th e
Fig. 2.4 The implant is tried on the dorsum for the initial carving.
 2 Augm ent ation Rhinoplast y Using Silicone Im plant s 17

for later closu re an d th ere is n o risk of n otch ing deform it y.

Th e colum ellar ap is elevated in th e conven t ion al m an -
ner. Elevat ion of th e skin ap from th e t ip is on th e supra-
perich on drial plan e for th e th in -skin n ed pat ien t s as u sual.
How ever, for th e th ick-skin n ed Asian p at ien t , th e defat t ing
procedure is frequen tly requ ired for debulking th e th ick
soft t issu e an d for bet ter de n it ion of th e t ip . For th e defat-
t ing procedure, a layer of soft t issue is deliberately left on
th e cart ilage surfaces elevat ing th e skin ap (Fig. 2.6).
Becau se th e t ip soft t issu e is arranged in a layered
fash ion , it is n ot qu ite as di cu lt to raise th e ap w ith an
even th ickn ess. Th is tech n ique is bet ter for sm ooth an d
even rem oval of th e soft t issu e along th e cart ilage su rfaces
th an defat t ing from th e un dersurface of th e skin ap after
su p rap erich on drial elevat ion . Th ere is th ick soft t issu e on
th e suprat ip area also, an d it can be rem oved or preser ved
depen ding on th e sit uat ion . On th e car t ilagin ou s dorsum ,
th e plan e is ch anged to th e su praperich on drial plan e.

Fig. 2.5 The initial carving is done using a no. 15 surgical blade. Creation of the Periosteal Pocket
The three most common shapes of implant s are shown (top, proxi-
mally thin and distally thick; middle, proximally thick and distally As dissect ion proceeds on th e n asal bon e, th e plan e is
thin; bottom, anatomically carved). Implants are further custom -
ch anged again to th e subperiosteal plan e (Fig. 2.7). It is
ized during the surgery.
ver y im p or t an t to accu rately raise th e periosteal ap from
th e n asal bon e. W h en th e im plan t is n ot correctly placed in
th e subperiosteal space, th e im plan t ten ds to be m ore m ov-
able an d m ore visible. To elevate th e periosteu m p recisely,
hypoch lorous acid is suit able for th is purpose because it is it is bet ter to u se a sh arp an d n arrow t ip elevator, su ch as
clear in n at ure an d relat ively less toxic, n on irritat ing, an d th e Joseph elevator, at rst . W h en th e subperiosteal space is
p oten t . correctly raised par t ially, th en a w ider elevator is in serted
an d th e sp ace is w id en ed . If a w ide an d blu n t in st ru m en t is
used from th e st art , th e periosteum is easily torn .
Harvest of Ear Cartilage Close to th e n asofron t al su t u re lin e, bleeding is likely
to en su e becau se of p roxim it y of vessels to th e su t u re lin e.
After local an esth et ic inject ion s at th e n ose an d th e ear,
con ch al car t ilage is h ar vested rst w h en it is expected to
be n ecessar y. Con ch al car t ilage is h ar vested com m on ly
th rough a postauricular in cision . An d it is h ar vested from
th e cavum con ch a an d cym ba con ch a separately, leaving
th e cru s of h elix as a bridge. Th is valuable an atom ic land-
m ark of th e au ricle is best preser ved for aesth et ic p u rposes
an d st ru ct u ral su p p or t , an d to m ain t ain th e abu n dan t n eu -
rovascular su pp ly of th is area. Th e h ar vested con ch al cart i-
lages are p reser ved in th e an t ibiot ic solut ion .

Incision and Elevation of the Skin Flap

For an open rh in oplast y, t ran scolum ellar an d m argin al
in cision s are m arked rst . In Asian p at ien t s, occasion ally
th e caudal m argin s of th e alar car t ilages are n ot prom in en t
th rough th e vest ibular skin . Th erefore, m arking for m ar-
gin al in cision is h elp fu l for a p recise an d sym m et ric in ci-
sion . Th e m argin al in cision is p laced 1 m m an terior to th e Fig. 2.6 Elevating the skin ap. A thin layer of soft tissue on the
caudal m argin of th e alar cart ilages, because th is is bet ter alar cartilage is deliberately left for the defat ting procedure.
18 II Rhinoplast y

Th e soft t issue on th e su rface of th e alar car t ilages an d

in the su prat ip area th at w as left deliberately du ring ap
elevat ion for th e defat t ing procedure is n ow rem oved. Clear
ident i cat ion an d delin eat ion of th e cart ilage m argin s are
im port an t at th is st age for later procedu res (Fig. 2.8). Mar-
gin al in cision s are exten ded laterally as n eeded, esp ecially
w h en th e ten sion on th e augm en ted t ip is expected to be
h igh . Th e p iriform ligam en t s m ay also be fu rth er released as
n ecessar y. For m ore release of ten sion , th e scroll area m ay
be dissected. How ever, th e dissect ion sh ould be as con ser-
vat ive as p ossible, becau se m ore dissect ion w ill cau se m ore
distort ion , scar form at ion , an d u npredictabilit y.

Harvest of Septal Cartilage

Next th e m em bran ou s sept u m is dissected an d th e cau dal
m argin of th e sept u m is iden t i ed. Th e septal cart ilage is
h ar vested, leaving th e L-st ru t . In Asian s, th e sept al car t ilage
is frequ en tly w eak an d sm all. In th ose pat ien t s w ith a w eak
sept u m , m ore of th e septal cart ilage sh ou ld be preser ved
th an th e conven t ion al 1 cm w idth for th e dorsal an d cau-
dal st rut to m ain tain th e st ru ct ural st abilit y. Th erefore, th e
am ou n t of h ar vested sept u m is frequ en tly ver y sm all. Even
w h en th e h ar vested am oun t of sept al car t ilage is en ough ,
th e caudal sept u m is too w eak an d frail to provide long-
Fig. 2.7 The dissection plane is supraperichondrial on the carti- term stable suppor t for th e sept al exten sion graft . In th is
laginous dorsum and subperiosteal on the nasal bone. regard, t ip surger y using sept al cart ilage on ly h as clear
lim itat ion s in m any Asian pat ien t s. How ever, despite th ese
draw backs, th e sept al exten sion graft is st ill on e of th e m ost
reliable t ip tech n iques for Asian s. It provides t ip project ion
an d rotat ion /derot at ion it self, as w ell as p roviding st rong
If th is bleeding is n ot con t rolled correctly, h em atom a can m edial su p port for com bin ed on lay graft s (Fig. 2.9). How -
arise postop erat ively on th e n asal root . Hem atom a is a seri-
ous com plicat ion , because if n ot adequately t reated, it w ill
be accom pan ied by bacterial in fect ion . Th e posit ion of th e
im plan t m ay also be ch anged by a h em atom a.
Th erefore, it is bet ter n ot to dissect overly exten sively
in th e ceph alic direct ion if it is n ot n ecessar y. Excessive
ceph alic dissect ion m ay also lead to ceph alic m igrat ion of
th e im plan t .
Th e subperiosteal pocket is w iden ed laterally as n eeded.
Th e space sh ould be close to sym m et ric an d adequately
w ide for th e im plan t to be sn ugly placed in side. W h en th e
su bp eriosteal pocket is too sm all, th e im p lan t m ay n ot be
placed properly an d m ay later be displaced or deviated. On
th e oth er h an d, an overly w ide pocket is also a com m on
cause of early postoperat ive displacem en t of th e im plan t .

Defatting and Release of

Ligamentous Attachments
After th e dissect ion along th e d orsu m is n ish ed, th e t ip
su rger y is in it iated . A su ccessfu l dorsal augm en tat ion can - Fig. 2.8 Cartilage m argins are clearly delineated after the defat-
n ot be accom p lish ed w ith ou t a su ccessfu l t ip augm en tat ion . ting procedure.
 2 Augm ent ation Rhinoplast y Using Silicone Im plant s
Fig. 2.9 Septal extension grafting is done on the caudal septum
as an overlapping pat tern.
ever, excessive ten sion from overzealou s t ip augm en t at ion
relying on ly on th e sept al exten sion graft w ill be a cause of
sept al bu ckling, long-term resorpt ion or w eaken ing of th e
caudal sept um , an d t ip drooping. Th erefore, a m in im al to
m oderate am ou n t of ten sion sh ou ld be app lied, con sider-
ing th e st rength of th e in dividual sept al car t ilage.
After h ar vest ing th e sept al cart ilage, osteotom ies are
p erform ed if required. Alth ough th e osteotom y is n ot a
con t rain dicat ion for alloplast ic dorsal augm en t at ion , th e
osteotom y sh ould be as at raum at ic as possible an d m u co-
sal tearing sh ou ld be m in im ized to exclu de th e ch an ce of
ascen ding bacterial in fect ion .
Insertion of the Implant
Th e prefabricated im plan t is n ow in ser ted in th e dorsal
pocket (Fig. 2.10). Th e excessive length ou t side th e pocket
is t rim m ed. Th e p ro le of th e n ose is closely exam in ed an d
com pared w ith th e plan n ed sh ape. Th e con form it y of th e
im p lan t on th e n asal dorsum is closely ch ecked. Th e proxi-
m al en d sh ou ld n ot be visible, read ily p alp able, or m ov-
able. Th e dorsu m sh ou ld be sm ooth an d st raigh t , or m ildly
con cave in w om en . To obt ain th e desired sh ape an d dorsal
sm ooth n ess, repeated car ving an d t rials of th e im p lan t m ay
be n ecessar y.
Th e p roject ion an d rot at ion of t h e t ip , w h ich is tem -
p orar ily for m ed by t h e d ist al t ip of t h e im p lan t , is care-
fu lly exam in ed . Th e im p lan t m ay be u sed as a d u m m y for
t h e t ip su rger y. Th e su rgeon can est im ate t h e requ ired
am ou n t of p roject ion by t h e t h ickn ess of t h e im p lan t t ip .
An d also t h e su rgeon can est im ate t h e d esired am ou n t of
rot at ion /d erot at ion by m ovin g t h e t ip of t h e im p lan t back
an d for t h .
19
Fig. 2.10 The prefabricated implant is inserted into the dorsal
pocket.
Preparation of the Stacked
Onlay Graft
Accord ing to th e est im ated am ou n t of t ip p roject ion ,
on lay graft s using sept al or auricular car t ilage are pre-
pared. Because th e am oun t of sept al car t ilage is lim ited in
Asian s usually, auricular car t ilage is gen erally used for th is
purpose.
Stacking of m u lt iple on lay graft s is frequen tly n eces-
sar y becau se th e requ ired am ou n t of t ip augm en t at ion is
com m on ly substan t ial in Asian s.4 Stacking of t w o or th ree
layers of auricu lar cart ilage is u sually requ ired, alth ough
th e n um ber is variable. Th e layered cart ilages m ay be
su t u red togeth er. Th ree layers of au ricu lar car t ilage w ill be
arou n d 5 m m in th ickn ess.
Th e graft sh ould be ceph alo-caudally long en ough to be
placed over th e dom es of th e alar cart ilages. Th e m argin s
of th e graft are m et iculously t rim m ed to be devoid of any
sh arp edges.
W h en th e stacked on lay grafts are prepared, th e sam e
ceph alo-cau dal length as used for th e graft is resected
from th e distal im plan t (Fig. 2.11). Th e rem oved part of
th e im plan t is replaced by th e on lay graft , w h ich is sut ured
to th e cut en d of th e im plan t . By su t uring th e graft to th e
im plan t , an u nbroken , seam less t ran sit ion from th e dorsum
to th e t ip is en su red. Tip m obilit y is m ildly decreased but
n ot rest ricted by su t u ring th e graft to th e im p lan t . How -
ever, w h en th e septal exten sion graft is u sed, decreased
t ip m obilit y is an in evitable t rade-o . Th e th ickn ess of th e
dist al en d of th e im plan t is adjusted to m atch th e th ickn ess
of th e on lay graft . Th e distal part of th e im plan t m ay be
beveled according to th e in clin at ion of th e lateral crura of
th e alar cart ilages.
Th e st acked on lay graft is suppor ted m edially by th e
sept al exten sion graft . With ou t strong m ed ial su p port , th e
20 II Rhinoplast y
Fig. 2.11 The same length of the silicone implant as the stacked
onlay cartilage tip graft is cut out from the caudal end.
e ect of th e graft w ill abate w ith th e collap se of colu m ella
an d m em bran ou s sept u m , requ iring m ore am ou n t s of car-
t ilage, an d th e colum ellar-lobular rat io w ill deteriorate.
Insertion of the Uni ed Graft and
Implant Hybrid
The uni ed graft an d im plant hybrid is inserted into th e
dorsal pocket , and the pro le is closely exam ined again.
The surgeon has to exam ine the nose carefully, tem porar-
ily closing the incision by pulling dow n the colum ellar ap,
because the pro le can be changed due to the tension on the
skin . Repeated car ving m ay be required at th is stage also.
W h en th e desired sh ape of th e n ose is n ally obt ain ed,
th e on lay graft is xed to th e alar cart ilages w ith sut ures.
Th e n al n e m odi cat ion of th e t ip an d t ip lobules is
don e by car ving an d addit ion al graft ing. A sh ield graft in
fron t of th e graft or addit ion al on lay grafts can be added
as n ecessar y.
Placement of the Wing Grafts
After obt ain ing a n al t ip sh ap e, so-called w ing graft s are
ap plied bilaterally on th e lateral sides of th e on lay graft
(Fig. 2.12). Th e w ing graft is sh ap ed to assim ilate th e lat-
eral cru ra of th e alar cart ilages, to corresp on d w ith th e
dom e n ew ly created by th e stacked on lay graft . Auricu lar
cart ilage is best suited to th is purpose because of it s n at u-
ral cu r vat ure. Th e pu rpose of th e w ing graft is to preven t
th e collapse or pin ch ing deform it y on th e lateral sides of
th e on lay graft . With out th e w ing grafts, th e t ip is cen t rally
prom in en t on ly n ear th e on lay graft , an d laterally t ip lob -
u les are collapsed an d pin ch ed. Th e w ing graft p rovides a
sm ooth t ran sit ion from th e t ip to th e lobu les, soften s th e
m argin s of th e on lay graft , an d act s as a st ru ct u ral su pp or t
again st soft t issu e collapse. Th e w ing graft is also h elp ful in
Fig. 2.12 The wing graft s are applied on both sides of the onlay
graft.
cases of alar rim ret ract ion , because it is secu rely xed to
th e on lay graft to provide st rong suppor t again st ret ract ion ,
com pared w ith the alar rim graft .
In a w idely u sed tech n iqu e for alloplast ic augm en t at ion
in Asia, th e t ip of th e im plan t (st raigh t or L-sh aped) is placed
on top of th e alar car t ilages, an d th en a piece of autologous
cart ilage is laid on top of (on lay-like) or in fron t of (sh ield-
like) th e dist al im plan t in an at tem pt to decrease th e risk of
skin p roblem s su ch as ext ru sion . Th ese tech n iqu es p rovide
t ip project ion an d rot at ion w ith relat ive ease, an d produce
fair ou tcom es in selected cases, esp ecially in th ose w ith
u n der-p rojected an d un der-rot ated n asal t ips. How ever,
th ese tech n iqu es h ave apparen t disadvan t ages. Th e resul-
tan t t ip ten ds to be over-rotated an d u n n at ural, because
th e project ion an d rotat ion in crease w ith out proport ion al
elongat ion of th e t ip. Th e in frat ip lobule becom es un n at u-
rally th ick w ith a decreased colum ellar-lobular rat io. Fin e
t ip m odi cat ion is also di cult using th ese tech n iques, an d
th e t ip often looks sh arp an d poin ted. In addit ion , th e piece
of cart ilage on th e dist al im plan t is likely to becom e con -
spicu ou s w ith t im e.
In con t rast , for th e previou sly described tech n iqu e
u sing th e st acked on lay graft , it is easy to elongate th e t ip .
Fin e t ip sh aping is possible w ith addit ion al car ving an d
graft ing. Com bin ing th e w ing graft s, it is m ore n at u rally
sm ooth in sh ape, an d th ere are n o visibilit y or con sp icu it y
problem s of on lay graft s over t im e.
Variant Techniques
Th e aforem en t ion ed procedures can be don e using th e
en don asal app roach . How ever, gen erally th is m akes it m ore
di cult to m an ipulate th e graft s an d to con t rol th e ten sion
on th e t ip skin . For m ore visualizat ion an d m ore release
 2 Augm ent ation Rhinoplast y Using Silicone Im plant s
of ten sion , a m argin al in cision is exten ded m edially over
th e foot plate to th e n asal sill, an d laterally to th e piriform
ligam en ts.
W h en th e h eight di eren ce bet w een th e t ip an d th e
an terior septal angle is sign i can t an d th e in clin at ion of
lateral cru ra is con siderable, a varian t tech n ique can be
u sed (Fig. 2.13). Th e su bst an t ial t ip -to-sept u m h eigh t d if-
feren ce an d lateral cru ral in clin at ion are com m on ly created
by th e st rong t ip project ion w ith th e sept al exten sion graft;
h ow ever, a con siderable t ip -to-sept u m h eigh t d i eren ce is
presen t even prior to surger y in som e pat ien ts. In th is sit u -
at ion , th e dist al im plan t is car ved in a w edge sh ape w ith
ap prop riate th ickn ess to t in th e cep h alic divergen ce of
alar car t ilages. Th e im p lan t m ay be su t u red to th e cep h alic
m argin s of th e alar cart ilages.
For som e pat ien t s, on ly th e low n asal bridge, n ot th e
t ip, is th e problem an d th eir con cern . Th en on ly a correctly
car ved im plan t according to th e in dividual dorsal an atom y
w ill su ce. Th e im plan t is in serted th rough th e m argin al
or in tercar t ilagin ous in cision . In adequ ately n arrow, sm all,
or asym m et ric dorsal pockets w ill predispose to ext rusion .
For th e sym m et r y of th e dorsal pocket , bilateral in cision
an d dissect ion are recom m en ded. Th e dist al en d of th e
im plan t is t apered to be p aper th in to sm ooth ly cont in u e
to th e ceph alic port ion of th e alar cart ilages. An im plan t
of excessive length , in a sm all or asym m et ric pocket , m ay
ext ru de, esp ecially w h en th e dist al im p lan t is in direct con -
tact w ith th e in cision site. In th is regard, m argin al in cision
is m ore app ropriate for th e alloplast ic im p lan tat ion . With
th e m argin al in cision , addit ion al t ip graft ing or oth er t ip
m an ipu lat ion s are also p ossible.
a b
Fig. 2.13 (a,b) When the gap is signi cant bet ween the tip and the anterior septal angle, the implant m ay be carved in a wedge shape
and suture xed to the cephalic margins of the alar cartilages.
21
Closure and Splinting
For th e n al procedure, m et iculous sut ure closure is don e.
Th en irrigat ion w ith an t ibiot ic an d an t isept ic solut ion s is
perform ed using a syringe after th e closure.
Taping is don e to decrease th e edem a an d to decrease
th e m obilit y of th e im plan t an d grafts. Th en a th erm o-
plast ic splin t is applied on th e dorsum . Th e splin t ing is
im port an t to im m obilize th e im plan t an d to preven t edem a
an d h em atom a on th e rad ix area in th e im m ed iate p ost-
operat ive period. Th e splin t sh ould be applied along th e
pre-m arked ver t ical lin e of th e augm en t at ion . Th e splin t is
m ain t ain ed for at least 7 days.
■ Key Technical Points
1. Design ing an im p lan t is th e rst an d m ost crit ical
step. Based on th e d esired sh ape an d in dividu al
an atom y, th e im p lan t sh ou ld be car ved correctly.
2. Th e subperiosteal pocket is created. Th e pocket
sh ou ld be sym m et ric an d ap prop riately w ide for
th e im plant to be sn ugly placed in side an d n ot be
excessively m obile.
3. For th e sept al exten sion graft , excessive ten sion on
th e graft is un desirable, especially w h en th e sept al
cart ilage is frail. It provides a st able platform for
th e on lay t ip graft , w h ich is u sed for furth er t ip
project ion an d de n it ion , com m on ly required in
Asian pat ien t s.
22 II Rhinoplast y
4. The pre-car ved im plan t is in serted in th e pocket
an d th e dorsal pro le is carefu lly ch ecked . Rep eated
car ving m ay be n ecessar y. Using th e distal im plan t
as a d u m m y for th e t ip augm en tat ion allow s
th e am oun t of t ip project ion an d rotat ion to be
est im ated .
5 . Th e on lay gra ft is p re p a re d . It is com m on ly
st acke d in m u lt ip le laye rs for su fficie n t t ip
p roje ct ion . Th e sam e le n gt h a s t h e on lay gra ft is
excise d from t h e d ist a l im p la n t . Th e on lay graft is
su t u re d t o t h e cu t e n d of t h e im p la n t .
6. The w ing graft is prepared m im icking th e lateral
cru s. It is placed on both sides of th e on lay graft to
p reven t th e p in ch ing deform it y of t ip lobu les, to
d ecrease th e con sp icuit y of th e on lay graft .
7. Fur th er n e t ip sh aping is ach ieved by delicate
car ving an d th e use of addit ion al on lay or sh ield
graft s.
8. Met iculous closure an d irrigat ion using an t ibiot ic
an d an t isept ic solu t ion s are don e. Use of a
com pressive dressing w ith a th erm oplast ic splin t is
im port an t to im m obilize th e im p lan t an d to preven t
edem a an d h em atom a.
■ Complications and
Their Management
Negat ive react ion s tow ard allop last ic im p lan t s for rh in o-
plast y w ere com m on in th e Western part of th e w orld. Th is
m ay stem from exp erien ce w ith injectable m aterials su ch
as p ara n oil, liqu id silicon e, an d early im p lan ts of exces-
sive size.5 In terest ingly, recen t research sh ow s m uch low er
com plication rates from silicon e im plan ts com pared w ith
rep or t s publish ed in th e 1960s an d 1970s. Th ese ch anges
are th ough t to be du e to im provem en ts in im p lan t d esign ,
con ser vative su rgical tech n iqu es, physician s h aving m ore
exp erien ce, an d u se of softer silicon e. Many p hysician s in
Asia perceive th e com plicat ion rates of silicon e im plan t s
as acceptable, in part d u e to m ore exp erien ce w ith rh i-
n op last y using silicon e im plan t s com pared w ith Western
p hysician s.
Com plicat ion s from silicon e im plan ts can be largely
grouped into t w o categories, th ose caused by in h eren t t rait s
of silicon e it self an d th ose result ing from th e su rgeon’s
tech n ical or judgm en t al errors. For a successful su rgical
resu lt , it is essen t ial to m in im ize th e in evit able problem s
from in h eren t p hysical ch aracterist ics of th e m aterial an d
to m ake e ort s to reduce tech n ical an d judgm en t errors.5
Com m on com plicat ion s, such as deviat ion , t ip skin
problem s, an d infect ion , are m ore frequen tly related to
techn ical errors th at are avoidable, an d less frequen tly to
th e physical ch aracterist ics of th e m aterial it self.
Problems Caused by Inherent
Physical Characteristics of
Alloplastic Implants
Capsule Formation
In cases w h ere com plicat ion s su ch as con t ract ion do n ot
occur, th e brous capsu le preven t s th e im plan t from bon d -
ing w ith skin , preven t s skin dam age, an d m ain tain s th e
th ickn ess of th e skin an d soft t issue to som e degree. On th e
oth er h an d, th e brou s cap su le h as a side e ect of m aking
th e area suscept ible to in fect ion by preven t ing an t ibiot ics
from e ect ively p en et rat ing th e area arou n d th e im p lan t
an d by let t ing th e silicon e im p lan t create dead sp ace w ith in
th e capsule as it m oves in side.
In cert ain sit u at ion s, th e cap su le cau ses severe com p li-
cat ion s, m ost n ot ably th e con t racted n ose.6 Creat ion of an
excessively th ick an d w ide capsu le an d con tract ion is u su -
ally cau sed by add it ion al factors su ch as bacterial in fect ion
an d excessive t issu e dam age.
Th erefore, to avoid overproduct ion of capsules an d it s
en su ing com p licat ion s, th e su rgeon m u st take care to p re-
ven t in am m at ion or in fect ion from occu rring du ring or
after su rger y, w h ile m in im izing t issu e dam age an d bleed -
ing by surger y.
Skin and Mucosal Damage
St im u lat ion of th e skin , dam age to skin an d appen dages,
skin th in n ing, skin con t ract ion , an d telangiect asis are long-
term com plicat ion s. Th e sligh t yet repet it ive dam age cau sed
by th e solid im plan t can h arm th e m ucous m em bran e an d
create recurring ch ron ic in am m at ion , possibly by ascen d-
ing bacterial in fect ion th rough sm all m u cosal defects. To
m in im ize su ch p hysical dam age from silicon e im p lan ts,
th e im plan t sh ould be of appropriate length an d w idth ,
an d it m u st be w ell t ted an d im m obile. Addit ion ally, u sing
a softer m aterial for th e im plan t can h elp redu ce p hysi-
cal st im ulat ion . Sut uring a layer of derm is or derm ofat on
th e ou ter surface of th e im plan t is h elpful in th in -skin n ed
pat ien t s or revision cases to decrease m ech an ical st im u la-
t ion , an d m obilit y an d visibilit y of th e im plan t (Fig. 2.14).
Calci cation
W h en rem oving a long-seated im plan t , the surgeon m ay
com e across calci cat ion of th e im plan t . A calci ed im plan t
form s a h arder an d rough er su rface, in creasing st im ulat ion
to th e overlying skin an d let t ing th e irregu lar su rface sh ow
th rough th e skin . Calci cat ion m ay w orsen w ith t im e.7 Cal-
ci cat ion also relates to m ech an ical st im ulat ion an d dam -
age to surroun d ing t issue.
 2 Augm ent ation Rhinoplast y Using Silicone Im plant s
Fig. 2.14 The outer and lateral surfaces of the silicone implant are
covered with a dermal graft.
Problems Caused by Technical or
Judgmental Errors of the Surgeon
Extrusion and Thinning of Tip Skin
Ext r u sion rates of silicon e im p lan t s rep or ted ly var y from
0.48% to 50%, p robably d u e to t h e d i e ren ces in su rgi-
cal tech n iqu e, im p lan t sh ap e, an d t h e su rgeon ’s level of
exp er ien ce.3 W h en excessive ten sion is ap p lied to t h e
n asal t ip ’s skin w it h t h e in ten t ion of givin g a ten t -p ole
e ect u sin g t h e im p lan t , esp ecially t h e L-sh ap ed silicon e
im p lan t w it h a lon g colu m ellar segm en t , t h e r isks of skin
d am age an d im p lan t ext r u sion in crease. An im p lan t of
excessive le n gt h m ay t h in t h e n asal t ip skin over t im e,
an d m ay even t u ally ext r u d e. Th e im p lan t can also
ext r u d e in to t h e n asal cavit y t h rough t h e m u cou s m em -
bran e. Ch ron ic in am m at ion an d in fect ion are also com -
m on cau ses of ext r u sion . Ext r u sion is a com p licat ion t h at
can be avoid e d by u sin g an ap p rop r iately size d im p lan t ,
t ip graft in g w it h au tologou s car t ilages, an d in fect ion an d
in am m at ion p rotect ion .
Implant Displacement and Movement
Im p lan t deviat ion is a frequ en t side e ect . To preven t
displacem en t , th e im plan t sh ou ld be placed in th e sub -
periosteal pocket . Silicon e im plan t s h ave a h igh er risk of
m ovem en t com pared w ith m aterials w ith pores, su ch as
Gore-Tex. Th erefore, it is im port an t to im m obilize th e sili-
con e im plan t for th e period of t im e using a splin t after sur-
ger y. Som e su rgeon s m ake w edge excision s or h oles on th e
23
im plan t for im m obilizat ion by t issue ingrow th . It is h elpful
to im m obilize th e im p lan t; h ow ever, it is di cu lt to cor-
rect w h en th e im plan t is xed bu t deviated. An d it is said
to be th e cau se of su dden h em atom a or bleed ing in th e late
postoperat ive period, because a su dden t raum a or m ove-
m en t of th e im p lan t w ill disru pt th e blood vessels of th e
ingrow n t issu e.
Constant m ovem ent by the m alpositioned im plant can be
a cause of chronic skin irritation and ch ron ic in am m ation.
Infection
Alloplast ic im plan t s are su scept ible to in fect ion an d , w h en
in fected, exh ibit t ypical sym ptom s such as er yth em a, sw ell-
ing, an d puru len t secret ion . How ever, tem p orar y er yth em a
an d sw elling in th e form of su bclin ical in fect ion can occu r
rep eatedly. Subclin ical in fect ion is th ough t to occur w h en
th e n u m ber of bacteria is sm all, or if bacteria are presen t in
th e form of bio lm on th e su rface of silicon e.
Th orough sterilizat ion of th e surgical eld is n ecessar y
for redu cing in fect ion , especially in th e n asal vest ibule an d
th e en t ran ce part of th e n asal cavit y. Du ring surger y, it is
im port an t to preven t disru pt ion of n at ural barriers su ch as
th e m ucou s m em bran e. A lengthy surgical t im e m ay reduce
blood ow to th e t issue an d increase th e risk of in fect ion .
Im p lan ts m u st be im m ersed in sterilizing solu t ion du ring
procedures.8
■ Case Studies
Case 1
A 22-year-old fem ale visited th e clin ic for a rh in oplast y
(Fig. 2.15). Sh e sh ow ed t ypical Asian facial feat u res su ch as
a at foreh ead, sh allow n asofron t al angle, at n asal bridge
w ith w eak t ip project ion , an d m axillar y ret rusion .
Con sidering th e sh allow n asofron tal angle an d u n der-
projected t ip, a silicon e im plan t w as car ved to be proxi-
m ally th in an d dist ally th ick. Bilateral m edial an d lateral
osteotom ies w ere perform ed. For su cien t project ion ,
a th ree-layer st acked on lay graft w ith w ing graft s u sing
con ch al cart ilage, an d a sept al exten sion graft w ere used
in com bin at ion for th e t ip. For m ore de n it ion of th e t ip,
defat t ing of th e soft t issue on th e t ip w as don e.
On e-year p ostop erat ive p ict u res sh ow adequ ate t ip
project ion , a m ore de n ed n asal t ip, an d an augm en ted,
narrow ed n asal bridge. Th e st igm a of rh in oplast y, in cluding
th e un n at urally at n asofron tal t ran sit ion , visible im plan t
con tour in th e radix, an d sh arp poin ted t ip, are barely
not iceable.
24 II Rhinoplast y
a b
c d
Case 2
A 25-year-old fem ale visited th e clin ic for revision rh i-
n op last y (Fig. 2.16). Sh e h ad developed an in fect ion
after silicon e im p lan tat ion in th e previou s su rger y. Sh e
sh ow ed severe con t ract ion , a at dorsu m w ith low radix,
an over-rotated t ip , an d irregu lar d eform ed t ip skin w ith a
depressed scar. Septal car t ilage w as u sed for th e t ip -plast y
in th e previou s su rger y.
Fig. 2.15 Case 1: Primary dorsal augmen-
tation with tip-plast y. (a,c) Preoperative
frontal and lateral views show at forehead,
shallow nasofrontal angle, at nasal bridge
with weak tip projection, and maxillary
retrusion. (b,d) One-year postoperative pic-
tures show adequate tip projection, a more
de ned nasal tip, and an augmented, nar-
rowed nasal bridge.
Bilateral extended spreader grafts using rib cart ilage
an d stacked on lay tip grafts w ith w ing grafts u sing auricular
cart ilage w ere em ployed. Auricular cart ilage has advan tages
over rib cartilage for th e on lay or sh ield graft an d th e w ing
graft, becau se of its n at ural cu r vat ure an d less st i n at ure.
The dorsum w as augm en ted w ith a silicone im plant , w hich
w as covered w ith a derm al graft from th e postauricu lar skin .
Use of th e silicon e im plan t is usually safe even in secon dar y
cases. In con trast to case 1, the im plan t w as designed to be
proxim ally th ick and distally thin. One year after the revi-
sion operat ion , th e resu lt rem ain ed stable.
 2 Augm ent ation Rhinoplast y Using Silicone Im plant s
a b
c d
References
1. Lee MR, Unger JG, Rohrich RJ. Man agem en t of th e n asal
d orsum in rh in oplast y: a system ic review of th e literat u re
regard ing tech n iqu e, ou tcom es, an d com p licat ion s. Plast
Recon st r Su rg 2011;128:538e–550e
2. Lam SM, Kim YK. Augm en t at ion rh in oplast y of th e Asian
n ose w ith th e “bird” silicon e im plan t . An n Plast Su rg
2003;51(3):249–256
3. Peled ZM, Warren AG, Joh n ston P, Yarem ch uk MJ. Th e use
of alloplast ic m aterials in rh in oplast y surger y: a m et a-
an alysis. Plast Recon st r Surg 2008;121(3):85e–92e
4. Ah n J, Hon rado C, Horn C. Com bin ed silicon e an d car t ilage
im p lan t s: augm en t at ion rh in op last y in Asian pat ien t s.
Arch Facial Plast Su rg 2004;6(2):120–123
25
Fig. 2.16 Case 2: Correction of the postop-
erative contracted nose. (a,c) Preoperative
photos show severe contraction, at dor-
sum with low radix, over-rotated tip, and
irregular deformed tip skin with a depressed
scar. (b,d) One-year postoperative photos
show elevated dorsum, decreased tip rota-
tion, and improved tip skin dimpling.
5. McCurdy JA, Lam SM, eds. Cosm et ic Surger y of th e Asian
Face. Lon don , UK: Th iem e Medical Pu blish ers; 2005
6. Jung DH, Moon HJ, Ch oi SH, Lam SM. Secon dar y rh in o-
plast y of th e Asian n ose: correct ion of th e con t racted n ose.
Aesth et ic Plast Su rg 2004;28(1):1–7
7. Jung DH, Kim BR, Ch oi JY, Rh o YS, Park HJ, Han W W. Gross
an d pathologic an alysis of long-term silicon e im plan t s in -
serted in to th e h um an body for augm en tat ion rh in oplas-
t y: 221 revision cases. Plast Recon st r Surg 2007;120(7):
1997–2003
8. Jang YJ, ed. Rh in oplast y an d Septoplast y. Seou l, South Ko-
rea: Koonja Pu blish ing; 2014
 3 The Use of Costal Cartilage for Dorsal
Augmentation and Tip Grafting
Victor Chung and Dean M. Toriumi
Pearls
• Rhinoplast y in an East Asian patient requires
at tention to a di erent set of aesthetic goals than
for a Caucasian patient. Digital im age m orphing
soft w are is very im portant to be able to com m un icate
proposed changes to the patient population.
• Th e East Asian n ose is de cien t in st ruct u ral
su p p or t . Augm en tat ion is n ecessar y to ach ieve th e
desired re n em en t . A st ruct ural approach to East
Asian rh in oplast y allow s th e surgeon to accom plish
th e est ablish ed goals.
• Alth ough allop last ic im plan t s h ave been w id ely u sed
in East Asian rh in op last y, autologou s costal cart ilage
is being used m ore frequen tly in th e East Asian n ose
as a desirable altern at ive.
• A th orough h istor y, in clu ding previou s su rger y,
in fect ion , im plan ts, or injectable llers, is n ecessar y
to elu cidate factors th at w ill in crease th e com plexit y
of th e surger y.
• For safe an d successfu l costal cart ilage h ar vest , th e
su rgeon m u st be fam iliar w ith th e an atom y of th e
rib cage to select th e rib w ith th e best con tou r for
th e n ecessar y graft s.
• Th e barrier to m astering cost al car t ilage graft ing is
learn ing to ju dge w h ere to u se each poten t ial graft
an d h ow to p rop erly p rep are th e grafts.
■ Introduction
Aesth et ic rh in op last y of th e East Asian face requ ires a dif-
feren t app roach th an th at u sed for th e Cau casian face. Th is
altern at ive ap proach is du e to di eren ces in n asal an atom y,
pat ien t expectat ion s, an d surgical tech n iques. Regardless
of th e approach , th e prin ciples of st ruct ure rh in oplast y
rem ain th e sam e: surgical m an ipulat ion of th e n asal con -
st ru ct cau ses w eakn esses su scept ible to scar con t ract u re.
For a long-term aesth et ic an d fun ct ion al outcom e, aug-
m en t at ion m u st w ith st an d th e distort ing forces of t issu e
h ealing.1 Su p port ing th e n ose by augm en t at ion requ ires a
sign i can t am ou n t of graft ing m aterial. Au tologou s cost al
cart ilage provides a boun t iful source of m aterial th at can
be used to produ ce a last ing aesth et ic an d fun ct ion al result
in th e East Asian face.
26
• Age is th e m ost im port an t factor to con sider w h en
car ving cost al car t ilage.
• On e of th e m ost im portan t con cepts in su ccessful
costal cart ilage grafting is to car ve th e m aterial
sequ en tially w ith repeated cycles of car ving, soaking,
an d dr ying th e graft to iden tify its n at ural ben d.
• Alth ough cross-h atch ing an d sp lin t ing are u sefu l,
it is im por tan t to u n derst an d th at th ese tech n iqu es
can n ot overcom e th e select ion of an in appropriate
piece of costal cart ilage.
• In th e set t ing of East Asian dorsal augm en tat ion ,
osteotom ies are u sually un n ecessar y.
• Serial car ving, perich on driu m cam ou age, an d rigid
xat ion are key st rategies in p erform ing dorsal
augm en tat ion .
• Tip augm en tat ion , accom p lish ed w ith sh ield or
h orizon tal on lay grafts, creates project ion an d
re n em en t; h ow ever, a st able fou n dat ion is required
to con t rol length an d rot at ion .
• In th e East Asian n ose, w ith it s w ide air w ay an d
th icker lateral sidew alls, alar bat ten an d alar rim
graft s are in frequ en tly in dicated.
• After st ru ct u red rh in op last y w ith au tologou s cost al
cart ilage augm en t at ion , tech n ically di cult base
redu ct ion s m ay be required to balan ce th e n ose.
■ Patient Evaluation
Th e in it ial pat ien t con sultat ion start s w ith a com plete h is-
tor y an d physical exam in at ion to d iagn ose th e st ru ct u ral
problem s th at cau se th e un desirable aesth et ic feat ures of
th e pat ien t’s n ose. In addit ion , th e con sult at ion sh ou ld
elucidate any h istor y of n asal obst ruct ion or com plicat-
ing h istor y: p revious su rger y, in fect ion , or foreign bod-
ies, in cluding im plan ts an d inject able llers. Th e physical
exam w ill con rm ch aracterist ic an atom ic feat u res of th e
East Asian n ose, in cluding: at glabella; low n asal dorsum
w ith cau dally placed n asal st ar t ing poin t; th ick, sebaceous
skin overlying th e n asal t ip an d su p rat ip; w eak low er lat-
eral car t ilages; sm all cart ilagin ou s sept u m ; foresh or ten ed
n ose; ret racted colum ella; an d th icken ed, h anging alar lob -
u les (Fig. 3.1).2
 3 The Use of Cost al Cartilage for Dorsal Augm ent ation and Tip Grafting
a b
Fig. 3.1 Native East Asian characteristics: thick skin, wide and low dorsum, retracted colum ella, underprojected and amorphous tip.
(a) Frontal view; (b) lateral with midpupillary horizontal line; (c) base view.
Preoperative Evaluation
Th e preoperat ive evalu at ion con t in ues w ith th e ph otod-
ocum en tat ion of th ese an atom ic feat ures in st an dardized
view s (fron tal, lateral, th ree-qu ar ter, an d base view s).
Th ree-dim en sion al stereoph otogram m et r y can be per-
form ed at th is p oin t to p rovide a baselin e for postoperat ive
com parison an d m easu rem en t s.3
Digit al im age m or p h in g soft w are p rovid es an op p or-
t u n it y for a fran k d iscu ssion b et w e e n t h e p at ie n t an d
su rge on . Ph otograp h ic m an ip u lat ion is a t ran sp are n t
m e d iu m for t h e com m u n icat ion of exp e ct at ion s, p r ior i-
t izat ion of goals, an d id e n t i cat ion of p ote n t ial p it falls.
Typ ical goals for t h e East Asian n ose in clu d e elevat ion of
t h e n asal d orsu m , re n e m e n t of t h e n asal t ip , n ar row in g
of t h e n asal base, an d cor re ct ion of colu m ellar ret ract ion .
Fu r t h e r m ore, t h e soft w are can p rom p t su bje ct ive p refe r-
e n ces (Weste r n ize d ve rsu s n at u ral) an d obje ct ive p aram -
et e rs: n asal le n gt h , d orsal h e igh t , p roje ct ion , rot at ion ,
w id t h , an d t ip re n e m e n t . Th rough ou t t h is exch an ge,
t h e su rge on n e e d s to cou n sel t h e p at ie n t t h at t h e fron -
t al view is t h e rst p r ior it y. Im p rove m e n t s w ill be m ad e
regard in g t h e p ro le an d b ase view s; h ow eve r, t h e fron -
t al view w ill n ot b e sacr i ce d for su ch im p rove m e n t s.
Agree m e n t on t h e p lan n e d ou t com e is n e cessar y p r ior t o
t h e op e rat ive d at e.
27
c
Preoperative Discussion and
Counseling
Fu rther preoperat ive coun seling sh ould in clude in ci-
sion p lacem en t (colu m ellar an d alar for base redu ct ion ),
in creased st i n ess of th e n ose, ext ra operat ive t im e for
cost al car t ilage h ar vest , com plicat ion s (pn eum oth orax an d
w arp ing), an d postoperat ive cou rse (sw elling, follow -u p
sch edu le). Th is is th e t im e to tell th e p at ien t th at to ach ieve
th e goals of dorsal augm en t at ion an d t ip re n em en t in th e
set t ing of th ick skin , a large am ou n t of graft ing m aterial w ill
be used, essen t ially m aking th e n ose bigger. Th is is n eces-
sar y in East Asian rh in op last y, as th e prim ar y cases w ill
often be lacking in septal car t ilage. Sim ilar to th e qualit y
of th e upper an d low er lateral car t ilages, th e sept um is th in
an d w eak. Accord ing to th e prin ciples of st ru ct u re rh in o-
plast y, destabilizing th e already w eak car t ilage by reducing
th e st ru ct ural com pon en t s w ill allow scar con t ract ure to
have an even m ore dram at ic an d often u n desirable e ect .
Th is em ph asizes th e n eed for augm en tat ion . To address th e
lack of m aterial, it is th e auth ors’ opin ion th at au tologous
cost al car t ilage can provide th e best aesth et ic an d fun c-
t ion al result s in th e East Asian pat ien t’s n ose. Cost al car-
t ilage is in h eren tly st ronger an d, th erefore, can be car ved
th in n er, avoiding bulk in th e n ose. Th e vascu lar dem an d is
less th an for auricular cart ilage, decreasing rates of resorp -
28 II Rhinoplast y
t ion . Cost al car t ilage is available in greater volum e, provid-
ing all of th e n ecessar y graft s from a single don or site. As
th ere is less cauter y required for h em ost asis at th e rib com -
p ared w ith th e ear, don or site pain is also less.4 Postopera-
t ive com plicat ion s seen w ith syn thet ic im plants—w oun d
in fect ion , graft ext rusion , inju red skin envelop e—are rare;
h ow ever, th e risk of com p licat ion s rem ain s for a lifet im e
(Fig. 3.2). For th ese reason s, au tologou s costal car t ilage is
ideal for th e East Asian n ose an d is th e focus of th is ch apter.
■ Surgical Techniques
Th e sen ior auth or (DMT) perform s augm ent at ion rh in o-
plast y th rough a st an dard extern al rh in oplast y approach
u n der gen eral an esth esia w ith en dot rach eal in t u bat ion in
an ou t p at ien t su rgicen ter. Th e su rgeon injects th e ch est
an d n ose w ith 1% lid ocain e w ith 1:100,000 ep in ep h rin e
prior to prepping an d draping to allow for opt im al vaso-
con st rict ion . W h ile inject ing th e sept um , th e surgeon can
in it iate th e elevat ion of m ucoperich on drial aps via hydro-
stat ic d issect ion . At th e sam e t im e, n eed le palp at ion can
di eren t iate cart ilagin ous versus bony n asal sept um , for
an est im at ion of available m aterial for graft ing. Th e n ose
is p acked w ith cot ton pledget s soaked in 0.05%oxym et azo-
lin e, for fu rth er vasocon st rict ion .
Opening the Nose
By op en ing th e n ose rst , th e su rgeon can m ake a clear
assessm en t of th e am ou n t of car t ilage graft ing m aterial
requ ired to com plete th e case. A m idcolum ellar inver ted-V
in cision is d em arcated w ith an t icipat ion of th e t ip projec-
t ion outcom es. If th ere is a plan n ed in crease of project ion ,
th e in cision is draw n sligh tly (1 m m ) posterior to th e m id-
colum ella. Th e colum ellar in cision is m ade w ith a n o. 11
blade scalpel. Margin al in cision s an d colum ellar in cision
exten sion s are m ade bilaterally w ith a n o. 15 blade scal-
pel. Using Converse scissors, th e in cision s are con n ected
sh arp ly. Part icu lar at ten t ion is d irected to preser ving th e
soft t issu e t riangles as w ell as m ain t ain ing an adequ ate cu
of t issue separat ing th e m argin al in cision from th e alar rim ,
~ 3 m m . Carelessn ess h ere can resu lt in n otch ing of th e alar
m argin . Using th ree-p oin t ret ract ion , th e skin envelop e is
raised sh arply. Preser ving th e subderm al plexus by m in i-
m izing blu n t sp reading im p roves h em ostasis an d m in i-
m izes p ostop erat ive edem a. Sh arp d issect ion con t in u es
from th e low er lateral cart ilages su p eriorly to th e car t ilagi-
n ou s dorsu m an d bony-cart ilagin ous ju n ct ion . A key poin t
is to u se th e Josep h periosteal elevator in a lim ited fash ion ,
preser ving a t igh t pocket in an t icipat ion of a dorsal graft . A
t igh t pocket w ill rest rict graft m ovem en t an d aid in rapid
xat ion to p reven t w arping.5 Ad dit ion ally, as m ost Asian
pat ien t s do n ot require a h um p redu ct ion , w ide subperios-
teal dissect ion is n ot w arran ted.
Fig. 3.2 L-shaped silicone implant rem oved in revision surgery.
Th e n asal sept um is exposed by lateral ret ract ion of th e
low er lateral car t ilages an d sh arp dissect ion to th e an terior
septal angle. Bilateral m u cop erich on drial ap s are raised
in the appropriate subperich on drial plan e to decrease th e
risk of septal perforat ion . Again , as m ost Asian pat ien t s do
n ot requ ire a h u m p redu ct ion , a su bm u cou s resect ion m ay
be perform ed at th is t im e, w h ile preser ving 15-m m caudal
an d dorsal st ru t s. Th e septal cart ilage h ar vest w ill p rovide
a sm all volu m e of graft ing stock th at is n ot p ar t icu larly
st rong bu t is at low risk for w arp ing.
After decon st ru ct ing th e n asal fram ew ork, th e su rgeon
su r veys th e n ose an d review s th e graft s an t icip ated to be
n ecessar y to resu pp or t th e n ose, augm en t th e dorsu m , an d
re ne th e n asal t ip before ch anging gloves an d t u rn ing to
th e chest .
Costal Cartilage Harvest
Prior to th e costal cart ilage h ar vest , th e surgeon m ust con -
sider several pat ien t factors, in clu ding age, breast an atom y,
an d excessive scarring. Despite variabilit y in n asal an atom y,
cost al car t ilage an atom y is relat ively con sisten t across dif-
feren t eth n ic backgrou n ds. Th e m ost im port an t factor is
th e age of th e pat ien t .6,7,8 You nger pat ien t s are at h igh er
risk for graft w arp ing. Older p at ien t s are at h igh er risk for
fract u ring du ring h ar vest or graft m an ipu lat ion . Pat ien t s
bet w een th e ages of 30 and 50 are gen erally at low er risk
of w arping, an d fract uring can usu ally be preven ted w ith
careful h an dling of th e graft s. In th e East Asian pat ien t
popu lat ion , th e average volum e of breast t issu e obligates
th e su rgeon to m in im ize the in cision length for th e sake of
a sm aller scar th at can n ot be h idden in an in fram am m ar y
crease (Fig. 3.3).
With th e in creased p revalen ce of breast augm en tat ion ,
in cision s h idden in th e in fram am m ar y crease m ay risk
pun ct ure or t raum a to the breast im plan t . Fur th erm ore,
ribs directly u n der an im p lan t (t ypically rib 6) p rovide
 3 The Use of Cost al Cartilage for Dorsal Augm ent ation and Tip Grafting 29

a b

Fig. 3.3 Scar comparison. (a) Harvested costal cartilage and chest incision intraop-
eratively. (b) Right scar marked with t wo dots is the costal cartilage harvest site after
5 years. Left scar is a breast augmentation scar (arrow).

im p ort an t st ru ct ural su pp ort to th e breast im plan t . Har vest 3.75-cm (1.5-in ), 27-gauge n eedle localizes th e osseocar-
of a support ing rib m ay resu lt in u n desired asym m et ries of t ilagin ou s jun ct ion an d determ in es the degree of ossi ca-
th e breast posit ion or discom for t from th e w eigh t of th e t ion . Be forew arn ed: Blin d n eedle pokes m ay pu n ct ure th e
im p lan t lying on th e m an ipu lated rib. Hyper t roph ic scar- pleura an d lung paren chym a, result ing in a closed ten sion
ring an d keloid form at ion sh ou ld be elu cidated from th e pn eum oth orax.
p at ien t’s h istor y for appropriate coun seling preoperat ively. On ce th e id eal rib h as been selected an d ch aracterized,
Abn orm al ch est w all an atom y an d elevated body m ass th e overlying skin is m arked an d th e surroun ding area is
in dex m ay also in crease th e com plexit y of th e h ar vest . injected w ith 1% lidocain e w ith 1:100,000 epin eph rin e.
W h en select ing a rib to h ar vest , on e m ust be fam iliar Cost al cart ilage from th e righ t side is preferred to avoid
w ith th e relat ion sh ips of th e in dividual ribs to on e an oth er. inju r y to th e pericardium an d con fusion of postoperat ive
Th e fth rib h as a free superior an d in ferior m argin ; h ow -
ever, it can lie u n d ern eath breast t issu e or p ectoralis m u s-
cle. It is also relat ively sh or t an d cur ved an d m ay n ot be of
adequ ate size for dorsal augm en tat ion . Th e sixth rib t yp i-
cally h as a free su perior m argin , but th e in ferior m argin is
con n ected to th e seven th rib m edially. Th e sixth rib is usu-
ally at an ideal depth , bu t it h as a sligh t gen u th at m ay n ot
be ideal if a long st raigh t segm en t is n eeded (Fig. 3.4).
Th e seventh rib is st raighter and w ill usually h ave con -
n ection s w ith th e surrounding ribs on both the superior and
1
in ferior borders. The eighth an d greater n on oating ribs 2
w ill h ave signi cant connect ions to surroun ding ribs an d 3
are th in n er an d m ay n ot be of adequate w idth for a dorsal 4
graft. Th e seven th an d eigh t ribs are located sligh tly deeper 5
Incision 6
u n dern eath the skin com pared w ith th e sixth rib. As the ribs
are follow ed m edially, th ey course deeper un der th e subcu- Infram am m ary fold
taneous t issue. Ult im ately, the rib w ith the best contour for
the necessar y grafts should be selected, but generally the
cartilage com ponent of the seventh rib has the best contour.
After th ese con siderat ion s, th e surgeon sh ould m an u-
ally p alpate th e ch est w all arou n d th e poten t ial ribs for
h ar vest . On ce orien ted, carefu l n eedle p alp at ion w ith a Fig. 3.4 Harvest incision placement.
30 II Rhinoplast y
discom fort w ith angin a. Th e don or site is a separate sterile
eld, an d cross-con t am in at ion w ith n asal ora sh ou ld be
avoided by ch anging gloves an d using a separate set of sur-
gical in st ru m en t s.
Du e to th e sen ior au th or’s experien ce, h e is able to
start w ith a 10-m m in cision th at m ay st retch to a n al
length of 12 or 13 m m . Th e ch est in cision is m ade sm all
to m inim ize th e visible scar an d m orbidit y to th e pat ien t .
For pat ien t safet y, surgeon s sh ould con t inu e to use a larger
in cision u n t il th ey are fam iliar w ith th e dissect ion .5 After a
skin in cision is m ade, sh arp dissect ion con t in u es th rough
th e subcu tan eous fat to th e fascia overlying th e m uscle. For
h em ostasis, bip olar cau ter y is u sed to m in im ize postop -
erat ive p ain . A n o. 15c scalpel is u sed in th e sm all w in d ow
to sh arply in cise th e m uscle fascia. Th e m u scle is blun tly
spread to decrease bleeding an d postop erat ive p ain . Th e
keyh ole p ersp ect ive is m ain tain ed w ith ret ractors to view
th e perichon drium overlying th e rib. Th is w in dow can be
t ran slated m edially an d laterally along th e course of th e
rib. Recall th at th e rib’s cou rse is n ot a st raigh t lin e, bu t
an obliqu e an d th ree-d im en sion al arc th at ch anges depth
as it cu r ves from lateral to m ed ial. Th rough th e process of
exp osing th e rib, th e bou n daries of th e rib sh ou ld be con -
rm ed by carefu l n eed le p alp at ion .
On ce exp osed , th e an terior p erich on d riu m is in cised
w ith a n o. 15c scalpel along th e lateral lim it , superior bor-
d er, an d in ferior border of th e rib. Th e perich on drium is
m obilized w ith a Freer elevator an d h ar vested sh arply. Th e
rest of th e perich on driu m w ill rem ain in t act to en sure th e
in tegrit y of th e h ar vest site.
Fig. 3.5 Costal cartilage harvest technique. (a) Blunt dissection through
muscle to the perichondrium on the anterior surface of the rib. (b) Lifting-
technique with Freer elevator to preserve the posterior perichondrium.
(c) Removal of costal cartilage en bloc. (Used with permission from Tori-
umi DM, Pero CD. Asian rhinoplast y. Clin Plast Surg 2010;37:335–352.)
Having op en ed th e n ose, th e su rgeon sh ou ld h ave in
m in d th e graft s th at w ill be u sed to st ru ct u re th e n ose. Th e
h ar vested costal cart ilage sh ou ld be taken in dim en sion s
ap prop riate for th e plan n ed graft s. Usu ally 3 to 4 cm of cos-
tal car t ilage is h ar vested. To en su re an in t act h ar vest site
an d avoid violat ion of th e pleu ra, th e rst in cision sh ou ld
start by u sing th e sh arp en d of th e Freer elevator to cu t 0.5
m m from th e su perior an d in ferior m argin s of th e rib. After
50% pen et rat ion th rough th e depth of th e car t ilage, th e
in cision is com pleted w ith th e blun t en d of th e Freer eleva-
tor. Th e goal is to m ain tain a p rotect ive cu of car t ilage th at
gu ides th e dissect ion in to a safe p lan e above th e p osterior/
deep perich on drium an d pleura. Medial an d lateral boun d-
aries of th e car t ilage are rst sh arply in cised w ith a n o. 15c
blade th rough 10% of th e th ickn ess, follow ed by a sh arp
Freer elevator th rough 70%; th e blun t Freer elevator com -
pletes th e n al 30%. On ce m obilized on in ferior, superior,
lateral, an d m edial borders, th e un dersu rface of th e rib is
freed w ith a Freer elevator u sing a lift ing m ot ion (Fig. 3.5).
Follow ing th e h ar vest , th e m edial an d lateral edges of th e
rem ain ing cart ilage are sm ooth ed w ith Takah ash i forceps.
Th e w oun d bed sh ould be in spected for violat ion s of
th e perich on drium or pleura, w ith poten t ial inju r y to th e
lung paren chym a an d a result ing pn eu m oth orax. Th e
w oun d bed is lled w ith salin e. A Valsalva m an euver con -
rm s an in t act h ar vest site, if th e salin e volu m e is con st an t
an d th ere are n o bu bbles. Any defect s sh ou ld be repaired
im m ediately. To repair su ch defects, th e lung is de ated
an d a cath eter is placed in th e defect . A p u rse-st ring st itch
sh ould be p laced arou n d th e defect an d t ied after th e cath -
c
 3 The Use of Cost al Cartilage for Dorsal Augm ent ation and Tip Grafting
eter is p laced on su ct ion , an d rem oved w h en th e lu ng h as
been m axim ally reexpan ded. A repeat in spect ion an d Val-
salva m an euver are w arran ted . Inju r y to th e lu ng p aren -
chym a m ay require a ch est t ube in sert ion .
The chest harvest site rem ains open for the duration of
the operation as a contingency for m ore graft m aterial or peri-
chondrium . The site is protected w ith an antibiotic-soaked
gauze sponge and blue towel. After com pleting the rhino-
plast y, the surgeon again changes gloves. The rib harvest site
is irrigated and inspected. Closure begins w ith 3–0 PDS suture
to reapproxim ate the m uscle and its fascia. Careful attention is
paid to this layer of closure to ensure the separation of m uscle
and fascia from the overlying subcutaneous tissue. A suture
spanning the t wo layers w ill result in tethering of the overly-
ing tissue to the deeper fascia, inhibiting independent m otion.
The subcutaneous fat is reapproxim ated w ith 4–0 PDS suture.
The deep derm al layer is closed w ith 5–0 PDS suture. The
subcuticular layer is closed w ith 6–0 Monocryl suture. The
cutaneous layer is reapproxim ated and everted w ith 5–0
fast-absorbing gut suture. Finally, cyano acrylate adhesive is
applied super cially to seal the wound.
Th e sen ior auth or recom m en ds rout in e postoperat ive
ch est X-ray an d a period of obser vat ion after cost al cart ilage
h ar vest u n t il th e su rgeon is fam iliar w ith th e p rocedu re.
For pat ien ts w ith a p ropen sit y for keloids or hyper t ro-
p h ic scars, Ken alog (10 m g/m L) m ay be injected at th e cos-
t al cart ilage h ar vest site. After th e skin glue falls o , silast ic
sh eet ing m ay be u t ilized to h elp m in im ize th e visibilit y of
an u n sigh tly scar.
Costal Cartilage Carving
At th is p oin t of th e p roced u re, th e su rgeon n eeds to focu s
on th e crit ical step of cart ilage car ving. Regardless of th e
am ou n t of en ergy exp en ded on th e h ar vest or com p lica-
t ion s en coun tered during th e h ar vest , th e surgeon can n ot
lose con cen t rat ion . Th e barrier to m astering costal car t i-
lage graft ing is learn ing to ju dge w h ere to u se each p oten -
t ial graft an d h ow to properly prepare th e graft . Prior to any
car ving, th e surgeon sh ou ld repeat th e sur vey of th e n ose
an d p lan all of th e n ecessar y graft s; on e sh ou ld n ot car ve
th e graft s as th ey are n eeded in th e procedure. If a large
dorsal augm en tat ion is plan n ed, an appropriately th ick
piece of cost al car t ilage stock n eeds to be preser ved for th e
dorsal graft , start ing w ith th e rst cut in to th e cost al car-
t ilage. Im proper car ving, select ion , or xat ion of th e cost al
cart ilage graft s could poten t ially create m ore deform it y
th an th e de cien cy on e is t r ying to repair.
Again , age is th e m ost im por tan t factor to con sider
w h en car ving th e cost al cart ilage. Th e cart ilage w ill h ave
a w h iter-ap pearing ou ter p ort ion , w h ich con t ain s a brou s
com pon en t . In th e younger pat ien t , th e outer por t ion of th e
rib h as an in creased ten den cy to ben d. In th e older p at ien t ,
th e ou ter brou s com pon en t is less pron e to fract ure, in
w h ich case it is preser ved.9,10 Th e cen t ral piece m ay ben d
31
less th an th e periph eral slices; h ow ever, it m ay be brit tle
an d pron e to fract u re in older p at ien t s. With th e prop er t ies
of th e cen t ral an d outer/ brou s com pon en t in m in d, th e
su rgeon m ay begin to car ve th e cost al car t ilage.
On e of th e m ost im port an t con cept s in su ccessfu l cos-
tal car t ilage graft ing is to car ve th e m aterial sequen t ially.
Repeat ing soaking an d dr ying cycles bet w een car vings
en cou rages th e car t ilage to reveal any ten den cy to ben d in
30 to 60 m in utes. First th e h ar vested segm en t is cut in to
th ree pieces along th e longest axis, creat ing an terior, cen -
t ral, an d posterior slices. Th ese pieces are allow ed to soak
an d th en th ey are car ved in to th in n er p ieces. After allow -
ing th e fresh ly car ved car t ilage to sh ow it s n at ural ben d ,
th e key is to ut ilize th at ben d w h en select ing in dividual
pieces for speci c grafts. Most graft s require som e degree
of cu r vat ure for opt im al fun ct ion . Th e in h eren t st rength of
cost al car t ilage allow s it to be car ved ver y th in to decrease
th e bulk in th e n ose; h ow ever, a th ickn ess less th an 1 m m
in creases th e risk of torqu ing. At tem pt ing to car ve th e car-
t ilage in to a st raigh t piece is n ot advised, as it m ay result in
unpredict able w arping after xat ion .
Lim ited m an ipu lat ion of th e cost al car t ilage is possible
an d is part icu larly u sefu l if w arping is a con cern . Th e t w o
tech n iques available to th e surgeon are cross-h atch ing an d
sp lin t ing, w h ich m ay be u sed sep arately or in com bin at ion .
Cross-h atch ing con sist s of part ial-th ickn ess cu ts in to th e
con cave side of a cur ved piece of cart ilage to release th e
bow ing forces on th e graft . Th e degree of release is di -
cult to predict , an d overzealous cross-h atch ing m ay result
in overcorrect ion an d cur vat u re in th e opposite direct ion .
Part ial-th ickn ess cu t s on th e convex side in crease th e exist-
ing cur vat ure. Splin t ing involves th e sum m at ion of cur ves.
Tw o cur ved pieces are sut ured togeth er w ith opposing con -
cavit ies to create a single st raigh t graft (Fig. 3.6). Alth ough
cross-h atch ing an d splin t ing are useful, it is im port an t to
un derst an d th at th ese tech n iques can n ot overcom e th e
select ion of an in ap prop riate p iece of costal cart ilage.
Management of the Bony Vault
Th e im port an ce of addressing th e bony vault in th e East
Asian n ose lies in set t ing th e foun dat ion for dorsal aug-
m en t at ion . Mism an agem en t of th e bony vau lt w ill resu lt
in failure to create a n at u ral-appearing dorsu m . Start ing
w ith a low, w ide n asal dorsum , it seem s coun terin t uit ive
to forgo n arrow ing osteotom ies. In fact , th e exist ing w ide
bony dorsum w ill create a desirable pyram idal sh ape w h en
a dorsal augm en t at ion graft is st acked on top of it . A bony
vau lt n arrow ed by aggressive osteotom ies w ill p rovide ver-
t ically orien ted sidew alls an d create an un n at ural t ubular
sh ape w h en com bin ed w ith a dorsal augm en tat ion graft
(Fig. 3.7). Addit ion ally, excessive n arrow ing of th e bony
upp er th ird m ay prove to be too m uch for th e an atom ic lim -
it at ion s of th e n asal base, creat ing an im balan ce bet w een
th e w idth s of th e ceph alic an d caudal port ion s of th e n ose.
32 II Rhinoplast y

Con ser vat ion of a low, w ide n asal dorsal fou n dat ion
sh ould n ot preclu de th e su rgeon from m an ip u lat ing th e
n asal bon es. Osteotom ies to address bony deviat ion m ay
be necessar y. Excessive w idth m ay require judicious n ar-
row ing osteotom ies. Depressed bony segm en t s m ay n eed
outfract ure. Avoiding m edial osteotom ies w ill h elp preven t
excessive n arrow ing. If th ick cort ical bon e is p reven t ing
back fract ure from th e lateral osteotom y sites, laterally fad-
ing m edial osteotom ies m ay be n ecessar y. Lateral osteoto-
m ies are p erform ed in a h igh -low -h igh fash ion . Th e sen ior
au th or p refers to u se a st raigh t 3-m m osteotom e to lim it
soft t issu e t rau m a. An d th e su rgeon sh ou ld lim it th e force
ap plied by th e dom in an t h an d w h en m an u ally adju st ing
th e nasal bon e to avoid a tellt ale “th um bprin t” sign .

Management of the Middle Third

a b
Fig. 3.6 Graft splinting technique. (a) A curved graft is matched
with a sliver of cartilage with opposing curvature.The graft and
sliver are sutured together with 6–0 Monocryl. (b) Final graft with
multiple splints.
After set t ing th e bony vau lt at an ap prop riate w id th , th e
su rgeon p roceeds cau dally to address th e m idd le th ird of
th e n ose, con t in u ing a rm st ruct ural foun dat ion for dorsal
graft ing. Th e m ost com m on ly u sed tech n iqu e is spreader
graft ing. In th e East Asian n ose, sp reader graft s op en th e
in tern al n asal valve an d aid in set t ing an d preser ving n asal
length an d p roject ion . By resist ing th e ceph alic pu ll on th e
t ip com plex, st rong spreader grafts preven t over-rot at ion
an d n asal sh or ten ing. Th ey st rength en th e dorsu m , p re-
ven t ing sadd ling. Th ey can be t u cked u n d er an ou tfract u red
n asal bon e to p reven t postoperat ive recollap se.
Sp reader graft s m ay be p laced t radit ion ally or in su b -
m u cosal pocket s (Fig. 3.8). By keep ing th e u p p er lateral
cart ilages at t ached to th e sept um , th e surgeon does n ot
n eed addit ion al t im e to recon st ruct th e m id dle n asal vault ,

Plane of
illustration

a b Osteotomy
Fig. 3.7 Dorsal augmentation graft without osteotomies. (a) Plane of Illustration. (b) When the dorsal augmentation graft is placed on
a wide base the outcome is a favorable contour with a smooth transition from graft to maxilla. Osteotomies that inappropriately narrow
the base disrupt this transition, creating a vertical drop-o from the graft to the cheek. (Used with permission from Toriumi DM, Pero CD.
Asian rhinoplast y. Clin Plast Surg 2010;37:335–352.)
 3 The Use of Cost al Cartilage for Dorsal Augm ent ation and Tip Grafting
a b
d e
w h ich requires close at ten t ion to avoid palpable an d visible
d eform it ies of th e brow –t ip aesth et ic lin e.
Unless addressing a saddle or weak L-strut, the spreader
grafts m ay be fashioned or carved from less desirable carti-
lage stock. It is m ore com m on to use the central portion of the
costal cartilage harvest for the spreader grafts unless the sur-
gery is for a younger patient, w here the central com ponent
m ay be better for the dorsal graft. The nasal anatom y m ay
be m easured from the bony-cartilaginous junction on the
dorsum to the tip -de ning point to extrapolate the appro-
priate graft length. Dim ensions of spreader grafts vary from
patient to patient, but t ypically are 15 to 20 m m in length..
The spreader grafts are tapered at each end. The inferior edge
is trim m ed to avoid obstruction of the valve. One should
note any deviations requiring for sm all adjustm ents of the
tip. The spreader grafts are t ypically oriented w ith opposing
convexities.11 Multiple or asym m etric grafts m ay be placed to
account for m iddle vault w idth or collapse. To assess, digital
33
c
Fig. 3.8 Submucosal spreader graft
technique. (a,b) Frontal views. The Cot-
tle elevator creates a submucosal tunnel
without dissection of the middle vault.
(c,d) Spreader grafts are placed in the tun-
nel. (e) Bilateral submucosal spreader grafts
in position.
palpation is m ore im portant than visual inspection, as soft
tissue swelling can be deceptive. Slight overcorrection is rec-
om m ended on the side of the depression.
Spreader grafts are secured w ith 5–0 PDS sut ure to th e
dorsal septal strut. Extended spreader grafts are sut ured to
the caudal septal extension graft or caudal septal replace-
m en t graft . Th e relat ion sh ip bet w een th e exten ded spreader
grafts an d caudal septal exten sion /replacem en t graft can be
adjusted to alter tip project ion , n asal length , dorsal h eigh t,
an d tip rotation . Th is is carefu lly set to avoid overprojection ,
excess length, and a sh ort or over-rotated tip.
Th e upper lateral cart ilages are sut ured to th e spreader
graft s to avoid an inverted-V deform it y. Care is t aken to
avoid en t rapping n asal m ucosa th at m ay blun t th e in tern al
nasal valve, an d clocking sut ures m ay be placed to adjust
for t ilt .12 On ce th e spreader grafts are secured to a st able
m idlin e n asal base, th e dorsal augm en tat ion graft can be
reliably set on top of th at st rong foun dat ion .
34 II Rhinoplast y
Management of the Nasal Base
At th e cau dal asp ect of th e n ose, th e n asal base is th e last
com pon en t to create a stable foun dat ion for all fut ure t ip
w ork an d dorsal augm en tat ion . Weakn ess at th e n asal base
m ay m an ifest as collap se over t im e resu lt ing in t ip ptosis,
loss of p roject ion , an d p olly-beak deform it y. Un addressed
deviat ion of th e n asal base w ill result in persisten t devia-
t ion of th e en t ire n ose. Prior to addressing th e n asal base,
it is im port an t to reexam in e th e preoperat ive p h otograph s
an d assess relevan t lan dm arks: cau dal sept u m , n asal spin e,
den t it ia, an d lip con tour. Th e best van tage poin t is th e h ead
of th e bed, w h ere th e deviat ion s or asym m et ries w ill reveal
th em selves.2
Pat ien t con siderat ion s to t ake in to accou n t in clu de
th e sm ile. Ch anges in th e n asal base m ay result in upper
lip st i n ess, ch ange in lip p osit ion , an d u pper lip crease
form at ion . In th e East Asian n ose it is com m on to blu n t
or m ove th e n asolabial angle. If th e n ose is m oved dow n ,
sm iles th at go u p at th e corn ers of th e m ou th w ill likely get
tethered m edially an d a h orizon tal crease w ill form . Th ese
poten t ial outcom es sh ould be discussed w ith th e pat ien t
preoperat ively.
Gen erally th e n asal base w ill be eith er m idlin e or devi-
ated. If it is m idlin e, th e n asal base m ay on ly n eed augm en -
tat ion , lengthen ing, or st rength en ing. If th ere is a caudal
septal de ect ion , a sw inging d oor m an euver or cau dal sep -
t um resect ion and a su btot al sept al recon st ruct ion m ay be
requ ired. Min or caudal septal de ect ion can be add ressed
w ith th e sw inging door m an euver, w h ich requires dissec-
a b
Fig. 3.9 Caudal septal extension graft splinted and secured with slivers. (a) Frontal view. Caudal septal extension graft external to nose.
(b) Frontal view. Caudal septal extension graft with supporting slivers. (c) Surgeon’s view. Caudal septal extension graft is secured to native
caudal septum with supporting slivers.
t ion of th e sept um o of th e m axillar y spin e. On ce posi-
t ion ed at m idlin e, th e n asal base is secured w ith t w o 4–0
PDS su t u res an ch oring th e sept u m to th e p eriosteu m . If
th ere is in adequate periosteum , on e can use 16-gauge n ee-
dles to bore in to th e n asal spin e to h old th e sut ure. Th in
slivers of costal cart ilage can be u sed as sp lin t ing graft s to
fu rth er st abilize th e n ew ly m idlin e st ru ct u re. If th e n asal
spin e is deviated , a 5-m m osteotom e p laced at m idlin e is
u sed to create a n otch in th e n asal spin e before securing th e
caudal sept um w ith t w o 4–0 PDS sut ures.
To su pp or t th e n asal base, t h e sen ior au th or p refers
cau dal sept al exten sion graft s or cau dal sept al replace-
m en t graft s to p rovid e th e st rength to su p p or t a large d or-
sal graft w it h ou t collap sing. Th ese cau dal sept al graft s are
secu red to th e n asal sept u m an d w ith exten d ed sp read er
graft s, an d st abilized w ith sp lin t ing slivers of cost al car-
t ilage or 0.25-m m PDS plates (Fig. 3.9). In th e au t h or’s
exp erien ce u se of a cau dal sept al rep lacem en t graft , an
advan ced tech n iqu e, is u sed to rep lace a severely d evi-
ated or dam aged n at ive cau dal sept u m , as less car t ilage
is requ ired for a m ore p redict able resu lt . It is im p or t an t
to kn ow th at th ese cau dal sept al graft s are th e on ly graft s
th at n eed to be st raigh t . Sept al car t ilage h as a low likeli-
h ood of w arp ing; h ow ever, it is t yp ically w eak in th e East
Asian n ose, m aking it a p oten t ially poor ch oice of sou rce
m aterial. In stead , cost al car t ilage m ay be u sed after it
h as gon e th rough m u lt ip le cycles of soaking an d d r ying
to determ in e it s ten den cy to w arp . Cross-h atch ing an d
sp lin t ing w ith slivers of cost al car t ilage m ay be u sed to
cou n teract a m in or deviat ion in th e graft .
c
 3 The Use of Cost al Cartilage for Dorsal Augm ent ation and Tip Grafting
Dorsal Augmentation
After laying dow n a st rong fou n dat ion at th e n asal base,
m iddle vau lt , an d n asal bon es, th e su rgeon is ready to
in crease dorsal h eigh t w ith a dorsal graft . Th e sen ior
au th or does n ot u se allop last ic m aterials an d ackn ow ledges
th e ch allenges involved w ith u sing autologous cost al cart i-
lage. Th e com p lexit y of th is graft lies in its in abilit y to toler-
ate visible edges or w arping. Serial car ving, p erich on drium
cam ou age, an d rigid xat ion are key st rategies to address
th ose ch allenges.5
In th e sen ior au th or’s opin ion , a single p iece of cos-
tal car t ilage w orks best . Th e cen t ral core of th e h ar vested
costal cart ilage is less pron e to w arping; h ow ever, as pre-
viously st ated , th e p at ien t’s age st rongly in u en ces th e ten -
den cy for w arping an d fract ure. It is im por tan t to serially
car ve th e car t ilage w ith soaking-dr ying cycles to allow th e
piece to dem on st rate it s cur vat ure. As th e cur vat ure can n ot
be t ruly con t rolled, th e surgeon sh ould u t ilize th e n at ural
cur ve by direct ing th e con cave side dow n an d in con t act
w ith th e n at ive dorsum . With rigid xat ion , th is orien ta-
t ion w ill lim it postoperat ive w arping. Th e convex side of
th e cart ilage is car ved in to a can oe sh ape to allow sm ooth
t ransit ion s from graft to n asal dorsum (Fig. 3.10). In th e
East Asian face, th is can oe-sh aped graft is ideally posi-
t ioned to m atch th e graft’s ceph alic m argin at th e pat ien t’s
m idp u p il.13
Perich on driu m h ar vested w ith cost al cart ilage h as
m any fu n ct ion s in th e dorsal augm en t at ion graft . Alon e it
can provide 1 m m of reliable augm en tat ion . It sh ould be
orien ted w ith th e previously car t ilage-exposed surface
facing th e osteo-cart ilagin ou s st ru ct u res an d th e m u scle-
exp osed su rface facing th e skin envelop e. As soft t issu e
coverage, cost al perich on drium provides a sm ooth t ran si-
b with concave surface facing down in lateral view.
35
t ion from th e graft to th e n asal dorsu m (Fig. 3.11). On th e
un dersu rface of th e dorsal augm en tat ion graft , th e cost al
perich on drium supplem en t s rigid xat ion , preven t ing
graft m obilit y an d m igrat ion .
From th e begin n ing of th e operat ion , th e surgeon
sh ou ld be th in king abou t rigid xat ion . Lim ited dissec-
t ion of th e dorsal skin envelope w ith th e Joseph periosteal
elevator w ill yield a t igh t pocket , w h ich is a key com ponen t
for rigid xat ion of th e dorsal graft . Th rough out th e pro-
cess of serially car ving th e graft , it is n ecessar y to place
th e graft in to th e pocket to evaluate dorsal h eigh t . Th e sur-
geon sh ou ld avoid excess m an ip u lat ion of th e pocket w h en
t ran sferring th e graft in to an d out of th e pocket . In addit ion
to a t igh t pocket , th e dorsal graft requ ires xat ion cau dally.
Th ree-poin t xat ion w ith 5–0 PDS sut ure on each side of
th e low er aspect of th e graft h olds th e car t ilage in place
un t il scar con t ract ure t akes over.14 To en sure a rigid xa-
t ion , th e bony dorsal surface is rough en ed by violat ing th e
cort ical bon e w ith a n o. 3 osteotom e or n arrow low -pro le
bon e rasp. Th e perich on driu m on th e un dersurface of th e
dorsal graft can in tegrate in to th e cor t ical defect s in th e
n at ive bon e, w ith form at ion of an ossi ed bon d bet w een
th e dorsal graft an d th e bony dorsum .
If th ere is n o t igh t pocket , d u e to excessive elevat ion ,
previous im plan t , or in fect ion , th e ceph alic aspect of th e
graft m ay be secured w ith a tem porar y 0.45-m m th readed
Kirsch n er w ire, rem oved on postoperat ive day 7.15 Th e
Kirsch n er w ire is advan ced th rough a sm all stab in cision
over th e u pp er asp ect of th e dorsal graft an d is engaged 3
to 4 m m in to th e bony dorsum (Fig. 3.12). If th e graft is
n ot th ick en ough to engage m u lt ip le th reads of th e w ire, a
t ran sn asal sut ure tech n ique ut ilizing 16-gauge n eedles to
create a t u n nel th rough th e n asal bon e is em ployed. Sut u res
looped th rough th e t un n el an d over th e dorsal augm en ta-
Fig. 3.10 Serial carving of dorsal augmentation graft.
(a) Dorsal augmentation graft is carved with a no. 10
blade. (b) Canoe-shaped dorsal augmentation graft in
frontal view. (c) Dorsal augmentation graft oriented
36 II Rhinoplast y

Perichondrium

Perichondrium

Rasped or perforated bone

Fig. 3.11 Perichondrium on undersurface of dorsal augmentation graft for xation. (a) Lateral view with concave surface facing down.
(b) Lateral view with superior undersurface of the graft covered in perichondrium. (c) Drawing showing the appropriate placement of
perichondrium on the undersurface of the dorsal augmentation graft in contact with the nasal bone for strong graft xation. (Used with
permission from Toriumi DM, Pero CD. Asian rhinoplast y. Clin Plast Surg 2010;37:335–352.)

a b c

Fig. 3.12 Kirschner wire placement. (a) Vertical incision with a no. 11
blade. (b) Placement of Kirschner wire. (c) Clipping Kirschner wire with
d cut ter. (d) Lateral view of Kirschner wire cut to length.
 3 The Use of Cost al Cartilage for Dorsal Augm ent ation and Tip Grafting 37

t ion graft en sure rm con t act for in tegrat ion an d bony xa-
t ion (Fig. 3.13). Fin al xat ion occu rs after t ip m an ip u lat ion
is com pleted to p erm an en tly set th e dorsal h eigh t in pro-
p ort ion to th e n asal t ip posit ion .
Tip Contouring
Typically, th e East Asian n ose w ill require t ip augm en t at ion
an d n arrow ing to add ress th e n at ive ch aracterist ics: sm all
an d w eak lateral cru ra, th ick sebaceou s skin , t ip bu lbosit y,
ret racted colum ella, an d h anging alar lobules.2 Favorable
t ip con tour can be ach ieved w ith au tologous costal cart i-
lage in th e East Asian n ose.
Using 4–0 plain gut sut ure on a Keith n eedle, the m edial
crura are reapproxim ated to the caudal septal extension
or replacem ent graft. Desirable tip projection and rotation
are con rm ed before securing the m edial and interm ediate
crura w ith 5–0 PDS sut ure. Tip bulbosit y due to convex lat-
eral crura is addressed w ith lateral crural strut grafts.16 The
strut grafts at ten the crura. It is rare that repositioning is
needed in the Asian patient unless they have alar retraction.
Due to cam ou aging thick skin , th e East Asian n ose rarely
requires repositioning of the lateral crura, regardless of tip
cartilage orientation. The Asian sit uation is the opposite of
the hanging colum ella-tip lobule and retracted ala fam iliar
in the Caucasian nose. More often East Asian noses have
retracted colum ella and hanging alar lobules. Repositioning
of the low er lateral cartilages is a powerful m aneuver that
could exacerbate the patient’s inherent problem . How ever, if
the ala is retracted or notched, lateral crural strut grafts w ith
repositioning can bring it dow n.

a b c

Fig. 3.13 Transnasal suture placement. (a) 16-gauge needle passed through nasal bones.
(b) Suture needle placed in lumen of 16-gauge needle. (c) Suture passed transnasally from
left to right. (d) Suture crosses back to the left side under the skin envelope and over the
d dorsal augmentation graft.
38 II Rhinoplast y
To prepare the site for lateral crural strut grafts, the
tightly adherent vestibular skin is dissected o of the under-
surface of the native lateral crura. Hydrodissection w ith 1%
lidocaine w ith 1:100,000 epinephrine m akes this task easier.
The plane of dissection is continued laterally tow ard the pir-
iform apert ure to create a pocket for the grafts. The carved
costal cartilage sh ould be evaluated for ideal pieces 25–30
m m × 4–5 m m × 1–2 m m w ith a sligh t curve. Wom en w ill
have shorter grafts than m en. After selecting ideal pieces
of costal cartilage w ith the concave side facing the vestib-
ular skin, the m edial edge is cut at 45 degrees and placed
directly under the apex of the dom e. It is secured w ith 5–0
PDS sut ure, keeping all kn ots aw ay from th e vestibular skin
to prevent extrusion (Fig. 3.14). Oblique dom e sutures are
placed to at ten the dom es and orient the lateral crura w ith
the caudal edge higher than the cephalic edge.
Reposit ion ing of th e low er lateral cart ilages involves
fu lly m obilizing th e lateral asp ect s of th e lateral cru ra. If
th ese cart ilages are large, th e lateral-m ost aspect m ay be
h ar vested for soft t issu e cam ou age. Th e lateral cru ral st ru t
graft s are p erform ed as described p reviou sly, except for th e
lateral pockets design ed to correct asym m et r y of th e ala: a
n eu t ral or h orizon t al p ocket for th e low er alar lobu le an d
a d ow nw ard-orien ted p ocket for th e ret racted alar lobu le.
In rep osit ion ing, any p lan n ed cep h alic t rim is redu ced, an d
a a
b b
Fig. 3.14 Lateral crural strut graft technique. (a) Lateral crura dis-
sected free. (b) Lateral crural strut grafts suture in position under-
neath lateral crura.
th in -sliver alar bat ten grafts m ay be n eeded to support th e
valve area previou sly h eld open by ceph alically orien ted
low er lateral cart ilages.
Tip augm en t at ion w ith autologous cost al car t ilage cre-
ates addit ion al project ion an d re n em en t . St retch ing th e
skin creates t ip d e n it ion . Th is can be accom p lish ed w ith
sh ield, lateral cru ral, an d bu t t ress graft s. Th e sh ield graft
provides th e project ion , but th e lateral crural an d but t ress
graft s st abilize th e t ip graft , p reven t ing rot at ion cau sed by
th e ceph alic pulling force of a th ick skin envelope. Adjust-
ing th e posit ion of th e sh ield graft varies th e am ou n t of
in creased project ion an d in frat ip augm en tat ion . In ad di-
t ion to st abilizat ion , lateral crural an d but t ress graft s bev-
eled to m eet th e sh ield graft sm ooth th e t ran sit ion s from
th e graft’s edges an d preven t graft visibilit y. Most pat ien t s
th at un dergo placem en t of a sh ield graft w ith lateral cru-
ral graft s do n ot n eed any oth er w ork don e on th e lateral
cru ra, as th ey are deep to th e in uen ce of th e sh ield graft .
A less aggressive altern at ive is a rect angu lar, h orizon t ally
orien ted t ip on lay graft secured w ith 6–0 Mon ocr yl sut ure
(Fig. 3.15). Variat ion in th e size an d p lacem en t of th e graft
can set th e project ion , t ip w idth , suprat ip break, an d over-
all re n em en t of th e t ip . With in creasing am ou n ts of t ip
augm en tat ion , th e n ost ril-to-colu m ellar rat io w ill m ove
from 2:1 to 1:1.
Fig. 3.15 Shield graft versus horizontal onlay graft. (a) Shield
graft seen in surgeon’s view. (b) Horizontal onlay graft seen in sur-
geon’s view.
 3 The Use of Cost al Cartilage for Dorsal Augm ent ation and Tip Grafting
After at ten ing the lateral crura, in creasing projection,
an d re n ing the tip, the surgeon replaces the dorsal graft and
redrapes the skin to assess the relationship bet w een projec-
tion and the dorsal height. Once it is considered satisfactory,
the dorsal graft can be secured into place for rigid xation.
Alar Batten and Alar Rim Grafts
In th e East Asian n ose, w ith it s w ide air w ay an d th icker
lateral sidew alls, alar bat ten an d alar rim graft s are in fre-
quen tly in dicated, because th e lobu les rarely pin ch or col-
lap se. Cost al car t ilage is an excellen t source m aterial sin ce
it m ain tain s it s st rength even w h en car ved ver y th in . If
cost al car t ilage is u sed for th ese grafts, a sm ooth t aper is
n ecessar y to preven t graft visibilit y.2
Alar bat ten graft s sh ou ld be placed in p recise p ockets
orien ted along th e su pra-alar crease an d sut ured in to place.
Th ese bat ten grafts are appropriate for in tern al valve col-
lapse an d if th e lateral crura h ave been reposit ion ed w ith
lateral cru ral st rut graft s. Alar bat ten graft s are in dicated
for add ressing lateral w all de cien cy an d p in ch ing from
aggressive cep h alic t rim or oth er p reviou s surger y. Alar
bat ten graft s are rarely n eeded in Asian pat ien t s, as th eir
air w ay ten ds to be relat ively large.
Alar rim grafts are p laced in precise pocket s along th e
m argin al in cision en d ing m edially beh in d th e t ip com p lex.
Th ese graft s address extern al n asal valve collapse, pin ch ing
of the t ip, an d irregular t ran sit ion s from th e t ip lobule to
th e alar lobule.
Closure
At this point, the surgeon needs to perform a m eticulous clo-
sure of the colum ellar incision to prevent the stigm ata of the
open rhinoplast y approach, a visible scar. Closure begins w ith
an interrupted 6–0 Monocryl suture in the m idline. This suture
aligns the soft tissue envelope and rem oves tension from the
skin edge. Using a 7–0 nylon suture, seven interrupted vertical
m attress sutures approxim ate and evert the inverted-V colu-
m ellar incision. Between the nylon sutures, 6–0 fast-absorb-
ing gut suture is placed in a sim ple interrupted fashion. The
m arginal incision is closed w ith sim ple interrupted 5–0 chro-
m ic gut sutures, w hile observing the nostril m argin. If there is
inadequate vestibular lining. this stitch can lead to notching of
the nasal rim , in w hich case a com posite graft m ay be neces-
sary. The m ucoperichondrial aps are reapproxim ated w ith a
4–0 plain gut suture on a Keith needle in a running m attress
fashion, closing the septum .
Radio-opaque 0.25-m m septal splin ts (Reuter bivalve
septal splin ts, Medtron ic, Jacksonville, Florida) are sutured
in place if turbinate or septal w ork was perform ed to pre-
vent synechiae form ation. Lateral w all splints are used if lat-
eral crural strut grafts w ere placed w ith reposition ing of the
lateral crura. If there is any nostril asym m etry a vestibular
splint can be used interm it tently. Th e senior author does not
use any nasal packing. The nose is taped and an external cast
is applied. Antibiotic ointm ent is applied to all incisions.
39
Base Reduction
After closure of the nose, the nasal base w idth is assessed.
As a result of structured rhinoplast y w ith autologous costal
cartilage augm entation, particularly w ith lateral crural strut
grafts, the East Asian nose m ay require nasal base reduction
to balance the nose w ith the w idth of the new ly augm ented
dorsum . This can be perform ed w ith techniques involving any
com bination of internal or external excision and base-cinch-
ing sutures. Caution is warranted, as sm all errors in perform -
ing base reductions result in glaring deform ities. Unsightly
scars at the nasal base are di cult to correct. To im prove out-
com es, plan for an incision slightly adjacent to the alar-facial
or alar-vestibular junction. Avoid local anesthetics as they
can deform the tissue contours. Using a no. 11 blade, create
a slight bevel of the incisions to prom ote eversion of the skin
edge. Avoid all cautery. Meticulously close the base reduction
sites w ith a deep 5–0 PDS suture, 7–0 nylon vertical m attress
sutures, and 6–0 fast-absorbing gut sim ple sutures.
Glabellar Augmentation
To further balance the nose, it is im portant to evaluate the
East Asian face w ith lateral views. From this perspective, a
de cient glabella m ay be observed. This observation m ay be
m ade preoperatively and discussed w ith the patient through
digital im age m orphing software. The senior author perform s
glabellar augm entation by an endoscopic technique. Attention
is directed at the forehead area, w here two hairline incisions
are m ade, and the endoscope is dropped dow n to the glabellar
region in a subperiosteal plane. A soft piece of septal cartilage
covered w ith perichondrium is sutured on both sides w ith 5–0
PDS, keeping the suture tail long w ith needles attached. The
graft is deposited through the scalp incision site. Then using
16-gauge needles, ports are created on the lateral aspects of
the de cient glabella. The needles connected to the graft are
passed through 16-gauge needles and delivered externally.
Sym m etry and positioning should be noted w ith the endo-
scope before t ying the anchoring sutures at the skin. The scalp
incisions are closed w ith 5–0 PDS and 5–0 fast-absorbing gut.
The anchoring sutures are cut in 7 days. Another option is to
use autologous fat augm entation of the glabella.
■ Postoperative Care
All patien ts are seen on postoperative day 1. Vestibular
splints m ay be rem oved. The n ose is clean ed and antibiotic
oin tm ent is applied. Patients undergoing costal cartilage
grafting receive oral uoroquinolone and perform uoroqui-
nolone antibiotic nasal soaks in addition to a second-gen-
eration cephalosporin. The external cast, tape, lateral w all
splints, Kirschner w ire, and colum ellar sutures are rem oved
in 7 days. If base reductions w ere perform ed, these sut ures
are rem oved at 10 to 14 days postoperatively. A m ild narcotic
pain m edication is provided, but an early transition to acet-
am in ophen is encouraged. Aspirin and n onsteroidal anti-
40 II Rhinoplast y

in am m ator y drugs are avoided postoperatively. Despite a
low level of discom fort, patients often refrain from taking
deep inspirations to protect the costal cartilage donor site.
Postoperatively, patien ts are en couraged to perform in cen -
tive spirom etr y and am bulation to avoid atelectasis.
but stressed that she preferred a “natural look.”. In her pre-
operative com puter im aging we agreed on a m odest degree
of dorsal augm entation that would com plem ent a m oderate
increase in nasal tip projection (Fig. 3.16). We also discussed
chin augm entation to com plem ent her nasal projection and
other facial features. We harvested a 3.5-cm segm ent of her
sixth rib through a 1.1-cm chest incision. Perichondrium was

■ Key Technical Points harvested from the surface of the rib as well.
Th e r ib car t ilage w as car ved in to t h ree sep arate
segm en t s t h at w ere exam in ed for t h e p rop er ben d in g
1. The chest incision is m ade sm all to m inim ize the
(Fig. 3.17). Over several h ou rs a p recisely car ved cost al
visible scar; h ow ever, a surgeon sh ou ld con tin ue to
car t ilage d orsal graft w as fash ion ed an d obser ved for a
u se a larger in cision u ntil fam iliar w ith th e dissect ion.
ten d en cy to ben d . An exter n al rh in op last y ap p roach w as
2. By m ain t ain ing a p rotect ive cu of p erich on d riu m ,
u sed (Fig. 3.18) an d sp ecial care w as t aken to d issect a
th e cost al cart ilage h ar vest tech n ique sh ould
t igh t su bp er iosteal t u n n el along t h e m id lin e of h er n asal
en su re an in t act h ar vest site, avoiding violat ion of
d orsu m . Th e base of t h e n ose w as st abilized u sin g a cau dal
th e pleura. All n al cut s of th e cost al car t ilage are
sept al exten sion graft su t u red to t w o exten d ed sp read er
p erform ed w ith th e blun t en d of th e Freer elevator.
graft s t h at w ere p laced in to bilateral su bm u cosal t u n -
A lift ing m ot ion is ut ilized to protect th e un derlying
n els u n d er t h e u p p er lateral car t ilages. Th e d orsal graft
p erich on driu m an d pleura.
w as fash ion ed so t h at it h ad a sligh t con cave cu r vat u re
3. W h en open ing th e n ose, th e Joseph periosteal t h at w as or ien ted again st t h e n asal dorsu m . A st r ip of
elevator sh ould be used in a lim ited fash ion , p er ich on d riu m w as su t u red to t h e u n d ersu r face of t h e
p reser ving a t igh t dorsal p ocket , in an t icipat ion of a su p er ior p or t ion of t h e d orsal graft w it h 5–0 PDS su t u re.
d orsal augm en tat ion graft . A n ar row n e rasp w as u sed to rough en t h e n asal d orsu m
4. In th e set t ing of spreader grafts or splin t ing, by to create a p orou s bon e su r face t h at cou ld t h en in tegrate
opposing con cavit ies, th e surgeon can ut ilize th e w it h t h e p er ich on d r iu m an d x t h e dorsal graft to t h e
n at u ral cu r vat u re of th e costal cart ilage grafts. n asal bon es. Th e d orsal graft t sn uggly in to t h e su bp er i-
5. By keeping th e upper lateral cart ilages at t ach ed osteal t u n n el, xing t h e d orsal graft in to p osit ion . Th en
to th e dorsum , th e surgeon can u se subm ucosal a sh ield graft w as p rojected ~ 3 m m above t h e exist in g
spreader grafts an d does n ot n eed addit ion al t im e to d om es an d su t u red to t h e m ed ial cr u ra. Bilateral lateral
recon st ruct th e dorsu m . cr u ral graft s w ere su t u red to t h e p oster ior su r face of t h e
6. Th e dorsal graft is secured on ly after all t ip w ork is sh ield graft an d t h en su t u red to t h e lateral cr u ra. To p re -
com plete. ven t graft visibilit y p er ich on d r iu m w as su t u red on to t h e
lead ing edge of t h e sh ield graft . Th e colu m ellar in cision
7. Th e dorsal augm en tat ion graft requ ires rigid xat ion
w as closed u sin g a 6–0 Mon acr yl su bcu t an eou s su t u re
to preven t w arping. Th e su perior aspect of th e graft
an d 7–0 ver t ical m at t ress su t u res.
m u st be secu red w ith a t igh t p ocket , t ran sn asal
su t u re, or Kirsch n er w ire.
8. Tip projection m ay be achieved w ith a shield graft or
h orizontal onlay graft. The horizontal onlay graft is
less aggressive and w ill not change the infratip lobule.
9. W h en in creasing project ion , on e m ust con t rol for
rot at ion w ith a st able fou n dat ion . Septal exten sion
graft s precisely con t rol th ese variables.
10. Base redu ct ion s are tech n ically di cu lt w ith th e
p oten t ial for deform it y. Avoid con tour-altering local
an esth et ics an d cau ter y w h ile p erform ing base
redu ct ion s.

■ Case Studies
Case 1
This Asian patient presented for augm entation rhinoplast y
and requested to have her rib cartilage used for the augm enta-
tion. She was interested in a m odest degree of augm entation
Fig. 3.16 Preoperative computer im aging showing proposed
modest change in nasal dorsal height and tip projection. Chin aug-
mentation was recommended as well.
 3 The Use of Cost al Cartilage for Dorsal Augm ent ation and Tip Grafting 41

a b

Fig. 3.17 (a) A 3.5-cm segment of the sixth rib was harvested through a 1.1-cm chest incision. (b) Harvested costal cartilage was carved
into three separate segment s to allow selection of the best piece for the dorsal graft.

a b c

d e f

Fig. 3.18 (a) Bilateral spreader grafts were used to stabilize the caudal septal extension graft. The extension graft was placed to control
nasal tip projection and rotation. (b) Dorsal graft with slight bend with the concave side oriented inferiorly against the dorsum of the nose.
Perichondrium was sutured to the undersurface of the upper margin of the dorsal graft. (c) Dorsal graft with perichondrium sutured to
the undersurface of the superior end of the graft. (d) Shield graft sutured to the medial crura. The graft is projecting 3 mm above the
existing domes. (e) Bilateral lateral crural grafts sutured to the posterior surface of the shield graft to prevent over-rotation of the tip graft.
(f) Perichondrium sutured to the leading edge of the shield graft to minimize the likelihood of graft visibilit y.
42 II Rhinoplast y

a b c

d e f

g h

Fig. 3.19 (a–c,g) Preoperative photo-

graphs. Preoperative frontal view shows
a lack of de nition of the upper dorsum.
Lateral and oblique view show low nasal
dorsum and under-projected chin. Wide
nasal base is noted on basal view. (d–f,h)
Postoperative (2 years) photographs. Fron-
tal view shows a nice improvement in upper
dorsal de nition with symmetric aesthetic
dorsal lines. Lateral and oblique views show
a modest increase in dorsal height and
increased tip projection. The chin augmen-
tation helps to balance the increase in tip
projection.
 3 The Use of Cost al Cartilage for Dorsal Augm ent ation and Tip Grafting 43

Th e pat ien t did w ell, w ith a n ice im provem en t in th e

ap pearan ce of h er p ostop erat ive view (Fig. 3.19). Th e ch in
im plan t balan ced th e ch anges to h er n ose an d com ple-
m en ted h er oth er facial feat u res.

Case 2
Th is pat ien t presen ted for secon dar y rh in oplast y. Th e
pat ien t w as un h appy w ith h er dorsal im plan t , w h ich occa-
sion ally becam e in am ed. Sh e u n der w en t t w o p reviou s
su rgeries an d w ish ed to h ave h er im p lan t rem oved an d
replaced w ith h er ow n cart ilage. Sh e w an ted a low er radix
an d im p roved t ip con tou r. We dem on st rated h er p ro le
ch anges u sing com pu ter im aging (Fig. 3.20).
At th e t im e of su rger y w e n oted a large Gore-Tex dor-
sal im p lan t . Th e im plan t h ad t w o layers in th e radix area
Fig. 3.20 Preoperative computer imaging showing lower radix.
an d w as ver y di cu lt to rem ove (Fig. 3.21). A 4.5-cm seg-
m en t of cost al cart ilage w as h ar vested from h er righ t ch est
(Fig. 3.22). Th e p at ien t u n d er w en t revision rh in oplast y
(Fig. 3.23). Sh e h ad h ad a colu m ellar st ru t placed in a p revi-
ous surger y. We left th e st rut in place an d sut ured a costal
cart ilage sh ield graft to th e m edial cru ra. Th e sh ield graft
w as st abilized u sing a bu t t ress graft su t u red beh in d th e t ip
graft . Soft t issu e an d scar w ere su t u red along th e lateral
edges of th e t ip graft . A costal cart ilage dorsal graft w as
design ed to set a low er radix. Perich on driu m w as sut u red
to th e u n dersu rface of th e d orsal graft to aid in xat ion of
th e dorsal graft . Mult iple perforat ion s w ere m ade in th e
bony dorsum to allow m ore rapid in tegrat ion w ith th e peri-
ch on driu m on th e un dersu rface of th e dorsal graft . A large
space w as created w ith th e dissect ion of th e Gore-Tex dor-
sal im p lan t . To xate th e dorsal graft a th readed Kirsch n er
w ire w as placed th rough a sm all dorsal in cision , th rough
th e dorsal graft an d in to th e bony dorsum . A com posite Fig. 3.21 Gore-Tex dorsal graft rem oved. Note the double layer of
skin -cart ilage graft w as h ar vested from th e righ t cym ba Gore-Tex over the radix region and its extension into the glabellar.
con ch a. Th e com posite graft w as sut ured in to th e left m ar-
gin al in cision w h ere th ere w as a vest ibu lar skin de cien cy.
Th e Kirsch n er w ire aided xat ion of th e dorsal graft to th e
bony dorsum . Th e Kirsch n er w ire w as rem oved on th e sev-
en th postoperat ive day. Th e p at ien t did w ell an d sh e w as
h ap py w ith h er ou tcom e (Fig. 3.24).

Fig. 3.22 Costal cartilage harvest from sixth rib.

44 II Rhinoplast y

a b c

d e f

g h

Fig. 3.23 (a) Shield graft sutured to medial crura. (b) But tress graft sutured behind leading edge of the shield graft. Soft tissue and scar
placed along edges of the shield graft for additional camou age. (c) Costal cartilage dorsal graft carved. (d) Perichondrium sutured to the
undersurface of the dorsal graft. (e) Kirschner wire advanced through a small incision over the nasal dorsum . (f) Composite skin-cartilage
graft harvested from right cymba concha. (g) Composite graft sutured into the left marginal incision. (h) Kirschner wire in position xing
the dorsal graft to the underlying bone.
 3 The Use of Cost al Cartilage for Dorsal Augm ent ation and Tip Grafting 45

a b c

d e f

g h

Fig. 3.24 (a–c,g) Preoperative photo-

graphs. (d–f,h) Postoperative (2 years)
photographs.
46 II Rhinoplast y
■ Conclusion
In th e East Asian n ose, au tologou s costal cart ilage is th e
m aterial of ch oice to address th e rh in op last y su rgeon’s
goals: dorsal augm en t at ion an d t ip re n em en t . Th is p re-
ferred bu t com plex m aterial is di cu lt to m aster, requiring
t im e for th e surgeon to develop th e ju dgm en t to properly
select , p repare, an d u t ilize th e graft s.
References
1. Toriu m i DM. St ruct ure approach in rh in oplast y. Facial Plast
Surg Clin North Am 2002;10(1):1–22
2. Toriu m i DM, Pero CD. Asian rhin oplast y. Clin Plast Surg
2010;37(2):335–352
3. Toriu m i DM, Dixon TK. Assessm ent of rh in oplast y tech -
n iques by overlay of before-an d-after 3D im ages. Facial
Plast Su rg Clin North Am 2011;19(4):711–723, ix
4. An an t an arayan an P, Raja DK, Ku m ar JN, et al. Cath eter-
based don or site an algesia after rib graft ing: a pro-
sp ect ive, ran dom ized, dou ble-blin ded clin ical t rial
com p aring rop ivacain e an d bu pivacain e. J Oral Maxillofac
Surg 2013;71(1):29–34
5. Toriu m i DM. Discu ssion: u se of autologous cos-
t al cart ilage in Asian rh inoplast y. Plast Recon st r Su rg
2012;130(6):1349–1350
6. Rejt arová O, Slízová D, Sm oran c P, Rejt ar P, Bukac J. Cos-
t al cart ilages—a clue for determ in at ion of sex. Biom ed Pap
Med Fac Un iv Palacky Olom ou c Czech Repu b 2004;148(2):
241–243
7. Balaji SM. Cost al cart ilage n asal augm en tat ion rh in o-
plast y: st u dy on w arping. An n Maxillofac Su rg 2013;3(1):
20–24
8. Sunw oo WS, Ch oi HG, Kim DW, Jin HR. Ch aracterist ics of
rib cart ilage calci cat ion in Asian pat ien t s. JAMA Facial
Plast Su rg 2014;16(2):102–106
9. Lopez MA, Sh ah AR, West in e JG, O’Grady K, Torium i DM.
An alysis of th e p hysical prop ert ies of cost al cart ilage
in a porcin e m odel. Arch Facial Plast Su rg 2007;9(1):
35–39
10. Kim DW, Sh ah AR, Toriu m i DM. Con cen t ric an d eccen t ric
car ved cost al cart ilage: a com parison of w arp ing. Arch Fa-
cial Plast Surg 2006;8(1):42–46
11. Ah m ed A, Im an i P, Vuyk HD. Recon st ru ct ion of sign i can t
saddle n ose deform it y u sing au togen ou s cost al car t ilage
graft w ith in corporated m irror im age spreader graft s. La-
r yngoscop e 2010;120(3):491–494
12. Guyu ron B, Uzzo CD, Scu ll H. A pract ical classi cat ion of
septon asal deviat ion an d an e ect ive guide to sept al su r-
ger y. Plast Recon st r Surg 1999;104(7):2202–2209, discu s-
sion 2210–2212
13. Toriu m i DM, Sw artou t B. Asian rh in oplast y. Facial Plast
Surg Clin North Am 2007;15(3):293–307, v
14. Gu n ter JP, Clark CP, Friedm an RM. In tern al st abilizat ion
of autogen ous rib car t ilage graft s in rhin oplast y: a bar-
rier to cart ilage w arping. Plast Recon st r Surg 1997;100(1):
161–169
15. Sarifakioglu N, Cigsar B, Aslan G. K-w ire: a sim ple an d safe
m eth od for in tern al st abilizat ion of cost al car t ilage in L-
st rut graft s. An n Plast Surg 2002;49(4):444
16. Gu n ter JP, Friedm an RM. Lateral cru ral st ru t graft: tech -
n ique an d clin ical applicat ion s in rh in oplast y. Plast Recon -
st r Su rg 1997;99(4):943–952, discussion 953–955
4 Nasal Tip Modi cation in Asians:
Augmentation and Rotation Control
Hong Ryul Jin and Jong Sook Yi
Pearls
• For t ip surger y in East Asian s, project ion , rot at ion ,
an d volu m e are th e th ree m ost im p or tan t factors to
con sider.
• Sin ce in h eren t t ip support is w eak an d th e skin is
relat ively th ick in Asian s, t ip augm en t at ion is m ostly
ach ieved by car t ilage graft ing rath er th an su t u re
m odi cat ion tech n iqu es alon e.
• Pat ien t p referen ce, th e ch aracter of th e t ip, an d
su rgeon exp erien ce an d preferen ce are som e of th e
factors to be con sidered in ch oosing th e app rop riate
ap proach for t ip su rger y.
• For th e t ypical Asian pat ien t , th e open approach
gives bet ter an d m ore diverse opt ion s for m odifying
th e t ip sh ape, w h ile th e closed approach is e ect ive
in lim ited cases.
• A cap graft w ith or w ith ou t a colu m ellar st ru t an d
in terdom al sut u re th rough th e en d on asal or open
ap proach p rovides an e ect ive in crease in t ip
project ion an d rot at ion .
■ Introduction
Th e gen eral goal in t ip -plast y is to create a n at ural-look-
ing n asal t ip th at is in h arm ony w ith th e n asal dorsu m
an d in balan ce overall w ith th e facial feat u res. Th is basic
ph ilosophy applies n ot on ly to Asian s but also to pat ien t s
from oth er eth n ic backgrou n ds. Su ch h arm ony can on ly be
ach ieved w ith a su cien t u n derst an ding of th e p er vad ing
cult ural environ m en t an d w ith con t in uous exposure an d
dedicat ion to th e speci c eth n ic pat ien t . It is m an dator y,
th erefore, th at each operat ion be h igh ly in dividu alized
according to th e eth n ic backgrou n d.
For t ip su rger y in Asian s, project ion , rot at ion , an d vol-
u m e are th e t h ree m ost im p or t an t factors to con sid er. A
h arm on iou sly m atch ed p roject ion of th e n asal t ip adju sted
to th e augm en ted dorsu m , w ith a gen t le rou n d sh ape
in stead of a w ell-de n ed, angu lated t ip , along w ith su bt le
accen t u at ion are th e id eals th at con tem p orar y Asian n asal
t ip su rger y asp ires to ach ieve.1 On e im por t an t poin t th at
sh ou ld be kept in m in d is th at m any Asian p at ien t s requ est
• Th e sept al exten sion graft is a w orkh orse u sed to
m odify th e t ip sh ap e, an d it sh ou ld be su p ported by
a st rong cau dal sept u m or rein forced w ith bat ten or
exten ded sp reader grafts.
• W h en design ing th e sept al exten sion graft ,
project ion an d rot at ion are m odi ed by carefu lly
design ing th e sh ape of th e graft con sidering th e
posit ion of th e n ew dom e.
• Ap p lying bon e as a septal exten sion graft or overly
aggressive applicat ion of th e sept al exten sion graft
sh ou ld be avoid ed to p reven t pain , h ard n ess, an d
discom for t at th e t ip.
• Even for relat ively th ick skin at th e n asal t ip, t ip
graft s n eed to be carefu lly beveled an d car ved to
keep from sh ow ing u p in th e long term .
• To com plem en t m odi cat ion of th e t ip sh ape,
ceph alic resect ion , th e sh ield graft , th e prem axillar y
graft , th e lateral cru ral graft , an d th e alar rim graft
are also u sed.
an in crease in t ip p roject ion w it h avoidan ce of exces-
sive in creased t ip rot at ion . Th e am ou n t of p roject ion an d
rot at ion n ecessar y for a case d i er according to p erson al
preferen ce, age, sex, occu p at ion , an d overall facial fea-
t u res. In gen eral, m ost p at ien t s requ ire an d u n dergo dor-
sal augm en t at ion , so t h e am ou n t of t ip p roject ion sh ou ld
be balan ced accordingly. Nasal t ip w idth sh ou ld alw ays
be evalu ated in th e con text of overall facial an atom y an d
n ot as an isolated feat u re. If t h e face is relat ively w id e, a
n arrow t ip can ap p ear con sp icu ou s an d d em on st rate an
operated-on look.
To obt ain a m ore aesth et ically pleasing n asal t ip in
Asian s, several procedures are em ployed. Com m on ly
ap plied p rocedu res are cart ilage graft ing tech n iqu es,
in cluding variou s t ip on lay graft s an d sept al exten sion
graft s. Th eoret ically, th ey m ay su ce w h en u sed in divid u-
ally, bu t in pract ice a com bin at ion of th e variou s tech n iqu es
is n ecessar y to ach ieve th e desired goal. Sin ce in h eren t t ip
su p p or t is w eak an d th e skin is relat ively th ick in Asian s, t ip
augm en tat ion is rarely ach ieved by su t u re tech n iqu es alon e
an d is reser ved for a select grou p of p at ien ts.2
47
48 II Rhinoplast y
■ Patient Evaluation
Cu rren t t ip sh ap e an d sup por t n eed to be carefully obser ved
an d an alyzed w h en p lan n ing for t ip su rger y. A dep en den t ,
caudally rot ated, less projected t ip w ith good cart ilagin ous
su p p or t is relat ively easy to t reat . Th e m ost di cu lt case is
a t ip th at is already sligh tly u pt u rn ed, is poorly p rojected ,
an d h as ver y w eak low er lateral car t ilages an d a de cien t
sept u m (Fig. 4.1). Care sh ou ld be t aken in th is case becau se
t r ying to in crease th e project ion of th e t ip w ith out proper
m an euvers w ill in crease th e cep h alic rotat ion an d create a
sh ort-looking n asal t ip .
Tip suppor t is evaluated by palpat ing th e t ip, th e cau -
dal sept um , an d th e skin because th ese st ruct ures are m ost
im p ort an t in deciding th e t ip sh ap e. A n asal t ip suppor ted
by large low er lateral car t ilages an d a st rong sept um is rela-
t ively easy to con t rol. How ever, m any Asian pat ien t s h ave
th e w orst com bin at ion , rudim en t ar y t ip cart ilages an d a
ret ruded an d de cien t caudal sept um w ith th ick skin .
Th e pat ien t’s w ish es an d expectat ion s are discussed.
Con tour of th e t ip sh ape is lim ited by m any factors. Skin
an d car t ilage are m ost im port an t . Th e p at ien t’s w ish es
sh ou ld be th orough ly ad dressed becau se th ere can be m is-
u n derst an ding during discussions. A ver y sen sit ive pat ien t
m ay com p lain of ver y su btle di eren ces in th e n ost ril sh ap e
as seen from below. Preop erat ive ph otos sh ou ld alw ays be
taken an d an alyzed before surger y. In creasing th e t ip pro-
ject ion m ay exaggerate pre-exist ing sligh t discrepan cies of
th e rim h eigh t or colum ellar slan t ing.
Pat ien t preferen ce, th e ch aracter of th e t ip, an d surgeon
exp erien ce an d p referen ce are som e of th e factors th at are
to be con sidered in ch oosing th e app rop riate app roach for
t ip surger y. Many pat ien ts st rongly dem an d an en don asal
ap proach to avoid a colu m ellar scar from an op en app roach .
a b
In su ch cases, advan t ages an d lim itat ion s of th e en don asal
ap proach sh ou ld be brough t for w ard du ring th e con su lta-
t ion an d th orough ly discu ssed.
Regarding th e ch aracter of th e t ip, t w o factors sh ou ld
be con sidered in deciding th e righ t approach . Th e rst is
t ip support . W h en th e size an d st rength of th e low er lat-
eral car t ilages are adequ ate, an en don asal app roach can
be a good choice. W h en th e car t ilages are w eak an d sup -
port is m in im al, h ow ever, en don asal t ip -plast y tech n iques
becom e in e ect ive.3 Th e secon d factor is th e st at us of t ip
project ion an d rotation . In sert ing a colum ellar st rut , con -
verging th e low er lateral cart ilages, an d p lacing a cap graft
w ill project th e t ip togeth er w ith sligh t ceph alic rot at ion .
Th is in crease in rot at ion m ay create an excessively over-
rot ated appearan ce in pat ien t s w h o already h ave a bor-
derlin e sh ort n ose. A sept al exten sion graft via an extern al
ap proach is m ore app rop riate for th ese p at ien t s. Th e best
in dicat ion , th erefore, for th e en don asal approach is w h en
th e t ip is sligh tly droopy w ith low er lateral car t ilages th at
are large an d st rong. It is also best u sed in p at ien ts w h o do
n ot h ave th ick skin an d severe deform it ies or asym m et r y of
th e t ip car t ilage.
■ Surgical Techniques
Augmenting Tip Projection via the
Endonasal Approach
Cap Graft via the Endonasal Approach
Th e site w h ere th e graft w ill be placed is m arked on th e t ip
skin . After th e h ar vest of cart ilage from th e n asal sept u m or
th e cym ba con ch a, t w o to th ree pieces are overlapped an d
Fig. 4.1 Evaluation of tip shape and sup-
port. (a) In this hump nose patient, the tip
is slightly caudally rotated and projection
is less than optimal, but the cartilaginous
support is strong. This t ype of tip shape is
relatively easy to change favorably either
by the endonasal or open approach. (b) A
slightly cephalic rotated tip with poor tip
projection and weak support. This tip tends
to rotate m ore cephalically if projection is
increased without speci c measures to pre-
vent cephalic rotation.
 4 Nasal 
Tip 
Modi cation 
in 
Asians: 
Augm ent ation 
and  Control  49
Rot ation 

su t u red, taking in to con siderat ion th e degree of augm en ta-

t ion n eeded an d th e exist ing t ip size. Th e size of th e graft
is design ed so th at it does n ot exceed th e usu al in terdom al
dist an ce, w h ich is 6 to 8 m m , an d th e m argin s are carefully
t rim m ed. On e or t w o kn ot s are m ade, an d th e th readed
n eedles are left u n cut . Th e m argin s of th e graft are t rim m ed
to m ake a sm ooth er t ran sit ion w ith th e su rrou n ding t issu e
or are m orselized using Brow n -Adson forceps. Failu re to do
th is m ay lead to graft visu alizat ion . Using an in fradom al
m argin al in cision , th e in sert ion p ocket is m ade sligh tly
larger th an th e graft (Fig. 4.2). Th e n eedles of a 5–0 PDS
su t u re are in t rodu ced th rough th e in cision site, com ing ou t
th rough th e previously m arked dot s on th e t ip. By pulling
on th e su t ure, th e graft can be placed at th e cen ter of th e
pocket (Fig. 4.3). Th e in cision site is closed w h ile gen tle
t ract ion is m ain tain ed on th e sut ure. Th e pulled-out sut u re
is xed w ith tape to th e skin an d rem oved after a w eek. Fig. 4.2 Cap graft through the endonasal approach. Using an
infradomal marginal incision, the graft insertion pocket is made
slightly larger than the graft.
Utilizing Columellar Strut, Interdomal
Suture, and Onlay Graft via the
Endonasal Approach
Cartilage h ar vested from th e n asal sept u m or th e ear is
designed according to the plann ed procedure (e.g., cap graft ,
sh ield graft, or colum ellar st rut). Th e in cision can be m odi-
ed based on th e size an d th e n at ure of th e in ten ded graft ,
but bilateral infradom al m arginal incisions extending to the
lateral colum ella are usually em ployed to expose and dissect
both low er lateral cartilage dom es an d the m edial crura. An
int radom al sut ure is done at the low er lateral cart ilage to
produce a slight in crease in projection. This sut ure begins
from th e upper part of th e m edial crus m edially, passing
through th e interm ediate crus to exit at the lateral crus.
Th e su t u re is th en don e in reverse, from th e lateral
to th e m edial cru s an d th e kn ot th row n m edial to th e
Fig. 4.3 A double layer of conchal cartilage is sutured with 5–0 PDS
m edial cru s. Care sh ou ld be t aken to m ain tain sym m et r y
and the needle is introduced through the incision, coming out through
of th e dom es an d to avoid excessive m edializat ion of th e
the previously marked center of the graft on the skin. The needle is
lateral crura or lateral crural steal. If th is h ap pen s, com - pulled gently until the graft is placed at the center of the pocket.
plicat ion s such as deform it y of th e low er lateral car t ilage
or an overly n arrow ed m edial an d lateral cru ral angle can
occur. To rein force t ip support , a pocket is m ade bet w een
th e m edial crura, follow ed by in sert ion of th e colum ellar
Tip Projection and Rotation Control
st ru t (Fig. 4.4). Th e colu m ellar st ru t , h ar vested from th e Using the Septal Extension Graft
n asal sept u m , sh ou ld be st raigh t w ith adequ ate length an d
st rength . An in terdom al su t u re, in corp orat ing th e colu m el- Concept
lar st rut by p assing th e n eedle from side to side, is don e
(Fig. 4.5). Altern at ively, both dom es are p u lled ou t to on e Th e septal exten sion graft is th e w orkh orse for t ip -plast y in
side of th e n ost ril an d su t u red as n ecessar y. Th e excess p or- th e Asian n ose. By providing a rm foun dat ion upon w h ich
t ion of th e colum ellar st rut th at project s over th e dom e is th e low er lateral cart ilages can be reposit ion ed, t ip projec-
t rim m ed. An on lay cap graft is placed above the dom e as t ion an d rot at ion are e ect ively con t rolled. By ch anging it s
described previously, if n ecessar y. Th e dom e is relocated sh ape an d locat ion , th e graft can be e cien tly u sed to aug-
to it s n at u ral posit ion , th e t ip is p osit ion ed, an d th e d orsal m en t , rot ate or de-rotate, or length en th e n ose, or to cor-
h eigh t is cross-ch ecked from th e lateral an d basal view s. rect th e n asolabial angle.4
50 II Rhinoplast y
Fig. 4.4 Colum ellar strut and interdomal suture through endona-
sal approach for tip augmentation. After bilateral infradomal mar-
ginal incisions extending to the lateral side of the columella, both
domes and medial crura are exposed. A columella strut is inserted
after making a pocket bet ween the medial crura. Both domes and
the strut are sutured together for stabilit y.
A septal exten sion graft is design ed w ith th e degree of
t ip project ion an d rot at ion t aken in to con siderat ion . Low er
lateral car t ilages are reposit ion ed an d su t u red to th e n ew ly
form ed cau dal sept u m , resu lt ing in im m ediate t ip elevat ion
an d rot at ion . Th is tech n iqu e is u sefu l in sh ort n ose cases or
to in crease t ip project ion in pat ien t s w h o lack t ip suppor t ,
sin ce st rong su p port of th e t ip can be ach ieved. How ever, it
w ou ld be p ru den t n ot to overu se th e septal exten sion graft
w h en oth er m eth ods of in creasing t ip project ion are avail-
able (e.g., colu m ellar st ru t or cart ilage t ip graft), becau se
th e sept al exten sion graft involves a m ore invasive proce-
d u re requ iring m ore t issu e dissect ion com p ared w ith oth er
m eth ods. On e draw back is decreased t ip elast icit y resu lt-
ing in a st i n asal t ip, w h ich , h ow ever, ten ds to im prove
over t im e. An oth er d raw back is th at th e exten sion graft can
ben d w h en excessive ten sion is applied.5 Th is usually h ap -
p en s w h en th e cau dal sept um is w eak or th e reposit ion ed
low er lateral car t ilage an d th e drap ing skin an d soft t issu e
exert too m u ch ten sion on th e n ew t ip . Th e su rgeon sh ou ld
be con scien t ious in in form ing th e pat ient of all th ese pos-
sibilit ies preoperat ively.
Types of Septal Extension Grafts
Tw o di eren t t ypes of sept al exten sion graft s exist: th e
overlap p ing t ype an d th e en d-to-en d t ype. Th e overlapp ing
sept al exten sion graft can be divided in to variou s t ypes
depen ding on th e car t ilage st rength an d in tegrit y of th e
caudal sept um , am oun t of available cart ilage, an d desired
t ip sh ape. A com m on t ype is a sept al exten sion graft over-
lapp ing th e en t ire cau dal sept um an d exten ding to th e
an terior n asal sp in e. Du e to its in creased st abilit y it can
be used in m ajor t ip augm en tat ion . It can be placed an d
Fig. 4.5 When performing this maneuver, start from the medial
crus going to the lateral crus, and then from the lateral crus mov-
ing to the medial crus. Care should be taken to maintain symme-
try of the domes and to avoid excessive medialization of the lateral
crus.
xed to a port ion of th e cau dal sept u m . Th is is u sed in cases
w h ere on ly a m oderate am oun t of project ion is requ ired
an d w h ere th e septal cart ilage is relat ively th ick an d st rong.
In any t ype, th e graft can be rein forced u sing septal car t i-
lage or bon e to preven t possible ben ding or buckling by th e
ten sion placed on th e graft .
An en d-to-en d septal exten sion graft rein forced by
exten ded sp reader graft s h as dist in ct advan t age com p ared
w ith th e overlapping t ype: It avoids th icken ing or buck-
ling of th e caudal sept um an d th us rarely causes n asal
obst ruct ion .
The Septal Extension Graft Technique
1. For e ect ive execut ion , m ost sept al exten sion
graft ing is perform ed via th e open approach . A large,
at piece of cart ilage is t ypically h ar vested from
th e posterior n asal sept um . Th e sept al exten sion
graft is design ed con sidering th e n al sh ape an d
stabilit y of th e t ip . For exam p le, to correct colu m ellar
ret ract ion , th e por t ion of th e sept al exten sion
graft correspon ding to th e colum ella is design ed to
prot rude past th e sept u m , an d th e m edial crura of
th e low er lateral car t ilage are su t u red in a tongue-in -
groove fash ion to th e n ew cau dal sept um created by
th e graft .
2. W h en th e in h eren t septal support is st rong, a sept al
exten sion graft can be ap plied as an overlap p ing
t yp e to th e cau dal sept u m (Fig. 4.6). Avoiding an
overly th ick cau dal sept u m by carefu l car ving is
im p ort an t for a w ell-breath ing n ose. A sligh tly
cur ved graft can be used in an e ort to place th e en d
of th e graft in th e m idlin e.
 4 Nasal 
Tip 
Modi cation 
in 
Asians:
Fig. 4.6 An overlapping t ype of septal extension graft depending
solely on the caudal septum for support.
3. After un ilateral dissect ion , un less in dicated
oth er w ise, con t ralateral dissect ion is m in im ized on ly
to th e exten t w h ere th e sept al exten sion graft can be
secu rely su t u red to th e cau dal sept u m (Fig. 4.7).
4. W h en th e cau dal sept um is w eak, rein forcem en t
is ach ieved in t w o w ays: First , th e posterior septal
angle of th e cau dal sept u m is su t u re- xed to th e
an terior n asal sp in e. Secon d, th e septal exten sion
graft is supported using a spreader graft or bat ten
graft . Using th in bon e for bat ten ing pu rposes is
n e, bu t u sing it as a sept al exten sion graft is n ot
advisable. If th e h ar vested car t ilage is big en ough ,
rein forcem en t an d exten sion can be ach ieved
sim u lt an eou sly by design ing th e graft as a bat ten
graft prot ruding from th e cau dal sept um .
5. In th e en d-to-en d st yle, th e sept al exten sion graft
is st abilized at t w o or th ree poin t s: Th e posterior
sept al angle is st abilized to th e an terior n asal spin e,
u sing gu re-of-8 sut u res x th e sept al exten sion
graft to th e en d of th e caudal sept um , an d th e septal
exten sion graft is stabilized w ith a u n ilateral or
bilateral exten ded spreader graft (Fig. 4.8).6,7
6. Th e low er lateral cart ilage can be reposit ion ed by
su t u ring it to th e sept al exten sion graft u sing 5–0
PDS or 6–0 clear nylon to create th e n ew dom e
(Fig. 4.9). Addit ion al su t u res bet w een th e low er
lateral car t ilage an d th e sept al exten sion graft
are p erform ed to st rength en th e xat ion . Fu r th er
 
Augm ent ation 
and  Control  51
Rot ation 
Fig. 4.7 An overlapping graft is xed on the left side of the cau-
dal septum. 5–0 or 4–0 PDS is used to securely x the graft onto
the caudal septum. Note that the septal mucosal dissection is done
entirely on the left side, but partially on the right side, just enough
to secure the extension graft.
rein forcem en t can be obt ain ed by t ran s xion
su t u ring of th e m em bran ou s sept u m to th e sept al
exten sion graft u sing 4–0 p lain gu t . If in dicated, a
cap graft or sh ield graft can be perform ed on th e
n ew ly created dom e, to obt ain furth er re n em en t in
t ip sh ape (Fig. 4.10).
Other Useful Techniques to
Modify Tip Shape
Shield Graft
A sh ield graft p laced at th e an tero-in ferior part of th e n asal
t ip (above th e m edial crus) can in crease t ip project ion
as w ell as en h an ce de n it ion of th e su p rat ip an d in frat ip
breaks. Sept al car t ilage is com m on ly used, w ith rib cart i-
lage used on occasion . Th e w idth of th e upper part of th e
sh ield graft is d esign ed to be 6 to 8 m m in size, sim u lat-
ing th e t ip de n ing poin ts. Th e m argin s of th e graft are
t rim m ed. At least four st itch es to th e m edial crus are m ade
to m ain t ain stabilit y (Fig. 4.11). In th is case a bu t t ress graft
sh ou ld be placed posterior to th e sh ield graft to preven t
t ilt ing of th e graft an d un in ten ded ceph alic rotat ion .8
52 II Rhinoplast y

Fig. 4.8 (a,b) An end-to-end t ype of septal extension graft is reinforced with a bilat-
eral extended spreader graft. In both t ypes, the graft shape is decided considering the
a amount of projection and rotation.

Fig. 4.9 Tip modi cation using a septal extension graft. Lower lat- Fig. 4.10 An additional onlay graft with conchal cartilage is used
eral cartilages are moved and xed to a new dome created by the for more projection or de nition.
septal extension graft.

Cephalic Resection of Low er Lateral
Cartilage Lateral Crus
W h en th e t ip looks too roun d or boxy du e to a w iden ed
in terdom al dist an ce of large low er lateral car t ilages (boxy
n asal t ip , bulbou s t ip), cep h alic resect ion of th e lateral crus
an d convergen ce of th e in term ediate cru s can redu ce th e
volu m e an d n arrow th e t ip . Th is m an euver also resu lts in
sligh t cep h alic rotat ion of th e t ip du e to secon dar y scar
con t ract ion . In pat ien t s w h o h ave relat ively th ick skin , th is
m an euver does n ot cau se a dram at ic decrease in t ip vol-
u m e, w h ile in th in -skin n ed pat ien ts it can be an e ect ive
tech n iqu e. Th is procedu re can be don e eith er en don asally
or w ith th e open approach . Th e resect ion sh ould leave at
least 7 to 8 m m of th e low er lateral car t ilages equally on
both sides.9,10 Care m u st be t aken n ot to resect th e in term e-
diate cru ra that form the t ip de n ing poin t s. Using a n o. 15
blade, a par t ial-th ickn ess in cision is m ade to preven t injur y
to th e u n derlying m u cosa of th e low er lateral car t ilage. Th e
car t ilage is then dissected from th e m ucosa using iris scis-
 4 Nasal 
Tip 
Modi cation 
in 
Asians: 
Augm ent ation 
and  Control  53
Rot ation 

Fig. 4.12 Cephalic resection to reduce tip volume. At least 7 to

8 mm of lateral crura should be preserved, maintaining symmetry
on both sides.

Fig. 4.11 Shield graft (arrow) via the open approach. The shield
graft is placed and secured to at least four sites using 5–0 PDS
or 6–0 clear nylon. The edges are beveled and a but tress graft is
added for more stabilit y if necessary.

sors (Fig. 4.12). Im m ediately after th e procedu re, th e t ip

becom es n arrow er. With t im e, secon dar y scarring takes
p lace, m aking th e t ip even n arrow er.

Lateral Crural Graft

Lateral cru ral graft s preven t collap se of th e low er lateral
cart ilages an d create a sm ooth er alar–t ip con tou r. Th ere are
t w o t ypes of lateral crural graft s: lateral crural on lay graft s
an d lateral cru ral st ru t grafts.
Lat e ral cr u ral on lay graft s are u se d to restore t h e lat -
e ral cr u s w h e n it h as be e n d am age d or d efor m e d , an d to
re in force t h e alar car t ilage w h e n t h e t ip is au gm e n t e d .1 1
W h e n t h e low e r lat e ral car t ilage is seve rely dam age d
w it h loss of t ip su p p or t , n asal t ip su p p or t is rst restore d
at t h e in t e r m e d iat e an d m e d ial cr u ra t h rou gh t h e u se
of a se pt al ext e n sion graft or colu m ellar st r u t . A graft
d esign e d to m at ch t h e lat e ral cr u ral sh ap e is t h e n p lace d
on t h e late ral cr u s (Fig. 4 .1 3). Usin g 5 – 0 ch rom ic gu t , t h e
car t ilage graft an d t h e vest ibu lar skin are su t u re d u sin g
t h rough -an d -t h rough su t u res. Sym m et r ical graft s an d
su t u r in g are im p or t an t to avoid p ostop e rat ive asym m e -
t r y of t h e n asal ala . Cap or sh ield graft in g can be p e r-
for m e d sim u lt an e ou sly, as n e e d e d .
Fig. 4.13 Lateral crural onlay graft. Septal or rib cartilage is
designed to match the shape of the lateral crus and is grafted onto
both lateral crura as a lateral crural onlay graft.
Lateral cru ral st ru t graft s are com m on ly u sed to correct
th e sh ape of or to reposit ion th e lateral crus (Fig. 4.14).12
W h en th e lateral crura are too con cave or too convex, th e t ip
sh ape m ay app ear u n n at u ral. A st raigh t p iece of car t ilage is
placed ben eath th e lateral crus to at ten or st raigh ten it ou t
an d m ake for a m ore n at u ral t ran sit ion bet w een th e lateral
an d in term ediate cru ra.12 After dissect ing th e vest ibular
skin ben eath th e lateral cru s, a st raigh t p iece of car t ilage
design ed from th e sept al cart ilage is in serted. Th e cart ilage
graft an d th e vest ibu lar skin are th en th rough -an d-th rough
su t u red u sing 5–0 ch rom ic gu t . More su t u res are add ed to
x th e graft if n ecessar y. Th rough th is p rocedu re th e lateral
crura can be at ten ed.
54 II Rhinoplast y

a b d

Fig. 4.14 Correction of alar-columellar disproportion. (a) Preoperative photo shows de cient nasal dorsum, hanging columella, and
slightly retracted alar rim . (b) Six months after surgery, the dorsum is well augmented and the ala and colum ella show a norm al relation-
ship. (c) After degloving, the lower lateral cartilage is round in shape due to lack of angulation bet ween the medial and lateral crura. (d) A
at piece designed from the septal cartilage is inserted in the dissected plane bet ween the lateral crus and vestibular skin. The intermedi-
ate crura are xed to the septal extension graft. The resulting change in the shape and angle formed by the intermediate and medial crura
can be appreciated.

In cases w here th e lateral crura are posit ioned along
the longit udinal axis of the nose (“m alposit ion ed”), the t ip
can look like a ball, cont ributing to an unnat ural look. The
appearan ce of th e t ip can be im proved by ch anging th e lat-
eral crura from a vertically orien ted position to a m ore h ori-
zontally oriented one. After the lateral crura are com pletely
dissected o from the vestibular skin, a long st rut graft
can be applied, extending past th e lateral crura. The lateral
crus is then rotated caudally and xed tow ard the piriform
apert ure after dissection of th e soft t issue in th at area. Th is
lateral crural repositioning m aneuver is w ell described an d
used in Caucasian s, but it is not so e ective in Asians, w ho
h ave relatively thick skin an d subcutan eous tissue.
Premaxillary Graft
In Asian s th e p rem axillar y area is com m on ly u n derde-
velop ed, resu lt ing in ret ru sion of th e su bn asale, an acu te
n asolabial angle, an d colum ellar ret ract ion . Autologous
(cart ilage, bon e) or art i cial (Gore-Tex, silicon e, Mersilen e)
graft s can be in ser ted n ear th e an terior n asal spin e or p re-
m a xilla, to im prove colu m ella ret ract ion an d to ach ieve a
n at u ral elevat ion an d rot at ion of th e n asal base.11,13
Au tologou s or syn th et ic grafts are in serted an terior to
th e m axilla an d just in ferior to th e an terior n asal spin e. A
fair am ou n t of m aterial is u su ally n eeded, m aking syn th et-
ics th at can be sh aped easily, such as Gore-Tex or Mersilen e
m esh , m ore com m on ly em p loyed . Rib car t ilage can p rovide
su cien t au tologou s graft ing m aterial. Th e p rem axillar y
area can be app roach ed after dissect ing bet w een th e m edial
cru ra or th rough sublabial in cision . A pocket sligh tly larger
th an th e graft is m ade, follow ed by in ser t ion of th e graft
m aterial. Aggregates of sm all cart ilages can be p lu m p ed in
th e pocket , or a large piece of cart ilage is in serted an d xed
to th e su rrou n d ing t issu e or an terior n asal sp in e to p re-
ven t slip ping d ow n or m igrat ion . It is im p or tan t to design
th e graft to t th e cur vat ure an d sh ape of th e prem axilla.
Diced car t ilage w rap ped w ith au tologou s fascia is an oth er
good opt ion . In case of an u n derdeveloped prem axilla w ith
poor t ip project ion , a prem axillar y graft in tegrated in to an
exten ded colu m ellar st ru t can be u sed.
Alar Rim Graft
Alar rim graft ing is a p rocedu re in w h ich a th in p iece of
cart ilage graft is placed along th e alar rim st ar t ing from th e
n asal facet (soft t issue t riangle), to obtain a sm ooth t ran -
sit ion from th e t ip lobu le to th e alar lobu le. It rein forces
th e alar m argin an d low ers th e alar rim sligh tly w h en alar
ret ract ion is presen t .14,15,16 In an open approach , soft t issue
d issect ion along th e alar rim is started, begin n ing from th e
n asal facet u sing sh arp iris scissors. Dissect ion is p erform ed
 4 Nasal 
Tip 
Modi cation 
in 
Asians: 
Augm ent ation
close to th e alar rim m argin , t aking care n ot to m ake th e
p ocket too big. A th in , at p iece 2 to 3 m m in w idth an d 12
to 15 m m in length is design ed from th e h ar vested sept al
cart ilage.16 Th e graft is in ser ted in to th e pocket an d th e in let
is su t u red after bru ising th e t ip w ith Brow n -Adson forceps.
■ Key Technical Points
1. An on lay cap graft th rough th e en don asal approach
is best ach ieved by adequate pocket dissect ion ,
careful graft car ving, an d exact posit ion ing th rough
gu idan ce su t u re.
2. A com bin at ion of in terdom al sut ure, colum ellar
st ru t , an d on lay t ip graft s th rough th e en don asal
ap proach gives a m in or to m oderate t ip
augm en t at ion w ith gen tle cep h alic rotat ion .
3. A sept al exten sion graft is design ed w ith
con siderat ion of th e vector n eeded to augm en t or
rot ate th e t ip .
4. Th e overlapping t ype of sept al exten sion graft is
cen tered in th e m idlin e by carefu l car ving an d
p osit ion ing of th e graft to avoid t ip deviat ion .
5. Th e en d-to-en d t ype of sept al exten sion graft is
p u t bet w een th e m edial crura an d align ed w ith
th e caudal sept um in en d-to-en d fash ion w ith
gu re-of-8 su t u res. It is fu r th er rein forced w ith
exten ded sp reader graft s or th in bat ten graft s.
6. Various tip m odifying techniques including shield grafts,
cephalic resection, lateral crural grafts, prem axillary
grafts, and alar rim grafts, are properly m ixed w ith
septal extension grafts to further m odify the tip.
■ Complications and
Their Management
Loss of Projection
Th e in creased project ion ach ieved w ith a colum ellar st rut
w ith on lay t ip grafts m ay lessen as t im e goes by. Decreased
sw elling w ith t im e an d graft absorpt ion m ay p lay a role
in p roject ion loss. To preven t th is, a sept al exten sion graft
su p p or ted at th e an terior n asal sp in e is u sed.
Over-rotation
Over-rotat ion is a com m on com p licat ion in w h ich th e p ro-
ject ion is overly in creased w ith ou t con sidering th e vector
of t ip rotat ion . With ou t appropriate preven t ive m easures,
in creased project ion using variou s t ip graft s an d st rut s
w ill even t ually rot ate th e t ip in th e ceph alic direct ion . Th is
com plicat ion can be preven ted by appropriately design ing
 
and  Control  55
Rot ation 
th e septal exten sion graft con sidering th e rot at ion an d pro-
ject ion of th e t ip.
Tip Asymmetry or Deviation
Tip asym m et r y or deviat ion is com m on w h en th e n at u ral
sh ape of th e t ip is m odi ed. Exact p osit ion ing of th e cau-
dal sept um or septal exten sion graft in th e m idlin e is a key
elem en t to preven t th is com plicat ion . In addit ion , t ip on lay
graft s n eed exact an d sym m et ric p osit ion ing an d su t u ring.
In m any cases, a ver y m ild asym m et r y of th in , sm all low er
lateral cart ilage is easily cam ou aged by th ick n asal skin .
How ever, ever y e ort n eeds to be exerted in graft car ving
an d p osit ion ing to avoid asym m et r y or t ilt ing.
Graft Show ing
Graft sh ow ing is n ot in frequ en tly seen in th in -skin n ed
pat ien t s. Carefu l car ving an d avoiding overly aggressive
elevat ion w ill preven t th is in m ost cases in m edium - to
th ick-skin n ed pat ien ts. How ever, in th e ver y th in -skin n ed
pat ien t , even th is kin d of m easu re w ill even t ually en d up
w ith th e graft ing sh ow ing. Perich on drium , fascia, or soft
t issue covering w ith ext rem e care on th e beveling of th e
graft s h elp s to p reven t graft sh ow -u p .
Pain or Discomfort
Pain or d iscom for t of th e t ip u su ally disap pears as t im e
goes by, bu t occasion ally th is rem ain s con t in u ou sly long
after su rger y. Too m u ch st retch ing of th e t ip by overzeal-
ous project ion using a sept al exten sion graft , using a h ard
m aterial su ch as sept al bon e or Med por for a sept al exten -
sion graft or colu m ellar st ru t , or overly aggressive/in adver-
ten t t issue w ork on th e t ip are th e proposed et iologies. It
w ou ld be p ru den t n ot to p u sh th e lim it s in project ing or
rot at ing th e t ip using a sept al exten sion graft an d to use
addit ion al on lay grafts on th e n ew dom e for m a xim al m od-
i cat ion of th e t ip. Often , p ain or discom fort disapp ears
after graft rem oval.
Nasal Obstruction
Nasal obst ru ct ion can occu r w h en an ap p lied septal exten -
sion graft/colu m ellar st ru t or th e exten ded spreader graft
used to h old th e sept al exten sion graft is too th ick, result-
ing in n arrow ing of th e n ost ril. Buckling or d islocat ion of
th e sept al exten sion graft or cau dal sept um is an oth er
sou rce of n asal obst ru ct ion . Carefu l d esign of th e graft to
avoid a th ick colum ella or caudal sept um an d a st rongly
secu red , w ell-cen tered sept u m on th e an terior n asal sp in e
are key elem en t s to p reven t bu ckling or dislocat ion of th e
caudal sept um .
56 II Rhinoplast y

(Fig. 4.15). After con su lt at ion , sh e decid ed to u se a silicon e

■ Case Studies
Case 1: Tip Augmentation w ith an
Endonasal Onlay Graft
A 40-year-old fem ale visited ou r clin ic an d w an ted to
im p rove h er n asal sh ap e. Physical exam in at ion sh ow ed a
low an d w ide dorsum w ith a sligh tly u n der-projected t ip
im plan t for dorsum augm en t at ion an d con ch al car t ilage for
th e t ip (Fig. 4.16). A 3-m m -th ick, I-sh ap ed silicon e im p lan t
w as car ved an d in serted via in fracar t ilagin ou s in cision
w ith in fradom al exten sion . Th e t ip w as augm en ted using
a t w o-layer con ch al cart ilage on lay graft in serted th rough
th e sam e in cision . Ph otograph s taken 6 m on th s after sur-
ger y sh ow im p roved t ip project ion w ith a n at u rally aug-
m en ted dorsu m (Fig. 4.17).

a b c

Fig. 4.15 (a–c) Case 1. A slightly low dorsum and less than ideal tip projection are observed from the preoperative photos.

Fig. 4.16 Case 1. Intraoperative photo shows a carved I-shaped

silicone implant with a t wo-layer conchal cartilage cap graft before
insertion.
 4 Nasal 
Tip 
Modi cation 
in 
Asians: 
Augm ent ation 
and  Control  57
Rot ation 

a b c

Fig. 4.17 (a–c) Case 1. Six months after surgery, the well-augmented dorsum and the tip are in balance.

Case 2: Tip Modi cation through an au gm en te d w it h r ib car t ilage. Th e t ip sh ap e w as m od i-

Open Approach
A 39-year-old fem ale d esir in g to im p rove t h e ap p earan ce
of h er n asal t ip an d d orsu m visite d ou r clin ic. Her n asal
d orsu m w as low w h ile t h e t ip w as w id e, am or p h ou s,
an d u n d e r-p roje cted , an d t h e alar-colu m ellar relat ion -
sh ip w as n ot in h ar m ony (Fig. 4.18). Her d orsu m w as
ed u sin g an en d -to -en d sep t al exte n sion graft re in -
force d w it h a bilateral exte n d ed sp read e r graft , cap graft ,
lateral cr u ral on lay graft , an d alar r im graft (Fig. 4.19).
Ph otograp h s t aken 1 year after su rger y sh ow im p roved
p roject ion , rot at ion , an d volu m e of t h e t ip w it h a h ar m o -
n iou s alar-colu m ellar relat ion sh ip . He r d orsu m w as ad e-
qu ately augm e n ted , givin g a m ore n at u ral-lookin g n ose
(Fig. 4.20).

a b c

Fig. 4.18 (a–c) Case 2. Preoperative photographs. Before surgery, a low dorsum with a poorly projected tip is evident.
58 II Rhinoplast y

a b c

d e f

Fig. 4.19 Case 2. Intraoperative photographs. (a) Rib cartilage harvest. (b) Septal extension graft using septal cartilage and reinforce-
ment with rib cartilage. (c) Repositioning of lower lateral cartilage. (d) Alar rim graft. After making an incision lateral to the nasal facet
and tunneling along the alar rim, a pre-designed piece of cartilage is inserted into the pocket. (e) Cap graft, lateral crural onlay graft, and
coverage with perichondrium. (f) Dorsal onlay graft with carved rib cartilage.

a b c

Fig. 4.20 (a–c) Case 2. Photos taken 1 year after surgery show a naturally augmented dorsum and the tip with good alar-columellar
relationship.
 4 Nasal 
Tip 
Modi cation 
in 
Asians: 
Augm ent ation
References
1. Park SS, Jin HR. Non -Caucasian rh in oplast y. In : Flin t PW,
ed. Cum m ings Otorh in olar yngology—Head an d Neck Sur-
ger y. Vol. 1, 5th ed . Ph iladelph ia, PA: Sau n ders Elsevier;
2010:568–579
2. Won TB, Jin HR. Nuan ces w ith th e Asian t ip. Facial Plast
Surg 2012;28(2):187–193
3. Sh een JH. Closed versus open rh inoplast y—an d th e debate
goes on . Plast Recon st r Su rg 1997;99(3):859–862
4. Ha RY, Byrd HS. Sept al exten sion graft s revisited: 6-year
exp erien ce in con t rolling n asal t ip p roject ion an d sh ape.
Plast Recon st r Su rg 2003;112(7):1929–1935
5. Kim MH, Ch oi JH, Kim MS, Kim SK, Lee KC. An in t ro-
d uct ion to th e sept al exten sion graft . Arch Plast Su rg
2014;41(1):29–34
6. Guyuron B, Vargh ai A. Length en ing th e n ose w ith a
tongu e-an d-groove tech n iqu e. Plast Recon st r Su rg
2003;111(4):1533–1539, discussion 1540–1541
7. Han K, Jin HS, Ch oi TH, Kim JH, Son D. A biom ech an i-
cal com parison of vert ical gu re-of-eigh t locking su t u re
for sept al exten sion graft s. J Plast Recon st r Aesth et Surg
2010;63(2):265–269
 
and  Control  59
Rot ation 
8. W h it aker EG, Joh n son CM Jr. Th e evolut ion of open
st ruct ure rh in oplast y. Arch Facial Plast Su rg 2003;5(4):
291–300
9. Zijlker TD, Vuyk H. Cart ilage graft s for th e n asal t ip. Clin
Otolar yngol Allied Sci 1993;18(6):446–458
10. Dan iel RK. Th e n asal t ip: an atom y an d aesth et ics. Plast Re-
con st r Su rg 1992;89(2):216–224
11. Bren n er MJ, Hilger PA. Graft ing in rh in oplast y. Facial Plast
Surg Clin North Am 2009;17(1):91–113, vii
12. Gu n ter JP, Friedm an RM. Lateral cru ral st ru t graft: tech -
n ique an d clin ical applicat ion s in rh in oplast y. Plast Recon -
st r Su rg 1997;99(4):943–952, discussion 953–955
13. Gu n ter JP, Lan decker A, Coch ran CS. Frequ en tly u sed graft s
in rh in oplast y: n om en clat u re an d an alysis. Plast Recon st r
Surg 2006;118(1):14e–29e
14. Roh rich RJ, Ran iere J Jr, Ha RY. Th e alar con tou r graft:
correct ion an d p reven t ion of alar rim deform it ies in rh i-
n oplast y. Plast Recon st r Surg 2002;109(7):2495–2505, dis-
cu ssion 2506–2508
15. Boah en e KD, Hilger PA. Alar rim graft ing in rh in op last y: in -
dicat ion s, tech n ique, an d ou tcom es. Arch Facial Plast Su rg
2009;11(5):285–289
16. Toriu m i DM. New con cept s in n asal t ip con tou ring. Arch
Facial Plast Su rg 2006;8(3):156–185
 5 Hump Resection
Tae-Bin Won and Hong Ryul Jin
Pearls
• Th ree com m on feat u res of th e Asian h um p n ose
are sm all size, low radix/low dorsu m , an d u n der-
projected t ip.
• Managem ent strategy should be focused on achieving
an ideal n asal pro le and not on hum p rem oval.
• Obt ain ing a n at u ral brow t ip aesth et ic lin e in th e
fron t al view is as im p ort an t as obt ain ing an ideal
pro le in th e lateral view.
• Th e am oun t of h um p resect ion sh ould be
tailored based on th e predicted am oun t of dorsal
augm en tat ion an d t ip p roject ion .
• Radix an d t ip augm en t at ion often m in im izes or
obviates th e n eed for h um p rem oval.
■ Introduction
Rh in oplast y is on e of th e m ost com m on facial plast ic su r-
geries p erform ed in Asia. Alth ough th e p rin cip les an d
goals m ay be sim ilar, th e act u al execu t ion is qu ite di eren t
from th e Western version . An atom ic ch aracterist ics of th e
Asian n ose coupled w ith di eren ces in aesth et ic stan dards
dem an d th at it be approach ed in a un ique w ay. Num erou s
art icles h ave been pu blish ed h igh ligh t ing th ese di eren t
ap proach es an d tech n iqu es.1,2,3,4 Rh in oplast y am ong Asian s
involves p ecu liarit ies th at dist ingu ish th e procedu re from
it s Cau casian cou n terpart .
Nasal h u m p su rger y is com m on ly regarded as a “redu c-
t ion ” surger y in m ost Western rh in oplast y textbooks an d
is also referred as “redu ct ion rh in op last y.” Th e com m on
goal of a h u m p n ose su rger y is to obt ain a n at u ral con tou r
of th e n asal dorsum th rough adequate dorsal reduct ion
w h ile dealing w ith th e issues of an open roof. Alth ough
th ere are Asian pat ien t s w h o h ave large h um ps, m ost Asian
h u m p n oses di er from Western on es in th at th e size of th e
n asal h u m p is n ot big, an d th e n ose is frequ en tly associated
w ith a relat ively low n asal dorsu m an d un der-project ion
or un der-rot at ion of th e n asal t ip. Nat urally, correct ing a
h u m p n ose in Asian s en t ails dist in ct d i eren ces both in
con cept an d tech n ique.
A sm all hu m p an d th e addit ion al n eed for augm en t a-
t ion of th e dorsum an d th e t ip often m in im ize th e am oun t
of h um p rem oval an d som et im es obviate th e n eed for
resect ion itself. Prof loplast y in stead of reduct ion rhino-
plast y m igh t be a m ore suit able w ord w h en dealing w ith
60
• Am ong variou s tech n iqu es for addressing h u m p
n ose, con ser vat ive h um pectom y of th e bony an d/or
cart ilagin ous h um p, follow ed by radix an d/or dorsal
augm en tat ion is th e m ost com m on ly u sed m eth od.
• In case of a large h u m p , com pon en t h u m p resect ion
w ith recon st ruct ion of th e rh in ion using spreader
graft s is recom m en ded.
• Com plicat ion s of h um p reduct ion in clude inverted-V
deform it y, dorsal irregularit y, an d n asal obst ruct ion .
Th ese can be preven ted by con ser vat ive h um p
rem oval and u se of spreader grafts or cam ou age
graft s.
Asian h u m p n oses. In th is ch apter, ch aracterist ics of th e
Asian h um p n ose w ill be addressed w ith em ph asis on sur-
gical tech n iqu es com m on ly u sed to obt ain reliable resu lt s.
■ Patient Evaluation
The key in preoperative planning is determ ining the ideal
pro le, w hich is som ew hat sim ilar to perform ing dorsal
augm entation. There are t wo im portant points. The rst is
determ ining the level and height of the nasion. The level of
the nasion, in other words, is the starting point of the nose.
Di erences in the starting point am ong di erent races have
been em phasized consistently.5 Traditionally, the supratarsal
crease has been considered the ideal starting point for Cauca-
sians and the m idpupillary line for Asians. However, there is a
trend in w hich contem porary Asian patients are asking for a
higher starting point. The authors consider the starting point
in Asians to be som ew here in bet ween the supratarsal crease
and m idpupillary line accounting for individual preferences
(Fig. 5.1). The height of the nasion is usually determ ined by
the nasofrontal angle. The ideal nasofrontal angle in Asians is
around 135 degrees for m ales and 140 for fem ales.
The next step is determ ining the desired nasal tip pos-
t ure, w hich is done by considering nasal projection and
rotation (nasolabial angle). The ideal pro le can be achieved
w hen a line is draw n from the nasion to the tip and the hum p
can be resected and/or the dorsum augm ented as needed.
Oth er practical issu es to consider in clu de skin th ickn ess,
character of the hum p, presence of deviation, and length of
 5 Hum p Resection 61

Supratarsal crease level

Ideal nasion level
Midpupillary level

Fig. 5.1 Starting point of the nose in Asians. The ideal starting
point of the nose or the level of the nasion in Asians is considered
to be in bet ween the supratarsal crease and the midpupillary line.

the nasal bones. The ch aracteristics of the nasal hum p are

evalu ated th rough careful visualization and palpat ion.
The hum p m ay be generalized or localized. The general- Fig. 5.2 Pseudo hump. A dorsal convexit y can be seen in a patient
ized hum p usually has a bony and cartilaginous com ponent who has a depressed lower vault near the supratip, resembling a
w hile a localized hum p can be the result of a prom inence of hump nose.
the nasal bone and/or upper lateral cartilage. A pseudo hum p
refers to the visual phenom enon of an accentuated height of
the rhinion (resem bling a hum p nose), w hich can be caused
by a deep radix and/or a depressed lower vault near the supra-
tip (Fig. 5.2). Strategies in this situation should be focused on Anatomic Consideration and
restoring support and augm entation instead of resection.
We u su ally st ress th e pro le or oblique view w h en
Clinical Implication
evalu at ing th e h u m p n ose pat ien t . How ever, th ere are also
Th e dorsal skin is th ickest in th e n asion an d th in n est in th e
salien t feat u res in th e fron t al view th at w e h ave to con sider
rh in ion (Fig. 5.3), resu lt ing in a sligh t n at u ral convexit y in
an d correct to ach ieve a good resu lt in h u m p n ose pat ien t s.
th e rh in ion area. Th ere are t w o clin ical im plicat ion s related
Th e fron t al view is th e m ost im port an t view after all. Hum p
to th is an atom ic feat u re of th e dorsum . First , w h en dissect-
st igm as in th e fron t al view in clu de u n n at u ral brow t ip aes-
ing n ear th e area of th e rh in ion or h um p, a cur ved perios-
th et ic lin es (n arrow ing, w iden ing, break, etc.), ligh t re ex
teal elevator com es in h an dy; an d secon d, w h en reducing a
in th e area of th e h u m p, an d skin th in n ing w ith frequen t
h u m p , a at dorsu m is in dicat ive of over-resect ion .
hyperem ia or discolorat ion . Obt ain ing a n at ural brow t ip
An atom y of th e rh in ion area of th e osseocart ilagin ous
aesth et ic lin e in th e fron t al view is as im p or tan t as obtain -
vau lt is an oth er im port an t p oin t to u n derstan d w h en p er-
ing an ideal pro le in th e lateral view.
form ing a h u m p red u ct ion . Th ere is a broad overlap of th e
n asal bon es above an d th e sept u m an d u pp er lateral cart i-
lage (ULC) below (Fig. 5.4a). Many t im es it is su cien t to
■ Surgical Techniques rem ove th is bony h um p u nt il it reveals th e un derlying car-
t ilage. Th ere is a ch ange in th e sh ape of th e dorsal sept um
It is im port an t to em p h asize again th at su rgical tech n iqu es an d in it s relat ion w ith th e ULC as it p rogresses cau dally
of h u m p reduct ion are n ot th at di eren t from th e Western from th e bony ju n ct ion —n am ely, from a broad “T” sh ap e to
procedures. How ever, th e decision of un dergoing reduct ion a “Y” sh ap e to an “I” sh ape (Fig. 5.4b). Resect ion of th e dor-
versu s augm en tat ion or redist ribu t ion is th e key in m an ag- sal sept u m w h ile p erform ing h u m p redu ct ion w ill dest roy
ing h um p n oses in Asian s. th is n at ural an atom y. Recon st ru ct ion w ith regard to th e
62 II Rhinoplast y

Fig. 5.3 Thickness of the dorsal nasal skin. The dorsal nasal skin
is thickest in the nasion and thinnest in the rhinion, resulting in a
slight natural convexit y in the rhinion area.

n at u ral th ickn ess of th e dorsal sept u m w ill preven t aes-

th et ic an d fun ct ion al com plicat ion s such as th e inverted-V
d eform it y an d n asal obst ruct ion .

The Approach: Open versus Closed

Hu m p redu ct ion it self can be perform ed w ith equ al su c-
cess via an en don asal or an open approach . Th erefore, th e
ch oice of approach is usu ally dict ated by th e n eed for con -
com it an t procedu res to th e dorsum an d t ip. Th e auth ors use
th e en don asal approach for a localized h um p th at does n ot
n eed ad dit ion al dorsal w ork oth er th an augm en t at ion (i.e.,
spreader graft) an d n eeds on ly m in or t ip m an ipu lat ion . A
u n ilateral or bilateral in tercart ilagin ous in cision com bin ed b
w ith a part ial t ran s xion or h em it ran s xion in cision is pre-
Fig. 5.4 Relationship of the bony and cartilaginous dorsum.
ferred for accessing th e dorsum , an d a sep arate m argin al (a) In the region of the rhinion area there is a broad overlap of
in cision is used for th e t ip. the nasal bones above and the septum and upper lateral cartilage
An open approach is preferred in th e m ajorit y of below. (b) The shape of the dorsal septum changes as it progresses
pat ien t s w h o h ave a gen eralized h um p n eeding rem oval of caudally from the bony junction from a broad “T” shape to a “Y”
th e dorsal sept al car t ilage, h ave con com it an t n asal defor- shape to an “I” shape.
m it ies su ch as asym m et r y or deviat ion , an d n eed m ajor
t ip ch anges. Alth ough th ese m an euvers can be perform ed
en don asally, th e au th ors p refer th e open ap p roach becau se
it p rovides bet ter visu alizat ion an d pat ien t com fort in W h en th ere is sign i can t septal deviat ion or a n eed for
ap plying an d secu ring graft s, th u s en su ring a m ore st able cart ilage h ar vest , septoplast y is perform ed rst . Usually
an d reliable resu lt . Th e draw back of th e op en ap p roach (i.e., th e sept al car t ilage is har vested leaving 10 m m of car t i-
a n ot iceable colu m ellar scar) can be m in im ized by adh ering lage dorsally an d caudally, but w h en a con siderable h u m p
to basic w ou n d closu re tech n iqu es. resect ion is plan n ed w e leave m ore car t ilage or h ar vest th e
septal cart ilage after h u m p ectom y.

Dissection and Septal Cartilage

Harvest
Regardless of th e approach , th e soft t issue is elevated in
a su p rap erich on d rial an d su bp eriosteal p lan e. Th e an te-
rior sept al angle is exposed an d th e en t ire n asal dorsu m
visu alized .
Sequence of Surgery and Tip-Plasty
Prior to dorsal w ork, w e usually perform tip surger y.
Rough ly 90% of the desired tip shape w ork (including pro-
ject ion , rotat ion, and de nit ion ) is accom plished. The n al
tou ch es are m ade after com plet ion of th e dorsal w ork. Th e
 5 Hum p Resection 63

auth ors use th is sequen ce becau se it often m in im izes or

obviates the n eed for dorsal reduction . It is n ot in frequen t
to n d yourself in th e odd sit uation w h ere you n eed to aug-
m en t th e dorsum again after dorsal reduction to m atch th e
desired height of th e dorsum . Techniques of t ip surger y are
beyond the scope of th is chapter and w ill be dealt w ith in
an oth er on e. Brie y, for th e t ypical Asian pat ien t w ith w eak
tip support, project ion and rotat ion are usually perform ed
in t w o steps. The rst step is stabilizat ion of the nasal t ip.
This is th e key step in Asian t ip -plast y. The object ive is to
establish a rm foundat ion on w hich furth er grafting can be
don e. Stabilizat ion of the nasal tip can be achieved by m eans
of either a colum ellar strut or a septal extension graft. Of
the t w o, th e septal extension graft is by far the m ore pow er-
fu l tool an d can be u sed reliably in pat ien ts w h o h ave ver y
w eak t ip support or n eed a substan tial in crease in tip pro-
ject ion . It can alter projection and con trol rotat ion sim u lta-
neously. The second step is ne sculpting of th e nasal tip.
This is done by com bining sut ures and a variet y of grafts to
obtain the desired outcom e (Fig. 5.5). Th e on lay graft su ch a
as a cap graft or sh ield graft is th e m ain w orkh orse.

Hump Reduction in Large -Hump

Asian Noses
Many tech n iqu es for n asal h u m p resect ion h ave been sug-
gested , in clu d ing en bloc resect ion , com p on en t resect ion ,
an d Skoog d orsal resect ion .6,7,8,9 In th e classic “com p osite
en bloc h u m p ectom y” th e com p on en t s of th e h u m p (bon e,
dorsal sept u m , an d both upper lateral cart ilages) are all
rem oved togeth er (en bloc), leaving an open roof. Th is
tech n ique is usually applied to th e gen eralized osseocar t i-
lagin ou s h um p com m on in Western n oses. Brie y, a n o. 15
blade is h eld at th e bony-cart ilagin ous jun ct ion of th e dor-
su m in th e h orizon t al p lan e an d advan ced cau dally in th e
plan e of reduct ion to excise th e car t ilagin ou s port ion of th e
h u m p , t ran sect ing th e u pp er laterals an d th e car t ilagin ou s
sept u m , leaving it at tach ed to th e n asal bon es. A 10-m m
Ru bin osteotom e is th en in serted u n der th e car t ilagin ous
b
segm en t an d th e bony dorsu m redu ced in th e d esired
plan e, rem oving th e en t ire osseocart ilagin ous h um p en
Fig. 5.5 Nasal tip surgery. Comm on steps in Asian tip-plast y with
bloc. Judicious rasping an d cart ilage t rim m ing is follow ed poor tip support. Tip support is restored by (a) applying a septal
w ith careful palpat ion of th e dorsum . extension graft followed by (b) ne sculpting with additional onlay
In “com pon en t h u m p ectom y” th e com p on en t s of th e tip grafts.
h u m p are redu ced on e by on e, allow ing precise m an ipu la-
t ion an d preser vat ion of th e n asal m ucosa. Th e upper lat-
eral car t ilages are separated from th e n asal sept u m p rior to
h u m p redu ct ion . Th e dorsal sept u m is red u ced, follow ed by
bony h u m p rem oval (Fig. 5.6). Fin ally, th e u p p er lateral car-
t ilage can be t rim m ed, placed above th e sept um , or used as
au tospreader graft s or spreader ap s (Fig. 5.7). Th e au th ors
prefer to use th is tech n ique in large-h um p Asian n oses.
Lateral osteotom y is perform ed eith er en don asally or
percut an eously in pat ien t s w h o h ave an open roof defor-
m it y, a w ide dorsu m , or an associated n asal d eviat ion .
64 II Rhinoplast y

b
a

c d

Fig. 5.6 Component hump reduction 1. (a) Visualization of the hump. (b) Upper lateral cartilages separated from the septum. (c) Reduc-
tion of the cartilaginous hump with a no. 15 blade. (d) Reduction of the bony hump with a Rubin osteotome.

a b c

Fig. 5.7 Component hump reduction 2. The upper lateral cartilages can be (a) trimmed with scissors or (b,c) used as autospreader aps.
 5 Hum p Resection 65

Spreader Grafts
Sp reader graft s are p referably p osit ion ed bilaterally in
pat ien t s in w h om w e h ave resected substan t ial am oun ts of
dorsal sept u m in th e rh in ion area (Fig. 5.8). Th e reason s
for in corp orat ing spreader grafts after a h u m pectom y are
as follow s:

1. To support and reinforce the rhinion (keyston e),

preventing th e inverted-V deform it y. This is
especially im portan t in patien ts w h o h ave sh ort n asal
bones. A short nasal bone m eans a short connection
bet w een the upper lateral cart ilage an d the nasal
bone, and often this connect ion is disrupted after
h um p rem oval, cau sing m iddle vau lt collapse.10
2. To con t rol m idvault w idth an d ach ieve a sm ooth
brow t ip aesth et ic lin e. Th e th ickn ess of th e sept um
in creases dorsally, an d excision of th e th ick d orsal
sept u m w ill n arrow th e m idvau lt .
3. To preven t n asal obst ruct ion . Th is is th e fun ct ion al
coun terpart of a n arrow m idvault , w h ich can cau se
n asal obst ru ct ion du e to in tern al valve n arrow ing.
4. To correct deviat ion or asym m et r y of th e m idvault ,
Fig. 5.8 Spreader grafts placed bilaterally in the dorsal septum
if p resen t .
after humpectomy.
5. Th ere is n o st u dy on th e am ou n t of cart ilagin ous
resect ion an d th e use of spreader graft s; h ow ever,
th e auth ors en courage th eir use w h en th ere is any
d ou bt .
w ill cam ou age for th e w ide n asal base. Min or resect ion of
th e cart ilagin ous h um p w ill decrease th e n eed for spreader
Conservative Humpectomy in Asian graft s an d rarely violates th e n asal m u cosa, w h ich can
Small-Hump Noses redu ce th e risk of in fect ion w h en using alloplast ic im plan t s
for dorsal augm en t at ion .
Becau se th e h u m p is relat ively sm all in m ost Asian h um p W h en th e desired dorsal h eigh t exceeds th e h eigh t of
n oses, com posite resect ion m ay n ot be a su it able tech - th e h um p, th ere is a ch oice bet w een leaving it alon e an d
n iqu e for h u m p rem oval. Often sim ple bony rasp ing w ith perform ing augm en t at ion on top of it . Th e auth ors prefer
m in or t rim m ing of th e dorsal sept al cart ilage is su cien t to perform h u m p red u ct ion to sm ooth th e dorsu m p rior
to ach ieve th e d esired dorsal h eigh t or obt ain th e p latform to augm en t at ion . Th e am ou n t of resect ion in th is sit u a-
for fu rth er dorsal augm en t at ion . Using a sm all st raigh t t ion depen ds on th e m aterial used for dorsal augm en t a-
osteotom e in stead of a big Rubin osteotom e follow ed by t ion . W h en silicon e is u sed, th e u n dersurface of th e rh in ion
in crem en tal rasp ing w ith sm all rasps or a drill un der direct area can be car ved aw ay, cam ou aging for sm all resid u al
visu alizat ion is h elp fu l. Bony h u m p ectom y w ill reveal th e convexit y. For oth er graft ing m aterials, such as car t ilage,
overlap p ing cart ilagin ou s vau lt u n dern eath , an d p recise exp an ded p olytet ra u oroethylen e (ePTFE), an d h om olo-
redu ct ion of th e cart ilagin ous vault can follow (Fig. 5.9). gou s fascia, a com plete h u m pectom y is p erform ed becau se
Th e auth ors use th e term conservat ive h um pectom y, an d it is bet ter to perform a u n iform augm en t at ion th at leaves
it is th e p rocedu re u sed in th e m ajorit y of sm all or isolated less ch an ce of an irregular dorsum or residual convexit y.
h u m p n ose Asian p at ien ts. Subsequen t dorsal augm en ta-
t ion w ith on lay graft s above an d/or below th e h um p in
com bin at ion w ith t ip surger y con t ribu tes to th e frequen t Final Touch: Dorsal Augmentation
u se of con ser vat ive h um p rem oval. and Tip Re nement
Alth ough th e overlapping upper lateral cart ilage can
be visible un dern eath th e n asal bon es in th e rh in ion , th ere Dorsal augm en tat ion is p erform ed to obt ain th e desired
is rarely an open roof, obviat ing th e n eed for lateral oste- heigh t of th e dorsu m an d cam ou age any rem ain ing irreg-
otom ies. An oth er reason th at lateral osteotom y is n ot fre- ularit ies. Th is can t ake th e form of radix augm en tat ion or
quen tly perform ed is because fu rth er dorsal augm en t at ion radix an d dorsal augm en t at ion (Fig. 5.10). Th e lat ter h as th e
66 II Rhinoplast y

a b

c d

Fig. 5.9 Conservative humpectomy in a small Asian hump nose. (a) Visualization of the hump. (b,c) Bony humpectomy using osteotome
and rasp. Bony humpectomy reveals overlapping cartilaginous vault in the rhinion. (d) Reduction of the cartilaginous hump (dorsal septum
and upper lateral cartilage).

a b

c d

Fig. 5.10 Radix and dorsal augmentation. (a) Radix augmentation with crushed cartilage, (b) Radix and dorsal augmentation with ePTFE.
(c) Radix augmentation with periosteum. (d) Radix and dorsal augmentation with perichondrium.

advan t age of a sm ooth an d gapless t ran sit ion in th e th in -
skin n ed rh in ion area. Carefu l palp at ion w ith w et gloves is
im p ort an t for detect ing irregularit ies after h u m pectom y.
Re n em en t of th e t ip is p erform ed at th e en d to produce
a h arm on iou s n ose. To obt ain a favorable facial balan ce
togeth er w ith a h arm on ious n ose, it is advisable to con sider
gen iop last y in th e p at ien t w h o h as a ret ru d ed ch in .
■ Key Technical Points
1. A com pon en t h um pectom y is used for large,
gen eralized h u m p n oses. Th e com p on en t s of th e
h u m p are red u ced on e by on e, allow ing p recise
m an ip u lat ion an d p reser vat ion of th e n asal m u cosa
an d u pp er lateral car t ilage.
2. A con ser vat ive h um pectom y is u sed in th e m ajorit y
of sm all or isolated Asian h um p n oses. Th is is usu ally
follow ed by dorsal augm en tat ion above an d/or below
th e h um p in com bin at ion w ith t ip surger y.
3. W h en perform ing dorsal augm en tat ion after
h u m p ectom y, a com bin ed radix an d d orsal
augm en tat ion h as th e advan t age of a sm ooth an d
gapless t ran sit ion in th e th in -skin n ed rh in ion .
4. Use soft t issue or crush ed cart ilage w h en perform ing
radix augm en t at ion sin ce solid cart ilage is p ron e to
sh ow in th is area.
5. Sp reader graft s or ap s are p erform ed w h en ever
th ere is any doubt to m in im ize th e ch an ces of an
inverted -V deform it y.
■ Complications and
Their Management
Inverted-V Deformity
Cau ses of an inverted-V deform it y are m id dle vau lt col-
lap se, failure to close th e bony open roof, an d detach -
m en t of th e u p p er lateral car t ilage from th e n asal bon es.
Alth ough th is deform it y is n ot com m on in sm all-h u m p
Asian n oses, pat ien ts w h o h ave sh ort n asal bon es are rela-
t ively predisposed. Sh ort n asal bon es m ean a sm all overlap
bet w een th e car t ilagin ous vault an d th e n asal bon es, an d
th is con n ect ion can be disrupted during h um p rem oval. To
preven t m iddle vau lt collapse an d subsequen t inver ted-V
deform it y, spreader graft s, bin ding sut ures, an d cam ou-
age on lay graft s can be u sed.
5 Hum p Resection 67
Functional Problems
(Internal Valve Collapse)
Preser vat ion of th e in tern al n asal valve after dorsal hu m p
redu ct ion is frequ en tly em ph asized in th e Western litera-
t ure. Dorsal reduct ion it self w ill n arrow th e n asal valve.
In ad dit ion , lateral osteotom y an d in fract u re of th e lateral
nasal w alls to close th e open -roof deform it y can subse-
quen tly m edialize th e upper lateral cart ilages, result ing
in in tern al valve collapse an d leading to sign i can t n asal
obst ruct ion . Tech n iques to preser ve or recon st ruct th e
m iddle vau lt an d in tern al valve in th e set t ing of h u m p
redu ct ion in clude u sing th e classic spreader graft s, th e
“p u sh dow n ” tech n iqu e,9 an d spreader or auto-spreader
ap s.11 How ever, obst ruct ion due to in tern al valve collapse
is rare in Asian s, even after m edializat ion of th e lateral
w alls, du e to th eir th ick skin an d soft t issu e envelope w ith
w ide intern al valve angle.12 A p reviou s st u dy in Asian h u m p
n ose pat ien t s sh ow ed n o in ciden ce of postop erat ive n asal
obst ruct ion after lateral osteotom ies regardless of th e use
of spreader graft s.2
Residual Convexity
Cau ses of residu al convexit y in clu de overly con ser vat ive
hu m pectom y, in adequate augm en t at ion or resorpt ion of
radix im plan t , an d t ip drooping. Failure in th e est im at ion
of th e appropriate am oun t of h u m p rem oval togeth er w ith
failu re to execu te on e or m ore step s of h u m p rem oval can
be th e cause of a residual t rue h um p. Th e th ough t th at th e
am ou n t of h u m p resect ion sh ou ld be m in im ized to adju st
th e am oun t of dorsum th at w ill be augm en ted m ay h ave
led to in su cien t h um p rem oval.
Irregularity of the Dorsum
Th e dorsum , especially th e rh in ion , w h ere th e skin is th in -
nest , is pron e to sh ow irregularit ies on long-term follow -
up. Visible dorsal irregularit ies are a com m on cause of
secon dar y rh in op last y.13 Th e relat ively th ick dorsal skin
of th e Asian n ose an d sim ult an eous dorsal augm en ta-
t ion w ith h um p rem oval can redu ce th e ch an ces of dorsal
irregularit ies. Veri cat ion of a sm ooth dorsu m by careful
palpat ion after redraping of th e skin is essen t ial. Con t in u -
ous augm en t at ion of th e dorsum (from radix to th e supra-
t ip) can also reduce th is problem . W h en perform ing radix
augm en tat ion , t r y to avoid u sing solid cart ilage graft s sin ce
th ey are pron e to sh ow. Th e auth ors prefer soft t issue graft-
ing m aterial such as fascia (au tologous or h om ologous) or
ePTFE. W h en m ore augm en t at ion is n eeded, cru sh ed car t i-
lage is in ser ted below th e soft t issue graft .
68 II Rhinoplast y

■ Case Studies
Case 1
A 35-year-old fem ale p at ien t com p lain ed of a bu m p on
h er n ose (Fig. 5.11). Ch aracterist ics of h er n ose in clu ded
a m oderate h u m p w ith a low radix, a sligh tly u n der-p ro -
jected t ip , an d m oderately th ick skin . Operat ive tech n iqu es
w ere as follow s:
1. Th e open approach
2. Septoplast y an d septal cart ilage h ar vest
3. Tip -plast y w ith colum ellar st rut an d cap graft
4. Con ser vat ive en bloc resect ion of th e bony-
cart ilagin ous h um p w ith bony rasping
5. Radix augm en tat ion w ith bruised septal cart ilage
The 1-year postoperat ive ph otos sh ow im proved brow
t ip aesth et ic lin es in th e fron t al view. Lateral an d oblique
view s sh ow a w ell-balan ced p ro le w ith sm ooth dorsu m
an d in creased t ip p roject ion an d rot at ion .

a b c

d e f

Fig. 5.11 Case 1. (a–c) Preoperative facial photographs of a 35-year-old female patient show a m oderate hump, low radix, and a slightly
under-projected nasal tip with moderate skin thickness. (d–f) Postoperative 1-year facial photographs show a balanced pro le with aug-
mentation of the radix and the tip.
 5 Hum p Resection 69

Fig. 5.11 (Continued) (g) Graphic drawing of operative procedures.

70 II Rhinoplast y

Case 2 3. Com pon en t h um pectom y: resect ion of th e dorsal

A 23-year-old fem ale p at ien t p resen ted w ith cosm et ic
issu es con cern ing h er n ose (Fig. 5.12). Sh e w an ted to get
rid of h er h u m p . An alysis of h er n ose revealed a gen eralized
h u m p , low radix, sligh tly ptot ic an d bu lbous t ip, an d m od-
erately th in skin . Op erat ive tech n iqu es w ere as follow s:
1. Sept al car t ilage h ar vest th rough a m od i ed Killian
in cision
2. Th e open approach an d degloving of th e n ose w ith
d etach m en t of th e u pp er lateral cart ilage from th e
sept u m
cart ilagin ous h um p w ith a n o. 15 blade, in crem en tal
redu ct ion of th e bony h um p w ith a Rubin osteotom e
an d rasp, an d t rim m ing of th e u p per lateral cart ilage
w ith scissors
4. Bilateral spreader graft to correct deviat ion an d
con t rol th e w idth of th e dorsum
5. Ceph alic resect ion , colum ellar st rut , an d cap graft to
re n e th e t ip
6. Bilateral lateral osteotom y to close th e open roof an d
n arrow th e bony pyram id
The 1-year postoperative photos show a balanced pro le on lat-
eral view, w ith tip re nem ent. The nose is straight on the frontal
view, w ith sm ooth brow tip aesthetic lines of adequate w idth.

a b c

d e f

Fig. 5.12 Case 2. (a–c) Preoperative facial photographs of a 23-year-old female patient show a generalized hump and slightly bulbous,
under-projected nasal tip with moderately thin skin. (d–f) Postoperative 1-year facial photographs show a balanced pro le with reduction
of the hump and the tip re ned. A straight nose with sm ooth brow tip aesthetic lines of adequate width is also noted in the frontal view.

Fig. 5.12 (Continued) (g) Graphic drawing of operative procedures.
References
1. Toriu m i DM, Sw artout B. Asian rhin oplast y. Facial Plast
Surg Clin s North Am 2007;15(3):293–307, v
2. Jin HR, Won TB. Nasal h um p rem oval in Asian s. Acta Oto-
lar yngol Su pp l 2007;558:95–101
3. Jin HR, Won TB. Nasal t ip augm en tat ion in Asian s us-
ing au togen ou s cart ilage. Otolar yngol Head Neck Su rg
2009;140(4):526–530
4. Won TB, Jin HR. Nuan ces w ith th e Asian t ip. Facial Plast
Surg 2012;28(2): 187–193
5. Jin HR, Won TB. Recen t advan ces in Asian rhin oplast y. Au -
ris Nasus Lar yn x 2011;38(2):157–164
6. Ish ida J, Ish ida LC, Ish ida LH, Vieira JC, Ferreira MC. Treat m en t
of the n asal h um p w ith preser vat ion of th e cart ilagin ous
fram ew ork. Plast Recon st r Su rg 1999;103(6):1729–1733,
d iscussion 1734–1735
7. Roh rich RJ, Mu za ar AR, Jan is JE. Com pon en t dorsal h um p
redu ct ion : th e im p ort an ce of m ain t ain ing dorsal aesth et-
ic lin es in rh in oplast y. Plast Recon st r Su rg 2004;114(5):
1298–1308, discu ssion 1309–1312
5 Hum p Resection 71
8. Skoog T. A m ethod of h um p reduct ion in rh in oplast y. A
tech n iqu e for p reser vat ion of th e n asal roof. Arch Otolar-
yngol 1966;83(3):283–287
9. Hall JA, Peters MD, Hilger PA. Modi cat ion of th e Skoog
dorsal reduct ion for preser vat ion of th e m iddle n asal vau lt .
Arch Facial Plast Su rg 2004;6(2):105–110
10. Sh een JH. Spreader graft: a m eth od of recon st ru ct ing th e
roof of th e m iddle n asal vau lt follow ing rh in oplast y. Plast
Recon st r Su rg 1984;73(2):230–239
11. Gru ber RP, Park E, New m an J, Berkow it z L, On eal R. Th e
sp reader ap in p rim ar y rh in op last y. Plast Recon st r Su rg
2007;119(6):1903–1910
12. Su h MW, Jin HR, Kim JH. Com p u ted tom ograp hy versu s
n asal en doscopy for the m easurem en t of th e in tern al na-
sal valve angle in Asian s. Act a Otolar yngol 2008;128(6):
675–679
13. Won TB, Jin HR. Revision rh in op last y in Asian s. An n Plast
Surg 2010;65(4):379
 6 Correction of the Deviated, Tw isted Nose
Hun-Jong Dhong
Pearls
• Precise preoperat ive clin ical an alysis of extern al
an d in tern al n asal st ru ct u res is th e corn erston e of a
su ccessfu l correct ive rh in op last y.
• It is essential to have a su cient preoperative
discussion bet ween the patient and the surgeon
about the surgical options and w hat can be corrected.
• Facial asym m et r y sh ould be th orough ly evaluated
preoperat ively, an d th e pat ien t sh ould be in form ed
of th e result s of th e evaluat ion .
• Th e surgeon sh ou ld con sider cosm et ic im provem en t
of th e deviated n ose as w ell as its fun ct ion al
restorat ion .
• Dorsal deform it ies frequ en tly accom pany a deviated
sept u m , an d th e m ost im port an t step in correct ive
rh in oplast y is to create a st raigh t sept um along th e
m idlin e.
• Th e stabilit y of a recon st ructed n ose is determ in ed
by th e st rength of th e st raigh ten ed sept um , w h ich
■ Introduction
In rh in op last y, correct ion of a crooked or t w isted n ose
rem ain s on e of th e m ost ch allenging surgeries. Nasal
asym m et r y is related to facial at t ract iven ess, pat ien t sat-
isfact ion , an d qu alit y of life.1,2 Deform it ies in clude n ot
on ly aesth et ic problem s bu t also fun ct ion al con sequen ces,
an d th u s correct ion of th ese coexist ing p roblem s sh ou ld
be accom plish ed sim ult an eously. Th e n asal an atom y of a
pat ien t w ith a t w isted n ose m ay be related to a bony pyra-
m id deform it y, sept al d eviat ion , asym m et r y of th e u p per
an d low er lateral car t ilages, or variou s com bin at ion s of
th ese. Th e problem can be congen it al, or acquired secon d-
ar y to t rau m a or p reviou s su rger y. Fu r th erm ore, p at ien t s
often h ave baselin e facial asym m et r y, an d th is a ects th e
outcom es of correct ive rh in oplast y. Because an an atom ic
recon st ru ct ion carries th e risk of w eaken ing th e suppor t ing
bony an d cart ilagin ous skeleton , a th orough un derstan ding
of n asal an atom y an d physiology, precise preoperat ive an d
in t raop erat ive an alysis, th e surgical kn ow ledge an d skill
to p erform a t ailored su rgical procedu re, an d m et icu lou s
postoperat ive m an agem en t are all essen t ial for correct ion
of a t w isted n ose. In addit ion , the surgeon sh ould be skill-
fu l an d com p eten t to p erform a revision su rger y if n eeded.
72
origin ates from th e in tegrit y of th e keyston e area,
rein forcem en t of th e L-st rut , an d a xat ion to th e
an terior n asal sp in e.
• All ext rin sic an d in t rin sic deform ing forces sh ou ld
be evaluated an d relieved in t raoperat ively w ith
m et icu lou s m an ip u lat ion of each osteocart ilagin ou s
fram ew ork.
• Bony deviat ion is corrected w ith accurate
osteotom ies based on detailed evaluat ion of each
bony pyram id.
• Th e preferred tech n iqu es for correct ion of th e low er
t w o-th irds of a deviated n ose are use of a spreader
graft an d septal exten sion graft .
• Deform ed osteocart ilagin ou s fram ew orks sh ou ld
be m an aged in a con ser vat ive m an n er to th e exten t
possible.
• Postop erat ive care an d follow -u p are as im p ort an t as
th e surger y.
■ Patient Evaluation
A th orough social an d m edical h istor y sh ou ld be obt ain ed
from th e p at ien t an d en tered in to th e m edical record.
In p ar t icu lar, th e obt ain ed in form at ion sh ou ld in clu de
sm oking st at u s, occu pat ion , degree of con cern w ith
facial app earan ce, n asal t rau m a, p reviou s n asal su rger y,
an d co-m orbidit ies su ch as allergic rh in it is an d ch ron ic
rh in osin u sit is.
Physical Examination
Examination of the External Nose
Th e in it ial ste p for su ccessfu l cor re ct ion of a d eviate d
n ose is a syst e m at ic p h ysical exam in at ion t h at an alyzes
exist in g aest h et ic p rob le m s an d u n d e rlyin g an at om ic
d efor m it ies. W h e n d raw in g a st raigh t lin e from t h e
m idglabellar area to t h e m e n t on , t h e n asal br idge an d
t ip sh ou ld be bise ct e d sym m et r ically in an id eal n ose.
Ad d it ion ally, t h e n asal d orsu m sh ou ld be ou t lin e d by
t w o sym m et r ic b row t ip aest h et ic lin es ext e n d in g from
t h e m e d ial su p raciliar y r idges t o t h e t ip - d e n in g p oin t s
 6 Correction of the Deviated, Twisted Nose 73

(Fig. 6 .1). Usin g t h is m et h od , t h e d egre e an d t yp e of

n asal d eviat ion can b e evalu ate d .
If th e deviat ion is am bigu ou s, a bird’s-eye view or lat-
eral illu m in at ion is h elp fu l to iden t ify any su btle defor-
m it y m ore clearly (Fig. 6.2 an d Fig. 6.3). Th en m et icu lou s
palpat ion of each an atom ic elem en t , in cluding th e bony
pyram id, upper an d low er lateral car t ilages, car t ilagin ous
dorsu m , an d colum ella, sh ould be perform ed to evaluate
size, sh ape, sym m et r y, an d resilien ce. Facial asym m et r y is
not rare in pat ien t s w ith a deviated n ose, an d m ost pat ien t s
becom e ext rem ely con scious of th eir facial appearan ce
after su rger y.3 Th erefore, any m in or asym m et ries sh ou ld be
described preoperat ively to preven t pat ien t s from at t ribut-
ing th em to su rger y. Th e com m on causes of facial asym -
m et r y are listed below.

Fig. 6.1 Facial midline and brow tip aesthetic line. The brow tip
aesthetic line begins at the medial brow, curving inferiorly along
Common causes of facial the dorsal border, and gently blending with the tip-de ning point.
It should be parallel, uninterrupted, and symmetric.
asymmetry include :
• Di eren ce in facial w idth
• Asym m et ric eyebrow s Examination of the Internal Nose
• Orbit al level di eren ce
• O -cen ter an terior n asal spin e A p at ien t w ith a deviated n ose sh ou ld be assessed for th e
• Lateral p lacem en t of th e p iriform apert u re presen ce of n asal obst ruct ion . Th rough en doscopic exam i-
• Non h orizon tal alar base nat ion of th e n asal cavit y an d n asop h ar yn x, p aten cy of th e
extern al an d in tern al valves, sept al deviat ion , an in ferior
• Maxillar y or m an d ibu lar hyp er-/hyp op lasia
t urbin ate con dit ion , aden oid hypert rophy, an d any abn or-
• Malar prom in en ce or recession
m al n dings m u st be evalu ated preoperat ively.4 Th ese

a b

Fig. 6.2 (a,b) A bird’s-eye view: Dorsal

irregularities are more obvious because
the distance bet ween the nasal tip and lips
and the distance bet ween the lips and chin
become less.
74 II Rhinoplast y
a b
alterat ion s sh ou ld be som ew h at pred ict able p reop erat ively
by several test s, such as acoust ic rh in om et r y an d paran asal
com puted tom ography. If th ere is anyth ing th at could cause
n asal obst ru ct ion , it sh ou ld be m an aged d u ring correct ive
rh in op last y.
Examination of the Nasal Skin and
Soft Tissue Envelope
Th e clin ical an alysis of extern al n asal deform it ies sh ould
in clu de an evalu at ion of th e skin –soft t issue envelope
(SSTE). If th e pat ien t h as a th ick SSTE, it w ill t ake longer
for th e ed em a to su bside an d w ill disru pt th e postopera-
t ive aesth et ic outcom e.5 In con t rast , a th in SSTE is likely to
reveal sm all rem n an t deform it ies u n dern eath th e skin .
Medical Photography
Stan dardized ph otograp h s are essen t ial in th e preop erat ive
facial evalu at ion to con rm th e clin ical an alysis of th e n ose
an d th e face. Fron tal, lateral, obliqu e, basal, an d bird ’s-eye
view s are th e basic p h otograp h s th at sh ou ld be obt ain ed.
Med ical p h otograp h s en able th e iden t i cat ion of im por-
tan t facial n dings th at m ay h ave been m issed during
in it ial in spect ion an d allow for com parison of th e p ostop -
erat ive ou tcom e an d p reop erat ive st at u s.6
Fu n dam en t al facial an alysis in clu des m easurem en t s
an d evalu at ion of p roport ion s of th e eyebrow s, m edial can -
th us, n asion , rh in ion , alar sidew all, alar facial ju n ct ion , col-
u m ella, colu m ellar-labial ju n ct ion , ph ilt ru m , m outh angle,
an d gn ath ion (Fig. 6.4).
Fig. 6.3 (a,b) E ect of oblique lighting.
A light and darkness contrast can exagger-
ate the deformit y of the brow tip aesthetic
lines.
Surgical Planning
Th e n ext step is plan n ing th e surgical procedure based on
clin ical an alysis. Th e surgical plan m ay con sist of correct ion
of th e deform it y an d rein forcem en t of th e fram ew ork. Th e
ap prop riate ap p roach an d su rgical tech n iqu es sh ou ld be
determ in ed according to th e deform it ies of each an atom ic
elem en t . If use of a graft tech n ique is an t icipated, th e sur-
geon sh ou ld kn ow th e m aterials p referred by th e pat ien t
before th e surger y.7 Pat ien t s m ust be in form ed abou t th e
pros an d con s of each graft m aterial, in cluding autologou s
(sept al, con ch al, or costal cart ilage), allograft (fascia lat a,
alloderm ), an d ar t i cial m aterials (Gore-Tex, silicon e).8
Patient Interview and Selection
On ce th e su rgeon h as develop ed a p lan , th ere sh ou ld be a
discu ssion w ith th e pat ien t about th e det ails of th e pro-
cedure an d expected surgical ou tcom e. Becau se th ere can
be discrepan cy in th e de n it ion of an opt im al outcom e
bet w een th e perspect ives of th e surgeon an d th e pat ien t ,
th e surgeon sh ould explain th e result s of th e an alysis an d
th e expected outcom e of surger y based on th e ph otograph s.
Addit ion ally, th e su rgeon sh ou ld exp lain th e p oten t ial dif-
feren ces bet w een surgical goals an d ult im ate outcom es.
Th e n al step of th e preoperat ive evalu at ion is pat ien t
select ion , an d th is is as im p ort an t as th e clin ical assess-
m en t . Pat ien ts w h o h ave a realist ic exp ectat ion for th e
su rger y an d an u n derst an ding of th e su rgical lim itat ion s
are good su rgical can didates. Su rgeon s sh ou ld p ay part icu -
lar at ten t ion to detect poor surgical can didates w h o sh ow

Facial analysis
• Eyebrows
• Medial canthus
• Nasion/rhinion
• Alar side wall
• Alar facial junction
• Columella
• Columellar–labial junction
• Philtrum
• Mouth angle
• Gnathion
excessive con cern abou t m in or deform it ies or h ave u n real-
ist ic expect at ion s.
■ Surgical Techniques
Choice of Approach
Th e ch oice bet w een en don asal an d extern al approach es
depen ds on th e surgical plan an d th e surgeon’s preferen ce.6
Alth ough p reop erat ive clin ical an alysis m ay en able selec-
t ion of a part icular approach , pat ien t s w h o un dergo th e
en don asal ap proach m u st be in form ed of th e p ossibilit y of
conversion to an extern al approach for m ore com plete cor-
rect ion . In gen eral, th e en don asal approach can be app lied
for cases w ith subtle deform it ies of th e u pp er or m iddle
vau lt , an d for p at ien ts w ith keloid, w h o requ ire avoidan ce
of unpredict able con t ract ures associated w ith an open
ap proach .9 Meanw h ile, an extern al ap p roach is p referred
for th e m an agem en t of deviat ion of th e low er t w o-th ird s
an d severe asym m et ries of th e n asal bon e, an d som e cases
requ ire m axim al exp osu re, m obilizat ion , an d resh aping.
Th rough bilateral m argin al in cision s con n ected to a t ran s-
colum ellar inverted-V in cision , com plete exposure of th e
n asal t ip an d m idvau lt in th e su praperich on drial plan e can
be ach ieved. To approach a bony pyram idal deform it y, an
exten ded dissect ion in th e su bp eriosteal plan e is essen t ial.
Correction of Deviation
Alth ough th ere h ave been variou s classi cat ion s for th e
deviated nose,3,4,10,11 th ey all originated from th e n eed for
stat ist ical an alysis of ou tcom es rath er th an a clin ical gu id e-
6 Correction of the Deviated, Twisted Nose 75
Fig. 6.4 Facial analysis. The nasion, nasal tip, and philtrum
should all be along the midline. The distance from each
landmark on both sides to midline should also be the same.
Evaluation of facial asymmetry is very important in consulta-
tion of deviated nose.
lin e for surger y. Th e deviated n ose n eeds to be an alyzed
according to each an atom ic dom ain (u p p er, m iddle, an d
low er th ird) an d reciprocal relat ion sh ips from a perspec-
t ive of align ing to th e m idlin e.
Upper-Third Deviations
Deviat ion of th e u p per on e-th ird of th e n ose is cau sed
by asym m et r y an d h um p of th e bony pyram ids. Th rough
m et icu lou s p alp at ion an d com pu ted tom ography, th e size,
sh ape, an d sym m et r y of each bony pyram id sh ou ld be
evaluated. In cases of m in or deform it ies, th e bony dorsu m
can be corrected by a cam ou age or rasping tech n ique. A
pat ien t w h o h as on ly a deviated bony dorsum is likely to
have a h istor y of n asal t raum a or a h um ped bony pyra-
m id.12 Gen erally, m ost bony pyram idal deviat ion s en tail a
de ected m iddle th ird of th e n asal d orsu m .
Cam ou age
Th is tech n ique can be applied to a pat ien t w h o h as a
localized depression or asym m et r y of th e bony pyram id.
Crush ed sept al cart ilage is th e preferred graft m aterial. Th e
m aterial is p laced u n der a periosteal ap to redu ce m obilit y
an d visibilit y. Th e skin over th e bony dorsu m is relat ively
th in ; th erefore, the surgeon m ust be cer tain to con ceal th e
con tour of th e graft on th e skin .13
Rasping
In som e cases w ith bony pyram idal deform it ies, rasp ing
can be a conven ien t surgical m odalit y. If th e bony pyra-
m id h as a sym m et ric arch bu t th e dorsal p ro le is devi-
ated or deform ed, th e rasp can be solely applied to correct
76 II Rhinoplast y

th e deform it ies. In m any cases, rasping is used to t rim th e
dorsal con tou r before bony pyram idal recon st ruct ion of
asym m et rical n asal bon es th rough osteotom ies. It sh ou ld
be n oted th at rasping m ust be perform ed carefully w ith
con siderat ion of h ow th e bony pyram id w ill be posit ion ed
after th e recon st ru ct ion .
Osteotom y
Th e osteotom y is on e of th e m ost essen t ial bu t di cu lt
tech n iqu es of correct ive rh in oplast y. It involves cut t ing th e
n asal pyram id bon es to correct a deviat ion . With out oste-
otom ies, th e deviated bony dorsu m can n ot be com p letely
corrected. Th e osteotom y is a blin d procedure, w ith n o
direct visualizat ion of cut t ing lin es; th erefore, it is ch al-
lenging to learn . Th u s, surgeon s sh ould m ake an e ort to
gain reliable an d reprodu cible su rgical skills.
To avoid un n ecessar y com plicat ion s, it is essen t ial to
h ave sou n d kn ow ledge of th e basic an atom y of th e bony
dorsu m before perform ing an osteotom y. Th e bony dor-
su m is com p osed of th e fron t al bon e, n asal bon e, an d fron -
tal process of th e m axilla; an d th ese st ruct ures are join ed
togeth er. Th e ch aracterist ics of th e bon e, especially ch anges
in th ickn ess, sh ou ld be un d erstood . Gen erally, th e n asal
bon e is th icker in m en th an in w om en . It is th ickest at th e
n asofron tal su t u re lin e (5 to 6 m m ) an d th en becom es pro-
gressively th in n er tow ard th e low er m argin (2 to 3 m m ).14,15
Th e lateral w all of th e bony dorsum con sist s of th e n asal
bon e an d th e fron tal process of th e m axilla, an d th e th ick-
n ess of th e lateral p rocess is less th an 2.5 m m .
Th ere are various t ypes of osteotom y, in cluding m edial
(m edial obliqu e, param edian ), lateral, t ran sverse, in term it-
ten t , an d double lateral (Fig. 6.5). Th ough osteotom ies are
u sually perform ed un dern eath th e soft t issue envelop e, a
percut an eous extern al approach can be used for lateral an d
t ran sverse osteotom ies. Pun ct ure site visibilit y after percu-
tan eous osteotom y is n egligible.16 To produ ce an accurate
fract u re lin e despite an atom ic di cu lt ies, th e t ip of th e
osteotom e sh ould alw ays be sh arp.
Lateral Osteotomy
Th e purpose of th e lateral osteotom y is to cu t th e n asal dor-
su m from th e side w all. It en ables th e su rgeon to obtain
com plete m obilit y of th e n asal bon es an d th en reposi-
t ion th em on th e m idlin e. As sh ow n in Fig. 6.6, th e lateral
osteotom y m akes a con t in uous cu r ved fract ure lin e on th e
lateral asp ect of th e bony pyram id w ith an osteotom e an d
h am m er. En don asal osteotom y is frequen tly perform ed
u sing th e vest ibular approach . First , a sm all lin ear in cision
is m ade w ith a n o. 15 blade on th e lateral en don asal w all at
th e an terior m argin of th e in ferior t urbin ate. Th en iris scis-
sors are in serted to dissect th e soft t issu es in th e su bp eri-
osteal plan e along th e lateral rim of th e piriform aper t ure.
Th e dissect ion on ly n eeds to be w ide en ough to in sert a
gu ard ed osteotom e (cu r ved or st raigh t). W h en determ in -
ing th e start poin t of a lateral osteotom y, Webster’s t riangle,
w h ich is a sm all t riangular port ion of th e fron t al process of
th e m a xilla, sh ould be preser ved because th e in ferior t ur-
bin ate in ser ts in to th is st ruct ure. Oth er w ise, th e in tern al
valve m ay be com p rom ised (Fig. 6.6). Th e t riangle can be
preser ved by start ing th e osteotom y at th e sligh tly an tero-
su p erior p oin t of th e p iriform ap ert u re edge.17 Th rough
caut ious palpat ion of th e guard t ip, th e lateral osteotom y

Fig. 6.5 Various t ypes of osteotomy. Compared with

a medial oblique osteotomy, a paramedian osteotomy
is more useful in the patient with short, narrow nasal
3 bones.
4

2
1

1 Lateral osteotomy
2 Medial osteotomy (medial oblique)
3 Transverse osteotomy
4 Medial osteotomy (paramedian)
5 Intermediate osteotomy

Fig. 6.6 Lateral osteotomy. To avoid over-narrowing of the nasal
cavit y, it is recommended that a small triangular area (yellow col-
ored area) of the piriform aperture at the level of the nasal oor be
preserved. Lateral osteotomy usually begins at or just above the
junction of the inferior turbinate and the lateral nasal wall.
can be con t in ued along th e design ated osteotom y lin e. Th e
osteotom y sh ould stop at th e level of th e in tercan th al lin e
an d ap proxim ate th e u p p er m argin of m edial osteotom y.
In som e pat ien ts w h o h ave a severe asym m etric con tour
or excessive convexit y of the lateral bony w all, a single lat-
eral osteotom y is n ot en ough to con st ruct a sym m et ric n ose.
In th ese cases, an addition al osteotom y on the deform ed lat-
eral bony w all is usefu l to produ ce a sym m etric an d n at ural
con cavit y of th e lateral n asal w all (dou ble osteotom y). Th e
fract ure lin e sh ould be parallel to th e lateral osteotom y an d
approxim ate th e n asom axillar y sut u re lin e.
Medial Osteotomy
Th e m edial osteotom y is a surgical tech n iqu e th at involves
sep arat ing th e m edial aspect of th e n asal bon e from th e
bony sept um . Gen erally, m edial oblique an d param edian
osteotom ies are preferred am ong th e various m edial oste-
otom ies. Using a 2- or 4-m m osteotom e, a m edial osteot-
om y sh ou ld begin at the in ferior m argin of th e jun ct ion of
th e n asal bon e w ith th e dorsal bony sept um , tow ard th e
u pp er m argin of th e lateral osteotom y. W h en p erform ing a
m edial osteotom y, it sh ou ld be n oted th at th e th ickn ess of
th e bony dorsum varies con siderably by region ; th erefore,
it is im port an t an d ch allenging to m ake a con t rolled aes-
th et ic fract ure lin e. Because th e n asal bon e gradually th ick-
en s tow ard th e fron t al bon e, an u p p er m argin of a m ed ial
osteotom y th at is too h igh can result in th e rest rict ion of
m edial sh ift ing of th e n asal bon e or a rocker deform it y.
Fin ally, back fract u re of th e m obilized n asal bon e is
perform ed at th e level of th e m edial can th al lin e an d can
be don e w ith a green st ick fract ure. After lateral osteotom y
w ith superior oblique exten sion of th e upper osteotom y
6 Correction of the Deviated, Twisted Nose 77
m argin , m ed ial m ovem en t of th e n asal bon e can in du ce a
green st ick fract u re of th e m edial an d u pp er p or t ion of th e
nasal bon e th at is n eeded for sh ift ing of th e n asal bon e.
How ever, th ese green st ick fract u res do n ot alw ays take
place appropriately, an d can result in an un desirable out-
com e. To avoid in com plete con n ect ion bet w een m edial an d
lateral osteotom ies, a percu t an eous t ran sverse osteotom y
can be perform ed. Asian s in par t icular h ave a relat ively
at an d th ick bony dorsu m .18 Becau se of th ese an atom ic
feat ures, a p ercut an eous t ran sverse osteotom y for back
fract u re is m ore frequ en tly requ ired th an in Cau casian s. A
m edial osteotom y m ay also be n eed ed for som e p at ien t s
w h o h ave a bony dorsum th at is too n arrow an d requires
w iden ing w ith a spreader graft . Th e upper lim it of th e
m edial osteotom y sh ou ld be un der th e level of th e in ter-
can th al lin e, par t icularly in a param edian osteotom y. An
osteotom y sh ould be su cien tly com plete to m obilize th e
bony pyram id w h ile decreasing t issue t raum a as m uch as
possible to ach ieve opt im al consisten cy.
Th e au th or’s t ips for perform ing a safe osteotom y are
as follow s:
1. Do n ot m ake periosteal elevat ion over th e n asal
bon e too far laterally. Periosteal at tach m en t over th e
bon es provides st abilit y of bony fragm en ts.
2. Use th e sm allest possible osteotom e. Th is m in im izes
t raum a to th e soft t issue adh eren t to th e in tern al
su rface.
3. Feel th e sen sat ion of th e break th rough th e bon e
d uring tapping.
4. Avoid dam age to th e ju n ct ion bet w een th e u pper
lateral car t ilage (ULC) an d n asal bon es.
5. Use a “low -to-h igh ” or “high -low -h igh ” lateral
osteotom y to avoid com plicat ion s.
Midvault and Tip Deviations
Deviat ion of th e low er t w o-th ird s of th e n ose is th e m ost
com plex con dit ion . Many com bin ed path ologies of th e
cart ilage fram ew orks m ay coexist an d a ect each oth er.
Th e surgeon sh ould evalu ate aberran t an atom y during th e
operat ion . Th e m ain surgical procedures in clude th e cam -
ou age graft , st raigh ten ing of th e sept um along th e m id -
lin e, recon st ruct ion of th e an terior n asal spin e, xat ion of
th e deviated low er lateral car t ilage to th e n ew ly posit ion ed
sept u m , form ing a sym m et ric dom e, an d rebu ilding a rm
an d st raigh t colu m ella.
Nasal Septum
Th e m ost im port an t an d fun dam en tal procedure in cor-
rect ion of th e t w isted or crooked n ose is st raigh ten ing of
th e n asal car t ilagin ou s sept um w ith or w ith out rein force-
m en t .19 Deform ing forces cau sing sept al deviat ion m ay be
78 II Rhinoplast y

eith er in t rin sic or ext rin sic. Release of ext rin sic forces is
essen t ial to correct th e cart ilagin ou s sept al deform it y, an d
th ese preven t surgical failure or recu rren ce.20 Ext rin sic
forces m ay origin ate from th e u p per lateral cart ilage, bony
sept u m , n asal spin e, septal m u cosa, low er lateral car t i-
lage, an d colu m ellar soft t issu e. Th rough elim in ation of th e
e ect s of ext rin sic forces on e by on e, a d eviated sept u m can
be st raigh ten ed. If th e freely m obilized sept um sh ow s any
d eform it y, in t rin sic deform ing forces m ust be add ressed
an d corrected. In t rin sic forces can be released by w eaken -
ing th e car t ilage or th rough rein forcem en t w ith su t ures
an d graft s.
Th e sept um sh ould be st raigh ten ed w h ile m axim iz-
ing residual dorsal n asal su pp ort . With th ese t w o goals
in m in d, th e deviated port ion of th e sept u m sh ou ld be
resected w h ile p reser ving at least an 8- to 10-m m dorsal
Fig. 6.7 L-strut of septal cartilage. It is important to preserve the
an d cau dal L-st ru t (Fig. 6.7).21 Th e resect ion can in clu de
L-strut with at least an 8- to 10-m m width to prevent saddle nose
th e m a xillar y crest , th e perpen dicular plate of th e eth m oid,
deformit y. The size of the L-strut depends on the strength and sti -
an d th e vom er. In th e keyston e area, th e L-st ru t sh ou ld ness of the remaining septal cartilage.
rem ain at t ach ed to th e perpen dicular plate. In addit ion , th e
at t ach m en t bet w een th e n asal spin e an d th e caudal port ion
of th e L-st rut sh ould be preser ved if possible. If th e cau dal
sept u m is su blu xated from th e m idlin e of th e n asal sp in e,
th e sept um n eeds an atom ic correct ion w ith separat ion Th rough m et iculous dissect ion of th e m idvault in th e
from th e n asal spin e an d low er lateral car t ilage, follow ed su p rap erich on drial p lan e, th e n asal dorsu m is exp osed
by xat ion using a gure-of-8 su t ure tech n ique (Fig. 6.8). en ough to be evalu ated . After in t raop erat ive evalu at ion of
Variou s su rgical tech n iqu es can be ap p lied for st raigh t- any dorsal deform it ies an d cau sat ive factors for each an a-
en ing th e sept u m , in clu d ing th e sw inging door tech n iqu e, tom ic com pon en t , th e bilateral su bp erich on d rial d issect ion
w edge resect ion , bat ten graft , sp reader graft , cu t t ing an d of the sept um is exten ded to th e dorsal sept u m an d across
su t u re tech n iqu e, an d scoring an d su t u re tech n iqu e.22,23,24,25,26 th e upper lateral cart ilage w h ile preser ving m ucoperich on -
In com plex cases, ext racorp oreal septop last y m ay be an drial in tegrit y. Th e dissect ion sh ould be w ide en ough to
e ect ive, safe, an d reliable tech n iqu e, especially for m ark- align th e sept u m to th e m idlin e. Next , th e dorsal sept u m is
edly t w isted n oses u n dergoing su rger y.27,28 released from th e upper lateral cart ilage, an d th is en ables
evalu at ion an d assessm en t of any in t rin sic deform it y of th e
Middle Third dorsal sept um . In th e presen ce of dorsal sept al deviat ion , a
un ilateral or bilateral spreader graft m ay be th e t reat m en t
After th e st raigh ten ed n asal sept u m h as been align ed in of choice (Fig. 6.9).
th e m idlin e, th e m idvault m u st be recon st ructed to ach ieve Th e spreader graft acts to x th e dorsal sept um in to a
an aesth et ic an d fu n ct ion al ou tcom e. Using variou s sept al st raigh t orien t at ion an d p reven t late ret u rn of th e defor-
su p p or t ing grafts an d p recise su t u re tech n iqu e, th e m id- m it y. In addit ion , th e graft s can m ain t ain or restore th e
dorsu m sh ould be rm ly st raigh ten ed. in tegrit y of th e in tern al n asal valves. Th e ideal graft m ate-

Fig. 6.8 Repositioning of the dislocated caudal septum . When the caudal septum is subluxated, it is frequently necessary to separate
the cartilaginous septum from the underlying bone. Then disarticulated cartilage should be xed to the anterior nasal spine using sutures.

Fig. 6.9 Spreader graft. After separation of the upper lateral carti-
lage from the septal cartilage, a spreader graft is inserted and xed
using 4–0 PDS. This procedure is helpful in widening the air passage
as well as in cosmetic improvement of m iddle-third deviation.
rial is septal car t ilage, esp ecially th e p osteroin ferior p or-
t ion , w h ich h as th e m ost con sisten t w idth . Th e grafts are
secu red w ith several 5–0 PDS m at t ress su t u res p arallel to
th e dorsal sept u m . To decrease th e likelih ood of recurren ce,
th e deviated sept al cart ilage can be cross-h atch ed before
su t u ring. In th e case of ou t w ard bow ing of th e m idvau lt on
th e convex side of th e dorsum , a bat ten graft can be placed
below the jun ct ion of th e sept um an d upper lateral car t i-
lage. As sh ow n in Fig. 6.10, sligh t dorsal d eviat ion can be
st raigh ten ed th rough th e di eren t ial su t u re bet w een th e
u p p er lateral cart ilage an d septal d orsu m .29 Sim ilarly, th is
su t u re tech n iqu e can be u sed to correct rem n an t deviat ion
after a sp reader graft .30
a b
Fig. 6.10 Oblique suture to correct cartilaginous deviation. Compared with the horizontal suture, the di erentially oblique suture pro-
vides force to draw deviated septal cartilage to the midline. This technique can be used to correct the cartilaginous deviation (a) without
or (b) with a spreader graft.
6 Correction of the Deviated, Twisted Nose 79
Lower Third
As in th e m idvault , correct ion of low er-th ird deform it ies is
based on h ow to m ake a st raigh t an d st rong caudal sep -
t um . Deform ing forces from th e cart ilagin ous fram ew ork
of th e m idvault frequen tly a ect th e t ip; th erefore, a care-
fu l dissect ion is som et im es n eeded to det ach th e low er
lateral car t ilages from th e up per lateral cart ilage. If th e
caudal sept um is n ot in th e m idlin e, it sh ould be carefully
released from th e m axillar y crest an d an terior n asal spin e
an d a xed to th e m idlin e. Fu rth erm ore, if th ere is congen i-
tal deform it y or post t raum at ic ch ange of th e an terior n asal
spin e or m axillar y crest it self, th ese deform it ies sh ou ld be
preferen t ially corrected. Caudal deviat ion of th e sept um
can be e ect ively corrected w ith an exten ded spreader
graft or sept al bat ten graft u sing h ar vested car t ilagin ou s
an d bony sept u m .31
Th e n ext step is to create a rm ver t ical st ru t in th e
m idlin e. A sept al exten sion graft is u sefu l w h en th e t ip
is w eak or d eviated . It is e ect ive for obt ain ing a st raigh t
cau dal en d an d p rom in en t project ion . How ever, on e m u st
be carefu l to avoid fu n ct ion al n asal obst r u ct ion cau sed
by th e th icken ed cau dal sept u m , an d th e p at ien t sh ou ld
be in form ed of th e loss of exibilit y of t h e m em bran ou s
sept u m . Th e en d of th e sept al exten sion graft sh ou ld be
beveled an d is a xed to th e cau dal sept u m w ith m u lt i-
p le an ch oring su t u res. Th e sept al exten sion graft act s as
a reliable st ru t n ot on ly for su p p or t ing th e low er lateral
car t ilages, bu t also to con t rol t ip p osit ion an d de n it ion
(Fig. 6.11). Th e d egree of t ip p roject ion an d rot at ion , an d
t h e colu m ellar pro le an d st rengt h can be deter m in ed by
t h e size an d sh ape of t h e design ed graft an d th e p osit ion . A
m ore st able colu m ella recon st r u ct ion is obt ain ed th rough
t ight xat ion of each of th e m iddle an d m edial cr u ra to th e
septal exten sion graft .
80 II Rhinoplast y
Fig. 6.11 Septal extension graft to correct the caudal deviation.
The septal extension graft is a very useful technique to correct cau-
dal deviation when the tip is weak and resilient.
Th e sym m et r y of th e lateral crus an d dom es sh ould
be evaluated an d properly corrected. Th e in terdom al liga-
m en t is su t u red to th e dom al segm en t of th e sept u m or th e
exten sion graft . Th e a xat ion sh ou ld be adju sted for ideal
sym m et r y of each d om e. Th e cep h alic border of th e lateral
cru s can be t rim m ed to be in lin e w ith th e pro le con tou r
of th e exten sion graft .
Wound Closure and Dressing
If an extern al app roach is ap plied, th e colu m ella in cision
sh ou ld be rep aired rst . Su bcu t an eou s ap p roxim at ion w ith
5–0 vicr yl sh ould be follow ed by m et icu lou s skin closure
w ith 6–0 nylon . Several quilt ing sut ures are n eeded on
th e dissected m ucoperich on drial ap, an d a sm all m uco-
sal in cision can be m ade on on e side of th e sept u m to p re-
ven t septal h em atom a, if n eeded. In tern al sp lin t s, su ch as a
silast ic sh eet , can be ap plied to avoid h em atom a bet w een
th e m ucoperich on drial aps an d to st abilize the recon -
st ru cted st ru ct u res, w h ich p rom otes th e h ealing process
an d preven t s m u cosal p roblem s like syn ech iae. A single
th rough -an d-th rough sut ure is su cien t to x th e splin t
to th e sept u m . Prophylact ic an t ibiot ics are n eeded w h ile
th e splin t is in place. Splin t s are gen erally rem oved 1 to 2
w eeks after su rger y in th e ou t pat ien t depart m en t . In cases
of exten sive sept al recon st ruct ion , th e splin t s rem ain in
place for longer periods (u p to 3 w eeks). Soft n asal packing
(e.g., NasoPore, Gelfoam ) is en ough to con t rol bleeding an d
to su p p or t a ap or graft . Packing is rem oved w ith in 1 to 2
days. Extern al dressings are com posed of soft t issue t aping
an d an extern al sp lin t . After skin prep arat ion w ith alcoh ol
an d skin ad h esive, th e n asal dorsu m is t aped w ith ¼-in ch
paper tape. St rips of di eren t length s are carefully applied
t ran sversely from th e bony dorsum to th e suprat ip w h ile
avoiding excessive pressu re over th e recon st ructed fram e-
w ork. Sym m et ric long st rip s are ap plied from th e bony dor-
su m along th e cau dal asp ect of th e n asal lobu le to su p port
th e t ip. An extern al splin t is applied for pat ien t s w h o h ave
u n dergon e osteotom ies to su ppor t th e reposit ion ed st ru c-
t ures an d to con t rol bon e bleeding. Th e splin t is placed over
th e u pper t w o-th irds of th e dorsum w h ile com pressing
m edially. Th e low er m argin of th e splin t sh ou ld n ot exten d
over th e su p rat ip area to avoid dead sp ace bet w een th e
su p rat ip skin an d th e u n derlying fram ew ork. After 5 to 7
days, colum ellar sut ures, skin t ape, an d th e extern al splin t
are gen tly rem oved.
■ Postoperative Management
Prophylact ic an t ibiot ics are used w h ile th e n asal splin t
is ap plied. Sh ort-term , h igh -dose steroids can be u sed
in t raoperat ively an d postoperat ively to m in im ize w ou n d
edem a. Gen erally, pat ien t s w h o h ave u sed an t icoagu lan t s
are in st ru cted to stop th e m edicat ion for 1 w eek p reop -
erat ively an d can begin th e m edicat ion 5 to 7 days p ostop -
erat ively. An algesics for p ostop erat ive p ain are p rescribed
as n eed ed . Pat ien ts sh ou ld avoid st rain ing related to con -
st ip at ion or n au sea, an d prop hylact ic m edicat ion for th e
causes of st rain ing sh ould be prescribed as n eeded. An t i-
biot ic oin t m en t sh ould be applied to th e in cision site daily.
Salin e n asal sp ray is u sed th ree to fou r t im es daily to keep
m u cosal su rfaces m oist an d clean . Pat ien t s sh ou ld avoid
su n exposu re to facial bru ises to p reven t skin p igm en tat ion .
At a m in im u m , pat ien t s sh ou ld be seen in follow -u p at 1
w eek, 1 m on th , 3 m on th s, an d 6 m on th s, an d p ostopera-
t ive m edical ph otography sh ould be obt ain ed. Th ereafter,
pat ien t s sh ould be evaluated ever y 1 to 2 years to assess
long-term result s.
■ Key Technical Points
1. Th e deviated n ose con sists of a bony upper th ird
an d cart ilagin ou s low er t w o-th irds, an d each
com par t m en t sh ould be assessed con sidering
di eren t su rgical con cept s an d tech n iqu es.
2. Th e ch oice of approach depen ds on a surgical plan
th at is based on an accurate preoperat ive clin ical
an alysis.
3. Th e m idvault an d t ip are dissected in th e
su p rap erich on drial plan e, an d th e bony dorsu m
requires subperiosteal dissect ion .
4. Precise osteotom y is a key procedure for correct ing
bony pyram idal deform it ies.

5. In correct ion of th e t w isted n ose, st raigh ten ing an d
rein forcem en t of th e n asal car t ilagin ou s sept um
are th e m ost im port an t p rocedu res. For th is, th e
sept u m sh ou ld be released from ext rin sic d eform ing
forces, w ith su bsequ en t assessm en t of th e in t rin sic
d eform it ies, w h ile preser ving th e L-st rut .
6. The in tegrit y of th e keyston e area m ust be
m ain t ain ed an d th e cau dal en d of th e L-st ru t sh ou ld
be rm ly a xed to th e an terior n asal spin e using
a gu re-of-8 su t u re. If th e an terior n asal sp in e is
d isp laced, it sh ou ld be rep osit ion ed.
7. A spreader graft is a usefu l tool for sim ultan eous
st raigh ten ing an d rein forcem en t of th e car t ilagin ou s
d orsu m .
8. Tip correct ion is based on a st raigh t an d st rong
caudal sept u m as a reliable ver t ical st rut in th e
m idlin e.
9. The a xat ion of low er lateral car t ilages sh ould be
adju sted for ideal sym m et r y of each dom e at th e
m idlin e.
10. The colum ellar in cision sh ould be repaired w ith
m et icu lou s su t u ring w ith ou t ten sion .
■ Complications and
Their Management
Bleeding/ Hematoma
Sligh t postop erat ive oozing is com m on in th e rst 48 h ou rs
after rh in op last y. Toilet gau ze d ressing is h elp fu l to redu ce
pat ien t discom fort , an d h ead elevat ion can reduce bleed-
ing by decreasing ven ous pressu re. If bleeding persists, th e
su rgeon sh ou ld im m ediately evalu ate th e w ou n d. W h en
fu rth er n asal p acking is n ot en ough to con t rol bleeding, th e
su rgeon sh ou ld con sider tot al rem oval of p acking m ate-
rials an d reevalu at ion of th e n asal cavit y. A pat ien t w h o
com plain s of un con t rolled n asal pain sh ould be assessed
for sept al h em atom a. Regardless of locat ion , postoperat ive
h em atom as requ ire im m ediate drain age. An u n t reated sep -
tal h em atom a can result in devastat ing com plicat ion s, such
as sept al abscess an d p erforat ion . In ser t ion of a silast ic
drain in to th e drain age site of th e h em atom a h elps preven t
recurren ce.
Persistent Edema
Postop erat ive edem a u su ally occu rs w ith in th e rst 4
w eeks. Variou s m odalit ies are available to m in im ize edem a,
in clu ding cold com presses, h ead elevat ion , t aping, an d
perioperat ive steroids. Late edem a can be obser ved several
m on th s postop erat ively, an d it origin ates from ongoing scar
rem odeling. Most late edem a is self-lim ited arou n d th e rst
6 Correction of the Deviated, Twisted Nose 81
year after su rger y; th erefore, th e pat ien t sh ou ld be given
reassu ran ce. In som e cases w ith excessive scarring, local
steroid (t riam cin olon e acetate) inject ion m ay be h elpfu l.
Su p er cial inject ion sh ou ld be avoided to preven t w h it ish
pigm en t at ion . Of n ote, steroid inject ion can resu lt in sub -
derm al at rophy w ith subsequen t u n desirable problem s,
in cluding dorsal con tour deform it ies an d t ran slu cen cy of
th e epiderm is.
Dorsal Irregularity/ Deviation
In som e p at ien ts, dorsal deviat ion or irregu larit y can pres-
en t d u ring th e p ostoperat ive p eriod. Th e cau se an d degree
of deform it ies sh ould be evaluated to determ in e w h eth er
revision surger y is n eeded. Com m on causes of late bony
deviat ion are listed below. Im m ediate postoperat ive devia-
t ion sh ould be reassessed as soon as possible, an d m in or
deform it ies in th e early postoperat ive period can be cor-
rected w ith m an ual pressure. If revision is required, it can
be don e 6 to 12 m on th s after th e prim ar y surger y.
Causes of late deviation of the bony
pyramid include :
• In com p lete osteotom ies: in com p lete con n ect ion
bet w een th e m edial an d lateral osteotom ies.
Mem or y of th e overlying soft t issu e can p u ll th e
n asal bon e to th e origin al posit ion .
• In com p lete correct ion of th e p osterior–su p erior
de ect ion of th e bony sept um .
• In su cien t correct ion of deform it ies of th e
cart ilagin ous low er t w o-th irds.
■ Case Studies
Case 1
A 22-year-old m an presen ted w ith a crooked n ose th at
had a C-sh aped deform it y of th e sept u m to th e righ t w ith
su bject ive n asal obst ru ct ion on th e righ t side. Th e brow t ip
aesth et ic lin es w ere asym m et ric, an d th e bony an d cart i-
lagin ou s d orsu m w as o th e m idlin e (Fig. 6.12).
Th is case required correct ion s of both th e bony dorsum
an d th e m idvau lt; th erefore, op en correct ive rh in oplast y
w as perform ed. Th e au th or p refers to u se th e extern al
ap proach to correct th e low er t w o-th irds deviat ion , w h ich
usu ally n eeds a spreader graft or septal exten sion graft .
Th rough th e extern al approach th e auth or can con den tly
ap ply graft m aterials as w ell as evalu ate th e an atom ic
82 II Rhinoplast y

abn orm alit ies. In term s of order of procedu res, septoplast y
is carried ou t rst after elevat ion of th e skin soft t issu e
envelop e. If th ere is a h u m p deform it y, rasp ing or h u m p ec-
tom y is don e. Th e n ext step is to correct th e low er t w o-
th irds deform it ies using graft ing an d sut ure tech n iques.
This is follow ed by t ip surger y, w h ich is m ain ly for cosm et ic
p u rposes. Medial an d lateral osteotom ies are usually don e
at th e en d of th e operat ion to avoid soft t issu e sw elling du r-
ing su rger y. In cases w ith a w ide alar base, its correct ion
w ill be th e n al procedu re.
In th is case, su rgical tech n iqu es in clu ded lateral an d
m edial osteotom ies, release of th e cart ilagin ou s sept u m
from th e u pp er lateral car t ilage, a left-sided sp read er graft ,
septoplast y, rep osit ion ing an d rein forcem en t of th e cau -
dal sept al L-st rut w ith a gu re-of-8 su t ure an d colu m ellar
st rut , ceph alic t rim of th e low er lateral car t ilage, an d in ter-
dom al su t ure on th e t ip. Th e pat ien t w as sat is ed w ith th e
fu n ct ion al an d aesth et ic ou tcom es after su rger y.
At 1 year after th e su rger y, th e dorsu m h ad a sym m et-
ric con tou r w ith ou t any p ostop erat ive distor t ion .

a b

c d

Fig. 6.12 Case 1. (a,b) Preoperative frontal and bird’s-eye views show a C-shaped deviated bony and cartilaginous dorsum. (c,d) Postop-
erative photographs show a straightened nose.

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 6 Correction of the Deviated, Twisted Nose 83

Fig. 6.12 (Continued) (e) Surgical diagram showing the techniques used.

Case 2 By m ean s of an extern al approach , th e h um p w as

A 27-year-old w om an presen ted w ith a n asal d eform it y
w ith out any h istor y of n asal t raum a or surger y. Her ch ief
com plain t w as a deviated n ose w ith sligh t n asal st u n ess
on th e righ t side. As sh ow n in preoperat ive m edical ph otog-
raphy, h er bony dorsu m w as st raigh t bu t h ad a sm all h um p
an d th e m idvau lt w as deviated to th e righ t side (Fig. 6.13).
rem oved u sing rasping, an d a left-sided exten ded spreader
graft an d in terdom al su t u re w ere u sed to st raigh ten th e
m idvau lt an d t ip . Th e sept al d eviat ion w as corrected w ith a
caudal w edge excision of th e sept um .
Ph otograp h s taken 14 m on th s after su rger y sh ow sym -
m etric brow t ip aesth et ic lin es an d a w ell-p osit ion ed dor-
su m in th e m idlin e.

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84 II Rhinoplast y

a b c

d e f

Fig. 6.13 Case 2. (a–c) Preoperative photographs show straight bony pyramid but deviated cartilaginous dorsum with mild hump. (d–f)
Postoperative photographs show well-aligned dorsum with reduced hump.

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 6 Correction of the Deviated, Twisted Nose 85

Fig. 6.13 (Continued) (g ) Surgical diagram showing techniques used.

http://e-surg.com
86 II Rhinoplast y
References
1. Roxbur y C, Ish ii M, Godoy A, et al. Im pact of crooked n ose
rh in oplast y on obser ver p ercept ion s of at t ract iven ess. La-
r yngoscop e 2012;122(4):773–778
2. Cingi C, Eskiizm ir G. Deviated nose at ten uates th e de-
gree of pat ien t sat isfact ion an d qu alit y of life in rh in o-
p last y: a p rospect ive con t rolled st u dy. Clin Otolar yngol
2013;38(2):136–141
3. Hafezi F, Nagh ibzadeh B, Nouh i A, Yavari P. Asym m et ric fa-
cial grow th an d deviated n ose: a n ew con cept . An n Plast
Su rg 2010;64(1):47–51
4. Pot ter JK. Correct ion of th e crooked n ose. Oral Maxillofac
Su rg Clin North Am 2012;24(1):95–107
5. Ch o GS, Kim JH, Yeo NK, Kim SH, Jang YJ. Nasal skin th ick-
n ess m easured using com puted tom ography an d it s ef-
fect on t ip su rger y outcom es. Otolar yngol Head Neck Surg
2011;144(4):522–527
6. Stepn ick D, Guyu ron B. Surgical t reat m en t of th e crooked
n ose. Clin Plast Su rg 2010;37(2):313–325
7. Din i GM, Iurk LK, Ferreira MC, Ferreira LM. Graft s
for st raigh ten ing deviated n oses. Plast Recon st r Surg
2011;128(5):529e–537e
8. Sh ipchan dler TZ, Papel ID. Th e crooked n ose. Facial Plast
Su rg 2011;27(2):203–212
9. Bagh eri SC, Khan HA, Jah angirn ia A, Rad SS, Mort azavi H.
An an alysis of 101 prim ar y cosm et ic rh in op last ies. J Oral
Maxillofac Su rg 2012;70(4):902–909
10. Jang YJ, Wang JH, Lee BJ. Classi cat ion of th e deviated
n ose an d it s t reat m en t . Arch Otolar yngol Head Neck Surg
2008;134(3):311–315
11. Boh lu li B, Moh aram n ejad N, Bayat M. Dorsal h u m p su rger y
an d lateral osteotom y. Oral Maxillofac Surg Clin North Am
2012;24(1):75–86
12. Higu era S, Lee EI, Cole P, Hollier LH Jr, St al S. Nasal t rau m a
an d th e deviated n ose. Plast Recon st r Surg 2007;120(7,
Su p pl 2):64S–75S
13. Toriu m i DM. St ru ct u re ap proach in rh in op last y. Facial Plast
Su rg Clin North Am 2005;13(1):93–113
14. Harsh barger RJ, Su llivan PK. Th e opt im al m ed ial osteoto-
m y: a st u dy of n asal bon e th ickn ess an d fract u re p at tern s.
Plast Recon st r Su rg 2001;108(7):2114–2119, discu ssion
2120–2121
15. Harsh barger RJ, Su llivan PK. Lateral n asal osteotom ies: im -
p licat ion s of bony th ickn ess on fract u re pat tern s. An n Plast
Su rg 1999;42(4):365–370, discu ssion 370–371
http://e-surg.com
16. Gr yskiew icz JM. Visible scars from percu t an eou s osteoto-
m ies. Plast Recon st r Su rg 2005;116(6):1771–1775
17. Bloom JD, Im m erm an SB, Con st an t in id es M. Osteoto-
m ies in th e crooked n ose. Facial Plast Su rg 2011;27(5):
456–466
18. Jang YJ, Alfan t a EM. Rh in op last y in th e Asian n ose. Facial
Plast Su rg Clin North Am 2014;22(3):357–377
19. Sykes JM, Kim JE, Sh aye D, Boccieri A. Th e im port an ce of
th e n asal sept u m in th e deviated n ose. Facial Plast Su rg
2011;27(5):413–421
20. Roh rich RJ, Adam s W P Jr. Nasal fract u re m an agem en t:
m in im izing secon dar y n asal d eform it ies. Plast Recon st r
Surg 2000;106(2):266–273
21. Roh rich RJ, Gu n ter JP, Deu ber MA, Adam s W P Jr. Th e de-
viated n ose: opt im izing results using a sim pli ed clas-
si cat ion an d algorith m ic approach . Plast Recon st r Surg
2002;110(6):1509–1523, discu ssion 1524–1525
22. Jang YJ, Yeo NK, Wang JH. Cu t t ing an d su t u re tech n iqu e
of the caudal sept al cart ilage for th e m an agem en t of cau-
dal sept al deviat ion . Arch Otolar yngol Head Neck Su rg
2009;135(12):1256–1260
23. Pastorek NJ, Becker DG. Treat ing th e cau dal sept al de ec-
t ion . Arch Facial Plast Su rg 2000;2(3):217–220
24. Sh een JH. Spreader graft: a m eth od of recon st ru ct ing th e
roof of th e m iddle n asal vau lt follow ing rh in oplast y. Plast
Recon st r Su rg 1984;73(2):230–239
25. Roh rich RJ, Hollier LH. Use of sp reader graft s in th e exter-
n al approach to rh in oplast y. Clin Plast Surg 1996;23(2):
255–262
26. Byrd HS, Salom on J, Flood J. Correct ion of th e crooked n ose.
Plast Recon st r Su rg 1998;102(6):2148–2157
27. Lee SB, Jang YJ. Treat m ent outcom es of ext racorporeal sep -
toplast y com pared w ith in sit u sept al correct ion in rhino-
plast y. JAMA Facial Plast Surg 2014;16(5):328–334
28. Gu bisch W. Ext racorp oreal septoplast y for th e m ark-
edly deviated sept um . Arch Facial Plast Surg 2005;7(4):
218–226
29. Pon t iu s AT, Leach JL Jr. New tech n iqu es for m an agem en t
of th e crooked n ose. Arch Facial Plast Surg 2004;6(4):
263–266
30. Guyu ron B, Beh m an d RA. Cau dal n asal deviat ion . Plast
Recon st r Surg 2003;111(7):2449–2457, discussion 2458–
2459
31. Byrd HS, An doch ick S, Copit S, Walton KG. Sept al exten sion
graft s: a m eth od of con t rolling t ip project ion shape. Plast
Recon st r Su rg 1997;100(4):999–1010
7 Correction of the Saddle Nose
Keng Lu Tan and Chae-Seo Rhee
Pearls
• Evalu at ion of th e degree of sept al su p p or t is th e
m ost im p or tan t step in p reop erat ive p lan n ing in a
pat ien t w ith saddle n ose deform it y. Th is is becau se a
sadd le n ose is often du e to a dam aged car t ilagin ou s
sept u m .
• Class 1 saddle n ose has good cart ilagin ous sept al
su p p or t w ith a m in or su p ra-t ip dep ression . Th is can
be easily corrected by cosm et ic dorsal cam ou age.
• Class 2 saddle n ose has m oderate loss of sept al
cart ilagin ous support w ith m oderate dorsal
depression , w h ich can be m an aged by rein forcem en t
an d recon st it u t ion of th e sept u m an d/or dorsu m .
• Class 3 saddle n ose has severe loss of septal
cart ilagin ous support w ith a m oderate to severe
■ Introduction
Nasal deform it ies a ect ing m ain ly th e low er t w o-th ird s of
th e n ose due to th e loss of sept al h eigh t an d t ip support
are d e n ed as “sadd le n ose” d eform it ies (Fig. 7.1). A sad -
dle n ose w as rst described by Joh n Orlan do Rose in 1887
as a “p ug n ose.” A p ug is a kin d of can in e w ith an alm ost
com plete absen ce of a sn out or n asal dorsum . Th e depres-
sion n oted on th e m iddle vau lt of th e n asal dorsal su rface
resem bles th e saddle of a h orse—h en ce th e term saddling.
Com plex deform it ies of th e n asal sept um can h ave both
an aesth et ic an d a fu n ct ion al im p act on a p at ien t’s n ose.
If th ere is a severe com prom ise of th e cart ilagin ou s sept al
in tegrit y w ith su bsequen t loss of m iddle vault su pp ort by
th e sept u m , dorsal depression develops, follow ed by loss
of t ip de n it ion an d oth er associated feat u res (Fig. 7.2
an d Fig. 7.3).1,2 Th is kin d of n asal deform it y is often ver y
d ist ressing to th e pat ien t as th e deform it y is obvious an d
u n at t ract ive. Fun ct ion ally, pat ien t s can com p lain of n asal
obst ruct ion due to th e collapse of th e in tern al n asal valve.
W h ile saddle n ose deform it y is caused by th e loss
of septal su pport an d sh ow s a t ru e loss of dorsal h eigh t ,
a pseu do sad dle is a relat ive depression of th e su prat ip
region cau sed by a h u m p n ose. For correct ion , a saddled
n ose requ ires th e recon st ru ct ion of th e sca old of th e dor-
su m —for in stan ce, th e sept u m —bu t a pseu do saddle n eed s
to h ave th e h um p resected to allow th e suprat ip region to
look n orm al again .
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dorsal depression . Subtotal sept al recon st ruct ion
w ith cost al car t ilage sh ou ld be adm in istered to
correct th is saddle deform it y.
• Class 4 saddle n ose has severe loss of septal
cart ilagin ous support w ith both bony an d
cart ilagin ous dorsal depression , in w h ich case th e
dorsal fram ew ork from th e radix to th e t ip n eeds to
be tot ally recon st ructed w ith cost al cart ilage.
• Correct ion frequen tly requires st raigh ten ing or
recon st it u t ing th e L-st ru t . A st able L-sh aped st rut
of sept al car t ilage to th e n asal spin e is crucial to
su p p or t th e u p per an d low er lateral cart ilages to
m a xim ize th e resu lts in creat ing a st raigh t an d
fu n ct ion al n ose.
■ Anatomic Considerations
Saddling of th e n ose is essen t ially cau sed by th e loss of
nasal sept al support for th e dorsum of th e n ose. Support of
th e n asal dorsum is provided by th e cart ilagin ous an d bony
st ru ct u res involved in n asal project ion . Th e n ose is d ivid ed
in to th e upper, m iddle, an d low er th irds, com m on ly know n
also as th e u pp er, m iddle, an d low er vau lt s.
Th e upper th ird is supported by th e pyram id of th e
nasal bon e. Th e in terlocking of th e quadrangular cart ilage
w ith th e n asal bon e form s th e keyston e area, w h ich is th e
key area th at sh ou ld be p reser ved to p reven t th e collap se
of th e saddling of th e dorsum an d creat ion of th e inver ted-
V dorsal deform it y (Fig. 7.2). Th e qu adrangu lar car t ilage is
th e single m ost im por t an t car t ilage th at support s th e low er
t w o-th ird of th e nose, in clu ding th e n asal dorsum an d th e
paired upper an d low er lateral cart ilages. Most of th e et i-
ologies m en t ion ed above disrupt th e in tegrit y of th is cart i-
lage to cau se saddle n ose deform it y. Th erefore, correct ion
of th e saddle n ose deform it y usually, if n ot alw ays, cen ters
on recon st ruct ing an d reest ablish ing th e st rength of th e
quadrangular cart ilage.
Th e paired upper lateral cart ilages con st it u te th e lat-
eral side of th e m iddle vau lt . Th e angle form ed by th e u p p er
lateral car t ilage an d th e n asal sept um is th e in tern al n asal
valve. Sin ce th e st rength of th e u p per lateral car t ilages
relies h eavily on th e n asal sept um , loss of support in th e
nasal sept um w ill resu lt in collapse of th e in tern al n asal
87
88 II Rhinoplast y

Fig. 7.1 Saddle nose and pseudo saddle.

a b
(a) Saddle nose shows loss of dorsal height
and support of the underlying nasal sep-
tal structures with upward rotated tip.
(b) As opposed to the presence of saddle,
the depression is due to an abnormal pro-
trusion over the dorsum rather than a true
depression itself.

Fig. 7.2 The keystone area and saddle. (a) Quadrangular cartilage, as seen in the illustration,
forms the single most important support structure for the nasal dorsum. The area of overlap-
ping with the nasal bone and upper lateral cartilage, the keystone area, deserves particular
attention. (b) When the keystone area is interrupted, it causes instabilit y to the quadrangular b
cartilage and thus saddling of the nasal dorsum, with a resulting inverted-V deformit y.

valve. Rect ifying a saddle n ose w ith ou t addressing th is area

w ill leave fu n ct ion al problem s such as n asal obst ruct ion .
Low er lateral cart ilages de n e th e tip an d are also sup -
ported by the septal cartilage. Loss of heigh t an d w idth of
the septal cart ilage w ill cause m isalignm ent of th e low er
lateral cartilages, result ing in loss of tip de nit ion, t ip ptosis,
cephalic rotat ion, and retrusion of the colum ella (Fig. 7.3).
■ Etiology of Saddle Nose
In recen t years, m ost sadd le n ose d eform it ies h ave com e
from t rau m a, an d from n asal su rgeries, in clu ding septo-
plast y an d rh in oplast y. In am m ator y diseases w ere com -
m on cau ses in th e p ast .2,3

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 7 Correction of the Saddle Nose 89

a b

Fig. 7.3 Loss of support of the nasal septum causes distortion of the lateral cartilages. (a,b) Considerable loss of septal support causes
the upper and lower lateral cartilage to distort. (c) Saddling of middle vault, tip ptosis with cephalic rotation, and columellar retrusion will
develop.

Trauma Systemic Diseases

Trau m a m ay physically dest roy th e cart ilagin ou s or bony
st ru ct u res of th e d orsu m an d th e n asal sept u m . Post t rau -
m at ic h em atom a in th e n asal sept u m m ay be a cau se of
sept al dest ru ct ion or p erforat ion du e to h em atom a orga-
n izat ion an d resorpt ion or in fect ion an d abscess form at ion
secon dar y to th e h em atom a. Saddle deform it y after t rau m a
is u su ally accom pan ied by a deviated n ose, septal deviat ion ,
an d n asal valve collapse.
System ic diseases such as gran ulom atous diseases an d
au toim m u n e diseases m ay com prom ise th e in tegrit y of
th e n asal su pport ing st ruct ures an d cause saddle n ose
deform it y. Gran ulom atous diseases such as Wegen er’s
gran u lom atosis; in fect ion su ch as lep rosy an d syp h ilis; an d
au toim m u n e diseases su ch as relap sing polych on drit is, sar-
coidosis, an d Croh n’s disease m ay dest roy th e septal car t i-
lage along th e disease process du e to ch ron ic in am m at ion .

Iatrogenic Factors Malignancy

Sa d d le n ose cou ld a lso b e a se con d ar y d efor m it y d u e
t o resor p t ion or a p rob le m at ic im p lan t u se d in n a sa l
se p t u m or n a sa l d or su m re con st r u ct ion , esp e cia lly if
t h e keyst on e a rea is in flict e d d u r in g se p t op la st y or rh i-
n op last y. Ove r - rese ct ion of t h e qu a d ra n gu la r ca r t ilage
cau sin g w ea ke n in g of t h e se p t a l ca r t ilage d u r in g su r ge r y
cou ld resu lt in sa d d lin g. It is t h e refore im p or t an t t o p re -
se r ve at le ast 10 m m of t h e d or sal a n d ca u d al p a r t of t h e
qu a d ran gu la r ca r t ilage w h e n cu t t in g t h e n a sa l se p t u m .
Som et im es sa d d lin g ca u se d by n a sa l su rge r y w ill n ot b e
ap p are n t im m e d iat ely a ft e r t h e su r ge r y b u t w ill slow ly
m an ifest ove r t im e.
NK-T-cell lym p h om a, squ am ou s cell carcin om a, m align an t
m u cosal m elan om a, aden ocarcin om a, m in or salivar y glan d
t um ors, an d m etast at ic lesion s are just som e of th e m alig-
nan cies kn ow n to dest roy st ruct ures th at provide dorsal
su p p or t to th e n ose, in du cing saddling.
Vascular Ischemia of the Nasal Septum
A classical cau se of saddling is sept al p erforat ion du e to
cocain e abuse, secon dar y to th e repeated an d sustain ed
act ion of su cking in cocain e th rough th e n ose. Isch em ia to

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90 II Rhinoplast y
th e n asal septal vasculat u re w ill even t ually result in a large
sept al perforat ion , especially in th e cart ilagin ou s p or t ion ,
an d collap se of th e dorsu m . Sim ilar assau lt to th e n asal sep -
t um could be caused by prolonged use of oxym et azolin e
n asal sp ray or oth er vasocon st rict ive agen ts.
■ Patient Evaluation
Assessment of the Patient
Histor y of t rau m a, previou s su rger y, system ic diseases,
u se of a top ical vasocon st rictor, an d cocain e abuse sh ould
be elicited. Det ails of previous su rger y an d th e surgical
m an ip u lat ion cou ld give in sigh t in to th e available rem n an t
cart ilage an d st ruct ural de cien cy th at h as resulted in th e
sadd ling.
Proper con sult at ion w ill st art w ith th orough an atom ic
evalu at ion for factors th at could a ect th e n asal deform i-
t ies. Carefu l palpat ion an d in spect ion can reveal th e rela-
t ion am ong th e st ruct ural deform it ies in cluding th e n asal
sept u m , car t ilagin ou s an d bony dorsu m , t ip , n asal valve,
an d t u rbin ate. Th e resist an ce an d resilien ce of cart ilage
sh ou ld be evalu ated in accordan ce w ith th e st rength an d
sh ape of th e t ip an d cau dal sept u m . Descript ion of th e n ose
sh ou ld be m ad e from all angles. In th e p h otos, th e lateral
n asal length , th e degree of depression , th e presen ce of col-
u m ellar ret ract ion , an d th e degree of t ip rot at ion /derot a-
t ion sh ould be carefully n oted.
In gen eral, saddle n ose sh ow s a broad d orsu m , w ide
base, an d inver ted-V deform it y in case of keyston e area
dam age on fron tal view. Lateral an d oblique view s reveal
low er pro le dorsum , saddling, ret racted an d sh ort colu -
m ella, low p roject ion of th e t ip , an d cep h alic rot at ion in
severe cases. Th e basal view reveals a low t ip, rou n d an d
ared n ost rils, sh or t colu m ella, an d w id e base (Fig. 7.3).
Th e presen ce of a dorsal h um p th at gives rise to a saddled
ap pearan ce m u st n ot be con fu sed w ith p seu do saddle.
Nasal cavit y evalu at ion sh ou ld be perform ed also.
Sept al evalu at ion is crit ical for evalu at ion of t rau m at ic
deform ed n ose. Som et im es overlapping fract ured car t ilage
an d rep lacem en t of scar t issu e in th e a ected car t ilage or
fract u re lin es can m ake sept al m u cosa elevat ion di cu lt .
Nasal valve obst ru ct ion sh ou ld be assessed clin ically fol-
low ed by acoust ic rh in om et r y or rh in om an om et r y tests,
w h ich could docu m en t an d assess th e level of obst ruct ion
prior to th e surger y. Th e availabilit y of sept al cart ilage, sep -
tal perforat ion , an d any deviat ion sh ould be carefully n oted
during en doscopic exam in at ion to facilitate plan n ing of th e
su rger y. If en doscopic n dings suggest oth er m edical p rob-
lem s cau sing th e loss of septal cart ilage, be sure th at th e
pat ien t is screen ed for autoim m un e or in fect ious diseases,
as previou sly discu ssed, before th e rep air is p lan n ed .
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After extern al an d in tern al exam in at ion , discu ssion
about th e p referred sou rces of graft s is m an dator y. Pat ien t s
sh ould be given th e ch oice of au tologou s, h om ologou s, or
syn th et ic graft s dep en d ing on th e circu m st an ces after th e
pros an d con s of each opt ion h ave been discussed. Rib cage
view s cou ld be n ecessar y if rib cart ilage graft ing is p lan n ed .
Most p at ien t s w an t to correct th e both cosm et ic an d
fu n ct ion al p roblem s. On som e occasion s, a pat ien t m ay
request a h igh er project ion an d a bet ter-de n ed t ip com -
pared w ith th e prem orbid n ose. Th erefore, a realist ic con -
su ltat ion sh ou ld be carried ou t w ith th e pat ien t .
Classi cation of Saddle Nose
Deformity
Saddle n ose can be classi ed in to fou r grou ps th at w ill
determ in e th e repair of th e n ose.3 Un derst an ding an d h av-
ing a m ap of th e deform it y involved is th e rst step to plan -
n ing for a su ccessfu l ou tcom e.
Class 1: Good cart ilagin ou s septal su p port w ith a
m in or su p ra-t ip d ep ression . Th is can be easily
corrected by cosm et ic dorsal cam ou age (Fig. 7.4a).
Class 2: Moderate loss of sept al cart ilagin ou s su pp ort
w ith m oderate dorsal depression , w h ich can be
m an aged by sept al rearrangem en t , recon st it u t ion ,
rein forcem en t of th e sept um , an d recon st ruct ion of
th e n asal dorsum (Fig. 7.4b).
Class 3: Severe loss of sept al car t ilagin ou s su p port
w ith m oderate to severe dorsal depression . Th is
deform it y calls for su btot al septal recon st ruct ion
(Fig. 7.4c).
Class 4: Severe loss of sept al car t ilagin ou s su p port
w ith both bony and car t ilagin ous dorsal depression ,
in w h ich case a dorsal on lay graft an d exten ded
colum ellar st ru t m ust be totally recon st ructed
w ith cost al car t ilage. Th is can bypass th e septal
recon st ruct ion . Th e exten ded colum ellar st rut
n eeds to be st abilized to th e an terior n asal sp in e
(Fig. 7.4d).
■ Surgical Techniques
Plan n ing for th e rep air of a sadd le n ose begin s w ith a m et ic-
ulous assessm en t . Treat m en t of th e un derlying causat ive
m edical con dit ion sh ou ld be com plete or at least th e bony
an d th e car t ilagin ou s st ru ct u re of th e n ose sh ou ld h ave sta-
bilized in it s deform it y before surgical repair is un der t aken .
Su rgical in ter ven t ion largely depen ds on th e degree of th e
sadd ling according to th e classi cat ion system m en t ion ed
previously.

a b
c d
Class 1 Saddling
On ly sim p le cam ou age on th e su p ra-t ip area u sing sept al
or con ch al car t ilage, soft t issue or fascia is recom m en ded
for saddles in th is class. It can be ach ieved by en don asal
tech n iqu es. In th in -skin n ed in dividuals, cam ou age graft s
u sing cart ilage sh ould be sligh tly bruised or crush ed to
preven t graft visibilit y th rough th e skin con tou r. In th ick-
skin n n ed in d ivid u als, bet ter-de n ed graft s m ay be n ec-
essar y in get t ing a d esired ou tcom e, or oth er w ise som e
su bcu tan eou s t issu e can be t rim m ed from th e overlying
soft t issu e cover. Pocket s of su bcu tan eou s t issu e of exact
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7 Correction of the Saddle Nose 91
Fig. 7.4 Four t ypes of saddle nose defor-
mit y. (a) Class 1: Good cartilaginous septal
support with a minor supra-tip depression.
(b) Class 2: Moderate loss of septal car-
tilaginous support with moderate dorsal
depression. (c) Class 3: Severe loss of sep-
tal cartilaginous support with moderate
to severe dorsal depression. (d) Class 4:
Severe loss of septal cartilaginous support
with both bony and cartilaginous dorsal
depression.
size sh ou ld be created for in sert ion of th e cam ou age
graft s to en su re th e graft st ays at w h ere it sh ou ld be. Dis-
placem en t of th e cam ou age graft an d distor t ion of th e
n al sh ap e w ill resu lt if th e size of th e p ocket created is
im precise.
Class 2 Saddling
In class 2 saddling, there is often loss of cartilaginous sep -
t um stabilit y. The stabilit y should be reconst it uted by add-
ing struct ural support. Th us, it requires open rhin oplast y
an d recon struct ion of th e dorsal fram ew ork. Such st ruct ural
92 II Rhinoplast y

su pport in cludes th e use of th e spreader graft, septal bat ten

graft , or septal exten sion graft w ith or w ith out rein force-
m en t of th e caudal sept um . Un ilateral or bilateral spreader
grafts can be used as th e exten ded version or n ot , depen ding
on the strength of the caudal part of the sept um . Spreader
grafts are u sually obtain ed from th e sept um if th ere is su f-
cien t cartilage to graft. W h en h ar vest ing septal cartilage
in Asians, care sh ould be taken since the cartilage is not as
strong an d th ick as in Caucasian s, an d aggressive h ar vest ing
of the septal cart ilage w ill only further com prom ise septal
instabilit y. Thus, it is im portant th at a 1.0-cm strut be left
dorsally, anteriorly, and especially at th e keyston e region.
Som et im es th e straigh t part of a perpen dicular plate of
eth m oid bon e can be used for reinforcem ent instead of th e
septal cartilage. After th e h ar vest ing of cart ilage, spreader
grafts (approxim ately t w o st rips 3 m m in w idth an d 15 to
25 m m in length each) are fashioned and placed over the
dorsal strut bilaterally. They are rst xed w ith a xation
n eedle an d subsequen tly anchored w ith 4–0/5–0 PDS at t w o Fig. 7.5 Bilateral spreader graft s are temporarily xed with needle
and sutured with horizontal mat tress sutures using 4–0/5–0 PDS.
or three posit ions (Fig. 7.5). An exten ded spreader graft can
be used w hen th e caudal sept um is oppy and needs ext ra
su pport. It can be used in conju n ct ion w ith th e septal exten -
sion graft an d/or septal bat ten graft for furth er rein force-
m en t. Th e exten sion of th e cau dal en d of th e graft beyon d
the low er border of th e upper lateral cartilage increases the
reinforcem ent caudally, providing struct ural support along
the w hole dorsum caudally dow n to the t ip.4
In cases of class 2 sad dling w ith rot ated t ip, m ore often
th an n ot th e cau dal sept um is de cien t , sh ort , an d oppy.
In such cases, a septal exten sion graft is n eeded to m ake
th e nasal t ip st rong an d to get a projected t ip (Fig. 7.6). Th e
septal exten sion graft is often fash ion ed from th e septal
cart ilage or th e cost al cart ilage. Th e car t ilage sh ould be a
at , broad p iece an d sh ou ld be overlap p ed w ith th e exist-
ing septal cart ilage. If th e sept al car t ilage h as a previous
fract u re lin e or cu r vat u re, th e overlap ped region sh ou ld
a
in clude th is area. If n eeded, th e oth er side of th e septal
exten sion graft can be fu r th er st rength en ed w ith an oth er
piece of cart ilage. Th e sept al exten sion can be su t ured at
th e sides to th e spreader graft s superiorly an d to th e an te-
rior n asal sp in e in feriorly to m ake su re th at th e cau dal
en d of th e n ose is su p ported from below in th e m id lin e, is
st raigh t , an d w ill n ot collap se or ben d du ring th e h ealing
period.

Class 3 Saddling
Su btot al recon st ru ct ion of th e n asal sept u m is recom -
m en ded . In th is d egree of sadd ling, on e w ill n d th e sept al
b
cart ilage n ot ju st w eak, bu t w ith part s of it m issing or w ith
volu m e, area, an d in tegrit y loss. Su btot al recon st ru ct ion of
Fig. 7.6 (a,b) The septal extension graft is the workhorse for sup-
th e sept um involves recon st it ut ing th e dorsal h eigh t of th e porting the caudal end of the septum. It can function to strengthen
n ose an d th e project ion an d rot at ion of th e t ip, by recon - and straighten the caudal septum , lift the medial crura of the lower
st ru ct ing th e L-st ru t . Th is m an euver often requ ires abu n - lateral cartilage, increase tip projection, and derotate the tip down-
dan t cost al car t ilage. The process begin s w ith fabricat ion of ward in the case of a rotated tip in a saddled nose.

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Fig. 7.7 Fabrication of the L-strut. The caudal septum is replaced
with a at costal cartilage piece and supported with an extended
spreader graft. The L-strut should sit rmly on the anterior nasal
spine and not oat on top of it. Support should be provided by it to
the lower lateral cartilages and not the other way around.
th e L-st rut using on e or t w o at an d st rong pieces of costal
cart ilage or sept al cart ilage. Th is cart ilage sh ould sit rm ly
on top of th e an terior n asal spin e, superiorly h eld rm ly by
th e bilateral spreader graft s (Fig. 7.7).
Oth er tech n iqu es th at can p rodu ce th e sam e st abilit y
are to car ve a th ick, st rong p iece of dorsal st ru t to in terlock
w ith a sh or ter but sim ilar sect ion of cart ilage at th e L-st rut .
Th e L-st rut can be an ch ored to th e an terior n asal spin e
w ith 4–0 PDS by drilling a h ole th rough the n asal spin e
w ith a 1-m m drill bit or a 16-gauge n eedle; or sut ured to
th e periosteum sn ugly using gure-of-8 sut uring at t w o
p oin t s, on e an terior an d on e posterior. The an terior n asal
spin e sh ou ld be ren dered st raigh t before th e an ch oring
is don e. Th e L-st ru t sh ou ld be p laced rm ly before th e
exten ded sp reader graft s are placed.
Th e n ew dorsum th at th e spreader graft form s sh ould
be st rong an d st raigh t , an d an overlap in to th e n asal bon e
is som et im es desirable to in crease graft st abilit y w h en th e
n asal bon e is stable en ough to en du re osteotom y. Th e t w o
sides of th e u p p er lateral car t ilage sh ou ld be rm ly su t u red
to th e spreader grafts using 5–0 PDS at t w o or th ree poin t s.
Sp ecial at ten t ion is to be p aid w ith regards to th e sym m e-
t r y of th e upper lateral car t ilage w h en sut uring so as n ot to
cause any iat rogenic deviat ion .
On ce th e graft s are rm ly in p lace, th e m edial cru ra of
th e low er lateral cart ilages sh ould be sut ured to th e n ew
L-st rut . Re n em en t can be ach ieved by adju st ing th e angles
of sut uring or by n al applicat ion of cam ou age grafts.
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7 Correction of the Saddle Nose 93
Class 4 Saddling
A tot al dorsal recon st r u ct ion from t h e radix to t h e t ip is
n ecessar y w h en th ere is m ajor loss in t h e sept al st r u ct u re
an d p ossible loss of th e n asal pyram id bon es. Tot al recon -
st ru ct ion of t h e n asal bon e m ay requ ire a rep lacem en t
graft u sing cost al car t ilage. How ever, in cases of severe
sad d lin g w it h loss of n asal bon e, or if sept al recon st r u c-
t ion is im p ossible or n ot n eeded, a on e-piece dorsal on lay
graft an d exten d ed colu m ellar st r u t cou ld be u sed alter n a-
t ively. Th e exten ded colu m ellar st r u t sh ou ld be st abilized
rm ly to th e an terior n asal sp in e. Th e on e-p iece block of
dorsal on lay graft cou ld be design ed u sing cost al car t i-
lage. It is form ed in to a boat sh ap e. Th e can t ilever on lay
graft sh ou ld id eally sp an t h e rad ix to th e low er lateral car-
t ilages. A groove is m ade in th e cau dal en d of th e on lay
graft , w h ich is u n ited w ith t h e exten d ed colu m ellar st ru t
over th e an ter ior n asal sp in e (Fig. 7.8). Th is can su p p or t
th e n ose w ith ou t recon st ru ct ion of t h e sept u m . Up per an d
low er lateral car t ilages restore to th e st able colu m ellar
st ru t– d orsal graft . Last bu t n ot least , after th e restorat ion
of th e dorsal h eigh t an d t ip p roject ion , t h e n asal t ip n eeds
to be addressed m et icu lou sly, w h ich is described in a sep a-
rate ch apter.5
■ Key Technical Points
1. Tech n iques for a saddle n ose correct ion var y
depen ding on th e degree of saddling. Proper
assessm en t of th e et iology an d d egree of sad dling
form s th e basis for th e su rgical tech n iqu e u sed.
2. Th e cam ou age graft is th e m ain tech n iqu e used for
class 1 saddling. Careful design of th e skin pocket is
th e key to a su ccessful surger y in cam ou age graft s.
3. Class 2 saddling requires par t ial recon st it ut ion an d
recon st ruct ion of th e sept um an d dorsum .
4. Subtot al septal recon st ruct ion is required to address
a class 3 sad dling. More often th an n ot cost al
cart ilage is n eeded to recon st ru ct th e dorsal su ppor t
an d th e L-st ru t . Th ese t w o st ru ct u res w ill form th e
pillars of n asal dorsal recon st ruct ion .
5. Th e recon st ructed caudal L-st ru t n eeds to be
an ch ored rm ly to th e an terior n asal sp in e to
preven t long-term sequaelae an d recurren ce of
sadd ling.
6. In th e class 4 saddling deform it y, tot al
recon st ruct ion is n eeded to restore n asal dorsal
h eigh t from th e radix to th e t ip. Com bin ed bony an d
cart ilagin ous dorsal recon st ru ct ion n eeds h inging
w ith th e colum ellar st rut cau dally, bypassing th e
sept al su pp ort .
94 II Rhinoplast y

a b

c d

Fig. 7.8 Total dorsal reconstruction bypassing septal support. The costal cartilage graft is carved to recreate the dorsum from the radix
to the tip and for bypassing the nasal septum support. (a) An extended colum ellar strut should be stabilized rm ly to the anterior nasal
spine. (b,c) Boat-shaped dorsal onlay graft carved from one piece of costal cartilage. An extended columellar strut is combined with the
onlay graft in tongue-in-groove fashion. The septum was partially replaced using carved costal cartilage. (d) The upper and lower lateral
cartilages are xed to the dorsal onlay graft.

Th e extern al approach w as u sed, follow ed by sept al

■ Case Studies
Case 1
A 31-year-old fem ale pat ien t visited th e clin ic com p lain -
ing of saddle n ose deform it y after previous septoplast y
(Fig. 7.9). Sh e h ad a septop last y 2 years p reviou sly an d
slow ly develop ed sadd le n ose deform it y after th e su rger y.
On p hysical exam in at ion , h er dorsu m sh ow ed depression
from th e rh in ion to th e t ip . Palp at ion of th e t ip an d dorsu m
sh ow ed n o u n d erlying sept al su p p or t . An in t ran asal exam
sh ow ed p osterior sept al d eviat ion to th e left side bu t n o
cart ilagin ous support on palpat ion .
m u cosa elevat ion (Fig. 7.10). Costal cart ilage an d p erich on -
drium w ere h ar vested. A boat-sh aped dorsal on lay graft
w as car ved from th e cost al cart ilage. Th e can t ilever dorsal
on lay graft exten ded from th e rh in ion to th e t ip. A groove
w as m ade at th e cau dal en d of th e dorsal on lay graft ,
w h ich w as h inged to th e exten ded colum ellar st ru t rm ly
an ch ored to th e an terior n asal sp in e. Up per an d low er lat-
eral cart ilages w ere restored to th eir p osit ion s an d su t u red
to th e d orsal on lay graft . Perich on d riu m w as u sed to drap e
th e dorsum from th e radix to th e on lay graft .
Six-m on th postoperat ive ph otos sh ow greatly im proved
n asal sh ap e (Fig. 7.11).

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 7 Correction of the Saddle Nose 95

a b c

Fig. 7.9 (a–c) Case 1. The patient had developed saddle nose after septoplast y. A middorsal depression is observed and the septum is too
weak to support an onlay cartilage graft. A dorsal onlay graft was carved from costal cartilage. An extended columellar strut was anchored
rmly onto the anterior nasal spine inferiorly and superiorly and extends into the groove created at the caudal end of the dorsal graft.

a b

Fig. 7.10 Case 1. Intraoperative photos. (a) Dorsal graft carved from the rib cartilage is hinged to the extended columellar strut.
(b) Lower lateral cartilages are reat tached to the new dome created by the grafts.

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96 II Rhinoplast y

a b c

Fig. 7.11 (a–c) Case 1. Six-month postoperative photos show improvement of saddle from three di erent views.

Case 2
A 22-year-old m ale visited th e clin ic du e to a deform ed
n ose an d n asal obst ruct ion (Fig. 7.12). He h ad a n asal
t raum a h istor y in early ch ildh ood. On physical exam in a-
t ion , h e w as foun d to h ave saddling of th e low er t w o-th irds
of h is n ose; an un der-projected, sligh tly upt urn ed n asal
t ip; an d hypert rophy of both t u rbin ates. Using au togen ous
rib cart ilage, an exten ded colu m ellar st ru t rein forced w ith
m in i bilateral exten d ed sp reader graft w as u sed for t ip an d
caudal support (Fig. 7.13). Lateral cru ral on lay graft s an d
t ip onlay graft s w ere added for t ip con touring. A dorsal
on lay graft u sing car ved rib cart ilage w as u sed for dorsal
augm en tat ion .
Th ree years after surger y, a n orm al-looking n ose can be
obser ved in all view s (Fig. 7.14).

a b c

Fig. 7.12 (a–c) Case 2. Preoperative photos show a t ypical severe saddle nose deform it y with middle vault collapse and tip ptosis with
slight cephalic rotation.

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 7 Correction of the Saddle Nose 97

Fig. 7.13 Case 2. Surgical ndings. (a) Intraoperative photograph

shows dorsal onlay graft, bilateral lateral crural graft s, and tip onlay
grafts using rib cartilage with overlying perichondrium. (b) Surgical
diagram showing operative techniques.

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98 II Rhinoplast y

a b c

Fig. 7.14 (a–c) Case 2. Three-year postoperative photos show well-augmented but smooth dorsum and more desirable tip projection
and rotation compared to preoperative status.

References
■ Conclusion
Saddle n ose d eform it y correct ion can range from a p ro-
cedure as sim ple as applying a cam ou age graft to a tot al
n asal recon st ruct ion . Saddle n ose is a com m on problem
presen ted by Asian pat ien t s due to th e in h eren t low -pro le
n ose w ith a soft an d u n d er-developed n asal sept u m su s-
cept ible to in sult . As a result , th e volum e an d exten t of sad-
dle n ose repairs in th e auth ors’ cen ters h ave provided th e
oppor t un it y to gain m u ch experien ce an d re n e tech n iques
in h an dling saddle n ose. It sh ould be assessed m et icu lou sly
an d su rger y plan n ed w ith all even t u alit ies an t icipated to
en su re th e best ou tcom e. Th e best ou tcom e is w h en th e
procedure is don e righ t th e rst t im e. Th at being said, m any
of th e recon st ruct ion s for saddle n ose m ay n eed revision s
in variou s stages.
1. Young K, Row e-Jon es J. Current approach es to sept al saddle
n ose recon st ruct ion using autograft s. Curr Opin Otolar yn -
gol Head Neck Su rg 2011;19(4):276–282
2. Kevin Bren n er JC. Saddle nose deform it y. In : Mu rphy M,
Azizzadeh B, Joh n son CM Jr, Nu m a W, eds. Master Tech -
n iques in Rh in oplast y. 1st ed. Saun ders; 2011:293–298
3. Durbec M, Disan t F. Saddle n ose: classi cat ion an d th era-
peut ic m an agem en t . Eu r An n Otorh in olar yngol Head Neck
Dis 2014;131(2):99–106
4. Tardy ME Jr, Schw art z M, Parras G. Saddle n ose deform i-
t y: autogen ous graft repair. Facial Plast Su rg 1989;6(2):
121–134
5. Dan iel RK. Rhin oplast y: sept al saddle n ose deform it y
an d com posite recon st ruct ion . Plast Recon st r Surg 2007;
119(3):1029–1043

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8 Alar Base Modi cation
Ian Loh Chi Yuan and Hong Ryul Jin
Pearls
• Modi cat ion s to th e d orsu m an d n asal t ip w ill
a ect th e alar base w id th , as w ell as th e deliberate
creat ion of illu sion s, as a resu lt of object ive ch anges.
• Alar base su rger y sh ou ld be p erform ed as th e n al
procedure in th e rh in oplast y sequen ce.
• Ap p ropriate design , sym m et r y, an d m et icu lou s
soft t issu e h an dling are p aram ou n t in creat ing th e
desired outcom e in alar base surger y.
• Th e m odi ed Weir excision is th e m ost com m on ly
em ployed d esign for East Asian s, w h o t ypically n eed
redu ct ion of alar aring, n ost ril size, an d alar base
w idth .
• Th e use of a cin ch ing sut ure to m ain tain a ten sion -
free skin closu re is an im p ort an t p ar t of alar base
su rger y.
■ Introduction
Th e alar base describes th e port ion of th e n ose w h ere th e
alar side w all at t ach es to th e m idface. Modi cat ion to th is
area ch anges th e alar base w idth , th e degree of alar aring,
an d n ost ril sh ap e an d size. Eth n ic variat ion s in th e alar base
h ave been w ell described. Th e m ajorit y of East Asian n oses
(especially th ose of South east Asian origin ) can n ot con form
to th e ideal an atom ic relat ion sh ip described in Cau casian s.
Th e alar base of th e East Asian n ose is w ider com pared w ith
th e European n ose, w ith a m arked ten den cy to are but n ot
to as severe a d egree as th ose fou n d in African s or Sou th -
east Asian s, in clu ding th ose of Filip in o, Malaysian , In d on e-
sian , an d Viet n am ese eth n icit y.1
The shape and extent of alar aring w ill depend on the
sh ape and elasticit y of th e un derlying n asal cartilage, the
connection bet w een the lateral crura and th e face, an d the
prom inence of the nasal tip. In addition to the aring and
w ide alar base, other abnorm alities such as alar rim hang-
ing,2 retrusion of colum ella, w ide colum ellar base, and exces-
sively th ick alar rim should also be con sidered. Tech niques
to change th e alar sh ape are ch osen after assessing all these
param eters individually and judging com prehensively, con -
sidering harm ony of the ala w ith the rest of the face.
Given th ese eth n ic variat ion s, it sh ou ld n ot be su rpris-
ing th at alar base su rger y is on e of th e m ost com m on ly
requested p rocedu res du ring con su ltat ion for East Asian
rh in op last y.
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• It is param ou n t th at a cu r ved port ion of th e n ost ril
be preser ved to avoid creat ing a teardrop n ost ril
during th e excision design .
• Con ser vat ism sh ould be obser ved during resect ion s,
as correct ion of over-excision is ver y d i cu lt .
• Com plicat ion s of alar base surger y in clude th e
creat ion of a teardrop n ost ril, asym m et r y of th e
nost rils, an d various scar-related com plicat ion s,
in cluding vest ibular sten osis w ith accom panying
nasal obst ruct ion .
• Most com p licat ion s are iat rogen ic an d can be
avoided w ith good design an d t issue h an dling.
• Th e ben e ts of alar base surger y m ust be w eigh ed
again st th e poten t ial for com plicat ion s; th is is
esp ecially t ru e for East Asian p eop les, w h ose skin is
m ore p ron e to scar-related com p licat ion s.
Th e poten t ial in dicat ion s for alar base surger y are (1)
in creased alar base w idth , (2) excessive aring of th e alar
side w alls, (3) large n ost rils, (4) th ick alar side w alls, (5)
h ooded or h anging alar side w alls, an d (6) cleft n ose or n os-
t ril asym m et r y.
■ Patient Evaluation
A carefu l an d det ailed h istor y sh ou ld be t aken du ring con -
su ltat ion to id en t ify th e pat ien t’s con cern s. Exam in at ion
of th e alar base sh ould focus on th e n ost ril shape, size,
an d sym m et r y; th e degree of alar aring; an d th e w idth
of th e n asal base. Any pre-exist ing asym m et r y of th e n os-
t rils sh ould be n oted an d poin ted ou t to th e pat ien t , an d
corrected w h en ever possible during surger y; th is is also
im port an t to avoid any con cern s th at m ay h ave arisen iat-
rogen ically after surger y.
Physical Examination
On fron t al view, th e alar rim sh ou ld arc an d en d h igh er th an
th e colum ella, giving a gull’s-w ing-in - igh t appearan ce.
Exaggerat ion of th e gull-in - igh t cur ve im plies ret ract ion
of th e ala or depen den cy of th e in frat ip lobule. On lateral
view, th e alar rim u su ally sit u ates 2 to 3 m m above th e
nasal colum ella, creat ing a colum ellar sh ow. Th e lateral
99
100 II Rhinoplast y
view is also th e best view for evaluat ing th e alar-colum el-
lar relat ion sh ip . W h en th e colu m ella is n ot seen , th is m ay
in dicate a ret racted colu m ella or h anging ala. Norm ally, th e
w idth of th e alar base is equal to the dist an ce bet w een th e
m edial can th i. Th e th ickn ess an d aring of th e ala an d th e
d egree of recu r vat ure of th e alar base in sert ion s sh ou ld
also be n oted. Ideally, th e n ose as seen from basal view
sh ou ld be an isosceles t riangle w ith a rou n d apex, sligh tly
bulging alar side w alls, an d n ost rils t ilted 30 to 45 degrees
from th e m idlin e, w ith th e ap p earan ce of a p ear. Th e rat io
of th e colu m ella an d in frat ip lobule is 2:1, an d th e begin -
n ing of th e are of th e m edial cru ral foot p lates divides th e
alar base in to h alves (Fig. 8.1).
The E ect of Illusions on the
Nasal Base
Alth ough alar base su rger y is frequ en tly requ ested as an
isolated procedu re, th e pat ien t m ust be in form ed th at th e
ap pearan ce of th e alar base is a ected by m odi cat ion of
th e n asal t ip an d dorsu m , an d th at surger y to th is area can -
n ot be con sidered in isolat ion . In creased n asal t ip projec-
t ion and dorsal augm en tat ion w ill both create an illusion of
decreased alar base w idth . Conversely, n arrow ing th e alar
base w ill create th e illusion of a broader n asal t ip. If su rger-
ies in th ese areas are also requ ired, th e pat ien t sh ould be
advised accordingly.
In cert ain cases, m odi cat ion of th e dorsu m an d t ip alon e
m ay su ce to create th e illu sion of decreased alar base
w idth an d aring, m aking alar base surger y un n ecessar y.
It is im p erat ive th at th e pat ien t be in form ed th at m odi-
cat ion s to th ese oth er areas in u en ce th e ch aracterist ics
a b
Fig. 8.1 Ideal alar shape of East Asians. (a) Frontal view. (b) Lateral view. (c) Basal view.
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of th e alar base, an d m ay m ake alar base surger y un n eces-
sar y. In case of d ou bt , alar base excision s sh ou ld also be
perform ed as a staged procedure, after th e pat ien t h as a
ch an ce to evaluate th e e ect th at th ese oth er m odi cat ion s
m ay h ave on th e alar base.
Quality of Skin
Alar base su rger y is essen t ially a skin excision of th e alar
base region . Th e qualit y of th e pat ien t’s skin is an im por-
tan t determ in an t of th e surger y’s outcom e. Th e skin of th e
alar base region is n at u rally th ick an d sebaceou s. In addi-
t ion , East Asian skin is th icker an d m ore pigm en ted th an
Cau casian skin . Th ese factors p redisp ose th e East Asian
pat ien t to hyper t roph ic scarring, keloid form at ion , an d
post-in am m ator y hyperpigm en t at ion w h en un dergoing
alar base su rger y.3
A p at ien t w ith th ick sebaceou s skin w h o gives a h is-
tor y of scar-related com p licat ion s sh ou ld be w arn ed of th e
possibilit y of th ese com plicat ion s w h en plan n ing alar base
su rger y. An d m et icu lou s p ostop erat ive care sh ou ld be prac-
t iced to m in im ize such com plicat ion s.
Function
Any st at ic an d dyn am ic collap se of th e extern al n asal valve
m u st be n oted. Alar base su rger y th at redu ces th e size of
th e vest ibular aper t ure can cau se extern al valve sten osis.
Th e pat ien t sh ould be asked to in spire th rough th e n ose
rapidly, an d any collapse of th e alar side w all sh ould be
noted. Pat ient s w ith sm all n ost rils sh ould h ave excision
design s th at do n ot furth er reduce th e n ost ril apert ure;
c
 8 Alar 
Base 
Modi cation 101

p at ien t s w ith dyn am ic collapse sh ould con sider fun ct ion al

su rger y to st rength en th e low er lateral car t ilages con com i-
t an tly, such as th e use of bat ten grafts, togeth er w ith alar
base surger y if required.

Photographs
Proper ph oto docu m en t at ion u sing a prim e port rait len s
an d di u se ligh t ing is a clin ical an d m edico-legal requ ire-
m en t for rh in op last y. A fron t al view, p ro le view, an d basal
view are u sed in evalu at ing for alar base su rger y. Com p u ter
sim u lat ion can be p art icu larly u sefu l to illu st rate th e com -
plex relat ion sh ips bet w een dorsal length , t ip project ion , t ip
bulbosit y, an d alar base w idth , w ith th e pat ien t’s decision s
carefully docum en ted.
From th e fron tal view ph otograph , th e w idth of th e
n asal base can be evaluated; th is sh ould ideally lie just out-
side of th e m iddle h orizon t al fth of th e face in Orien tals.
Th e base can appear w ide from excessive aring or from a Fig. 8.2 De nition of alar aring. The aring is determined
large in ter-alar distan ce. Excision t arget ing th e righ t areas according to the degree of alar projection based on a vertical line
m u st be design ed to add ress th ese problem s. drawn at the alar-facial groove as seen from the basal view.
From th e basal view th e size of th e n ost rils an d degree
of aring can be object ively assessed. Ver t ical lin es pass-
ing th rough th e alar facial groove can be draw n in th e basal
view. Excess alar side w all lateral to th is lin e gives an objec- ap proach h as been perform ed, th e colu m ella in cision is
t ive m easu rem en t of th e degree of alar aring an d aids in closed w ith a few m on o lam ent sut ures to restore ten sion
plan n ing th e excision design (Fig. 8.2). to th e skin pocket . Th e n eed for alar base su rger y is th en
From th e lateral view, a lin e draw n th rough th e long assessed from th e basal view, fron tal view, an d pro le view
axis of th e n ost ril allow s th e su rgeon to evalu ate th e exten t as ou tlin ed earlier in th e ch apter.
of h anging alar deform it y an d th e am oun t of “lift” required Th e alar base region con sist s of th ick sebaceous skin
to correct alar h ooding.2 extern ally, h air-bearing vest ibu lar skin in tern ally, an d
bro-fat t y t issu e in bet w een . Th ere are n o car t ilagin ou s
st ru ct u res fou n d h ere. Th e ju n ct ion of th e alar side w all an d
lateral n asal sill form a n at ural cu r vat ure at th e in ferior lat-
■ Surgical Techniques eral asp ect of th e n ost ril, w h ich m u st be preser ved d u ring
any alar base su rger y to avoid creat ing a teardrop n ost ril.
Surgical Anatomy Th e jun ct ion bet w een th e alar side w all an d m idface
form s th e alar facial groove, an d w h en ever possible, th is
Alar base su rger y is perform ed as th e n al procedu re in sh ou ld be p reser ved. Leaving beh in d a 1-m m cu of soft
th e rh in oplast y sequen ce. Th is allow s th e su rgeon to fully t issue above th e alar facial groove w h en plan n ing th e in fe-
evalu ate th e e ect s from any m odi cat ion s to th e dorsu m rior in cision greatly facilitates closu re an d faster w ou n d
an d t ip on th e alar base (Fig. 8.3). If an op en rh in op last y healing.

Fig. 8.3 Increased nasal tip projection

leads to decreased alar are. (a) Alar aring
is noticeable in the preoperative basal view.
(b) As the nasal tip is augmented, the are
of ala is decreased without any alar base
procedure being done.

a b

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102 II Rhinoplast y
Excision Design
Th e con ce p t of n ar row in g t h e alar base w as in t rod u ce d
by Robe r t W ie r in 1892, an d h e d escr ibe d t h e u se of
ext e r n al alar w e dge excision s to cor re ct t h e u n at t ract ive
alar are. Di e re n t m od i cat ion s of t h e We ir alar base
excision are p ossib le, an d t h e excision d esign is d e p e n -
d e n t on t h e su rgical obje ct ives (Fig. 8.4). Th e alar ar-
in g is im p rove d by p e r for m in g a cresce n t -sh ap e d w e dge
rese ct ion of t h e ala alon g t h e alar-facial groove. Th e w id e
alar base can b e re d u ce d by a slid in g alar ap or n ost r il
sill excision . On t h e ot h e r h an d , a w id e alar base com -
bin e d w it h alar ar in g can be im p rove d by com bin in g
alar w e dge an d n ost r il sill excision .
a for con st rict ion of th e blood vessels.
b Bleeding is u su ally con t rolled by su t u ring an d rarely
c th e brofat t y t issue in th e free cut edge of th e alar side
d
Fig. 8.4 Types of alar base surgery. (a) Wedge resection of the
ala to decrease the alar aring. (b) Resection of the nostril sill to
decrease the width of the alar base. (c) Sliding alar ap to reduce
the width of the alar base. (d) Combined sill and wedge resection
to correct the alar aring and wide alar base.
http://e-surg.com
Combined Alar Wedge Resection and
Sill Excision
The use of a m odi ed Weir excision for reduct ion of alar
aring, n asal base w idth , an d n ost ril size is dem on strated
in Fig. 8.5. Th is is th e m ost com m on ly em ployed design in
East Asian pat ients. The excision design is draw n using a
n e-t ipped felt m arker or tooth pick stain ed w ith m ethylen e
blue prior to inject ion. The incision for the alar w edge exci-
sion is m arked at 1 to 2 m m above th e alar-facial ju n ct ion .
This preser ves the nat ural sulcus and m akes eversion of the
sut ure easy, th u s m axim ally cam ou aging th e in cision scar.
Excision inside the nost ril m ust preser ve the cur ved portion
of the nost rils and be checked m eticulously for sym m etr y.
In alar w edge resect ion , th e in cision sh ou ld n ot exten d
to th e m edial side of ala, an d in n ost ril sill excision , th e n os-
t ril base adjacen t to th e colum ella sh ould be preser ved to
preser ve th e n at ural alar sulcus an d to preven t a ten t pole
app earan ce.
In lt rat ion is th en adm in istered. A sm all am ou n t of
in lt rate con t ain ing adren alin e an d lidocain e is preferred
by th e auth ors. Th e volum e of in lt rate sh ould be kept
sm all to avoid distor t ion to th e su rrou n ding t issu e. Ten
m in u tes is allow ed to lap se before th e in cision s are m ad e
A fresh n o. 15 blade is used to m ake th e in cision s st art-
ing w ith th e superior lim b of th e w edge excision follow ed
by th e in ferior lim b. Th e in cision s are beveled sm ooth ly
tow ard each oth er to en su re sym m et rical w edges of soft
t issu e are rem oved from each side. On ly skin an d subcuta-
neous t issue are resected, an d care sh ou ld be t aken to n ot
violate th e m u scle in th e deep plan e.
needs cauterizat ion . If n ecessar y, h em ost asis is ach ieved
using bipolar cauter y. A gure-of-8 sut ure is th en passed
th rough th e prem axillar y soft t issue. A PDS 3–0 sut ure is
m ou n ted on a large free n eedle an d p assed th rough th e
m edial in cision on th e righ t side, t raversing deeply th rough
th e prem axillar y soft t issu e to em erge th rough th e m edial
in cision on th e con t ralateral side. Th e n eedle th en catch es
w all before being passed back in a sim ilar m an n er to catch
th e brofat t y t issue of th e righ t alar side w all. Th e sut ure
is th en t ied ju st t igh tly en ough to relieve ten sion on th e
excision sites, bu t n ot so t igh tly as to cau se bu n ch ing of th e
prem axillar y soft t issu e. Th e kn ot s are th en buried in th e
soft t issu e.
Met icu lou s closu re u sing n e m on o lam en t (6–0
nylon ) sut ures is th en perform ed. Th e au th ors use absorb-
able su t u res to close th e in cision on th e in side of th e n ost ril.
Su t u re rem oval is p erform ed on th e fth p ostoperat ive day.
Sim ilar m eth ods are u sed for isolated sill (Fig. 8.4b) an d
alar side w all excision s (Fig. 8.4a). Th e ap ex of th e w edge
excision sh ou ld n ot exten d in to th e vest ibu lar skin if redu c-
t ion of th e n ost ril size is deem ed un desirable.
 8 Alar 
Base 
Modi cation 103

a b c

d e f

Fig. 8.5 A combined sill excision and wedge resection of ala. (a) Preoperative picture of a patient with under-projected tip and dorsum,
bulbous tip, and wide alar base. (b) The tip has been projected with the use of a columellar strut and cap grafts, and the dorsum has also
been augmented. An illusion of inter-alar distance narrowing has already been created through tip projection. The design for alar base
excision has been marked out. Note how a portion of the curved area of the nostril has been preserved to avoid the creation of a teardrop
nostril. Also note how a small strip of vertical skin has been preserved on the right to facilitate closure later. (c) The right wedge excision
has been performed. (d) The gure-of-8 suture has been passed from right to left through the deep premaxillary tissue. Note how the
needle has engaged the brofat t y tissue of the cut free edge of the alar side wall. (e) The direction of the needle is reversed and the needle
is passed back in a similar manner to catch the alar brofat t y tissue on the other side. (f) The suture is tied and the knot buried. The inci-
sions are closed with ne m ono lament sutures.

V-Y Advancement for Large Alar Correction of Too -Wide Columellar

Wedge Resection
W h en a con siderable am oun t of alar w edge resect ion is
don e, a diam eter di eren ce bet w een th e upper an d low er
alar in cision s w ill n ot create a n at u ral alar-facial su lcu s. A
V-Y sh ap ed su t u ring can solve th is problem ; h ow ever, it can
create a n ew scar, w h ich is best cam ou aged by placing it
along th e n asolabial su lcu s.
Correction of Hanging Alar
Base
W h en th e m edial crura are too divergen t or prom in en t , th e
colum ellar base is too w ide an d som et im es causes n asal
obst ruct ion by obst ruct ing th e n ost ril. To correct th is, a lat-
eral colu m ellar in cision is don e bilaterally an d th e m edial
cru ra are dissected an d exposed (Fig. 8.7). Often su t u re
ligat ion of th e t w o dissected m edial crura is n ot en ough to
narrow th e colum ellar base. Rem oval of sm all am ou n t of
soft t issu e bet w een th e t w o cru ra or part ial cru ral resec-
t ion h elps to redu ce th e base e ect ively.

For correct ion of h anging ala, refer to Ch apter 9 of th is book.

■ Key Technical Points

Alar Base Surgery for the Cleft Nose
Com plete correct ion of th e cleft n ose deform it y requires
reposit ion ing an d recon st ruct ion of th e low er lateral car-
t ilage, reposit ion ing of th e colum ella, an d augm en tat ion of
th e prem axillar y region in addit ion to alar base m odi ca-
t ion (Fig. 8.6). Det ailed descript ion of th ese com plicated
tech n iqu es is n ot w ith in th e scope of th is ch apter.
1. Th e resect ion am ou n t sh ou ld be kept con ser vat ive.
Revision excision s are sim ple to perform but
restorat ion of excised t issue is ext rem ely di cult .
2. Preser vat ion of th e cur ved por t ion in side of th e
n ost ril du ring excision is n ecessar y to p reven t a
teardrop deform it y.
3. Th e in cision for th e alar w edge excision is m arked at
1 to 2 m m above th e alar-facial jun ct ion .

http://e-surg.com
104 II Rhinoplast y
a b
4. The superior extent of wedge sections should be kept
as inferior as possible in the alar facial groove. The skin
in this area is thick and sebaceous, and scar-related
com plications here are conspicuous and unforgiving.
The lateral nasal artery also runs 4 m m superior to the
level of the nasal sill and should be preserved.4
5. Ten sion sut ures ( gure-of-8) passed u n der th e
p rem axillar y soft t issue aid in ten sion -free closure
an d h ealing of th e in cision s.
■ Complications and
Their Management
Scarring
Ach ieving an aesth et ically accept able scar is p ossible w ith
proper excision design , m et iculous soft t issue h an dling an d
closu re during su rger y, an d good postoperat ive care. Th e
a b
Fig. 8.7 Narrowing of columellar base. (a) Too-wide columellar base by divergent medial crura causes nasal obstruction. (b) After lateral
columellar incision and dissection, the divergent medial crura are exposed, excised, and cinched together. (c) Im mediately after surgery,
the columellar base looks narrower than before the surgery.
http://e-surg.com
Fig. 8.6 Unilateral cleft nose deformit y.
(a) Preoperative photo shows t ypical asym -
metric alar base of unilateral cleft nose
deformit y. (b) Three-month postoperative
photo shows improved symmetry with ele-
vated left alar base.
excision design sh ou ld be p laced as m u ch as p ossible in
th e alar-facial groove to ach ieve good cam ou age; a sm all
ver t ical cu of skin from th e ala can be preser ved to facili-
tate closure. With expected scar con t ract ure, th is in cision
sh ou ld even t u ally lie w ell cam ou aged in th e groove it self.
In in st an ces w h ere th e in cision is m ade in th e groove
directly, closure of th e n ear ver t ical alar side w all skin to
th e h orizon t al m idface skin w ill be di cult . Th e ten uous
ep ith elializat ion of skin over th is righ t-angled closu re site
is often delayed an d w ill break dow n frequen tly w ith m in or
displacem en t , resu lt ing in poor w oun d h ealing, gran u la-
t ion , an d scarring (Fig. 8.8).
Th e excision design sh ou ld also be kept as in ferior as
possible in th e alar-facial groove. High excision design s are
con spicuou s, especially in th is sebaceous area of th e face,
w h ich scars poorly, an d can be seen from th e fron t al, pro le,
an d basal view s, often resu lt ing in p at ien t dissat isfact ion .
Occlu sive an t ibiot ic oin t m en t sh ou ld be ap p lied to th e
excision sites t ill ep ith elizat ion occu rs an d st itch rem oval
is com p leted . Th ereafter, silicon e gel sh ou ld be ap plied for
th e follow ing 3 m on th s. Th e pat ien t sh ou ld also be advised
c

Fig. 8.8 Complications of alar base surgery. This patient demon-
strates several complications of alar base surgery including obvious
scarring in the alar-facial groove, asymmetric nostrils, and the cre-
ation of a right teardrop nostril.
again st excessive u lt raviolet exp osu re to th e op erat ive site.
In t ralesion al steroid s can be ad m in istered if hyp er t rop h ic
scarring d evelop s.
Teardrop Nostril
A teardrop nostril occurs w hen the curved portion of the nos-
tril is not preserved during alar base resection. This results
in the alar side wall and nasal sill m eeting at an acute angle
after closure of the wedge excision. When seen from the
basal view, there is a loss of the norm al kidney bean shape of
the nostril, w ith the nostril resem bling a teardrop (Fig. 8.8).
The creat ion of a teardrop deform it y is best avoided
w ith correct excision design , preser ving th e cur ved por t ion
of th e n ost ril.
Asymmetry
Any p re-exist ing asym m et r y of th e n ost rils m u st be iden t i-
ed an d docu m en ted (Fig. 8.8). Correct ion of n ost ril asym -
m et r y is a tech n ically di cu lt p art of rh in op last ic su rger y.
It is im p or tan t to poin t th is out to th e pat ien t before sur-
ger y. Asym m et r y in th e alar base can be corrected w ith
n on -sym m et ric excision s. How ever, asym m et ries occur-
ring h igh er in th e alar side w all, su ch as alar ret ract ion
asym m et ries secon dar y to con tou r, n eed to be corrected
th rough m an ipu lat ion of th e low er lateral car t ilages, rim ,
an d/or com posite graft s. Th ese sh ou ld be d iscu ssed w ith
th e pat ien t beforeh an d.
Poor Harmony of Alar Base w ith
Nasal Dorsum and Tip
Th e in t im ate relat ion sh ips bet w een th ese th ree areas h ave
been elaborated earlier, an d a careful preoperat ive assess-
m en t is n ecessar y to avoid creat ing a dish arm on iou s-
http://e-surg.com
8 Alar 
Base 
Modi cation 105
looking n ose after alar base surger y. Isolated an d excessive
redu ct ion of alar aring an d inter-alar dist an ce can create
th e illusion of a bulbou s t ip or accen t uate th e appearan ce of
a long n ose; th e n ose can also app ear p in ch ed or boxy from
th e basal view if th e colum ella project ion is in adequate.
Th is occurs because th e appearan ce of th e t ip w idth an d
nasal length is referen ced again st th e in ter-alar dist an ce
from th e fron t al view, w h ile th e adequ acy of colu m ella
project ion is referen ced again st th e in ter-alar dist an ce in
th e basal view. Reduct ion of th e in ter-alar w idth th erefore
creates an illusion of in creased t ip w idth , n asal dorsum
length en ing, an d decreased t ip project ion . Con siderat ion
of th e in terplay bet w een these factors is im por tan t w h en
plan n ing rh in oplast y.
Nasal Obstruction
Aggressive reduct ion of th e alar base an d redu ct ion in
th e n ost ril size can resu lt in nasal obst ruct ion . Th e n ost ril
form s th e an terior boun dar y of th e extern al n asal valve.
W h en th is aper t ure is excessively reduced in absolu te
term s, a st at ic extern al n asal valve obst ruct ion can result .
A dyn am ic collap se can also resu lt if th e p at ien t h as p re-
exist ing w eak low er lateral car t ilages.
Excision design s that spare the vest ibular skin should be
used in patients w ho have sm all nostrils. Any pre-exist ing
w eakn ess of th e low er lateral cart ilages sh ould also be iden -
ti ed preoperat ively and the patient inform ed of th e poten -
tial risk for nasal obst ruct ion after alar base surger y, w ith
the option of rein forcing the low er lateral cart ilages w ith
bat ten grafts during the rh inoplast y o ered to the pat ient .5
■ Case Studies
Case 1: Combined Nostril Sill and
Alar Wedge Resection
A 25-year-old w om an visited th e clin ic desiring rem oval of
her n asal h um p an d re n em en t of h er nasal t ip (Fig. 8.9).
Physical exam in at ion revealed a m ild reverse C-sh ap ed
dorsu m w ith a sm all h um p. Her n asal t ip w as bulbou s
w ith insu cien t project ion an d h er n asal base w as w ide.
Th ere w as n o sept al deviat ion , an d h er skin w as fair an d of
m ediu m th ickn ess.
An open septorhinoplasty approach was taken and her
septal cartilage harvested. Osteotom ies were perform ed to
straighten her deviated dorsum w hile a caudal septal extension
graft was used to elevate her nasal tip. Soft tissue reduction of
the nasal tip was perform ed, w ith the excised m aterial used as
a radix graft. Septal cartilage was used for dorsal augm entation.
Th ereafter, as par t of th e n al rh in oplast y sequen ce, a
m odi ed Weir resect ion w as u sed to resect both th e alar
side w all an d th e n asal sill to e ect redu ct ion in alar aring,
nost ril size, an d n asal base w idth .
106 II Rhinoplast y
a b
a b
Postop erat ive p ict u res t aken 2 years later sh ow sign i -
can tly n arrow ed n asal t ip, alar base w idth , an d alar aring
(Fig. 8.10). In creased radix, dorsu m , an d t ip p roject ion is
eviden t . Th e d orsal h um p h as been cam ou aged.
Case 2: Combined Nostril Sill and
Alar Wedge Resection
An 18-year-old m an w as seen in t h e clin ic d esir ing re n e-
m en t of t h e n asal t ip , cor rect ion of t h e d eviated n ose, an d
augm en t at ion of t h e n asal d orsu m (Fig. 8.11). Physical
exam in at ion revealed an u n d er-p rojected n asal d orsu m
d eviated to t h e left . Th e n asal t ip w as boxy an d bu lbou s
w it h p oor p roject ion . Th e alar base ap p eared w id e an d
http://e-surg.com
Fig. 8.9 Case 1. Patient with combined
nostril sill and alar wedge resection. (a,b)
Preoperative photos show a mild reverse
C-shaped dorsum with a small hump. Her
nasal tip is bulbous with insu cient projec-
tion and her nasal base is wide.
Fig. 8.10 (a,b) Case 1. Two years after
surgery, the tip shows signi cant narrow-
ing with reduced alar base width and alar
aring.
n ost r il asym m et r y w as n oted . En d oscopy revealed a r igh t -
deviated n asal sept u m . Th e p at ien t ’s skin w as t h ick an d
sebaceou s.
An open septorh in oplast y approach w as un der taken
an d th e sept al car t ilage w as h ar vested . Osteotom ies w ere
used to st raigh ten th e bony dorsum . A colum ellar st ru t w as
used to in crease t ip project ion togeth er w ith t w o st acked
cap graft s to th e t ip. Stacked sept al cart ilage w as used to
augm en t th e dorsu m . Fin ally, a m odi ed Weir excision w as
used to excise th e sill an d alar side w alls to reduce aring,
alar base w idth , an d n ost ril size.
The 1-year postoperative photographs dem onstrate
straightening and augm entation of the dorsum w ith increased
tip projection and tip re nem ent (Fig. 8.12). The alar base
w idth, nostril size, and alar aring have all been reduced.

a b
a b
References
1. Farkas LG, Hreczko TA, Deut sch CK. Object ive assessm en t
of st an dard n ost ril t ypes—a m orph om et ric st udy. An n Plast
Su rg 1983;11(5):381–389
2. Yap E. Im proving th e h anging ala. Facial Plast Surg
2012;28(2):213–217
http://e-surg.com
8 Alar 
Base 
Modi cation 107
Fig. 8.11 Case 2. Patient with combined
nostril sill and alar wedge resection. (a,b)
Preoperative photos show an under-pro-
jected and deviated dorsum and boxy,
bulbous nasal tip with poor projection.
The alar base appears wide and the nostrils
asymmetric.
Fig. 8.12 (a,b) Case 2. After 1 year, his
nose is straight and the dorsum is well aug-
mented. The bulbous tip has been re ned
and the tip projection increased. The alar
base width, nostril size, and alar aring have
all been reduced.
3. Raw lings AV. Eth n ic skin t ypes: are there di eren ces in
skin st ruct ure an d fu nct ion ? In t J Cosm et Sci 2006;28(2):
79–93
4. Jung DH, Kim HJ, Koh KS, et al. Arterial supply of the nasal tip
in Asians. Laryngoscope 2000;110(2 Pt 1):308–311
5. Ballert JA, Park SS. Fun ct ion al con siderat ion s in revision
rh in oplast y. Facial Plast Surg 2008;24(3):348–357
 9 Aesthetic Rhinoplasty for Southeast Asians
Eduardo C. Yap
Pearls
• Th e bony-car t ilagin ous st ruct u re of South east Asian
n oses is gen erally sm all in all dim en sion s, result ing
in a relat ive abun dan ce of skin an d soft t issu e. To
ach ieve a long-last ing e ect , a st rong fram ew ork is
n eeded to cou n teract th e forces of w oun d h ealing
an d th e h eavy skin an d soft t issu e com p lex.
• Hanging ala of variou s d egrees is often n oted an d
can be easily corrected via “sail” excision . Th is
procedure also im proves colum ellar sh ow.
• Th e sept al exten sion graft (SEG) is th e w orkh orse in
providing st urdy su pport to th e t ip.
• Th e SEG m ay be in adequate as su ppor t in som e
cases. Addit ion al graft s can be used to support th e
SEG (e.g., exten ded spreader an d cau dal m argin
exten sion graft s). Becau se of th e pau cit y of sept u m
th at can be h ar vested, folded con ch al cart ilage
at t ach ed ben eath th e SEG is often u sed.
• Tip -p last y is don e before dorsal augm en tat ion . After
m odifying th e t ip as desired , th e dorsal graft is m ade
to blen d th e n ew t ip an d th e radix.
• Am ong syn th et ic produ cts for d orsal augm en tat ion
m aterial, exp an ded p olytet ra u oroethylen e (ePTFE,
■ Introduction
Noses of Sou th east Asian p eop les are gen erally sm all an d
sh ort w ith a bu lbou s t ip , th ick skin an d soft t issu e envelop e
(SSTE) an d a low n asal dorsum . Nasal bon es m ay be w ide
at th e at t ach m en t to th e u pp er lateral car t ilage. The t ip is
u su ally u pt u rn ed. Th ere is a cer tain degree of h anging ala,
an d colu m ellar sh ow is often de cien t . Th e n asal fram e-
w ork is u su ally sm all, w ith a sm all n asal sept u m . Th e low er
lateral car t ilages are also sm all an d w eak, an d th e dom e is
ill de n ed w ith sh or t m edial crura. Th e an terior n asal spin e
an d p rem axilla are often u n d erdevelop ed.
Becau se of t h e feat u res ju st m en t ion ed , t h e su rger y
p lan n ed sh ou ld in clu d e elon gat ion an d p roject ion of
t h e t ip , augm en t at ion of t h e d orsu m , alar lift ing an d re-
st r u ct u r in g of t h e colu m ella for a bet ter colu m ellar sh ow
an d alar-colu m ellar relat ion sh ip , an d augm en t at ion of
t h e p rem a xilla to im p rove t h e n asolabial angle. Th e m ost
cr it ical p roced u re is p rop er rot at ion an d p roject ion of t h e
108
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popu larly kn ow n as Gore-Tex) is preferred because it
h eals by t issu e adh esion w ith n o capsu lar form at ion .
It p rovides a m ore n at u ral look albeit w ith som e
un desirable poten t ial com plicat ion s such as
deviat ion , visibilit y, an d in fect ion .
• ePTFE in sh eet form or preform ed sh ou ld be lim ited
to a single piece if p ossible. St acking of sh eet s m ay
t rap con t am in an t s. Th e im plan t sh ould be rem oved
from it s p ackage on ly w h en it is t im e for dorsal
augm en tat ion to avoid prolonged air exp osu re.
• ePTFE in sh eet form is p referred for a sh allow
radix w h ereas th e preform ed t ype is preferred for
correct ing a deep radix.
• Th e im plan t sh ould be car ved to follow th e con tou r
of th e n ose. Th e caudal en d of th e im plan t sh ould
be sut ured to th e dom e to ach ieve a con t in uous
st ru ct u re of th e dorsu m an d th e t ip .
• A gap of space u su ally is left at th e ju n ct ion of
th e upper cart ilage an d low er cart ilage after
placem en t of th e im plan t . Th is space sh ould be lled
w ith car t ilage to preven t postoperat ive su prat ip
depression .
t ip to a n ew p osit ion . As t h e sept u m is t h e m ost st able
st r u ct u re, t h e cen t ral p ar t of t h e sept u m is h ar vested an d
is u sed for an exten d ed sept al su p p or t graft for xat ion of
t h e low er lateral car t ilage to for m a w h ole n ew t ip . Th is
m an eu ver also exten d s t h e colu m ella for a bet ter colu -
m ellar sh ow . Th e op en ap p roach is often u sed . Th e SSTE
dissect ion is w id ely exten d ed u p to t h e p ir ifor m ap er t u re
laterally, n asal sp in e in fer iorly, an d glabella su p er iorly.
Th e d issect ion p lan e sh ou ld be below t h e su p er cial m u s-
cu lo-ap on eu rot ic layer system (SMAS) on t h e u p p er an d
low er lateral car t ilages, an d below t h e p er iosteu m on t h e
n asal bon e.
■ Patient Evaluation
“Th an k you Dr. Yap for [th e] n ice w ork you d id on m y
nose; h ow ever, I don’t like to look at m yself in th e m irror
because I see a di eren t person ” (a fem ale pat ien t , 1 m on th
postoperat ive).

Rh in oplast y rem ain s th e m ost com m on facial aesth et ic
procedure don e in th e South east Asian region . Pat ien ts
sh ou ld determ in e th e righ t su rgeon for th em selves th rough
th orough con sultat ion w ith prospect ive su rgeon s. Prior to
discu ssing th e surgical plan , th e pat ien t sh ould alw ays be
asked abou t th e im p rovem en t sough t for h is or h er n ose.
Com puter sim ulat ion can be a dangerous tool because it
m ay lead to fu t u re dissat isfact ion resu lt ing in argu m en ts
w ith th e surgeon . It sh ould be explain ed to th e pat ien t
th at im provem en ts from th e su rger y largely depen d on
th e exist ing st ruct ures. Th e aim of aesth et ic rh in oplas-
t ic surger y is to im prove th e curren t appearan ce, not to
ach ieve p erfect ion . Th e m ajorit y of ou tcom es are good an d
fall w ith in p at ien ts’ an d su rgeon s’ exp ect at ion s. How ever,
th ere m ay be som e cases w h ere th e outcom e falls drast i-
cally sh ort of expectat ion s. Th is is often seen in n oses w ith
m u lt iple aesth et ic de cien cies (e.g., sm all n ose, low bridge,
bulbous upt urn ed t ip, ret racted colu m ella, ret ru ded pre-
m a xilla, h anging ala, an d w ide alar base).
Th e pat ien t sh ould be aw are th at after th e rh in oplast y
su rger y, th ere are a few p ossible react ion s to th e n ew n ose.
Peop le w h o h ave frequ en t en cou n ter w ith th e p at ien t (e.g.,
fam ily m em bers, o ce m ates, an d th e pat ien t h erself) m ay
n d th e ch ange ver y obviou s. Th ose w h o see th e p at ien t
occasion ally (e.g., h igh sch ool an d college alum n i frien ds)
m ay n ot be able to n ot ice th e di eren ce; th ese p eop le w ill
gen erally com m en t th at th e p at ien t looks m ore beau t ifu l
th an before. People w h o h ad n ever m et th e pat ien t prior to
th e surger y m ay n ot even n ot ice th at th e pat ien t h as h ad
su rger y don e on th e n ose.
Pat ien t s sh ould be in form ed of th e surger y in det ail
beforeh an d: exten t of th e surger y, durat ion of th e surger y,
t yp e of an esth esia given , don or site, possible m orbid-
it y after h ar vest , an d oth er per t in en t poin t s. Risks of th e
operat ion sh ould be discussed th orough ly as w ell. Set t ing a
realist ic su rgical goal is im port an t . Pat ien t s are advised to
keep an old pict u re of th em selves close at h an d for t w o p u r-
poses: for iden t i cat ion an d to rem in d th em selves of th eir
previous appearan ce. Th eir n ew n oses sh ould be com pared
w ith th eir previous on es, n ot w ith oth er people’s n oses.1
■ Surgical Techniques
Conchal Cartilage Harvest
Most Sou th east Asian rh in op last ies n eed con ch al car t ilage
for graft ing sin ce th e h ar vested car t ilage available from th e
sept u m is lim ited. Th is p rocedu re is don e before th e act u al
rh in oplast y. Histologically, sept al cart ilage is a hyalin e car-
t ilage an d is rm er; h en ce it is used as a support graft . Con -
ch al car t ilage, w h ich is an elast ic cart ilage, is softer an d is
u sed m ain ly for con tour, ller, and cam ou age graft s.
The surger y can be don e un der gen eral an esthesia or
in t raven ou s sedat ion . Follow ing th e usual asept ic tech -
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9 Aesthetic Rhinoplast y for Southeast Asians 109
nique, th e face an d th e auricles are draped as a w h ole.
Lidocain e 2% w ith 1:100,000 adren alin e is used as local
an esth et ic. Cau t ion is advised tow ard th e safe dose of lido-
cain e w ith adren alin e, w h ich is 7.0 m g per kilogram of
body w eigh t .
Th e con ch al car t ilage is h ar vested eith er an teriorly,
if on ly a sm all am oun t of cym ba an d cavum con ch a is
needed, or posteriorly, if a bigger am oun t is n eeded. Th e
an terior in cision is d on e at th e p osterolateral p or t ion of th e
cavum con ch a. Th e skin of th e cavum con ch a is dissected
above th e p erich on driu m an d elevated to th e cym ba con -
ch a. An in cision in th e cart ilage is th en m ade n ear th e skin
in cision site, leaving 2 m m of car t ilage ben eath . Dissect ion
is th en perform ed at th e posterior side, m aking sure th at
th e perich on drium is preser ved an d rem ain s at t ach ed to
th e car t ilage. Th e con ch al cart ilage h ar vested sh ould con -
tain perich on drium on both sides to preser ve th e st rength .
It sh ou ld be soaked in n orm al salin e solu t ion at all t im es
before being fash ion ed as graft s.
For th e p osterior ap p roach to con ch al cart ilage h ar vest ,
an in cision is m ade bet w een th e su lcu s an d th e h elix. Dis-
sect ion is above th e p erich on driu m . Bleeders can be cau ter-
ized. To m axim ize th e h ar vest of cym ba an d cavum con ch a,
t w o or th ree hypoderm ic n eedles are used to pierce an teri-
orly at th e edge of th e con ch al car t ilage th rough an d th rough .
Th e car t ilage is th en in cised an d dissect ion is carried
above th e p erich on driu m an teriorly, p reser ving 5 to 8 m m
of con ch al car t ilage n ear th e extern al auricular can al.
Closu re of in cision s is a bit di eren t . For in cision s
don e an teriorly at th e cavum th e donor defect sh ould h ave
2 m m of con ch al cart ilage below th e site of skin in cision .
Th is w ill be h elpful because it w ill ser ve as a platform for
skin w ou n d h ealing. Closu re w ith a sim p le in terru pted
su t u re is don e u sing nylon 5–0, in clu ding th e car t ilage to
avoid a crum pled look at th e in cision site. A bolster sut ure
is also applied to avoid h em atom a form at ion . For a poste-
rior in cision , closu re is don e u sing nylon 5–0 vert ical m at-
t ress sut ures. Som et im es th e h ar vest site of th e cym ba an d
cavum con ch a con t ract s, especially at th e big auricle; to
avoid collapse an d con t ract ure, a st rip of cart ilage bet w een
th e cym ba an d cavum is preser ved.
Alar Lift Surgery via Sail Excision
Hanging ala is com m on in Sou th east Asian n oses. Before
th e st ar t of surger y th e t ip is m an ually pu lled to its desired
posit ion to sim u late coun ter-rot at ion an d project ion .
At ten t ion sh ou ld also be given to th e alar-colu m ellar rela-
t ion sh ip. If th ere is a n eed for alar lift ing it sh ould be don e
as th e in it ial procedu re sin ce th e w h ole low er p art of th e
nose is st ill m obile an d w ill allow m axim al exibilit y in
m an euvering th e ala du ring m arking, t ract ion , excision ,
an d su t u ring.
Th e alar rim can be lifted by excision of a t riangular
piece of t issue in th e in n er lateral vest ibu lar skin (Fig. 9.1).
110 II Rhinoplast y
Apex
Cephalic side
(vestibular
groove) Apex (peak of gull wing)
Caudal side
Base
Th e irregular t riangular piece of skin t issue is sh aped like
th e sail of a sailboat . Th e t w o sides are m arked at th e in n er
alar rim m argin , an d a skin groove in th e lateral vest ibu le
area is m arked by th e t ran sit ion of th in vibrissae to th ick
vibrissae. Th e apex of th e t riangle is located at th e h igh est
cur ve in th e “gull w ing” on the fron t al view. Th e alar rim
skin is m ade to roll cep h alically as a ap, th u s lift ing th e
w h ole alar rim . Th e defect is closed using nylon 6–0 sim ple
in terru pted su t u res (Fig. 9.2).2
Th ere are som e in st an ces w h ere th e alar base is low er
th an th e colum ellar base. Th e alar lift su rger y sh ould
be aggressive to lift th e alar base as w ell. Th is procedure
involves a radical “sail” excision by exten ding th e in cision
in feriorly an d posteriorly follow ing th e vest ibular groove.
Th e design of the exten ded sail excision is act ually a sm all
t riangle in ferior to th e sail diagram ; it s apex is poin t ing
in ferior-p osterior (Fig. 9.3). Closu re is don e via absorbable
su t ure 6–0 sim p le in terru pted at th e sill area an d nylon 6–0
sim ple in terru pted at th e rim (Fig. 9.4).
The Approach
Sin ce th e m ajorit y of South east Asian n oses n eed st ruc-
t ural m odi cat ion , an open approach is preferred for bet ter
visu alizat ion . A m argin al in cision is rst m ade. Th e colu -
a b
Fig. 9.2 Closure of the sail excision. (a) Markings for the triangle shaped “sail” are made. If there is a need for alar base surgery, the mark-
ings are made higher. (b) The defect after excision of skin and subcutaneous tissue. (c) Closure using nylon 6–0 starts at both ends. The
caudal side act s as a ap that coapts with the cephalic side and the base.
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Fig. 9.1 Designing the “sail” for alar lift. The
t wo sides of the triangular sail are the caudal side,
which is the inner margin of the alar rim, and the
cephalic side, which is determined by a groove
in the lateral vestibule. The base is m arked just
before the area of the sill. The apex is determined
by the highest point of the wing of the “gull in
ight” on frontal view.
m ellar in cision at th e m edial cru ra is m ade beh in d th e skin
m ou n d an d an terior to th e h air-bearing area. An oth er in ci-
sion is m ade 2 to 3 m m cau dal to th e edge of th e low er
lateral car t ilage. Th e m edial in cision an d th e caudal m ar-
gin al in cision s are th en con n ected m ain t ain ing 2 to 3 m m
of skin . Main t ain ing a 2- to 3-m m vest ibu lar skin allow an ce
en su res good coapt at ion du ring closing w ith su t u res.
Dissect ion of th e low er lateral cart ilage is ap p roach ed
at th ree sites: rst at th e m edial crura, th en at th e low er
lateral car t ilage, an d n ally at th e dom e. A soft t issue dis-
sect ion is don e at th e m edial cru ra. Th e dissect ion of th e
low er lateral car t ilage is done above th e perich on drium . At
th is t im e a t ran scolum m ellar in cision can be m ade an d th e
dom es are dissected aw ay from th e overlying skin an d soft
t issue envelope. Th e dissect ion of th e low er lateral car t ilage
is carried superiorly an d laterally up to th e scroll jun ct ion
of th e u pper lateral car t ilage an d th e lateral en ds of th e
low er lateral cart ilage.
Th e dissect ion of th e dorsu m at th e area of th e upper
lateral cart ilage sh ou ld take place ben eath th e SMAS. Th is
is ach ieved by carefully applying blun t an d sh arp dissec-
t ion at th e dorsal sept um n ear th e an terior angle. On ce th e
plan e is iden t i ed at th e dorsal sept u m , a blun t dissect ion
is don e lateral-w ard un t il th e piriform open ing edge of th e
m a xillar y bon e is reach ed . At th is t im e th e low er lateral
cart ilage sh ould be fully m obile for t ip reposit ion ing.
c

Fig. 9.3 Extended sail excision for correction of hanging alar rim
and alar base. The extended correction is done by designing a small
triangle posterior to the sail diagram and following the vestibu-
lar groove as a guide infero-posterior to the nasal sill. Removing
the vestibular skin with its subcutaneous tissues and suturing the
defect will result in maximum lift at the alar base.
Th e upper dorsum com prises th e n asal bon es. Th e
plan e of dissect ion is subperiosteal. Use a sh arp periosteal
elevator, an d take care to avoid injur y to th e dorsal n asal
n er ve th at exit s 5 to 6 m m lateral to m idlin e bet w een th e
n asal bon es an d u p per lateral cart ilage (Fig. 9.5).
Membranous Septum Dissection:
Two Points in a Plane Determine a Line
Th e m em bran ous sept um sh ould be open ed for access to
th e caudal edge of th e sept um . Th e dissect ion also frees th e
m edial cru ra an d foot p late for ten sion -free t ip reposit ion -
ing an d colu m ellar sh ow.
Fig. 9.5 Dorsal nasal nerve (arrows) as it exits bet ween the nasal
bone and upper lateral cartilage. Care should be taken to preserve
it. The subperiosteal dissection for the dorsal implant should be
medial to the nerves.
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9 Aesthetic Rhinoplast y for Southeast Asians 111
a b
Fig. 9.4 Extended sail excision. (a) Preoperative and (b) imme-
diately postoperative correction of hanging alar rim and alar base.
This maneuver is done as an initial step, with no other procedures
having been done yet. Note the instant lift of the alar base and bet-
ter alar-columellar relationship.
A safe ap proach to sp lit th e m em bran ou s sept u m is fol-
low ing th e geom et ric ru le of “t w o poin ts in a plan e deter-
m in e a lin e.” Poin t A is th e an terior angle of th e sept u m
an d p oin t B is th e foot p late. Th e “p lan e” is th e m em bran ou s
sept u m . After iden t ifying th e an terior angle of th e sept u m ,
th e bers of th e opposing m edial crura are dissected via
blu nt dissect ion up to th e an terior n asal spine. Th is m an eu-
ver exp oses th e foot p lates. A sh arp dissect ion of th e m em -
branous sept um bet w een th e an terior angle of th e caudal
sept u m (p oin t A) an d th e foot p late (p oin t B) is n ow p er-
form ed u n t il on e reach es th e cau dal m argin of th e sept u m .3
Septum Dissection: It Is Not How
Much You Have but How Much
You Leave Behind
After th e cau dal edge of th e sept u m is iden t i ed, th e brou s
at t ach m en t s of th e m ucosa are sh arply dissected to expose
th e perich on drium . A bilateral subperich on drial dissect ion
is m ade un t il th e bony part s of th e sept um are reach ed. Th e
cen t ral quadrangu lar sept al cart ilage is h ar vested, leaving
at least 10 m m of caudal an d dorsal st rut . Any deviat ion
in th e rem ain ing sept u m is st raigh ten ed w ith various tech -
niques (Fig. 9.6). Any bony spu rs an d deviat ion are rem oved
using rongeur forceps.3,4,5
Th e at tach m en t s of th e upper lateral cart ilage w ith th e
sept u m m ay be divided an d corrected w ith sp read er graft s
in cases w h ere th ere is a gross deviat ion . Min or deviat ion s
can be cam ou aged w ith a dorsal graft .
112 II Rhinoplast y
Fig. 9.6 Dorsal and caudal strut s. At least 10 mm of strut should
be preserved. In instances where there is a need for a bigger sep-
tum for support, more can be harvested from the caudal side, thus
leaving a smaller caudal strut of ~ 8 mm.
Designing the Septal Extension Graft:
Achieving Strength and Symmetry
Because the septum in Southeast Asian noses is usually
sm all, any septal cartilage h ar vested is utilized m ain ly for
support grafts (e.g., SEGs and spreader grafts). Th erefore,
on e should alm ost alw ays h ar vest con chal cartilage for con -
tour and cam ou age grafts. The vector of th e tip reposition -
ing should be kept in m ind before com m encing surgery to
achieve th e ideal tip projection. At tention should also be
given to the varied thickness of th e SSTE w hen redraping
the restructured nose since the fram ew ork w ill be elongated
an tero-caudally and the SSTE w ill be stretched. The nor-
m ally thicker radix skin w ill be redraped caudally, an d th e
thick bro-fat t y tip skin w ill be relocated cephalically at the
Fig. 9.7 Manual stretching of the SSTE for simulation. In struc-
tural rhinoplast y where the nose is elongated, the thicker radix skin
is pulled caudally when the SSTE is stretched to redrape the new
tip. The supra-tip bro-fat t y skin will appear more cephalic and the
low radix will appear higher.
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supratip area (Fig. 9.7). In traoperative m an euvering of the
SSTE h elps in th e nal design of th e SEG and dorsal grafts.
After the quadrangular cartilage is h arvested, the edges
of the harvested cartilages, especially the inferior at tach-
m ents to the palatine crest, are checked for irregularities and
shaved for a sm ooth plane. Th e h ar vested cartilage from the
dorsal area is usually thicker and is best suited for use as SEG.
The inferior portions are used as additional support grafts
(e.g., spreader graft, caudal m argin extension graft).5,6,7,8
Placem en t of th e SEG n eeds th ree or fou r su t u res for
xation : on e cen t ral, on e an terior, on e in ferior, an d n ally
a loop arou n d (Fig. 9.8). Th e loop -arou n d su t u re preven t s
th e sw inging door deform it y of th e SEG, w h ich m ay cause
in tern al valve obst ruct ion an d t w ist ing of th e t ip. Th e SEG
m ay be w eak or d eviated, an d it m ay be st rength en ed u sing
oth er su p p or t graft s (e.g., sp reader graft or cau dal m argin
exten sion graft). Th e u se of cau dal exten sion graft s also
im proves th e colum ellar sh ow an d augm en t s th e prem ax-
illa. Folded con ch al car t ilage is also a good m aterial for sup -
port of SEGs. It is placed bet w een th e in ferior m argin of th e
SEG an d th e cau dal st ru t . (Fig. 9.8 an d Fig. 9.9).9,10
Tip Projection and Counter-Rotation:
A Must for the Southeast Asian Tip
Becau se th e low er lateral car t ilage is n ot alw ays sym m et ric,
th e dom es are rst m arked w ith gen t ian violet an d th en
xed to th e an terior angle of th e SEG u sing a 25-gauge
hypoderm ic n eedle, m aking su re th ere is n o buckling of th e
SEG or deviat ion of th e t ip . Avoid excessive ten sion of th e
low er lateral cart ilage. Tw o polydioxan on e (PDS) 5–0 xa-
t ion sut ures are placed on th e dom e. Th e posterior edge of
th e m edial cru ra is sut ured to th e SEG via polyglact in (Vic-
r yl) 5–0 in th e sequ en ce vest ibu le skin –m edial cru ra–SEG–
m edial cru ra–vest ibu le skin .11
Fig. 9.8 The four-point suturing of the SEG and the folded conchal
cartilage for support of the SEG. The SEG should be xed with three
anterior sutures (dorsal, central, and caudal) and a loop-around
structure to prevent deviation and tip t wisting. After the conchal
cartilage is scored on the concave side and folded, it is anchored
bet ween the SEG and the caudal strut.

Fig. 9.9 Folded conchal cartilage as support for the SEG. This
graft prevents the collapse of the SEG and augments the anterior
nasal spine, improving the premaxilla.
A sh ield graft an d a backstop graft are design ed to fur-
th er coun ter-rotate an d project th e t ip. Grafts are sut ured
at th e cau dal port ion of th e dom e u sing PDS 5–0 (Fig. 9.10).
On ce th e t ip graft s are xed in p lace, th e sept al m u cosa can
be sut ured using a Vicr yl 5–0 run n ing quilt closure start-
ing at th e in ferior port ion of caudal st rut an d ru n n ing ran -
dom ly in a loop fash ion . Make sure th e areas of th e in tern al
valve an d th e m em bran ou s sept u m are w ell coapted. At
th is poin t th e SSTE can be draped to ch eck th e t ip projec-
t ion an d coun ter-rot at ion . On ce th e surgeon is sat is ed
w ith th e rest ruct ured t ip, a dorsal graft can used to blen d
th e n ew t ip w ith th e radix.9
Fig. 9.10 Contour tip grafts. Once the lower lateral cartilages are
at tached to the SEG, multiple backstop, shield, and onlay grafts are
put in place for further counter-rotation and projection of the tip.
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9 Aesthetic Rhinoplast y for Southeast Asians 113
Osteotomy: For Safety, Guide and Glide
Osteotom y is d on e on n oses sh ow ing an inverted -V defor-
m it y bu t on ly on ce th e fram ew ork of th e t ip is accom -
plish ed. Th e inver ted-V deform it y usually disappears on ce
a dorsal im plan t is pu t in place, or som et im es ju st a lateral
osteotom y m ay be n eeded.
A m edial osteotom y com m ences at 5 to 6 m m from the
m idline and is directed superolaterally not to extend beyond
the im aginary line bet ween the m edial canthi. A w ide plat-
form is needed to accom m odate the dorsal im plant. Oste-
otom y follow s the “guide and glide” principle, w here the
surgeon guides the osteotom e to cut the bones and glides
along the desired path, w hich is usually thin. There w ill be a
feeling of resistance or a change in pitch from tapping of the
m allet w hen one reaches a solid bone. The lateral osteotom y
can be approached directly transcutaneously or intranasally.
The transcutaneous approach is done using a 3-m m osteo-
tom e. The intranasal approach com m ences at the aperture
near the nasal process of the m axillary bone superior to the
inferior turbinate. A guarded curve osteotom e is introduced
through a sm all stab incision in the nonhair-bearing area of
the vestibule just above the attachm ent of the inferior turbi-
nate. The guard should be palpated transcutaneously w ith the
nondom inant hand along the tract of the lateral osteotom y.
The tract should run through the softer bones at the nasal
process of the m axilla. Som e surgeons have approached the
lateral osteotom y intraorally at the gingivo-buccal sulcus.12
Designing the Dorsal Implant
Th e m ajorit y of South east Asian n oses n eed dorsal aug-
m en t at ion . In gen eral, th e th icker th e im plan t th e m ore vis-
ible it m ay becom e. Dorsal im plan t s usually range from 2 to
4 m m in th ickn ess. Depen ding on th e design , th e im plan t
sh ou ld be on e w h ole p iece from th e radix to th e u p p er
lateral car t ilage or exten d sligh tly caudally over th e low er
lateral car t ilage.
Th ere are several m aterials used for dorsal im plan t s.
Au tologou s m aterials are st ill th e best , an d in clu d e car t i-
lages, derm is, fascia, an d fat . How ever, because of th e n eed
for volum e in dorsal augm en tat ion , syn th et ic m aterials
are p referred. Syn th et ic m aterials in clu de silicon e, ePTFE
(Gore-Tex), an d porous polyethylen e (Medpor). Th ere are
also h om ograft s su ch as p rocessed derm is, fascia, an d rib.10
Of all th e m aterials m en t ion ed, th e th ree m ost com -
m on ly u sed in dorsal im p lan ts are silicon e, ePTFE, an d car-
t ilage. Th ese m aterials h ave th eir respect ive ben e t s an d
risks. On e ben e t of silicon e is th at it is relat ively ch eap an d
easy to rem ove w h en in fected . How ever, w h en h ealed th ere
is a capsu lar form at ion th at m ay give a surgical look years
later because th e subcu tan eous fat of th e SSTE at roph ies
w ith t im e. Silicon e is also m obile despite th e precise design
of the subperiosteal pocket . It h as a ten den cy to m igrate
su p eriorly to th e rad ix or cau dally to th e t ip, cau sing
114 II Rhinoplast y
ch ron ic pressure n ecrosis an d su bsequen t ext rusion . Th e
im p lan t sh ap es are gen erally classi ed as “I” or “L” sh apes.
The “I” sh ape im plan t exten ds from radix to th e t ip, w h ile
th e “L” sh ape im plan t h as a st rut th at goes bet w een th e
m edial cru ra to th e an terior sp in e. Th e “L” sh ape m ain t ain s
th e t ip project ion an d preven t s superior m igrat ion of th e
im p lan t; h ow ever, it is frequ en tly associated w ith t ip skin
p ressu re n ecrosis.
Expan ded PTFE, on th e oth er h an d, h eals w ith adh esion
an d d oes n ot form a cap su le. It closely adh eres to th e n asal
bon e an d car t ilages, giving a m ore n at ural look. How ever,
in cases of long-st an ding react ion an d in fect ion it m ay be
d i cu lt to rem ove. Th e in ciden ce of ePTFE in fect ion varies
w orldw ide, bu t if st rict sterilit y an d p rop er su rgical tech -
n iqu e are em p loyed, th e in ciden ce is low.
Cartilage as an im plan t is best for correction of sm all
dorsal defects. Since the septal cartilage is m ainly used for
su pport, con ch al cartilage is u sed for th e dorsal graft. If m ore
volu m e is n eeded, bilateral h ar vest of con ch al cart ilage is
done. The cartilage is cut into 5- to 8-m m strips. Th e st rips
are scored on th e con cave side an d stacked using nylon or
PDS sut ures. Stacked con ch al cart ilage is e ective; h ow ever,
the st rips resorb and m ay w arp over tim e. There m ay also be
irregu larities found w hen palpat ing the dorsum .13
Com paring th e ben e t s an d risks of th e th ree m ost
com m on m aterials used for dorsal augm en t at ion , th e use
of ePTFE is preferred because of its n at u ral look an d low
risk of react ion an d ext ru sion . It com es preform ed an d in
sh eet s. Alth ough ePTFE sh eet s can be stacked an d su t u red
togeth er, it is recom m en ded th at a single p iece of im p lan t
be used as m u ch as possible because of th e risk of con t am i-
n an ts becom ing t rap p ed bet w een sh eet s du ring h an d ling.
Noses w ith a low radix n eed m ore augm en t at ion , so a
preform im plan t is w ell suited w h ile a n ose w ith a sh al-
low radix m ay just n eed a th in sh eet . In su t uring of sh eet s,
m on o lam en t su t u res sh ou ld be u sed. Avoid u sing absorb -
able braided su t u res to preven t im p u rit ies being in t ro-
duced an d em bedded in th e ePTFE m aterial.
a is carved using a no. 10 surgical blade.
http://e-surg.com
Designing a Preformed ePTFE Implant
Preform ed ePTFE im plan ts sh ould be rem oved from th e
sterile p ackaging on ly w h en it is t im e for in sert ion . In sert-
ing th e im plan t is a t rial-an d-error procedu re. First th e SSTE
sh ou ld be redrap ed an d th e radix dow n to th e t ip sh ou ld
be palpated to determ in e th e ven t ral sh ape of th e im plan t .
Th e ven t ral side of th e im plan t is th en car ved accordingly.
Th e im plan t is rein serted an d th e length of th e im plan t is
ch ecked again st th e dom e. If th e im plan t is long, th en it is
cut (Fig. 9.11).
At ten t ion is th en d irected at th e n ew radix, su p rat ip,
w idth , an d rh in ion . Because th e rh in ion’s convexit y w ill be
at a di eren t site from th e st retch ed SSTE w h en redraped,
care sh ould be t aken to avoid a h um p look of th e im plan t .
Th e rh in ion side of th e im plan t can be determ in ed in t w o
w ays. On e w ay is to app ly extern al p ressu re to th e dorsu m
to p rodu ce a convexit y of th e im plan t; th e oth er w ay is by
using a Brow n -Adson forceps (on e jaw ben eath th e im p lan t
to p alp ate th e bony-cart ilagin ou s ju n ct ion an d on e jaw
above th e im p lan t) an d m ake a p in ch m ark on ce th e bony-
cart ilagin ous jun ct ion is located (Fig. 9.12). Th e im p lan t is
th en rem oved an d car vings are don e accordingly.13
Sin ce m ost t ips in rh in oplast y go dow n on long-term
follow -u p, it is recom m en ded th at th e cau dal en d of th e
im plan t be sut u red to th e dom e to allow th e w h ole un it of
th e dorsum to blen d w ell w ith th e t ip, even w ith long-term
resorpt ion of th e t ip. Th e sut u ring also preven t s caudal
deviat ion of th e im plan t .
Th ere m ay be a space bet w een th e upper cart ilage an d
th e ven t ral side of th e im plan t . Th e space sh ou ld be oblit-
erated, p referably w ith car t ilage rath er th an a th in sh eet
of ePTFE because th e lat ter m ay cause ch ron ic pressu re at
th e m ucosa bet w een th e upper lateral cart ilage an d low er
lateral car t ilage, w ith subsequen t in fect ion (Fig. 9.13).
Fig. 9.11 Preformed ePTFE implant. (a) The dorsal shape is ana-
lyzed to match the ventral side of the implant. (b) The ventral side
 9 Aesthetic Rhinoplast y for Southeast Asians 115

a b

c d

Fig. 9.12 Two ways to determine the rhinion. (a) External pressure on both ends will give a convexit y of the ePTFE. (b) A bet ter way is
inserting a Brown-Adson forceps up to the junction of the upper lateral cartilage and the nasal bone; the implant is pinched as a marker for
the rhinion. (c) The marks of the forceps teeth are noted and marked. (d) The marked area is carved out.

a b

Fig. 9.13 Gap bet ween ePTFE and upper lateral cartilage. (a) A space is often noted in the area of the upper lateral cartilage, especially
in a tip repositioned for projection. (b) The space can be lled up with cartilage. This is done to prevent collapse of the implant, causing
supratip depression.

http://e-surg.com
116 II Rhinoplast y
Designing a Sheet ePTFE Implant
Sh eet ePTFE com es in several th ickn esses. Usu ally sh eets
of 2 or 3 m m th ickn ess are used for m in im al augm en ta-
t ion w h ile preform ed im plan ts are u sed for bigger aug-
m en t at ion . Depen ding on th e d im en sion s of th e sh eet , it is
cut in to in dividual st rips of at least 50 m m length an d 13
m m w idth . Th e st rip s are in dividu ally packed in a dou ble
pouch an d sterilized by gas or steam . Dividing a sh eet for
m u lt iple-p at ien t u se in t raop erat ively sh ou ld n ot be don e
because of th e possibilit y of cross-con t am in at ion .
In design ing a sh eet im plan t , th e length is rst est i-
m ated by p lacing th e sh eet on top of th e n ose. Th e sid es
are t rim m ed u sing a n o. 10 blade an d m ain t ain ing 5 to 6
m m at th e m ed ial port ion . Th e ceph alic an d cau dal en ds
are t rim m ed ben eath an d at th e corn ers. Th e sh eet im p lan t
is th en in ser ted, n ot ing speci cally any depression th at is
fou n d, w h ich is usually in th e m iddle th ird of th e n ose. A
sm all ePTFE sh eet or car t ilage is u sed to elevate th e sh eet
for bet ter form . Car t ilage is preferred over ePTFE sh eet as
th e m aterial used to elevate th e sh eet im plan t because th e
lat ter m ay dislodge th e im plan t in to th e m ucosa bet w een
th e upper lateral cart ilage an d low er lateral cart ilage, caus-
ing ch ron ic pressu re an d subsequen t erosion an d in fect ion
(Fig. 9.13).
Th e SSTE is redraped for n al in spect ion . Palpat ion is
im p or t an t at th is t im e to iden t ify a sm ooth dorsum from
th e radix to th e t ip. After m aking cer tain th at th e n ew dor-
su m w ith ePTFE sh eet im p lan t is sm ooth w ith n o depres-
sion , th e cau dal en d of th e sh eet im p lan t is th en su t u red at
th e dom e using nylon 6–0. If fur th er project ion or coun -
ter-rot at ion is n eeded, addit ion al on lay or sh ield grafts
are u sed . Cam ou age graft s are also u sed at th is p oin t if
deem ed n ecessar y.13
Closure of the Incision
Closu re of th e t ran s-colum ellar in cision sh ould be don e in
t w o layers. Vicr yl 6–0 is rst used to sut ure th e subcut an e-
ous t issue, an d th e skin is closed using nylon 6–0 sim ple
in terru pted sut ures. To ach ieve sym m et r y in skin closure, it
is advisable to sut ure altern ately left an d righ t to follow th e
cut pat tern of th e in cision .
http://e-surg.com
Alar Base Surgery
Th e alar base m ay appear w ide despite project ion of th e t ip.
Alarplast y is don e as th e last p roced u re. An ellip se of skin
t issue in th e n asal sill is excised follow ing Weir’s tech n ique.
Cin ch ing of th e alar base h elps in coapt ing th e alarplast y
defect for ten sion -free closure. Cin ch ing sh ould n ot be t igh t
because it can cause discom fort an d a rot at ion look of th e
t ip. Closure is by nylon 5–0 sim ple in terru pted sut ures.
■ Key Technical Points
1. In n oses w ith h anging ala, perform an alar lift
su rger y via a “sail” excision as th e rst step becau se
th e w h ole t ip an d ala are fully m obile, allow ing
accu rate m arking, excision , an d closu re of th e d efect .
2. Th e plan e of dissect ion is above th e perich on drium
in th e low er lateral cart ilage an d upper lateral
cart ilage, an d is subperiosteal in n asal bon es.
Dissect ion sh ou ld be w ide to allow redraping of th e
SSTE w ith n o ten sion .
3. Fixat ion of a SEG n eeds four sut ures to ach ieve
stabilit y. Add it ion al graft s are u sed to su pp ort th e
SEG if d eem ed n ecessar y.
4. Fixat ion of the dom e to th e SEG sh ould be free from
ten sion . Ch eck for bu ckling of th e SEG or deviat ion
of th e t ip.
5. Im plan ts sh ould be car ved carefully in all
dim en sion s to ach ieve a good blen ding of th e
im plan t w ith th e un derlying st ruct ures.
6. Th e caudal en d of th e im plan t sh ould be sut ured to
th e dom e to ach ieve a un i ed st ruct ure. If th e t ip
loses it s project ion over th e long term , th e w h ole
t ip—in cluding th e im plan t—w ill go dow n as on e
u n it bu t st ill h ave good t ip de n it ion . Th e xat ion
also preven t s su blu xat ion of th e im p lan t , cau sing
deviat ion .
7. A gap of space m ay occu r bet w een th e im plan t an d
u pp er lateral car t ilage an d it sh ou ld be lled u p w ith
cart ilage.
8. Th e caudal m argin of th e im plan t sh ou ld be cleared
from th e lin e of in cision .
9. Closure of in cision s sh ould be m et iculous. No
few er th an seven su t u res sh ou ld be u sed in th e
m idcolu m ellar in cision .
10. Alarplast y is don e as th e last procedure.

■ Complications and
Their Management
As m ost rh in oplast y in South east Asian s involves alterat ion
of th e n ose’s st ruct ural fram ew ork, com plicat ion s of th e
su rger y are also closely related to th e rest ru ct u red fram e-
w ork. Most of th e t im e, th e am ou n t of n asal sept u m h ar-
vested is on ly su cien t for th e SEG. Th ere is alm ost alw ays
a n eed to u se con ch al cart ilage for con tou r graft s (e.g.,
sh ield graft s, cap grafts). Sou n d ju dgm en t is im p or tan t as
to th e am ou n t of dorsal an d cau dal st ru t th at is left beh in d,
w h ich sh ou ld be en ough to h old th e st ruct ural grafts an d
con tour graft s an d to w ith st an d th e pressure force from th e
SSTE du ring closu re. Gen erally, a sm all n ose w ith a sm all,
rm sept u m m ay n eed on ly 8 m m of st ru t w h ile a n ose
w ith a th in sept um n eeds 10 to 12 m m of st rut .10
Th e surgeon sh ould be able to visualize th e vector for
th e new t ip to properly place th e SEG. Th e low er lateral car-
t ilage sh ould n ot be pu lled too m uch because such forces
m ay cau se bu ckling of th e SEG. Th is, in t u rn , w ill cau se
t w ist ing of th e t ip an d com pression of th e in tern al n asal
valve.4 Th e low er lateral cart ilage sh ould be sym m et rically
xed to th e SEG. Any de cien cy in th e d esired t ip p rojec-
t ion and coun ter-rotat ion can be corrected by th e u se of
con ch al car t ilage for on lay or sh ield graft s, respect ively. Do
n ot app ly too m u ch ten sion on th e dom e w h en xing it to
th e SEG.
If tw isting of the tip is noticed w hile still in surgery,
all grafts should be rem oved and all structures should be
realigned. In late-onset t w isting of the tip, correction should
involve m inim al access and m inim al m anipulation of the
w hole structure. Correction is usually accom plished by place-
m ent of a cam ou age graft (crushed cartilage, tem poralis
fascia, or sacroderm al fat) to achieve sym m etry; if there is an
accom panying obstruction in the internal valve, subm ucous
resection or scoring/suturing of the SEG can be done.
Palp at ion is ver y im p ort an t to detect any gap bet w een
th e im plan t an d it s u n derlying st ruct ures in th e radix an d
su p ratip area. Th e t ip sh ou ld be w ell de n ed visu ally an d
con rm ed by palpat ion before n al closure.13
Su rgeon s sh ou ld adh ere to th e st rict m an n er of h an -
dling dorsal im plan ts to avoid in fect ion . In fect ion occur-
ring in th e rst 2 m on th s m ay be iat rogen ic, w h ile in fect ion
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9 Aesthetic Rhinoplast y for Southeast Asians 117
beyon d 2 m on th s is usu ally related to im m u n e respon se.
Early sign s of in fect ion can be reversed by in t ake of an t ibi-
ot ics. Persisten t edem a of th e dorsu m after augm en t at ion
rh in oplast y m ay require rem oval of th e im plan t an d revi-
sion u sing an au tologou s graft .13
Tip cart ilage visibilit y is seldom en cou n tered in Sou th -
east Asian n oses becau se of th e th icker t ip skin ; h ow ever,
in exten sive t ip project ion an d coun ter-rotat ion , cart ilage
visibilit y m ay be an u n exp ected sequ ela. Th erefore, it is
recom m en ded th at crush ed cart ilage or a soft t issue graft
be placed over th e n al t ip graft .8
Th e n al appearan ce of th e recon st ructed n ose in t raop -
erat ively w ill rep resen t th e n al ou tcom e of th e n ew n ose
postoperat ively. In t raoperat ive palpat ion is an im port an t
step to h elp visu alize th e n al sh ap e of th e recon st ru cted
n ose postop erat ively in th e m on th s to com e.
■ Case Studies
Case 1
A 25-year-old w om an w an ted a rh in op last y to im p rove
th e appearan ce of h er face (Fig. 9.14). Physical exam in a-
t ion sh ow ed a st raigh t dorsu m an d sept um . Th e dorsum ,
h ow ever, w as low ; n asal bon es ap p eared w ide; th e t ip w as
bulbous an d sligh tly upt urn ed; th e colum ella w as sligh tly
ret racted w ith a ret ruded prem axilla; th e alar base w as
w ide w h ile th e alar rim w as h anging.
Alar lift surger y via a sail excision w as don e as th e rst
step. Con ch al cart ilage w as h ar vested an teriorly. Th e su r-
ger y w as an open ap proach septorh in oplast y w ith a sept al
exten sion graft at th e righ t side of th e cau dal st ru t . Folded
con ch al cart ilage w as placed below th e SEG for suppor t an d
for p rem axillar y augm en t at ion (Fig. 9.15). After th e d om e
of th e low er lateral car t ilages w as xed to th e SEG, con ch al
car t ilage w as used for t ip grafts. A 3-m m ePTFE sh eet w as
used to augm en t th e dorsum an d w as blen ded in w ith th e
n ew t ip an d th e radix. A sm all p iece of con ch al cart ilage
w as p laced bet w een th e u n derside of th e im p lan t an d th e
upper lateral cart ilage. A plum ping graft using pieces of
con ch al cart ilage w as in ser ted in to th e prem axilla. Alar
base su rger y w ith a cin ch ing tech n iqu e w as don e as th e last
procedure. Results are sh ow n in Fig. 9.16.
118 II Rhinoplast y

Fig. 9.14 Case 1. A t ypical Southeast

a b
Asian nose is shown. (a) Preoperative fron-
tal view shows a low but straight dorsum.
The tip is upturned, wide, and bulbous.
The nasal bones are wide. The alar base
is wide, the rim is hanging, and the colu-
mella is retracted. (b) Lateral view shows a
low dorsum and retracted premaxilla. The
columella is not visible and the alar rim is
hanging.

Fig. 9.15 Case 1. Schematic drawing of the soft tissue correction and structural grafting. The main support graft is a SEG, which is fur-
ther supported with an extended spreader and folded conchal cartilage. Tip de nition grafts include shield, backstop, and crushed onlay
grafts. Medial and lateral osteotomies were done. A 3-mm ePTFE sheet was used for dorsal augmentation. Soft tissue correction includes
sail excision for alar lift and alar base surgery.

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a b
Case 2
A 28-year-old m an desired im p rovem en t of h is n ose, esp e-
cially it s t ip (Fig. 9.17). Physical exam in at ion sh ow ed a
st raigh t dorsu m an d sept u m . Th e dorsu m , h ow ever, w as
low w ith p rom in en t glabellar fron t al bossing; n asal bon es
w ere w id e; th e t ip w as low an d bu lbou s; th e colu m ella w as
ret racted w ith a ret ruded prem axilla; th e alar base w as
w ide w h ile th e alar rim w as h anging.
An alar lift via sail excision w as don e as the rst step.
Cavum an d cym ba con ch al cartilage w as h ar vested an teri-
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9 Aesthetic Rhinoplast y for Southeast Asians 119
Fig. 9.16 Case 1. (a) Postoperative frontal
view shows a bet ter dorsal nasal aesthetic
line. The tip is narrower and counter-
rotated. The alar width is narrower. There is
a bet ter alar-columellar relationship. (b) Lat-
eral view shows good tip counter-rotation
and projection. The dorsum is augmented
and the premaxilla is fuller. The columella is
visible and the alar rim is elevated.
orly. The surger y w as an open approach septorh inoplast y
w ith a septal exten sion graft at the right side of the caudal
stru t an d a caudal m argin exten sion graft . After th e dom al
cart ilages w ere xed to the SEG, conchal cart ilage w as used
for t ip grafts (Fig. 9.18). A 4-m m preform ed ePTFE piece w as
used to augm ent the dorsum . A sm all piece of conchal car-
tilage w as used to ll up the space bet w een the underside
of the im plan t an d the upper lateral cartilage. Pieces of con-
ch al cartilage w ere used for a plum ping graft . After closure
of th e rhinoplast y incision, alar base surger y w ith cinching
w as th en carried ou t. Results are sh ow n in Fig. 9.19.
120 II Rhinoplast y

Fig. 9.17 Case 2. (a) Preoperative frontal

view shows a wide ala, a retracted colu-
mella, and a de cient middle vault. (b) Lat-
eral view shows a low dorsum, bulbous tip,
and retracted premaxilla. The middle vault
seems de cient.

a b

Fig. 9.18 Case 2. Schematic drawing of the soft tissue correction and structural grafting. The m ain support graft is a SEG, which is further
supported with a caudal margin extension graft. Tip de nition grafts include shield, backstop, and crushed onlay grafts. Medial and lateral
osteotomies were done. A 4-mm preformed ePTFE implant was used. Soft tissue corrections included a 5-mm sail excision for alar lift and
a 2-mm alar base resection.

http://e-surg.com

a b
References
1. Akkus AM, Er yilm az E, Gun eren E. Com parison of th e ef-
fect s of colum ellar st rut and sept al extension graft s for t ip
support in rh in oplast y. Aesthet ic Plast Surg 2013;37(4):
666–673
2. Baladiang DE, Olveda MB, Yap EC. Th e “sail” excision
tech n iqu e: a m odi ed alar lift p rocedu re for Sou th east
Asian n oses. Ph ilip p J Otolar yngol Head Neck Su rg. 2010;
25:31–37
3. Byrd HS, An doch ick S, Copit S, Walton KG. Sept al exten sion
graft s: a m eth od of con t rolling t ip project ion shape. Plast
Recon st r Su rg 1997;100(4):999–1010
4. Ch oi JY, Kang IG, Javidn ia H, Sykes JM. Com plicat ion s of
sept al exten sion graft s in Asian pat ien t s. JAMA Facial Plast
Su rg 2014;16(3):169–175
5. Jang YJ, ed. Rh in oplast y an d Septoplast y. Seoul, Korea:
Koonja; 2014
6. Kim JH, Song JW, Park SW, Oh WS, Lee JH. E ect ive sep -
t al exten sion graft for Asian rh in oplast y. Arch Plast Surg
2014;41(1):3–11
http://e-surg.com
9 Aesthetic Rhinoplast y for Southeast Asians 121
Fig. 9.19 Case 2. (a) Postoperative frontal
view shows a good dorsal nasal aesthetic
line. The alar-columellar relationship is bet-
ter. The alar base is narrower. (b) Lateral
view shows a good augmented dorsum and
projected tip. The premaxilla is fuller and
there is columellar show. The alar rim is well
lifted.
7. Koch CA, Friedm an O. Modi ed back-to-back autogen ous
con ch al cart ilage graft for cau dal sept al recon st ru ct ion :
th e m edial cru ral exten sion graft . Arch Facial Plast Su rg
2011;13(1):20–25
8. Lin J, Ch en X, Wang X, et al. A m odi ed sept al exten -
sion graft for th e Asian nasal t ip. JAMA Facial Plast Surg
2013;15(5):362–368
9. Pern ia NE, Galvez JA, Victoria FA. Th e dim en sion s of th e
n asal sept al cart ilage: a prelim in ar y st udy in adu lt Filipi-
n o Malay cadavers. Ph ilipp J Otolar yngol Head Neck Su rg.
2011;26:10–12
10. Toriu m i DM, Bared A. Revision of th e su rgically oversh ort-
en ed n ose. Facial Plast Surg 2012;28(4):407–416
11. Yap E. Im p roving th e h anging ala. Facial Plast Su rg 2012;
28(2):213–217
12. Yap EC. Prin cip les of st ru ct u ral rh in op last y in Sou th East
Asian n oses. Ph ilipp J Otolar yngol Head Neck Su rg. 2014;
29:41–44
13. Yap EC, Abu bakar SS, Olveda MB. Exp an ded p olytet ra u o-
roethylen e as dorsal augm en tat ion m aterial in rh in op last y
on Sou th east Asian n oses: th ree-year experien ce. Arch Fa-
cial Plast Surg 2011;13(4):234–238
 10 Correction of the Short, Contracted Nose
Hong Ryul Jin
Pearls
• Repeated rh in oplast ies causing t rau m a to th e skin ,
soft t issu e, an d car t ilages, im p lan t u se over th e
low er lateral cart ilage causing pressure n ecrosis,
an d over-resect ion of car t ilages w ill en su e scar
con t ract u re w ith resultan t sh or t , con t racted n ose.
• With every e ort m ade to correct the deform ity, often
the postsurgical contracted, short nose cannot be
elongated to a level equal to patient expectations. It is
crucial to have an adequate consultation before surgery.
• Th e st rategies for correct ing secon dar y sh or t n ose
deform it y in clude skin envelope release th rough
w ide un derm in ing, elongat ion an d derot at ion of
th e t ip com pon en t , augm en t at ion of th e dorsum ,
an d u se of com posite graft m aterial to ll th e gap
bet w een th e elongated skin envelope an d th e
u n derlying vest ibular skin .
• In m ost cases of sh ort n ose correct ion , cost al
cart ilage is n ecessar y for st ru ct ural suppor t an d
on lay graft ing.
• A sept al exten sion graft st rongly su pp or ted w ith
bilateral exten ded spreader grafts using rib cart ilage
■ Introduction
Th e sh ort n ose, th e so-called sn ub n ose, is object ively
de n ed as h aving a decreased n asal length w ith an
abn orm ally in creased n ost ril sh ow from th e fron t al view
(Fig. 10.1). Th e t ip is rotated cep h alically w ith a m ore
obt use n asolabial angle on th e lateral view. Th e ast ute
su rgeon sh ou ld also n ote th at a d eep n asofron tal angle
con t ribu tes to th e subject ive appearan ce of a sh ort n ose,
esp ecially w h en com bin ed w ith an obt u se n asolabial angle.
The short nose can be congenital in origin, but is usually
acquired secondary to traum a or from a previous rhinoplast y.
In postsurgical cases, over-resection of the lower lateral carti-
lage is a frequent predisposing factor in Caucasian rhinoplast y.
On the other hand, in East Asian patients, a postsurgical short
nose deform ity arises from di erent m echanism s.
Th e exact path ogen esis of sh or t n ose developing after
rh in oplast y using an alloplast ic im plan t is u n kn ow n yet
but capsular con t ract ion aroun d th e im plan t used for dor-
sal augm en tat ion , low er lateral car t ilage n ecrosis by long-
term pressure from im plan t s, ch ron ic in am m at ion , an d
122
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is th e key st ruct u ral foun dat ion on w h ich th e low er
lateral car t ilage can be reposit ion ed.
• An en d -to-en d t yp e septal exten sion graft h as th e
advan t ages of align ing th e cen ter in to m idlin e an d
avoiding caudal sept al deviat ion com pared w ith th e
overlap p ing t yp e.
• Various on lay grafts over th e reposit ion ed low er
lateral car t ilage can h elp to length en or augm en t th e
t ip.
• A ch on drocu t an eou s com posite graft taken from
th e cym ba con ch a is often needed to ll th e gap
bet w een th e length en ed skin envelope an d th e
vest ibu lar lin ing.
• A staged operat ion or even a foreh ead ap w ill
be n ecessar y if th e skin sh ort age is severe in an
ext rem ely con t racted or dest royed n ose.
• Warping of th e rib car t ilage u sed as a dorsal on lay
graft can be m in im ized w ith prop er tech n iqu es
but is n ot com pletely avoidable. It can be corrected
w ith revision surger y after fu ll-blow n w arping h as
occurred.
scar con t ract ion from m u lt ip le rh in op last ies are th ough t to
be possible et iologies. Th is con dit ion is rath er com m on in
pat ien t s w ith w eak low er lateral car t ilages w h o h ad m ul-
t iple rh in oplast ies w ith silicon e im plan tat ion .
Tech n iques to length en th e n asal t ip are orien ted to
adding car t ilage graft s to th e cau dal sept u m to cau dally
rot ate th e t ip, securing spreader grafts to a colu m ellar st rut ,
t ip graft s of various sh apes, an d placem en t of radix graft s
to elevate th e n asion .1 Most post su rgical con t racted n oses
h ave both st ru ct u ral problem s, su ch as w eak alar cart ilage
an d decreased skin com plian ce cau sed by a dam aged skin –
soft t issu e envelop e. Becau se of th ese feat u res, sh ort n ose
correct ion h as becom e on e of th e m ost di cult procedures
in rh in oplast y.
■ Patient Evaluation
Th e pat ien t’s h istor y of previous su rger y n eeds to be qu es-
t ion ed ver y th orough ly. Dates an d n um ber of surgeries,
su rgeon s’ n am es, m aterials u sed, tech n iqu es u sed, an d any
speci c reason s for m u lt ip le su rgeries, in clu ding com plica-

a b
Fig. 10.1 Typical postoperative short nose deformit y. (a) Abnor-
mally increased nostril show and short nose are evident from the
frontal view. (b) Lateral view shows excessively cephalically rotated
nasal tip, low dorsum, acute nasofrontal angle, and obtuse naso-
labial angle.
t ion s, n eed to be evaluated. Th orough dat a are im port an t in
p lan n ing su rger y.
Th e extern al n ose is palpated carefully to evaluate th e
skin , u n derlying bon e, an d cart ilage. W h en th e skin is too
th ick or h as a scar th at decreases it s m obilit y, th e am oun t
of lengthen ing of th e n asal t ip can be lim ited. A sen se of th e
adequ acy of skin m obilit y can be gain ed by p ressing dow n
on th e skin an d pulling on it (Fig. 10.2). Ext rem ely th in an d
adh eren t skin m ay cau se di cu lt y in u n derm in ing an d w ill
raise th e possibilit y of skin dam age. Ever y e or t sh ou ld be
exerted n ot to dam age th e skin in th is case.
Th e n asal cavit y, especially th e sept um , sh ould be th or-
ough ly evalu ated. In revision cases, th ere is a h igh ch an ce
th at sept al cart ilage h as already been used in th e previous
su rger y an d n ot in frequ en tly th ere are sept al perforat ion s.
Th e in t act-looking sept um n eeds to be carefully palpated
Fig. 10.2 Evaluation of skin mobilit y. Skin mobilit y is assessed by
pulling the dissected skin and soft tissue envelope over the carti-
lage infrastructure during the surgery.
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10 Correction of the Short, Contracted Nose 123
w ith cot ton t ips, an d often a th in , m em bran ous posterior
sept u m w ith m issing car t ilage can be felt . In ext rem e cases,
th e caudal sept um is m issing, causing severe sh rin kage an d
con t ract ion of th e t ip. In th ese cases, length en ing of th e
nose is possible on ly after th e caudal sept um is restored.
Elongat ing a sh or t , con t racted n ose is a ver y di cult
job, an d even w ith exten sive st ruct ural groun dw ork, th e
nose can be length en ed on ly by 3 to 4 m m . Th erefore, th e
lim itat ion s of th e su rger y n eed to be explain ed th orough ly
to th e pat ien t an d a reason able su rgical goal n eed s to be
set . Often th e p at ien t s ten d to h ave u n realist ic expect a-
t ion s, su ch as th at th e n ose w ill look n orm al an d m ore
beaut iful com pared w ith it s preoperat ive st at us. Realist ic
pat ien t expect at ion s an d a reason able surgical goal con sid-
ering th e n asal stat u s an d th e su rgeon’s exp erien ce are th e
m ost im p or tan t factors in th e su ccess of th e su rger y.
■ Surgical Techniques
Strategies for Correction
If th e degree of cep h alic rotat ion is m ild an d th e t ip su p -
port is st rong, adding car t ilage graft s on th e t ip an d th e
dorsu m m ay give som e degree of caudal rot at ion of th e t ip
an d th e illu sion of n asal length en ing by dorsal augm en ta-
t ion . In a ver y sh ort n ose caused by severe ceph alic rot a-
t ion of th e t ip -de n ing poin t , m erely raising th e n asion
w ith an im plan t on th e n asal dorsum , or pulling dow n th e
t ip -de n ing poin t sligh tly by placing a graft on th e n asal t ip
has lim ited length en ing e ect . More radical reorgan izat ion
an d rep osit ion ing of th e low er n asal fram ew ork an d skin
envelop e are n ecessar y. Proper su rgical tech n iqu e is ch osen
con sidering th e prior operat ive h istor y, pat ien t expect a-
t ion s, th e degree of ceph alic rotat ion of th e n asal t ip pres-
en t , skin m obilit y, an d th e am ou n t of available cart ilage for
use as graft s.
In m ost post su rgical con t racted , sh or t n ose, cau dal
rot at ion of th e t ip -de n ing poin t an d raising th e n asion
su p eriorly are t w o key su rgical goals. Cau dal rotat ion of th e
t ip -de n ing poin t is obt ain ed by caudally readjust ing th e
low er lateral cart ilage on th e septal exten sion graft w ith or
w ith out addit ion al t ip on lay graft s (Fig. 10.3). To cau dally
rot ate th e t ip w ith out losing project ion , a rm st ru ct ural
su p p or t rein forcing an d length en ing all th ree legs of th e
“t rip od” of th e n asal t ip is n eed ed .
W h en th e cen t ral part of th e n ose (i.e., th e colu m ella
an d th e t ip lobu le) is length en ed w ith a sept al exten sion
graft , th e lateral cru s m oves ver t ically u pw ard an d so d oes
th e alar m argin . Th e alar m argin s also n eed to be low ered
to create a m ore balan ced n ost ril after th e p lacem en t of th e
sept al exten sion graft . Sligh t im balan ce can be adju sted
w ith a lateral cru ral on lay or st ru t graft . Placing a long lat-
eral cru ral st ru t graft–lateral cru ral com plex in to a p ocket
m ade in th e piriform ap er t u re m ay low er th e alar m argin
in th e th in -skin n ed Caucasian pat ien t , but th is m an euver
124 II Rhinoplast y

a b

Fig. 10.3 Illustrations showing key techniques used to correct short nose defor-
mit y. Septal extension grafts reinforced with extended spreader grafts and tip onlay
grafts are used to lengthen the nasal tip. (a) End-to-end t ype. (b) Overlapping t ype.
(c) Bilateral conchal composite grafts are applied when the elongated skin envelope
c and the vestibular lining cannot be primarily closed.

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is n ot as e ect ive for East Asian s, w h o h ave th icker skin . In
m ost cases, th e st i an d in elast ic skin envelope an d de -
cien t vest ibular skin are th e m ost com m on ly en coun tered
lim it ing factors du ring th e low ering procedu re of th e alar
rim . Th e au th or p refers to u se con ch al com posite graft s
from th e cym ba con ch a to ll th e gap bet w een th e elon -
gated skin envelope an d th e de cien t vest ibu lar m u cosa, at
th e sam e low ering th e alar m argin (Fig. 10.3c).
Many Asian p at ien t s w an t t ip augm en t at ion even in a
sit u at ion th at calls for th e correct ion of sh ort , con t racted
n ose; h ow ever, it is n ot easy to get both an im p roved p ro-
ject ion an d cau dal rot at ion of th e n asal t ip . W h en su cien t
p roject ion is ach ieved, th e n ose is fou n d to be adversely
rot ated cep h alically. Conversely, correct ing th e sh ort n ose
w ith on ly caudal rot at ion usually en ds in in su cien t t ip
p roject ion . Th u s, an adequate com prom ise bet w een aug-
m en t at ion an d cau dal rot at ion of th e t ip n eed s to be fou n d.
Graft Material Harvesting
In m ost cases, th e sept al car t ilage or con ch al car t ilage is
in su cien t an d costal car t ilage is used. Before deciding
to u se cost al cart ilage, it is p ru den t to ch eck th e rib series
for p ossible calci cat ion of th e cart ilage. Not in frequen tly,
you ng fem ale pat ien t s h ave severe calci cat ion of th e cos-
tal car t ilage.2 Calci cat ion m akes h ar vest ing an d car ving of
th e car t ilage di cult . If th e cart ilage is tot ally calci ed, it is
ver y di cu lt to u se as graft m aterial.
The costal cart ilage graft is h ar vested m ostly from th e
sixth or th e seven th rib for u se in rh in op last y. In fem ale
p at ien t s, th e in cision is placed just above th e in fram a-
m m ar y crease for bet ter cosm esis (Fig. 10.4). In m ale
p at ien t s, th e in cision is m ade directly over th e ch osen rib.
Th e proper car t ilage is located after palpat ion , an d th e cos-
Fig. 10.4 Harvest of rib cartilage. Rib cartilage is being removed
from the small, inframammary incision. The incision can be mini-
mized by exactly locating the costochondral junction by probing
the cartilage using a 26-gauge needle.
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10 Correction of the Short, Contracted Nose 125
toch on dral ju n ct ion is con rm ed by serial probing w ith a
26-gauge n eedle. Marking is usually 1.5 to 2.0 cm in length
in th in -skin n ed pat ien ts an d 2.0 to 2.5 cm in th ick-skin n ed
pat ien t s. A local an esth et ic is in lt rated at th e in cision site.
Ten m in utes after inject ion , th e skin an d subcut an eous t is-
su e is in cised w ith a n o. 10 blade. Th e su bcu t an eou s fat is
altern ately sep arated an d ret racted u sing Sen n ret ractors
un t il th e fascia an d th e extern al oblique m uscle layer are
exp osed . Th e fascia is th en in cised an d th e m u scle bers
sep arated w ith Kelly or m osqu ito forcep s. To adequ ately
exp ose th e su rgical eld, th e m u scle layer is ret racted w ith
an Arm y-Navy ret ractor for bet ter visu alizat ion , in stead of
cut t ing w ith a Bovie, to m in im ize postoperat ive pain . Th e
perich on drium an d th e rib are su cien tly exposed after
ret ract ing th e soft t issue an d m uscle.
Tw o parallel in cision s are m ade on th e perich on drium
of th e rib along th e superior an d in ferior borders, leaving
th e cen t ral st rip of perich on drium on th e an terior surface
in t act . Follow ing th is, several cut s are m ade perpen dicu-
lar to th e longit udin al in cision to facilitate circum feren t ial
re ect ion of th e perich on drium , w h ich is th en dissected
from th e rib w ith a Freer elevator. Th e st raigh t p ort ion of
th e rib is often foun d to be of in su cien t length for dorsal
im plan t at ion , n ecessitat ing exten sion of th e cart ilagin ous
cut up to th e syn ch on drosis por t ion to obtain a longer piece
of cart ilage.
Har vest ing is facilit ated if an an terior cu t is m ade at
th e m edial en d of th e cart ilage before com plet ing th e dis-
sect ion of th e posterior su rface of th e cost al car t ilage. Th e
perich on drium of th e posterior surface of th e rib is dis-
sected o as m u ch as p ossible w ith a cu r ved elevator. Th e
costoch on dral jun ct ion is iden t i ed visually or w ith th e
help of a 26-gauge n eedle an d th e cart ilage cut is m ade.
Th ere is a great risk of injuring th e un derlying pleura if a
com plete cut is m ade using th e n o. 15 blade; th us, th e n al
cut is com pleted w ith th e Freer elevator to preven t su ch an
inju r y. After th e lateral cut , a sm all t w o-prong ret ractor is
used to pu ll up th e cost al cart ilage to expose th e posterior
su rface an d th e dissect ion is con t in u ed m edially. After com -
plete dissect ion of th e posterior perich on drium , th e cost al
cart ilage is separated at th e m edial cut an d delivered out .
A 3- to 4-cm length of cost al cart ilage is t ypically h ar-
vested . Th e cen t ral st rip of p erich on d riu m is dissected
an d preser ved for later u se. Th e h ar vested costal car t ilage
is soaked in w arm salin e to assess for an d in duce w arping
prior to car ving. Test ing for air leakage from th e pleura is
perform ed by lling th e dissect ion pocket w ith salin e an d
th en in it iat ing posit ive-pressure hyper ven t ilat ion . If n o air
leakage in th e form of bu bbles is eviden t , th e don or site is
packed w ith an t ibiot ic-soaked gauze un t il th e operat ion
is com pleted. Addit ion al cost al car t ilage can be h ar vested
during th e operat ion or th e cart ilage rem ain ing after graft-
ing can be rein serted an d preser ved un der th e m uscle layer
for use in fut ure revision surger y. If air leakage is n oted, a
Nélaton cath eter is in serted at th e leakage site an d su t u red
in a pu rse-st ring m an n er. After t igh t closure of th e subcu -
126 II Rhinoplast y
tan eous an d skin w oun d, th e Nélaton cath eter is rem oved
w h ile sim ultan eously adm in istering in ten se posit ive-pres-
su re hyp er ven t ilat ion .
Th e separated m uscles are t igh tly approxim ated to
dim in ish postoperat ive pain an d th e w oun d is closed layer
by layer using 4–0 Vicr yl sut ures. No drain is in serted. Th e
skin m argin s are often bru ised w ith discolorat ion du e to
excessive ret ract ion , an d th ese are t rim m ed an d su t u red
w ith 6–0 nylon an d a com pressive dressing is applied. Th e
nylon su t ures are rem oved on th e seven th to ten th postop -
erat ive day. Ordering a ch est X-ray to ch eck for p n eu m o-
th orax im m ediately after th e operat ion is n ot obligator y
if th e su rgeon is con den t th at th ere w as n o air leakage
th rough th e h ar vest w oun d. If th e pat ien t presen t s w ith
sign s an d sym ptom s of p n eu m oth orax follow ing su rger y,
th en a ch est X-ray is w arran ted. Rarely, a pn eum oth ora x
can occu r even th ough th ere w as n o leakage during th e
in t raop erat ive ch ecking. Mild pn eum oth orax can resolve
spon t an eou sly w ith a serial follow -u p of ch est X-ray; h ow -
ever, a ch est t ube is in ser ted to expan d th e collapsed lung
in n on resolving or severe cases.
Carving of Costal Cartilage
Har vested au tologou s costal cart ilage is design ed an d
car ved in to various form s depen ding on th e purposes of th e
graft: d orsu m augm en t at ion , rein forcem en t of th e sept u m
in th e form of bat ten or septal exten sion graft s, exten ded
spreader graft s to rein force th e sept al exten sion graft , t ip
on lay grafts, or as a prem axillar y graft .
Cost al cart ilage con sists of a core an d periph eral
region s surrou n ding th e core; a balan ce an d stasis are
m ain t ain ed by th e in tern al st ress created by th e t w o com -
pet ing region s.3 Cen t rally cu t pieces of car t ilage w arp
m ore qu ickly th an th e p erip h erally cu t p ieces; h ow ever,
th e periph erally cut cart ilage w arps at a greater rate th an
th e cen t rally cut segm en t .4 Side-to-side w arp ing is m ore
clin ically eviden t du e to less soft t issue resist an ce in th is
d im en sion .5 To prep are a n onw arp ing im p lan t for d orsal
Fig. 10.5 Design for dorsal onlay graft. (a) A straight portion of the harvested rib cartilage
is selected and marked. (b) After excising the peripheral portion, a central portion remains
a for additional carving.
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augm en tat ion , th e p erip h er y of th e cost al car t ilage is sym -
m et rically cu t aw ay, leaving a cen t ral core of th e cart ilage.
Th e cen t ral part of th e cart ilage is car ved w ith a n o. 10 scal-
pel an d u sed as a dorsal im plan t . First , an appropriate sh ape
for th e dorsum is design ed. If a st raigh t piece of rib cart i-
lage w ith su cien t length is har vested, th is is th e ideal sit -
uat ion . In m ost cases, a sligh tly cur ved cart ilage is obtain ed
an d a st rategic ap p roach an d design are n eeded to obtain a
st raigh t graft . After cu t t ing aw ay th e p erip h eral cart ilage
according to th e design , th e cen t ral p ar t is scu lpted in to th e
target sh ape (Fig. 10.5).
Th e car t ilage is periodically soaked in physiologic
salin e for 10 to 20 m in u tes at a t im e, an d th en brough t ou t
to con t in u e th e car ving w h ile w atch ing ou t carefu lly for
sign s of w arping. On ce w arping is eviden t , th e rem ain ing
periph eral con cave por t ion of th e cart ilage n eeds to be cut
out . W h en th e im plan t is car ved in th is m an n er, postopera-
t ive w arping can be m in im ized.6 It takes abou t an h ou r to
scu lpt ever y p iece of th e h ar vested car t ilage in th is m an -
n er to m in im ize th e risk of w arping. Th e com p leted, fu lly
car ved cart ilage graft h as rounded m argin al part s an d
progressively n arrow ed upper and low er part s, yielding a
can oe-like sh ape from th e fron tal view. W h en seen from
th e lateral view, it h as a sligh tly con cave side th at com es
in to con tact w ith th e n asal dorsum , an d a dorsal side th at
is sligh tly convex (Fig. 10.6). How ever, n ot w ith st an ding all
th ese e ort s, ver y m in or w arping occur. Making several
cut s in th e graft fur th er m in im izes th e w arping, alth ough
th ese cut s m ay cause a poten t ial w arping deform it y later.
A at , st raigh t p iece of car t ilage is n ecessar y for u se as
a sept al exten sion graft an d exten ded sp reader graft . For
th ese purposes, th e cart ilage is cu t an d car ved as a at
piece an d soaked in w arm salin e to ch eck for any w arping
before graft ing. To m in im ize w arping, th e car t ilage is cu t
longit udin ally or t angen t ially, leaving periph eral por t ion s
sym m et rically th ick on th e t w o sides of th e cen t ral p or t ion ,
w h ich coun teract s an d n egates the expected distor t ion on
both sides (Fig. 10.7). Th is at , long piece of car t ilage is
resist an t to w arping as long as the periph eral port ion s on
th e sides rem ain sym m et rical.

Fig. 10.6 Final shape of dorsal onlay graft. The completed, carved
cartilage graft has a canoe-like shape from the frontal view. When
seen from the lateral view, it has a slightly concave side that comes
into contact with the nasal dorsum, and a dorsal side that is slightly
convex. A perichondrium at tached to the cephalic side prevents
movement of the graft.
Skin Undermining
Wid e dissect ion of th e skin –soft t issu e envelop e is im p or-
tan t to allow th e skin to be m axim ally st retch ed w h en it
is is redrap ed to th e elongated fram ew ork. Th e th ick scars,
esp ecially th ose on th e low er lateral car t ilage an d ju n ct ion
of low er an d u pper lateral cart ilages, n eed to be excised
an d/or released to m ake th e skin m ore exible an d easily
m an euvered. In a severely scarred case, in adverten t dam -
age to th e overlying skin m ay take p lace, in w h ich case a
n e su t u ring of th e skin w ith an u n derlay of soft t issu e
su ch as fascia h elps to h eal th e scar.
Elongating the Framew ork
Th e suppor t ing st ruct ure to reposit ion an d x low er lateral
cart ilages is th en con st ructed. After dividing th e low er lat-
eral cart ilage an d elevat ing th e sept al ap , a septal exten -
sion graft is added. With th e overlap p ing t yp e, th e sept al
exten sion graft is design ed to reach th e an terior n asal spin e
in feriorly an d to project th e n asal t ip superiorly w h ile
rot at ing it cau dally (Fig. 10.8a). Th e rem ain ing n asal sept al
cart ilage an d th e graft placed n eed to be rm ly xed at th e
an terior n asal spin e. Esp ecially in cases w h ere sept al car-
t ilage w as separated from th e anterior n asal spin e, su t ure
xat ion n eeds to be m et icu lou sly p erform ed . Becau se th e
redraping skin ten sion is h igh , th e n asal sept um an d th e
t ip easily t w ist .
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10 Correction of the Short, Contracted Nose 127
Fig. 10.7 Carving of rib cartilage for a at, straight piece. The car-
tilage is cut and carved as a at piece by cut ting in the longitudinal
or tangential direction. Symmetric peripheral portions on the t wo
sides of the central portion counteract and negate the expected
distortion on both sides.
Th e sept al exten sion graft is rein forced w ith a sept al
bat ten graft or exten ded spreader graft to preven t t w ist-
ing. Th e sept al cart ilage an d th e upper lateral cart ilage are
sep arated in th e sam e p lan e, u sing th e sh arp sid e of a Freer
elevator or w ith iris scissors. It is im port an t to en su re th at
th e sept al m ucoperich on drium is dissected upw ard con t in -
uously un t il th e u pper lateral cart ilage is reach ed, to m ake
su re th at accu rate sep arat ion of th e ju n ct ion of th e n asal
sept u m an d th e u p p er lateral car t ilage is ach ieved. Th e cau -
dal en d of th e exten ded spreader graft n eeds to be t apered
th in to preven t th icken ing of th e upper part of th e caudal
sept u m , w h ich can lead to n asal obst ru ct ion .7 Th e graft is
placed bet w een th e upper lateral cart ilage and th e n asal
sept u m along th e u pp er side of th e sept u m an d th en xed
tem porarily w ith a n eedle (Fig. 10.8b). Su t u ring w ith 5–0
or 4–0 PDS is used to x th e spreader graft to the n asal sep -
t um an d th e separated upper lateral cart ilage to th e sept al
car t ilage–spreader graft com plex using h orizont al m at t ress
su t u res (Fig. 10.8c). Care sh ou ld be t aken d u ring th e su t u r-
ing to ensure th at th e upper lateral car t ilage on on e side is
equ al in length to th e oth er side.
Tip Repositioning and Tip Grafts
Th e low er lateral car t ilage is released from th e upper lat-
eral car t ilage an d piriform ap ert u re an d reposit ion ed on
th e n ew elongated n asal sept um (Fig. 10.9a). A length en ing
e ect can be obt ain ed by low ering th e n asal t ip an d rot at-
ing it caudally.
Addit ion al length en ing can be gain ed th rough th e u se
of various graft s on th e n ew ly exten ded low er lateral car-
t ilage. Sh ield grafts an d cap grafts are com m on ly used. For
128 II Rhinoplast y

a b c

Fig. 10.8 Elongation of the framework. (a) An overlapping t ype of septal extension graft is xed to the caudal septum. The septal exten-
sion graft is designed to reach the anterior nasal spine inferiorly and to extend the nasal tip anteriorly while rotating it caudally. It can be
xed to the anterior nasal spine for further stabilit y. (b,c) Bilateral extended spreader grafts are reinforcing the septal extension graft. 4–0
PDS sutures are used to x the grafts and reat tach the upper lateral cartilage to the graft complex.

a w eak lateral cru s, lateral cru ral on lay graft s are p laced
to rein force it (Fig. 10.9b). If rot at ion an d p roject ion of
th e n asal t ip are excessively adjusted, th e alar m argin can
ap pear u n n at u ral, sligh tly ret racted, or collapsed.
Alar rim graft s can be used to provide a sm ooth er n at u-
ral con t in u at ion from th e n asal t ip to th e alar m argin an d to
low er th e alar rim sligh tly (Fig. 10.9c). A soft t issu e d issec-
t ion along th e alar rim is m ade begin n ing at th e n asal facet
using sh arp iris scissors. Dissect ion is perform ed close to
th e alar rim m argin , w ith care t aken n ot to m ake th e pocket
too big. A th in , at piece, 2 to 3 m m in w idth an d 12 to 15
m m in length , is design ed; th e m edial en d of th e graft is
sligh tly bru ised u sing Brow n -Adson forcep s an d in serted
in to th e pocket .

Fig. 10.9 Repositioning of lower lateral cartilages and additional tip grafts.
(a) Lower lateral cartilages are released from the upper lateral cartilage and
piriform aperture and repositioned on the new elongated nasal septum. (b)
Additional lengthening can be achieved with cap grafts and lateral crural
onlay grafts. (c) An alar rim graft is being introduced into the pocket made
c along the alar rim.

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Dorsal Augmentation
Car ved boat-sh aped graft s, u n like silicon e graft s, ten d to
m ove over th e n asion an d th e rh in ion becau se th e sh ap e
does n ot com pletely t over th e n asal bon e an d u pper lat -
eral car t ilage (Fig. 10.10). To redu ce graft m obilit y, a st rip of
cost al perich on driu m is sut ured to th e un dersurface of th e
n asion en d of th e car ved cart ilage after rasping of th e radix.
Th e h ar vested perich on drium is also used on th e radix an d
dorsu m to preven t step form at ion an d to create a sm ooth
t ran sit ion bet w een th e dorsal graft an d glabella. Th e cos-
tal cart ilage is xed to th e cau dal par ts of th e upper lateral
cart ilage an d n asal sept um w ith 5–0 PDS or 6–0 clear nylon
su t u res. Th e graft is xed at th e n asion p ar t in side th e t igh t
su bperiosteal pocket . Th e dorsal on lay graft exten d ed to
in clu de th e n asion m akes th e n ose appear longer.
Th e qualit y of cart ilage varies in dividually. Sligh tly
h ard cart ilage w ith out any calci cat ion in th e m iddle-aged
pat ien t is th e best m aterial. It is di cult to con t rol th e w arp -
ing com pletely in you ng pat ien t s, as th eir cost al car t ilage is
often sh ort , th in , an d excessively w eak or soft . In calci ed
Fig. 10.10 Dorsal augmentation. A carved rib cartilage graft is
being introduced to the dorsum.
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10 Correction of the Short, Contracted Nose 129
cart ilage, on th e oth er h an d, car ving is di cult an d th e ossi-
ed port ion m ay resorb w ith t im e, leaving irregu larit ies on
th e dorsum .2 In su ch sit u at ion s, th e cart ilage can be diced
in to ver y sm all pieces, w rapped in tem poralis fascia, an d
th en grafted to th e n asal dorsum . Th is is called th e “Turkish
deligh t” m ethod an d h as th e advan tage of h aving n o risk of
cart ilage distor t ion an d th e sh ape of th e dorsum appears
n at u ral.8,9 How ever, th e tem poralis fascia n eeds to be in de-
pen den tly h ar vested, an d m aking th e graft com pletely t
th e sh ape of th e dorsum is n ot easy. Resorpt ion is kn ow n
to be m in im al, bu t th e exact d egree is som ew h at di cu lt
to p redict. After on e year, a 10 to 20% resorpt ion com p ared
w ith th e im m ediate postoperat ive volum e is expected. Th is
m ay in crease if th e origin al cart ilage is ver y soft .
Composite Graft and Skin Closure
W h en th e length en ed skin an d vest ibular skin can n ot be
prim arily sut ured togeth er, a ch on drocu tan eous com posite
graft t aken from th e cym ba con ch a is pru d en tly u sed to ll
th e gap, especially in th e area of th e soft t issu e t riangle. Th e
nat ural cu r vat ure of car t ilage h ar vested from th e cym ba
con ch a ts w ell w ith th e defect at th e in ten ded graft site,
esp ecially at th e soft t issu e t riangle, an d th e resu lt ing don or
site scar is u su ally n ot p rom in en t p ostoperat ively. Th e
sh ape of th e in ten ded graft is m arked on th e skin , w h ich
is th en in cised along th ose m arks togeth er w ith th e car t i-
lage, but sparing th e con t ralateral perich on drium an d skin .
In lt rat ion of an esth et ic solu t ion directly over th e h ar vest-
ing port ion is avoided to in crease th e viabilit y of th e graft .
Dissect ing th is p erich on d riu m from th e posterior con ch al
bow l to free th e graft com pletes h ar vest ing of th e con ch al
com posite graft . A sm all don or site defect is closed prim ar-
ily; a full-th ickn ess skin graft , usually sourced from th e
post auricu lar area, m ay be n ecessar y w h en th e th e defect
is too big to close prim arily.10 W h en h ar vest ing post au ricu -
lar skin to graft any residual defect at th e cym ba con ch a, a
sligh tly bigger area th an th e act u al defect size is h ar vested
becau se th e skin usually con tracts on ce it is det ach ed from
th e don or site. Rem oving th e subcu tan eous fat an d soft t is-
su e from th e skin graft in creases th e graft’s viabilit y after
im plan t at ion . A com pression dressing is placed on th e
cym ba con ch a for 3 to 4 days an d an an t ibiot ic oin t m en t
ap plied to keep th e w ou n d m oist .
Before prim ar y closu re of th e colu m ella, th e cau dal
part of con ch al com posite graft is sut ured at th e m argin al
in cision follow ed by th e cephalic part , w h ich is sut ured to
th e vest ibular skin to ll th e defect (Fig. 10.11). After su t u r-
ing th e com posite graft on the recipien t sites, th e graft is
xed to th e recip ien t bed w ith gen tle pressu re eith er by
packing or th rough -an d-th rough sut u res w ith silast ic sh eet
ap plicat ion .
130 II Rhinoplast y
Fig. 10.11 Adding a chondrocutaneous composite graft. When
the skin of nasal vestibule and lengthened nasal skin cannot be
sutured primarily, a chondrocutaneous composite graft is used to
ll the gaps bet ween them.
■ Key Technical Points
1. A su cien t am oun t of cart ilage is n eeded to build
a st able p latform to length en th e n ose. Usu ally, rib
cart ilage h ar vest ing ser ves th is pu rpose.
2. Rib car t ilage car ving is st rategically t ailored
according to th e sites w h ere graft s are u sed. For
a dorsal on lay graft , th e cen ter of th e car t ilage is
u sed; tangen t ially cu t car t ilage is u sed for exten ded
spreader grafts or sept al exten sion graft s.
3. Wide un derm in ing of th e skin envelope is n ecessar y
to redrape over th e length en ed platform .
4. An en d-to-en d t ype or overlapping t ype of septal
exten sion graft to length en th e cau dal sept u m is a
p latform to reposit ion th e low er lateral car t ilage.
5. Th e sept al exten sion graft is design ed con sidering
th e rot at ion an d project ion of th e t ip an d n eeds to
be st rongly supported w ith a bilateral exten ded
spreader graft .
6. Th e low er lateral cart ilage n eeds to be released
from th e u p per lateral cart ilage an d scar t issu e for
rep osit ion ing to th e n ew dom e.
7. Th e n asion is m oved upw ard by adding a dorsal
on lay graft in th e low dorsum . Addit ion al t ip
on lay grafts are used to add to caudal rot at ion an d
p roject ion of th e t ip.
8. Th e lateral crural on lay graft an d alar rim graft h elp
to low er an d suppor t th e alar rim .
9. A ch on drocut an eous com posite graft from th e
cym ba con ch a lls th e gap bet w een th e skin
envelop e an d de cien t vest ibu lar lin ing.
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■ Complications and
Their Management
Skin Damage
W h en th e skin envelope is st rongly adh eren t to th e un der-
lying scar t issue, in adver ten t skin dam age can occur du ring
th e dissect ion . Dorsal skin t igh tly adh ering to un derlying
scar t issu e is som et im es ext rem ely d i cu lt to dissect . Th e
torn skin n eeds to be carefu lly su t u red an d th e soft t issu e
or fascia un derlin ed for fur th er support .
Pneumothorax
Pn eu m oth orax follow ing rib car t ilage h ar vest can be pre-
ven ted by carefu l h ar vest ing, leaving u n derlying p eri-
ch on driu m beh in d. In m ost cases, if n o air leakage w as
iden t i ed w ith th e Valsalva m an euver after h ar vest ing,
th ere is n o n eed to ch eck th e ch est X-ray after surger y
un less th e pat ien t com plain s of ch est t igh t n ess w ith low
oxygen sat u rat ion . If air leakage is n oted, a Nélaton cath -
eter is in ser ted at th e leakage site an d su t u red in a pu rse-
st ring m an n er. After t igh t closu re of th e su bcu t an eou s
an d skin w ou n d, th e Nélaton cath eter is rem oved w ith
sim u lt an eou s adm in ist rat ion of in ten se posit ive-p ressu re
hyper ven t ilat ion .
Warping of Implanted Rib Cartilage
Warping m ay occu r after replacing th e dorsal alloplast ic
im plan t w ith rib car t ilage (Fig. 10.12). Even th ough th e
au th or takes all p reven t ive m easu res to p reven t w arp ing,
su ch as balan ced car ving u sing th e core of th e rib cart ilage,
repeated im m ersion an d ch ecking of cur vat ure, creat ion
of a t igh t pocket for in sert ion , an d su t u re xat ion on th e
dorsum , it is st ill alm ost im possible to com pletely pre-
ven t w arping of cost al cart ilage. In su ch cases, th e au th or
takes out th e cur ved rib graft an d car ves it st raigh t before
rein ser t ing it in to place, w h ich solves th e problem in m ost
in st an ces. If th at is n ot possible, th e auth or dices th e cur ved
rib an d w rap s it in tem poralis fascia. In th e au th or’s exp eri-
en ce, au togen ou s rib cart ilage is able to m ain tain it s origi-
n al volu m e even years after th e su rger y. Adding som e soft
t issue such as th e m astoid periosteum w ill h elp to re n e
th e radix in th is case.
Movability of the Costal Cartilage
Onlay Graft
Movem en t of a cost al cart ilage on lay graft after revision is
rare. Possible reason s for m igrat ion of th e im plan t in clu de a
large an d w ide pocket created during dissect ion to rem ove
 10 Correction of the Short, Contracted Nose 131

a b c

Fig. 10.12 Warping of dorsal onlay rib graft. (a) Warping developed after placement of dorsal onlay graft with autogenous rib cartilage.
(b) Six months after revision, the nose is straight. (c) In revision surgery, the dorsal onlay cartilage was removed in pieces. (d) The warped
portion was recarved and put together by wrapping with mastoid periosteum before reinsertion.

a large or st u bborn ly p lan ted allop last ic im p lan t arou n d th e
radix area; residu al cap su le after silicon e im p lan t rem oval;
an d in app rop riate xat ion of th e cost al cart ilage, especially
at th e radix area. To preven t th is, com plete rem oval of th e
u n derlying capsu le, rough en ing of th e radix w ith rasp , an d
p erich on driu m applied on th e un dersurface of th e radix
skin above th e graft are n ecessar y. In rare cases, a K-w ire
xat ion of th e graft at th e radix p ar t is n eeded .
Nasal Obstruction
Ap p lying a too-th ick sept al exten sion graft , esp ecially th e
overlap p ing t ype, can m ake th e n ost ril in let sm all, cau s-
ing n asal obst ru ct ion . An en d-to-en d t ype sept al exten -
sion graft w ith a th in , at p iece of car t ilage can preven t
th is com plicat ion . Also, beveling an d th in n ing th e exten ded
port ion of th e exten ded spreader graft bin ding to th e sept al
exten sion graft is im port an t to p reven t th icken ing of th e
caudal sept um . If th e septal exten sion graft is w eak, th e
caudal sept um m ay buckle, causing deviat ion an d n asal
obst ruct ion .
Tip Problems
Too m uch ten sion exerted on th e skin , especially w hen th e
sept al exten sion graft is m ade of sept al bon e or allop las-
t ic m aterial such as Medpor, m ay cause pressure sen sit iv-
it y or pain in th e n asal t ip. In m ost cases, th is discom for t
decreases w ith t im e; h ow ever, in som e cases th e graft
needs to be rem oved. Asym m et r y of th e n ost rils m ay occu r
w h en th e sept al exten sion graft is n ot exactly in th e m id-
lin e or if t ip on lay graft s are n ot sym m et ric.
■ Case Studies
Case 1: Correction of Short Nose
Due to Contracture after Multiple
Rhinoplasties
A 28-year-old fem ale presen ted w ith sh ort n ose an d left
nasal obst ru ct ion (Fig. 10.13). Sh e h ad u n dergon e fou r rh i-
noplast ies using Gore-Tex t w ice, silicon e on ce, an d autolo-
gou s cost al car t ilage on ce over th e p ast 9 years, w ith th e
m ost recen t su rger y 2 years previou sly. Sh e h ad a t ypical
post surgical sh or t , con t racted n ose w ith exaggerated n os-
t ril sh ow in th e fron t al view an d severely ceph alic rotated
nasal t ip w ith low -set n asion in th e lateral view.
Her su rgical diagram sh ow s th at a sept al exten sion
graft , d orsal on lay graft , bilateral exten ded sp read er graft s,
lateral cru ral on lay graft s, sh ield graft , an d cap graft w ere
placed using irradiated h om ologous cost al cart ilage. Bilat-
eral con ch al ch on drocu t an eou s com posite graft s w ere
used to ll th e gap bet w een length en ed skin an d vest ibular
lin ing.

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132 II Rhinoplast y

Fig. 10.13 Case 1. (a,b) A short, con-

a b
tracted nose, developed after multiple rhi-
noplasties, is evident from the frontal and
lateral views.

Her app earan ce 2 years after th e op erat ion sh ow ed

im provem en t in th e con t racted an d sh or t n ose. Caudal
rot at ion of th e n asal t ip, a decreased n asolabial angle, an d
in creased h eigh t of th e n asal dorsu m m ake th e n ose appear
sign i can tly longer th an p rior to revision (Fig. 10.14).

Fig. 10.14 Case 1. (a,b) Two years after

a b
revision surgery using rib cartilage, the
nose looks much bet ter than before. Her
dorsum is well elevated and the tip is cau-
dally rotated.

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Case 2: Correction of Postsurgical
Short Nose w ith Tw o -Stage Revisions
A 26-year-old fem ale visited th e clin ic com p lain ing of n asal
deform it y (Fig. 10.15). Sh e h ad h ad th ree rh in oplast ies
before, w h ich in cluded silicon e dorsal augm en t at ion an d
rem oval of th e silicon e im plan t . On physical exam in at ion ,
sh e h ad a st raigh t n ose, bu t th e d orsal h eigh t w as sh ort ,
an d th ere w as excessive n ost ril sh ow from th e fron t al view.
Her t ip w as severely u pt u rn ed an d h ad skin dim p ling on
th e t ip lobule.
a b
a b
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10 Correction of the Short, Contracted Nose 133
Sh e u n der w en t a t w o-st age op erat ion : At rst revision ,
length en ing of th e n ose using autogen ou s rib cart ilage w as
t ried th rough an open approach . A sept al exten sion graft ,
dorsal on lay graft , bilateral exten ded spreader grafts, lat-
eral cru ral on lay graft , an d t ip on lay grafts w ith a con ch al
com posite graft w ere used. Th e secon d revision w as don e 1
year after th e rst revision . At th e secon d revision , h er t ip
w as length en ed m ore u sing con ch al cart ilage on lay graft s
on th e t ip th rough th e endon asal approach . On e year after
th e secon d revision , h er n asal sh ape im proved in both th e
fron t al an d lateral view s (Fig. 10.16).
Fig. 10.15 Case 2. (a) Frontal and (b)
lateral views before the rst revision. Too
much nostril show, colum ellar retraction,
dimpling of tip skin, and short, scooped-out
dorsum are evident.
Fig. 10.16 Case 2. (a,b) Photos taken 1
year after the second revision show much
improved nasal shape from both the frontal
and lateral views.
134 II Rhinoplast y
References
1. Na cy S, Baker SR. Length ening th e sh ort n ose. Arch Oto-
lar yngol Head Neck Su rg 1998;124(7):809–813
2. Sunw oo WS, Ch oi HG, Kim DW, Jin HR. Ch aracterist ics of
rib cart ilage calci cat ion in Asian pat ien t s. JAMA Facial
Plast Su rg 2014;16(2):102–106
3. Fr y H. Nasal skelet al t raum a an d th e in terlocked st resses
of th e n asal sept al cart ilage. Br J Plast Surg 1967;20(2):
146–158
4. Harris S, Pan Y, Peterson R, St al S, Spira M. Car t ilage
w arping: an experim en t al m odel. Plast Recon st r Surg
1993;92(5):912–915
5. Kim DW, Shah AR, Torium i DM. Con cen t ric an d eccen t ric
car ved cost al cart ilage: a com parison of w arp ing. Arch Fa-
cial Plast Surg 2006;8(1):42–46
http://e-surg.com
6. Adam s W P Jr, Rohrich RJ, Gunter JP, Clark CP, Robinson JB Jr.
The rate of warping in irradiated and nonirradiated hom o-
graft rib cartilage: a controlled com parison and clinical im pli-
cations. Plast Reconstr Surg 1999;103(1):265–270
7. Park JH, Mangoba DC, Mun SJ, Kim DW, Jin HR. Length en -
ing th e sh ort n ose in Asian s: key m an euvers an d su rgical
results. JAMA Facial Plast Surg 2013;15(6):439–447
8. Erol OO. Th e Turkish deligh t: a pliable graft for rh in oplast y.
Plast Recon st r Su rg 2000;105(6):2229–2241, discu ssion
2242–2243
9. Daniel RK, Calvert JW. Diced cartilage grafts in rhinoplast y
surgery. Plast Reconstr Surg 2004;113(7):2156–2171
10. Dan iel RK. Graft s. In : Dan iel RK. Mastering Rh in op last y: A
Com preh en sive Atlas of Su rgical Tech n iqu e. New York, NY:
Springer; 2004:225–267
11 Management of Alloplast-Related Complications
Eunsang Dhong
Pearls
• Th e perspect ive of using an alloplast ic im plan t in
com plicated septorh in oplast y is com pletely di eren t
from th at of u sing a sim p le dorsal augm en t at ion .
Th e locat ion of th e pat ien t’s sellion is altered
follow ing im plan t at ion . It m igh t be h igh er or low er
th an th e origin al posit ion , an d it usually m igrates
ceph alically from th e origin al site.
• A long-st an ding im p lan t dest roys n ot on ly th e bony
dorsu m , but th e cart ilagin ous dorsum as w ell.
• The capsule surrounding a silicone im plant does not
dissolve even after the im plant is extracted. Therefore,
if a patient undergoes m ultiple revisions, various
layers of the capsule can be seen during surgery.
• A h ealthy capsu le can be reu sed w h ile it is at t ach ed
for th e su bst it ut ion of soft t issue in a secon dar y
rh in oplast y.
• Con t ract ure aroun d th e capsule m oves th e n asal t ip
ceph alically, w ith th e pat ien t en ding up w ith a sh or t
■ Introduction
Th e m ost popular alloplast s in Asian rh in oplast y are poly-
m eric silicon e, exp an ded polytet ra u oroethylen e (ePTFE,
or Gore-Tex [W. L. Gore an d Associates]), porous h igh -den -
sit y p olyethylen e (pHDPE, or Med por), an d acellu lar h u m an
derm is (AlloDerm ).1 Silicon e is th e m ost w idely used, fol-
low ed by Gore-Tex. Medpor is preferred as th e st ru t for t ip -
plast y an d AlloDerm is used for various t ypes of soft t issue
en h an cem en t . For m any decad es, th e conven t ion al m eth -
ods for prim ar y East Asian rh in oplast y h ave used th ese
allop last s for dorsal augm en t at ion . Th e gen eral con sen su s
h as been th at dorsal im p lan tat ion of silicon e or Gore-Tex
is a n ovel tech n ique for augm en tat ion for a low n asion an d
bony dorsum . Besides th e probable com plicat ion s of apply-
ing alloplast s, in m any cases of secon dar y rh in oplast y, th e
sept u m an d th e con ch a car t ilage h ave already been u sed
previously for th e don or grafts. Th erefore, u sually th e
on ly don or site left for th e autograft is th e rib cart ilage.
Som et im es th e su rgeon h as n o ch oice bu t to u se allop last s
according to th e p at ien t’s dem an d . Even after several revi-
sion al operat ion s, pat ien t s are st ill left w ith th e u n correct-
able n asal deform it y.
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n ose deform it y. All con t racted t issu es, in clu d ing
th e capsule, sh ould be rem oved to correct th is
deform it y.
• Using Medp or (St r yker) as a sept al su p port or as a
spreader graft becau se exten sion frequ en tly lead s to
sept al p erforat ion .
• Mu lt ilayered AlloDerm (LifeCell) m ay form avascu lar
scar t issu e in th e cen ter.
• Sin ce an alloplast ic im plan t for rh in oplast y h as a
n ite lifespan , pat ien t s sh ou ld be in form ed abou t
th e lim ited ben e ts of using an alloplast ic im plan t .
• Placing an allop last ic im plan t over an op en roof
or dissected u pper lateral car t ilage from th e h igh
sept u m m ay lead to disast rou s resu lts.
• Most im p lan t-related com plicat ion s resu lt from
a sh or t age of prop er soft t issu e coverage. In su ch
cases, im plan t s are often exposed to th e n asal cavit y
th rough a con cealed m u cosal lacerat ion .
Th e com plicat ion rates in using silicon e im plan t s var y
from 2 to 7%according to m any rep ort s. In oth er report s, th e
rem oval rate for both Gore-Tex an d Medpor w as reported
as 3.1%, w h ereas th e rem oval rate for silicon e im plan t s w as
sign i can tly h igh er, at 6.5%.2,3 Th is an alysis m ay be accu rate
for sim p le rh in op last y, w h ich con sists of pu t t ing an allo-
plast ic im plan t on th e n asal dorsum in less th an an h ou r.
Yet th e con cept of sim ple “augm en t at ion rh in oplast y” h as
long disappeared in Korea. In East Asian s, th e com plicated
procedure of open septorh in oplast y is frequen tly per-
form ed. As th e in ciden ce of com p licated septorh in op last y
in creases, th e rate of severe com plicat ion is also on th e rise.
Th e sept al exten sion graft is ver y popular for th e correct ion
of sh ort n ose in East Asia, in creasing th e average operat ion
t im e. More severe com plication s h ave appeared recen tly
in pat ien t s in w h om com plicated sept al su rger y w as per-
form ed w ith allop lasts in serted sim u lt an eou sly (Fig. 11.1).
Th erefore, an alyzing th e com plicat ion rates of alloplast s
according to past rep or t s is m ean ingless. Th e com p licat ion
rates for variou s t yp es of allop lasts sh ou ld be classi ed
according to th e com plexit y of th e op erat ion p erform ed .
Th e perspect ive of using an alloplast ic im plan t in com -
plicated septorh in oplast y is com pletely di eren t from th at
u sed for sim p le dorsal augm en t at ion . In th is ch apter, th e
135
136 II Rhinoplast y
Fig. 11.1 Popular techniques in East Asian rhinoplast y for dorsum
and tip projection. Septal extension graft using septal cartilage
after submucosal resection with dorsal silicone implanting.
m an agem en t of variou s p roblem s in u sing alloplast s w ill be
d iscu ssed, w ith special at ten t ion to doctors out side of East
Asia an d to begin n ers in rh in oplast y.
■ Patient Evaluation
A carefu l assessm en t is n eeded for secon dar y rh in op last y,
esp ecially w h en allop last s h ave been app lied. Th e presen ce
of dest royed st ruct ures un der th e con cealed scar t issue is
u su ally u npredict able. Secon dar y rh in oplast y t akes a dif-
feren t rou te from th e begin n ing, depen ding on w h eth er a
pat ien t h as alloplast ic m aterials in th e n ose or n ot . Most
allop last ic im plan t s in serted p reviou sly sh ou ld be rem oved
in th e secon dar y operat ion . Th e an atom y un derlying th e
allop lasts h as been dest royed ; th erefore, th e am ou n t of
au tograft th at is n eeded in recon st ru ct ion is u su ally m u ch
greater th an exp ected. In m ost cases of East Asian p rim ar y
rh in oplast y, an alloplast ic im plan t is used w ith autograft s
at th e n asal t ip . Th u s, in secon dar y procedu res, surgeon s
en cou n ter a sh or t age of don or sou rce for au tograft s.
Here is th e au th or’s person al ch ecklist for exam in ing
a p at ien t:
1. Do n ot overlook any previou s h istor y of surger y.
2. Th rough close in spect ion , m ake a problem list .
Pat ien t s w ill be m ore sat is ed w ith th e result s if
th ey rst approve th e surgeon’s problem list .
3. Th e h ardn ess of th e scar an d th e soft t issue resilien ce
arou n d th e n asal t ip sh ou ld be assessed w ith digit al
p alp at ion , an d th is m ay in clude pu lling dow n on th e
n ost rils.
4. Th e exten t of pocket dissect ion is determ in ed by th e
h ardn ess an d th e exten t of scar m ass.
5. Th e caudal in t ran asal path ology m ay be determ in ed
by sim ple rh in oscopic evaluat ion .
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6. Th e in t ran asal environ m en t , in cluding th e in ferior
t u rbin ate an d t races of previous subm ucosal
resect ion of th e sept um , sh ould be iden t i ed
u sing in t ran asal in sp ect ion in clu ding en doscop ic
evalu at ion .
7. A lateral X-ray (n asal bon e view ) is h elpful for th e
evalu at ion of th e origin al locat ion of th e n asion an d
for m easu ring th e th ickn ess of th e im p lan t an d th e
overlying skin ap .
8. A long-st an ding im plan t dest roys n ot on ly th e
bony dorsu m but also th e car t ilagin ous dorsum .
For th e evalu at ion of bony dest ru ct ion u n d er th e
im plan t , com puted tom ography (CT) in cluding
3D recon st ruct ion is h elpful. It is useful for
pat ien t s su ering from n asal obst ruct ion an d for
pat ien t s u n dergoing secon dar y septoplast y an d/or
t u rbin oplast y.
9. It is di cu lt to p redict th e am ou n t of scarring
arou n d an im p lan t an d th e severit y of th e
dest ruct ion adjacen t to th e low er lateral car t ilage
(LLC) an d upper lateral cart ilage (ULC), even after th e
evalu at ion of CT scan s. Preop erat ive predict ion s m ay
di er from th e act ual in t raoperat ive n dings.
An im p lan t on th e n asion blu rs th e act u al locat ion of th e
sellion . Th e th ickn ess of th e capsu le arou n d th e im p lan t
also a ect s th e est im at ion of th e th ickn ess of th e overly-
ing skin ap (Fig. 11.2). Th e locat ion of th e pat ien t’s sel-
lion ch anges after im plan t at ion . It m igh t be h igh er or low er
than it s origin al posit ion , an d it u sually m igrates ceph ali-
cally from th e origin al site.
Alloplast s u sed on th e n asal t ip dest roy th e adjacen t
cart ilage, an d th e t ip loses suppor t after th e rem oval of
allop last s. Th e t ip project ion u su ally can n ot be m ain tain ed
w ith out grafts du e to th e w eakn ess of th e rem ain ing LLC.
On e of th e issu es in dealing w ith silicon e im p lan t s is
the m an agem en t of th e capsule aroun d th e im plan t . Th ere
are t w o cap su les arou n d th e silicon e im p lan t: th e an terior
an d posterior cap su les (Fig. 11.3). Variou s layers of capsu les
are fou n d in p at ien ts w h o w ere op erated on m any t im es
previously. Th e capsu le surroun ding th e silicon e im plan t
does n ot dissolve spon t an eously after im plan t ext ract ion
(Fig. 11.4).
A h ealthy capsu le can be reu sed w h ile it is at t ach ed
for th e su bst it u t ion of soft t issu e in a secon dar y rh in o-
plast y. Th e an terior capsule is left alm ost in t act , so as n ot
to en danger th e viabilit y of th e dorsal skin ap . Even th e
posterior capsule m ay be reused if fou n d in a good state for
soft t issu e rein forcem en t .
Th e en t ire capsule sh ould be rem oved in th e case of
im plan t calci cat ion an d capsular con t ract ure. Con t ract ure
arou n d th e cap su le disp laces th e im p lan t cep h alically, an d
result s in sh ort n ose deform it y (see Case 1). Rem oval of th e
capsule an d th e adjacen t soft t issue con t ract ure results in
soft t issu e de cien cy (Fig. 11.5).
 11 Managem ent of Alloplast -Related Com plications 137

a b

Fig. 11.2 Bone destruction after long-standing dorsal implanting. (a) The rhinion after 5 years’ presence of a silicone implant. (b)
Another patient with a silicone implant for 14 years.

Fig. 11.3 Capsules after dorsal silicone implanting. There are t wo

capsules around the silicone implant at the anterior (orange) and
posterior (red) sides.

Fig. 11.4 Multiple layers of capsules from quarterly revision.

A capsule does not dissolve spontaneously postoperatively, even
after more than 10 years.

There is no or ver y lit tle form at ion of capsule around

Fig. 11.5 Removal of the capsule and the adjacent soft tissue
contracture. Resection of capsules results in de ciency of soft tis-
sue at the dorsum with thin dorsal skin.
Gore-Tex im plan ts. The soft t issue dest ruction found during
im plant rem oval is less for Gore-Tex than for silicone or Med-
por. The dissection around the Medpor im plan t is relat ively
di cult, due to the soft tissue integrat ion in to the pores of
the im plant. How ever, the rem oval of a Medpor im plant
located in the subperichon drial space is easier th an for on e
located in the supraperichondrial space. The use of Med-
por in the caudal or anterior sept um for a septal extension
graft or spreader graft frequ en tly leads to septal perforat ion
(Fig. 11.6). Th is is du e to th e relat ive physical w eakn ess of
the septal m ucosa. Even its application at the m em branous
septum for colum ellar stru t is com plicated. Th e n asal tip is
the m ost m obile port ion of the n ose. Frequent m ovem ent
of the m em branous sept um cannot overcom e the physical
tough n ess of Medpor, even if th e im plan tation du ring th e
im m ediate postoperative period w as successful.

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138 II Rhinoplast y

a b

Fig. 11.6 Septal perforation found after removal of intranasal Medpor. (a) Before removal of the Medpor in the left side of the nasal cav-
it y. (b) A huge defect at the high septum.

In th e n asal t ip area, rigid scar t issu e is frequ en tly
fou n d . In m ost cases, it is th e resu lt of m u lt ilayered Allo-
Derm ap p licat ion . Th e cen t ral p ort ion of th e scar t issu e
lacks vascu lar supply; h en ce, an avascu lar scar m ass form s
(Fig. 11.7).
Severe con t ract u re associated w ith im p lan t s is fre-
quen tly foun d in pat ien ts w h o u n der w en t com plicated
sept al su rger y sim u ltan eou sly. Sept al su p port is u su ally
lost after su bm ucosal resect ion (SMR), an d the gravit y an d
ten sion from th e alloplast ic im plan t m ay be t roublesom e
over an op en roof or d issected ULC from th e h igh sept u m .
Mu cocele is on e of th e frequ en t p ath ologic n dings resu lt-
ing from th is sit uat ion . Th is m ay be foun d in in t ran asal
or ext ran asal areas (Fig. 11.8). Most of th e m u cocele m ay
be related to th e sh or tage of proper soft t issue coverage
un dern eath : an exposed n asal cavit y ben eath th e im p lan t
or con cealed m ucosal lacerat ion after osteotom y of th e
nasal bon e.
■ Surgical Techniques
Correcting Noninfectious Conditions
Deviated Implant
If th e p ocket is dissected w ider th an th e act u al size of th e
im plan t , th e im plan t h as a ten den cy to deviate to on e side
of th e lateral n asal w all. Moreover, if th e im plan t is longer

a b

Fig. 11.7 Common nding in revision tip surgery. (a) Huge scar mass with conchal cartilage on the top of the tip. Underneath it m ultiple
layers of Alloderm were found. (b) After removal of allograft s, the LLCs underneath were destroyed to some extent.

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 11
a b
th an th e dissected pocket , th e im plan t is distorted due to
it s axial pressu re. Th e u n d erlying discrepan cy bet w een
th e n asal bony axis an d car t ilagin ous a xis result s in devia-
t ion of th e im plan t even after careful sculpt ing of th e
u n dersu rface.
For correct ion , th orough bilateral capsulotom y is h elp -
fu l in re-im plan t ing if th e capsu le h as already form ed . A
lateral n asal osteotom y an d h igh sept al sp reader graft are
n eeded for th e discrep an cy bet w een th e bony axis an d
h igh septal axis. In th ese cases, replacing th e im p lan t w ith
a d erm ofat graft is st rongly recom m en d ed . Secu re t ap ing
an d im m obilizat ion du ring th e im m ediate postop erat ive
p eriod are cru cial.
Dorsal Skin Redness and Visible Implant
In p at ien t s w h o h ave ver y th in skin , th e im p lan t m ay be
visible u n der direct su n ligh t . Esp ecially in cases w ith Gore-
Tex, th e dorsal con tour m ay be seen th rough th e dorsal
skin . As for th e Gore-Tex, du e to it s lack of capsu le form a-
t ion , th e im plan t h as a ten den cy to skeletonize an d sh rin k.
Th e redn ess of th e dorsal skin can rem ain long after
th e operat ion in th in -skin n ed pat ien ts. Subst it ut ion of
im p lan t s w ith derm ofat graft s is n eeded in m ost cases.
Wrap p ing th e im plan t w ith au tologou s su per cial tem po-
ral fascia m ay be h elp fu l. How ever, w rapp ing th e im plan t
w ith allograft is con t roversial due to poor vascu larizat ion
an d h igh er ch an ces of postop erat ive in fect ion .
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Managem ent of Alloplast -Related Com plications 139
c
Fig. 11.8 Mucocele formation by silicone
implant. (a) Before the surgery. Epidermal cyst-
like protrusion at the right nasal root with blunted
hard nasal tip. (b) After the surgery. The thin
dorsal skin was salvaged after total extirpation
of mucocele. Tip-plasty using conchal cartilage
with dorsal dermal graft was also performed. (c)
Thick peri- and intracapsular mucocele dissected
after removal of the silicone implant.
Mobile Implant
If th e p ocket is dissected su bcu t an eou sly at th e bony dor-
su m , th e silicon e im plan t h as a ten den cy to be m obile.
Precise pocket dissect ion is perform ed subperiosteally
for re-im plan t ing. Gore-Tex h as a lesser ten den cy tow ard
m obilit y.
Implant Calci cation
In long-st an ding allop last ic im plan t s, dyst roph ic calci ca-
t ion arou n d th e im plan t an d capsule is occasion ally fou n d
(Fig. 11.9). Th e m ech an ism of calci cat ion is st ill u n der
debate, bu t degen erated t issu e aroun d th e capsule (den se
scar) m ay p lay a role in calci cat ion .4 Com p lete ext irp at ion
of th e an terior an d posterior capsules is n eeded, an d a der-
m ofat graft is su bst it u ted for th e im p lan t .
Implant Protrusion
Most prot ru sion s resu lt from th e u sage of am ou n t s of allo-
plast ic im plan t s exceeding th e th resh old of skin ten sion .
Th e im plan t sh ould be rem oved im m ediately. If th e im plan t
is t ran sparen t but n ot prot ruded, th en th e operat ion can
be perform ed as a single st age. How ever, if th e im plan t is
already p rot ru ding, recon st ru ct ion sh ou ld be p erform ed
sep arately.
140 II Rhinoplast y

a c d

Fig. 11.9 Implant calci cation. (a) Removed calci ed silicone implant and
entire capsules. (b) Double-layer dermal graft for the dorsum and cymba con-
cha for the tip. (c) Before the surgery. Transparent implant through the skin
with thinning and telangiectasia is noted. (d) After the surgery.

Hard Nasal Tip Correcting Infectious Conditions

Th e applicat ion of AlloDerm h as been accepted in m any
elds of facial plast ic su rger y as an opt ion for soft t issu e
en h an cem en t .5,6 Bu t m u lt ilayered AlloDerm on th e n asal
t ip frequen tly form s an avascular scar m ass. Th e cen t ral
port ion of th e grafted AlloDerm is foun d to be avascular
after scalp el in cision . Th e n asal t ip w ill feel ver y rigid w ith
th is scar t issue. After rem oval of th is scar t issue, a large
am ou n t of soft tissu e m u st be rep laced.
Mucocele
After h u m pectom y, th ere m ay be a sm all degree of exp o-
su re to th e n asal m u cosa, an d th e ingrow th of m u cosa in to
th e dissected pocket m ay result in m ucocele form at ion
(Fig. 11.10). Th e en doth elial ingrow th or m et ap lasia of th e
capsular pocket is st ill un cert ain an d n eeds to be st udied
fu rth er.7 On ce th e m u cocele is iden t i ed, tot al ext irp at ion
is n eed ed.
In ammation
Relapsing in am m at ion is n ot rare during th e im m ediate
postoperat ive period. Rem oval of th e alloplast ic im plan t
is usually recom m en ded; h ow ever, com plicat ion s m ust be
ap proach ed on an in d ivid u al basis. In som e cases, delayed
hem atom a at th e n asion m ay be m isdiagn osed as a u c-
t uat ion of in am m at ion , but th is can be salvaged by n eedle
asp irat ion .
Relapsing edem a, in m any pat ien ts, is du e to th e un st a-
ble scar (capsule) form at ion arou n d th e im plan t . Micro-
com m un icat ion bet w een th e extern al environ m en t an d th e
in t ra-capsular area m ay result in th e u ct uat ion of sh ort-
term edem a. Relapsing subclin ical in am m at ion does n ot
drain pus an d m ay im prove w ith th e use of broad-spect rum
an t ibiot ics. Th e decision on rem oving th e im plan t is a con -
t roversial on e. Alth ough con ser vat ive t reat m en t m ay be
pursued in m ild in am m at ion , th is route frequen tly result s
in un successful result s. Th e relapsing in am m at ion fre-
quen tly result s in capsu lar cont ract ure.

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 11 Managem ent of Alloplast -Related Com plications 141

a c d

Fig. 11.10 Mucocele form ation after humpectomy with dorsal silicone implant.
(a) Preoperative X-ray reveals previous humpectomy (dot s) with migrated L-t ype
implant with thick scar. (b) Rem oved mucocele with thick capsules. (c) Before
the surgery. Short nose deformit y in patient with mucocele, who su ered from
relapsing edema and drainage of intranasal discharge. (d) After the surgery.
After total extirpation of previous alloplast s, dorsal augmentation with autograft
was performed (dermofat graft with concha cartilage graft).

Infected Implant Correcting Short Nose Deformity

Th e rare acute in fect ion in septorh in oplast y m an ifest s as
toxic sh ock syn d rom e, sep sis, m en ingit is, an d en docardi-
t is. Drain age of pus th rough th e in cision al site is n ot a rare
com plicat ion .
Su rger y u sing alloplast s is com p licated an d p ron e to
in fect ion , so p rophylact ic an d postoperat ive an t ibiot ic
t reat m en t is essen t ial. Irrigat ion of th e pocket in t raopera-
t ively is m ore ben e cial th an t reat ing w ith an t ibiot ics. Seg-
regat ing th e in st rum en ts th at w ere used w ith in th e n asal
cavit y from th ose used for pocket dissect ion is also im por-
tan t . Silicon e im plan ts th at w ere already in con t act w ith
th e skin sh ould be clean sed by salin e or alcoh ol. Gore-Tex is
bet ter prepared by soaking it in bet adin e.
Im p lan ts drain ing pu s can n ot be salvaged an d sh ou ld
be rem oved. If th e rem oval is delayed, th e st ruct u ral defor-
m it y m ay get w orse. Recon st ru ct ion sh ou ld be p ost pon ed
for at least 6 m on th s to a year un t il com plete resolu t ion .
In severe con t ract u re associated w ith sh or t n ose deform it y,
th e dissect ion sh ould be m ade w ider (Fig. 11.11). Sim u lt a-
neous resect ion of th e capsule an d th e con t racted soft t is-
su e arou n d th e im plan t sh ou ld be perform ed.
In rem oving th e cap su le th ere are t w o di eren t opt ion s,
dissect ing th e an terior capsule rst or dissect ing th e pos-
terior capsule rst . For tot al resect ion of th e an terior an d
posterior capsu les, it is easier to dissect th e an terior cap -
su le rst .
To dissect th e an terior capsu le rst:
1. Perform hydro-dissect ion bet w een th e skin ap an d
th e an terior capsu le.
2. Tr y to ret ain th e in tegrat ion of th e an terior capsule
u p to th e m ost cep h alic p or t ion .
3. Rem ove th e im plan t after th e com plet ion of an terior
capsule dissect ion .

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142 II Rhinoplast y

a c d

Fig. 11.11 Correction of short nose deformit y. (a) Schematic of dissection:

myotomy of the bilateral transverse nasalis, bilateral subperiosteal dissection
around the bony pyramid, separation bet ween the septum and ULCs, caudal nasal
bone and ULCs, and ULCs and LLCs (the scroll area) was performed incrementally.
(b) Sculpted rib cartilage for septal reconstruction and rectus fascia for wrapping
the diced cartilage. (c) Before the surgery. (d) After the surgery.

4. If th e ceph alic capsule w as n ot dissected com pletely,

bilateral capsu lotom y sh ould be perform ed to
rem ove any soft t issu e irregu larit ies th at m ay arise
at th e n asion lateral to th e im plan t .
5. Dissect th e un dersurface of th e posterior capsule;
th is plan e is usually adh eren t to th e periosteum .
To reu se th e an terior capsule, th e posterior capsu le is dis-
sected rst , after th e rem oval of th e ret ain ing im p lan t . To
d issect th e p osterior capsule rst:
1. Perform a caudal capsulotom y, th en rem ove th e
im p lan t .
2. Irrigate th e pocket vigorously.
3. Dissect th e un dersurface of th e posterior capsule;
th is plan e is usually th e subperiosteal space.
4. Bilateral capsulotom y sh ould be perform ed th rough
th e en t ire longit udin al plan e so as n ot to create any
lateral ban d-like deform it y.
■ Key Technical Points
1. Con sider th e silh ou et te of th e skin ap rst . If th e
skin ap is too th in , it is bet ter to reu se th e an terior
capsule. If th ere is a relat ively th ick scar ban d lateral
to th e im plan t , bilateral capsulotom y is n eeded.
2. Make a dorsal pocket subperiosteally for th e
reim plan tat ion .
3. Com plete rem oval of th e capsu le is n eeded in cases
of im plan t calci cat ion an d m u cocele.
4. Prepare proper autografts con sidering th e
dest ruct ion of th e un derlying bony an d car t ilagin ou s
st ru ct u res. Th e am ou n t of au tograft is m u ch greater
th an expected w h en tot al ext irpat ion of th e capsule
an d con t ract u re is p erform ed .

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 11
5. After capsule m an ipulat ion , re-drape th e skin ap.
If th e skin ap is n ot m oving freely, m yotom y of th e
bilateral t ran sverse n asalis or bilateral subperiosteal
d issect ion m ay be perform ed aroun d th e bony
pyram id.
6. If th e skin ap looks u n n at u ral du e to th e scar
ban d aroun d th e t ip, careful cross-h atch ing or
m orselizat ion of th e an terior cap su le m ay be
p erform ed.
7. If th e t ripod of th e t ip is n ot elongated w ell after
th e posterior capsu lectom y, furth er dissect ion is
p erform ed. Th e sept um an d ULCs, caudal n asal bon e
an d ULCs, an d ULCs an d LLCs (th e scroll area) are
d issected an d separated accordingly (Fig. 11.11a).
8. If th e t ip is not elongated even after all of th e
e ort s listed, m et icu lou s vert ical scoring at th e
su bperich on driu m of th e m em bran ou s sept u m m ay
be perform ed. How ever, th is sh ould be don e w ith
caut ion as it is a ver y h azardous procedu re.
■ Infections in Septorhinoplasty
Th e in fect ion rate for rh in oplast y is reported as 1 to 4%, an d
th at of septoplast y bet w een 2 an d 7%. How ever, th e in fec-
t ion rate for septorh in oplast y varies from 2 to 14%, depend-
ing on w h eth er it is a prim ar y, secon dar y, or com plicated
septorh in oplast y.8 Com p licated septorh in op last y is su rger y
th at in cludes septal recon st ruct ion , osteotom y, subm uco-
sal resect ion , an d free t ran sp lan tat ion th at resu lt s in long
operat ion t im e. Most East Asian rh in oplast ies u sing allo-
p last s fall in to th is categor y.
Perich on drit is an d sept al abscess are n ot rare in acute
in fect ion . Th e m ajor con cern is th e cosm et ic ou tcom e after
th e dest ruct ion of th e rem ain ing septal L-st rut . Th e pat ien t
m ay com p lain of severe sadd le n ose deform it y an d sh ort
n ose deform it y.
Th e n orm al ora of th e n asal cavit y in clu des diph -
th eroids (Corynebacterium ), m icrococci (Staphylococcus
epiderm idis), Staphylococcus aureus, St reptococcus (α , β,
h em olyt ic), en terococci, yeast (Candida spp .), fu ngi, etc.
Th ey are n ot alw ays path ologic.9
Meth icillin -resist an t Staphylococcus aureus (MRSA),
m eth icillin -su scept ible Staphylococcus epiderm idis (MSSE),
an d Enterobacter sp p. are poten t ially in fect iou s n asal ora
(PINF), an d th e rout in e prophylact ic an t ibiot ics are use-
less if th e colony sprou ts. Som e 20 to 60% of th e n orm al
populat ion are repor ted to h ave PINF in their n asal cavit ies.
Th e predisposing factors of in fect ion are th e stat us of n asal
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Managem ent of Alloplast -Related Com plications 143
physiology of poor ciliar y clearan ce, con ch al hyper t rophy,
an d disru pt ion of th e n asal m u cosal barrier. Long op erat ion
t im e, n asal packing, w ide dissect ion , an d allo- an d auto-
t ran splan tat ion are oth er in t raoperat ive factors th at pre-
dispose pat ien ts to in fect ion .
On e rep or t on th e correlat ion of septorh in op last y an d
bacterem ia revealed th at 15%of 53 cases of septoplast y an d
septorh in oplast y sh ow ed bacterem ia postoperat ively, an d
16.9% did so after rem oval of n asal packing.10 In an oth er
st u dy, it w as reported th at 3% of th e p at ien t s experien ced
bacterem ia after septoplast y an d 13% after septorh in o-
plast y.11 In th e perspect ive of su rgical con t am in at ion , rh i-
noplast y w ith ou t septal w ork m ay be categorized as a clean
su rger y, bu t septorh in op last y is categorized as a clean con -
tam in ated surger y.12
Regarding th e prophylact ic an t ibiot ic t reat m en t ,
a st u dy of 100 cases of revision rh in op last y revealed 5
pat ien t s w ith severe in fect ion an d 9 pat ien t s w ith localized
in fect ion . Th ese pat ien t s w ere n ot covered by prophylac-
t ic an t ibiot ics. On th e oth er h an d, in th e t reated group 1
sh ow ed severe in fect ion an d 3 sh ow ed localized in fect ion .13
An t ibiot ic packing p roved to be e ect ive in d ecreasing th e
colony t w o to seven t im es com pared w ith placebo packing
in a st udy of 110 cases of septoplast y.14
Th ere are debates on th e sen sit ivit y an d speci cit y of
preoperat ive n asal sw abs. Th e auth or’s protocol depen ds on
th e result s of colon izat ion an d sen sit ivit y test in preparing
for com plicated septorh in op last y an d rh in op last y involving
alloplast ic im p lan t ing. Th e prim ar y ch oice of an t ibiot ics in
colon izing MSSA an d MSSE are rst- or secon d-gen erat ion
cephalosporin s an d Augm en t in (Beach am Ph arm aceu t i-
cals). In th e cases of MRSE, MRSA, an d Enterobacter, ap ply-
ing suscept ible an t ibiot ics h as been con sidered a prim ar y
ch oice.
■ Case Studies
Case 1
In a 38-year-old fem ale, rh in oplast y u sing an L-t ype sili-
con e im plan t h ad been perform ed 11 years previously
(Fig. 11.12). Sh e com p lain ed of u pt u rn ed t ip an d sh ort
nose. Th e operat ion w as perform ed an d in cluded low ering
th e sellion , rem oving th e ent ire capsule, recon st ruct ion of
th e rem ain ing L-st rut using cost al cart ilage, project ing th e
dorsal soft t issue pro le w ith fascia of th e rect u s abdom i-
nis, an d project ing th e n asal t ip using cost al cart ilage
(Fig. 11.13). Resu lt s are sh ow n in Fig. 11.14.
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b c

Fig. 11.12 Case 1. (a–c) Patient photos before the surgery.

Fig. 11.13 Case 1. Operative procedures.

(a) Original nasion (green arrow) and low-
ered sellion (yellow arrow). (b) Intraopera-
tive removal of L-t ype silicone. (c) Septal
reconstruction with costal cartilage and
dorsal rectus fascia. c

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 11 Managem ent of Alloplast -Related Com plications 145

b c
a

Fig. 11.14 Case 1. (a–c) Patient after the surgery.

Case 2
In a 42-year-old fem ale, rhinoplast y using I-t ype silicone
h ad been perform ed w ith a n asal tip onlay graft using con -
ch al cart ilage 8 years previou sly. Sh e w as dissat is ed w ith
the dorsal dem arcat ion of th e silicone im plant an d long nose
appearan ce. Th e operation in clu ded low ering th e sellion
by ch anging th e silicon e im plan t an d sh orten ing th e n asal
length (Fig. 11.15). Addit ion al procedures w ere reu sing th e
posterior capsule to sm ooth out the dorsal dem arcation,
an d grafting of th e folded cym ba con ch a at th e caudal sep -
t um as a septal strut to project the nasal t ip and to elevate
the subnasale using cavum con cha at the dorsum . Folded
Gore-Tex w as in serted to augm ent the alar crease jun ction.
Case 3
In a 25-year-old fem ale, rh in op last y u sing an I-t yp e silicon e
im plan t an d an un kn ow n m aterial (presum ably AlloDerm )
w as p erform ed t w ice by th e sam e su rgeon ; 1 an d 3 years
previously (Fig. 11.16). Th e pat ien t su ered from relap s-
ing in am m at ion an d con sequ en t drain age of pus from
th e t ip. Th e form er surgeon h ad injected an cillar y ller to
th e t ip, but th is resu lted in t ip deform it y. Th e pat ien t com -
plain ed of t ip deform it y an d h igh n asal dorsum . Mult ilay-
ered capsu le w as rem oved an d th e radix w as redu ced . Th e
dorsal silicon e im plan t w as ch anged to a th in n er on e. Tip -
plast y using th e cym ba an d cavum con ch a w as perform ed
(Fig. 11.17). Resu lt s are sh ow n in Fig. 11.18.

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146 II Rhinoplast y

Fig. 11.15 Case 2. (a,b) Before the surgery.

a b
(c,d) After lowering the sellion, elevating the
subnasale, and augmenting the alar crease
junction.

c d

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 11 Managem ent of Alloplast -Related Com plications 147

Fig. 11.16 Case 3. (a–c)

a b c
Patient photos before the
surgery.

Fig. 11.17 Multilayered capsules, dorsal silicone implant, and

columellar Medpor was rem oved, and the implant was changed
with a thinner silicone; tip-plast y using the cymba and cavum con-
cha cartilage, and a soft tissue graft using super cial m astoid fascia
were performed.

Fig. 11.18 Case 3. (a–c)

a b c
Patient photos after the
surgery.

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148 II Rhinoplast y
References
1. Ferril GR, Wudel JM, Win kler AA. Man agem en t of com pli-
cat ion s from allop last ic im plan t s in rh in oplast y. Cu rr Op in
Otolar yngol Head Neck Su rg 2013;21(4):372–378
2. Hong JP, Yoon JY, Choi JW. Are polytet ra uoroethylen e
(Gore-Tex) im p lan ts an altern at ive m aterial for n asal
d orsal augm en tat ion in Asian s? J Cran iofac Surg 2010;
21(6):1750–1754
3. Peled ZM, Warren AG, Joh n ston P, Yarem ch uk MJ. Th e use
of alloplast ic m aterials in rh in oplast y surger y: a m et a-
an alysis. Plast Recon st r Surg 2008;121(3):85e–92e
4. Park CH. Histological st udy of expan ded polytet ra uoro-
ethylene (Gore-Tex) im plan ted in th e h um an n ose. Rh in ol-
ogy 2008;46(4):317–323
5. Gurn ey TA, Kim DW. Applicat ion s of porcin e derm al colla-
gen (ENDURAGen ) in facial p last ic su rger y. Facial Plast Su rg
Clin North Am 2007;15(1):113–121, viii
6. Bee YS, Alon zo B, Ng JD. Review of AlloDerm acellular h u-
m an derm is regen erat ive t issu e m at rix in m u lt ip le t yp es
of ocu lofacial plast ic an d recon st ruct ive surger y. Oph th al
Plast Recon st r Su rg 2015;31(5):348–351
http://e-surg.com
7. Sw elam W, Ida-Yon em och i H, Saku T. Angiogen esis in m u-
cou s reten t ion cyst: a h u m an in vivo–like m od el of en -
doth elial cell di eren t iat ion in m ucous subst rate. J Oral
Path ol Med 2005;34(1):30–38
8. Georgiou I, Farber N, Men des D, Win kler E. Th e role of an t i-
biot ics in rh in oplast y and septoplast y: a literat u re review.
Rh in ology 2008;46(4):267–270
9. Haug RH. Microorgan ism s of th e nose an d paran asal si-
n u ses. Oral Maxillofac Surg Clin Nor th Am 2012;24(2):
191–196, vii–viii
10. Kaygu su z I, Kizirgil A, Karlidağ T, et al. Bacteriem ia in sep -
toplast y an d septorh in oplast y su rger y. Rh in ology 2003;
41(2):76–79
11. Oku r E, Yildirim I, Aral M, Ciragil P, Kiliç MA, Gu l M.
Bacterem ia d u ring open septorh in op last y. Am J Rh in ol
2006;20(1):36–39
12. Cru se P. Su rgical in fect ion : in cision al w ou n ds. In : Ben n et t
JV, Brach m an n PS, eds. Hosp ital In fect ion s. 2n d ed. Boston ,
MA: Lit tle, Brow n ; 1986:423–436
13. Schäfer J, Pirsig W. [Preventive antibiotic adm inistration in com -
plicated rhinosurgical interventions—a double-blind study.]
Laryngol Rhinol Otol (Stuttg) 1988;67(4):150–155
14. Bandhauer F, Buhl D, Grossenbacher R. Antibiotic prophy-
laxis in rhinosurgery. Am J Rhinol 2002;16(3):135–139
III
Blepharoplasty

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http://e-surg.com
12 Double -Eyelid Surgery: Nonincisional Suture
Techniques
Jin Joo Hong and Hae Won Yang
Pearls
• Th e pat tern of skin fold form at ion in th e open ing
ph ase of th e u pper eyelid is ch aracterist ic of th e
East Asian in dividual. In a double eyelid, th e upper
border of th e eye con sist s of t w o outlin es, as if th e
u pp er eyelid w ere com posed of dual layers.
• The creation of an arti cial connection of skin (anterior
lam ella) and levator (posterior lam ella) at a higher level
is the m ain feature of the double-eyelid procedure.
• Non in cision al su t u re ligat ion creates a fold w ith ou t
dissect ion . It is a sim ple, n on invasive, an d e cien t
tech n iqu e to m ake a double fold, but it h as also
m any con t rain dicat ion s. For exam p le, revision
bleph aroplast y is perform ed to reduce th e h eigh t
of th e fold, especially after a previou s in cision al
bleph aroplast y.
• Th e n on in cision al su t ure tech n iqu e n eeds to be
m odi ed con sidering variou s factors su ch as pu y
eyelid, w eak levator fun ct ion , an d exoph th alm os. For
a p u y eyelid, th e sept al fat sh ou ld be rem oved as
m u ch as possible, an d th e n ew crease lin e design ed
to be as low as p ossible. Too h igh a fold m ay h in der
th e full open ing of th e apert u re an d yield open ing
discom for t , especially in a subclin ical or clin ical
ptot ic eyelid. If exoph th alm os is prom in en t , th e lin e
of th e crease sh ould be low ered m ore th an usual to
avoid an excessively h igh fold.
• Th e lid m argin m ay be closed (“in side fold”) or
open (“out side fold”) at th e m edial en d according to
w h eth er or n ot th e t w o upper ou tlin es of th e eye,
■ Introduction
Double Eyelid and Single Eyelid
On e of th e m ost im port an t fu n ct ion s of th e u pp er eyelid is
to altern ately protect an d exp ose th e eye w ith it s rep et it ive
sh u t ter-like excu rsion m ovem en t . Along w ith th e altern at-
ing m ot ion of th e closing an d open ing ph ases, th e upper
eyelid ch anges its extern al sh ape con t in u ously. In th e clos-
ing ph ase, th e lid is exten ded w ide to cover th e corn ea an d
bulbar conjun ct iva of th e eyeball; in th e open ing ph ase, th e
lid is ret racted to expose th em . During th e open ing period,
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th e edge of th e skin fold, an d th e t ru e lid m argin
w ith th e eyelash es are join ed togeth er m edially.
• Th e m iddle port ion of th e double fold sh ould be
su cien tly h igh er th an th e m ed ial an d lateral
port ion s in th e closed state to preven t st raigh ten ing
of th e dou ble fold w h en th e eyes are open .
• After p reop erat ive design , ve p u n ct u res or sm all
slit s sh ou ld be m ade w ith a n eedle or n o. 11 blade.
A 7–0 n on absorbable su t u re is p assed th rough th e
skin to th e u pp er m argin of th e t arsu s an d ret u rn ed
th rough th e sam e site of th e t arsu s to th e skin . Th en
th e lid skin is xed on th e t arsal plate.
• W h en rem oving th e septal fat , th e posit ion of th e
fat m u st be con sidered . Th e sept al fat m oves to an
upper an d lateral area in th e supin e posit ion .
• For Mü ller m uscle t u cking, 7–0 nylon th read is
in t roduced th rough th e skin to th e upper m argin of
th e t arsu s. Th e sut ure is passed th rough th e tarsus
to th e poin t of th e conju n ct iva n ear th e su p erior
forn ix an d ret urn ed th rough th e sam e poin t on th e
conjun ct iva to th e t arsus, t ucking th e Mü ller m uscle.
Th e sut ure exit s th rough th e t arsus to th e skin an d is
kn ot ted to t igh ten th e th read.
• W h en th e sut ure passes th rough th e t arsus, th e
su t u re m ay ap p ear on th e conju n ct ival side, w h ich
can in duce a foreign body sen sat ion an d severe pain .
If th e p at ien t com p lain s of a foreign body sen sat ion ,
th e eyelid is everted an d th e t arsal plate is carefully
scru t in ized.
th e enveloping cover (skin an d palpebral conjun ct iva)
sh ou ld be folded to elim in ate red u n dan cy in tem p orar y cov-
erage. Alth ough conju n ct ival folding is n ot obser ved w h en
looking at th e face, th e pat tern of skin fold form at ion in th e
open ing ph ase of th e upper eyelid is ch aracterist ic of each
East Asian in dividu al.1 Th is p at tern an d m an n er of folding
th e ou ter skin determ in es th e sh ape of th e eyes, part icu-
larly in th e upper border of th e palpebral apert ure. Usu ally,
th e skin is folded at the m iddle of th e eyelid, an d th e edge
of th e skin fold is located above th e eyelash to expose th e
corn ea com pletely in the fully open ed st ate. Th e edge of th e
skin fold an d th e eyelid m argin w ith th e eyelash es parallel
to each oth er form th e u p per border of th e palp ebral aper-
151
152 III Blepharoplast y
a b
t u re (dou ble eyelid) togeth er. In a double eyelid, th e upper
border of th e eye con sist s of t w o outlin es as if th e upper
eyelid w ere com p osed of du al layers (Fig. 12.1).
In con t rast , th e single eyelid h as on ly on e bord er,
because th e skin fold is form ed below th e lid m argin . Th e
edge of th e skin fold h id es th e real lid m argin an d p u sh es
th e eyelash es from above in th e open ing ph ase (Fig. 12.2).
Com pared w ith th e double eyelid, th e palpebral apert ure
is redu ced by th e low er skin fold. Th e single-lin ed upper
border is a un ique feat u re of East Asian in dividuals (Korean ,
Ch in ese, Japan ese, an d Mongolian ), w h ile th e dou ble lin e is
th e m ost prom in en t eyelid fold pat tern in Caucasian , Afri-
can Am erican , an d South Asian in dividuals.
Anatomy of the Upper Eyelid
Th e upper eyelid is a layered st ruct ure, divided in to th e
an terior, m idd le, an d posterior lam ellae. Th e an terior
lam ella is com posed of th e skin an d u n derlying orbicularis
oculi m uscle. Th e posterior lam ella con sist s of th e tarsus
an d u n d erlying conju n ct iva. Th e m iddle lam ella con sists of
th e orbit al sept u m an d fat separat ing th e orbit al con ten t s
from th e p resept al st ru ct u res.2 In th e sagit t al sect ion al
a b
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Fig. 12.1 Typical double eyelid in South Asian
women. In a double eyelid, the upper border
of the eye consists of t wo outlines because the
edge of the transverse skin fold is formed above
the lid margin. The edge of the skin and lid mar-
gin create the dual-lined upper border of the
eye, and the eye is fully exposed when opened.
an atom y, th e inver ted t riangle-sh ap ed u pp er eyelid h as a
th ick u pper por t ion w ith th ree dist in ctly separated lam el-
lae an d a th in distal lid m argin in w h ich th e an terior an d
posterior lam ellae are at ten uated an d con den sed rm ly
togeth er (th e skin , orbicu laris ocu li m u scle, an d tarsu s).
Th e in ter ven ing orbit al sept um an d orbit al fat (m iddle
lam ellae) exten d on ly to th e fusion lin e, w h ich can be iden -
t i ed as a skin crease on th e outer surface. Th e con den sed
dist al lid m argin is at t ach ed to th e levator m ech an ism
(levator ap on eu rosis, su p erior levator palp ebralis m u scle,
an d Mü ller m u scle) an d act ively ret ract s at th e begin n ing
of th e open ing ph ase (Fig. 12.3). Meanw h ile, th e an terior
an d m iddle lam ellae above th e fu sion lin e (t ran sverse
skin crease) are p assively fold ed according to th e op en ing
m ovem en t .
With th e su p erior levator p alpebralis m u scle con t ract-
ing, th e distal lid m argin (red-colored surface) directly con -
nected to th e levator m ech an ism begin s to ret ract upw ard ,
leaving th e upper an terior lam ella (above th e fusion lin e,
green - an d blu e-colored su rface) st at ic in sit u . As th e
degree of open ing in creases, th e an terior lam ella ju st above
th e crease is passively lifted from its distal en d (green -
colored surface). At th is level, th e t ran sverse skin crease
becom es prom in en t an d is folded furth er as open ing pro-
Fig. 12.2 Typical single eyelid of East Asian
women. (a) In the opening phase, the skin is
folded at a level too low, and the skin crease is
hidden under the upper part of the palpebral
aperture and (b) the eyelashes get pushed
down. In comparison with the double eyelid,
the palpebral aperture looks reduced by the
distal skin fold, which lies at a lower level.
 12 Double-Eyelid 
Surgery: 
Nonincisional 
Suture 
Techniques 153

th e fold lies above th e lid m argin an d does n ot obst ruct th e

norm al visu al eld (Fig. 12.4).3,4

Nonincision Suture Ligation for

a b c form at ion , w h ich is th e result of th e th in n ing an d fusion of
Fig. 12.3 Opening process of the upper eyelid. (a) In the rest-
ing phase, the outer skin of the upper eyelid is expanded. (b) At
the beginning of eyelid opening, the skin just above the crease
(green zone) is rolled up with the lid margin elevated. (c) In the
fully opened phase, the green zone skin is completely behind the
upper skin.
gresses. With furth er open ing, th e dist al skin of th e an te-
rior lam ella (green ) is ip p ed u p an d en ters ju st beh in d it s
u pp er skin (blu e-colored su rface) to create a fold .
In th e single eyelid, th e m iddle lam ella is w ell devel-
oped an d abun dan t orbit al fat exten ds to a low er level.
Th erefore, th e an terior an d posterior lam ellae fuse at a
low er level th an th ey do in a dou ble eyelid, an d th e h eigh t
of th e con den sed dist al lid m argin (red) is too low. As a
con sequen ce, th e skin of th e an terior lam ella is folded at a
m u ch low er level (low er t arsal crease) in th e open ing ph ase
an d h ides th e en t ire lid m argin , in clu ding th e eyelash es.
Fur th erm ore, th e u pper por t ion of th e palpebral aper t ure
is p ar t ially eclip sed by th e skin fold, desp ite th e fu ll open -
ing of th e eyelid . Hen ce, in a severe case, th e fron t alis act s
to lift th e eyelid skin fold to provide adequate vision , as in
a p at ien t w ith a bleph aroptosis. Meanw h ile, in a dou ble
eyelid, th e fold is form ed at a h igh er level an d th e edge of
Double -Eyelid Formation
Th e m ost im port an t an atom ic di eren ce bet w een a single
an d d ou ble eyelid is th e level of th e lid crease an d skin fold
th e an terior an d posterior lam ellae. In a double eyelid, th e
skin fold lies w ith in th e lid above th e eyelash in a relaxed
for w ard gaze, because th e fold-form ing lid crease is w ell
de n ed an d su cien tly h igh . Th e creat ion of an art i cial
con n ect ion of skin (an terior lam ella) an d levator (posterior
lam ella) at a h igh er level is th e m ain feat ure of th e double-
eyelid procedure.
Tradit ion ally, th e procedure can be divided in to t w o
m ajor categories: n on in cision al su t u re ligat ion (bu ried
su t u re tech n iqu e) an d th e extern al-in cision tech n iqu e.
W h ile th e n on in cision al tech n ique con n ects th e skin an d
th e deeper act ive levator m ech an ism w ith a sim ple th read
loop, th e extern al-in cision tech n iqu e con sist s of reducing
th e volum e of both lam ellae an d xing th em togeth er w ith
scar adh esion . Th e extern al-in cision tech n iqu e also requ ires
a bu ried su t u re to con n ect th e skin an d levator m ech an ism ,
so a su t u re loop ligat ion is com m on to both tech n iqu es.
Regardless of th e u se of an in cision , a buried sut ure loop in
th e lid is an essen t ial part of double-eyelid creat ion . In fact ,
th e n on in cision sut ure ligat ion tech n ique en t ails form ing a
fold w ith sut ure ligat ion w ith ou t dissect ion . Various surgi-
cal approach es for n on in cision al sut ure ligat ion h ave been
reported. Th e n on in cision sut ure ligat ion tech n ique h as
been developed for correct ion of bleph aroptosis as w ell as
for th e sim ple form at ion of th e double-eyelid fold. From th e
conjun ct ival side, th e ret ractor can be plicated to in crease
th e ten sion of th e levator m ech an ism .

Resting phase Opening phase Resting phase Opening phase

a Single eyelid b Double eyelid

Fig. 12.4 Single and double eyelid. The most important anatomic di erence bet ween a single and double eyelid is the level at which the
fusion bet ween the anterior and posterior lamellae occurs, and thus the level at which the anterior skin is folded. The pat tern of the skin
fold in the opening phase determines the shape of the eye. (a) In a single eyelid of an Asian, the skin fold is formed at a lower level and the
folding skin hides the real lid margin and eyelashes as well as the upper part of the palpebral aperture. (b) In contrast, the skin fold of a
double eyelid lies at the upper level and the fold edge is formed far above the eyelashes.

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154 III Blepharoplast y
■ Patient Evaluation
With th e except ion of severe blep h aroptosis w ith w eak
levator fu n ct ion or ext rem ely th ick lid soft t issue, th e
n on in cision sut ure ligat ion tech n ique can be applied to
t ran sform th e lid from single to dou ble in m ost pat ien t s.
How ever, th e procedu re is selected based on th e speci c
requ irem en ts of th e case an d th e an atom ic an d fun ct ion al
con dit ion s of th e pat ien t .
Pu y Eyelid
A st able adh esion of th e previou sly sep arated an terior an d
posterior lam ellae at a h igh er level is th e prim ar y goal of
double-eyelid su rger y. Th e in ter ven ing loose volum in ous
t issue (orbicularis oculi m u scle an d presept al an d sept al
fat) bet w een th e skin (an terior lam ella) an d levator m ech a-
n ism (p osterior lam ella) is th e m ain h in dran ce to th e fu sion
of th e lam ellae. Hen ce, excessive soft t issue in th e upper
eyelid is an u n favorable factor for double-eyelid form at ion
u sing eith er th e extern al-in cision or n on in cision al sut u re
ligat ion p rocedure. W h ile th e sept al fat can be rem oved
w ith a sm all in cision before sut ure ligat ion (part ial in cision
su t u re ligat ion ), th e p resept al fat an d orbicu laris ocu li m u s-
cle can n ot be reduced w ith out a full-length in cision al tech -
n iqu e. For a p u y eyelid, th e sept al fat sh ould be rem oved
as m u ch as p ossible, an d th e n ew crease lin e sh ou ld be
design ed to be as low as possible in a n on in cision sut ure
ligat ion p rocedu re (st rictly speaking, th is sh ould be n am ed
“p ar t ial in cision su t u re ligat ion ” becau se th e fat is rem oved
th rough a sm all in cision before sut ure ligat ion ).
Weak Levator Function
Alth ough Mü ller m u scle t u cking can resolve m ild blep h a-
roptosis, it is con t rain dicated in m ost cases of severe bleph -
aroptosis w ith a loose levator ap on eu rosis th at requ ires
direct levator advan cem en t . Th e creat ion of a h igh er fold-
ing crease in creases th e load of th e dyn am ic par t of th e lid.
Fu rtherm ore, th e upper por t ion of eyelid skin is th icker an d
requ ires m ore force to fold. Too h igh of a fold m ay h in der
th e fu ll open ing of th e aper t ure an d yield open ing discom -
fort , esp ecially in a subclin ical or clin ical ptot ic eyelid.
Exophthalmos
Eyelid excu rsion is in u en ced by th e an atom y of th e n eigh -
boring st ruct ure, relat ive volum e of th e fat , depth of th e
orbit , degree of eyeball prot rusion , an d oth er factors. Th e
su sp en sion of th e skin fold is t igh ter in exop h th alm os th an
in en op h th alm os because th e eyeball push es th e lid for-
w ard . Th e edge of th e fold is relat ively h igh an d th e u n der-
lying lid m argin is exposed at a h igh er level, especially in
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th e cen ter of th e eyeball. If exoph th alm os is prom in en t , th e
lin e of th e crease sh ou ld be low ered m ore th an usu al to
avoid an excessively h igh fold.
Shape of the Lid Margin Exposure
Double-eyelid surger y not only opens the h idden upper
portion of the palpebral apert ure but also changes the
upper border from having a single to a double outline. The
new ly form ed outer line is determ ined by the edge of th e
fold rather than by the supratarsal crease itself. The lid
m argin (skin bet w een th e fold edge an d th e lid m argin ) is
the fringe of the eye th at is an at t ract ive feat ure and a good
place to add m akeup to m ake the eye appear w ider. There-
fore, one of the m ain purposes of double-eyelid surger y is
to obtain an adequ ate an d beaut ifu l lid m argin . Because th e
lid m argin changes according to the view ing direct ion or
degree of open ness in a gaze, it should be designed during
a relaxed for w ard gaze. Th e lid m argin is th e area bet w een
the height of the supratarsal crease an d th e vert ical depth
of the fold. The fold is deepest at the m idpoin t due to th e
m axim al vert ical open ing of th e apert u re, w h ich m ean s
that the lid retracts higher in the m iddle than at both sides.
Therefore, th e m iddle portion of the crease line sh ould be
adequately elevated to avoid a n arrow lid m argin in th e m id-
dle (Fig. 12.5). Th e sh ape of th e lid m argin is determ in ed by
the edge of th e fold and the distal border of the lid.
Inside and Outside Folds
Th e lid m argin m ay be closed (“in side fold”) or open (“out-
side fold”) at th e m ed ial en d according to w h eth er or n ot
th e t w o u pper outlin es of th e eye, th e edge of th e skin
fold an d th e t rue lid m argin w ith th e eyelash es, are join ed
togeth er m edially. In an eye w ith an in side fold, th e t ran s-
verse skin fold is conjoin ed to th e ep ican th al fold. To op en
m edially, th e fold crease sh ou ld be located separately an d
high er th an th e st ar t of th e epican th al fold. Curren tly, on e
of th e m ost popular lid m argin sh apes is m idw ay bet w een
th e in side an d out side folds. How ever, th ere can n ot be a
posit ion m idw ay bet w een open an d closed. Th erefore,
in th e “in /out” or “n eut ral” fold, th e m edial side is open
w ith a sm all gap, but th e h eigh t of th e double lid gradu-
ally in creases laterally. Th u s, it is act u ally an ou t side fold,
but because of it s m in im al opening m edially an d in creas-
ing h eigh t laterally, it can be seen as an in side fold from a
dist an ce (Fig. 12.6).
Revision Case
Becau se th e an terior lam ella just above th e fusion lin e is
passively folded by th e ret ract ion of th e posterior lam ella,
even an un n ot iceable subcu tan eou s scar can disru pt th e
con t in uit y of th e even skin fold. In a severe case, th e scar
 12 Double-Eyelid 
Surgery: 
Nonincisional 
Suture 
Techniques 155

a b c

Fig. 12.5 Di erent shapes of lid margin. (a) The shape of the lid margin is determined by the edge of the fold and the distal border of
the lid. If the middle portion of the lid margin is too wide, the shape of the eye looks too round or oval-shaped. (b) If the middle portion
of the lid margin is too narrow, the eye appears as though it is frowning. (c) The upper and lower sides of the lid margin should be parallel
or gradually grow farther apart.

sh ou ld be excised (u sing an in cision al tech n iqu e) or th e Suture Material

d esign ed lin e sh ould be put h igh er th an th e scar (using a
n on in cision al tech n iqu e) to keep th e skin ju st above th e
crease u n iform . For th is reason , th e n on in cision al m eth od
can n ot be used to redu ce th e h eigh t of th e fold, especially
after a p reviou s in cision al blep h arop last y.
Becau se n o dissect ion is perform ed during n on in cision al
su t u re ligat ion , th e adh esion of th e an terior an d p osterior
lam ellae is m ain t ain ed on ly by th e ten sile st rength of th e
su t u re m aterial an d kn ot clam p ing. Th erefore, th e ch oice

a b c

Fig. 12.6 Three t ypes of double fold. (a,b) The lid margin may be closed (“inside” fold)
or open (“outside” fold) at the medial end according to whether or not the t wo upper
outlines of the eye, the edge of the skin fold and the true lid margin with the eyelashes,
join together medially. (c) In the “in/out” or “neutral” fold, the m edial side is open with a
small gap, but the height of the lid margin is gradually increasing laterally. (d) Design of
d the outside fold (red), in/out or neutral fold (yellow), and inside fold (blue).

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156 III Blepharoplast y
of sut ure m aterial is im port an t . Frequen tly u sed nylon
(p olyam ide, 7–0 nylon ) is a n on absorbable, m on o lam en t
su t u re m aterial. Alth ough a m on o lam en t nylon su t u re h as
a great m em or y to ret u rn to its p reviou s sh ape an d a p ro-
clivit y for kn ot slippage, it h as a low in fect ion rate. Un dyed
t ran slucen t nylon is preferred for a n on in cision sut ure liga-
t ion procedu re, because un dyed nylon h as a greater ten sile
st rength th an th e dyed form , w h ich in clu d es im p u rit ies.
How ever, t ran slu cen t su t u re m aterial is h ard to n d in a
revision procedu re.5,6
Choice of Needle
Needle ch oice d ep en ds on th e an t icip ated locat ion of th e
su t u re loop in th e eyelid t issu e. Con n ect ing loop (s) can be
m ade by p erforat ing th e fu ll th ickn ess of th e lid or by p ar-
t ial t agging of th e lid skin to th e tarsus. For a perforat ion
procedure, a long, circu lar n eedle is conven ien t (24 m m
rou n d ⅜ circu lar n eedle w ith 7–0 w h ite nylon ). How ever,
a sm aller n eed le is p referred for th e p ar t ial tagging proce-
dure. A t riangu lar cut t ing n eedle can dam age large vessels,
so a rou n d or rectangu lar cu t t ing n eed le is ch osen .
■ Surgical Techniques
Nonincisional Suture Technique of a
Double -Eyelid Operation
It is bet ter to design a dou ble eyelid w ith th e clien t in an
u prigh t p osit ion because th e sh ape of th e eyes an d th e
double fold can ch ange in a supin e posit ion . Th e surgeon
can bet ter predict th e surgical outcom e for th e pat ien t in
an u p righ t posit ion .
Th ere are th ree classi cat ion s for th e start ing poin t of
th e double fold. An in side fold is on e in w h ich th e double
fold lin e st ar t s below th e epican th al fold. It ten ds to be m ore
n at u ral bu t th e eyes can look sm aller th an w ith oth er form s
of fold. An out side fold is on e in w h ich th e double fold lin e
start s above th e epican th al fold. Th e eyes look bigger th an
w ith an in side fold, but th e appearan ce m ay be un n at ural. A
n eu t ral fold or in /ou t fold is a t ype of out side fold in w h ich
th e st art ing poin t is low er th an it is for th e classical out side
fold . It looks n at ural an d th e eyes look bigger; m any Asian
clien ts prefer th is fold (Fig. 12.6d).7
Th e preoperat ive design of th e double fold lin e sh ould
be m arked w ith a sh arp surgical m arking pen along th e
n at ural cu r vat u re of th e eyelid skin . Gen erally, th e m ean
h eigh t of a dou ble fold is 6 to 8 m m from th e eyelash , an d
th e h eigh t ranges from 4 to 10 m m . Th e range of tarsal
w idth in Asian in dividu als is usu ally 6 to 8 m m , so a sut ure
th at pen et rates th e skin can be xed on th e t arsal plate.8
Th e m iddle port ion of th e fold sh ould be h igh er th an
th e m edial an d lateral por t ion s in th e closed st ate, to pre-
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ven t st raigh ten ing of th e d ou ble fold w h en th e eyes open .
If th e p at ien t h as th in eyelid skin an d good levator fu n c-
t ion , a h igh er double fold is possible. On th e con t rar y, if th e
pat ien t h as th ick eyelid skin an d poor levator fu n ct ion , it is
bet ter to m ake th e double fold lin e low er because it ten ds
to look u n n at u ral if a h igh er fold is m ade in su ch a p at ien t .
Th e ve m arkings vert ical to th e double fold lin e in terrupt
an d divide th is lin e in to fou r areas (Fig. 12.7). Th e m edial
en d sh ou ld be at or im m ediately lateral to th e u pp er en d of
th e epican th al fold. Th e lateral en d sh ould be at th e lateral
en d of th e p alp ebral ssu re.
Th is surgical procedure is usually perform ed un der
local an esth esia using 2% lidocain e m ixed w ith 1/100,000
ep in ep h rin e an d m ild in t raven ou s sedat ion . For skin an es-
th esia, sh allow in sert ion of a 26-gauge n eedle in to th e sub -
derm al layer is perform ed, because if th e n eedle is in ser ted
deep, bleeding an d sw elling m ay occur an d th e su rgeon
m ay n ot be able to predict th e ou tcom e of su rger y. Th e
conjun ct iva is also an esth et ized w ith lidocain e inject ion .
A 0.5% op h th alm ic solu t ion of p rop aracain e hyd roch loride
is used to an esth et ize th e corn ea. A plast ic corn ea protec-
tor can be u sed to p rotect th e eyeball. Th e su rgical step s
of th e n on in cision al sut ure tech n ique for a double-eyelid
operat ion are sh ow n in Fig. 12.8. Du ring local an esth esia,
th e poin t s previously m arked w ith gen t ian violet are pun c-
t ured w ith th e 26-gauge n eedle. Th ese tem porar y m ark-
ings can in dicate th e en t ran ces an d exit s of th e 7–0 nylon
su t u re. In stead of a pu n ct u re, a sm all st ab in cision can be
m ade w ith a n o. 11 blade.
If th e orbit al sept al fat volu m e is ver y bu lky an d th e
upper eyelid appears pu y, sept al fat rem oval can be p er-
form ed th rough a sm all in cision on th e lateral port ion of
th e dou ble fold. W h ile h olding th e sept um w ith tooth ed
forceps, a sm all in cision is m ade on the sept um w ith sh arp
scissors, an d th e sept al fat is ext racted w ith sm ooth forcep s.
Fig. 12.7 Preoperative design of the nonincisional suture tech-
nique. The m idportion of the fold should be higher than the medial
and lateral portions in the closed state to prevent straightening of
the double fold when the eyes open.
 12 Double-Eyelid 
Surgery: 
Nonincisional 
Suture 
Techniques 157

a b c

d e f

Fig. 12.8 Surgical procedures for the nonincisional suture technique. (a) After local anesthesia using 2% lidocaine mixed with 1/100,000
epinephrine and mild intravenous sedation, the points previously marked with gentian violet are punctured with a no. 26G needle. These
temporary tat toos can be the entrance and exit points for 7–0 nylon sutures. (b) Septal fat removal can be done through a small incision on
the lateral portion of the double fold. (c) The suture is passed through the skin to the upper margin of the tarsus. As the suture is passed,
the upper eyelid is everted with wide sm ooth forceps or other forceps for the tarsus. (d) The suture needle is returned through the same
site at the tarsus to the skin. (e) The suture is passed through the subdermal layer to the next puncture of the skin. (f) The same procedure
is repeated on the following punctures.

Th e ext racted fat is coagu lated w ith an elect rical coagulator
an d th en cu t . Met icu lou s coagu lat ion is n ecessar y becau se
th ere are sm all vessels w ith in th e sept um .
A 7–0 m on o lam en t n on absorbable sut ure w ith a
t apered 24-m m ⅜c n eedle is used. A roun d n eedle sut ure
is u sed becau se an angled n eedle m ay cu t th e nylon acci-
d en t ally. Th e su t ure is passed th rough th e skin to th e upper
m argin of th e t arsu s an d ret u rn ed th rough th e sam e site
of th e tarsus to th e skin . Th en th e lid skin is xed on th e
t arsal plate.
W hen th e sut ure is being passed, the upper eyelid is
everted w ith a w ide sm ooth forceps, or another t ype of
forceps for th e tarsus. Th ere are m any t ypes of forceps for
h an dling th e tarsu s. To pen etrate th e tarsus in th e sh ortest
distance, the needle should be vert ical to the tarsus. If the
n eedle is n ot vert ical to th e tarsus, th e soft tissue ben eath
the skin can be xed to th e tarsus an d unw anted dim pling
w ill develop. The distance from the eyelid m argin to the
h ole in th e skin side sh ou ld be sim ilar to th e distan ce from
the eyelid m argin to the conjunct ival ent rance. If the length
of the skin side exceeds that of the conjunct ival side, the
double fold w ill be deeper an d the eyelashes w ill be everted.
If th e skin side is shorter th an the conjun ctival side, the skin
below the double fold w ill sag. After the sut ure exits th e
hole of the skin again , it is passed th rough th e subderm al
layer to the n ext skin punct ure, w ith the procedure repeated
on each punct ure. The sequence of the procedure can be
ch anged. Nu m bering skin en tr y poin ts as 1 th rough 5 from
m edial to lateral, th e au th ors proceed in th e order 5–3–1–
2–4–5. W h en the septal fat is rem oved, the order proceeds
as 4–5–3–1–2–4 (Fig. 12.9). Th e en ds of th e sut u res are t ied
at the lateral posit ion and the kn ot is buried w ithin the sub-
derm al layer. The kn ot can be placed in any locat ion, but
the cent ral area is avoided because the knots can be visible
there. The skin incision is closed w ith nylon 7–0, or m ay not
need to be closed w hen th e incision is ver y sm all.
The patient opens his/her eyes and the surgeon checks the
shape of the double fold and the sym m etry of both eyes. An
ice bag is applied to the periorbital area for 2 days to reduce
swelling. The skin stitches are rem oved 3 to 5 days later.

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158 III Blepharoplast y
Fig. 12.9 Typical sequence of needle passes in the nonincisional suture technique. Numbering skin entry points as 1 through 5 from
medial to lateral, the authors proceed in the order 5–3–1–2–4–5. The ends of the sutures are tied at the lateral position and the knot is
buried within the subdermal layer.
Transconjunctival Müller Tucking
In th e u n ilateral or bilateral m ild ptosis case, t ran sconju n c-
t ival Mü ller t ucking can be don e w ith th e double-eyelid
operat ion (Fig. 12.10). Th e preop erat ive design of th e dou -
ble fold lin e sh ould be perform ed along th e n at ural skin
crease. Th e locat ion s of Mü ller t u cking sut ures are m arked
on th e vert ical lin e of th e m edial an d lateral lim bi. Th e sur-
gical p rocedu re is u su ally perform ed u n der local an esth esia
u sing 2% lidocain e m ixed w ith 1/100,000 epin ep h rin e an d
m ild in t raven ou s sedat ion . Sm all in cision s are m ade w ith
a n eed le or n o. 11 blade on p oin t s th at th e n eedle w ou ld
pen et rate. Ever t ing th e u pper lid, a t ract ion sut ure is m ade
on th e upper m argin of th e t arsus w ith nylon 5–0.
For Mü ller m uscle t ucking, 7–0 nylon th read is in t ro-
duced th rough th e skin to th e upper m argin of th e t arsus.
Th e sut ure is passed th rough th e t arsus to th e poin t of th e
conjun ct iva n ear th e superior forn ix an d ret u rn ed th rough
th e sam e poin t on th e conjun ct iva to th e tarsus, t ucking th e
Mü ller m u scle. Th e su t u re exit s th rough th e t arsu s to th e
skin an d is kn ot ted to t igh ten th e th read. Th e sam e p roce-
dure sh ou ld be perform ed at oth er sites of Mü ller m u scle
t ucking, an d th en th e t ract ion sut ure is rem oved. Next , th e
com m on procedu re for th e dou ble fold is perform ed. Th e
kn ots of th e th reads sh ould be buried w ith in th e skin so
th at th ey are n ot exposed.9,10
■ Key Technical Points
1. In th e design of th e double fold, th e h eigh t of
th e m iddle por t ion of th e dou ble fold sh ould be
su cien tly h igh er th an th e m ed ial an d lateral
p ort ion s in the closed state to preven t st raigh ten ing
of th e dou ble fold w h en th e eyes are open .
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2. W h en rem oving th e sept al fat , th e posit ion of th e fat
m u st be con sid ered . Th e sept al fat m oves to an u pp er
an d lateral area in th e su p in e p osit ion .
3. During th e sut ure pass th rough th e t arsu s, an
u nw an ted kn ot can be m ade on th e conju n ct ival side
th at can in du ce a foreign -body sen sat ion an d severe
pain . If th e pat ien t com plain s of th e sen sat ion of
a foreign body, th e eyelid is everted an d th e t arsal
plate is obser ved rst .
4. For t ran sconju n t ival Mü ller t ucking, an assist an t
sh ou ld pu ll th e t ract ion su t u re an d pu sh th e eyelid
in th e opposite direct ion w ith a cot ton sw ab to m ake
th e procedu re easier to perform .
5. It is best if th e poin t of th e conjun ct iva at w h ich th e
su t u re exit s is n ear th e su p erior forn ix.
■ Complications and
Their Management
Relapse
Becau se th ere is n o t issue adh esion bet w een th e an terior
an d p osterior lam ellae of th e u pp er eyelid, u n like th e case
in an in cision al bleph aroplast y tech n ique, the con n ect ion
bet w een th e t w o st ruct ures depen ds on ly on th e sut ure
loop in a n on in cision al tech n ique. A sut u re loop in evit ably
loses it s h old on t issues over th e postoperat ive m on th s an d
th e am oun t of t issu e h eld by each loop gradually reduces
over t im e. Hen ce, th e xat ion bet w een th e t w o lam ellae
loosen s, even w ith a t igh t relat ion sh ip at th e begin n ing.
Alth ough m oderate loosen ing is a n orm al, n at u ral drift
tow ard an equ ilibriu m , excessive loosen ing e aces th e skin
fold or m akes m u lt iple skin folds in oth er creases (relap se).
Th is relapse is th e m ain draw back of th e n on in cision sut ure
ligat ion bleph aroplast y tech n ique. Various au th ors h ave
 12 Double-Eyelid 
Surgery: 
Nonincisional 
Suture 
Techniques 159

a b c

d e

Fig. 12.10 Transconjunctival Müller tucking. (a) Preoperative design for transconjunctival Müller tucking. The points 2 and 4 are for Mül-
ler tucking suture. The points 1, 3, 5, and 6 are for the double fold procedure. (b) A traction suture is located on the upper margin of the
tarsus. (c) The suture is passed through the skin to the upper m argin of the tarsus. (d) The Müller tucking suture is passed through the
tarsus to a point of the conjunctiva near the superior fornix. The surgeon’s assistant should pull the traction suture and push the eyelid in
the opposite direction using a cot ton swab to facilitate the procedure. (e) The Müller tucking suture returns through the same point of the
conjunctiva to the tarsus to tuck the Müller muscles.

rep or ted th eir ow n relapse rates, bu t th ese are n ot clin ically
m ean ingfu l. In pat ien t s w ith u n favorable feat u res (e.g.,
th ose w ith pu y eyelids), th e rate of fold relapse in creases.
Th e m ost com m on cause of relapse is a sut ure loop
h olding t issu e w ith less brou s com p on en t s. Th eoret ically,
th e surgeon sh ould dist ribute th e ten sion of each loop
even ly, an d in clu de m ore brou s t issu e in each loop as a
su p port ing st ru ct u re. An oth er cau se of relapse is w eakn ess
of th e su t ure m aterial. Pure nylon is t ran slucen t an d ver y
exten sible, bu t colored nylon m ixed w ith p igm en t loses its
exten sibilit y an d breaks easily. How ever, a sim p le su t u re
m aterial problem occu rs in frequ en tly.11,12,13
Irregular Fold
Fold form at ion of th e upper lid skin during eye op en ing
from th e closing p h ase p roceed s dyn am ically an d gradu -
ally. At th e begin n ing of th e op en ing, th e skin fold along
th e crease becom es gradually deeper as th e globe exposure
w iden s. Becau se th e fold h angs over th e skin crease, a lin -
ear sh adow of th e fold ap pears parallel to th e crease an d
fold . At th is t im e, u n less th e crease is parallel to th e relaxed
skin ten sion lin e (RSTL), m u lt ip le part ial obliqu e folds can
be created, disrupt ing th e con t in uit y of th is fold sh adow.
Unw an ted obliqu e folds n ear the crease during th e open ing
m ovem en t dim in ish th e n at u ral look of th e dou ble-eyelid
crease. Th e crease sh ould be design ed perfectly parallel to
th e RSTL in any case.
Alth ough th e irregularit y of th e skin folds can be
prom in en t at th e site of th e sut ure loop in th e im m ediate
postoperat ive period due to local pin ch ed t issu e, th e skin
can recoil an d th e irregularit y fades aw ay w ith in 3 m on th s.
How ever, dim p ling in an area of scar t issu e can n ot easily
fade aw ay becau se scar t issu e h as less recoiling pow er. In
addit ion , a scar in th e skin p reven t s even fold form at ion ,
so th e scar sh ou ld be located below th e skin fold ing crease
(Fig. 12.11).

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160 III Blepharoplast y
Fig. 12.11 Prominent scar. Dimpling in an area of scar tissue does
not easily fade away because scar tissue has less recoiling power. In
addition, a scar in the skin prevents even fold formation, so the scar
should be located below the skin folding crease.
Strangulation
Th e sut ure loop h olding th e t issu e preven t s n orm al blood
circulat ion an d m ay cau se ven ou s or lym ph at ic congest ion .
Sim ple lid m argin congest ion w ith out t issue injur y does
n ot cau se long-term problem s, alth ough it causes tem po-
rar y blep h aroptosis or p roblem s w ith eye op en ing in th e
im m ediate p ostoperat ive period. It can delay recover y w ith
th e w eigh t of th e lid m argin in creased. Th e am ou nt of t is-
su e en circled by loop s sh ou ld be m in im al an d th e ten sion
sh ou ld be dist ribu ted even ly.
a b
Fig. 12.12 Tension eversion. (a) Lid margin skin tension should be adequate and considered in the design at the beginning of the proce-
dure. An abrupt di erence in skin thickness along the crease looks unnatural and arti cial. (b) In addition, the eyelashes might be everted
to a large extent, and the hidden conjunctival mucosa might appear abnormal. (c) The prospective crease would be lowered and would
undulate into an unnatural curve.
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Lid Margin Tension Eversion
Th e h eigh t s of th e sut ure pen et rat ion sites from th e lid m ar-
gin on th e ou ter an d in n er su rfaces can di er. If th e level at
th e posterior lam ella (apon eurosis or tarsus) is h igh er th an
th at at th e anterior lam ella (skin ), th e skin below th e crease
is st retch ed. With in a n orm al range, m ild st retch ing of th e
skin looks good, w ith th e eyelash es lift ing u p sligh tly. How -
ever, in a severe case, th e st retch ed low er skin becom es too
th in w h ile th e push ed upper skin becom es th ick. An abrupt
di eren ce in skin th ickn ess along th e crease looks u nn at u -
ral an d art i cial (Fig. 12.12a). In addit ion , th e eyelash es
m igh t be everted to a large exten t , an d th e h id den conju n c-
t ival m ucosa m igh t appear abn orm al (Fig. 12.12b). Ten sion
is usu ally relieved w ith t im e, un like th e sit uat ion w ith th e
in cision tech n ique. How ever, th e prospect ive crease w ould
be low ered an d w ould un dulate in to an un n at ural cur ve
(Fig. 12.12c). Ach ieving adequ ate skin ten sion of th e an te-
rior lam ella is im port an t in m aking a dou ble-eyelid crease.
Stitch Abscess and Exposure of the Knot
Becau se m on o lam en t nylon h as a long m em or y an d p oor
kn ot securit y, it sh ould be t ied in m u lt iple squ are kn ots to
preven t slipping or kn ot loosen ing. Th e m ult i-t ied bulky
kn ot sh ould be buried in an appropriate deep site to avoid
palpat ion or exposure. Becau se th e cen t ral port ion of th e
eyelid is th in n er th an th e m edial an d lateral p ort ions d u e
to th e oval sh ape of th e globe p rot ru sion ben eath th e u pp er
eyelid in th e closing ph ase, a kn ot in th e m id port ion can be
easily n ot iceable an d is exp osed m u ch m ore readily th an if
it w ere in an oth er locat ion . Ch oosing a deep locat ion for th e
kn ot is also im por tan t , an d it sh ould be placed ben eath th e
orbicularis oculi m uscle layer. Im proper posit ion an d depth
of kn ot s m ay cause st itch abscess or exposure, in w h ich
case all lin ked st itch es sh ould be rem oved.
c
 12 Double-Eyelid
■ Case Studies
Case 1: Nonincision Suture Ligation
for Double Fold Formation
A 25-year-old fem ale p at ien t w ith a low an d asym m et ric
double fold w an ted a n eut ral or out side fold an d a h igh er
double fold (Fig. 12.13a). Sept al fat rem oval an d n on in ci-
sion su t u re ligat ion for dou ble-eyelid form at ion w as p er-
form ed. Sym m et ric an d sligh tly h igh er outside folds w ere
obser ved after 6 m on th s (Fig. 12.13b).
a a
b b
Fig. 12.13 Case 1. Nonincision suture ligation for double fold for-
mation. (a) This 25-year-old female patient with a low and asym -
metric double fold wanted a neutral or outside fold and a higher
double fold. (b) Six months after septal fat removal and nonincision
suture ligation, she has a sym metric and higher double fold.
References
1. Zide BM, ed. Surgical An atom y aroun d th e Orbit: Th e Sys-
tem of Zon es. Ph iladelph ia, PA: Lip pin cot t , William s &
Wilkin s; 2006
2. Most SP, Mobley SR, Larrabee WF Jr. Anatomy of the eyelids.
Facial Plast Surg Clin North Am 2005;13(4):487–492, v
3. Fralick FB. An atom y an d physiology of th e eyelid. Tran s Am
Acad Op h th alm ol Otolar yngol 1962;66:575–581
4. Reid RR, Said HK, Yu M, Hain es GK III, Few JW. Revisit ing
u pper eyelid an atom y: in t roduct ion of th e sept al exten -
sion . Plast Recon st r Surg 2006;117(1):65–66, discussion
71–72
5. Moy RL, Lee A, Zalka A. Com m only used suture m aterials in skin
surgery. Am Fam Physician 1991;44(6):2123–2128
6. Lober CW, Fenske NA. Sut ure m aterials for closing th e
skin an d subcut aneous t issu es. Aesth et ic Plast Su rg 1986;
10(4):245–248
7. Spelzini F, Konstantinovic ML, Guelinckx I, et al. Tensile
strength and host response towards silk and type I polypro-
http://e-surg.com
 
Surgery: 
Nonincisional 
Suture 
Techniques 161
Case 2: Transconjunctival Müller
Tucking
A 35-year-old fem ale p at ien t presen ted w ith ptosis of th e
left eyelid an d an asym m et ric double fold (Fig. 12.14a).
Sh e h ad h ad an in cision al dou ble-eyelid op erat ion 1 m on th
previously. Tran sconju n ct ival Mü ller t u cking w as don e on
th e left side on ly. Th e h eigh t of th e dou ble fold w as n ot
ch anged. After 2 w eeks, ptosis of th e left side resolved an d
a sym m et ric dou ble fold w as ach ieved (Fig. 12.14b).
Fig. 12.14 Case 2. Transconjunctival Müller tucking. (a) A 35-year-
old female patient with ptosis of the left eyelid and asymmetric
double fold. She had an incisional double-eyelid operation 1 month
previously. (b) Two weeks after transconjunctival Müller tucking on
the left side only, the ptosis of the left side and asymm etry of the
double fold have resolved.
pylene im plants used for augm entation of fascial repair in a rat
m odel. Gynecol Obstet Invest 2007;63(3):155–162
8. Ch o IC, Eed. The Art of Bleph aroplast y. Seou l, Korea: Koon -
ja; 2013
9. Wong JK. A m eth od in creat ion of th e superior palpebral
fold in Asian s u sing a con t in uous buried tarsal st itch
(CBTS). Facial Plast Su rg Clin North Am 2007;15(3):
337–342, vi
10. Park JW. Non -in cision t ran sconju n ct ival Mu ller t u cking in
bleph aroplast y. Arch Aesth Plast Surg. 2012;18:31–34
11. Ah n YJ. Cases of m ild ptosis correct ion w ith su t u re-m eth -
od. Arch Aesth Plast Surg. 2012;18:15–20
12. Hom m a K, Mu tou Y, Mu tou H, Ezoe K, Fujit a T. In t raderm al
st itch bleph aroplast y for orien t als: does it disappear? Aes-
th et ic Plast Su rg 2000;24(4):289–291
13. Ko RY, Baek RM, Oh KS, Lim JH. Com plicat ion of n on -in -
cision Orien t al bleph aroplast y: is disappearan ce of th e lid
crease a fearful com plicat ion ? J Korean Soc Plast Reconst r
Surg 2000;27:199–203
 13 Double -Eyelid Surgery: Incisional Techniques
Jae Woo Jang
Pearls
• Th e East Asian upper eyelid h as several dist in ct
an atom ic ch aracterist ics, in clu ding a low, poorly
de n ed, or absen t eyelid crease; n arrow palpebral
ssu re; an d ep ican th al fold.
• Th e goal of upper bleph aroplast y for th e Asian
pat ien t is to m ake eyes fresh , you th ful, an d
at t ract ive w h ile m ain t ain ing th eir eth n ic appearan ce
by surgically creat ing a suprat arsal crease.
• Th e in dicat ion s for th e in cision al tech n iqu e are
redu n dan t skin , bulky eyelids due to soft t issu e an d
fat , disapp earan ce of th e eyelid crease after su t u re
or par t ial in cision al tech n ique, an d reoperat ion
due to various com plicat ion s after eyelid crease
su rger y. Scarring is n ot a p roblem if th e tech n iqu e is
delicately perform ed.
• Th e eyelid crease h eigh t in East Asian s is 6 to 8
m m in fem ales an d sligh tly low er in m ales. A 2- to
■ Introduction
Upper lid bleph aroplast y is th e m ost com m on cosm et ic
su rgical p rocedu re in East Asia (Korea, Jap an , an d Ch in a).
Asian bleph aroplast y, also kn ow n as “dou ble-eyelid sur-
ger y,” involves th e su rgical creat ion of a su prat arsal crease.
How ever, becau se th e creat ion of a su prat arsal crease does
n ot act u ally involve th e form at ion of an oth er eyelid, th e
term double eyelid is act u ally a m isn om er.1,2,3
It is gen erally agreed th at ~ 50%of Asian s are born w ith
n at urally occu rring u pp er eyelid creases. How ever, for m ost
of this populat ion , th e h eigh t of th e double-eyelid crease
is low, an d w ell-de n ed double eyelids are presen t in on ly
~ 10% of Asian m en an d 33% of Asian w om en . Th e goal of
bleph aroplast y for Asian s, w ith or w ith out related pro-
cedures, is fresh , youth ful, an d at t ract ive eyes th at retain
th eir eth n ic appearan ce. Th e Asian u pper eyelid h as several
dist in ct an atom ic ch aracterist ics, in cluding a low, poorly
de ned or absen t eyelid crease; n arrow palpebral ssure;
an d ep ican th al fold. Th e u p p er eyelid m argin of a single
eyelid in East Asian s is in m ost cases covered by u p p er lid
skin . Th erefore, w h en dou ble-eyelid su rger y is p erform ed,
th e upper eyelid skin is pu lled upw ard, result ing in an
ap paren t in crease in th e size of th e eyes. Dou ble-eyelid su r-
162
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3-m m pret arsal sh ow, 20 to 30% of th e length of th e
in terpalpebral ssure, is opt im al in East Asian s.
• Th e h eigh t an d sh ape of th e eyelid crease sh ould
be in dividualized depen ding on a pat ien t’s eyelid
ssu re or ep ican th al fold . Th e favorite t yp es of eyelid
creases are th e in side crease an d out side crease—
fan t yp e or m ixed t ype—in East Asian s, esp ecially
Korean s.
• Proper rem oval of th e orbicularis m uscle an d orbit al
fat is n ecessar y to create a m ore secu re eyelid crease.
Som et im es ret ro-orbicu laris orbital fat (ROOF)
rem oval is required depen ding on th e pu n ess of
th e in dividual’s eyelid.
• Ap p ropriately design ed d ou ble-eyelid h eigh t an d
proper xat ion resu lt in a n at ural an d aesth et ically
pleasing double eyelid.
ger y is con sidered by East Asian s to m ake th e eye app ear
larger an d m ore aesth et ically pleasing.4
Eyelid crease su rger y is p erform ed n ot on ly for aes-
th et ic purposes, but also for th e correct ion of problem s
su ch as en t rop ion , lash ptosis, p seu d optosis, an d ptosis.
Most p at ien ts ten d to w an t th e su rgeon to p erform eyelid
crease surger y sim ultan eously w h ile correct ing th ese oth er
problem s. W h en pat ien t s w ith bleph aroptosis un dergo
eyelid crease surger y, th e p alp ebral ssures becom e w ider
an d can create a m ore p leasing eye sh ape.5
It is im p or tan t to recogn ize th at Asian u pp er bleph aro-
plast y is n ot a Western izat ion procedure, an d th e aim is to
create an upper eyelid crease sim ilar to a n at urally occur-
ring on e.
■ Anatomy of the East Asian
Eyelid
Th e m ost obvious ch aracterist ics of th e Asian eyelid are
th e absen t or ver y low lid crease, an d fuller upper eyelid.
Asian eyelids w ith n o lid crease are referred to as “single
eyelids.” Alth ough n ot visible, a sm all fold com m on ly exists
un der th e overh anging eyelid skin . Cau casian eyelids t yp i-

cally h ave an eyelid crease, but Asian eyelids can be catego-
rized in to th ree t yp es: single eyelid, low eyelid crease, an d
d ou ble eyelid.
The causes of an absen t or low er crease in an Asian
u pp er eyelid in clu de th e follow ing: (1) Th e orbital sept u m
fu ses to th e levator ap on eu rosis below th e su perior t arsal
border. (2) Preapon eurot ic fat pad prot rusion an d a th ick
su bcu tan eou s fat layer preven t levator bers from exten d-
ing tow ard th e skin n ear th e su p erior t arsal border. (3) Th e
p rim ar y in sert ion of th e levator apon eu rosis in to th e orbi-
cularis m uscle an d in to th e upper eyelid skin occurs closer
to th e eyelid m argin in Asian s (Fig. 13.1).6,7 Asian single
eyelids h ave m ore prom in en t subcut an eous and ret ro-orbi-
cularis fat in th e suprat arsal region . Several com pon en t s,
su ch as a su bm u scu laris bro-adip ose t issu e layer an d a
low er-posit ion ed t ran sverse ligam en t , h ave been iden t i ed
an d are fou n d exclu sively in th e Asian eye.
Th e prim ar y goal of double-eyelid su rger y is n ot sim -
ply to create a suprat arsal crease but to create a crease th at
is con sisten t w ith th e n at ural con gurat ion presen t in th e
gen eral East Asian p op u lat ion .
■ When Should the Incisional
Technique for Double -Eyelid
Surgery Be Performed?
Th e t ypes of double-eyelid surger y in clude th e sim ple
su t u re tech n iqu e, th e part ial in cision al tech n iqu e, an d
th e in cision al tech n ique. Th e ch oice of tech n ique is based
on pat ien t preferen ce, skin qualit y, an d th e volum e of fat
t issue in th e upper eyelid. Th ere are advan t ages an d dis-
advan t ages to th e in cision al tech n iqu e an d n on in cision al
tech n iqu es. Th e advan tages of n on in cision al tech n iques are
a b
Fig. 13.1 Di erences in upper eyelid anatomy bet ween (a) East
Asians and (b) Caucasians. In Asians, the orbital septum fuses with
the levator aponeurosis below the superior tarsal border. The pro-
truded pre-aponeurotic fat and thick subcutaneous fat layer disturb
extension from the levator aponeurotic bers toward the skin.
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13 Double-Eyelid 
Surgery: 
Incisional 
Techniques 163
th at pat ien t s recover m ore quickly w ith n o scarring, w h ile
th e disadvan tages in clu de th e in abilit y to rem ove pre-apo-
neurot ic fat an d soft t issue, w h ich leads to th e disappear-
an ce of th e dou ble fold.
Th e in dicat ion s for th e in cision al tech n ique are (1)
redu n dan t skin , (2) bulky eyelid due to soft t issue an d fat ,
(3) disappearan ce of th e eyelid crease after th e use of a
non in cision al sut ure tech n ique or par t ial in cision al tech -
nique, an d (4) an addit ion al operat ion due to various com -
plicat ion s after eyelid crease surger y (Fig. 13.2).
Th e m ajor disadvan tage to th e in cision al tech n ique is
th e long recover y t im e (usually 1 w eek is required to reduce
postoperat ive sw elling an d edem a). Scarring is n ot a prob -
lem w h en th e procedure is perform ed precisely an d deli-
cately. Th e in cision lin e is m ore prom in ent w ith th e part ial
in cision tech n ique com pared w ith th e in cision al tech n iqu e
because th ere is an apparen t abrupt en ding w ith th e m ore
lim ited in cision al m eth od.8
■ Patient Evaluation
Most pat ien t s d esire p erm an en t an d n at u ral-looking eyelid
creases. At th e in it ial con sult at ion , th e pat ien t’s goals an d
exp ectat ion s sh ou ld be iden t i ed. Th e eyelid crease h eigh t
usually depen ds on th e in terpalpebral ssure size an d tar-
sal p late h eigh t . Th e prop er eyelid crease h eigh t in East
Asian s is 6 to 8 m m in fem ales an d sligh tly low er in m ales.
Th e rst step is to sim ulate th e est im ated eyelid crease
in fron t of th e m irror by push ing th e eyelid skin w ith
devices such as a forceps, a lacrim al probe, a paperclip, or a
w ooden cot ton -t ip ped app licator; th e di eren t sh ap es an d
w idth s of th e eyelid crease can be created an d visualized
using th ese tools. Th e h eigh t an d sh ape of th e eyelid crease
requ ired for a n at ural look sh ould be decided via discus-
sion w ith p at ien t . Sh ou ld th e p at ien t requ est a h eigh t an d
sh ape th at d o n ot m atch th e eyelid sh ap e, a m ore th or-
ough explan at ion w ill be required to assist in th e decision
m aking p rocess. Som e p at ien t s m ay n ot fu lly express th eir
desires, w h ich can m ake th ese cases ver y di cult to m an -
age. As m en t ion ed previously, m ost Asian s w an t a crease
th at is con sisten t w ith th ose th at occur n at urally in th e
popu lat ion .
Fig. 13.2 A t ypical indication for the incisional technique for eye-
lid crease surgery. The eyelids show pu ness, skin laxit y, and an
epicanthal fold in a 25-year-old woman.
164 III Blepharoplast y
Ptosis of the upper eyelid is assessed by m easuring the
palpebral ssure w idth and m argin re ex distance 1 (MRD1,
from th e ligh t re ex on th e pat ien t’s corn ea to th e cen t ral
upper eyelid m argin). Lash ptosis or dow nw ard angulat ion
of the lashes ow ing to relaxat ion of the anterior lam ella of
the eyelid should also be noted and corrected during upper
lid blepharoplast y.9 Early m yasth en ia gravis sym ptom s are
sim ilar to th ose of ptosis an d require a di eren tial diagn osis.
Periorbit al fat is im port ant for bleph aroplast y, espe-
cially w h en subbrow fat (ret ro-orbicularis orbital fat , or
ROOF) is dist ributed up to th e orbital sept u m level an d fu ll-
n ess in th e u p p er eyelid can be seen ; th is is dist ingu ish able
from orbit al fat h ern iat ion .7 Th e orbital fat of th e u p p er eye-
lid is divided in to t w o groups: cen t ral an d m edial. Cen t ral
orbit al fat h as a yellow, but ter color, w h ile m edial orbit al
fat is w h it ish in color an d is com posed of sm aller lobu les.
Blep h arop last y m ay be adapted according to th e qual-
it y of th e eyelid skin . Th e surgeon w ill con sider eyelid skin
th ickn ess (th in or th ick), dehydrat ion of th e skin , an d th e
loss of elast ic an d collagen bers, depen ding on th e degree
of aging. With a greater degree of aging, bleph aroplast y for
th ick eyelid skin requires that th e skin in cision be m ade at
a low er level an d th e procedu re n ot involve excessive skin
rem oval.
Before su rger y, th e pat ien t’s eyebrow shape an d posi-
t ion , th e appearance of th e eyelids an d degree of sagging,
an d th e degree of fat bu lging sh ou ld be recorded u sing
pain t ings or ph otograph s. Th ese records can also play an
im port an t role in resolving any com plain ts or con icts th at
m ay occu r follow ing su rger y.
■ What Is the Favorite Type
of Double Fold in Asians
in Relation to the Medial
Epicanthal Fold?
Th e sh ape of an eyelid crease can be ch aracterized as
n asally t ap ered, parallel, or sem ilun ar. Asians rarely h ave
a sem ilu n ar sh ap e, w h ich is com m on in Cau casian s. Asian s
a b
Fig. 13.3 Variations of East Asian creases. (a) Inside crease. (b) Outside crease, fan t ype. (c) Outside crease, parallel t ype.
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w ith a n at ural crease h ave eith er a n asally t apered crease
or a parallel crease, as described in various repor t s. Ch en
noted th at inside fold an d out side fold are less ap p rop riate
term s; h ow ever, in Korean populat ion s, th e in side crease is
w ell m atch ed w ith th e n asally tapered crease, bu t th e p ar-
allel crease does n ot exactly m atch th e ou t side fold.2 Th ere-
fore, in th is ch apter, th e au th or w ill u se th e term s inside
crease an d out side crease in stead of nasally tapered crease
an d parallel crease.
1. Inside crease. A n at u ral, low er crease th at converges
tow ard th e m edial can th us an d run s parallel across
th e ciliar y m argin , over th e cen t ral port ion , and
ares aw ay from th e ciliar y m argin as it app roach es
th e lateral can th us (fan t ype) (Fig. 13.3a).
2. Out side crease. Th e crease ru n s fairly p arallel to th e
lash m argin from th e m edial can th us to th e lateral
can th us. Th e ou tside crease is divided in to th ree
t yp es: (a) fan t yp e, (b) fan -p arallel or m ixed t yp e
(th e eyelid crease gradually ares aw ay from the
lid m argin tow ard th e cen ter port ion an d th en run s
parallel to th e ciliar y m argin tow ard th e lateral
can th us), an d (c) parallel t ype (th e crease run s at th e
sam e w idth from th e m edial to th e lateral can th u s)
(Fig. 13.3b,c).
Usu ally an in side crease becom es a fan t yp e an d an ou t-
side crease becom es a fan , fan -parallel, or p arallel t yp e.
In gen eral, th ere is a greater ten den cy to create an in side
crease th an an out side crease in pat ien ts w ith a st rong
m edial ep ican th al fold. Th e in side fold is con sid ered to be
m ore n at u ral an d con ser vat ive, w h ereas th e ou t side fold is
con sidered to be m ore m odern an d outgoing. Alth ough th e
h igh er ou t side-crease eye w as on ce t ren dy, it is u n n at u ral-,
art i cial-, an d Western -looking (Fig. 13.4), East Asian s,
esp ecially Korean s, p refer th e in side crease an d ou tsid e
crease fan t ype or out side crease m ixed t ype. Moreover, it
is n ow un com m on for East Asian s to ch oose a sem ilun ar
crease like th at of Caucasian s.
It is reported th at ep ican th al folds are fou n d in 50 to
80% of Sou th Korean s. Due to th e epican th al fold, in 70% of
eyelids th e caru n cle an d lacrim al lake are n ot overtly vis-
c

Fig. 13.4 The higher outside crease. The high outside creases
may look cool, but they also look unnatural, arti cial, and Western.
ible. Th e sh ap e of th e eyelid crease dep en ds on th e h eigh t ,
th e degree, an d th e sh ape of th e epican th al folds. Th e eyelid
crease m ay be t w o lin es at th e m edial can th us an d be oper-
at ive in ap p earan ce if th e out side crease is m ade w ith out
m edial ep ican th oplast y (Fig. 13.5). To m ake eyes larger an d
m ore at t ract ive, m edial ep ican th oplast y is recom m en d ed
at th e sam e t im e as th e dou ble-eyelid surger y, especially
for m od erate to severe ep ican th al folds.
What Is the Best Height of the
Double Eyelid?
Th e eyelid crease h eigh t usually depen ds on th e in terpal-
pebral ssure size an d t arsal plate h eigh t . Th e eyelid crease
h eigh t of East Asian s is 6 to 8 m m in fem ales and sligh tly
low er in m ales. In pat ien t s w ith a large in terpalpebral s-
su re or th in eyelid skin , m aking a h igh er-set eyelid crease is
bet ter. Oth er w ise, a low er-set eyelid crease is preferable for
pat ien t s w ith a sm all in terpalpebral ssure.
Eyeball p rot ru sion an d ver t ical/h orizon t al in terp alp e-
bral ssures are im port an t for determ in ing th e h eigh t of
th e eyelid crease. If th e h orizon t al ssure of th e eye is sm all,
th e h igh eyelid crease w ill appear un n at ural an d art i cial.
A h igh er eyelid crease looks n at u ral in pat ien t s w ith a large
h orizon tal ssu re of th e eye. How ever, h igh eyelid creases
do n ot look n at ural in pat ien ts w ith th ick eyelid skin an d a
large am ou n t of p ret arsal soft t issue. East Asian s often h ave
prot ruding eyeballs; a h igh eyelid crease is st rong-looking
in th ese cases.
With regard to Asian eyelid creases, th e crease is par-
t ially covered by th e fold of skin th at overlays it . Th e w idth
of th e eyelid crease during eye open ing is called th e pre-
tarsal sh ow (Fig. 13.6a).10 Th e h eigh t of th e eyelid crease (or
design ed incision al lin e) is determ in ed from th e pret arsal
sh ow. Th e p ret arsal sh ow in East Asian s is opt im al at ~ 2 to
3 m m or 20 to 30% of th e in terpalpebral ssure, but it m ay
depen d on th e h eigh t of th e supratarsal fold an d th e lax-
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13 Double-Eyelid 
Surgery: 
Incisional 
Techniques 165
Fig. 13.5 Webbing of the crease. Webbing is noted at the
medial canthus because the outside crease was m ade without
epicanthoplast y.
it y of th e supratarsal skin draping th e crease an d pretarsal
skin (Fig. 13.6b).11 Th e am ou n t of redu n dan t skin excision
depen ds on th e pre-determ in ed pret arsal sh ow w h en th e
in cision al tech n ique is perform ed. Even th ough design ed
at th e sam e h eight as th e eyelid crease, th e h eigh t of th e
crease is determ in ed according to th e am oun t of skin . If th e
am ou n t of excised skin is large, th e eyelid crease w ill be
h igh after eyelid crease su rger y. Th e dou ble-eyelid crease
can be created w ith or w ith out a pret arsal sh ow by m an -
aging th e excised am oun t of th e skin as per th e pat ien t’s
desires.
■ Surgical Techniques
Design of the Double -Eyelid Crease
Th e m eth od for deciding th e heigh t of th e eyelid crease h as
been described as follow s in previous repor ts. Th e upper lid
is everted an d th e vert ical h eigh t of th e t arsus over th e cen -
t ral por t ion of th e lid is m easured using calipers. Th e poin t
is m arked at th e sam e h eigh t as th e extern al eyelid skin .
Th e au th or does n ot usually use calipers, but rath er deter-
m in es th e n at u ral crease by sim p ly p u sh ing th e eyelid w ith
a cot ton -t ipp ed ap p licator. In gen eral, a h igh -set crease
m akes an ou tsid e crease, w h ereas a m oderate- to low -set
crease m akes an in side crease. Th e sh ape of th e eyelid
crease depen ds on th e epican th al fold. Th ere is a greater
ten den cy to create an in side crease in pat ien t s w ith an epi-
can th al fold. If a larger an d m ore pleasing eyelid crease is
sough t , m edial epican th op last y is u su ally don e sim u ltan e-
ously during eyelid crease surger y.
After th e sh ape an d h eigh t of th e eyelid crease h as been
determ in ed, th e proposed crease is m arked w ith a m ark-
ing pen or th e sh aved-o t ip of a cot ton -t ipped applicator
dipped in gen t ian violet . Th e upper in cision lin e is m arked
according to th e skin la xit y on a 1- to 2-m m st rip w ith ou t
skin laxit y (Fig. 13.7). Th e m ed ial th ird of th e in cision lin e
is m arked such th at it tapers tow ard th e m edial can th al
area or m erges w ith th e epican th al fold . Th e lateral th ird
166 III Blepharoplast y

Supratarsal crease
Pretarsal show
(width of double eyelid)

Double eyelid fold

x
a
y z

Fig. 13.6 Pretarsal show. (a) The width of the eyelid crease during eye opening.
(b) The pretarsal show depends on m anaging the amount of skin excised using the
incisional technique: height of incision line (x) = 6–8 mm; pretarsal show (y) = 2
mm ; amount of skin excision is z × 2. b

is u su ally m arked in a leveled or are con gu rat ion . Th e
m arkings on th e opp osite eye sh ou ld be design ed to be as
sym m et rical as p ossible.
Anesthesia
taken to inject the anesthet ic solut ion only in the super cial
area of th e orbicu laris oculi m u scle to avoid th e occu rren ce
of a hem atom a due to m uscle injur y. To avoid bleeding, light
pressure is applied to th e area w h ere th e needle en ters th e
skin . Th e su rgeon takes care to adm in ister th e an esth et ic
solution th rough out th e proposed lesion of in cised skin .

Usually, surger y is perform ed un der local an esth esia. A m ix-

t ure of 2% lidocaine (Xylocaine, AstaZeneca) at a 1:100,000
dilut ion of epinephrine is com m only used. W hen a surgeon
w an ts to use hyaluron idase, 10 m L of 2% lidocain e con tain -
ing a 1:100,000 dilution of epin eph rine is m ixed w ith 150
units of hyaluronidase. Hyaluronidase prom otes an esthetic
dispersion and tissue perm eabilit y, w hich facilitates th e
e ects of th e an esth etic an d redu ces th e am ou n t of an es-
thetic required. If the operation t im e is long, a 50:50 m ix-
t ure of 2% lidocaine and 0.5% or 0.75% bupivacaine is used.
The anesthet ic is slow ly injected to reduce pain. Care is
Skin Incision
Th e in cision is m ade w ith a n o. 15 surgical blade (Bard-
Parker, Asp en Su rgical) along th e u pp er an d low er lin es.
To reduce bleeding, a CO2 laser or radiofrequen cy w ave
can be used on th e skin incision (Fig. 13.8a). Th e st rip of
skin is excised w ith scissors or m on op olar cau ter y w ith a
Colorado n eedle t ip (St r yker) just below th e subcut an eous
plan e, th rough out th e plan ned in cision lin e.

Removal of Skin and Orbicularis

Fig. 13.7 Eyelid crease design and marking. The upper incision
line is marked according to skin laxit y on a 1- to 2-mm strip without
skin laxit y.
Muscle
Th e orbicularis m uscle is excised togeth er w ith th e skin
by th e st rip of m yocut an eous ap or excised after th e skin
rem oval. Elevat ing th e skin w ith forceps can protect th e
orbit al sept um from iat rogen ic dam age during th e excision .
Excessive debulking of the orbicularis m uscle is n ot usu-
ally recom m en ded. Som e orbicu laris m u scle sh ou ld be left
arou n d th e u p p er skin ap as a t rip le fold is com m on ly seen
w h en th e en t ire orbicularis m uscle is rem oved aroun d th e
upper skin ap (Fig. 13.8b).

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a b
If p ret arsal soft t issu e is abu n dan t , it s rem oval is n eces-
sar y to create ad equ ate ad h esion s. Care sh ou ld be t aken n ot
to in cise th e tarsu s u pp er m argin to preven t dam age to th e
term in al in terdigit at ion of th e levator apon eurosis w h en
excising th e p retarsal soft t issu e. Excessive rem oval of p re-
tarsal soft t issue m ay result in t igh t adh esion bet w een th e
skin an d t arsu s, w h ich m ay lead to a st at ic dou ble-eyelid
crease. If th ere is n ot su cien t pret arsal soft t issue in th e
h igh eyelid crease, an ad dit ion al op erat ion su rger y from a
h igh to low crease is ver y di cu lt an d t ricky.
Removal of Orbital Fat and ROOF
The orbital sept um can easily be distinguished from th e
prot ruded pre-aponeurotic fat by pressing th e eyeball gen -
tly w hen the eyes are closed. The upper eyelid should be
ret racted t ightly anteriorly and slightly dow nw ard w hile
forceps apply counter-t ract ion to tense the orbital sept um .
The exposed orbital sept um is pen etrated by the tip of the
scissors or Colorado n eedle to create a w in dow an d th e pre-
apon eurotic fat is exposed th rough th e open ing (Fig. 13.9a).
The orbital sept um is divided m edially and laterally w ith
scissors or by cau ter y to expose th e levator apon eurosis an d
pre-apon eurotic fat . Yellow ish central pre-aponeurot ic fat is
obser ved w hen the orbital sept um is open ed.
Th e fat p ad is grasp ed w it h a h em ost at an d excised
across a closed h em ost at . Bleed in g is con t rolled to t h e en d
of t h e excised fat p ad by en su r ing t h at t h e h em ost at is
n ot loosen ed . Th e clam p is loosen ed on ly after ad equ ate
h em ost asis. If a CO2 laser is u sed , t h e fat p ad is excised
w it h ou t t h e h em ost at (Fig. 13.9b). To rem ove t h e m ed ial
a b
Fig. 13.9 Opening of the septum and fat removal. (a) Tenting of the orbital septum during opening is necessary for preventing damage
to the levator aponeurosis. After opening the septum, the glistening levator aponeurosis is seen under the orbital fat. (b) Orbital fat is
removed with a CO2 laser. (c) Descended ROOF can be removed if desired.
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13 Double-Eyelid 
Surgery: 
Incisional 
Techniques 167
Fig. 13.8 Skin incision and orbicularis
removal. (a) Skin incision with a CO2 laser.
(b) Some orbicularis muscle (arrow) should
be left around the upper skin ap to prevent
a triple fold.
fat p ad , t h e orbit al sept u m is in cised m ed ially. Th e color of
t h e p rot r u d ing fat is m ore w h it ish t h an t h at of t h e cen t ral
fat p ad . W h en rem ovin g t h e n asal fat p ad , care is t aken n ot
to dam age t h e ar ter ies t h at are r u n n ing m ed ially, or t h e
ar ter ies sh ou ld be cau ter ized in advan ce to avoid bleed -
in g. Su p p lem en t ar y local an est h esia inject ion is n eed ed
for p ain con t rol before rem ovin g t h e n asal fat p ad . It is
im p or t an t to rem ove t h e sam e am ou n t of fat p ad from
each eye.
Som et im es lateral-h alf ROOF rem oval is n ecessar y in
pat ien t s w ith th ick redun dan t t issues even after rem oving
th e pre-apon eu rot ic fat (Fig. 13.9c). Care sh ou ld be t aken
not to rem ove th e ROOF th at is close to th e m uscle.
Excessive rem oval of fat or th e pret arsal orbicularis
m u scle along th e low er in cision lin e can cau se m u lt iple
folds in you ng pat ien t s after th e in cision al eyelid crease
su rger y. Th e su rgeon m ay t ap e th e fold or inject absorbable
ller in m in or cases (Fig. 13.10).
Low er-Positioned Transverse
Ligament
The low er-positioned t ransverse ligam ent (LPTL) is the
oth er tran sverse ligam en t in th e upper eyelid, w ith less elas-
ticit y th an W hitnall’s ligam ent. It origin ates from the ante-
rior su rface of th e t roch lea, exten ds in ferolaterally tow ard
the w hite lin e, and is re ected onto the orbital sept um ,
inserting into the lateral orbital rim . The LPTL is th ought to
prevent eyelid opening, and severing this ligam ent allow s
furth er excu rsion of th e u pper eyelid an d is recom m en ded
w h en perform ing eyelid crease surger y (Fig. 13.11).12,13
c
168 III Blepharoplast y

a b

Fig. 13.10 Triple fold. (a) The triple fold occurred after eyelid crease surgery due to excessive orbicularis muscle excision. (b) The triple
fold was managed by hyaluronic acid ller.

skin is th in , th e bu ried kn ot s m igh t be visible th rough th e

Fig. 13.11 Lower-positioned transverse ligament or LPTL (arrow).
Severing this ligament helps further excursion of the upper eyelid
and is recommended when performing eyelid crease surgery.
Fixation Suture of the Eyelid Crease
Th e m eth ods for xat ion of th e eyelid crease depen d on
th e surgeon’s preferen ce an d in clude (1) skin -levator-skin ,
(2) skin -t arsu s-skin , (3) levator apon eurosis to th e in ferior
su bcu tan eou s p lan e (or orbicu laris m u scle), an d (4) t arsal
plate to th e in ferior subcu tan eous plan e.13
Eyelid crease xat ion is perform ed eith er extern ally or
in tern ally u sing 6–0 or 7–0 nylon or Prolen e (Eth icon ). In
th e in tern al xat ion m eth od, th e 7–0 nylon or Prolen e is
passed th rough th e subderm al t issue an d xed to th e tar-
sal plate or levator apon eu rosis; th e su t u re is t ied an d th en
th e kn ot s are bu ried. In th e extern al xat ion m eth od, 6–0
nylon or Prolen e is passed th rough th e edge of th e low er
skin in cision to th e t arsu s or levator ap on eu rosis, exit ing
th rough th e edge of upper skin in cision .14 Th ere is n o dif-
feren ce in p erm an en ce or con t in u it y bet w een th ese m eth -
ods, bu t th e auth or prefers th e skin -levator-skin xat ion
tech n iqu e (Fig. 13.12). Usu ally, th ree xat ion su t u res are
requ ired, bu t in th e au th or’s pract ice m ore xat ion sut ures
are p laced on each side to p reven t late obliterat ion . Th e x-
at ion su t u re to th e tarsus can result in a st rong eyelid an d a
clearly visible crease during closing of th e eyes. In in tern al
xat ion to th e t arsu s or levator ap on eu rosis, if th e eyelid
skin .
In m aking th e low eyelid crease, xat ion to th e t arsal
plate can be m ore e ect ive th an xat ion to th e levator apo -
neurosis. Excessively h igh bite along th e levator apon eu -
rosis result s in a deep crease w ith lift ing of th e eyelash es
due to th e pulling-up act ion of th e skin . Th is can produce
a st rong im p ression an d m ake a su n ken groove w h en th e
pat ien t closes th e eyes. If th e pat ien t h as proptosis, th e
su rgeon n eeds to avoid creat ing a deep crease. Conversely,
too low xat ion com p ared w ith th e design ed crease h eigh t
can cau se w rin kles an d bulging (Fig. 13.13). Th e prom in en t
depression or n otch ing w ill occur if th e in tern al or extern al
xat ion s to th e levator ap on eu rosis are n ot ap prop riate an d
are too h igh com p ared w ith oth er xat ion s.
Appropriate eyelid crease xat ion can correct th e eye-
lash direct ion in pat ien t s w ith lash ptosis an d en t ropion .
Th e degrees of lash direct ion sh ould be adjusted du ring th e
xing of th e su t u res. In East Asian s, a h igh er xat ion w ith
a low -d esign ed eyelid crease can p rodu ce m ore eversion of
th e eyelash es. Th is m ay bring about an an atom ically in ap -
propriate or aesth et ically un desirable eyelid crease an d
poor cosm et ic result . It is preferable to correct th e eyelash
direct ion at ~ 90°. An appropriately design ed eyelid crease
heigh t an d proper xat ion w ill resu lt in a n at ural an d aes-
th et ically pleasing double eyelid.
Fig. 13.12 Fixation suture for the eyelid crease and the skin clo-
sure. The wound is closed in skin-levator-skin xation fashion.

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Fig. 13.13 Skin bulging after upper blepharoplast y. Too-low xa-
tion rather than the designed crease height can cause skin bulging.
Skin Suture
After xation of the eyelid crease, the eyelid skin suture is
perform ed w ith a ne suture after con rm ation of complete
hem ostasis. In Korea, the interrupted or continuous suture w ith
6–0 nylon or 6–0 fast-absorbing sutures are com m only used.
The skin of Asians is di erent from that of Caucasians, w ith the
form er requiring a greater num ber of sutures (Fig. 13.14).
Levator Advancement or Ptosis
Correction
In East Asia, w hen a patient w ith norm al levator function and
w ithout pathologic ptosis desires the appearance of a larger
eye, levator aponeurosis advancem ent or levator aponeurosis
plication are com m only perform ed sim ultaneously during
double-eyelid surgery.1 However, the e ect of plication of the
levator is not predictable and disappears at long-term follow -
up. After dissection of the levator aponeurosis, the am ount of
aponeurosis advancem ent is decided by observing the eyelid
level and degree of sym m etry in the seated position.
In asym m et ric or u n ilateral ptosis, th e h eigh t of th e
eyelid crease sh ou ld be a lit tle less th an th at for a n orm al
eyelid. In bilateral ptosis, th e h eigh t of th e eyelid crease is
1 or 2 m m less th an the n orm al 6 to 8 m m .5 If you do n ot
a b
c eyelid creases are symmetric.
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13 Double-Eyelid 
Surgery: 
Incisional 
Techniques 169
Fig. 13.14 Interrupted skin closure was performed with 6–0
nylon sutures. In general, Asians require a higher number of sutures
than Caucasians.
carr y out full ptosis correct ion , it is bet ter n ot to m ake an
eyelid crease. Oth er w ise, th e eyelid crease m ay be ver y h igh
or fain t , giving th e appearan ce of sleepy eyes, w h ich is n ot
aesth et ically accept able. Fu ll ptosis correct ion is m an da-
tor y before eyelid crease su rger y (Fig. 13.15).
■ Key Technical Points
1. In gen eral, a h igh -set crease m akes an ou tside crease,
w h ereas a m oderate- to low -set crease m akes an
in side crease. Th e sh ape of th e eyelid crease also
depen ds on th e epican th al fold; th ere is a greater
ten den cy to create an in side crease in pat ien t s
w ith an epican th al fold. Th e creat ion of out side
crease fan -t ype or m ixed-t ype lids requires th e
m odi cat ion or rem oval of th e ep ican th al fold .
2. Th e pret arsal sh ow in East Asian s is opt im al at 2 to
3 m m or 20 to 30% of th e in terpalpebral ssu re. Th e
am ou n t of redu n dan t skin excision depen ds on th e
pre-determ in ed pret arsal sh ow.
3. Appropriately design ed eyelid crease h eigh t an d
proper xat ion result in a n at ural an d aesth et ically
pleasing double eyelid.
Fig. 13.15 The asymmetric eyelid crease after a nonincisional
technique due to the missed ptosis. (a) The preoperative photo.
(b) The right eyelid crease is high compared with the left eyelid
crease after the nonincisional technique because blepharoptosis
was missed. (c) After levator advancement of the right eye, the
170 III Blepharoplast y
■ Postoperative Management
After th e op erat ion , th e w ou n d is clean ed daily an d an t i-
biot ic eye oin t m en t is applied for 3 w eeks. Th e pat ien t is
in st ru cted to con t in ue ice com pression to reduce sw elling
an d ecchym osis for 24 to 48 h ou rs after su rger y. Th e u se
of oral an t ibiot ics for 3 days is usually n ot n ecessar y, but
is often don e for th e preven t ion of un even tful in fect ion .
Su t u res are rem oved w ith in 5 to 7 days dep en ding on th e
su t u re m aterial. Eye m akeu p m ay be u sed after 2 w eeks.
Som et im es a scar-redu cing oin t m en t (e.g., Con t rat u bex,
Merz) or oral d rug (Rizaben capsu le, Kissel Ph arm aceu t ical)
is u sed to preven t scarring after in cision su rger y in Korea.
■ Complications and
Their Management
Asymmetry
A com m on ly occu rring com p licat ion after dou ble-eyelid
su rger y is asym m et r y, w h ich is cau sed by design fau lt ,
asym m et ric skin resect ion , asym m et ric fat rem oval, di er-
en t xat ion h eigh t of levator ap on eu rosis or t arsu s to create
a dou ble-eyelid crease, or di eren ces in adh esion bet w een
su bcu tan eou s t issu e an d levator ap on eu rosis. Th erefore, a
su rgeon m u st alw ays keep in m in d th e variou s factors th at
m ay cau se asym m et r y du ring th e op erat ion .
Disappearance of the Eyelid Crease
Th e fading or disappearan ce of th e eyelid crease is caused
by in correctly xed su t ures from th e subderm al t issu e
below th e skin in cision to th e levator apon eu rosis or tarsus,
or by u n stable xat ion du e to postoperat ive h em atom a.
Th is con dit ion is m ore com m on w ith sut ure tech n iques
th an w ith th e in cision al tech n ique. If th e pat ien t h as pre-
viou sly u n d ergon e th e n on in cision al m eth od, th e su rgeon
can perform th e n on in cision al m eth od again or th e in ci-
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sion al m eth od, w h ich requ ires de-bu lking of th e fat an d
un derlying soft t issue; th e surgeon m ust th en t igh tly su t u re
th e levator apon eu rosis an d skin w ith m u lt iple kn ots. If
th e pat ien t previously un der w en t th e in cision al m eth od,
th e surgeon can con duct th e n on in cision al m eth od or th e
in cision m eth od, w h ich requ ires st rong adh esion by t igh t
xat ion su t u res. If th e p at ien t h as m ild ptosis, levator ap o-
neurosis advan cem en t sh ould be con du cted w ith th e dou -
ble-eyelid su rger y.
High or Low Eyelid Crease
If t h e eyelid crease is too h igh , an u n n at u ral crease is
m ad e, an d if t h e d ou ble eyelid is too low , th e crease m ay
be u n clear. For low crease cor rect ion , creat ing a n ew fold
above t h e p reviou s low crease is n eed ed . In th e case of a
h igh fold , if th ere is en ough rem ain ing skin , t h e su rgeon
w ill decide th e n ew crease h eigh t an d th en excise t h e
skin toget h er w ith th e p reviou s in cision lin e. How ever, if
th ere is n ot en ough skin , a fu ll-th ickn ess skin graft cou ld
be n eeded. Du r ing th e operat ion , su rgeon s ten d to avoid
m aking t h e h igh crease at t h e sam e level as is p revalen t in
Western pract ice becau se correct ion su rger y from a h igh
to a low crease is m ore com plex an d th e su rgical resu lt s
are som et im es u n d esirable. An ad d it ion al op erat ion to
cor rect a h igh ou t side crease to a low ou t side crease or
in side crease is ver y di cu lt .
■ Case Studies
Case 1: Correction from the Short
Inside Crease to the Outside Crease
A 22-year-old w om an visited th e au th or’s clin ic for eyelid
crease surger y (Fig. 13.16a). Sh e w an ted an ou t side crease.
Sh e h ad a low an d sh or t in side crease in both eyes. In ci-
sion al blep h arop last y w ith m edial epican th op last y w as
perform ed. After eyelid crease surger y, th e in side crease
ch anged to an ou tside crease (Fig. 13.16b).
 13 Double-Eyelid 
Surgery: 
Incisional 
Techniques 171

a b

Fig. 13.16 Case 1. From the short inside crease to the outside crease with the incisional technique. (a) The preoperative photo revealed a
short inside fold in both eyes. (b) The patient had an outside fold after the incisional technique with medial epicanthoplast y.

Case 2: Correction from High Crease
to Low Crease
A 22-year-old w om an visited th e au th or’s clin ic becau se
of eyelid creases th at w ere too h igh (Fig. 13.17a). Sh e h ad
u n dergon e eyelid crease su rger y via th e n on in cision al
tech n iqu e 4 w eeks previously. Sh e w as ver y un h appy an d
w an ted to h ave a low er eyelid crease. First , th e au th or
rem oved all of th e buried sut ure m aterials th at could pre-
ven t or redu ce th e adh esion . After 3 m on th s, th e righ t eyelid
crease disappeared an d th e left h igh eyelid crease rem ain ed
(Fig. 13.17b). Good, n at u ral-looking in side creases w ere
m ade in an add it ion al operat ion u sing th e in cision al tech -
nique after 6 m on th s (Fig. 13.17c).

a b

Fig. 13.17 Case 2. From the high crease to the low crease with the
incisional technique. (a) The high eyelid creases were made after
nonincisional eyelid crease surgery. (b) The right eyelid crease disap-
peared and the left high eyelid crease still remained 3 months after
removal of buried suture materials. (c) Good, natural-appearing
inside creases were created after an additional operation with the
c
incisional technique.

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172 III Blepharoplast y
References
1. Lee CK, Ah n ST, Kim N. Asian upper lid bleph aroplast y sur-
ger y. Clin Plast Su rg 2013;40(1):167–178
2. Ch en W PD, Park JDJ. Asian upper lid bleph aroplast y: an
u pdate on indicat ion s an d tech n iqu e. Facial Plast Surg
2013;29(1):26–31
3. Kang DH, Koo SH, Ch oi JH, Park SH. Laser bleph aroplast y
for m aking dou ble eyelids in Asian s. Plast Recon st r Surg
2001;107(7):1884–1889
4. Scaw n R, Josh i N, Kim YD. Upper lid blepharoplast y in
Asian eyes. Facial Plast Su rg 2010;26(2):86–92
5. Park DH, Kim CW, Shim JS. Strategies for sim ultaneous double
eyelid blepharoplast y in Asian patients w ith congenital bleph-
aroptosis. Aesthetic Plast Surg 2008;32(1):66–71
6. Jeong S, Lem ke BN, Dort zbach RK, Park YG, Kang HK. Th e
Asian u p per eyelid: an an atom ical st u dy w ith com parison
to th e Cau casian eyelid . Arch Op h th alm ol 1999;117(7):
907–912
7. Saonanon P. Update on Asian eyelid anatom y and clinical rel-
evance. Curr Opin Ophthalm ol 2014;25(5):436–442
http://e-surg.com
8. Lam SM, Karam AM. Suprat arsal crease creat ion in th e
Asian u p p er eyelid . Facial Plast Su rg Clin Nor th Am 2010;
18(1):43–47
9. Lee TE, Lee JM, Lee H, Park M, Kim KH, Baek S. Lash pto-
sis an d associated factors in Asian s. An n Plast Surg
2010;65(4):407–410
10. Park JI, Toru m i DM. Dou ble eyelid op erat ion : orbicu laris-
levator xat ion tech n iqu e. In : Park JI, Toru m i DM, eds.
Asian Facial Cosm et ic Su rger y. Ph iladelp h ia, PA: Elsevier
Saun ders; 2007:49–59
11. Flow ers RS. Asian blep h arop last y. Aesth et Su rg J 2002;
22(6):558–568
12. Kakizaki H, Malh ot ra R, Selva D. Up per eyelid an atom y: an
u pdate. An n Plast Surg 2009;63(3):336–343
13. Ban M, Mat su o K, Ban R, Yu zu rih a S, Kan eko A. Develop ed
low er-posit ion ed t ran sverse ligam en t rest rict s eyelid
opening an d folding an d determ in es Japan ese as being
w ith or w ith out visible superior palpebral crease. Ep last y
2013;13:e37
14. Wong JK. Aesth et ic su rger y in Asian s. Cu rr Op in Otolar yn -
gol Head Neck Su rg 2009;17(4):279–286
14 Aging -Related Upper Blepharoplasty
Hokyung Choung and Namju Kim
Pearls
• Un derstan ding an atom ic di eren ces an d
involu t ion al ch anges in th e eyelids of East Asian s,
w h ich are speci c to age an d gen der, is th e key to
ach ieving opt im al resu lt s.
• Too m uch is as unw elcom e as too lit tle. Th e t ren d
in Asian aging-related bleph aroplast y is tow ard
con ser vat ive excision of skin an d fat , m aking a
n at u ral-looking, low -posit ioned dou ble eyelid (or
n ot m aking an art i cial double eyelid).
• It is im port an t to h ave a realist ic u n derstan ding
of th e outcom e of bleph aroplast y th rough an
in -depth d iscussion bet w een th e surgeon an d th e
pat ien t before su rger y. Th e goal of aging-related
bleph aroplast y is to restore th e in dividual’s
you th fu l ap p earan ce w h ile ret ain ing th e eth n ic
ch aracterist ics. Th is is especially t rue in th e case of
t reat ing th e Asian upper eyelid.
• Th e upper crease is usually low or absen t in th e
Asian eyelid. Sligh tly folded upper eyelid skin over
th e double-eyelid crease, or a low double-eyelid
crease (e.g., 3–4 m m in h eigh t) looks m ore n at ural
an d blen ds w ell. Usu ally, a dou ble-eyelid crease over
7 to 8 m m in h eigh t looks ver y un n at ural in Asian s,
even in fem ale pat ien t s.
• Brow ptosis usually occurs after m iddle age, an d
derm atoch alasis an d bleph aroptosis m ay appear
accen t u ated d u e to brow ptosis. Th erefore, th e
su rgeon m u st recogn ize brow ptosis before
su rger y an d decide w h eth er to p erform a brow
lift in advan ce or do it in conjun ct ion w ith th e
bleph aroplast y.
■ Introduction
East Asian s are th e w orld’s largest eth n ic group, an d th e
eyelids’ posit ion in th e cen ter of th e face is a dist inguish ing
feat u re an d m akes a st rong im pression . Blepharoplast y is
th e m ost com m on an d a rapidly grow ing cosm et ic su rger y
procedure in Asia. Un derstan ding an atom ic di eren ces
related to eyelid surger y is th e key to ach ieving opt im al
result s. A t ypical Asian eyelid is a single eyelid w ith an
ep ican th al fold or Mongoloid slan t . Im p roving a p at ien t’s
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• Many aged p eop le w h o w an t blep h arop last y m ay
have bleph aroptosis of som e degree but m ay
not be aw are of it becau se it is con cealed by th e
derm atoch alasis.
• If the patient com plains of ocular irritation sym ptom s,
problem s w ith tear secretion such as dry eye syndrom e
could be present. The surgeon should m ake the patient
understand that ocular irritation m ay be aggravated
after blepharoplasty and that such problem s need to be
m anaged before blepharoplasty.
• Th e m ost di cult cases of aging-related
bleph aroplast y in Asian s involve pat ien ts w h o h ad
un dergon e previous bleph aroplast y w ith excessive
skin an d fat rem oval, w ith a ver y h igh -posit ion ed
double-eyelid crease. In th ese cases, au tologous fat
or ller inject ion along th e brow an d upper eyelid
com plex is m ore h elpfu l in im proving th e cosm et ic
outcom e th an a bleph aroplast y.
• Th e lacrim al glan d is located laterally just beh in d
th e orbit al rim , an d n orm ally it is n ot seen during
bleph aroplast y. With aging it prolapses, w h ich
m igh t be m istaken for lateral fat p rolapse, especially
in Asian pat ien t s w h o have th ick skin over the
lacrim al glan d.
• Com plicat ion s after aging-related bleph aroplast y are
usually th e result of excessive skin or fat resect ion ,
lack of h em ostasis, an in adequate preoperat ive
assessm en t , or careless postop erat ive m an agem en t .
Ever y e or t sh ou ld be m ade to m in im ize or preven t
com plicat ion s du ring or after bleph aroplast y by
recogn izing kn ow n risk factors an d paying careful
at ten t ion during an d after surger y.
ap pearan ce w h ile m ain t ain ing th e p erson’s eth n ic ch ar-
acterist ics is th e goal of Asian eyelid su rger y.1 Th e goal of
aging-related bleph arop last y is to restore th e in dividual’s
you th fu l ap p earan ce, n ot to create a m orph ologic ch ange
th at brings a novel look. Th is is especially t rue in th e case of
t reat ing th e Asian upper eyelid. Loss of eth n ic iden t it y can
result in a n egat ive react ion both from th e pat ien t as w ell
as from h is or h er frien d s an d fam ily.2
In th e p ast it w as gen erally accepted th at Asian pat ien t s
w an ted to h ave dou ble eyelids to p roject a m ore Western
ap pearan ce, w h ich th ey fou n d m ore at t ract ive. How ever,
173
174 III Blepharoplast y
th e t ren d th ese days in Asian aging-related bleph aroplast y
is tow ard con ser vat ive excision of skin an d fat , giving a n at-
u ral-looking, low -posit ion ed double eyelid an d n ot creat ing
an art i cial-app earing dou ble eyelid. Now adays m ost aging
Asian pat ien t s w an t to restore th eir youth ful appearan ce
but at th e sam e t im e ret ain th eir eth n ic characterist ics, n ot
Western ize th eir eyelids, th rough bleph aroplast y su rger y.
Periorbit al ch anges w ith aging in clude derm atoch ala-
sis, crow ’s feet , an d p eriorbit al fat p rolap se, an d th ese lead
to ch anges in eyelid con tou r. Th e goal of blep h arop last y in
aging p at ien t s is to correct th ese processes an d to allow th e
pat ien t to look younger. Bleph aroplast y in elderly people
is m ostly in cisional bleph aroplast y. To im prove th e perior-
bital w rin kles or superior h ollow n ess, ller or bot ulin um
toxin inject ion s m ay follow. Periorbit al ch ange w ith aging
is a dyn am ic process involving th e aging of facial t issu e an d
bony st ruct ures, an d several ch anges are com m on . Epider-
m al th in n ing an d decreased collagen cau se th e skin to lose
it s elast icit y. Loss of fat , coupled w ith gravit y an d m uscle
pull, leads to w rin kling an d th e form at ion of dyn am ic
lin es. Th e aging process h as also been sh ow n to a ect facial
bon es. Mult iple st udies suggest that bon e aging of th e orbit
an d m idface occu r p rim arily du e to con t ract ion an d m or-
ph ologic ch anges. Th is loss of bony volum e an d projec-
t ion m ay con t ribute to th e aged appearan ce. Th e e or t to
u n derst an d each pat ien t’s in dividual involut ion al ch anges,
w h ich are speci c to age an d gen der, is m an dator y. Th ere-
fore, id en t ifying th e pat ien t’s person al n eeds an d select ing
th e righ t t reat m en t accordingly is crucial for ach ieving th e
best outcom e both for th e clin ician an d for th e pat ien t .3
The eyelid is im portant not on ly in its funct ional
aspects such as tear distribut ion from blin king, but also in
its cosm etic aspects because it greatly a ects other people’s
im pressions by de ning one’s facial characteristics. The
drooped brow an d eyelid skin can obscure one’s view and
look heavy, and lateral eyelid skin can be folded and thus
cause eczem a.4 Th e eyelid becom es pu y due to the pro-
lapse of orbital fat from the loosening of the orbital sept um .
Blep h aroptosis refers to d roop ing or in frat ran sp osi-
t ion of th e u p per lid. Th e m ost com m on t ype of acqu ired
a b
Fig. 14.1 Typical pat tern of blepharoptosis in an aged female. Blepharoptosis caused elevated eyebrow by compensation and this
resulted in forehead creases.
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ptosis resu lt s from st retch ing or w eaken ing of th e levator
palp ebralis du e to involu t ion al ch ange or disin ser t ion of
th e levator apon eu rosis from th e t arsal plate. It cau ses
n ot on ly cosm et ic p roblem s bu t also visu al d iscom for t
su ch as obscu rin g th e view. Alt h ough th e su p erior visu al
eld is p rim arily involved , m any p at ien t s com p lain of d if-
cu lt y w it h read ing becau se th e ptosis is aggravated w it h
dow n -gazing. Park et al rep or ted th at Korean s age 50 years
or older sh ow ed a ver y h igh frequ en cy (54.9%) of pto-
sis, an d as th e age in creases, t h e frequ en cy of ptosis also
in creases.5 Th e exam in er sh ou ld n ote t h e p at ien t’s h ead
p osit ion , ch in -u p p osit ion , or brow p osit ion to d etect th e
p resen ce of ptosis.
Pat ien ts often involu n tarily at tem pt to com pen sate for
derm atochalasis by ch ron ic u se of th e fron t alis m uscle an d
th is can lead to h igh -posit ion ed eyebrow an d deep (prom i-
n en t) t ran sverse fu rrow s in th e foreh ead (Fig. 14.1). Un like
oth er areas of th e body, w h ere th ere is descen t of soft t is-
su es, th ere m ay be p aradoxical elevat ion of eyebrow s w ith
aging, especially th e m edial an d m idbrow. So th e clin ician
sh ou ld t r y to determ in e th e eyebrow m orp h ology an d
posit ion of th e in dividu al pat ien t an d select ively elevate th e
lateral brow to h ave a rejuven at ing e ect on th e upper th ird
of th e fem ale face.6
On th e oth er h an d, brow ptosis frequ en tly accom p an ies
derm atoch alasis, an d th e pat ien t can be over-diagn osed as
h aving ver y severe droop ing of th e u pp er eyelid skin an d
excessive excision of skin w ith su bsequ en t fu rth er drag-
ging of th e eyebrow dow nw ard. Th erefore, th e exam in er
sh ould ch eck for any h istor y of facial n er ve p alsy in case
of unilateral brow ptosis (Fig. 14.2). Seo an d Ah n an alyzed
th e m orph ologic ch anges of th e eyelid according to gen der
am ong di eren t age grou ps in Korean s an d rep or ted th at
th e degree of brow ptosis sh ow ed a st at ist ically sign i can t
in crease from th e seven th decade of life in m en an d from
th e sixth decade in w om en . In part icu lar, th e lateral brow
drooped m ore th an th e cen ter brow. Th e lateral h ood w idth
of the eyelid sh ow ed a st at ist ically sign i can t in crease from
th e seven th decade of life in m en an d from th e sixth decade
in w om en .7

Fig. 14.2 Brow ptosis masquerading as blepharoptosis. A patient
with prior left facial nerve palsy had left brow ptosis and an asym -
metric eyebrow.
■ Patient Evaluation
Dermatochalasis
Elderly p eop le com m on ly com plain of “blep h aroptosis,”
but m ost cases are n ot real ptosis but rath er derm atoch a-
lasis: sim p le skin an d m uscle drooping. To dist inguish real
ptosis from sim ple derm atoch alasis, raise th e drooped skin
an d ch eck th e p osit ion of th e eyelid m argin . Pat ien t s w ith
sim p le derm atoch alasis sh ow n orm al eyelid h eigh t sim ilar
to th at of you ng p eop le, an d th ose cases u su ally n eed exci-
sion of th e skin an d m u scle on ly.
Deep Superior Sulcus
Th e deh iscen ce of th e levator apon eurosis from th e upper
tarsal plate can cause h igh placem en t of m ult iple creases
an d h ollow su p erior su lcu s (Fig. 14.3). Deh iscen ce of th e
levator also cau ses ptosis, an d subsequen t brow elevat ion
to com pen sate for th is ptosis can aggravate su perior su l-
cus deepen ing.8,9 Som et im es p reviou s excessive fat rem oval
m ay cau se a deep an d h ollow su p erior su lcu s w ith involu -
t ion al ch anges.
Fig. 14.3 Typical presentation of involutional blepharoptosis.
Patients with involutional blepharoptosis frequently show high-
located multiple creases and hollow superior sulcus.
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14 Aging-Related Upper Blepharoplast y 175
The Degree of Blepharoptosis and
Levator Function
Many aged p eop le w h o w an t blep h arop last y m ay h ave
bleph aroptosis of var ying degrees. To ch eck th e degree of
bleph aroptosis an d levator fun ct ion , th e pat ien t sh ould
stay com for table an d sh ou ld n ot u se th e fron t alis m u scle.
First , exam in e w h eth er th e p osit ion of th e low er lid is n or-
m al. Secon d, ch eck th e m argin -re ex dist an ce (MRD), th e
dist an ce from th e upper eyelid m argin to th e corn eal ligh t
re ex in th e prim ar y posit ion , w h ich is th e m ost e ect ive
m easu rem en t in d escribing th e am ou n t of blep h aroptosis
(Fig. 14.4). Pat ien t s w ith severe derm atoch alasis m ay also
have bleph aroptosis; h ow ever, th ese pat ien ts can be over-
looked because derm atoch alasis can con ceal th eir bleph a-
roptosis. Th e m ost sim ple an d e ect ive w ay to n d h idden
bleph aroptosis is to curl up redun dan t skin an d n d th e real
MRD from th e eyelid m argin to th e re ex, n ot th e m an ifest
MRD, from th e skin m argin to th e re ex (Fig. 14.5).
Th ird, m easure th e levator fun ct ion by determ in ing th e
dist an ce (in m illim eters) th e upper eyelid m argin m oves
from dow n -gaze to u p -gaze w h ile th e brow is xated w ith
th e exam in er’s ngers (Fig. 14.6). Decreased lift ing force
m igh t also explain lash ptosis, w h ich is n ot on ly p resen t
in th e single eyelid but also in creases in prevalen ce in th e
double eyelid w ith aging.10 Th e degree of lash ptosis corre-
lates w ith th e degree of bleph aroptosis an d decreased lift-
ing force of th e levator aponeurosis.11
Brow Position
Th e brow is n orm ally posit ion ed at th e level of th e supe-
rior orbit al rim , an d th e m ale brow is low er th an th e fem ale
brow. Brow posit ion an d con tour determ in e youth fu l
ap pearan ce to som e degree. With aging, th e tem p oral brow
start s to droop m ore prom in en tly becau se th e fron t alis
Fig. 14.4 Method of measuring margin-re ex distance (MRD).
MRD is measured by the distance from the upper eyelid margin to
the corneal light re ex in the primary position.
176 III Blepharoplast y

a b

c d

Fig. 14.5 Di erentiation bet ween dermatochalasis and blepharoptosis. (a) Young male patient who worried about right blepharoptosis.
(b) After curling up redundant skin, margin-re ex distances were symmetric and there was no real blepharoptosis. (c) Older female patient
complained of “drooped skin” of the right upper eyelid. It looks like there is dermatochalasis in her right eye. (d) However, after curling
up the right upper eyelid skin, margin-re ex distance was smaller than on the left side. This patient had both right upper blepharoptosis
and dermatochalasis.

m u scle is n ot presen t in th e lateral brow area. Droop ing of
th e brow is called brow ptosis. Brow ptosis occurs usually
after m iddle age, an d derm atoch alasis an d blep h aroptosis
m ay app ear accen t u ated du e to brow ptosis. Th e su rgeon
m u st recogn ize th e brow ptosis accom p anying d erm a-
toch alasis as a cont ribut ing factor in th e pat ien t’s aged
ap pearan ce before su rger y. In th e p resen ce of brow ptosis,
th e su rgeon m u st decide w h eth er to perform a brow lift
in advan ce or in conjun ct ion w ith th e bleph aroplast y. Th e
m edical h istor y m u st be ch ecked for facial n er ve palsy in
cases of un ilateral brow ptosis or m ore prom in en t droop -
ing of th e un ilateral u pper eyelid skin . If brow ptosis w as
overlooked , iat rogen ic p ostop erat ive lagop h th alm os can
result from th e resect ion of too m uch skin an d m uscle.
Th erefore, to get good result s, th e brow lift h as to precede
bleph aroplast y.

a b

Fig. 14.6 Method of measuring the levator function. It was de ned as the movement of the upper eyelid margin in millimeters from (a)
down-gaze to (b) up-gaze while xating the brow with the examiner’s ngers.

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Upper Eyelid Crease
Th e u p p e r eyelid crease is m a d e by at t a ch m e n t of t h e
levat or a p on e u rosis ext e n d in g t h rou gh t h e orb icu la r is
in t o t h e skin . Th e u p p e r eyelid crea se is h igh e r in fe m a les
t h a n in m a les. Th e u p p e r eyelid crea se is u su a lly low
or a bse n t in t h e Asian eyelid . Th e ave rage Asia n eyelid
crea se is 2 m m low e r com p a re d w it h Cau casia n s,1 2 w it h
a h e igh t of 6 t o 8 m m in fe m ales an d 4 t o 6 m m in m a les.
Asym m et r ic h e igh t or m u lt ip le d ou b le - lid crea ses m ay
refle ct st ret ch in g or d isin se r t ion of t h e levat or a p on e u -
rosis. Th e d ou b le - eyelid cre ase it self is u su a lly elevat e d
w it h involu t ion al ch a n ges, b u t t h e ove rlyin g d e r m at o -
ch a la sis m ay con cea l t h at , esp e cially in t h e Asia n eld e rly.
High d u p licat e d eyelid crea ses m ay in d icat e d isin se r t ion
of t h e levat or a p on e u rosis.
Th e Asian pat ien t w ith a double-eyelid crease created
during previous surger y is t reated in th e sam e w ay as th e
pat ien t w ith a n at ural crease. But th e m ost di cult com -
plicat ion in aging-related bleph aroplast y in Asian s is a
ver y h igh -p osit ion ed dou ble-eyelid crease in th e pat ien t
w h o un der w en t excessive skin an d fat rem oval at a young
age, an d w h o is aging n ow. Th ese pat ien t s h ave lit tle skin
rem ain ing to resect an d m ay h ave som e adh esion s w ith
u n derlying t issu es. Th erefore, rem oving m ore skin or lift ing
th e brow can m ake an un n at ural eyelid crease n ot iceable. If
th e pat ien t h as som e drooping skin over th e eyelid crease,
m aking th e “visible” eyelid crease look n at u ral an d n ot too
h igh , it is bet ter n ot to do su rger y an d ju st leave it as it is.
In stead, au tologou s fat or ller inject ion along th e brow an d
u pp er eyelid com p lex m ay be h elpfu l in im proving cosm e-
sis. On ly th e p at ien t w ith p rofou n d bleph aroptosis n eeds
to u n dergo correct ive su rger y by levator advan cem en t or
by resect ion to elevate th e eyelid an d to m ake th e visible
eyelid crease look sm aller.
Orbital Fat Prolapse
Periorbit al fat is ver y im p or t an t in blep h arop last y, esp e-
cially in aged people. In som e pat ien t s, subbrow fat can
droop dow n to th e orbit al septal area, an d it m akes for a
pu y u pper eyelid appearan ce. It sh ould be di eren t iated
from orbit al fat p rolap se.
Th e p re -ap on e u rot ic fat p ocket s are im p or t an t su r-
gical lan d m arks, as t h ey id e n t ify t h e p lan e im m e d iately
p oste r ior to t h e orb it al se p t u m an d im m e d iately an t e r ior
to t h e levator ap on e u rosis. Th e re are t w o fat p ocket s in
t h e u p p e r eyelid , on e m e d ial an d on e ce n t ral, se p arat e d
by fascial con n e ct ion s con t in u ou s w it h t h e t roch lea . Th e
m e d ial fat p ocket is w h it e r t h an t h e ce n t ral fat p ocket .
W it h agin g, t h e se pt u m be com es t h in an d la x, resu lt in g
in fat p rolap se an d p u y eyelid . Alt h ou gh it is ge n e rally
kn ow n t h at t h e re is n o lat e ral fat p ocket in t h e u p p e r eye -
lid , it is qu ite com m on for t h e ce n t ral p re -ap on e u rot ic
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14 Aging-Related Upper Blepharoplast y 177
fat p ocket to exte n d late rally an d cove r t h e an t e r ior
asp e ct of t h e lacr im al glan d . In a p reviou s st u d y b ase d on
Korean age d p e op le, t h e eyelid fat w as m ost p rot r u d e d at
t h e ce n t ral low e r p ar t .7
Corneal Protection Mechanism
Ocu lar m ot ilit y an d Bell’s ph en om en on sh ou ld be ch ecked
carefully before surger y. Con rm th at th e eyelid is com -
pletely closed w ith a blin k. Poor Bell’s ph en om en on can
cause exposure kerat it is or corn eal ulcer postoperat ively.
Bell’s ph en om en on m ust be n orm al.
Tear Secretion
If t h e p at ie n t com p lain s of ocu la r ir r it at ion sym p t om s, it
is likely t h at t h e p at ie n t h a s a p rob le m w it h t ea r se cre -
t ion su ch as d r y eye syn d rom e. Te ar film b rea ku p t im e,
t h e p rese n ce of lagop h t h alm os, an d sym p t om s or sign s
of d r yn ess sh ou ld also be a ssesse d p re op e rat ively. Dr y-
n ess can b e aggravat e d aft e r su r ge r y, esp e cia lly in t h e
eld e rly p at ie n t . Th e su rge on w h o is n ot fam iliar w it h
t h ose ocu la r exa m in at ion s ca n con su lt an op h t h a lm olo -
gist t o ch e ck t h e p rese n ce an d seve r it y of d r y eye. Also,
t h e p at ie n t sh ou ld b e n ot ifie d t h at h is or h e r sym p t om s
w ill n ot im p rove a n d m ay eve n b e aggravat e d a ft e r
ble p h a rop la st y. So if t h e p at ie n t com p la in s of seve re
sym p t om s of d r y eye, t h e su r ge on sh ou ld m ake t h e
p at ie n t u n d e r st an d t h at ocu lar ir r it at ion m ay b e aggra -
vat e d a ft e r b le p h a rop la st y. Aft e r a t h orou gh d iscu s-
sion of t h e r isk fa ct ors, a d e cision sh ou ld b e m ad e on
w h et h e r t o p roce e d w it h t h e b le p h a rop last y p roce d u re
as p la n n e d or n ot .
Lacrimal Gland Position
Th e lacrim al glan d is located laterally just beh in d th e orbit al
rim , an d n orm ally it is n ot seen du ring bleph aroplast y.
With aging an d th e th in n ing of th e fascial system su pp ort-
ing th e lacrim al glan d, it prolapses an d m igh t be m ist aken
for lateral fat prolapse, especially in Asian pat ien t s w h o
have th ick skin over th e lacrim al glan d, an d th is prolapsed
lacrim al glan d can be easily overlooked.
Eyelid Wrinkles
Horizon t al an d ver t ical w rin kles from th e proceru s an d
corrugator m uscles at th e glabella an d crow ’s-feet from
th e orbicularis at th e lateral eyelid form w ith aging. Th ese
w rin kles can be par t ially rem oved w ith bleph aroplast y,
but m ost of th e t im e bot ulin um toxin or ller inject ion is
necessar y.
178 III Blepharoplast y

Skin Texture and Thickness

Skin text ure ch ange in aging pat ien ts is h igh ly variable
am ong in dividuals bu t is usually proport ion al to th e in di-
vidual’s environ m en tal sun exposu re.13 Epiderm al thin ning
an d decrease in collagen cau se skin to lose its elast icit y. Loss
of fat , coupled w ith gravit y and m uscle pull, leads to w rin-
kling and the form ation of dynam ic lines. The aging process
h as also been show n to a ect facial bones. In Asians, w ho
h ave relat ively thicker skin, a low er double-eyelid fold and
con ser vat ive skin resect ion are recom m en ded in such cases.
Fig. 14.7 Surgical techniques of Asian upper eyelid blepharo-
plast y. The skin to be excised was demarcated by grasping redun-
■ Surgical Techniques dant skin and marking.

Anesthesia
pat ien t s do n ot w an t an art i cial-looking crease, th e in ci-
Blep h arop last y can be perform ed un der gen eral, seda-
sion lin e can be m arked ver y close to th e eyelid m argin . If
t ive, or local an esth esia, bu t local an esth esia is preferable.
th e pat ien t h as lateral h ooding of th e skin , th e in cision m ay
Recen tly, m on itored an esth esia care (MAC) h as been gain -
be exten ded to th e lateral can th al area, but n o m ore th an 1
ing pop u larit y in bleph aroplast y. MAC is a plan n ed proce-
cm from th e lateral can th al angle. Th is design is in ten ded to
dure during w h ich th e pat ien t un dergoes local an esth esia
excise m ore lateral skin th an skin from th e m edial or cen -
togeth er w ith sedat ion an d an algesia. Pat ien t s u n dergoing
t ral side.
con sciou s sedat ion are able to an sw er to orders appropri-
Using sm ooth forceps, th e redu n dan t skin is grasp ed
ately an d h ave th e eyelid h eigh t an d con tou r ch ecked in
an d m arked. Lid ocain e m ixed w ith epin ep h rin e (1:100,000)
th e sit t ing posit ion during surger y. Tw o percen t lidocain e
is injected subcut an eously along th e previous m arking lin e.
m ixed w ith epin eph rin e (1:100,000) is u su ally u sed as th e
Th e in cision is m ade w ith a n o. 15 or 15T Bard-Parker blade
local an esth et ic. Local an esth esia is to be injected slow ly
or scissors Recen tly CO2 lasers an d radiofrequen cy w aves
to redu ce pain du ring inject ion an d sh ou ld n ot be injected
have been used to m in im ize bleeding.
in to th e m u scle layer to avoid bleeding. After th e local an es-
th esia inject ion , ligh t com pression is applied to preven t
pressure an d to dist ribute th e an esth et ic drug even ly to th e
Redundant Skin Excision
su rgical eld.
Th e skin an d orbicu laris m u scle are in cised an d dissected
from th e sept u m (Fig. 14.8). Th e skin an d orbicu laris are
Designing the Eyelid Crease and excised in on e layer. Th is skin -m u scle excision tech n iqu e
Skin Excision causes less bleeding an d m akes it easy to protect th e orbit al
sept u m . Care sh ou ld be taken n ot to cau se inju r y to th e
The m ost im portant step in blepharoplast y is design- orbit al sept um , w h ich is a w h it ish m em bran ous st ruct ure.
ing, w hich is deciding the am ount of skin and m uscle to
be excised. It is im portant that the sam e am ount of skin
bet w een the brow an d eyelid fold be kept in both eyes, rather
than rem oving sym m etrical am ounts of skin (Fig. 14.7).
After design ing th e eyelid crease lin e w ith th e pat ien t
in th e su p in e posit ion , th e pat ien t is t urn ed to th e sit t ing
posit ion . Th e surgeon grasps th e skin an d decides h ow
m u ch of th e redu n dan t skin is to be excised w h ile th e
pat ien t is asked to open an d close th e eye. W h en grasping
th e skin to excise, developm en t of a 1-m m lagoph th alm os
or sligh t eversion of th e eyelash is proper. Caut ion sh ou ld
be t aken to leave at least 15 m m of skin bet w een th e eye-
brow an d double-eyelid fold. In case of design ing a double
lid, care sh ou ld be taken to en sure a sym m et ric h eigh t . Th e
in cision lin e is m arked at 4 to 7 m m from th e eyelid m argin Fig. 14.8 Skin and orbicularis muscle were incised along previous
an d is recom m en ded n ot to exceed 10 m m . In cases w h ere marking and dissected from the septum.

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 14 Aging-Related Upper Blepharoplast y 179

Fat Removal th en rem oved after h em ost asis is secured. Th is procedure

At th is poin t orbit al fat can be seen beh in d th e th in sept u m .
Orbit al fat prolap ses easily w h en th e eyeball is com pressed
(Fig. 14.9a). W h en th e sept u m is in cised, at ten t ion sh ou ld
be paid to m ake sure th e in cision lin e is above th e lin e
w h ere th e apon eurosis an d sept am are fused. A rake ret rac-
tor is placed at th e u p per in cision m argin , p u lling th is edge
u pw ard an d sligh tly elevat ing it , an d th e pat ien t is asked to
open an d close th e eyes; th en th e dyn am ic dim pling lin e
becom es visible. Th is lin e is w h ere th e apon eurosis an d
sept u m are fu sed. Th e in cision sh ou ld be m ad e above th is
lin e to avoid inju r y of th e levator apon eurosis.
Th e orbit al sept um is th en par t ially open ed an d th e
pre-apon eurot ic fat is exposed an d rem oved (Fig. 14.9b).
Orbit al fat rem oval is n ot an in dispen sable procedu re an d
depen ds on th e am oun t of fat prolapse presen t or th e in di-
vidu al’s desire. It is also im port an t th at th e volu m e an d dis-
t ribut ion of rem ain ing fat be alm ost th e sam e bilaterally.
On ce th e fat is id en t i ed an d separated from su rrou n ding
t issues such as th e sept um an d levator apon eurosis, it is
clam ped w ith a n e-tooth ed m osqu ito forceps (Fig. 14.9c)
an d cu t w ith scissors or elect rocau ter y n eed le t ip . Elect ro-
coagulat ion is applied to th e rem ain ing fat w hile th e clam p
is st ill engaged (Fig. 14.9d). Th e grasp ing in st ru m en t is
can cause pain ; th erefore, addit ional local an esth esia injec-
t ion before fat rem oval is recom m en ded.
Eyelid Crease Formation
Th ere are several w ays to approach eyelid crease form at ion ,
an d th e au th ors m ain ly u se on e of t w o m eth ods: levator
xat ion or tarsal xat ion . We prefer tarsal xat ion : Non -
absorbable su t u res su ch as 7–0 nylon are app lied th rough
th e skin , epitarsal t issu e, an d th e skin of th e opposite side
(Fig. 14.10). In th e levator xat ion m eth od, su t u res are
ap plied bet w een th e fu sed sept u m -levator en d an d th e
su bcu tan eou s t issu e of th e low er in cision m argin .
Skin Closure
Th e skin is closed w ith 6–0 or 7–0 n on absorbable
su t u res an d an t ibiot ic oin t m en t is ap plied to th e w ou n d
(Fig. 14.11). Before su t u ring th e skin , th e pat ien t sit s an d
th e sym m et r y of th e eyelid con tour an d th e h eigh t of th e
double lid are ch ecked by both th e pat ien t an d surgeon . Th e
orbit al sept um sh ould n ot be sut ured.

a b

c d

Fig. 14.9 (a–d) The orbital septum was opened and orbital fat was identi ed. Orbital fat was grasped, cut, and cauterized using mono-
polar cautery.

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180 III Blepharoplast y
Fig. 14.10 A crease was made using tarsal xation suture: sutures
are applied through the skin, epitarsal tissue, and the skin of the
opposite side.
■ Postoperative Care
Ice p ack com p ression is app lied du ring th e rst 48 h ou rs
after su rger y to m in im ize bleeding an d edem a. In n on dia-
bet ic pat ien ts, in t raven ous steroid inject ion can be h elpful
to decrease in am m at ion an d edem a. Th e skin su t u res are
rem oved after 5 to 7 days.
■ Key Technical Points
1. Design of th e surger y is th e m ost im port an t step in
bleph aroplast y. W h en determ in ing th e am oun t of
skin an d m u scle to excise, it is im p or tan t th at th e
sam e am ou n t of skin bet w een th e brow an d eyelid
fold rem ain in both eyes, avoiding th e rem oval of an
asym m et ric am ou n t of skin .
2. In th e case of design ing a double lid, th e in cision lin e
is m arked at 4 to 7 m m from th e eyelid m argin an d is
recom m en ded n ot to exceed 10 m m .
3. Fat is rem oved after grasping w ith a n e-tooth ed
m osqu ito forcep s, an d elect rocoagu lat ion is ap p lied
to th e rem ain ing fat w h ile keeping th e forceps
engaged. Th e grasp ing in st ru m en t is rem oved after
h em ostasis is con rm ed .
4. At th e n al st age of th e su rger y, th e p at ien t is asked
to sit up an d sym m et r y of th e eyelid con tour an d
h eigh t of th e dou ble lid are ch ecked by both th e
p at ien t an d th e surgeon .
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Fig. 14.11 Skin was closed using a continuous running suture.
■ Complications and
Their Management
Many di eren t blep h arop last y tech n iqu es h ave been in t ro-
duced an d all of th ese are associated w ith cer tain preven t-
able com p licat ion s. In th is sect ion , th e m ost com m on an d
sign i can t com plicat ion s an d th eir preven t ion an d m an-
agem en t w ill be described.
Under-Correction or
Patient Dissatisfaction
Th e m ost com m on com plicat ion of bleph aroplast y in
elderly people is un der-correct ion or pat ien t dissat isfact ion .
It is im p ort an t to prom ote a realist ic u n derst an ding of th e
outcom e of bleph aroplast y th rough an in -depth discu ssion
bet w een th e surgeon an d th e pat ien t before th e surger y.
Usu ally a dou ble-eyelid crease over 7 to 8 m m in h eigh t
looks ver y un n at ural in Asian s, even in fem ale pat ien t s.
Sligh tly folded u p p er eyelid skin over th e dou ble-eyelid
crease or a low double-eyelid crease, such as 3 to 4 m m ,
looks m ore n at ural an d blen ds w ell. Som et im es, pat ien t s
have di eren t or un realist ic expect at ion s; th us a th orough
preoperat ive discussion of th e an t icipated results is crit ical.
Su rgeon s sh ou ld exp lain reason able postop erat ive exp ec-
tat ion s an d possible com plicat ion s before surger y.
Most doctors w ou ld exp ect a p at ien t to be sat is ed
w ith w ider vision after th e correct ion of obscu red vision
due to upper eyelid drooping in an elderly pat ien t . How -
ever, pat ien t s w ere foun d to be sat is ed on ly w ith an excel-
len t cosm et ic outcom e even th ough th at w as n ot th eir
prim ar y con cern prior to th e surger y. A sm all blun der in
th e cosm et ic appearan ce postoperat ively can easily cause
disappoin t m en t in a pat ien t even th ough th e visu al eld is
greatly im proved, to th e exten t th at som e m ay even con -
sider th e su rger y a u seless on e.

Asymmetric or Unnatural Eyelid
Contour
Severe derm atochalasis can obscure pre-existing eyelid
asym m etry, and m any patients do not realize this before sur-
geons point it out to them . In these patients, cautious design
is m andatory to m aintain sym m etric skin and fat, instead of
rem oving a sym m etrical am ount of skin and fat. Surgeons
should also pay attention to the position of the eyebrow,
because asym m etric eyebrow can cause postoperative asym -
m etry or under-correction. Aging-related blepharoplast y is
usually perform ed in conjunction w ith levator aponeurosis
m anipulation, and xation sutures bet ween the levator apo-
neurosis and the tarsal plate can lead to an asym m etric or
unnatural contour. To prevent this com plication the xation
should be carefully placed.
Excessive Skin Removal
Excessive rem oval of skin is a seriou s com plicat ion an d ver y
di cult to correct . Th e auth ors h ave seen m any pat ien t s
w h o h ad too m uch upper eyelid skin excised during cos-
m et ic bleph aroplast y, especially in th e elderly, an d are in
agreem en t w ith Flow ers’s dict u m th at 20 m m of an terior
lam ella is n ecessar y for n orm al fun ct ion ing of th e upper
eyelid.14 If brow ptosis is presen t , th e su rgeon m u st con fer
w ith th e pat ien t an d decide w h eth er to correct it or n ot;
d ep en ding on th e result , th e am ou n t of skin resect ion th en
h as to be decided.
Lagophthalmos
Lagophthalm os is not a com plication but an unavoidable out-
com e of aging-related bleph aroplast y, especially in patients
w ith decreased levator function. A topical lubricant and
oin tm ent are helpful during th e early postoperative stage,
an d m any w ill resolve over tim e w ithout surgical interven -
tion. Skin grafts m ay be needed in cases of severe lagoph-
thalm os and keratitis caused by excessive skin excision.
Orbital Hemorrhage
An tiplatelet m edication s, aspirin , an d n on steroidal an ti-
in am m ator y agen ts are com m only used by oth er depart-
m en ts in elderly pat ien ts. Th e m edical h istor y an d records
sh ould be carefu lly ch ecked an d con sultation s sh ou ld be
m ade about stopping drugs th at m ay a ect coagulat ion . It
is also im portan t to ascertain that the pat ien t is norm oten-
sive preoperat ively an d during surger y. It is also crucial to
understand and identify th e anatom y of upper eyelid vas-
culat ure in the surgical eld. W hen rem oving and cauter-
izing pre-aponeurot ic fat, clam ping w ith a n e-toothed
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14 Aging-Related Upper Blepharoplast y 181
m osqu ito forceps sh ou ld be m ain tain ed, an d after releasing
the clam p, hem ostasis of the rem aining fat edge should be
secured. Hem orrh age from th e orbital fat can cause retro-
bulbar hem orrhage and opt ic ner ve com pression, leading to
visu al im pairm en t . If retrobu lbar orbital h em orrh age cau s-
ing visual im pairm ent is suspected, the w ound should be
opened up im m ediately, the bleeding focus should be found
an d coagulated, an d th e drain sh ou ld be left for som e tim e.
Exposure Keratopathy
Upper eyelid bleph aroplast y can a ect th e blin king fun c-
t ion , an d in elderly pat ien t s dr yn ess m ay be aggravated.
Th erefore, it is im port an t to evaluate tear breaku p t im e an d
Bell’s ph en om en on before m aking th e decision in favor of
bleph aroplast y. Proper explan at ion an d m an agem ent of
th e dr y eye syn drom e is m an dator y.
Lacrimal Gland Injury
A p rolap sed lacrim al glan d m ay n ot be recogn ized preop -
erat ively, or in t raop erat ively. If p rolapse of a lacrim al glan d
is iden t i ed, th e prolapsed glan d sh ou ld be ret urn ed to
th e origin al posit ion by xat ing it to th e adjacen t perios-
teum an d sh ould n ot be excised. A n orm al lacrim al glan d is
pale pin kish in color, h as a n ely lobulated st ruct u re, an d
is rm er th an a fat com pon en t . If it is n ot corrected prop -
erly, lateral u p p er eyelid fu lln ess w ill be left after blep h a-
roplast y. Th erefore, if lacrim al glan d prolapse is n ot iceable
after su rger y, th e p at ien t m ay be brough t back to th e oper-
at ing room to h ave th e lacrim al glan d reposit ion ed.
Too -High Double -Lid Fold
In Asian s, an absen t or low -p osit ion ed dou ble-eyelid fold is
nat ural-looking. During det ailed preoperat ive con sult at ion ,
th e surgeon an d pat ien t sh ou ld decide w h eth er an eyelid
crease w ill be m ade an d h ow h igh it sh ould be. Som et im es
a tooth p ick an d a m irror are u sefu l in d eterm in ing th e
heigh t of th e eyelid crease. Som e elderly Asian s w ill n ot
w an t art i cial eyelid creases.
Deep Superior Sulcus
Excessive fat rem oval is usually preven t able at th e t im e of
su rger y. Now adays, p at ien ts w an t to h ave a n at u ral, sem i-
pu y, young-looking eyelid rath er th an a h ollow superior
su lcu s; th erefore, fat rem oval sh ou ld be cau t iou sly p er-
form ed, w ith care t aken n ot to excise th e en t ire eyelid fat t y
t issue. Moreover, excessive fat rem oval can cause m u lt iple
eyelid creases an d it is h ard to correct due to th e st rong
adh esion bet w een th e levator an d orbicu laris.
182 III Blepharoplast y

His brow p osit ion w as sym m et ric an d h ad m in im al fat

■ Case Studies
Case 1
A 65-year-old Asian m an w h o did n ot w an t th e creat ion
of n ot iceable eyelid creases visited th e auth ors’ clin ic
(Fig. 14.12a). He ju st w an ted to rem ove droopy eyelid skin
an d to h ave a n at u ral eyelid crease so th at h e cou ld h ave a
w ider visual eld.
prolapse. Th e m ain problem w as droopy eyelid skin th at
caused visual eld im pairm en t an d lateral can th al eczem a.
In t raoperat ively, redu n dan t skin , in clu ding th e lateral
can th al droopy skin , w as carefully rem oved, leaving sym -
m etric am ou n t s of skin bilaterally.
After skin rem oval an d form at ion of a low -sit t ing eyelid
crease, h e could see m ore com fort ably an d th e eczem a at
th e lateral can th al angle also disappeared (Fig. 14.12b).

a b

Fig. 14.12 Case 1. Blepharoplast y making a natural eyelid crease. (a) A 65-year-old man has a droopy eyelid skin that causes visual eld
impairment and lateral canthal eczema. (b) After the excision of the droopy skin with low-sit ting eyelid crease formation, he could see
more comfortably and the eczema at the lateral canthal angle disappeared.

Case 2 In t raoperat ively, redu n dan t skin , in clu ding th e lateral

A 59-year-old m an d id n ot w an t to h ave an eyelid crease
created, but just w an ted th e droopy skin rem oved an d to
h ave th e eyelid h eigh t lifted (Fig. 14.13a). Th e m ain p rob -
lem w as droopy eyelid skin th at caused visual eld im pair-
m en t an d lateral can th al eczem a.
can th al angle skin droop, w as carefully rem oved to leave
sym m et ric am ou n t s of skin bilaterally. A larger am ou n t of
skin an d m u scle w as excised in th e lateral eyelid. After skin
an d m u scle w as rem oved, th e skin w as closed w ith con t in -
uous sut ures w ith out m aking an eyelid fold (Fig. 14.13b).

a b

Fig. 14.13 Case 2. Blepharoplast y without creation of an eyelid crease. (a) A 59-year-old man who has droopy eyelid skin with lateral
canthal eczema. (b) After the skin and m uscle excision but without creation of an eyelid fold.

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 14 Aging-Related Upper Blepharoplast y 183

Case 3
A 72-year-old Asian wom an wanted to have droopy lateral
skin rem oved and to im prove skin eczem a (Fig. 14.14a). The
preoperative picture showed asym m etry of the brow and
m ore skin drooping over the right upper eyelid, w hich was
not noticed by the patient before consultation w ith the sur-
geon. After thorough discussion, the authors found that she
also wanted a distinct but natural crease and a younger and
m ore cheerful appearance. The operative plan was to rem ove
the droopy skin beyond the lateral canthal angle and create an
eyelid crease at 6 m m from the eyelid m argin w ith tarsal xa-
tion using nonabsorbable sutures. Additionally, levator apo-
neurosis advancem ent was planned to raise the eyelid level.
After bleph aroplast y w ith levator advan cem en t sh e
could see m ore com fort ably, an d th e eczem a of th e lat-
eral can th al angle an d brow asym m et r y also im p roved
(Fig. 14.14b).

a b

Fig. 14.14 Case 3. Blepharoplast y with creation of a noticeable eyelid crease. (a) A 72-year-old Asian woman wanted to remove droopy
lateral skin, improve skin eczema, and have a distinct but natural crease and a younger, cheerful appearance. During the surgery, droopy skin
was removed beyond the lateral canthal angle, an eyelid crease was made at 6 mm from the eyelid margin, and levator aponeurosis advance-
ment was performed. (b) After surgery, she could see more comfortably and the eczema of the lateral canthal angle and brow asymmetry
also improved.

6. Mat ros E, Garcia JA, Yarem ch u k MJ. Ch anges in eye-

■ Conclusion
In con clu sion , m aking th e e ort to u n d erst an d each
pat ien t’s in dividual involut ion al ch anges, w h ich are spe-
ci c to a pat ien t’s age an d gen der, is m an dator y. Addit ion -
ally, iden t ifying th e pat ien t’s p erson al n eeds an d select ing
th e righ t t reat m en t accordingly is crucial for ach ieving th e
best outcom e both for th e clin ician an d th e pat ien t .
References
1. Saonanon P. Update on Asian eyelid anatom y and clinical rel-
evance. Curr Opin Ophthalm ol 2014;25(5):436–442
2. Karam AM, Lam SM. Managem en t of th e aging upper
eyelid in th e Asian pat ien t . Facial Plast Su rg 2010;26(3):
201–208
3. Loeb R. An atom ical con siderat ion s. In : Loeb R, ed. Aesth et-
ic Su rger y of th e Eyelids. New York, NY: Springer-Verlag;
1989:1–12
4. Lot t P, Caldiera AM, Lucas A, Grigalek G. Envejecim ien to
facial. Papelde la órbit a sen il. Cir Plast Ibereo-lat in oam er
1996;22:21–30
5. Park CY, Jeon SL, Woo KI, Ch ang HR. Th e frequen cy and as-
p ect s of ptosis in Korean old age. J Korean Oph th alm ol Soc
2007;48:205–210
brow posit ion and sh ape w ith aging. Plast Recon st r Surg
2009;124(4):1296–1301
7. Seo HR, Ah n HB. Morph ological ch anges of th e eyelid ac-
cording to age. J Korean Op h th alm ol 2009;50:1461–1467
8. Matsuo K, Kondoh S, Kitazawa T, Ishigaki Y, Kikuchi N. Patho-
genesis and surgical correction of dynam ic lower scleral
show as a sign of disinsertion of the levator aponeurosis from
the tarsus. Br J Plast Surg 2005;58(5):668–675
9. Su lt an a R, Mat su o K, Yu zu rih a S, Ku sh im a H. Disin sert ion
of the levator apon eu rosis from th e t arsu s in grow ing ch il-
dren . Plast Recon st r Surg 2000;106(3):563–570
10. Malik KJ, Lee MS, Park DJ, Harrison AR. Lash ptosis in con -
gen it al and acqu ired bleph aroptosis. Arch Oph th alm ol
2007;125(12):1613–1615
11. Lee TE, Lee JM, Lee H, Park M, Kim KH, Baek S. Lash pto-
sis an d associated factors in Asian s. An n Plast Su rg 2010;
65(4):407–410
12. Liu D, Hsu W M. Orien t al eyelids. An atom ic di erence
an d surgical con siderat ion . Oph th al Plast Recon st r Surg
1986;2(2):59–64
13. Ben edet to AV. Th e environm en t an d skin aging. Clin Der-
m atol 1998;16(1):129–139
14. Flow ers RS. Bleph aroplast y. In : Court iss EH, ed. Male Aes-
th et ic Su rger y. St Lou is, MO: Mosby; 1982
 15 Epicanthoplasty and Aesthetic Lateral
Canthoplasty
Yongho Shin
Pearls
• Cosm et ic epican th oplast y releases th e epican th al
fold an d m odi es th e m ed ial corn er of th e p alpebral
ssu re, th u s revealing m ore of th e m edial p ort ion of
th e eye an d decreasing th e in terepican th al distan ce.
• Th e lacrim al carun cle can be t riangu lar, roun d,
or h ook-sh aped, an d th ese variat ion s n eed
to be con sidered in select ing an ap proach for
ep ican th op last y.
• W h en m odifying th e can th u s for aesth et ic reason s,
a con ser vat ive ap p roach is recom m en ded becau se
an over-corrected epican th u s is ext rem ely di cu lt
to revise.
• Righ t an d left lacrim al caru n cles h ave di eren t
scales of grow th an d direct ion , w h ich n eeds
con siderat ion in th e design of epican th oplast y.
• W h en a double-fold operat ion is com bin ed w ith
ep ican th op last y, redu n dan t skin from th e u pp er ap
of th e dou ble eyelid sh ould be rotated tow ard th e
■ Epicanthoplasty
Th e epican th al fold is excessive brous t issu e th at lies in a
ver t ical, sem ilu n ar orien t at ion , an d it is a dist in ct ive fea-
t ure of th e Asian eyelid. Cosm et ic epican th oplast y releases
th e epican th al fold an d m odi es th e m edial corn er of th e
palpebral ssure. Th e operat ion reveals m ore of th e m edial
port ion of th e eye w h ile sim ult an eou sly decreasing th e
in terepican th al dist an ce (Fig. 15.1).
In East Asian p op u lat ion s, th e m ean in terep ican th al
dist an ce is reported to be 3.48 to 3.6 cm .1 Am ong beaut y
con testan t s in th e 2003 “Miss Korea” con test , th is dist an ce
w as 3.17 cm on average, w h ich is sh or ter th an th e m ean
valu e, an d th is im plies th at th e con test an ts p robably did
n ot h ave h igh ly con spicu ou s epican th al folds. Th e in terep i-
can th al distan ce sh ould be in terpreted in the con text of th e
overall relat ion sh ip bet w een th e ep ican th al fold an d th e
rem ain der of th e eye. Ep ican th al folds appear m ost n at ural
w h en less th an h alf of th e carun cle is covered. Usually, 80
to 90% exposure of th e carun cle is aesth et ically pleasing.1,2
The shape of the lacrim al caruncle can be triangular,
round, or hook-shaped. Triangular caruncles account for 53%
and are m ostly found am ong Asian patients. The round carun-
184
de cien t skin on th e in n er part of th e low er eyelid to
decrease th e risk of par t ial ect ropion .
• Th e t w o m ost frequen t com plicat ion s of
ep ican th op last y are scarring an d th e aggravat ion
of th e epican th u s inversus. Th ese risks can be
redu ced by design ing th e skin in cision s along th e
relaxed skin ten sion lin es an d avoiding a con n ect ion
bet w een th e epican th oplast y an d bleph aroplast y
in cision s.
• In aesth et ic lateral can th oplast y, n ot on ly h orizon t al
palpebral exten sion but also proper posterior
deepen ing is im port an t to m ain t ain a proper con t act
bet w een th e eyeball an d palpebral conjun ct iva.
• Com bin ed lateral can th oplast y an d low ering of
low er eyelid slan t w ill m ake th e eyes look m ild
an d big. Mongolian slan t low ering can be d on e by
su t u ring bet w een th e t arsu s an d cap su lopalp ebral
fascia.
cles represent ~ 10%. The hook shape (37%) is accom panied
by a dow n-pointing m edial palpebral com m issure (Fig. 15.2).3
For t riangular an d rou n d carun cles, th e exten t of
ep ican th al release is determ in ed con sidering th e w h ole
propor t ion of th e eyes. How ever, h ook-sh aped carun cles
requ ire a di eren t app roach becau se epican th al ten don s
ru n dow nw ard along th e ou ter cu r vat u re. If too m u ch of
th is epican th al fold is elim in ated, th e outcom e w ill be an
aggressive app earan ce th at w ill m ost likely to be u n ac-
ceptable to th e pat ien t . Th e size of visible caru n cle after
ep ican th op last y is an im port an t con siderat ion . In East
Asian pat ien ts, th e carun cle is visible for 3 to 5 m m at th e
m edial side. If th e ep ican th al fold covers th e caru n cle an d
th e extern ally visible par t of th e carun cle is 1 m m or less, a
m ore drast ic in ter ven t ion m ay be requ ired.
Epican th al folds can be divided in to four t ypes: epi-
can th u s su praciliaris, epican th us palpebralis, epican th us
tarsalis, an d epican th us inversus (Fig. 15.3).1 Epican th al
fold s rep resen t a w ide spect ru m of soft t issu e con gu ra-
t ion s w ith var ying et iologies, an d th us th ere can n ot be a
single op erat ion th at is su ited for all pat ien t s an d sit u a-
t ion s. Th e sh eer n um bers an d variat ion s of epican th oplast y
tech n iqu es ser ve to dem on st rate th is fun dam ental con cept
in epican th oplast y.
 15
A
B
Fig. 15.1 Distance bet ween the eyes. A, intercanthal distance; B,
interepicanthal distance
Early in it s developm en t , epican th oplast y con sisted
on ly of skin excision w ith th e idea th at epican th al folds
w ere m an ifest at ion s of redu n dan t skin arou n d th e m edial
can th u s. How ever, a com m on com plicat ion of th is m eth od
w as visible scarring cau sed by excessive ten sion in th e skin ,
esp ecially in th e low er on e-th ird of th e m edial can th u s. On
on e h an d, skin redun dan cy in th e upper th ird of th e epi-
can th al fold is usually accom pan ied by a skin de cien cy of
th e low er th ird. In su ch con gurat ion , th e redun dan t skin
sh ou ld be u sed as a ap to relieve th e ten sion on th e low er
th ird, w h ich is crucial in th e preven t ion of ect ropion along
th e m edial por t ion of th e low er eyelid. On th e oth er h an d,
skin redu n dan cy of th e low er sect ion in dicates th at th e ep i-
can th al fold is caused by m ult iple factors. Even if th e low er
skin is n ot de cien t , u p per excessive skin excision sh ou ld
be m in im ized in su ch cases.
Patient Evaluation
It is im p ort an t to m easu re th e in terep ican th al d ist an ce an d
th e am oun t of exposed lacrim al carun cle. Pat ien t s w ith
ext rem e ep ican th al fold an d w ide in terep ican th al dis-
tan ce can realize a dram at ic ben e t from th is procedu re.
A pat ien t can in sp ect th e ch anges after epican th op last y
by nger t ract ion of th e in n er can th us. Un der-correct ion
is safer th an over-correct ion becau se an u n der-corrected
ep ican th al fold can be revised m u ch m ore easily th an an
over-corrected ep ican th al fold.
Of th e fou r t yp es of ep ican th al folds, epican th u s t ar-
salis is m ost com m on in East Asian s. Not all epican th al
fold s requ ire correct ion , an d ep ican th u s t arsalis allow s for
a b c
Fig. 15.2 Three shapes of lacrimal caruncle. (a) Triangular shape.
(b) Round shape. (c) Hook shape.
Epicanthoplast y and Aesthetic Lateral Canthoplast y 185
a m ore n at u ral-looking ep ican th u s w ith dou ble fold . East
Asian s ten d to h ave th icker skin n ear th e n asal bridge an d
ep ican th al area th an in th e u p p er eyelid, w h ich is m ore
react ive an d pron e to hypert roph ic scarring after epic-
an th op last y. Preop erat ively, p at ien t s sh ou ld alw ays be
in form ed th at un der-corrected or asym m et ric epican th u s
m ay develop as a com plicat ion .
Each epican th al fold can be divided in to upper, m id-
dle, an d low er th irds. For each port ion , an atom ic feat ures
sh ou ld be th orough ly exam in ed, su ch as skin redu n dan cy,
exten t of skin h ooding, an d am ou n t of soft t issu e ten sion .
Even in a single pat ien t , th e sizes of th e bilateral lacrim al
carun cles m ay di er, so th e side of th e sm aller carun cle
sh ou ld be op en ed m ore w idely to m ake for sym m et r y after
ep ican th op last y. Th erefore, it is cru cial to p repare a p recise
m edical exam in at ion an d diagn osis.
Double -Fold Operation and
Epicanthoplasty
In East Asian pat ien t s, th e dou ble-fold operat ion is com -
m on ly perform ed in conju n ct ion w ith ep ican th oplast y. In
su ch a com bin ed op erat ion , th e redu n dan t skin from th e
upp er ap of th e double eyelid sh ould be rot ated tow ard
th e de cien t skin on th e in n er par t of th e low er eyelid. Th is
redist ribut ion of soft t issue is h elpful in decreasing th e risk
of par t ial ect ropion caused by epican th oplast y (Fig. 15.4).
If ep ican th op last y is p erform ed w ith ou t th e d ou ble-
fold operat ion , a dog-ear m igh t form on th e upper an d
m edial p art s of th e ep ican th al fold an d w ill n eed excision .
Occasion ally, th is excision can resu lt in a n ew, u nw an ted
double-eyelid lin e. To preven t th is n ew double-eyelid lin e,
a b
c d
Fig. 15.3 Classi cation of epicanthal folds as proposed by John-
son. (a) Epicanthus supraciliaris. (b) Epicanthus palpebralis. (c) Epi-
canthus tarsalis. (d) Epicanthus inversus.
186 III Blepharoplast y

a b

c d

Fig. 15.4 The reverse Fuente's design. (a,b) The triangular ap from the inner upper part of the epicanthal fold is rotated toward the
incision site of the lower eyelid to hide the scar. (c) A 19-year-old girl wanting epicanthoplast y and double-eyelid surgery. Medial epican-
thoplast y with reverse Fuente’s design and incisional double-eyelid surgery were performed. (d) After surgery, more exposed caruncle
with double eyelids makes the eyes more beautiful.

th e dog-ear sh ould be resected as close to th e upper cilia
as possible. If th e skin is in su cien t on th e lid m argin of
th e m edial carun cle, th e dog-ear port ion of th e upper ap
sh ou ld be p reser ved an d t u rn ed in to a t riangu lar ap to
be rot ated in to th e in n er por t ion of th e n ew can th otom y
st ru ct u re (Fig. 15.5). An oth er p ossibilit y is to release th e
ban d-sh aped epican th us inversus on th e low er par t of th e
ep ican th al fold by rot at ing th e ap m ad e by th e dog-ear
an d advan cing th e t riangu lar ap p erp en dicu larly to th e
ep ican th u s inversu s.
Surgical Techniques
Th ere is n o single tech n ique th at can address th e fu ll spec-
t rum of epican th al folds, an d th e surgeon m ust rely on a set
of tech n iques th at are applicable to speci c t ypes of epican -
th al folds. Most epican th oplast y tech n iques are variat ion s
an d com bin at ion s of a few fu n dam en t al con cept s: sim ple
skin excision , V-Y advan cem en t , Z-plast y, an d W-p last y.
Th e follow ing ve quest ion s m ust be an sw ered before th e
ap prop riate ep ican th op last y tech n iqu e can be ch osen .
1. How w ill I m an age th e skin redun dan cy an d
d e cien cy?
2. How w ill I con t rol th e exten t of carun cle exposure?
3. Can th e t ran sverse in cision be placed in a n onvisible
area or along a relaxed skin ten sion lin e?
4. Is it possible to leave a skin bridge bet w een th e
ep ican th op last y in cision an d th e dou ble-eyelid
in cision ?
5. Of th e appropriate operat ive tech n iques, w h ich am I
m ost com for t able w ith ?
Simple Skin Excision
Sim ple skin excision is not com plicated an d can be per-
form ed even by inexperienced surgeons. Alth ough skin-only
excision can be suitable for som e cases, excessive tension in
the low er ap is a con cern an d can result in postoperative
scarring. To decrease ten sion , th e soft t issue m u st be dis-
sected an d th e perpen dicular accessor y ber m ust be tran -
sected. Th is m eth od is n ot com m on ly perform ed n ow adays.
V-Y Advancement Methods
Th ere are several kn ow n variat ion s of V-Y advan cem en t .
Th e Roveda m eth od involves advan cem en t of th e n asal side
skin an d rem oval of th e rem ain ing skin from th e top an d
bot tom to preven t dog-ear. Uch ida m odi ed th e Roveda
 15
Fig. 15.5 Rotation of the triangular ap into the canthotomy site
allows greater exposure of the caruncle.
m eth od, bu t th e Uch ida design w as too close to th e lacrim al
carun cle to preven t n ot iceable scars. Th e Uch ida m eth od
h as been fu rth er m odi ed to th e p ericiliar y ep ican th al fold
in cision m eth od, w h ich involves a large V-sh ap ed in cision
follow ed by dissect ion an d excision of th e su rrou n ding skin
to com pletely h ide th e scar (Fig. 15.6).4
Z-Plasty Flap
Th is is a frequen tly used tech n ique w ith m any variat ion s to
allow for exibilit y in th e locat ion an d size of th e t w o skin
ap s. Fu en te’s design in corporates h alf of a Z-p last y, w h ich
takes th e t riangular ap from th e low er part of th e epican -
th al fold an d t ran sfers it to th e m iddle par t , an d exten ds th e
double-eyelid fold in cision lin e tow ard the in n er upper part .
Th is m eth od is recom m en ded for pat ien t s w ith a pre-exist-
ing dou ble-eyelid fold . How ever, resect ion of redun dan t
skin is n ecessar y, if th e tech n iqu e is p erform ed sim u lt an e-
ously w ith th e double-fold lin e operat ion (Fig. 15.7).
Park’s m eth od is a m odi cat ion of Fuen te’s m eth od an d
incorporates partial resect ion of redun dant skin bet w een
the double-eyelid fold lin e and the epicanthoplast y site. This
m eth od rotates skin from th e low er epican th al fold to th e
m iddle portion . Th e redu n dan t skin in th e upper epican th al
fold is resected. This procedure is suitable for patients w h o
h ave th e redundant skin in th e low er epican thal fold w ith
h igh ten sion in th e m iddle portion. The tech n ique is also
useful in addressing th e dog-ear from the redundan t skin
along th e u pper bleph aroplast y in cision lin e.
Th e reverse design of Fuen te’s m eth od can be used
for p at ien ts w ith redu n dan t skin on th e u pp er part of th e
ep ican th al fold an d lack of skin on th e low er p art . In su ch
cases, th e t riangular ap sh ould be m ade on th e u pper
in n er part an d rot ated dow nw ard (Fig. 15.4). If less th an 1
m m of lacrim al caru n cle is visible, th en th e t riangu lar ap
from th e u p p er p ar t of th e epican th al fold is rotated in to
th e m edial can th otom y site (Fig. 15.5).
Epicanthoplast y and Aesthetic Lateral Canthoplast y 187
x
x' z
Fig. 15.6 Design of periciliary V-Y advancement epicanthoplast y.
The innermost point of the lacrimal caruncle x becomes x’ after V-Y
advancement. Extended skin incision along the upper and lower
ciliary margin (y, z) is necessary for dog-ear removal.
Skin Redraping Method
An oth er frequen tly u sed epican th oplast y tech n iqu e is th e
skin redraping m eth od. It can be perform ed sim ultan eously
w ith the double-eyelid fold operation. The skin redraping
design w as origin ally rectilinear but the design needs to be
m odi ed from a rect ilin ear lin e to a roun d or sligh tly trian -
gular lin e. Th is m odi cation can preven t ectropion at th e
m edial side of th e low er eyelid (Fig. 15.8). W h en epican th o-
plast y is perform ed w ith out the double-eyelid fold opera-
tion , th e t riangular ap should be placed as close to the
ciliar y line as possible. In addition, the incision should be
extended to allow adequate resection of the redun dant skin.
Un derdeveloped lacrim al caru n cle cases are ext rem ely
ch allenging to address. In such pat ien t s, th e m edial can th al
ten don requires plicat ion to reveal m ore of th e m edial cor-
ner of th e eye. Th e can th al ten don can be secured th rough a
hole drilled th rough th e n asal bon e u sing eith er m et al w ire
or th ick nylon su t u re.5
■ Complications and
Their Management
Th e t w o m ost frequen t com plicat ion s of epican th oplast y
are scar an d th e aggravat ion of th e epican th u s inversu s.
Th e risk of th ese com plicat ion s can be reduced by design -
ing th e skin in cision s along th e relaxed skin ten sion lin es
an d avoiding a con n ect ion bet w een th e epican th op last y
an d blep h arop last y in cision s. It is bet ter to sep arate ep ic-
an th op last y an d blep h arop last y in cision lin es becau se th e
m ovem en t of th e u pp er eyelid can t ran sm it ten sion from
th e upper bleph aroplast y in cision to th e epican th oplast y
in cision in case th ese t w o in cision s are con t in uou s. Rota-
t ion of th e redu n dan t upper skin to th e low er por t ion of th e
ep ican th u s redu ces th e ten sion ect ropion . Iat rogen ic ep i-
can th u s inversus is aggravated by perpen dicular ten sion ,
188 III Blepharoplast y
Modified Uchida’s m ethod
Mat sunaga’s m odified “M”-plast y m ethod
Fuente’s transposition flap
Jordan’s “a deep tissue approach” method
Yoon’s “one-arm ed jum ping m an” m ethod
Wu’s square-flap m ethod
Park’s “Z-plast y” m ethod
Fig. 15.7 Various t ypes of epicanthoplast y commonly used in
Asian patients
an d is p reven ted by t ran sect ing th e accessor y ber of th e
orbicularis m uscle. Th e t ran sected bers sh ould be reori-
en ted by advan cing th e skin ap t ran sversely.
Th e postoperat ive scar sh ould be placed in a h idden
area, as m u ch as th e su rgical design allow s. Th e ten sion
across th e su rgical w ou n d sh ou ld be h eld by absorbable
d erm al su t ures, n ot by sup er cial skin su t u res. Th e skin
layer sh ould be closed w ith th e th in n est sut ure n eeded (i.e.,
7–0) un der th e surgical lou pe.
x'
w x y z
a
x'
x'
w x y
z
Fig. 15.8 (a,b) Skin redraping method of epicanthoplast y. To
avoid ectropion, the skin redraping design is modi ed from a rec-
tilinear line to a round or slightly triangular line. For example, the
point x is moved to x′ to avoid ectropion.
Th e epican th oplast y site is t reated w ith topical steroid
oin tm en t for 6 w eeks after surger y to lim it th e proliferat ion
of broblast s bet w een 2 to 6 w eeks. Pat ien t s w ith a h istor y
of hypert ropic scar or keloid are prescribed t ran ilast (oral
T-cell grow th factor [TGF] β-in h ibitor) for 6 to 12 w eeks.
Un der-corrected epican th al folds can be revised w ith in
th e rst w eek of th e in it ial operat ion . Beyon d th is period,
h ow ever, revision s sh ou ld n ot be at tem pted u n t il after 6
m on th s, or u n t il th e hypert roph ic resp on se h as su bsided .
Frequen tly, revision s are required due to asym m et r y in
 15
th e n al sh apes of th e epican th al fold an d m edial can th al
angle. To preven t u n n ecessar y recon st ru ct ive su rgeries,
p at ien t s sh ould be provid ed w ith su cien t explan at ion s
abou t h ow th e t w o lacrim al caru n cles h ave d i eren t scales
of grow th an d direct ion .
Hyp ert rop h ic scar is t reated w ith t riam cin olon e injec-
t ion , but th e t riam cin olon e m ust be diluted four t im es
m ore th an th e u su al dose. Oth er w ise, th ere cou ld be som e
visible w h ite pow ders appearing th rough t ran slucen t skin
for a long p eriod . With ou t dilu t ion of th e t riam cin olon e,
d erm is at rop hy an d telangiect asia m ay develop .
Reconstructive Epicanthoplasty
If the interepicanthal distance is less than 3 cm , then the eyes
look too close together. In addition, if m ore than 5 m m of
lacrim al caruncle is exposed on both sides, it could cause an
uncom fortable look. Besides excessive exposure of the lacri-
m al caruncle, there could be som e prom inent epicanthoplasty
scarring. Reconstructive epicanthoplasty reduces and conceals
this scarring and changes the unnatural parallel fold (outfold)
into a m ore favorable natural-shaped epicanthal fold.
A fu n dam en t al w orkh orse for recon st ruct ive epican -
th oplast y is th e V-Y advan cem en t ap. Mostly, th e epi-
can th u s inversus appears arou n d th e low er par t of th e
ep ican th u s du e to p erp en dicu lar ten sion of th e u pp er part .
On e m eth od to t reat su ch a con dit ion cou ld be a back-cu t
skin in cision in th e low er p art of th e ep ican th u s (Fig. 15.9).
An oth er m eth od is to m ake a long, in feriorly directed
V- ap in th e V-Y advan cem en t ap d esign to p reven t ep i-
can th us inversus. Th e low er in cision of th e V- ap start s
from th e m ore lateral sid e of th e back-cu t site an d passes
parallel to th e low er cilia an d exten ds to th e m edial side.
In stead of th e back-cu t design , th e V- ap is rot ated an d
lls th e skin de cien cy. By th is V- ap rot at ion , th e su rgeon
a b
d e
Epicanthoplast y and Aesthetic Lateral Canthoplast y 189
preven t s back-cut scars an d avoids th e relapse of excessive
exp osu re of th e lacrim al caru n cle (Fig. 15.10).
Even after recon st ru ct ive epican th op last y, recu rren ce
of skin exten sion an d asym m et r y of th e eyes m ay develop.
Th us, it is st rongly recom m en ded th at th e surgeon in form
pat ien t s about th e possibilit y of developing m icro di er-
en ce bet w een th e left an d th e righ t , th e p ossibilit y of ad di-
t ion al operat ion s, an d th e lim it s of th ese operat ion s before
su rger y.2
■ Aesthetic Lateral Canthoplasty
Gen erally, lateral can th oplast y refers to all of th e su rgeries
t ran sform ing th e lateral can th u s. Notably, a lot of Western
st u dies h ave com m on ly in t rodu ced lateral can th op last y as
a su rgical m eth od th at correct s can th al laxit y or low er lid
m alp osit ion an d relieves aging-related sign s on th e low er
eyelid an d m idface. “Lateral can th u s exten sion ” surger y
perform ed for Asian s as a cosm et ic procedure is also con -
sidered lateral can th op last y. How ever, to be p recise, lateral
can th oplast y is an expan sion of th e lateral can th us an d a
resh aping of th e lateral can th al area in clu ding th e angle of
lateral can th us. Sin ce th e eyeball is sph erical in sh ape, th e
palpebra is a th ree-dim en sion al st ru ct ure. For cosm et ic lat-
eral can th op last y, n ot on ly h orizon t al p alpebral exten sion ,
but also proper posterior deepen ing sh ould be perform ed
so th at a p roper con t act bet w een eyeball an d palp ebral
conjun ct iva can be m ain t ain ed.6
Patient Evaluation
As w ith ever y cosm et ic eyelid su rger y, it is n ecessar y to
ch eck th e pat ien t’s eye con dit ion before u n dergoing lateral
can th oplast y. Con siderat ion s in th e select ion of good can -
c
Fig. 15.9 V-Y advancement and low back-cut design for
epicanthal reconstruction. (a) Design without skin traction.
(b) Design with skin traction. (c) Sutured state after V-Y
advancement. (d) Back-cut for avoiding epicanthus inversus.
(e) Sutured state with no skin tension.
190 III Blepharoplast y
a b
c d
Fig. 15.10 Epicanthal reconstruction with V-Y advancement and
rotation ap. (a) V ap design with skin traction. (b) V-Y ap partial
advanced state. (c) Rem nant ap rotation. (d) The rotated ap was
inset and sutured.
d idates in clu de th e degree of exoph th alm os an d th e loca-
t ion of orbital bon e an d cilia. Gen erally, people w h o h ave
exop h th alm ic eyes h ave bet ter at t ach m en t bet w een eyeball
an d p alp ebral conju n ct iva after lateral can th op last y th an
p eop le w h o h ave en op h th alm ic eyes. In addit ion , pat ien t s
w ith exoph th alm ic eyes sh ow m ore visible expan sion of
th e lateral can th us from th e front al view. W h en th e dis-
t an ce bet w een th e lateral can th u s an d th e lateral orbit al
rim is ver y sm all, p at ien t s h ave low er sat isfact ion after
su rger y du e to th e d ecreased h orizon tal expan sion e ect .
Lateral can th oplast y is n ot recom m en ded in p at ien ts w h o
h ave severe ptosis becau se th e pow er of th e vector occu r-
ring from th e lateral an d p osterior exten sion of th e can th u s
ten ds to aggravate upper eyelid ptosis.7,8
Good can didates for aesth et ic lateral can th oplast y are
pat ien t s w ith (1) exoph th alm ic eyes, (2) a dist an ce of 4 m m
or m ore bet w een th e lateral can th us an d lateral orbit al rim ,
an d (3) a lateral forn ix deep er th an 3 m m .9
a b
Fig. 15.11 Von Ammon’s method for lateral canthoplast y. (a) After a lateral canthal incision, the conjunctiva is undermined. (b) The
conjunctiva is pulled out and sutured to the skin edges. Double-armed sutures are passed through the conjunctiva, brought out lateral to
the canthus, and tied over a peg.
Surgical Techniques
Western literat ure h as detailed th e surgical m eth ods for
exp an sion of th e lateral can th u s an d h orizon t al exp an -
sion of th e p alpebral ssu re. Becau se lateral can th oplast y
h as been in t roduced as a t reat m en t for bleph aroph im osis
an d recon st ru ct ive su rger y, som e su rgical m eth ods are
n ot su it able for Asian s w h o w an t th is su rger y for cosm et ic
im provem en t on ly.
Von Ammon’s Method
Von Am m on’s m eth od is th e oldest procedu re for lateral
can th u s expan sion an d h as been used as a lateral can th o-
plast y m eth od for Asian s. In cise th e full layer of lateral can -
th us h orizon t ally as desired. Elevate th e conjun ct ival ap
m edially from th e lateral en d (Fig. 15.11a). Pu ll th e en d of
th e conjun ct ival ap an d sut ure it to th e skin of th e lateral
corn er. Th e rem ain ing skin in cision is closed separately. A
double-arm ed sut u re is passed th rough th e conjun ct iva at
th e can th us, brough t out lateral to th e can th us, an d t ied
over a peg (Fig. 15.11b). Th is w ill preven t th e n ew ly form ed
forn ix from get t ing roun d an d at an d w ill m ake th e n ew
lateral can th u s deeper. Disadvan t ages of th is m eth od are
th e exposure of red conjun ct iva w h en th e conju n ct iva is
pulled too m uch an d a visible scar at th e lateral part of th e
low er eyelid.10
Blaskovics’ Method
To perform Blaskovics’ m ethod, m ake a V-shaped incision
on the lateral canthus and lean the triangular ap upward
(Fig. 15.12a). Make a full-layer incision of the lateral canthus
horizontally as in Von Am m on’s m ethod (Fig. 15.12b). Suture
the wedge-shaped incision site m ade by elevation of the tri-
angular ap. Trim the skin of the triangular ap and suture to
 15 Epicanthoplast y and Aesthetic Lateral Canthoplast y 191

a b c

Fig. 15.12 Blaskovics’ method for lateral canthoplast y. (a) The lateral canthus is incised as a V shape and a skin ap is made. (b) The skin
ap is elevated and the transverse incision is made. (c) The wedge-shaped incision site on the lower lid is closed. The upper eyelid lateral
skin ap is trim med and sutured.

the upper and lateral part of the upper eyelid (Fig. 15.12c). can th oplast y is perform ed on pat ien ts w ith Mongolian
Because this surgical m ethod uses skin tension only in the slan t , th e lateral can th u s w ill n ot seem to be exten d ed
lateral canthus, the e ect of expansion is not dram atic. en ough an d th e eyes w ill look m ore slan ted. Com bin ing
low ering of th e slan t w ith lateral can th op last y w ill m ake
th e eyes look bigger an d m ilder at th e sam e t im e an d
Fox’s Method en h an ce pat ien t sat isfact ion . How ever, th ese procedu res
sh ou ld be ap plied on ly to th e p at ien ts w h o h ave eyes w ith
To apply Fox’s m eth od, select a desired lateral exten sion steep Mongolian slan t .
poin t ~ 4 m m aw ay from th e in digen ous lateral can th us
(Fig. 15.13a). Split on e-qu ar ter of th e lateral p art of th e
u pp er an d low er eyelids bet w een th e an terior an d p oste-
rior lam ellae. Exten d th e sp lit u pp er palp ebral lin e 4 m m
m ore follow ing th e exten sion lin e of th e u p p er p alpebral
border. Con n ect th e th ree poin t s of x, y, z an d elevate th e
ap (Fig. 15.13b,c). Pu ll y to x an d su t u re th em . Elevate th e
low er eyelid ap con sidering x′ as th e vertex an d p u ll x′ to z
an d su t u re th em . Elevate a conju n ct ival ap of ap prop riate
x y
size from th e lateral an d su t u re to th e skin (Fig. 15.13d,e ). x'
z
a

Shin’s Method xz
xz
In Sh in ’s m et h od , 2 m m of t h e u p p e r cr u s a n d 3 m m yx'
x' y
of t h e low e r cr u s of t h e lid m a r gin are elevat e d for a d
rot at ion fla p (Fig. 1 5 .1 4 a,b). Th e elevat e d fla p is u se d b
for low lat e ral lid ext e n sion . Th e lat e ral e n d of t h e ele -
vat e d flap is su t u re d t o t h e p e r iost e u m w it h n ylon 6 – 0
xz
t o ext e n d t h e lat e ra l can t h u s lat e ra lly a n d d ow nw ard
(Fig. 1 5 .1 4 c). Close all t h e in cision s of t h e lat e ral can - yx' y
t h u s a n d t h e conju n ct iva (Fig. 1 5 .1 4 d). Eve n t u ally, t h e e
lat e ra l can t h u s w ill b e ext e n d e d lat e ra lly a n d d ow n - c
w a rd . Th is p roce d u re is relat ively sim p le a n d com p lica -
t ion s a re n ot fre qu e n t ; h ow eve r, t h e lat e ra l ca n t h u s w ill
Fig. 15.13 Fox’s method of lateral canthoplast y. (a) Find a desired
b e low e re d in eve r y p at ie n t . lateral extension point y ~ 4 mm away from the indigenous lateral
canthus. Split one-quarter of the lateral part of the upper and lower
eyelids bet ween the anterior and posterior lam ellae. Extend the
Lateral Canthoplasty Combined w ith split upper palpebral line 4 m m more following the extension line
of the upper palpebral border. (b,c) Connect the three point s of x,
Mongolian Slant Low ering y, z and elevate the ap. Pull z to x and suture them. (d,e) Elevate
the lower eyelid ap considering x′ as vertex, and pull x′ to y and
East Asian s are m ore likely to h ave u pw ard-slan ted eyes suture them. Elevate a conjunctival ap of appropriate size from the
com pared w ith European s. In dividuals w h o h ave Mongol- lateral end of the conjunctiva toward the m edial side and suture the
oid slan t m ay give th e im pression of being angr y. If lateral the end of the ap to y.
192 III Blepharoplast y
Palpebral
conjunctiva
Cornea
a d
Lateral can th al exten sion w ith low ering of th e Mongo-
lian slan t is possible if a t riangu lar ap can be m ade on th e
u pp er, lateral par t of th e lateral can th u s as in Sh in’s m eth od
of lateral can th oplast y. Usu ally, it is n ot easy to m ake th e
t riangular ap in revision cases due to scar. Even in prim ar y
su rger y, it is h ard to m ake th e t riangu lar ap if th e distan ce
bet w een th e lid m argin an d cilia is too close or if th e cilia
are located in th is area.
Use th e follow ing tech n iqu e:
1. According to th e slope bet w een th e lateral part of
th e upper eyelid an d th e lateral can th us, perform an
obliqu e can th otom y st ar t ing from th e lateral can th u s
an d exten ding laterally an d in feriorly. Th e length
of th e in cision is usually 4 to 5 m m , alth ough it can
be longer or sh orter based on th e desired exten ded
length (Fig. 15.15).
2. In cise th e conjun ct iva less th an 1 cm at 1–2 m m
low er par t of th e tarsal plate of th e low er eyelid.
Du ring th e p rocedu re, coagu late th e visible vessels.
3. Make a dissect ion bet w een th e orbicularis ocu li
m u scle an d th e orbit al sept u m to secu re a clear view,
an d m ake a m in im al in cision of th e orbital sept u m
so th at th e lateral orbital fat can be exp osed.
4. W h ile an assist an t t akes th e exposed orbit al fat
d ow nw ard, n d th e capsulop alpebral fascia (CPF) at
th e rear of th e exposed orbit al fat an d grab it w ith
th e forceps.
2 mm
3 mm
5 mm
b c
Fig. 15.14 Shin’s cosmetic lateral canthoplast y. (a) The
palpebaral conjunctiva is exposed with traction. (b,c)
Two m illim eters of the upper crus and 3 mm of lower the
crus of the lid margin were elevated for the rotation ap.
The elevated ap is used for low lateral lid extension. The
lateral end of the elevated ap is sutured to the perios-
teum with nylon 6–0 (star) to extend the lateral canthus
laterally and downward. (d) After closure.
5. Penet rate th e CPF using nylon 7–0 an d th en
pen et rate th e area you w ish to low er on th e low er
border of th e tarsus from side to side, an d su t ure
th em .8,11 Th e xat ion locat ion can be ch anged
d epen ding on th e am oun t of desired lid low ering.
Usu ally, t w o areas of th e CPF are xed on th e tarsal
plate (Fig. 15.16).
6. Sut ure the in cision site of th e u pper eyelid m argin
exp osed by can th otom y an d x th e lateral en d of
th e low er eyelid to th e periosteum of th e lateral
orbit al rim using nylon 6–0. En sure th at a n ew lateral
can th u s is form ed as desired.
7. To rem ove th e dog-ear skin surroun ding th e lateral
can th u s, m ake th e m in im ual in cision follow ing th e
cilia on th e low er eyelid, resect th e rem ain ing skin ,
an d close th e w ou n d.12,13
Postoperative Care
Du e to th e n at u re of th e lateral can th al area, th e dressing of
a lateral can th op last y is d i cu lt . App lying oin t m en t to th e
su rgical site is en ough as p ostop erat ive care. St itch rem oval
is perform ed on p ostop erat ive day 7 or 8.
 15 Epicanthoplast y and Aesthetic Lateral Canthoplast y 193

a b

Cant hotom y

Lowering

Enlargem ent of lateral scleral triangle

c d

Lateral cant hal expansion &

Mongoloid slant change Mongoloid slant change

Fig. 15.15 Cosmetic lateral canthoplast y and Mongolian slant lowering. (a) The area of lateral scleral expansion is triangular and colored
pink. (b) Following the slope of the upper eyelid, a lateral oblique canthotomy with preseptal dissection is performed. The lateral part of
the lower eyelid tarsal plate is xed to the capsulopalpebral fascia (CPF) in t wo sites, using nylon 7–0. (c) Fix the lateral end of lower eyelid
to the periosteum of lateral orbital rim using nylon 6–0. The slope of palpebral ssure becomes less steep (from pink to red line). (d) The
lateral canthus is extended laterally and downward exposing more sclera.

IO IO
3.1
3.1 TM TM
5.4
5.4

CPF CPF

OS OS
Lid
lowering

a Dissection plane b Suture

Fig. 15.16 Mongolian slant lowering. (a) Open the lateral orbital septum and reach the capsulopalpebral fascia (CPF) using the transcon-
junctival preseptal approach (blue line). (b) Suture the CPF and lower border of the tarsus with nylon 7–0 to lower the lower eyelid (red line).
194 III Blepharoplast y

an th op last y (Fig. 15.17a). Ep ican th al recon st ru ct ion w as

■ Case Studies
Case 1: Epicanthal Reconstruction
A 24-year-old w om an com p lain ed of over-exp osed car-
u n cle w ith a n ot iceable depressed scar after m edial epic-
don e w ith V-Y advan cem en t an d a rot at ion ap. Th e ap
w as elevated from th e dep ressed scar of th e n asal side.
After su rger y, a decreased caru n cle exposu re an d m ore
n at u ral-looking in tercan th al area w ith ou t n ot iceable scar
are obser ved (Fig. 15.17b).

a b

Fig. 15.17 Case 1. Before (a) and after (b) epicanthal fold reconstruction. A 24-year-old woman with noticeable depressed scar after
medial epicanthoplast y had epicanthal reconstruction with V-Y advancement and a rotation ap. After surgery, caruncle exposure
decreased and the intercanthal area looks natural without noticeable scar.

Case 2: Lateral Canthoplasty w ith
Mongoloid Slant Low ering
A 26-year-old w om an w an ted to m ake h er eyes m ore beau -
t iful. A physical exam sh ow ed sm all eyes w ith an invis-
ible caru n cle by th e ep ican th al fold, n o double fold, an d
Mongolian slan t ing (Fig. 15.18a). Ep ican th oplast y w as
perform ed w ith Z-plast y (reverse Fuen te’s design ). Double-
eyelid surger y w as p erform ed u sing th e in cision al m eth od.
A lateral can th al exp an sion w ith Mongoloid slan t low ering
w as also d on e. After su rger y, th e caru n cle is m ore visible
an d h er eyes look bigger an d m ild er th an before su rger y
(Fig. 15.18b).

a b

Fig. 15.18 Case 2. Lateral canthoplast y and Mongoloid slant lowering. (a) A 26-year-old woman with epicanthal fold, no double fold,
and Mongolian slanting had an epicanthoplast y, double-eyelid surgery, and lateral canthoplast y with Mongoloid slant lowering. (b) After
surgery, the caruncle is more visible and her eyes look bigger and milder than before surgery.
 15
References
1. Ch o IC, ed. Th e Art of Bleph aroplast y. Seoul: Koonja; 2013
2. Baek BS, Park DH, Nah ai F. Cosm et ic an d Recon st ruct ive
Ocu loplast ic Su rger y. 3rd ed . Seou l: Koonja; 2009:29
3. Kao YS, Lin CH, Fang RH. Epican th oplast y w ith m odi ed
Y-V advan cem en t p rocedu re. Plast Recon st r Su rg 1998;
102(6):1835–1841
4. Sh in YH, Hw ang PJ, Hw ang K. V-Y an d rot at ion ap for
recon st ruct ion of th e ep ican th al fold. J Cran iofac Su rg
2012;23(4):e278–e280
5. Oh YW, Seul CH, Yoo W M. Medial epican th oplast y us-
ing th e skin redrap ing m eth od . Plast Recon st r Su rg
2007;119(2):703–710
6. Sh in YH, Hw ang K. Cosm et ic lateral can th oplast y. Aesth et ic
Plast Su rg 2004;28(5):317–320
7. Baek BS, Park DH, Nah ai F. Cosm et ic an d Recon st ruct ive
Ocu loplast ic Su rger y. 3rd ed . Seou l: Koonja; 2009:300
Epicanthoplast y and Aesthetic Lateral Canthoplast y 195
8. Hw ang K, Ch oi HG, Nam YS, Kim DJ. An atom y of arcu ate
exp an sion of cap su lop alpebral fascia. J Cran iofac Su rg
2010;21(1):239–242
9. Fox SA. Op h th alm ic Plast ic Su rger y. 5th ed. New York, NY:
Gru n e & St rat ton ; 1976:223–225
10. Von Am m on FA. Klin ish edarstellu ngen der angeh oren en
kran kh eiten u n d bildlu ngsfh ler des m en sch lich en der aug-
es u n d der augen lider. Berlin , Germ any: G. Reim er; 1841:6
11. Hw ang K, Kim DJ, Hw ang SH, Ch ung IH. Th e relat ionsh ip of
capsu lop alp ebral fascia w ith orbit al sept u m of th e low er
eyelid: an an atom ic st udy un der m agn i cat ion . J Cran iofac
Surg 2006;17(6):1118–1120
12. Park DH. Anthropom etric analysis of the slant of palpebral
ssures. Plast Reconstr Surg 2007;119(5):1624–1626
13. Hiroh i T, Yoshim ura K. Vertical enlargem ent of th e palpebral
aperture by static shortening of the anterior and posterior
lam ellae of th e lower eyelid: a cosm etic option for Asian
eyelids. Plast Recon str Surg 2011;127(1):396–406
 16 Low er Blepharoplasty
Yoon-Duck Kim and Kyung In Woo
Pearls
• Th e surgical procedure of low er bleph aroplast y
evolved from fat an d skin excision in to volum e
en h an cem en t . A cu stom ized app roach con sid ering
each pat ien t’s low er eyelid con gu rat ion is essen t ial
to th e su ccess of su rger y.
• Su rgeon s m u st discu ss w h at th ey can or can n ot do
w ith pat ien t s. Fin e or dyn am ic w rin kles, local skin
pigm en t at ion , or skin scars can n ot be addressed
w ith low er bleph aroplast y, an d th is sh ould be
ackn ow ledged to th e p at ien ts w h o w an t low er
bleph aroplast y.
• Th e surgeon sh ou ld ch oose an approach :
t ran sconjun ct ival versus t ran scut an eous. A
t ran sconjun ct ival approach is ideal for pat ien t s
w h o sh ow fat prolapse w ith out skin or eyelid laxit y.
A t ran sconju n ct ival ap p roach is also app licable
for th ose w h o don’t w an t a skin scar, w h o are
u n dergoing reoperat ion for fat prolapse, or w h o h ave
a ten den cy to d evelop hyp erp igm en tat ion on a skin
in cision site.
• Th e surgeon m ust decide h ow m uch orbit al fat
is to be rem oved or redist ributed. If tear t rough
depression is eviden t relat ive to fat prolapse,
fat redist ribu t ion is recom m en ded to avoid a
postoperat ive h ollow appearan ce. Gen tle pressure
to th e globe is h elp fu l in deciding w h eth er or h ow
m u ch fat excision is n eeded becau se lying dow n on
a su rgical t able does n ot sim u late th e con dit ion s of
sit t ing u p .
■ Introduction
Th e dem an d for bleph aroplast y am ong person s of East
Asian descen t is in creasing in the Un ited States. In a 2013
plast ic surger y stat ist ics report , Asian s/Paci c Islan ders
accou n ted for 6.2% of all cosm et ic blep h arop last y proce-
dures in th e Un ited States; th e proport ion for th is procedure
w as th e h igh est am ong all cosm et ic su rgical p rocedu res.1
For successful bleph aroplast y for Asian s, un derstan d-
ing of th e ch aracterist ic feat u res of th e eyelid is m ost
im port an t . Asian faces h ave m ore m elan in pigm en t an d
th icker skin , so th e in cision scar from surger y can be hyper-
t roph ied or hyperpigm en ted.2 Low er eyelids of Asian s are
196
• Th e surgeon m ust assess th e degree of low er eyelid
laxit y w ith a sn ap -back test or a lid dist ract ion
test an d m ust perform a h orizon tal lid t igh ten ing
procedure if th e laxit y is sign i can t en ough to a ect
postoperat ive low er lid ret ract ion .
• Du ring th e fat red ist ribu t ion procedu re, ocu lar
m ovem en t sh ou ld n ot be rest ricted on a fat
an ch oring su t u re. If th ere is m ovem en t rest rict ion ,
release th e sut ure, perform fur th er dissect ion , an d
con rm th at m ovem en t is n ot h in dered by a re-
xat ion su t u re.
• Proper h em ost asis is n eeded during orbit al fat
resect ion to avoid th e disast rous com plicat ion
of orbit al h em orrh age. Tract ion on th e fat t issue
sh ou ld be m in im ized to avoid h em orrh age from th e
deeper orbit , an d a clam p -cut-cauter y tech n ique is
recom m en ded for resect ion of th e m edial fat p ocket
h arboring relat ively large-bored blood vessels.
• Th e skin excision sh ould be con ser vat ive to avoid
low er eyelid ret ract ion during t ran scu t an eou s
bleph aroplast y. It is h elpful to h ave th e pat ien t open
h is or h er m ou th an d look up w h en th e skin excision
am ou n t is m easu red w ith a drap ing m eth od, to
m in im ize skin over-resect ion .
• Postop erat ive cau t ion sh ou ld be st ressed to th e
pat ien t to preven t orbit al h em orrh age. Cold
com pression is recom m en ded for 48 h ours, an d
avoidan ce of h ead dow n posit ion ing an d of physical
exert ion sh ou ld be em p h asized.
ch aracterized by a fuller appearan ce th an th ose of Cauca-
sian s, w h ich is cau sed by p rot ru ded orbital fat .3 Asian s h ave
heavier soft t issue an d larger am oun t s of m alar fat , w h ich
are su bjected to greater gravit at ion al force.2 Th e eyelid an d
adjacen t st ru ct u res are t igh t; som et im es w ider in cision s
an d exp osu res h ave been advocated in periocu lar su rger-
ies for Asian pat ien ts.4,5 Th erefore, preoperat ive evalu at ion ,
judiciou s skin m an ipulat ion , an d proper postoperat ive care
are im port an t to en su re a good su rgical ou tcom e for Asian
low er eyelid bleph aroplast y.
Th e con cept of aging in low er bleph aroplast y h as been
ch anged. In conven t ional th ough t , th e periocu lar aging
ch ange w as regarded as th e result of th e descen t of m idface,
un opposing, w eaken ed supp or t ing st ruct u res an d orbit al

fat p rolapse. After th e volu m e de at ion con cept w as in t ro-
d u ced in th e in terpret at ion of th e aging process, aesth et ic
ap proach es to p at ien ts h ave been m odi ed t rem en dou sly.
In th e h istorical view of su rgical m an agem en t of th e
low er eyelid aging process, th e protot yp e procedu re w as
orbit al fat excision w ith a t ran scut an eous approach . Low er
lid t igh ten ing p rocedures w ere developed to preven t or
t reat eyelid m alposit ion , w h ich w as th e m ost com m on
com plicat ion of th e conven t ion al tech n ique.6,7,8 Th e t ran s-
conjun ct ival approach subsequen tly becam e popu lar in
bleph aroplast y, as it could preven t postoperat ive eyelid
ret ract ion an d leave n o visible scar w h ile providing w id e
exposu re.9 Sin ce th e t ran sconju n ct ival app roach w as ap p li-
cable on ly to pat ien t s w h o did n ot n eed skin excision , th e
con com itan t skin pin ch tech n iqu e w as used to address th e
excess skin in t ran sconju n ct ival blep h arop last y.
How ever, for p at ien ts w h o h ad p seu doh ern iat ion of th e
fat an d tear t rough depression , rem oving low er eyelid fat
can create a con cave con tour deform it y of th e low er eyelids
an d cau se a h ollow ap pearan ce.10 In addit ion , deep en ing
of th e superior sulcu s h as been n oted after th e orbit al fat
rem oval p rocedu re.11 Th erefore, volu m e en h an cem en t h as
becom e an im por t an t issue in rejuven at ion of the low er eye-
lid . Con sequen tly, a custom ized app roach to each p at ien t is
essen t ial; th e sp eci c con gu rat ion of each pat ien t n eeds
to be assessed an d addressed.12
■ Patient Evaluation
Goldberg et al analyzed the con gurat ion of aging low er
eyelids in patien ts seeking aesth et ic surger y an d revealed
an atom ic factors con t ributing to eyelid bags.12 They assessed
patients in six anatom ic categories; tear trough depres-
a b
Fig. 16.1 Aging changes in the lower eyelid. (a) Orbital fat prolapse is prominent. Tear trough depression (black arrows) and palpebroma-
lar groove (open arrows) are noted. (b) Negative vector con guration with pseudoherniation of fat. Malar depression is noted (arrowhead).
(c,d) Oblique line (arrow) is accentuated with facial expression due to prom inent orbicularis oculi muscle.
16 Lower Blepharoplast y 197
sion w as th e m ost sign i can t con tribu ting factor, follow ed
by orbital fat prolapse, loss of skin elast icit y, eyelid uid,
orbicularis prom inence, and t riangular m alar m ound. In an
an alysis of low er eyelid aging in an Asian populat ion , Asian s
sh ow ed a ten den cy tow ard less con t ribut ion of tear trough
defect and m ore con tribut ion of fat prolapse to eyelid bags
com pared w ith Caucasian pat ien ts.13 The periocular aging
changes can be assessed by analyzing th ese categories.
Tear Trough Depression and
Palpebromalar Groove
Tear t rough depression occurs at th e in ferom edial aspect of
th e low er eyelid. With aging, th is deform it y is seen m ore
prom in en tly (Fig. 16.1). Tear t rough dep ression is kn ow n
to be ch aracterized by loss of su bcu t an eou s fat an d skin
th ickn ess along w ith th e in ferom edial orbit al rim , w h ich
is accen t uated by fat prolapse an d ch eek descen t .14 In a
m icroscopic st u dy com p aring th e you ng an d th e aged, th e
elderly in d ividuals sh ow ed sign i can t t issu e at rop hy in
variou s layers, m alar fat at rop hy an d d escen t , an d orbit al
fat bu lging.15
To correct tear t rough depression , various tech n iques
h ave been t ried, in clu d ing fat redrap ing blep h aroplast y,
variou s inject ion s, an d tear t rough im p lan ts of variou s
design s. Fat inject ion is n ot a recom m en ded procedure for
th is region becau se injected fat ten ds to leave sm all, rm
n odules of fat an d scarring, an d p rovides irregu larit y an d
sh adow s. Filler inject ion su ch as hyalu ron ic acid gel is
in creasing in th is region an d get s favorable result s; h ow -
ever, repeated inject ion s are n eeded.16
The volum e change in the tear trough area was addressed
by Ham ra w ith fat preservation blepharoplasty, w hich corre-
d
198 III Blepharoplast y
sponded to an epoch in lower blepharoplasty.10 Since then, sev-
eral m odi cations have been introduced. The procedure can be
perform ed transconjunctivally or transcutaneously, and the fat
can be transposed subperiosteally or supraperiosteally.4,17,18,19,20
To address th e palpebrom alar groove, an orbit al rim
depression of th e cen t ral to lateral region , orbital ret ain ing
ligam en t release is an im port an t step th at can be com bin ed
w ith suborbicularis oculi fat (SOOF) elevat ion or th e orbi-
cularis t igh ten ing procedure.15,19
Sin ce Asian pat ien ts h ave relat ively th icker skin an d
su bcu tan eou s t issu e at th e tear t rough or palp ebrom alar
region , th e fat resect ion p rocedure alon e can ach ieve a
good cosm et ic ou tcom e in selected cases.21
Orbital Fat Prolapse
Three orbital fat com partm ents are separated by inferior
oblique and arcuate expansion. The pockets are called m edial,
central, and lateral fat pockets. It is im portant to have the
patient look up during exam ination because the fat pockets are
m ore noticeable w hen the patient is looking up. It is also useful
to have the patient lie dow n, m im icking intraoperative state,
and to see the degree of retroposition of fat preoperatively.
Th e tot al volum es of in t raorbital fat an d fat an terior
to th e in ferior orbit al rim h ave been sh ow n to in crease
u n t il 60 years of age an d th en decrease, in a st u dy of com -
puted tom ography (CT) an alysis for Korean s.22 Th erefore,
an in crease in orbit al fat volu m e is con sidered to con t rib -
u te to low er eyelid p rom in en ce in Asian p at ien ts. As Asian
p at ien t s h ave su bst an t ially m ore prot ru ded orbit al fat ,
m any art icles h ave asserted th e im p ort an ce of fat resect ion
d u ring low er bleph aroplast y for Asian s.15 Fat rem oval w as
also st ressed in an oth er grou p , saying th at an Asian pat ien t
w ith a brach ioceph alic face m ay n ot be a good can didate
for th e fat t ran sp osit ion p rocedu re u n less it is m odi ed
by m ore fat rem oval.5 Of n ote, fat resect ion sh ould be p er-
form ed ju diciou sly, esp ecially for th e aged, to avoid a h ol-
low look postoperat ively.
Loss of Skin Elasticity
Th e low er eyelid skin sh ow s w rin kles an d grooves result-
ing from sun dam age an d su bcu t an eous volum e loss. A skin
t igh ten ing procedure is con sidered if a sign i can t am oun t
of skin laxit y is en cou n tered, in cluding surgical resect ion ,
ch em ical peeling, or laser skin resurfacing. In Asian pat ien ts,
skin er yth em a an d hyp erp igm en tat ion can resu lt from skin
su rface ablat ion t reat m en t; th erefore, care sh ou ld be taken
in deciding th e t reat m en t m odalit y for each p at ien t .23
Eyelid Fluid
If u id is accu m u lated in th e low er eyelid from system ic
or local edem a, it can m im ic fat prolapse. It can be dist in -
gu ish ed by its di u se n at u re, u ct u at ion in degree, lack of
com par t m en talizat ion , or purplish color w h en it is severe.12
Even th ough th e p resen tat ion of eyelid u id w as fou n d
to be ver y rare in a Korean st u dy, it sh ou ld be on e of th e dif-
feren t ial diagn oses of fat p rolap se in Asian p eop le.13
Orbicularis Prominence
Orbicu laris ocu li p rom in en ce also con t ribu tes to low er eye-
lid aging feat ures, w ith st at ic an d dyn am ic w rin kles. Hori-
zon t al or oblique lin es accen t uated w ith facial expression s
can be n ot iced in m any pat ien ts, an d m ay be m ore com m on
in Asian p at ien t s (Fig. 16.1c,d).13,24
Orbicu laris prom in en ce can be dealt w ith by th e orbi-
cularis oculi suspen sion procedure in bleph aroplast y.
Triangular Malar Mound
Th e t riangular m alar m ou n d is a uid sponge boun d above
by th e orbit al rim ligam en t an d below by th e orbitozygo-
m at ic ligam en t .13 Th is is relat ively rare in Asian p at ien ts.13
Position of the Globe and the
Inferior Orbital Rim
Th e relat ive posit ion of th e globe an d in ferior orbit al rim
sh ou ld be exam in ed p reop erat ively becau se th is is h elp -
fu l in d eciding w h ich p rocedu re is ap p ropriate for each
pat ien t . In th e sagit t al plan e, w h en th e an terior m argin of
th e in ferior orbital rim is posterior to th e an terior-m ost
poin t of th e corn ea, th e pat ien t h as a n egat ive vector an at-
om y (Fig. 16.1b). Pat ien t s w ith a n egat ive vector ten d to
h ave preoperat ive scleral sh ow du e to m idfacial hypopla-
sia. Sim p le excision of th e orbit al fat often leads to exacer-
bat ion of th e tear t rough depression an d in creased scleral
sh ow. Pat ien ts in th is categor y sh ou ld be con sidered for fat-
preser ving bleph aroplast y.
If th e an terior m argin of th e in ferior orbit al rim is an te-
rior to th e an terior-m ost p oin t of th e corn ea, th e p at ien t
h as a posit ive vector an atom y. For a pat ien t w ith posit ive
vector, con ser vat ive excision of fat is recom m en ded.
Low er Eyelid Laxity
Th e m ost sign i can t com plicat ion related to low er bleph -
aroplast y is eyelid m alp osit ion su ch as ret ract ion or
ect ropion .6 To preven t th ese com plicat ion s, preoperat ive
evaluat ion of th e low er eyelid laxit y is im por tan t .8
First of all, the eyelid position needs to be recorded as
m argin-to-re ex distance 2 (MRD2), w hich is de ned as the
distance from the lower eyelid to the corneal light re ex, to doc-
um ent the am ount of preoperative eyelid retraction, if present.
Eyelid laxit y can be determ in ed by th e sn ap -back test
or the dist ract ion test . With a sn ap -back test , th e restoring
force of th e low er eyelid can be assessed after dow nw ard
eversion of th e eyelid. If th e eyelid goes back to its n orm al
posit ion in st an tly, th e h orizon t al t igh ten ing procedu re
 16 Lower Blepharoplast y 199

w on’t be n ecessar y. If th e eyelid goes back after blin king, th e subconjun ct ival space an d fat pockets. Make a conju n c-
h orizon tal t igh ten ing p rocedures such as orbicu laris ocu li t ival in cision 3 to 4 m m below th e in ferior m argin of th e
su sp en sion m igh t be n eeded. If th e eyelid does n ot go back tarsus (Fig. 16.2), an d proceed to dissect tow ard th e in fe-
even after blin king, a lateral t arsal st rip p rocedure is rec- rior orbital rim u n t il th e orbit al fat p ocket s are exp osed
om m en ded to avoid eyelid ret ract ion after bleph aroplast y. (Fig. 16.3). With th is ap p roach , th ere is n o scar form at ion
With a dist ract ion test (for w ard t ract ion test), m edial on th e orbit al sept um because th e sept um is n ot violated.
an d lateral can th al ligam en t an d eyelid laxit y can be Th is ret rosept al t ran sconjun ct ival approach can avoid th e
assessed. If th e eyelid can be p u lled over 8 m m from th e com m on com plicat ion s of low er lid bleph aroplast y su ch as
corn ea w ith for w ard t ract ion of th e eyelid, a h orizon t al eyelid ret ract ion an d scleral sh ow.
t igh ten ing procedu re is recom m en ded. A preseptal t ran sconjun ct ival low er bleph aroplast y is
also p erform ed by som e su rgeon s: a conju n ct ival in cision
is m ade below th e tarsu s, dissect ion th en proceeds in feri-
Surgical Considerations in orly, an d a presept al space is assessed. Th e orbital sept um is
Asian Patients open ed to expose th e orbital fat . Propon en ts of th e presep -
tal approach suggest th at th e scar form at ion on th e sept um
For pat ien t s requiring low er eyelid bleph aroplast y, sign i - m ay bolster again st th e pseu do-h ern iat ion postoperat ively.
can t factors in th e aging process in each pat ien t sh ould be No sign i can t di eren ce in eyelid p osit ion bet w een p re-
assessed an d suggest ive su rgical m eth ods discu ssed w ith an d ret ro-sept al ap proach es h as been rep or ted.27,28
th e pat ien t .25
If a p at ien t sh ow s fairly good skin ton e, sim p le fat exci-
sion w ith th e t ran sconju n ct ival app roach is th e rst ch oice
for prim ar y eyelid bags.21,25 If a pat ien t h as redun dan t skin
an d w rin kles w ith ou t sign i can t laxit y of th e eyelid, t ran s-
conjun ct ival fat rem oval w ith pin ch skin excision or t ran s-
cut an eous fat excision bleph aroplast y can be perform ed.24
Th e orbicularis m u scle t igh ten ing procedure can be added
to t ran scu t an eou s bleph aroplast y for th ose w h o sh ow
m oderate eyelid la xit y.
If a pat ien t h as a tear t rough d ep ression an d m idface
sagging resu lt ing in sign i can t volu m e dep let ion at th e
in ferom edial orbit al rim , fat t ran sposit ion bleph aroplast y
is n eeded t ran sconju n ct ivally or t ran scu t an eously.26 If th e
p at ien t sh ow s sign i can t palpebrom alar groove, orbicu -
laris ret ain ing ligam en t release an d orbicu laris susp en sion
an d/or SOOF lift are recom m en ded.
Ph otograp h s sh ou ld be t aken p reop erat ively w ith eye- Fig. 16.2 Surgical procedure for transconjunctival fat resection
lid closed an d open an d w ith th e p at ien t looking up an d and skin resection with the pinch technique. Conjunctiva is incised
d ow n . Th ese p h otos are for legal protect ion or in case of 3 to 4 mm below the tarsus (arrowheads).
p ostop erat ive p at ien t dissat isfact ion .

■ Surgical Techniques
Transconjunctival Fat Excision
Blepharoplasty
With th e t ran sconju n ct ival ap p roach , th e in tegrit y of th e
orbicularis m uscle an d th e orbit al sept u m can be m ain -
tain ed. Equal exposu re to th e fat pads is provided w ith th e
t ran scut an eous approach , an d th e skin pin ch tech n ique is
allow ed for redu n dan t skin .

Conjunctival Incision
Before su rger y, assess th e am ou n t of prolapsed orbit al fat Fig. 16.3 Capsulopalpebral fascia and conjunctiva are pulled with
from each com p ar t m en t w h ile th e p at ien t sit s u p . Wait 15 forceps and the lower eyelid is retracted with a Desmarres retractor
m in u tes for h em ost asis after local an esth et ic inject ion in to to expose orbital fat.
200 III Blepharoplast y
Fat Pocket Exposure
In cising th e conju n ct iva an d p u lling it back w ith a low er
eyelid ret ractor, fat pocket s becom e visible, especially
m edial an d cen t ral fat p ocket s. W h en th e globe is p ressed
gen tly, th e orbit al fat can be easily accessed .28 Th ree fat
pocket s are iden t i ed w ith fascial dissect ion bet w een th e
pocket s (Fig. 16.4). Th e in ferior obliqu e m u scle, w h ich sep -
arates th e m ed ial an d cen t ral fat p ads, sh ou ld n ot be dam -
aged to avoid postoperat ive d iplopia (Fig. 16.5).
Fat Excision
A base of h ern iated orbital fat is clam p ed w ith h em o-
stat s, an d fat t issu e is cu t w ith scissors an d cau terized
w ith a bipolar cauter y (Fig. 16.6). Th e base of fat pedicle
Fig. 16.4 Gentle pressure to the eyeball facilitates fat extrusion.
Fascial tissue bet ween t wo fat pockets is visible (arrow).
a b
Fig. 16.6 (a) Medial fat pedicle is clamped with a hemostat. (b) The pedicle is excised and the cut end is cauterized for hemostasis.
is grasped w ith forceps before releasing th e clam p, an d
sh ou ld be ch ecked for bleeding on clam p release. Th e fat
pedicle can also be resected w ith a m on opolar cauter y; th e
fat p edicle sh ou ld be drap ed on a cot ton sw ab to p rotect
th e t issues below an d excised w ith a m on opolar cauter y
u sing a Colorado n eedle t ip (St r yker). Th orough h em ostasis
is im port an t . If sm all vessels in th e fat pocket ret ract an d
bleed in side th e orbit , it is h ard to n d an d t reat th e bleed-
ing focu s.
Gen tle pressu re to th e globe is h elpfu l in determ in -
ing w h eth er an d h ow m uch fat excision is n eeded becau se
lying dow n in a su rgical table does n ot represen t th e con di-
t ion s of sit t ing up. Th e am oun t of fat resect ion from each
pocket sh ould be determ in ed by ch ecking preoperat ive
ph otograph s an d in t raoperat ive obser vat ion . Th e am oun t s
of rem oved fat are com pared bet w een com par t m en t s for
sym m et r y of th e eyes. Th e conju n ct ival in cision is closed
Fig. 16.5 Inferior oblique muscle (arrow) is identi ed with dissec-
tion bet ween t wo fat pockets.

in terru ptedly w ith 6–0 plain gut or 7–0 Vicr yl (Eth icon ) in
a bu ried fash ion so as n ot to irrit ate th e eyeball.
Pinch Skin Excision
For th e pat ien t s w h o h ave redun dan t skin after t ran s-
conjun ct ival bleph aroplast y, th e excessive skin can be
addressed u sing th e pin ch tech n iqu e skin excision w h ile
preser ving th e orbicularis m uscle.29 Th is tech n iqu e is suited
to Asian pat ien t s at risk for pigm entar y ch anges w ith laser
or ch em ical peel resu rfacing.
Using t w o n e Brow n -Ad son forcep s, th e excess skin is
rm ly p in ch ed, creat ing a skin fold from th e lateral can th u s
exten ding m edially (Fig. 16.7). Th e fold form s a m axim u m
h eigh t below th e lateral can th u s, an d is t ap ered m edially
an d laterally. Th rough ou t th is p in ch ing procedu re, th e p osi-
t ion of th e low er eyelid sh ould n ot be draw n dow nw ard. If
th e eyelid posit ion is ch anged, th e am oun t of skin pin ch ed
sh ou ld be red u ced. St raigh t scissors are u sed to excise th e
skin fold, leaving th e orbicu laris m u scle in tact (Fig. 16.8).
After h em ostasis, th e skin is closed con t in uously w ith a
6–0 fast-absorbing plain gut or a 7–0 nylon sut ure.
Postoperative Care
For postoperat ive care, cold com pression is recom m en ded
for 24 to 48 h ou rs to con st rict blood vessels sh ow ing
in creased perm eabilit y from su rger y. Pat ien t s sh ou ld take
a rest w ith th e h ead elevated an d sh ou ld ch eck th eir vision
for 24 h ou rs by self-exam . Th ereafter, w arm com pression
is recom m en ded to decrease edem a an d bruising because
vascu lar perm eabilit y recovers at th at m om en t . An t ibiot ic
eye drops w ith cort icosteroid are adm in ist rated for 1 w eek.
Fig. 16.7 Excess skin is rmly pinched to create a skin fold from
the lateral canthus to the medial side.
16 Lower Blepharoplast y 201
Transcutaneous Approach
The t ranscutaneous approach can be used w hen there is
extensive skin excess, m alar bags, or festoon form at ion.
W hen concurrent lid tightening procedures are planned, the
transcutaneous approach is preferred by m any surgeons.28
After local an esth et ic is injected, a su bciliar y skin in ci-
sion is m ade 1 m m below th e lash lin e (Fig. 16.9). Sin ce a
su rgical scar over 10 m m lateral to th e lateral can th u s can
be not iceable, th e lateral exten sion sh ou ld be m in im ized to
an am ou n t ju st su itable to rem ove th e redu n dan t skin an d
orbicularis m uscle. Th e lateral por t ion of th e in cision t akes
a h orizon tal or dow nw ardly in clin ed path to th e w rin kle
lin es, keeping a m in im u m of 5 m m distan ce from th e upper
skin in cision lin e to avoid w ebbing in case u pp er blep h a-
roplast y is con com it an tly perform ed. Th en , a skin -m u scle
ap is raised an d dissected from th e orbit al sept u m u sing
blu nt an d sh arp dissect ion (Fig. 16.10). Th e th ree com p ar t-
m en t s of orbital fat are su bsequ en tly exp osed by in cising
th e sept um (Fig. 16.11). Th e orbit al fat is in lt rated w ith
th e anesth et ic solu t ion an d rem oved u p to th e am oun t
w h ere gen tle globe pressu re sh ow s th e an terior surface of
th e fat to be th e sam e as th e in ferior orbital rim level.
A sm all am ou n t of low er lid pretarsal skin can th en be
judiciously excised. It is recom m en ded th at th e su rgeon
h ave th e pat ien t look u p an d open th e m ou th w h ile d eter-
m in ing th e am ou n t of resect ion to avoid over-resect ion
(Fig. 16.12).
Buried closure w ith a 6–0 absorbable sut ure is n eeded
at the lateral can th al region to align th e skin -m u scle aps
an d to lessen skin ten sion . Skin m argin s are th en closed
con tin uou sly w ith a 7–0 nylon su t ure; m et iculous closure
is requ ired for th e lateral por t ion to m in im ize scar form a-
t ion. Th e su t u res are rem oved 4 to 5 days after surger y.
Fig. 16.8 Straight scissors are used to excise the skin fold.
202 III Blepharoplast y
Fig. 16.9 Transcutaneous lower eyelid blepharoplast y. Skin inci-
sion is made with a no.15 B-P blade.
Fig. 16.11 The fat pocket is excised with a monopolar cautery.
Fat Preservation Blepharoplasty
Fat preser vat ion bleph aroplast y is ben e cial, especially for
th ose w h o h ave n egat ive vector an d tear t rough depression .
Ham ra origin ally described a sept al reset p roced u re for fat-
preser ving bleph aroplast y, w h ich h as been m odi ed.10,20
For th e fat t ran sposit ion procedure, su rgical dissect ion
proceeds to th e in ferior orbit al rim after conjun ct ival or
t ran scut an eous in cision , an d the orbit al sept um is open ed
in feriorly. Th e m edial an d cen t ral fat pocket s are to be
t ran sposed over th e orbital rim , an d usually a lateral pocket
n eeds to be resected. After fat t ran sp osit ion , com plete sep -
tal release is recom m en ded to preven t sept al teth ering.19
Th ere are t w o approach es to fat t ran sposit ion .
Fig. 16.10 A skin muscle ap is raised and dissected.
Fig. 16.12 Excessive skin is excised judiciously while the patient
is looking up.
Subperiosteal Transposition
A su bp eriosteal app roach is claim ed to provide easier dis-
sect ion in th e su bp eriosteal p lan e, w ith less ch an ce of
bleeding an d bet ter con tour after fat t ran sposit ion com -
pared w ith th e supraperiosteal approach .17
After reach ing th e in ferior orbit al rim , a periosteal in ci-
sion is m ade w ith a m on op olar cau ter y. Su bp eriosteal dis-
section is th en p erform ed below th e in fraorbit al rim an d
lateral to th e poin t w h ere fat t ran sfer is n eeded. If excess
fat is p resen t , p art ial resect ion is p erform ed to im p rove
con touring. Sin ce orbital fat is con n ected w ith th e orbit al
fascial system –related ocu lar m ot ilit y system , care sh ou ld
be t aken n ot to cause any rest rict ion in fash ion ing fat ped-

icles. A forced du ct ion test sh ould be adm in istered before
t ran sposit ion to verify th at th ere is n o ext raocular m ot il-
it y abn orm alit y. Th en t w o m at t ress percu tan eous 4–0 or
5–0 sut ures are n eeded to secure th e fat pedicles in feriorly.
Con rm ing th e adequacy of e acem en t of th e tear t rough
by th e t ran sposed fat , th e sut ures are t ied over bolsters. Th e
su t u res an d bolsters are rem oved in 1 w eek.
Supraperiosteal Transposition
A ben e t of th e su praperiosteal approach is easier an es-
thesia an d dissect ion com pared w ith the subperiosteal
approach becau se subperiosteal dissection along th e orbital
rim is n ot easy.18
For the supraperiosteal approach , dissect ion is per-
form ed dow n to the inferior orbital rim after t ran scon -
ju n ct ival or transcu tan eou s incision . Then careful blunt
dissection is com pleted in the plane of th e suborbicularis
oculi fat (SOOF) to a level 8 to 12 m m below the orbital
rim (Fig. 16.13). Preser vation of th e zygom at ic bran ch of
the facial n er ve during dissection is essent ial; the critical
zone is a circle w ith a diam eter of 1 cm located 2.5 cm aw ay
from th e lateral can th us at an angle of 30 degree.30 If the
dissection is don e too far in feriorly, orbicularis den er vation
an d ect ropion m igh t resu lt .18 Th e vascularit y of th is plan e
necessitates proper hem ostasis; in fact, it is claim ed th at
this m ay cont ribute to in creased sur vival of the fat pedicle.18
Each fat pocket is open ed, an d th e fat is allow ed to
prolapse over th e in ferior orbit al rim . Part ial fat excision
is d on e as n ecessar y. On e or t w o m at t ress 5–0 sut ures are
ap plied to th e fat p edicle an d p eriosteu m or SOOF p ocket
Fig. 16.13 Surgical procedures of fat repositioning blepharo-
plast y. A blunt dissection is made below the orbital rim.
16 Lower Blepharoplast y 203
(Fig. 16.14). Du e to th e su p er cial p lan e of dissect ion ,
orbit al fat can be m ore apparen t or lum py after surger y.
Th is sh or t-term h arden ing of th e t ran sposed fat resolves
w ith t im e an d in t ralesion al steroid inject ion .
SOOF Lifting
Th is procedure is ver y useful for palpebrom alar groove
correct ion . A palpebrom alar groove is exacerbated by th e
descen t an d decreased volum e of th e m alar fat pads an d
SOOF. Th erefore, th e SOOF lift p roced u re along w ith an
orbicularis-retain ing ligam en t release tech n ique can ll th e
defect .19,27
Orbicularis-Retaining Ligament Release
and Orbitomalar Suspension
After reach ing th e in ferior orbital rim , th e orbicu laris-
retain ing ligam en t is released; th e at t ach m en t s of th e
orbicularis-retain ing ligam en t are liberated in feriorly an d
laterally w ith blun t dissect ion an d cut t ing cauter y in th e
preperiosteal plan e. Th e origin of the orbicularis-retain ing
ligam en t an d SOOF can be su spen ded w ith a 5–0 Prolen e
(Eth icon ) sut ure to th e su perior-m ost par t of th e lateral
orbit al rim . Th ey can also be su spen ded to th e superolat-
eral orbit al rim of th e lateral orbital w all via th e u pp er eye-
lid bleph arop last y in cision in case u pper blep h aroplast y is
perform ed sim ult an eously. More su t ure resuspen sion is
perform ed to th e presept al orbicularis in case sign i can t
orbicularis laxit y is fou n d.19
Fig. 16.14 The fat pedicle is transposed and xed to the
periosteum.
204 III Blepharoplast y
Horizontal Laxity Correction
Procedures
For pat ien t s w ith preoperat ive eyelid laxit y or eyelid m al-
posit ion such as low er scleral sh ow, a low er eyelid t igh t-
en ing p rocedu re sh ou ld be p erform ed at th e sam e t im e as
low er bleph arop last y. Am ong th e variou s m eth ods p er-
form ed for h orizon t al laxit y correct ion , som e easily appli-
cable an d e ect ive procedures are described n ext .
Orbicu laris ocu li su spen sion is an e ect ive m eth od for
th e pat ien t w ith m ild low er eyelid laxit y an d is an adjun c-
t ive procedu re to t ran scutan eous approach bleph aroplast y.
Min im ally invasive lateral can th op last y is an oth er good
procedure, on e w h ich doesn’t violate th e an atom y of th e
m u cocu tan eou s lateral can th al angle. If m ore sign i can t
low er eyelid laxit y is fou n d, a h orizon tal eyelid st rength -
en ing p rocedu re su ch as th e lateral t arsal st rip p rocedu re
is n eeded to preven t postoperat ive eyelid ect ropion or
ret ract ion .
Orbicularis Oculi Suspension
Mild h orizon t al laxit y can be add ressed by th is procedu re
w ith th e t ran scut an eous approach . After orbit al fat resec-
t ion or th e t ran sposit ion m an euver is com pleted, th e skin -
m u scle ap is drap ed an d orbicu laris m u scle su spen sion
is perform ed. Th e presept al orbicularis m u scle is sut u red
to th e periosteu m of th e lateral orbit al rim w ith a 5–0
m on o lam en t su t u re. Th e ten sion an d xat ion p oin t of th e
orbicularis sh ould be tailored so as n ot to result in lateral
can th al posit ion abn orm alit y.
Minimally Invasive Lateral Canthoplasty
Th is procedure can be added to eith er th e t ran sconjun ct i-
val or t ran scu t an eou s app roach . Th rough a sm all lateral or
stan dard u p per crease in cision for u p p er bleph aroplast y,
th e lateral orbit al rim an d th e lateral can th al ten don are
exp osed . Th en th e lateral can th al ten don is dissected from
it s p eriosteal at t ach m en t . If lateral fat is prom inen t , th e
orbit al fat pad can be debulked th rough th e sam e in ci-
sion . If eyelid laxit y is sign i can t , th e lateral low er tarsu s
is t rim m ed. A d ouble-arm ed, 4–0 absorbable su t ure is used
to re-at tach th e lateral can th u s to W h it n all’s t u bercle. After
t w o n eedles are passed th rough th e sam e spot of th e lat-
eral p ar t of th e low er eyelid at th e gray lin e, on e arm p asses
th e low er h alf of th e t arsus an d th e oth er, m ore super cial
arm p asses th e u p per t arsu s. Th e su t u res are th en t ied an d
secu red below th e crease skin in cision .31
Lateral Tarsal Strip Procedure
Th e lateral tarsal st rip procedu re is a t radit ion al m eth od
of h orizon t al laxit y correct ion . A lateral can th al in cision is
m ade, w h ich is follow ed by release of th e in ferior cru s of
th e lateral can th al ten don to m obilize th e low er eyelid com -
pletely. Th e proper am ou n t of t arsus to sh or ten is m arked
an d th e lateral t arsal st rip is m ade; th e eyelid m argin is
t rim m ed, th e low er tarsal border is severed from th e eye-
lid ret ractor, an d th e t arsal conju n ct iva is scrap ed o . Th e
tarsal st rip is resu spen ded to th e periosteum ju st in side th e
lateral orbital rim w ith 5–0 Prolen e su t u re. Lateral can th al
form ing sut ure, a buried sut ure re-align ing th e gray lin es of
th e upper an d low er eyelids, is th en placed w ith 7–0 Vicr yl.
■ Key Technical Points
1. As East Asian pat ien t s ten d to h ave th icker an d
darker skin th an Caucasian s, skin m an ipulat ion
sh ou ld be m in im ized to avoid hyp ert rop h ic scar
form at ion .
2. Skin resect ion sh ould be con ser vat ive du ring
t ran scut an eous bleph aroplast y. Having th e pat ien t
gaze u pw ard w ith th e m ou th op en is a valu able
m an euver to p reven t skin over-resect ion .
3. Orbital fat is covered w ith th in sh eath s con tain ing
blood vessels. Tract ion on orbit al fat can tear
deep orbit al vessels an d m ay precipit ate orbit al
h em orrh age.
4. Fat over-resection should be avoided. Under-corrected
fat can be addressed w ith a second procedure;
how ever, overzealous rem oval results in a hollow
appearan ce and precludes furth er corrective surger y.
5. Orbicu laris su spen sion is a useful tech n ique for Asian
pat ien t s n ot on ly for h orizon t al laxit y correct ion , bu t
also for cosm et ic ou tcom es. Th is is du e to th e ver y
large n um ber of Asian s h aving severe laxit y of th e
orbicularis m u scle an d deep skin w rin kles associated
w ith it .
6. An in t raoperat ive sit t ing posit ion for th e pat ien t
is h elpfu l to ch eck for th e presen ce of ect rop ion ,
ret ract ion , or th e presen ce of residual fat because
th ese con dit ion s can be cam ou aged in a su pin e
posit ion .
7. Th e essen t ial factors in m in im izing th e com plicat ion
of low er eyelid m alposit ion in a t ran scutan eous
bleph aroplast y are m axim izing pret arsal orbicularis,
con ser vat ive excision of low er eyelid skin, correct ing
eyelid laxit y, an d su sp en sion of th e orbicu laris
m u scle to th e lateral orbit al rim .27

■ Complications and
Their Management
Com plicat ion s of low er bleph aroplast y sh ould be preven ted
during surger y an d t reated properly if th ey occur. Th e m ost
frequ en t com p licat ion resu lt ing from low er blep h aroplast y
is eyelid m alposit ion , alth ough m ore seriou s com plicat ion s
su ch as visu al loss h ave been rep or ted.
Eyelid Retraction
Eyelid ret ract ion can resu lt from several factors related to
low er bleph arop last y. Pat ien t s w h o h ave n egat ive vector
con gurat ion are predisposed to eyelid ret ract ion , an d loss
of orbicularis m uscle fun ct ion from surgical in ter ven t ion
also con t ribu tes to th e eyelid posit ion . Fu rth erm ore, m id -
dle eyelid lam ellar sh orten ing an d t igh ten ing from surger y
also a ect low er eyelid p osit ion .32,33
As t im e elapses after surger y, eyelid sw elling an d
in am m at ion su bside an d orbicularis ton e is gain ed. Th ere-
fore, su p port ive care is im p or t an t in th e early postoperat ive
period, in cluding eyelid taping, steroid inject ion , an d th e
use of an an t i-in am m ator y agen t .
If th e ret raction is associated w ith sign i cant m iddle
lam ellar shortening and tightening, surgical inter vent ion
is unavoidable. Forced upw ard t raction testing to see if the
eyelid can be elevated w ith a surgeon’s nger is im portan t to
evalu ate th e tigh t ness in th e m iddle lam ella. In case m iddle
lam ellar con tract ure is evident , m iddle lam ellar release and
a spacer graft to relieve th e vertical tigh t n ess are n eeded.
For a m iddle lam ellar spacer, hard palate, ear cartilage, or a
cellular derm is (AlloDerm , LifeCell) is frequently used.
a b
Fig. 16.15 Ectropion complicated lower blepharoplast y on the left eye. (a) SOOF lift and lateral tarsal strip were performed to correct
anterior lam ellar shortage and horizontal laxit y. (b) Three months after surgery.
16 Lower Blepharoplast y 205
Ectropion
Ect ropion can occur tem porarily du e to low er eyelid sw ell-
ing in case of eyelid laxit y, or perm an en tly w ith th e an terior
lam ellar sh or tage from excessive skin excision (Fig. 16.15).
Ju diciou s skin excision du ring su rger y is essen t ial as a p re-
ven t ive m easu re.
If ectropion occurs a few days after surgery w ith in am -
m atory signs, upward eyelid taping and an intrafat pad steroid
injection can lessen the condition, reducing the postsurgical
in am m ation reaction. If ectropion persists, watchful waiting
w ith m assaging and use of steroid ointm ent is recom m ended
for 3 to 6 m onths before surgical correction is perform ed.
Horizon t al eyelid t igh ten ing procedu res are n eeded if
low er eyelid laxit y is sign i can t . A SOOF lift or skin graft
can be applied to an terior lam ellar length en ing. Th e SOOF
lift procedure sh ould be t ried prim arily, if possible, because
a skin graft m ay leave cosm et ic blem ish an d u n accept able
scarring in th e Asian p op u lat ion .
Asymmetric or Lumpy Appearance
Fault y est im at ion of fat prolapse preoperat ively or im proper
debu lking of fat pads during su rger y m ay resu lt in an asym -
m et ric ap pearan ce bet w een th e t w o eyelids. Residu al fat
prolapse can be corrected w ith furth er resect ion after 6 to
8 w eeks, w h ile a sun ken appearan ce can be revised w ith a
fat graft from th e con t ralateral fat p ad or elsew h ere.
A prom in en t lateral fat pad m ay be foun d after t ran s-
conjun ct ival bleph aroplast y for pat ien t s w h o h ave exces-
sive fat p rot ru sion in th e lateral fat p ad. Reresect ion
th rough a n ew, sm all skin in cision at th e lateral can th al
area m ay relieve th e lu m py ap p earan ce.
206 III Blepharoplast y
Diplopia
Dip lop ia can resu lt , tem p orarily, from sw elling of ext ra-
ocular m uscles or from e ects of local an esth et ics, w h ich
t yp ically reverse postop erat ively. If diplop ia persist s in
th e postoperat ive period, th e causes of diplopia sh ould be
assessed w ith com plete exam in at ion s.
In ferior obliqu e m u scle inju r y can resu lt from in adver-
ten t m edial an d cen t ral fat pad excision because th e m uscle
is located bet w een t w o fat p ockets. In ferior rect us paresis
an d m ech an ical rest rict ion h ave also been reported .34,35
In fat p reser vat ion blep h aroplast y, ext raocu lar m ove-
m en t abn orm alit y also h as been reported in relat ion to
fat ped icle t ran sposit ion .36 A forced duct ion test n eeds to
be perform ed after fat pedicle xat ion to avoid th is com -
p licat ion . If a rest rict ion on eyeball m ovem en t is foun d
in t raoperat ively, th e xat ion sut u re ough t to be released
an d fu rth er d issect ion sh ou ld be p erform ed. Th en a re x-
at ion su t u re is placed. If the rest rict ion is n ot iced after th e
su rger y, m ild sym ptom s w ill u su ally be relieved by ver t i-
cal forced ocular m ovem ent exercise an d w ait ing. In case
th e rest rict ion is n ot recovered, th e fat pedicle an d adja-
cen t t issues can be released or st rabism us surger y m ay be
p erform ed.34 Mech an ical oscillop sia h as also been rep orted
after t ran scut an eou s fat reposit ion ing blep h arop last y, an d
can be am eliorated by severing th e cicat rix bet w een th e
in ferior obliqu e m u scle an d th e an terior sup er cial m u s-
culo-apon eurot ic system .37
Conjunctival Chemosis
Th e m an age m e n t of p e rsist e n t conju n ct ival ch e m osis
aft e r low e r b le p h arop last y is ch alle n gin g. Low e r ble p h a-
rop last y u sin g e it h e r a t ran sconju n ct ival or a t ran scu -
t an e ou s ap p roach can be com p licat e d w it h ch e m osis.
Th ough t h e exact m e ch an ism h as n ot be e n est ablish e d ,
in crease d vascu lar p e r m eab ilit y aft e r su rge r y an d b lock-
age in lym p h at ic an d ve n ou s d rain age are con sid e re d to
e e ct conju n ct ival ch e m osis. Th e r isk fact ors for d evel-
op in g d r y eye sym p tom s an d ch e m osis w e re re p or t e d to
in crease w it h in t raop e rat ive can t h op exy, p ostop e rat ive
te m p orar y lagop h t h alm os, con cu r re n t u p p e r an d low e r
ble p h arop last y, an d t ran scu t an e ou s ap p roach es violat -
in g t h e orb icu lar is m u scle.38
In th e early p ostop erat ive period, a p ressu re patch w ith
steroid eye oin t m en t an d oral steroid m edicat ion can h elp
to lessen an in am m ator y react ion . As m ost cases recover
in several w eeks to m on th s, art i cial tear drops an d oin t-
m en t u sage are requ ired w ith ou t sp eci c t reat m en t in th e
early postop erat ive p eriod .
If ch em osis p ersists, su rgical in ter ven t ion is w arran ted .
Treat m en t s in clud ing perilim bal n eedle m an ipulat ion an d
conjun ct ivoplast y h ave been reported.39,40 High -frequen cy
radio w ave elect rosu rger y h as been p erform ed for p ersis-
ten t ch em osis, w ith en cou raging result s.41
Orbital Hemorrhage
The m ost detrim ental com plicat ion of cosm et ic blepharo-
plast y is visual loss related to orbital hem orrh age, w hich
can occur in 1 of 22,000 surgeries.42 Preoperative evalu ation
of m edicat ion histor y is im portant , and ant icoagulat ion
drugs and h erbal supplem ents should be discon tinued to
prevent th is problem . Intraoperatively, gentle m anipulat ion
is required as orbital h em orrh age can result from vascular
rupt ures in th e deeper orbit from in adverten t dragging of
the fat pedicle. Pat ients sh ould be inform ed of th e need for
em ergen cy care if orbital pain an d visual im pairm en t occu r.
Presept al h em atom a m ay occu r after low er bleph a-
rop last y an d is m an aged w ith local cold com p ression an d
h ead elevat ion w ith ou t h em atom a drain age.43 Usu ally, p re-
sept al h em atom a d oes n ot a ect visu al acu it y or th e n al
outcom e un less a ret robulbar h em atom a coexists.
Ret robulbar h em atom a can a ect vision from ret in al
vascu lar com p rom ise or opt ic n er ve com p ression du e to
in creased in t raorbital pressu re. Severe pain , exop h th alm os,
visu al im p airm en t , lim itat ion of ext raocu lar m ovem en t ,
an d in creased in t raocu lar p ressu re can be m an ifested . If
cen t ral ret in al ar ter y occlusion is detected w ith fun du s
exam in at ion , em ergen cy care sh ou ld be p rovided w ith ou t
delay, because th is is a t rue oph th alm ic em ergen cy an d is
associated w ith poor p rogn osis for visu al recover y.
If a t e n se orb it from ret rob u lb ar h e m atom a is p res-
e n t , e m e rge n t late ral can t h ot om y an d in fe r ior can -
t h olysis sh ou ld be p e r for m e d to d e com p ress t h e orbit al
p ressu re; t h e n su rgical w ou n d exp lorat ion sh ou ld b e
d on e.4 3 A syst e m ic cor t icost e roid can be ad m in ist e re d to
p reve n t or m an age isch e m ic op t ic n e u rop at h y. If visu al
acu it y is n ot regain e d , b ony orbit al d e com p ression can
b e con sid e re d .
■ Case Studies
Case 1
A 62-year-old fem ale pat ien t h ad fat prolap se an d prom i-
n en t orbicularis w ith out sign i can t skin or eyelid laxit y.
Sh e u n der w en t fat rem oval an d orbicu laris su sp en sion
w ith th e t ran scut an eous approach (Fig. 16.16).
 16 Lower Blepharoplast y 207

a b

Fig. 16.16 Case 1. Transcutaneous blepharoplast y with the orbicularis oculi suspension procedure was done in a 62-year-old female.
(a) Preoperative photo showing prominent orbicularis (arrow). (b) One year after surgery.

Case 2
A 58-year-old fem ale p at ien t sh ow ed tear t rough dep res-
sion , p alp ebrom alar groove, an d m ild orbicu laris p rom i-
n en ce. Each com pon en t w as addressed. Fat reposit ion ing,
orbitom alar ligam en t release an d SOOF lift to th e upper
part of th e lateral orbit al w all, an d orbicularis m uscle
resuspen sion w ere perform ed (Fig. 16.17).

a b

Fig. 16.17 Case 2. A 58-year-old female patient with a negative vector con guration. Fat repositioning, SOOF lift, and orbicularis m uscle
anchoring with the transcutaneous approach were performed. (a) Before the surgery. (b) One year after the surgery. A skin wrinkle line is
moved upward with this procedure (arrows).
208 III Blepharoplast y
References
1. Am erican Society of Plastic Surgeons. 2013. Plastic Surgery
Statistics Report. Available at: http://w w w.plasticsurgery.org/
Docum ents/news-resources/statistics/2013-statistics/plastic-
surgery-statistics-full-report-2013.pdf. Accessed 2015
2. Shirakabe Y, Suzuki Y, Lam SM. A new paradigm for the aging
Asian face. Aesthetic Plast Surg 2003;27(5):397–402
3. Carter SR, Sei SR, Gran t PE, Vign eron DB. Th e Asian low er
eyelid: a com parat ive an atom ic st u dy using h igh -resolu-
t ion m agn et ic reson an ce im aging. Op h th al Plast Recon st r
Surg 1998;14(4):227–234
4. Liao SL, Wei YH. Fat reposit ion ing via supraperiosteal dis-
sect ion w ith in tern al xat ion for tear t rough deform it y in
an Asian popu lat ion . Graefes Arch Clin Exp Ophth alm ol
2011;249(11):1735–1741
5. Kaw am oto HK, Bradley JP. Th e tear “TROUF” procedure:
t ran sconju n ct ival rep osit ion ing of orbital u n ip edicled fat .
Plast Recon st r Su rg 2003;112(7):1903–1907, discu ssion
1908–1909
6. McCord CD Jr, Shore JW. Avoidan ce of com plicat ion s in
low er lid blep h arop last y. Oph th alm ology 1983;90(9):
1039–1046
7. Shorr N, Fallor MK. “Madam e Butter y” procedure: com -
bined cheek and lateral canthal suspension procedure for
post-blepharoplast y, “round eye,” and lower eyelid retraction.
Ophthal Plast Reconstr Surg 1985;1(4):229–235
8. Jacobs SW. Prophylactic lateral canthopexy in lower blepha-
roplasties. Arch Facial Plast Surg 2003;5(3):267–271
9. Zarem HA, Resn ick JI. Expan ded applicat ion s for t ran s-
conju n ct ival low er lid bleph aroplast y. Plast Recon st r Su rg
1991;88(2):215–220, discussion 221
10. Ham ra ST. Arcu s m argin alis release an d orbit al fat p res-
er vat ion in m idface rejuven at ion . Plast Recon st r Surg
1995;96(2):354–362
11. Sch iller JD, Lin S, Neigel JM. Deep en ing of th e su p erior su l-
cu s after isolated low er t ran sconju n ct ival blep h arop last y.
Op h th al Plast Recon st r Su rg 2004;20(6):433–435
12. Goldberg RA, McCan n JD, Fiasch et t i D, Ben Sim on GJ. W h at
causes eyelid bags? An alysis of 114 con secut ive pat ien t s.
Plast Recon st r Su rg 2005;115(5):1395–1402, discu ssion
1403–1404
13. Lee H, Ah n SM, Ch ang M, Park M, Baek S. An alysis of
low er eyelid aging in an Asian pop u lat ion for cu stom ized
low er eyelid bleph arop last y. J Cran iofac Su rg 2014;25(2):
348–351
14. Flowers RS. Tear trough im plants for correction of tear trough
deform it y. Clin Plast Surg 1993;20(2):403–415
15. Yang C, Zh ang P, Xing X. Tear t rough an d p alp ebrom alar
groove in you ng versu s elderly adu lt s: a sect ion al an atom y
st u dy. Plast Recon st r Su rg 2013;132(4):796–808
16. Lam bros V. Models of facial aging an d im p licat ion s for
t reat m en t . Clin Plast Su rg 2008;35(3):319–327, discu ssion
317
17. Goldberg RA. Tran sconju n ct ival orbit al fat rep osit ion ing:
t ran sposit ion of orbit al fat pedicles in to a subperiosteal
pocket . Plast Recon st r Su rg 2000;105(2):743–748, d iscu s-
sion 749–751
18. Moh adjer Y, Holds JB. Cosm et ic low er eyelid blep h aroplas-
t y w ith fat reposit ion ing via in t ra-SOOF dissect ion: su rgi-
cal tech n iqu e an d in it ial ou tcom es. Op h th al Plast Recon st r
Surg 2006;22(6):409–413
19. Korn BS, Kikkaw a DO, Coh en SR. Tran scu t an eou s low er
eyelid bleph aroplast y w ith orbitom alar su spen sion : ret-
rosp ect ive review of 212 con secu t ive cases. Plast Recon st r
Surg 2010;125(1):315–323
20. Ham ra ST. The role of the septal reset in creating a youthful
eyelid-cheek complex in facial rejuvenation. Plast Reconstr
Surg 2004;113(7):2124–2141, discussion 2142–2144
21. Kim SW, Kim WS, Cho MK, W hang KU. Transconjunct ival la-
ser bleph aroplast y of low er eyelids: Asian experien ce w ith
1,340 cases. Derm atol Su rg 2003;29(1):74–79
22. Lee JM, Lee H, Park M, Lee TE, Lee YH, Baek S. Th e volu m et-
ric ch ange of orbit al fat w ith age in Asian s. Ann Plast Surg
2011;66(2):192–195
23. Rich ter AL, Barrera J, Marku s RF, Brisset t A. Laser skin
t reat m en t in n on - Cau casian pat ien t s. Facial Plast Su rg Clin
North Am 2014;22(3):439–446
24. Ren L, Yang D, Song Z, Ying L. Tran sconju n ct ival low er
bleph aroplast y for Ch in ese pat ien t s com bin ed w ith a
subciliar y in cision for skin rem oval. Aesth et ic Plast Surg
2011;35(4):677–680
25. Gu o L, Bi H, Xu e C, et al. Com p reh en sive con siderat ion s in
bleph aroplast y in an Asian populat ion : a 10-year experi-
en ce. Aesth et ic Plast Surg 2010;34(4):466–474
26. Mom osaw a A, Ku rit a M, Ozaki M, et al. Tran sconju n ct ival
orbit al fat reposit ion ing for tear t rough deform it y in you ng
Asian s. Aesth et Su rg J 2008;28(3):265–271
27. Gran t JR, Laferriere KA. Periocu lar rejuven at ion : low er
eyelid bleph aroplast y w ith fat reposit ioning an d th e
suborbicu laris oculi fat . Facial Plast Surg Clin North Am
2010;18(3):399–409
28. Peng GL, Jacon o A, Massr y GG. Globe ret ropu lsion an d
eyelid depression (GRED)—a surgeon -con t rolled, un i-
m an ual m an euver to access p ost sept al fat in t ran sconjun c-
t ival low er blep h aroplast y. Op h th al Plast Recon st r Su rg
2014;30(3):273–274
29. Rosen eld LK. Th e pin ch bleph aroplast y revisited. Plast
Recon st r Surg 2005;115(5):1405–1412, discu ssion
1413–1414
30. Hw ang K. Su rgical an atom y of th e low er eyelid relat-
ing to low er bleph aroplast y. An at Cell Biol 2010;43(1):
15–24
31. Taban M, Nakra T, Hwang C, et al. Aesthetic lateral cantho-
plast y. Ophthal Plast Reconstr Surg 2010;26(3):190–194
32. Goldberg RA. Review of p rophylact ic lateral can th opexy
in low er bleph aroplast ies. Arch Facial Plast Surg 2003;
5(3):272–275
33. McCord CD, Bosw ell CB, Hester TR. Lateral can th al an ch or-
ing. Plast Recon st r Su rg 2003;112(1):222–237, discu ssion
238–239
34. Syn iu t a LA, Goldberg RA, Th acker NM, Rosen bau m AL. Ac-
quired st rabism us follow ing cosm et ic bleph aroplast y. Plast
Recon st r Su rg 2003;111(6):2053–2059
35. Pirou zian A, Goldberg RA, Dem er JL. In ferior rect u s pu lley
h in dran ce: a m ech anism of rest rict ive hypert ropia follow -
ing low er lid su rger y. J AAPOS 2004;8(4):338–344

36. Goldberg RA, Yuen VH. Rest ricted ocu lar m ovem en t s fol-
low ing low er eyelid fat rep osit ion ing. Plast Recon st r Su rg
2002;110(1):302–305, discussion 306–308
37. Th in da S, Vaph iades MS, Maw n LA. Mech an ical oscillopsia
after low er eyelid blepharoplast y w ith fat reposit ion ing. J
Neu rooph th alm ol 2013;33(1):71–73
38. Prisch m ann J, Sufyan A, Ting JY, Ru n C, Perkins SW. Dry
eye sym ptom s an d chem osis follow ing blepharoplast y: a
10-year retrospective review of 892 cases in a single-sur-
geon series. JAMA Facial Plast Surg 2013;15(1):39–46
39. Cheng JH, Lu DW. Perilim bal needle m anipulation of conjunc-
tival chem osis after cosm etic lower eyelid blepharoplast y.
Ophthal Plast Reconstr Surg 2007;23(2):167–169
16 Lower Blepharoplast y 209
40. Jon es YJ, Georgescu D, McCan n JD, An d erson RL. Sn ip con -
jun ct ivoplast y for postoperat ive conju n ct ival ch em osis.
Arch Facial Plast Su rg 2010;12(2):103–105
41. Woo KI, Ch oi CY. High -frequ en cy radiow ave elect rosu r-
ger y for persisten t conju nct ival ch em osis follow ing cos-
m et ic bleph arop last y. Plast Recon st r Surg 2014;133(6):
1336–1342
42. Hass AN, Pen n e RB, Stefanyszyn MA, Flan agan JC. In ciden ce
of postbleph aroplast y orbit al h em orrh age an d associ-
ated visu al loss. Op h th al Plast Recon st r Su rg 2004;20(6):
426–432
43. W h ip p le KM, Korn BS, Kikkaw a DO. Recogn izing an d m an -
aging com p licat ion s in blep h arop last y. Facial Plast Su rg
Clin North Am 2013;21(4):625–637
 17 Correction of Ptosis
Woong Chul Choi and Juwan Park
Pearls
• Margin -re ex d ist an ce 1 (MRD1, distan ce from th e
corn eal ligh t re ex to th e upper lid m argin ) in a
sit t ing p osit ion is th e m ost im p or tan t param eter for
ptosis evaluat ion .
• Histor y, levator fu n ct ion test , an d m easu rem en t of
lid lag on dow n -gaze help di eren t iate bet w een
ap on eu rot ic an d congen ital ptosis.
• Levator fu n ct ion is th e m ost im port an t p aram eter
in determ in ing th e su rgical m eth od (levator
advan cem en t , fron t alis sling, etc.) an d th e m ost
reliable predictor of surgical respon se.
• Mild ptosis w ith good levator fu n ct ion can be
t reated w ith conju n ct ivo-Mü llerectom y.
• Bilateral su rger y is m ore likely to be predict able an d
reliable th an un ilateral surger y, especially in elderly
pat ien t s or pat ien t s w ith poor levator fun ct ion .
■ Introduction
Up p er eyelid ptosis is evalu ated by m argin -re ex d ist an ce
1 (MRD1), w h ich is t h e d ist an ce from t h e cor n eal ligh t
re ex to t h e u p p er lid m argin an d n or m ally ran ges from
3.5 to 4.5 m m in Cau casian s. How ever, MRD1 dep en d s on
age, sex, an d race an d ten d s to sh ow low er valu es in t h e
eld erly, m ales, an d Asian s. Un ilateral ptosis is d iagn osed
w h en on e eyelid is p osit ion ed over 2 m m low er t h an t h e
ot h er eyelid .
Th e levator p alp ebral m u scle is t h e p r im ar y u p p e r
eyelid ret ract or. Th e Mü lle r an d fron t alis m u scles are
also in volve d in lift in g t h e u p p e r eyelid . Fu n ct ion al
or an atom ic abn or m alit ies of t h e u p p e r eyelid ret rac-
tors (m ost ly t h e levator m u scle an d ap on e u rosis) are
t h e m ain reason s for ble p h arop tosis. Pat ie n t s w it h p to -
sis u su ally sh ow brow elevat ion be cau se t h e fron t alis
m u scle is ove r u se d to com p e n sate for t h e w eak p r im ar y
u p p e r eyelid ret ractor.
In con t rast to t ru e blep h aroptosis, pseu doptosis is n ot
associated w ith abn orm alit ies of th e ret ractors. Com m on
causes of pseudoptosis are con t ralateral lid ret ract ion ,
hypot ropia, en oph th alm os or con t ralateral exoph th alm os,
pu y lid in Asian s, an d derm atoch alasis (skin redun dan cy
w ith out apon eu rot ic ptosis).
210
• Th e burden factors such as redun dan t skin,
orbicularis m u scle, an d fat sh ould be addressed
because th ey can aggravate th e ptosis or cause
su bclin ical ptosis.
• St ru ct u ral w eakn ess an d th e pretarsal fat pad are
m ore easily seen in th e m edial part am ong eld erly
East Asian s, an d an e or t to overcom e th ose factors
is required for bet ter resu lt s.
• Addit ion al p rocedu res to form a lid crease after
ptosis correct ion are usually required for a du rable
lid crease form at ion in Asian pat ien t s.
• Met icu lou s h em ostasis an d in t raop erat ive
cooling are h elpfu l in im proving th e accuracy of
in t raoperat ive adjust m en t .
• Asym m et r y after ptosis repair can be xed in th e
early postop erat ive p eriod of a w eek or so.
■ History of Ptosis Surgery
Ptosis surger y has show n m any revolut ionar y changes as
our know ledge of anatom ic and physiologic processes h as
expanded. In addit ion, expansion of the variet y of m ateri-
als h as revolut ion ized th e eld of ptosis surger y sin ce its
an cien t h istor y. Referen ces sh ow th at th e earliest t reat-
m en ts w ere perform ed by an cien t Arabian oph th alm olo-
gists. More recen t descript ion s w ere provided by Scarpa, an
Italian an atom ist and su rgeon, in 1806.1,2 How ever, th e refer-
en ces from th e early days regarding th e treatm en t of ptosis,
resecting the upper part of the eyelid, were insu cient and
of only tem porar y relevance. Therefore, altern ative w ays to
elevate th e eyelid had to be researched an d developed.
Th e levator m uscle an d apon eurosis, Mü ller’s m uscle,
an d th e fron t alis m u scle are th e u pp er lid ret ractors th at
are th e prim ar y t issu es targeted du ring ptosis su rger y.
Ptosis surger y restores or rein forces th e n at ural pow er
of th e eyelid ret ractor m uscles (levator m uscle or Mü ller
m u scle resect ion ). It can also produ ce n ew m ech an ical
lift ing p ow er (front alis suspen sion ) w ith or w ith out an cil-
lar y procedures to sh or ten th e eyelid length or to redu ce
th e burden factors (t arsus, skin , an d fat resect ion ). Surgical
tech n iqu es along w ith an atom ical discoveries an d surgical
m aterials h ave developed as follow s.

Frontalis Sling
Dran sart adapted exogen ou s m aterial as a su spen der an d
ap plied it to bu ried catgu t su t u res in 1880. Hess in t rod u ced
a tem p orar y p lacem en t of silk su t u re in 1893.3,4 De Wecker
em ployed th e rst au togen ou s sling w ith a com bin at ion of
skin , orbicu laris m u scle, an d silk su t u re as a su sp en der.5
In 1909 Payr in t rodu ced a th igh fascia th at m arked a
sign i can t advan ce in fron t alis slings an d st ill rem ain s
on e of th e gold st an dard m aterials.5 Yasu n a described a
fron t alis sling u sing cadaveric fascia lata, w h ich received
exten sive at ten t ion du ring th e 1970s.6,7,8,9,10,11 In 1966 Til-
let recom m en ded th e u se of silicon e st rip s, w hich received
fu rth er at ten t ion an d are st ill in u se. In 1986 An derson sug-
gested th at sling m aterial be p laced beh in d th e sept u m .
Th is resulted in a m ore cosm et ically accept able appearan ce
an d a m ore n at u ral-looking lid crease.12
Levator Muscle and Aponeurosis Repair
Levator su rger y did n ot gain p op u larit y u n t il th e en d of th e
19th cen t u r y. More reliable altern at ives such as th e fron t a-
lis sling w ere preferred. It w as Bow m an w h o t argeted th e
ret ractor m uscle in stead of w eaken ing th e prot ractor m us-
cle for th e rst t im e.13 In 1857 h e resected both th e levator
m u scle an d th e t arsu s u sing an in tern al/extern al ap proach .
In terest in levator su rger y w as revived w ith th e in t ro-
duct ion of an extern al approach , levator t ucking, by Ever-
busch an d levator apon eurosis resect ion by Sn ellen in
1883.14,15 In 1896 Wol devised a procedure for isolat ing,
m obilizing, an d advan cing th e levator m u scle.16 On th e
oth er h an d, Blaskovics suggested an in tern al ap p roach w ith
excision of th e t arsu s an d levator in 1909.17
In terest in th e extern al ap p roach w as con t in u ed by
Jon es, w h o devised a su rger y th at advan ces th e levator
ap on eu rosis w h ile preser ving Mü ller’s m u scle in 1960.18
An d erson , a great invest igator of levator su rger y, p u blish ed
h is w ork exten sively on eyelid an atom y an d levator ap o-
n eu rosis su rger y in n eu rom yop ath ic, involu t ion al, an d m ild
cases of congenit al ptosis, m aking th e 1980s “th e Age of
Ap on eu rot ic Aw aren ess.”19,20,21,22 Du ring th is period, variou s
tech n iqu es w ere in t rodu ced, in cluding th e m an n er of apo-
n eu rot ic rep air, th e n u m ber of xat ion su t u res, adju stable
su t u re tech n iqu es, an d altern at ives in th e size or locat ion of
th e in cision m ade by a variet y of in st rum en t s.21,22,23,24
Müller Muscle Surgery
Conju n ct ival t arsal Mü llerectom y, oth er w ise kn ow n as
th e Fasan ella-Ser vat procedure, w as in t rodu ced in 1961.25
It w as regarded as a t ype of levator resect ion in it ially bu t
w as later u n derstood to w ork du e to it s act ion on Mü ller’s
m u scle. In 1972 Pu t term an devised a clam p an d rep orted
17 Correction of Ptosis 211
a m odi cat ion th at resect s Mü ller’s m u scle an d conju n c-
t iva w h ile sparing th e t arsus (Mü ller’s m uscle conjun ct iva
resect ion , or MMCR).26,27
To avoid corn eal irrit at ion by sut ures, Lauring reported
a sut u reless Fasan ella-Ser vat operat ion an d Bodian u sed
extern al secu ring w ith 5–0 nylon su t u re.28,29,30 W h ile Wein -
stein d escribed a m arking su t u re to m ore easily isolate
Mü ller’s m u scle an d p lace th e Pu t term an clam p , Ili in cor-
porated levator apon eu rosis in to th e operat ive site w ith a
Fasan ella-Ser vat-like approach .31,32
■ Patient Evaluation
In blep h aroptosis evalu at ion , n ot on ly t h e lid bu t also t h e
w r in kles on t h e foreh ead , h eigh t of bot h eyebrow s, an d
t h e p resen ce of lid crease sh ou ld be evalu ated . If t h ere is a
lid crease, ch ecking w h et h er t h e crease is d ist in ct or m u l-
t ip le is n ecessar y. Occasion ally, ptosis is m asked by redu n -
dan t eyelid skin or fat bu lge, lead ing to an ap p aren t ptosis
after sim p le u p p er blep h arop last y. Moreover, in p at ien t s
w h o h ave ptosis in t h e d om in an t eye, t h e ot h er eye m igh t
h ave ret racted d u e to Her in g’s law . Th erefore, it is im p or-
t an t to evalu ate t h e p at ien t carefu lly p r ior to t h e su rger y
to d etect any m asked p roblem s an d t h u s red u ce t h e rate
of revision .
An atom ic st ruct u res of Asian lids w ith out creases
(low er orbit al sept u m –levator fu sion level w ith p re-apo-
neurot ic fat h anging over th e tarsal plate; m ore prom in en t
su bcu tan eou s, su bderm al, su borbicu laris, an d pretarsal
fat; an d low er p rim ar y in sert ion of th e levator ap on eu ro-
sis on to th e u p per lid derm is) in terfere w ith eye open ing
an d can be regarded as a categor y of ptosis.33 By rem oving
th ose burden factors in stead of doing levator surger y, th e
su rgeon can obt ain excellen t cosm et ic im provem en t on a
pu y, sm all, an d droopy Asian lid.
History Taking and
Physical Examination
In severe u n ilateral ptosis, th e eyebrow on on e sid e can be
elevated relat ive to th e oth er w ith predom in an t foreh ead
w rin kles. In addit ion to th e pat ien t’s h istor y an d age, u pper
lid lag is a h elpful clue in dist inguish ing congen ital ptosis
from ap on eu rot ic ptosis. If a dow n -gaze m akes on e eyelid
bigger th an th e oth er, or if an up -gaze m akes th e eyeball
hide beh in d th e upper eyelid, congen ital ptosis w ith poor
levator fu n ct ion can be suspected (Fig. 17.1). Su ch a p h e-
nom en on occu rs because of th e levator m uscle’s in h eren t
in abilit y to relax du e to dysgen esis an d brofat t y degen -
erat ion . Pat ien t s w ith apon eu rot ic ptosis can h ave a deep
su p erior su lcu s du e to th e ret ract ion of th e pre-ap on eu -
rot ic fat pad. Th e lid crease of an eye w ith ptosis get s h igh er
due to th e levator’s st retch or deh iscen ce (Fig. 17.2).
212 III Blepharoplast y
a b
Fig. 17.1 Congenital ptosis. This 13-year-old boy who has (a) right congenital ptosis (b) shows poor levator function on up-gaze and
(c) lid lag on down-gaze.
Fig. 17.2 Aponeurotic ptosis. This 65-year-old female has apo-
neurotic ptosis of the right eye and shows right eyebrow elevation,
multiple lid creases, and a deep superior sulcus.
Sin ce Asian s often h ave m ed ial ep ican t h al fold s,
m ed ial ep ican t h op last y can be p er for m ed at t h e sam e
t im e as t h e ptosis su rger y. It is essen t ial to t ake p h otos
before t h e su rger y for d ocu m en t at ion , review, ed u ca-
t ion , an d m edicolegal p u r p oses. Pat ien t s n or m ally d o n ot
rem em ber t h eir p reop erat ive feat u res. By com p ar in g t h e
p reop erat ive an d p ostop erat ive p h otos, t h e resu lt s of t h e
su rger y can be object ively an alyzed an d evalu ated . Th is
h elp s to est ablish t r u st bet w een t h e p at ien t an d t h e su r-
geon . W h en t h e p at ien t com p lain s, review t h e p h otos; if
som et h in g is fou n d lackin g, d iscu ss it w it h t h e p at ien t an d
con sid er p er for m ing a revision su rger y for bet ter resu lt s.
If a p at ien t d oes n ot w an t p h otos to be t aken before t h e
su rger y, t h e op erat ion sh ou ld be recon sid ered . Ph otos are
t aken w h ile t h e p at ien t is looking ah ead , u p , an d d ow n . To
ch eck t h e con dit ion s of t h e eyelash es, ad d it ion al lateral
view p h otos sh ou ld be t aken . If t h ere are any im p or t an t
or u n iqu e occu r ren ces du r ing t h e su rger y, in t raop erat ive
p h otos sh ou ld be t aken as w ell. To evalu ate t h e p rogress
of t h e su rger y, p h otos are t aken 1 w eek, 1 m on t h , an d 3
m on t h s after t h e su rger y.
c
Diagnosis of Ptosis
It is im p or t an t to m easu re t h e MRD an d levator fu n ct ion
to obt ain p rop er evalu at ion s. MRD1 is kn ow n to be t h e
m ost p red ict able m easu rem en t for p tosis evalu at ion .34
MRD1 m u st be exam in ed w it h t h e p at ien t in a p r im ar y
p osit ion w it h n o excessive u se of t h e fron t alis m u scle or
orbicu lar is m u scle. For an accu rate exam , a ligh t sou rce (a
p en ligh t or ash ) m u st be p osit ion ed at t h e sam e h e igh t
as t h e p at ien t ’s eyes. MRD1 is t h e d ist an ce from t h e cor-
n eal ligh t re ex to t h e u p p er eyelid m argin , n ot t h e h an g-
in g skin m argin . If t h e h an gin g u p p er lid skin is cover in g
t h e u p p er lid m argin of a p at ien t w it h d e r m atoch alasis,
t h e skin sh ou ld be ge n t ly p u lled u p an d t h e lid m argin
sh ou ld be obser ved d u r in g t h e exam . MRD2 (d ist an ce
from t h e cor n eal ligh t re ex to t h e low e r lid m argin )
d ep en d s on t h e p osit ion of t h e low er lid . Th e su m of t h ese
t w o is t h e in ter p alp ebral ssu re (IPF).
Th e levator fu n ct ion is d eter m in ed by m easu r ing
t h e excu rsion of t h e eyelid m argin , or t h e tot al d ist an ce
t raveled by t h e lid m argin from dow n -gaze to u p -gaze.
A n or m al levator fu n ct ion is ~ 15 m m . Levator excu rsion
is con sid ered to be p oor w h en t h e d ist an ce is less t h an
4 m m , m oderate w h en t h e d ist an ce is bet w een 5 an d 10
m m , an d good w h en t h e d ist an ce is above 10 m m . To p re-
ven t fron t alis recr u it m en t d u r in g t h ese m easu rem en t s,
it is advisable to eit h er h ave t h e foreh ead lean in g on a
su p p or t bar or u sin g on e’s h an d s to h old t h e foreh ead .
By u sin g a r u ler at t ach ed to t h e sid e bar of t h e slit lam p ,
t h e valu es of MRD1, IPF, levator fu n ct ion , an d lid lag are
record ed in d et ail (Fig. 17.3). Usin g t h ese kin d of reliable
record s to object ively exp ress p at ien t s’ st at u s often bu ild s
p at ien t s’ t r u st .
Th e m ost com m on clin ical ptosis occurs from st retch -
ing an d deh iscen ce of th e levator apon eurosis. Typical apo-
n eu rot ic ptosis is fou n d in cases of frequ en t eye ru bbing
due to atopy or w earing con t act len ses for a long t im e, an d
sen ile ch anges du e to aging. Sim ilar cases can be fou n d in
pat ien t s after oph th alm ic surger y, t raum a, or frequen t lid
 17 Correction of Ptosis 213

a b

Fig. 17.3 Measuring MRD1, MRD2, IPF, and levator function. (a) Precise measurements of levator function using a ruler at tached to the
slit lamp. (b) The blue line is MRD1, and the yellow line is MRD2. The sum of these t wo is IPF.

sw elling.35,36 Gen eral clin ical ch aracterist ics of apon eurot ic
ptosis in clude
• Eyebrow elevat ion of th e a ected eye
• Deep su p erior su lcu s
• High er or m u lt ip le lid creases
• Lid drooping
• Good levator fu n ct ion
Th e lid crease h eigh t is th e dist an ce bet w een th e lid m argin
an d th e crease form ed by th e at t ach m en t of levator ap o-
n eu rosis bers to th e su bcu t an eou s t issu e. Th is can var y
am ong races an d by sex. Lid crease h eigh t m ay in crease
in sit uat ion s of ptosis ow ing to apon eurot ic deh iscen ce.37
Levator fu n ct ion in p at ien t s w ith ap on eu rot ic ptosis is
good in gen eral. How ever, if th e levator apon eu rosis tot ally
det ach es from th e t arsal plate, th e levator fun ct ion w ill
be ver y poor.38 Th is is especially t rue for elderly pat ien t s
w h o h ave h ad oph th alm ic surger y several t im es an d w h ose
levator apon eurosis is often totally det ach ed from th e tar-
sal plate (Fig. 17.4).
Most apon eu rot ic ptosis resu lts from aging an d is com -
m on ly detected in elderly pat ien t s. On th e oth er h an d, con -
gen ital ptosis is th e m ost com m on t yp e in ch ild ren . Un like
ap on eu rot ic ptosis, congen ital ptosis sh ow s poor to fair
levator fu n ct ion an d lid lag on dow n -gaze due to th e loss of

a b c

Fig. 17.4 (a–c) Poor levator function in aponeurotic ptosis. This 72-year-old
female shows very poor levator function on upward gaze and severe lid drooping
on downward gaze. (d) Operative dissection shows a total detachment of the
d levator aponeurosis from the tarsal plate.
214 III Blepharoplast y
levator m u scle elast icit y. In som e cases, in com plete lid clo-
su re (lagop h th alm os) is also presen t . Th e h istologic n d -
ing of congen it al ptosis is dyst rophy of th e st riate m u scle
bers.39 Som e pat ien t s w ith m ild congen ital ptosis are n ot
d iagn osed t ill adu lth ood.
Contact Lens–Induced Ptosis
Prolonged con t act len s u sage is w ell kn ow n to poten t ially
cause acquired ptosis.40,41 Th e clin ical feat ures of apon eu -
rot ic blep h aroptosis in du ced by th e u se of con t act len ses do
n ot d i er from th ose related to oth er cau ses. Con t act len s-
in du ced ptosis can be caused by an allergic react ion to th e
p reser vat ives in th e con t act len s solut ion , t arsal conjun ct i-
val irritat ion by th e con t act len s edge, an d levator ap on eu -
rosis dam age by p hysical op en ing of th e eyelid for con t act
len s placem en t . Ptosis in duced by h ard con t act len ses is
caused by brosis of th e Mü ller m u scles.42
In m ost cases of con tact len s–in du ced ptosis, th e leva-
tor apon eu rosis is con n ected to th e tarsal p late sin ce su r-
geries are p erform ed in you ng an d m iddle-aged pat ien t s.
Tem porar y ptosis caused by con t act len s usage is t reated by
prohibit ing th e use of con t act len ses an d prescribing an t i-
in am m ator y eye drop s to redu ce conjun ct ival sw elling.
Alth ough d eh iscen ce or rarefact ion of th e levator apon eu -
rosis is m ore often foun d in pat ien t s w ith con t act len s–
in duced ptosis, gross n dings of ap on eurot ic disin sert ion
or defect s can be obser ved (Fig. 17.5).
Phenylephrine Test
It w as Dort zbach w h o fou n d th at a p h enylep h rin e test is
u sefu l to p red ict th e postoperat ive lid posit ion after Mü l-
ler’s m uscle resect ion .43 A d rop of 10% or 2.5% p h enylep h -
Le vat or ap one urosis
Mü lle r m uscle
Sup e rior b ord e r
of t arsal p lat e
Fig. 17.5 Contact lens–induced ptosis. This 53-year-old female
has a history of 40 years of hard contact lens wearing. Operative
ndings show levator aponeurosis disinsertion from the tarsal plate.
rin e is in st illed in cases of m ild ptosis w ith good levator
fu n ct ion . On ce th e eyelid goes u p to a n orm al p osit ion , it
is regarded to be a good can didate for a conjun ct ivo-Mü l-
lerectom y. Th is m eth od is advan t ageous for pat ien ts w h o
n eed u n ilateral surger y an d do n ot w an t skin excision or
any ch an ce of get t ing a skin scar.
■ Preoperative Considerations
Eye Protective Function
Sin ce ptosis surger y basically pulls th e upper lids upw ard,
lagoph th alm os m ay occur tem p orarily in th e early p ost-
operat ive stage or becom e perm an en t . To avoid th is com -
plicat ion , on e sh ould ch eck th e pat ien t’s eye protect ive
m ech an ism s an d in form th e p at ien t of in evit able p roblem s
su ch as lid lag an d lagop h th alm os. Con dit ion s su ch as sig-
n i can t dr y eye syn drom e, facial palsy, dysfu n ct ion of th e
su p erior rect u s m u scle, an d absen ce of Bell’s ph en om en on
m u st be ch ecked prior to th e su rger y. If th e protect ive fu n c-
t ion is w eak or absen t , overcorrect ion sh ould be avoided.
Visual Field Test
A visu al eld test is often n eeded for in su ran ce coverage
purposes in th e Republic of Korea. Surger y on a droopy
u pp er lid blocking th e pupil is covered by in suran ce th ere.
Hering’s Law and Latent Ptosis
Th e levator m uscles are yoke m uscles, w h ich en able th em
to w ork in syn ch rony w ith each oth er. As a resu lt , a er-
en t inp u t from on e eyelid can a ect th e p osit ion of both
eyelids. W h en th e degree of ptosis di ers bet w een th e t w o
eyes, th ere is an excessive n er ve im pu lse to open th e m ore
ptot ic eye. Due to Hering’s law, th e less ptot ic eye w ill seem
like a n orm al eye. How ever, th is eye w ill sh ow a droop ing
ph en om en on (laten t ptosis) after surger y on th e eye w ith
m an ifest ptosis.44,45,46 There is a low er inciden ce of bleph a-
roptosis in th e dom in an t eye an d a h igh er in ciden ce of
p ostoperat ive con t ralateral eyelid droop w h en th e dom i-
n an t eye is ptot ic. Th ese n dings su p port th e hyp oth esis of
in creased in n er vat ion to th e dom in an t eye.47
Hering’s law dependence can be assessed by gentle
m echanical elevation of the ptotic eyelid w ith the patient’s
eye xed on a distant target. The contralateral eyelid is then
assessed for any changes in position. Any decrease in the MRD1
can be considered as a positive test, and the new MRD1 should
then be docum ented. If there is no change in the eyelid posi-
tion after 30 seconds, the test is considered to be negative.48
An oth er m eth od to d iagn ose laten t ptosis is to occlu de
th e ptot ic eye for m ore th an 15 secon ds an d in st ill 10% or
2.5% ph enyleph rin e to th e ptot ic eye. If th e opposite eyelid
droops at th is t im e, it is bet ter to correct both eyelids.

Desp ite a n egat ive Hering’s test , th ere are p at ien ts w h o
st ill develop a postop erat ive decrease in th eir MRD an d
resu lt ing ptosis.43,44,45,46,47,49
Unilateral or Bilateral Surgery?
In patients w ith asym m etric or unilateral ptosis, latent ptosis
of the norm al-appearing eye should be identi ed by elevat-
ing, closing, or instilling phenylephrine to the ptotic eye. Any
decrease in the contralateral lid position is considered to be a
positive test. In such a case, the patient should be inform ed of
the increased likelihood of postoperative ptosis in the contra-
lateral eye, and bilateral ptosis surgery should be considered.44
W h en th ere is n o laten t ptosis in th e opposite eye after
th e screen ing test s, you can correct on e side on ly. In cases
of un ilateral surger y, 1.0 to 2.0 m m of overcorrect ion is
n eeded com p ared w ith th e n onptot ic eye. Th is is don e both
to com p en sate for th e e ect of local an esth et ics m ixed w ith
ep in ep h rin e to p aralyze th e orbicu laris m u scle an d st im u -
late th e Mü ller m uscle, an d to coun teract th e postopera-
t ive fall after ptosis repair. How ever, bilateral ptosis su rger y
provides fun ct ion al an d cosm et ic advan t ages because a
pat ien t w ith un ilateral ptosis an d a n egat ive Hering’s test
m ay develop postoperat ive con t ralateral ptosis.
Direction of the Eyelashes
Harrison categorized th e direct ion of eyelash es in to fou r
t yp es (n orm al, m ild, m od erate, severe) in Cau casian s.50 Bu t
th e eyelash es of Korean s are usu ally classi ed in to grades 1
to 5, w ith 15-degree in crem en t s in each grade (Fig. 17.6).
Grade 1 is w h ere eyelash es p rot ru de perp en dicu larly to th e
ver t ical p lan e of th e face. Grade 5 is th e case w h ere th e eye-
lash es are p osit ioned 60 degrees dow nw ard.
Lash ptosis is m ore com m on ly n oticed in ptot ic eyes
than in norm al ones,51 an d th us it should be veri ed that
the lash ptosis has been corrected by obser ving the direc-
t ion of the eyelashes at the end of the surger y. Sat isfactor y
postoperat ive results can be con rm ed by checking th e lash
direct ion in the supine position , w here it should appear
sligh tly over-corrected, in stead of ch ecking it in th e sit ting
posit ion during the operat ion. It is fairly com m on for m edial
lash ptosis in Asians to be aggravated by epican th al folds as
w ell as by loosen ing of m edial st ruct ures such as m edial
pretarsal m uscle at tachm ents to the tarsus. Therefore, addi-
t ion al at tent ion to m edial lash ptosis is required, and if nec-
essar y, m edial epican thoplast y w ith a preferred tech n iqu e
to reduce the burden factor should be considered.
Selection of Repair Method
In gen eral, th ere are th ree t ypes of su rger y in ptosis correc-
t ion : (1) levator surger y—t ucking, advan cem en t , resect ion ;
(2) conjun ct ivo-Mü llerectom y (MMCR or th e Fasan ella-
Ser vat p rocedu re); an d (3) th e fron talis sling.
17 Correction of Ptosis 215
1 15°
2
3
4
5
Fig. 17.6 Grading of lash ptosis in Koreans. Grades have a
15-degree di erence.
Alth ough levator su rger y is th e m ost p opu lar tech n iqu e
to correct ptosis, on e sh ou ld con sider p erform ing a fron t a-
lis sling if th e levator fu n ct ion is p oor (LF < 4 m m ). MMCR
can be ch osen for pat ien t s w ith m ild ptosis an d good leva-
tor fu n ct ion (LF > 10 m m ). In t raoperat ively, th e con d it ion
of the levator is exam in ed from t arsal plate to W h it n all’s
ligam en t , regardless of th e levator fun ct ion an d ptosis
degree. In a case w h ere it is h ard to expect good resu lt s due
to severe fat t y degen erat ion an d brot ic ch anges, im m edi-
ate conversion to a fron t alis sling is advised. Th erefore, in
case of severe ptosis or poor levator fu n ct ion , th e surgeon
sh ould d iscu ss w ith th e p at ien t p reop erat ively th e pos-
sibilit y of ch anging th e su rgical p lan . Even th ough som e
pat ien t s w orr y about scarring above th e eyebrow, scar is
usu ally n ot a m ajor con cern sin ce it w on’t be n ot iceable 2
to 3 m on th s after th e su rger y.
■ Surgical Techniques
Instruments
In st ru m en t s u sed in clu de a calip er, Wescot t an d Steven s
scissors, n e t issu e forceps, locking n eed le h older, an d
st raigh t h em ostat (Fig. 17.7).
Preoperative Preparation
Th e auth ors design th e in cision lin e preoperat ively w ith
th e pat ien t in a sit t ing posit ion . After m akeup rem oval, th e
desired in cision lin e is m arked, using a n e m arking pen ,
216 III Blepharoplast y

Fig. 17.8 Surgical techniques of ptosis correction. With a lid

crease maker and a very ne marking pen, the lid crease line is
designed where the patient wants it.

Fig. 17.7 Instrum ents used in ptosis surgery: Castroviejo caliper,

6–0 nylon suture material, straight hemostat, Castroviejo needle
holder, Westcot t tenotomy scissors, Adson micro tissue forceps,
Castroviejo suturing forceps, surgical blade holder (in a clockwise
direction from the left upper corner).
w h ere th e pat ien t w an t s h is or h er eyelid crease (Fig. 17.8).
If th e p at ien t h as ptosis in on e eye, th e lid crease lin e is
m ade 0.5 m m sm aller on th e eye w ith ptosis sin ce th e
u pp er lid level w ill go dow n as t im e goes on .
Anesthesia
Th e an atom ic st ruct ure th at is foun d after th e skin in cision
is th e orbicularis m uscle. An orbicularis m u scle st ran d is
rem oved to approach th e orbital sept u m (Fig. 17.10). W h en
excising th e orbicu laris m u scle, an obliqu e su p erior direc-
t ion sh ould be used to preven t levator apon eu rosis injur y.
Th e n ext st ru ct ure th at can be obser ved is th e orbit al sep -
t um (Fig. 17.11).
Dissection
Th e surgeon an d an assist an t sh ould h old th e in ferior ap
an d su p erior aps w ith n e t issu e forcep s an d ap p roach th e
sept u m carefu lly to avoid any dam age to th e levator apo-

Ptosis su rgeries can be perform ed using local an esth esia for

adu lts. If th e p at ien t is too n er vou s, in t raven ou s sedat ive
m edicin e su ch as m idazolam (dosage based on pat ien t’s
age an d w eigh t) can be adm in istered. Th e sam e an esth e-
sia th at is u sed for a d en t al p roced u re, con sist ing of a m ix-
t ure of 2% lidocain e an d 1:100,000 epin eph rin e, is used.
If th e su rger y is exp ected to take longer, bu p ivacain e can
be added. How ever, it is usually en ough to use lidocain e
m ixed w ith epin eph rin e, as ptosis su rger y u su ally does n ot
take too long. W h en local an esth esia is perform ed, inject
slow ly from th e lateral side u sing a n e 30-gauge n eedle
(Fig. 17.9). Norm ally 1.0 to 1.5 m L p er eyelid is injected.

Incision
Th e surgeon uses th e ngers to st retch th e eyelid out w ard
an d in cises th e skin in on e sm ooth step u sing a Bard-Parker Fig. 17.9 Injection of local anesthetic subcutaneously with a
(Aspen Su rgical) n o. 15 kn ife, to avoid a zigzag in cision . 30-gauge needle from the lateral side.

Fig. 17.10 Removal of the orbicularis muscle strand with West-
cot t scissors.
n eu rosis. Th e n ext st ru ct u re ben eath th e orbit al sept u m is
th e pre-apon eurot ic fat . If th ere is di cult y in n ding th e
fat , th e eyeball can be gen tly p ressed w ith a nger from th e
low er eyelid. Th en th e fat w ill bu lge out . Th e surgeon n eeds
to rem ove on ly th e fat th at n at urally com es out at th is t im e
(Fig. 17.12). A deep su p erior su lcu s w ill resolve after th e
ptosis correct ion becau se th e eyebrow s w ill go dow n after
th e surger y, except in cases of severe fat de cien cy. Sau -
sage deform it y, w h ich m igh t occu r after th e su rger y, can
be preven ted by rem oving th e pretarsal orbicularis m uscle.
Th is procedure sh ould especially be perform ed on Asian s,
w h o h ave ver y th ick eyelids. After th e su rgeon lift s th e
ap on eu rosis, w h ich is loosely at t ach ed to th e an terior tar-
sal su rface, an d delam in ates it u sing scissors in an u pw ard
d irect ion up to th e su perior tarsal border, th e p eriph eral
p alp ebral arcad e can be obser ved, w h ich run s on th e Mü l-
ler m u scle (Fig. 17.13).
Fig. 17.12 After opening of the septum, bulging fat is clamped
with a hemostat and resected.
17 Correction of Ptosis 217
Fig. 17.11 After removal of the orbicularis muscle, the orbital
septum is revealed.
If the surgeon needs m ore levator advancem ent, then
the aponeurosis can be further delam inated up to the level
of W hit nall’s ligam ent. The Mü ller m uscle tends to bleed, so
you sh ou ld coagulate th e vessels carefully to preven t bleed-
ing before dissection (Fig. 17.14). If cauter y of th e Mü ller
m uscle is con ducted w ith a corn eal protector in place, it w ill
not cause inadvertent th erm al dam age to the cornea. Alter-
nat ively, th e surgeon should pull the eyelid up w ith forceps
to distan ce it from th e corn ea before u sing th e cauter y.
Fixation of Levator-Müller
Muscle Flap
W h en perform ing a levator advan cem en t , th e su rgeon
sh ou ld sep arate th e levator ap on eu rosis rst from th e tar-
sal plate, an d th en from th e Mü ller m u scle w ith Westcot t
Fig. 17.13 Dissecting the levator aponeurosis up to the superior
border of the tarsal plate after lifting the levator aponeurosis that is
loosely at tached to the tarsal plate.
218 III Blepharoplast y
Fig. 17.14 Dissecting a larger portion of the levator aponeurosis.
scissors w h ile carefu lly cau terizing th e large vessels in th e
Mü ller m u scle. Th e su rgeon can advan ce th e levator-Mü ller
com plex 3 to 4 m m , at t ach ing it to th e superior t arsal bor-
d er m edial to th e pup il rst an d th en lateral to th e lim bus
u sing 6–0 n on absorbable su t u re m aterial. Th e rst su t u re
sh ou ld be placed m edially to th e pu p il. Th is area is th e
h igh est p ar t of th e u p per lid. W h en dealing w ith involu -
t ion al pat ien t s w h o h ave lateral displacem en t of th e tarsal
p late, it is advisable to su t ure m ore m edially to th e tarsal
p late to avoid lateral aring. Pass m at t ress su t u res bet w een
th e levator apon eurosis an d tarsal plate u sing 6–0 nylon ,
6–0 Prolen e (Eth icon ), or 5–0 Vicr yl (Eth icon ) (Fig. 17.15).
Th e sut ure bites sh ould be ~ 3 to 4 m m to preven t loosen -
ing an d sh ould n ot be too super cial to en su re th at th ey
secu rely xate on to th e t arsal p late (Fig. 17.16). Th e n ext
su t u re is p laced bet w een th e p u p il an d th e lateral lim bu s.
Both su t u res sh ou ld be placed 3 to 4 m m below th e su p e-
rior border of th e t arsal p late. If th e su t u re is p laced too
Fig. 17.15 A needle is passed through the levator aponeurosis at
the part medial to the pupil.
low, eyelash ect ropion w ill occur. If th e sut ure is placed too
h igh , en t ropion w ill occur.
A sh allow xat ion to th e t arsal plate m ay result in easy
loosen ing or u n der-correct ion . Th erefore, w h en sut uring to
th e t arsal plate, it is bet ter to an ch or w ith levator apon eu-
rosis 3 to 4 m m in w idth . If th e sut ure is p assed th rough th e
tarsal plates too deeply, it m ay pen et rate th e t arsal plates. It
can be ch ecked w h eth er th e n eedle h as passed th rough th e
tarsal plate or n ot by evert ing th e eyelid during th e surger y
(Fig. 17.17).
Photographs in Sitting Position
Have t h e p at ien t sit u p after su t u r in g t h e t w o p ar t s, an d
let t h e assist an t t ake p ict u res u sing a d igit al cam era w it h
t h e ash on w h ile asking t h e p at ien t to look st raigh t an d
t h en d ow n (Fig. 17.18). En large t h e p ict u res an d evalu -
ate w h et h er t h e degree of cor rect ion an d con tou r ing of
t h e eyelid s are p rop er or n ot . If t h e h eigh t or con tou r-
in g is n ot sat isfactor y, release t h e bow t ie an d t r y again .
On ce a sat isfactor y lid h eigh t an d con tou r are obt ain ed ,
t h e excessive ap on eu rot ic rem n an t s sh ou ld be t r im m ed
below t h e xat ion p oin t s after t h e levator advan cem en t . It
is bet ter to rem ove t h e fat t h at n at u rally bu lges after leva-
tor advan cem en t to avoid u p p er lid p u n ess. Th e brow
an d ret roorbicu lar is ocu li fat (ROOF) w ill com e d ow n after
t h e ptosis correct ion .
Lash Ptosis Correction
At th e en d of th e su rger y, lash ptosis sh ou ld be ch ecked
an d corrected to obt ain a bet ter cosm et ic resu lt . In case
of severe lash ptosis, th e surgeon sh ou ld sut ure th e t ar-
sal p late to th e in ferior ap of th e orbicu laris m u scle an d
overt u rn th e direct ion w ith bu ried su t u res. Th e lash ptosis
Fig. 17.16 The levator is sutured to the tarsal plate not super -
cially, but deeply, and tied with mat tress suture.

Fig. 17.17 Check whether the needle has passed through the tar-
sal plate by everting the lid.
can be corrected by m aking skin –levator apon eu rosis–skin
su t u res. Th is also acts as a secu rit y su t u re for longevit y of
th e upper lid crease.
Levator Resection
Th e di eren ce bet w een levator resect ion an d levator
advan cem en t is a vert ical in cision of th e m ed ial an d lateral
h orn s to release an d advan ce th e levator m u scle m ore. Th e
su rgeon sh ou ld rem ove rem n an t s of th e levator ap on eu ro-
sis at th is t im e.
Conjunctivo -Müllerectomy
Th e sim plicit y an d predict abilit y of th is procedure m ake it
at t ract ive. Th is tech n iqu e is preferred in m ild ptosis cor-
rect ion .27,52,53 If th e eyelid rises to th e level of th e opposite,
n orm al eyelid after th e in st illat ion of 2.5% or 10% p h enyl-
ep h rin e eye drop s an d sh ow s good fu n ct ion of th e levator
m u scle, good p ostop erat ive resu lts w ith th is tech n iqu e can
be expected. In con t rast to levator su rger y, w h ich requires a
skin in cision , th is tech n iqu e w ill n ot leave an extern al scar.
In addit ion , a relat ively p recise resu lt can be p redicted .
Inject 1 m L of 2% lidocain e in to th e su bconju n ct ival space
an d 0.5 m L in to th e lateral th ird of th e u p p er eyelid. Ever t
th e u pper eyelid, an d th en m ark th e am oun t of conjun ct iva
to be excised. Hold th e conju n ct iva w ith a Pu t term an clam p
or t w o h em ost at s.
Make a st ab in cision th rough th e skin tem p orally. Pass
a 6–0 nylon su t u re th rough th e st ab in cision an d w eave a
con t in uou s su t u re 1 m m below th e clam p from tem poral
to m ed ial. Rem ove th e clam p after cu t t ing below it , th en
su t u re th e cu t st u m p by con t in u ing th e su t u re, n ow w eav-
17 Correction of Ptosis 219
Fig. 17.18 Photographs taken at the sit ting position during
the correction of congenital ptosis in a 25-year-old woman show
(a) 1 to 1.5 mm over-correction of the right eye on prim ary gaze
and (b) lid lag on down-gaze.
ing from m edial to tem p oral an d th en exit ing th rough
th e tem poral skin st ab in cision . Tie th e sut u re en ds, an d
rem ove th e st itch es in a w eek.
Frontalis Sling
Fron t alis sling is a ver y e ect ive surger y for revision cases
after m u lt ip le levator su rgeries or in cases sh ow ing p oor
levator fu n ct ion below 4 m m (Fig. 17.19). Th ere are diverse
sling m aterials su ch as au tologou s fascia lata, preser ved
fascia lat a, silicon e rod, Su pram id (S. Jackson ), exp an d ed
polytet ra u oroethylen e (ePTFE, or Gore-Tex [W. L. Gore]),
an d oth ers. Th e au th ors p refer th e single rh om boid sling
m eth od w ith ePTFE su t u res (Gore-Tex CV-3).
Th e surgeon in cises th e skin 3 to 5 m m above th e lid
m argin , exp oses th e t arsal p lates, an d p asses th e Gore-Tex
su t u re h orizon tally th rough th e tarsal plate ~ 3 m m in ferior
to th e su p erior t arsal border. Th e n eedle sh ou ld be passed
un der th e an terior surface of th e t arsal plate deep en ough
to p reven t loosen ing of th e su t u re. How ever, if th e su t u re
is passed too deeply, th e n eedle w ill pen et rate th e t arsal
conjun ct iva. Th erefore, th e upper eyelids sh ou ld be everted
to ch eck w h eth er th e sling m aterial is exp osed or n ot . Th e
sling m aterial p assed th rough th e tarsal p late is xated
w ith 6–0 nylon sut ures at th e m edial an d tem poral sites.
Th is preven t s loosen ing after th e surger y.
220 III Blepharoplast y
a
b 30 m inu tes in th e recover y room . If th e am oun t of levator
Fig. 17.19 Frontalis sling to correct ptosis. (a) This 35-year-old
woman has had t wo previous ptosis surgeries and still has ptosis.
(b) Postoperative photo shows correction of ptosis after use of
bilateral ePTFE (Gore-Tex CV-3) frontalis slings.
Th e surgeon creates m edial, cen t ral, an d tem poral slit
in cision s above th e eyebrow. Using a Wrigh t n eedle, each
en d of th e sling m aterial from th e tarsal p late is passed
deeply in fron t of th e foreh ead periosteu m th rough th e
m edial an d tem poral brow in cision s. Th en th e en d s are
passed th rough th e cen t ral brow in cision . Th e upper eye-
lid in cision is closed w ith 6–0 nylon before t ying th e sling
m aterial at th e cen t ral brow in cision . Th e sling m aterial is
t ied at th e cen t ral brow incision an d st itch kn ots using 5–0
Vicr yl su t ures are used to preven t loosen ing. Th e skin in ci-
sion above th e eyebrow is closed w ith deep 6–0 nylon or
Prolen e sut ures so th at th e sling m aterial is n ot exposed.
■ Key Technical Points
1. On e-sm ooth -step skin in cision is recom m en ded to
avoid creat ing a zigzag in cision .
2. Excise the orbicularis m uscle in an oblique superior
direction to prevent indeterm inate aponeurosis injury.
3. To n d th e fat , gen tly push th e eyeball by pressing
th e low er eyelid w ith th e ngers.
4. Iden t ify th e levator apon eurosis un der th e
p reapon eu rot ic fat .
5. Hold th e levator apon eurosis, w h ich is loosely
at t ach ed to th e t arsal plate an d dissect it u p to th e
su p erior border of th e t arsal p late.
6. Make a levator-Mü ller m u scle ap w h ile ver y
carefully cauterizing th e large vessels in th e Mü ller
m u scle.
7. Advan ce th e levator-Mü ller com plex 3 to 4 m m ,
at t ach ing it to th e su perior t arsal border m edial to
th e pupil rst an d th en lateral to th e lim bus.
8. Ever t th e upper eyelid an d ch eck w h eth er th e n eedle
h as passed th e t arsal p late n ot in fu ll th ickn ess, bu t
in par t ial th ickn ess.
9. Take ph otos to evaluate lid h eigh t (MRD1), contour,
an d lid lag in th e sit t ing p osit ion .
■ Postoperative Care
An t ibiot ic oin t m en t is app lied to th e in cision after th e su r-
ger y an d an ice p ack is h eld to th e closed eyelid for 20 to
advan cem en t is large or th e pat ien t h as severe lagoph th al-
m os du e to a fron t alis sling, ar t i cial tears an d lu brican t
oin t m en t are ben e cial. Th e surgeon sh ould advise th e
pat ien t to apply art i cial tears frequen tly an d lift up th e
low er eyelid to dist ribu te th e tears even ly on to th e corn ea
during th e day, as w ell as put t ing th e oin t m en t in to th e
eyes before sleep.
Th e pat ien t is advised to use a plast ic eye sh ield to pre-
ven t ru bbing of th e eyes by th e h an d s du ring sleep. St itch es
are n orm ally rem oved 6 to 7 days after th e su rger y, an d an
an t ibiot ic oin t m en t is ap plied for an ad dit ion al 3 to 4 days
follow ing th e rem oval of th e st itch es.
■ Complications and
Their Management
Over-correction and
Under-correction
Over-correct ion is m ore com m on in pat ien t s w ith good
levator fu n ct ion , in revision cases, an d in post t raum at ic
ptosis. Postoperat ive dow nw ard t ract ion m assage w ill eas-
ily overcom e a m ild over-correct ion (less th an 1 m m ). If th e
eyelid is sligh tly over-corrected postop erat ively, st retch ing
th e upper lid dow nw ard in th e early postoperat ive period
w ill correct such a m ild over-correct ion .
Un der-correct ion can occur in cases of poor leva-
tor fu n ct ion . Possible reason s for u n der-correct ion are
im proper xat ion of th e levator-Mü ller m uscle ap on to
th e tarsal plate an d loosen ing of sut ure kn ot s. Perform ing
a revision at 1 w eek after levator advan cem en t is recom -
m en ded if th e eyelid is 1.0 m m above or below th e target
h eigh t , or if th ere is asym m et r y bet w een th e t w o eyelids of
1.0 m m or m ore (Fig. 17.20).

a can be perform ed to lift up th e low er lid.
b pressure patching, partial conjunctival resection is needed.
c
Fig. 17.20 Under-correction and early postoperative revision. (a)
A 27-year-old patient had levator advancement for contact lens–
induced ptosis. (b) On day 7 after surgery, the right eyelid was a lit-
tle droopy. (c) After early postoperative revision (re-advancement)
on the right eye, the eyelids look symmetric.
Contour Deformity
Con tour deform it y is cau sed by an in correct xat ion of th e
levator-Mü ller m uscle ap on to th e t arsal plate or un even
ten sion on th e t arsal plate in cases of m axim um levator
advan cem en t . W h en a con tou r deform it y occu rs, it can be
t reated by early postoperat ive revision .
Entropion and Ectropion
Entropion and ectropion occur w hen the levator-Müller m us-
cle ap is xated too high or too low, respectively, onto the
tarsal plate. Changing the xation point can solve these prob-
lem s. Mild lash ptosis can be xed w ith buried lash eversion
sutures (aponeurosis–inferior ap of orbicularis sutures).
Lid Lag and Lagophthalmos
Lid lag an d lagoph th alm os are in evit able com plicat ion s
after m axim u m levator advan cem en t an d fron t alis sling
procedures. Pat ien t s sh ould be in st ructed to use art i cial
tears an d oin t m en t frequ en tly.
17 Correction of Ptosis 221
Keratitis
Th e causes of kerat it is after ptosis surger y are corn eal
exp osu re an d p oor corn eal p rotect ive m ech an ism s (dr y eye
syn drom e, facial n er ve palsy, poor or absen t Bell’s p h en om -
en on ). Lu brican t s sh ou ld be prescribed an d Frost su t u res
Conjunctival Prolapse
Conjunctival prolapse can be seen in cases of signi cant leva-
tor advan cem en t. It is caused by dam age to th e suspensory
ligam ent in the superior fornix. If it does not im prove w ith
Early Postoperative Revision
If th e lid levels of th e t w o eyes are n ot even after u p p er
bleph aroplast y or ptosis surger y, sim ple revision m igh t
be n eeded at 1 w eek postoperat ively. As suppor ted by th e
long-term n dings of m any oth er repor ts, 1 w eek postop -
erat ive lid h eigh t is a reliable in dicator of th e n al resu lt .48
For early revision surger y, th e surgeon does n ot n eed
to use local an esth esia. How ever, if a p at ien t is n er vou s or
com plain s of pain during th e surger y, inject ion of a sm all
am ou n t of lidocain e w ith ou t epin eph rin e is st an dard . Th e
revised eyelid h eigh t is gen erally ver y accurate because
th ere is lit tle sw elling. Th e gen eral recover y period after
a revision is n ot sign i can tly di eren t from th at follow -
ing th e prim ar y su rger y. Postoperat ive dow nw ard t ract ion
m assage w ill easily overcom e a m ild over-correct ion (less
th an 1 m m ). If th e eyelid is sligh tly over-corrected postop -
erat ively, st retch ing th e u pp er lid dow nw ard in th e early
postoperat ive period m igh t x th e problem . How ever, in
th e case of persisten t asym m et r y over 3 m on th s, revision
su rger y sh ou ld be con sidered.
■ Case Studies
Case 1
A 27-year-old m ale pat ien t visited th e clin ic w ith a t ired
look an d prom in en t foreh ead w rin kles (Fig. 17.21a). An
eye exam in at ion sh ow ed MRD1 of –1 m m w ith out fron t alis
act ion an d levator fu n ct ion of 10 m m in both eyes. His real
MRD1 w ith lift ing of th e u p per red u n dan t skin sh ow ed 1.5
m m in both eyes. His brow elevat ion w as du e to th e p res-
en ce of bleph aroptosis an d lash ptosis.
Bu rden factors w ere rem oved, levator advan cem en t
w as p erform ed, an d lash ptosis w as rep aired in both eyes.
Postop erat ively, th e p at ien t h ad larger in terpalp ebral s-
su res, n o longer n eeded to u se h is fron t alis m u scle for lid
elevat ion , an d w as m ore com for table (Fig. 17.21b).
222 III Blepharoplast y

a b

Fig. 17.21 Case 1. (a) A 27-year-old male with a tired look and prominent forehead wrinkles with brow elevation due to bilateral blepha-
roptosis and lash ptosis. (b) After levator advancement and lash correction, he does not use his forehead muscle any more and feels
comfortable.

Case 2 MRD1 of 0 an d 2.5 m m , levator fu n ct ion of 8 an d 12 m m ,

A 25-year-old fem ale p at ien t p resen ted to th e clin ic w ith
a droopy righ t lid sin ce bir th an d con st an t brow elevat ion
(Fig. 17.22a). Sh e com plain ed of a gh ost-like appearan ce
due to h er in ferior scleral sh ow. Sh e h ad ptosis surger y
w h en sh e w as 9 years of age. Eye exam in at ion sh ow ed
an d lid lag of 5 an d 4 m m for th e righ t an d left eyes, respec-
t ively. Th e auth ors perform ed levator advan cem en t of th e
righ t eye an d u p p er blep h arop last y of both eyes. Postop -
erat ively, h er righ t droopy lid w as im p roved, h er in ferior
scleral sh ow w as resolved, an d both eyebrow s w ere n o lon -
ger elevated (Fig. 17.22b).

a b

Fig. 17.22 Case 2. (a) A 25-year-old female with congenital ptosis. She has a history of ptosis correction at 9 years old. (b) After levator
advancement of the right eye and bilateral upper blepharoplast y, the right, droopy lid improved, inferior scleral show resolved, and both
eyebrows are down.

Gen erally, th ere are th ree t ypes of surger y in ptosis

■ Conclusion
A p rop er p reop erat ive evalu at ion of ptosis w ill gu ide th e
ap prop riate su rgical m an agem en t . It is n ecessar y to eval-
u ate th e p at ien t’s protect ive fun ct ion s, such as dr y eye
syn drom e, facial p alsy, dysfu n ct ion of th e su p erior rect u s
m u scle, an d absen ce of Bell’s p h en om en on . In cases of
asym m et ric ptosis, th e su rgeon m u st evalu ate for con t ra-
lateral ptosis by perform ing a m an ual elevat ion test , occlu-
sion test , or p h enylep h rin e test . W h en th ere is a posit ive
Hering’s test on p reop erat ive exam in at ion , th e su rgeon
sh ou ld con sider bilateral ptosis rep air.
correct ion : levator surger y, conjun ct ivo-Mü llerectom y
(MMCR or th e Fasan ella-Ser vat procedure), an d fron t alis
sling. Select ion of th e rep air m eth od is based on con sider-
at ion of th e degree of ptosis an d levator fu n ct ion .
Th e possibilit y of revision is alw ays presen t due to
n u m erou s in t raoperat ive an d postop erat ive variables as
w ell as p at ien t-related factors. Obt ain ing opt im al h eigh t
an d con tou r for both eyelids can be di cu lt in ptosis su r-
ger y. For th e m ost sat isfying resu lt s, th e su rgeon sh ou ld t r y
to m in im ize th e con t rollable variables as m u ch as possible.
If th e levels of th e t w o eyelids after ptosis correct ion are n ot
sym m et ric, postop erat ive revision sh ou ld be p erform ed at
1 w eek postoperat ively to ach ieve good result s.

References
1. Beard C. Histor y of ptosis su rger y. Adv Oph th alm ic Plast
Recon st r Su rg 1986;5:125–131
2. Ser vat J, Man t illa M. Th e histor y of ptosis su rger y. Adv
Op h th alm ic Plast Recon st r Su rg 1986;5:133–137
3. Dran sart HN. Un cas de bleph aroptose opere par un pro-
ced e special a l’au teu r. An n Ocu l 1880;84:88
4. Hess C. Operat ion m eth ode gegen ptosis. Arch Augen h eilkd
1893;28:22
5. Payr E. Plast ik m it tels freier faszien t ran splan t at ion bei
ptosis. Dt sch Med Woch en sch r 1909;35:822
6. Yasun a E. Use of prepared fascia lat a in correct ion of ptosis.
Am J Op h th alm ol 1962;54:1097–1103
7. Argam aso RV. An adju st able fascia lat a sling for the cor-
rect ion of blep h aroptosis. Br J Plast Su rg 1974;27(3):
274–275
8. Argam aso RV, Lew in ML. Fascia lat a sling in bleph aroptosis:
en h an cem en t of result by postop erat ive adju st m en t . J Pe-
d iat r Op h th alm ol 1976;13(1):51–55
9. Craw ford JS. Repair of ptosis u sing fron t alis m u scle an d
fascia lat a: a 20-year review. Oph th alm ic Surg 1977;8(4):
31–40
10. Patrinely JR, Anderson RL. The septal pulley in frontalis sus-
pension. Arch Ophthalm ol 1986;104(11):1707–1710
11. Bow m an W P. cited by Bader D. Rep ort of th e ch ief op -
erat ion s perform ed at th e Royal Op h th alm ic Hospit al for
th e qu arter en ding Septem ber 1857. Op h th al Hosp Rep
1857;1:1857–1859
12. Everbu sch O. Zu r op erat ion en der congen it alen blep h arop -
tosis. Klin Mon at sbl Augen h eilkd 1883;21:100
13. Sn ellen H. Levator Ten don Sh orten ing for Ptosis. Heid el-
berg: Report of th e Germ an Oph th alm ology Societ y; 1883
14. Wol H. Der verlageru ng des m u scu lu s levator p alp ebrae
superioris m it durch t ren n ung der in sert ion : Zw ei n eue
Meth oden gegen ptosis congen it al. Arch Augen h eilkd
1896;33:125
15. Blaskovics L. A n ew op erat ion for ptosis w ith sh orten ing of
th e levator an d tarsu s. Arch Oph th alm ol 1923;52:563
16. An derson RL, Beard C. Th e levator apon eu rosis. At t ach -
m en ts an d th eir clin ical sign i can ce. Arch Oph th alm ol
1977;95(8):1437–1441
17. Anderson RL, Dixon RS. Neuromyopathic ptosis: a new surgical
approach. Arch Ophthalm ol 1979;97(6):1129–1131
18. An derson RL, Dixon RS. Ap on eu rot ic ptosis su rger y. Arch
Op h th alm ol 1979;97(6):1123–1128
19. An derson RL. Age of ap on eu rot ic aw aren ess. Op h th al Plast
Recon st r Su rg 1985;1(1):77–79
20. Baker SS, Mu en zler WS, Sm all RG, Leon ard JE. Carbon d i-
oxide laser bleph aroplast y. Oph th alm ology 1984;91(3):
238–244
21. Melt zer MA, Elah i E, Tau p eka P, Flores E. A sim p li ed tech -
n ique of ptosis repair using a single adju st able su t ure. Oph -
th alm ology 2001;108(10):1889–1892
22. Fasan ella RM, Ser vat J. Levator resect ion for m in im al
ptosis: an oth er sim p li ed op erat ion . Arch Oph th alm ol
1961;65:493–496
17 Correction of Ptosis 223
23. Pu t term an AM, Urist MJ. Mü ller’s m u scle-conju n ct ival re-
sect ion in th e t reat m en t of ptosis. Modi cat ion , th eor y an d
clam p for th e Fasan ella-Ser vat ptosis op erat ion . Arch Oph -
th alm ol 1972;87:665–667
24. Pu t term an AM, Urist MJ. Mü ller m u scle-conju n ct iva resec-
t ion . Tech n iqu e for t reat m en t of bleph aroptosis. Arch Oph -
th alm ol 1975;93(8):619–623
25. Lau ring L. Let ter: su t u reless Fasan ella-Ser vat blep h aropto-
sis correct ion . Am J Oph th alm ol 1975;80(4):778
26. Lau ring L. Blep h aroptosis correct ion w ith th e su t u re-
less Fasan ella-Ser vat op erat ion . Arch Oph th alm ol
1977;95(4):671–674
27. Bodian M. A revised Fasan ella-Ser vat ptosis op erat ion . An n
Op h th alm ol 1975;7(4):603–605
28. Wein stein GS, Bu erger GF Jr. Modi cat ion of th e Mü ller’s
m uscle-conjun ct ival resect ion operat ion for bleph aropto-
sis. Am J Oph th alm ol 1982;93(5):647–651
29. Du an e TD, ed. Clin ical Op h th alm ology. Hagerstow n , MD:
Harper & Row ; 1976
30. Jeong S, Lem ke BN, Dort zbach RK, Park YG, Kang HK.
Th e Asian upper eyelid: an an atom ical st udy w ith com -
parison to th e Caucasian eyelid. Arch Oph th alm ol 1999;
117(7):907–912
31. Takah ash i Y, Kakizaki H, Mito H, Sh iraki K. Assessm en t
of the predict ive value of in t raoperat ive eyelid h eigh t
m easu rem en t s in sit t ing an d su pin e posit ion s during
bleph aroptosis repair. Oph th al Plast Recon st r Surg 2007;
23(2):119–121
32. Ah u ero AE, Hat ton MP. Eyelid m alposit ion after cat aract
an d refract ive surger y. In t Oph th alm ol Clin 2010;50(1):
25–36
33. Gri n RY, Sarici A, Un al M. Acqu ired ptosis secon dar y to
vern al conju n ct ivit is in you ng adu lt s. Op h th al Plast Recon -
st r Surg 2006;22(6):438–440
34. Fin sterer J. Ptosis: cau ses, p resen t at ion , an d m an agem en t .
Aesth et ic Plast Su rg 2003;27(3):193–204
35. McCord CD, Tan en bau m M, Nu n er y W R. Ocu lop last ic Su r-
ger y. 3rd ed. New York, NY: Raven ; 1995:176
36. Su t u la FC. Histological ch anges in congen ital an d acqu ired
bleph aroptosis. Eye (Lon d) 1988;2(Pt 2):179–184
37. Kitazaw a T. Hard con t act len s w ear an d th e risk of ac-
quired bleph aroptosis: a case-con t rol st udy. Eplast y 2013;
13:e30
38. Ep stein G, Pu t term an AM. Acqu ired blep h aroptosis sec-
on dar y to con t act-len s w ear. Am J Ophth alm ol 1981;
91(5):634–639
39. Wat an abe A, Araki B, Noso K, Kakizaki H, Kin osh it a S.
Histopath ology of bleph aroptosis in du ced by p rolonged
h ard cont act len s w ear. Am J Oph th alm ol 2006;141(6):
1092–1096
40. Dortzbach RK. Superior tarsal m uscle resection to correct bleph-
aroptosis. Ophthalm ology 1979;86(10):1883–1891
41. Zou m alan CI, Lism an RD. Evalu at ion an d m an agem en t of
u n ilateral ptosis an d avoiding con t ralateral ptosis. Aesth et
Surg J 2010;30(3):320–328
42. Meyer DR, Wobig JL. Detect ion of con t ralateral eyelid re-
t ract ion associated w ith blep h aroptosis. Op h th alm ology
1992;99(3):366–375
224 III Blepharoplast y
43. Bodian M. Lip droop follow ing con t ralateral ptosis repair.
Arch Oph th alm ol 1982;100(7):1122–1124
44. Lyon DB, Gon n ering RS, Dort zbach RK, Lem ke BN. Un ilat-
eral ptosis an d eye dom in an ce. Op h th al Plast Recon st r Surg
1993;9(4):237–240
45. Worley MW, Gal O, An derson RL, al Hariri A. Eye dom in an ce
and Hering’s law e ect on bilateral blepharotosis repair.
Ophthal Plast Reconstr Surg 2013;29(6):437–439
46. Erb MH, Kersten RC, Yip CC, Hudak D, Kulw in DR, McCul-
ley TJ. E ect of u n ilateral blep h aroptosis repair on con -
t ralateral eyelid posit ion . Op h th al Plast Recon st r Su rg
2004;20(6):418–422
47. Malik KJ, Lee MS, Park DJJ, Harrison AR. Lash ptosis in con -
gen it al and acqu ired blep h aroptosis. Arch Oph th alm ol
2007;125(12):1613–1615
48. Lee TE, Lee JM, Lee H, Park M, Kim KH, Baek S. Lash pto-
sis an d associated factors in Asian s. An n Plast Su rg 2010;
65(4):407–410
49. Morris CL, Morris W R, Flem ing JC. A h istological an alysis
of th e Mü llerectom y: rede n ing it s m echan ism in ptosis
repair. Plast Recon st r Surg 2011;127(6):2333–2341
50. Jang SY, Ch in S, Jang JW. Ten years’ exp erien ce w ith u n i-
lateral conju n ct ival Mu llerectom y in th e Asian eyelid. Plast
Recon st r Su rg 2014;133(4):879–886
51. Steinkogler FJ, Kuchar A, Huber E, Arocker-Met t inger E.
Gore-Tex soft-tissue patch fron talis su spen sion tech n iqu e
in congenital ptosis and in blepharoph im osis-ptosis syn -
drom e. Plast Recon st r Su rg 1993;92(6):1057–1060
52. Karesh JW. Polytet ra u oroethylen e as a graft m aterial
in oph th alm ic plast ic an d recon st ru ct ive su rger y. An ex-
perim en t al an d clin ical st u dy. Op h th al Plast Recon st r Surg
1987;3(3):179–185
53. Bajaj MS, Sast r y SS, Gh ose S, Beth aria SM, Pu sh ker N.
Evalu at ion of polytet ra u oroethylen e su t u re for fron t alis
suspen sion as com pared to polybut ylate-coated braid-
ed polyester. Clin Experim en t Oph th alm ol 2004;32(4):
415–419
18 Management of Double -Eyelid Surgery
Complications
In-chang Cho and Aram Harijan
Pearls
• Ident ify an d nd w ays to avoid th e origin al m istake.
Oth erw ise, secon dar y an d tert iar y operat ion s w ill
only com pound th e problem from the rst operat ion.
• Railroad scar from d elayed rem oval of st itch es
sh ou ld n ever h ap p en .
• Mech an ical resistan ce to fold ing of th e eyelid skin
varies from pat ien t to pat ien t . Th is resist an ce is
evaluated by obser ving h ow long a tem p orar y crease
stays after u sing a bougie.
• Deeper folds u su ally accom p any h igh creases, bu t
crease h eigh t is n ot th e sam e as fold depth .
• In secon dar y eyelid operat ion s, th e rst goal sh ou ld
be decon st ruct ion of layers th rough release of
adh esion an d sep arat ion of app rop riate p lan es.
■ Introduction
Aesth et ic st an dards for eyelids var y across eth n ic grou p s
an d cu lt u res. W h ile a cert ain con tem porar y aesth et ic st an -
dard m ay be sat isfactor y to a large n u m ber of pat ien t s,
com plicat ion s after dou ble-eyelid operat ion s are speci c to
th e in dividual pat ien t . Th erefore, th e authors believe th at
an ou tcom e th at fails to m eet realist ic p at ien t expect at ion s
qu ali es as a pract ical de n it ion for a com plicat ion of an
aesth et ic op erat ion .
In th e con text of East Asian blep h arop last y, th e m ost
com m on com plicat ion s are problem s of crease h eigh t (low
versu s h igh ), fold d epth (sh allow versu s deep), ext ran e-
ous creases (t riple folds), pret arsal fulln ess, ptosis, an d
asym m et r y arising from any n u m ber of previou s con di-
t ion s.1 Th is ch apter w ill id en t ify th e m ist ake or th e p rob -
lem beh in d each com plicat ion an d presen t th e solu t ion th e
sen ior au th or h as developed over h is career as an ocu lo-
p last ic su rgeon .
■ Patient Evaluation
Proper operat ion depen ds on proper in dicat ion . An d
proper in dicat ion origin ates from proper diagn osis. In each
n ew preop erat ive con sult at ion , th e surgeon m u st un der-
stan d th e cou rse of even ts th at p rom pted th e pat ien t to
• Th e secon d goal is th e preven t ion of fur th er
com plicat ion s.
• Th e th ird goal is to create th e desired eyelid sh ape,
in cluding n ew crease h eigh t an d fold depth .
• Th e problem beh in d pretarsal fulln ess is in
th e h eigh t (n ot th e volum e) of th e pretarsal
com par t m en t . Rath er th an rem oving soft t issue, th e
h igh crease sh ould be replaced w ith a low er on e.
• It is t h e su rgeon ’s job to h elp t h e p at ien t
u n d erst an d t h at t h ere is n o w ay to rem ove an
eyelid crease an d m ake t h e eyes look like t h eir
or igin al for m s. A bet ter solu t ion is to low er t h e
crease to t h e eyelid m argin an d to bu r y t h e in cision
scar w it h in t h e fold .
seek fu rth er su rgical t reat m en t . Th is u n derstan ding com es
on ly if th e pat ien t is given am ple oppor t un it ies to tell th e
stor y. Physical exam in at ion m u st correlate w ith th e h istor y.
Any d iscrepan cies bet w een th e stor y an d p hysical n ding
sh ou ld ser ve as a w arn ing, an d th e su rgeon m u st perform
due diligen ce in at tem pt ing to rediscover per t in ent aspect s
of th e pat ien t’s m edical an d surgical h istor y.
More often th an n ot , th e p at ien t w ith an u n sat isfac-
tor y ou tcom e w ill h ave m u lt ip le com p lain t s. In assessing
an d cou n seling th e pat ien t , th e su rgeon m u st t r y to o er
th e ideal operat ion , w h ich is th e one th at addresses all of
th ese com plain ts at on ce. If n o such operat ion is possible,
th e su rgeon m ust then o er th e opt im al solut ion , w h ich
w ill address as m any of th e problem s as possible at on ce.
For exam ple, a pat ien t m ay presen t w ith a h igh crease, deep
fold, an d excessive pretarsal fulln ess of th e upper eyelid. If
th e su rgeon un derst an ds th at both deep fold an d pretarsal
fu lln ess are in t rin sically t ied to th e p roblem of h igh crease,
he or sh e can appreciate th at all th ree of th e problem s m ay
be solved by a single procedure: low er th e crease.2
On ce th e sim p lest solu t ion h as been id en t i ed, th e
su rgeon m u st sh are th is in form at ion . Th e p at ien t sh ou ld
un derst an d th at th e in ten t ion is to im prove all of th e un de-
sirable feat u res to an acceptable d egree, rath er th an to
com pletely solve on ly a sm all fract ion of th e problem s. If
th e surgeon can o er an approach an d th e pat ien t accept s
it , m eet ing th e expect at ion becom es a m ere problem of
techn icalit y.
225
226 III Blepharoplast y

■ Surgical Techniques
Scar
Eyelid skin d oes n ot d evelop hypert roph ic resp on se in m ost
cases. W h en hypert roph ic respon se is obser ved after an
eyelid operat ion, th e fu n dam en t al problem could be th e
pat ien t’s ten den cy to develop hypert roph ic scar. In m any
in st an ces, h ow ever, th e problem is n ot w ith th e pat ien t but
w ith th e surgeon w h o perform ed th e in dex operat ion .
Th e m ost com m on tech n ical m ist ake is a lack of un der-
stan ding of th e d ist ribu t ion of th e su p erior-p osterior force
Fig. 18.1 On opening the eyes, the lower ap is dislocated as it
vector of th e levator m u scle. If th is vector is u n equ ally
is pulled inward by the xation suture there. For prevention, skin
dist ributed to th e low er ap, it is possible to dislocate th e
sutures must be done closely to su ciently bite the tarsal plate.
low er ap from th e u pp er ap (Fig. 18.1). Th is occu rs m ore
frequ en tly in th e lateral p or t ion of th e u p per eyelid becau se
th e apon eurosis is deeper in th e t issue. To m in im ize such a
risk, th e su rgeon m u st en su re th at th e u pw ard p u ll of th e
levator is t ran sferred to th e t arsu s—n ot th e skin —via a su -
cien t n um ber of bites of th e plate. In younger pat ien t s, skin
excision s do n ot h ave to be exten ded along th e fu ll length
of th e eyelid to create a crease of desirable length ; a sh orter
in cision design is usu ally su cien t . A less tech n ical bu t
st ill com m on m ist ake is leaving su t u res in for m ore th an
5 days; epith elial t un n els form aroun d sut ures on ly 7 days
after op erat ion . Railroad t rack scars from delayed su t u re
rem oval are u n accept able. Eyelid scars are m ore n ot iceable
Fig. 18.2 Depressed scars from excessive removal of orbicularis
w h en th ey are depressed. Such scars result from exces- muscle. Depression is seen beneath the fold from removal of orbi-
sive rem oval of th e orbicu laris m u scle, con n ect ive t issu e cularis muscle.
(Fig. 18.2), or deep fold (Fig. 18.3).3,4
An eyelid scar revision m u st obey th e w ou n d h eal-
ing prin ciples th at govern all aspect s of surgical care. Th e
operat ion m ust be asept ically possible. Both surgeon an d
in st ru m en t m ust be at rau m at ic w ith respect to th e eyelid
t issues. All layers—n ot just skin —sh ould be approxim ated
w ith as lit tle ten sion as possible.
Excision an d re-approxim at ion of th e skin does n oth -
ing to address scars th at are depressed. Th e m issing layer
of orbicu laris oculi m ust be recon st ructed by un derm in -
ing an d advan cing th e m u scle edges from both u pper an d
low er aps. Su ch un derm in ing is also ben e cial if th e
problem is th at th e skin adjacen t to th e pre-exist ing scar is
inverted. W h en approp riate, u n derm in ing of th e skin aps Fig. 18.3 Depressed crease line from ectropion. The lower ap is
sign i can tly m it igates th e ten sion p laced directly across stretched upward.
th e derm is (Fig. 18.4). Sim p le con t in u ou s su t u re can p lace
diagon al ten sion across th e w oun d. An in terlocking con t in -
u ou s su t u re w ill m ain t ain an even perpen dicular ten sion .
In clu sion cysts resu lt from a p rolonged foreign body
react ion to th e su t u re placed bet w een th e up per an d low er Loss of Fold
skin ap s or from sebaceou s glan d act ivit y. Th ese cyst s
m ay d evelop over w eeks to m on th s after an op erat ion an d All su rgically created eyelid creases at ten u ate du ring th e
sh ould be excised if th ey do n ot resolve sp on t an eou sly rst few m on th s. Th is ch ange m igh t be m in im al, or th e fold
(Fig. 18.5). In clu sion cyst s are best avoid ed by u sing th e m igh t disap p ear altogeth er. Th e degree to w h ich a p ostop -
orbicularis m uscle—n ot th e derm is it self—as th e an ch oring erat ive fold soften s is d eterm in ed by p at ien t ch aracterist ics
point for th e su t u res. an d su rgical tech n iqu e.
 18 Managem ent of Double-Eyelid Surgery Com plications
a b
Fig. 18.5 Inclusion cyst. If anchoring is done on the dermis, and
inclusion cyst may be formed from foreign body reaction, due to
the thin nature of the upper eyelid skin.
Th e pat ien t-related factors th at prom ote soften ing or
loss of crease are as follow s: (1) th ick skin an d abun dan t
soft t issu e, (2) blep h aroptosis, (3) su n ken eyelid, (4) en op h -
th alm os, (5) h istor y of failed double-eyelid operat ion , (6)
you nger age, (7) low -lying p reop erat ive crease, (8) p resen ce
of epican th al fold, an d (9) ext rem e w eigh t gain . Operat ive
factors associated w ith tech n ical failu re are as follow s: (1)
in accu rate approxim at ion of con n ect ive t issue, (2) in su -
cien t xat ion to t arsal plate, (3) low -set xat ion , an d (4)
loosen ing of th e xat ion due to h em atom a or ed em a.
In adequ ate soft t issu e rem oval along th e top m argin
of th e t arsal plate can preven t close approxim at ion of th e
con n ect ive t issue as w ell as bun ch ing of fat t issue in to th e
loop of th e su t ure. Fat t issu e w ith in th e loop can in t rodu ce
m ech an ical red u n dan cy w ith exp an sion from ed em a an d /
or h em atom a an d subsequen t disappearan ce of th e surgi-
cally created crease.
Alth ough th e im p or tan ce of su t u res can n ot be over-
em p h asized , a n e dist in ct ion m u st be m ade bet w een a
st rong xat ion an d a prop er xat ion . A su rgically created
eyelid fold is a con sequen ce of th e adh esion bet w een th e
an terior an d p osterior lam ellae. Postop erat ive folds soften
227
Fig. 18.4 Correction of depressed scar. (a) The inci-
sional scar is resected. (b) The upper orbicularis mus-
cle ap is minimally undermined. (c) Skin and muscle
c are repaired together.
an d/or disapp ear over t im e becau se th e rep et it ive m ove-
m en t an d sh ift ing of variou s layers are en ough to disru pt
th is adh esion bet w een th e layers. To preven t such ch anges,
th e adh esion s—n ot th e sut ure m aterial—m ust be st ronger.4
Th e resist an ce of an eyelid again st form ing a fold is est i-
m ated d u ring th e p reop erat ive con su ltat ion . Fold-resist an t
eyelids ten d to require sign i can tly m ore force w h en using
th e st ylus, an d th e created fold disappears rath er qu ickly
com pared w ith th e eyelids, w h ich m ain tain postoperat ive
creases w ith out sign i can t ch anges. Pat ien t factors th at
predict h igh resist an ce to fold form at ion in clu de th ick skin ,
abu n dan t soft t issu e, blep h aroptosis, h igh ly elast ic skin in
you nger p at ien t s, su n ken eyelids, en op h th alm os, h istor y
of failed double-eyelid operat ion , an d adh ered low er ap.
Eyelids w ith ep ican th al fold s sh ow h igh resist an ce along
th e m edial side. Th ough th is is n ot a preoperat ive pat ien t
factor, w eigh t gain in th e in term ediate p ostoperat ive p eriod
can precipit ate loss of a surgically created fold.
To preven t loss of folds, th e surgeon m ust t ie th e sut u re
w h ile avoiding th e in t rusion of soft t issu e bet w een th e
levator apon eu rosis an d derm is or th e orbicularis m u scle
in to th e loop . If a pat ien t h as fold-resist an t eyelids, it is
im port an t to create a fold th at is deep en ough to resu lt in
th e sligh test ect ropion th at w ill subside after a sh or t post-
operat ive du rat ion . Excessively deep xat ion s can resu lt in
persisten t ect ropion , even if th e fold becom es sh allow er
over t im e.
Shallow or Deep Fold
Shallow Fold
At tim es, th ere is ext ran eous fat or con n ective t issu e in th e
pretarsal space. This is especially com m on on the m edial
side of th e u pper eyelid, w h ere pretarsal fat is abun dan t.
Part ial resection of th is con n ective tissue can aid in form -
ing an adhesion. If a patient has blepharoptosis or a de nite
epican th al fold, th ese elem en ts m u st be dealt w ith rst to
reduce fold resistance. Other w ise, a deeper fold is n ecessar y.
228 III Blepharoplast y

If th ere is adh esion in th e low er ap w ith soften ing of

th e fold, th e adh esion w ill in terfere w ith th e form at ion of a
n ew crease. In su ch cases, th e low er ap m u st be released
an d redrap ed p rior to tarsal xat ion . In pat ien t s w h ose
eyelid skin lacks elast icit y after th e previou s op erat ion , th e
n ew ly created fold sh ou ld be deeper th an u su al to p reven t
a rep et it ive loss of fold (Fig. 18.6).

Deep Folds or Ectropion
Deep folds an d ect ropion are cau sed by creases th at w ere
xated too h igh on th e eyelid. Th is p laces an u n du e u pw ard
ten sion on th e low er ap an d ever t s th e eyelid m argin . A
pat ien t often com plain s about th e un in ten ded im pres-
sion of aggression conveyed by th e ever ted eyelids. Th e
depressed scar is visible w h en th e eyes are closed. Th e
pat ien t m ay also com plain of a t ugging sen sat ion in th e
eyelids. Th e palp ebral ssu re m ay becom e larger. Th e skin
ju st su perior to th e fold ten ds to bu lge.
High xat ion s in adverten tly in crease th e p alpebral s-
su re becau se th e levator ap on eu rosis is p licated w h en th e
low er ap is xed at a h igh p oin t on th e levator apon eu ro-
sis. In case of severe ect rop ion , th e conju n ct iva is exposed .
Th e m ucocut an eous jun ct ion becom es kerat in ized, leading
to dr y eye syn drom e.
Th e rst step in correct ing th e deep fold is to release
th e adh esion s an d re-approxim ate th e layers at a low er
poin t along th e eyelid. If th is part of th e operat ion does n ot
resolve th e ect ropion , th e low er ap m ust be un derm in ed
an d redrap ed over th e t arsal p late to d ecrease th e ever t ing
force of th e ad h esion in th e low er ap. Th e secon d por t ion
of th e operat ion is to preven t th e form at ion of t riple folds.
Th e surgeon m ust t ake care n ot to allow re-adh esion by
in t roducing th e orbit al fat in to th e sp ace bet w een th e apo-
n eurosis an d orbicularis m uscle.
Deep crease is often accom p an ied by a h igh fold, an d
th e operat ion s to correct th ese t w o feat ures are ver y sim i-
lar. Th e on ly sign i can t di eren ce bet w een th e t w o correc-
t ion m eth ods is th at th e locat ion of th e previou s crease is
m ain t ain ed in cases of d eep crease w ith ou t h igh fold, th e
n ew crease is design ed low er th an th e previou s crease, an d
th e skin in bet w een is excised in cases of h igh fold alon e.
Correct ion of deep crease w ill be described again along
w ith correct ion of h igh fold in th e follow ing sect ion .
Adhesion
Fig. 18.6 Correction of a shallow crease. Release the previous
adhesion at the pretarsal area. Since elasticit y is compromised from
brous change and a relapse is common, xate at a higher point
than usual.
Th ere are th ree approach es to correct a low fold. Th e
rst is an open blep h aroplast y by w h ich th e skin an d orbi-
cularis m uscle are excised above th e previous crease. Th e
secon d ap p roach is to create a m ech an ically overriding
crease above th e previous on e. Th e th ird com bin es soft t is-
su e excision an d m ech an ical xat ion above th e prior crease
(Fig. 18.8).4
Th e rst approach (open bleph aroplast y) can in corpo-
rate scar revision an d allow s for excision of redun dan t skin
in old er pat ien t s. How ever, th e su rgeon m ust leave en ough
eyelid skin to m in im ize th e risk of postbleph aroplast y brow
ptosis. In pat ien ts w ith out sign i can t redun dan cy of eyelid
skin , excision of th e orbicu laris m u scle above th e old crease
is m ore im port an t th an excision of th e skin . Maxim u m ele-
vat ion of th e eyebrow s sh ou ld resu lt in 80 to 90% elevat ion
of the upper eyelid m argin in pat ien t s w ith an appropri-
ate am ou n t of skin excised. Th is is an im p or tan t par t of th e
preoperat ive an d in t raoperat ive guidelin e on est im at ing
h ow m u ch of th e u p per eyelid skin is redu n dan t .
Th e secon d approach (t arsal xat ion ) allow s con sider-
able elevat ion of th e fold crease bu t w ill create an addit ion al
scar, if secon dar y in cision s are n ecessar y. Th is ap p roach

Low Crease
In a crease th at is too low, ver y lit tle skin w ill sh ow bet w een
th e eyelid m argin an d th e crease. Th is is usu ally a problem
of th e act ual crease design being too low, but a sh allow
fold can som et im es give th e appearan ce of a low crease
(Fig. 18.7). Red u n dan cy of skin can also m ake a crease
ap pear low er th an it really is. Fig. 18.7 Low fold due to a shallow crease.
 18
Skin and
OOM excision
Previous
incision
line
a b
Fig. 18.8 Methods of raising low fold. (a) The skin and orbicularis oculi m uscle (OOM) are removed around the previous incision line.
(b) A new crease is made above the previous incision line, by a buried suture method or a short incision method. (c) Combination of a and
b methods; excision of soft tissue is performed above the previous incision line.
is m ore ap prop riate for pat ien t s w h o h ave in con spicuous
scars from th e rst op erat ion an d w ish for th e eyelid fold
to be h igh er. If th e previous fold is st rongly de n ed (i.e., too
d eep ), th en a sim ple m ech an ical xat ion m ay resu lt in m ul-
t iple eyelid folds. To m in im ize such risk, th e low er ap can
be un derm in ed th rough a sm all in cision w in dow. Th is can
sign i can tly at ten u ate th e p rim ar y fold to a fain t ap pear-
an ce. Pat ien t s sh ou ld be w arn ed of th e p oten t ial for p ret ar-
sal fu lln ess from th e scar t issu e after th e in it ial op erat ion .
Th e com bin ed approach of open bleph aroplast y an d
m ech an ical xat ion is reser ved for p at ien ts w ith ver y low
folds an d great redu n dan cy of skin .
High Crease
In m any East Asian cu lt u res, h igh eyelid crease is associated
w ith an aggressive or an tagon ist ic person alit y. High creases
are u su ally accom pan ied by deep folds, an d p at ien ts com -
plain of u n n at ural appearan ce, depressed scar, an d exces-
sive eversion of th e eyelash es. Pat ien t s m ay also com plain
abou t pretarsal fu lln ess th at h as n ot im proved w ith t im e.
Sligh t bleph aroptosis can be seen in p at ien t s w ith an ad h e-
sion bet w een th e skin an d levator ap on eu rosis th at p re-
ven t s recu rsion of th e levator m u scle.
Causes
High creases can be cau sed by h igh -p osit ion ed skin crease
design , h igh xat ion , excessive skin excision , un in ten ded
adh esion , blep h aroptosis, or su n ken eyelid . Am ong th ese,
h igh crease design from th e in it ial operat ion is th e m ost
com m on . Fixat ion of th e low er ap to a h igh poin t can
result in h igh folds w ith ect ropion . Th e problem can also
result from excessive skin resect ion , w h ich leaves in su -
cien t skin to cover th e crease. Pat ien ts w ith bleph aropto-
sis ten d to develop h igh folds after an eyelid fold operat ion
Managem ent of Double-Eyelid Surgery Com plications 229
Soft tissue
New line excision
New line
c
th at failed to address th e m ech an ical et iology beh in d th e
ptosis (Fig. 18.9).
High creases can be obser ved w ith deep, n orm al, or
sh allow fold depth s. Th e m ost com m on form is a fold th at is
both high an d deep, w h ich is often accom pan ied by ect ro-
pion . At t im es, pat ien t s m igh t h ave folds of var ying depth
(e.g., a fold th at is sh allow on th e m edial side but deep over
th e pupils).4
Correction of High Creases
Like oth er com plicat ion s, h igh creases sh ould be corrected
according to th e cau se. Gen erally, th e secon dar y op erat ion
in corporates an op en bleph aroplast y w ith skin excision .
Th e u pper m argin of th is excision is along th e fold th at is
to be revised, an d th e low er m argin m arks th e n ew crease
heigh t . If th e skin lacks redun dan cy an d lagop h th alm os
is expected, skin is n ot resected. Rath er, a low er in cision
can be used to u n derm in e th e upper ap an d release th e
high fold th rough eith er th e pre-apon eurot ic layer or p re-
sept al layer. Releasing th e fold th rough th e p re-apon eu rot ic
layer m in im izes th e risk of re-adh esion becau se it is in th e
deeper layer. In pat ien t s w ith bleph aroptosis, th is deeper
dissect ion plan e is a n at ural ch oice, as it allow s th e opera-
tor to access th e levator m ech an ism . For th e sam e reason ,
how ever, th is plan e of dissect ion can injure th e levator
ap on eu rosis an d resu lt in postoperat ive blep h aroptosis. In
con t rast , releasing th rough th e pre-sept al layer m in im izes
th is risk but is associated w ith in creased risk for t riple fold
form at ion .
Deep folds respon d bet ter to dissection of th e upper ap
through the deeper plane. How ever, a deep fold m ay rem ain,
even w ith adequate release ben eath th e upper ap. In su ch
sit uation s, th e low er ap m igh t also con t ribute to fold depth
an d sh ould be released from th e un derlying tissue. Th e
low er ap should then be xed at the desired height . This
also addresses th e problem of ect ropion , if presen t .
230 III Blepharoplast y
a b
c d
Fig. 18.9 Causes of high fold. (a) High incision line. (b) High fold from ectropion. (c) High fold from blepharoptosis. (d) High fold from
sunken eyelid.
High creases w ith n eu t ral fold depth can be ad dressed
by sim ple open bleph aroplast y, as described previou sly.
Sh allow eyelid folds are corrected in a sim ilar m an n er to
n eu t ral folds, by op en blep h arop last y. Even w ith a com -
p lete loss of fold, h ow ever, th e low er ap can st ill h ave
severe adh esion s an d requ ire ad h esiolysis. If n o su ch adh e-
sion s are p resen t , th e low er ap sh ou ld h ave en ough laxit y
to allow adequate xat ion at th e desired h eigh t .1
Failures after Correction of High Crease
Th e t w o m ajor problem s th at occur after h igh fold correc-
t ion are ect ropion an d m ult iple folds. Failu re rates for h igh
fold correct ion can be un accept ably h igh for su rgeon s w h o
do n ot grasp th e fun dam en tal prin ciple beh in d second-
ar y op erat ion s: th at u nw an ted adh esion is th e en em y. Th e
prim ar y reason of failure in revising th e h igh lid crease is
an in com p lete release of th e t issu e arou n d th e old eyelid
crease. Th e failure m ay also be caused by re-adh esion of th e
t issue th at w as adequ ately freed.
In com p lete lysis of adh esion s or re-adh esion m ay resu lt
in ect ropion w ith an eyelid crease th at appears to ch ange
h eigh t w ith m ovem en t . With th e eyes closed, th e crease
w ill appear low ered, as in ten ded. How ever, th e sam e crease
does n ot appear low ered w h en th e eyes are open because
th e skin is expan ded an d bun ch ed from th e ever ted eyelid.
Mu lt ip le eyelid creases can form after correct ion
of h igh creases. In such post secon dar y bleph aroplast y
pat ien t s, each crease represen ts th e xat ion s perform ed in
prim ar y an d secon dar y operat ion s, w h ere th e low er crease
is th e desired crease an d th e h igh er crease reappeared at
th e site of th e in it ial operat ion . Even after com plete adh e-
siolysis, th e p osterior lam ella can re-adh ere to th e an terior
lam ella. Th e problem s of t riple folds are so com m on th at it
is discussed as a dist in ct topic in a later part of th is ch apter.
To preven t th ese secon dar y com plicat ion s, th e sur-
geon m u st m ain tain su cien t t issu e volu m e, th orough ly
free th e adh ered t issu e p lan es, an d m ake e ort s to p reven t
re-adh esion . To accom plish th ese goals, it is im port an t to
abide by th e follow ing gu idelin es:
1. Resect on ly th e skin an d leave th e scar t issue to
rein force th e u pper ap (Fig. 18.10).
2. If the upper ap lacks su cient soft tissue bulk, the
orbital fat along w ith the septum can be lowered
to add volum e to the upper ap and also provide
a gliding m em brane bet ween the orbicularis oculi
and the levator aponeurosis. This latter function of
interposition ap is extrem ely im portant in preventing
re-adhesion of separated elem ents (Fig. 18.11).
3. In th e sam e m an n er, th e orbicularis m uscle can be
u sed as an in terp osit ion ap (Fig. 18.12).
4. If th ere is in su cien t orbital fat or orbicu laris
m u scle, a con n ect ive t issu e ap can be elevated for
rein forcem en t . Derm ofat graft , fat graft , or m icrofat
inject ion deep to th e orbicularis oculi are possible
altern at ive solu t ion s an d are also e ect ive in
low ering th e risk of re-adh esion .
 18 Managem ent of Double-Eyelid Surgery Com plications 231

a b c

Fig. 18.10 Correction of high fold. (a) Resection of skin down to the newly created lower
crease. Resect only the skin, without resecting any scar tissue. (b) Adhesiolysis at the pre-
aponeurotic layer. (c) Con rm complete adhesiolysis by holding the upper skin ap. If ever-
sion remains, undermine the lower ap. (d) Fixate the lower ap at a lower point and close
d the skin.

Fig. 18.11 Failure in high fold correction.

(a) If the previous adhesion is incompletely
lysed, eversion of eyelid develops because
the lower ap is pulled up and adhered.
(b) Triple fold may also develop due to re-
adhesion of the previous adhesion site.
Previous adhesion site Previous adhesion site

New fixation site New fixation site

a b

5. To increase the resistance to inward folding of skin at

the initial operative site, a bulky roll of upper ap can
be m ade by suturing the skin and orbicularis together
after skin closure. The needle is passed through the
skin and orbicularis oculi beneath the new crease, then
through the orbicularis oculi and skin of the upper
ap. In addition to increasing eyelid resistance along
the length of the old crease, it separates the anterior
lam ella from the posterior lam ella (Fig. 18.13).
6. DuoDERM dressing (ConvaTec) an d adh esive t ape
can be used as a splin t to in crease fold resist an ce
over th e low er edge of th e u p per ap (Fig. 18.14).
a b
7. If correct ion of eversion is di cu lt du e to severe
Fig. 18.12 Remove only the skin and use the resected orbicu-
adh esion , inject ing or spraying dilu ted steroids m ay
laris muscle and scar tissue as an interposition ap to reinforce the h elp in th e postop erat ive period .
upper ap volume.
232 III Blepharoplast y
Fig. 18.13 Correction or prevention of triple fold. Creating a skin–
orbicularis oculi roll prevents re-adhesion.
8. Excessive skin excision w ill result in th e low er crease
being pulled up tow ard th e eyebrow s, result ing in
eversion . To preven t th is, th e low er ap can be xed
by secu ring it to a par t ial purch ase in th e t arsal plate
during closure. Th is is e ect ive in coun teract ing th e
upw ard pull from th e t igh t eyelid skin (Fig. 18.15).
9. Skin de ciency can be partially o set by un derm ining
a 2-m m m argin of skin in the upper ap.
Fig. 18.15 To prevent eversion in eyelids with de cient skin, x
the lower ap to the tarsal plate by biting through the tarsal plate
partially during skin closure.
Fig. 18.14 Adhesive tape or DuoDERM dressing can be used as a
splint to increase fold resistance over the lower edge of the upper
ap.
Partially High Crease or
Undesirable Curvature
A com m on m ist ake in correct ing a part ially h igh crease is to
part ially address th e problem . For exam ple, a part ial revi-
sion of on ly th e m ed ial side w ill in t rodu ce a kin k to th e cu r-
vat u re of th e crease su ch th at th e ou ter p or t ion w ill ap pear
h igh er th an th e m edial port ion . Th is could also in t rodu ce a
t riple fold appearan ce along th e m edial side.
Part ially h igh creases sh ould be repaired using th e sam e
prin ciples as h igh crease correct ion : skin excision , lysis of
adh esion s, an d xat ion . Th e n ew crease sh ou ld be allow ed
to p ar t ially overlap th e cou rse of th e p reviou s crease.
Pretarsal Fullness
Com m on ly obser ved w ith h igh creases, pretarsal fulln ess is
also described as “sau sage eyelid” am ong Korean p at ien t s.
It refers to th e u nw an ted soft t issu e p roject ion in th e area
over th e tarsal p late in p ostbleph arop last y eyelids. Preop -
erat ive factors th at p redict pretarsal fu lln ess in clu de th ick
eyelid skin an d orbicularis m uscle. Pat ien t s w ith th ese fea-
t ures sh ou ld receive eyelid folds th at are design ed low er
th an usual to coun teract th is propen sit y.
Pretarsal fulln ess in creases in propor t ion to th e
squ are of th e h eigh t of th e p ret arsal soft t issu e com part-
m en t , w h ich im plies th at sm all ch anges in h eigh t can
resu lt in great ch anges in th e volum e of th is com par t m en t
(Fig. 18.16). For exam p le, an eyelid crease th at ch anges
h eigh t from 4 to 3 m m w h en open ing th e eye w ill h ave a
volu m e redu ct ion close to 50% (9/16).
 18
F = ∂H²
F: fullness
∂: tissue variabilit y
H: height
H F F lid laxit y, brow h eigh t , crease h eigh t , an d crease sh ape.
H
F F
a b
Fig. 18.16 Relation bet ween height and fullness of pretarsal tis-
sue. Fullness of the pretarsal tissue is proportional to the square of
the height. The ∂ variable signi es the characteristic di erences in
individual eyelids, such as thickness of skin or amount of orbicu-
laris oculi muscle mass. (a) Eyes that are prone to develop fullness.
(b) Eyes that are less prone to develop fullness.
A com m on m iscon ce pt ion is t h at p ret arsal fu lln ess
can be cor rected by re m ovin g t h e con ten t s of t h e p ret -
arsal com p ar t m en t , su ch as t h e p ret arsal p or t ion of t h e
orbicu lar is m u scle. Th is at te m pt at red u cin g volu m e is
fu t ile for seve ral reason s. For on e, t h e rem oved volu m e
is rep lace d w it h brou s con n ect ive t issu e. An ot h er rea-
son is t h at t h e brou s t issu e in ter feres w it h t h e accord ian
e e ct of fold h eigh t be in g red u ced w it h op en in g of t h e
eye. Th is d e crease in elast icit y resu lt s in st at ic fu lln ess of
t h e com p ar t m en t . Th e t h ird reason is t h at t h e act u al soft
t issu e t h at re p rese n t s p ret arsal fu lln ess is t h e low e r m ost
2 to 4 m m of an op en eyelid . Rem ovin g soft t issu e in t h is
area is fraugh t w it h d i cu lt y becau se of t h e eyelash fol-
licles an d t h e m argin al ar ter ial arcad e.
To decrease th e soft t issue volum e in th e pret arsal
area, on e m u st recogn ize th e h eigh t-volu m e relat ion sh ip
m en t ion ed p reviou sly. On ce th is p rin cip le is u n derstood,
th e tech n ical solut ion is to perform a secon dar y operat ion
(open bleph aroplast y) to low er th e crease an d e ect ively
red u ce th e h eigh t an d volu m e of th e pretarsal soft t issu e
com part m en t .
Asymmetry
From th e perspect ive of clin ical m an agem en t , th ere are t w o
m ain cau ses of p ostop erat ive eyelid asym m et r y. In exp eri-
en ced su rgeon s often operate on a pre-exist ing asym m et r y
th at w as n ot n ot iced during th e preoperat ive exam in at ion .
A th orough exam in at ion sh ou ld in clu de p alpebral ssu re
h eigh t , redun dan cy of th e eyelid skin , h eigh t of th e brow,
an d u n equ al eyelash es.
Managem ent of Double-Eyelid Surgery Com plications 233
A less com m on cause of eyelid asym m etry is techn i-
cal failure on the part of the surgeon. Operative m aneuvers
m ust be self-consistent from the left to th e righ t eyelid. Sligh t
variations in design, incision, soft tissue rem oval, and xa-
tion can result in signi cant di erences in overall outcom e.
Con t ribut ing factors for pre-exist ing asym m et r y
in clude on e-sided bleph aroptosis an d di eren ces in eye-
Pat ien t s are u su ally m ore sen sit ive to th e d i eren ce
bet w een th e h eigh t s of eyelid creases th an to th e di er-
en ce bet w een th e p alpebral ssu re h eigh ts. Any exist ing
bleph aroptosis sh ould be corrected before double-eyelid-
plast y, but if th e di eren ce is m in im al an d th e pat ien t does
n ot w an t a blep h aroptosis correct ion , th e n ew eyelid crease
sh ould be m ade low er for th e ptot ic eyelid.
Un equal skin redun dan cy sh ould be addressed by a
greater am ou n t of skin excision , of cou rse. W h ile d oing
so, it is im p or t an t to adju st th e low er m argin su ch th at th e
crease h eigh t is equal on both eyelids. Correct ion of asym -
m etr y by var ying crease h eigh t is n ot recom m en ded, sin ce
it is tech n ically dem an ding. Even if th e result ing crease
h eigh ts ap pear equ al on p rim ar y gaze, th ere w ill be a dif-
feren ce on dow nw ard or u pw ard gaze. Addit ion ally, dow n -
w ard gaze w ill accen t u ate pretarsal fu lln ess on th e side
w ith skin redun dan cy.
Any brow asym m et r y sh ou ld be ad dressed before or at
th e tim e of bleph aroplast y. How ever, if th e pat ien t does n ot
w ish for an addit ion al operat ion or if th e asym m et r y is n ot
great en ough to w arran t an op erat ion , th en excising skin
on the elevated side m ay be a pract ical solut ion in a clin ical
set t ing, p rovided th at th e p at ien t is cou n seled adequ ately
regarding postoperat ive outcom es.
W h en both eyelid creases are h igh er th an usual, sm all
di eren ces in crease h eigh t usu ally do n ot lead to n ot ice-
able asym m et r y. In con t rast , low creases ten d to exacerbate
di eren ces in h eigh t an d th e eyelids w ill appear drast ically
asym m et ric.
Th e palpebral ssu re w ith a low er fold, or n o fold at all,
w ill appear sm aller because th e skin appears droopy. Th is
sit u at ion is often overlooked or m ist aken for u n equ al or
un ilateral bleph aroptosis. W h en asym m et r y of th is t ype is
su spected, th e palp ebral ssu re sh ou ld be com p ared from
left to righ t w h ile u sing a st ylus to create equal eyelids.
Th e operat ion sh ou ld be perform ed in th e u sual m an n er—
ign oring th e illusion of asym m et r y—by design ing both
fold s at th e sam e h eigh t .
Multiple Creases (Triple Folds)
Mu lt ip le eyelid creases, or t rip le folds, can form for vari-
ous reason s an d can be classi ed by clin ical presen t at ion
(Fig. 18.17).
Prim ar y t riple folds are foun d in pat ien ts w ith ou t any
prior su rgical h istor y an d are caused by th e loss of fat vol-
234 III Blepharoplast y

a
b
c

Fig. 18.17 The height of extra folds corresponds to the underly-

ing cause. (a) De ciency or excess removal of orbital fat. (b) Excess
removal of connective tissue and/or ROOF. (c) Excess removal of
orbicularis oculi muscle.
Fig. 18.18 Triple fold from excision of connective tissue. Removal
of the oculi muscle in the upper ap (upper arrow) can result in
triple fold. This is especially true when the oculi muscle excision is
further away from the xation point (bottom arrow, loop).
u m e (su bcu t an eou s or deep fat) in th e u p per eyelid above
a n at u rally exist ing su p ratarsal fold. Th is p resen tat ion is
w ith in th e spect rum of sun ken eyelids an d develops over a
placem ent of well-organized septum and orbital fat bet ween
relat ively long t im e p eriod . Most often , prim ar y t rip le folds
the orbicularis oculi and the levator aponeurosis. The post-
are p resen t ing sym ptom s in eld erly p at ien ts an d in p at ien t s
orbicularis fascia and m uscle are lowered from the previous
w h o h ave lost sign i can t body w eigh t .
site of adhesion and anchored to the tarsal plate (Fig. 18.22).
Secon dar y t riple folds are p resen t in p at ien ts after th e
in dex blep h aroplast y. Overzealou s soft t issue rem oval in
th e upper ap can create adh esion an d subsequen tly result
in an ext ra eyelid crease above th e su rgically created fold.
In p ar t icu lar, rem oval of th e m ed ial ret ro-orbicu laris ocu li
fat (ROOF) m ay lead to t riple fold an d sh ou ld be avoided. At
t im es, pret arsal or pre-apon eurot ic soft t issue is rem oved Area of fixation
to facilitate adh esion an d form at ion of th e eyelid crease. Area of soft
How ever, rem oval of th is t issu e above th e poin t of xat ion tissue rem oval
sh ou ld be avoided becau se it m ay resu lt in t rip le fold for-
m at ion (Fig. 18.18 an d Fig. 18.19).
Tert iar y t riple folds form after secon dar y operat ion s for
correct ion of h igh fold, ect ropion , or eyelid ret ract ion . Th e
ext ra creases are all con sequ en ces of re-ad h esion from p re- a
vious operat ion s (Fig. 18.20 an d Fig. 18.21).
If th e ext ran eou s crease is sh allow, fat inject ion alon e
m igh t be en ough to bolster th e skin an d preven t fu r th er A line in high risk of
triple fold form ation
p rogression of th e crease. Min or adh esion s can be released Area of soft
u sing an 18-gauge n eedle su bcision , bu t th is does n ot tissue rem oval
allow for in terposit ion ap s. In m ost cases, open access is Area of fixation
requ ired for m et iculous release of adh esion s an d to per-
form p reven t ive m easu res.
The upper ap should be released bet ween the levator
aponeurosis and orbital septum . Usually, this division alone
is su cient in releasing the adhesion form ing the extrane-
ous crease. If this is not the case, however, the space bet ween b
the postorbicularis fascia and the orbital septum should be Fig. 18.19 Soft tissue removal and area of xation. (a) Fixation
cleared for additional separation of outer and inner elem ents. should be done at the highest point of soft tissue removal. (b) If
The later plane of dissection should be m ore extensive and xation is done lower than the area of soft tissue removal, a triple
extend superiorly. Re-adhesion is prevented by inferior dis- fold can be formed at the area of soft tissue removal.
 18 Managem ent of Double-Eyelid Surgery Com plications 235

Previous
fixation level
New fixation level

Fig. 18.20 In case high xation is lowered, a triple fold can

develop because a double fold can easily develop at the area of the
previous xation site.

Fig. 18.21 Triple fold formation by absence of xation point. (a)

Point of xation (x) descends after blepharoptosis correction, which
has the e ect of correcting and preventing triple fold. (b) On the
other hand, and by the same principles, the absence of a xation
point by levator muscle recession during the correction of retracted
eyelid can result in triple fold.

a b c

Fig. 18.22 Correction or prevention of triple fold. (a) If the release of the upper ap bet ween the levator aponeurosis and the orbital
septum is not su cient to correct the triple fold, the space bet ween the postorbicularis fascia and the orbital septum should be dissected
extensively and superiorly for additional separation of outer and inner elements. (b) Re-adhesion can be prevented by inferior displace-
ment of well-organized septum and orbital fat bet ween the orbicularis oculi and the levator aponeurosis. (c) The postorbicularis fascia and
muscle are lowered from the previous site of adhesion and anchored to the tarsal plate.
236 III Blepharoplast y
An oth er m eth od to p reven t re-adh esion is to create a
roll w ith th e skin an d orbicu laris ocu li m u scle of th e u pper
ap . Th e m eth od is to pass th e n eedle th rough th e skin
an d orbicu laris ocu li ju st ben eath th e crease, th en th rough
th e orbicularis oculi an d skin of th e upper ap, creat ing a
sligh tly bu n ch ed kin d of roll (Fig. 18.13).
Postop erat ive blep h aroptosis can coexist w ith m u lt iple
creases. In such cases, early correct ive operat ion for ptosis
is e ect ive in separat ing th e an terior and posterior layers,
w h ich w ere previously adh ered.5
Sunken Eyelid/Primary Triple Fold
Su n ken eyelid s occu r from de cien cy of orbit al fat or soft
t issue an d rarely from adh esion bet w een super cial an d
deep st ruct ures. For th is reason , prim ar y t riple fold an d
su n ken eyelids can be th ough t of as a single clin ical en t it y.
As su ch , t reat m en t for sun ken eyelid is sim ilar to t reat m en t
for p rim ar y t rip le fold.
The lost volum e of soft t issue can be replenished by
fat injection , derm ofat graft , or grafting of oth er soft tis-
su es such as m u scle fascia (Fig. 18.23 an d Fig. 18.24). Fat
inject ion to th e subcutan eous layer or oculi m uscle layer
can create irregularit y in text ure. Microfat inject ion in the
deeper plane bet w een the orbicularis oculi m uscle and the
sept um redu ces th e poten tial for surface irregularit y. How -
ever, inject ing into th e deeper layer h as the poten tial for
levator m uscle injur y, w hich w ould result in bleph aroptosis.
Injection in to the ROOF can also cause blepharoptosis from
the added w eight, although this is usually t ransient . Never-
theless, th e risk of this com plication can be m inim ized by
inject ing the fat just above the periosteum w hile the upper
eyelid is pulled upw ard and th e eyes are w ide open . This
b Fig. 18.24 Correction of sunken eyelid by dermofat graft. (a) A
Fig. 18.23 (a) Preoperative sunken eyelid is (b) corrected with
microfat injection.
w ill en sure th at th e levator m uscle is w ell w ithin the orbital
rim an d w ill decrease th e w eigh t bu rden on th e m u scle.
Inject ing fat in to th e orbicu laris ocu li m u scle can be
e ect ive for a t rip le fold cau sed by an adh esion w ith in a
su p er cial layer. In m ost cases, h ow ever, th is can n ot be rec-
om m en ded becau se of th e problem w ith surface irregulari-
t ies. Fat can be injected ben eath th e orbital sept u m if th e
sept u m can be visu alized by an in cision . Th e graft su r vival
rate is relat ively h igh , w ith m in im al risk of surface irregu-
larit y or lum p form at ion w ith closed eyelid s. It is, h ow ever,
n ot a w idely pract iced tech n ique an d m ay rep resen t a ch al-
lenge in term s of tech n ical kn ow h ow.
Blepharoptosis
In th e im m ediate postop erat ive p eriod, m ild to m oder-
ate blep h aroptosis m ay sim p ly be due to edem a, w h ich
is t ran sien t an d w ill disap pear. If a m oderate to severe
bleph aroptosis does n ot recede w ith edem a, th e surgeon
m u st su spect inju r y of th e levator apon eu rosis as a cau se
(Fig. 18.25).
a
sunken eyelid is marked on the left upper eyelid. (b) Intraoperative
view shows dermal fat before graft. (c) Postoperatively, the sunken
eyelid is corrected.
 18 Managem ent of Double-Eyelid Surgery Com plications
a be approxim ated and plicated m inim ally so that the Müller
b
c a su rgically created eyelid fold . Th e rst is th at a visible scar
Fig. 18.25 Correction of postoperative blepharoptosis. (a) The
patient su ered from bilateral high fold and traumatic blepharop-
tosis following blepharoplast y. (b) Intraoperative nding of the
dehiscent levator aponeurosis from the tarsus. (c) Postoperative
photo.
Th e m ost com m on locat ion at w h ich th e levator
m ech an ism is violated is at th e ju n ct ion bet w een th e leva-
tor apon eurosis an d th e u pper border of th e t arsal plate.
W h ile soft t issue excision along th e top m argin of th e t arsal
p late is n ecessar y at t im es to in d uce derm ot arsal xat ion ,
rem oval of soft t issue su perior to th e tarsal p late can vio-
late th e bers con n ect ing th e apon eurosis to th e plate. Th e
resu lt ing bleph aroptosis m ay n ot be n ot iced in th e im m e-
d iate p ostop erat ive p eriod becau se of th e edem a an d th e
com pen sat ion by th e Mü ller m uscle. Over th e n ext several
years, th e Mü ller m u scle u n dergoes m ech an ical failu re
from th e dem an d of op en ing th e eyelid w ith ou t th e h elp
of th e levator apon eurosis. Th is is th e m ost likely scen ario
for delayed blep h aroptosis in p at ien t s w h o h ave h ad dou ble
eyelid op erat ion s m ore th an a decade ago.
The levator function test is especially im portant for
elderly patients. Com pensating by brow elevation m ay also
m ask m in im al blepharoptosis. As stated previously, m inor
unilateral blepharoptosis can easily be m issed and becom e a
cause for unexpected postoperative asym m etry. Likew ise, it
is im portant to distinguish bet w een true ptosis (levator fail-
ure) and derm atochalasis (drooping skin) in elderly patients.
237
If levator m uscle injury is recognized, the surgeon should
consider w hich tissue to advance and by how m uch. This
advancem ent w ill stretch out the levator or the Müller m uscle,
so it is im portant to assess the tension through the full thick-
ness of the levator m echanism . The injured tissues should
m uscle is m inim ally stretched. If the injury was to the upper
septum w ith resultant adhesion, sim ply releasing the adhe-
sion m ay free the levator and correct the blepharoptosis.4,6
In iat rogen ic blep h aroptosis cases, th e p at ien t m u st
un derst an d beforeh an d th e goals an d lim it at ion s of th e
operat ion . Th e goal is to ach ieve a n orm al an d sym m et ric
eld of vision on p rim ar y gaze. How ever, th e levator m u scle
m ay lack th e n orm al range of m ot ion from brot ic ch anges,
an d th e pat ien t m u st u n derst an d th at lid lag or lagop h th al-
m os can p ersist after w ard.
Removal of the Eyelid Fold
Several fact s m u st be p resen ted by th e su rgeon , an d th ose
fact s sh ou ld be u n derstood by th e p at ien t before rem oval of
w ill be presen t even w h en th e eyes are open . Th e secon d
is th at th e fold can reappear w ith t im e. Th e th ird is th at
th e eyelid m ay appear an d feel bulkier du e to th e scar t is-
su e, inject ion of fat graft , or in ferior disp lacem en t of fat an d
sept u m dow n to th e area in risk of re-adh esion .6
Becau se of th ese poten t ial issues, th e auth ors u sually
recom m en d an in n er eyelid fold rath er th an tot al rem oval
of the eyelid fold. In n er eyelid folds are created in a m an -
n er sim ilar to th e op erat ion of correct ing h igh creases. Th e
adh esion form ing th e exist ing crease is decon st ru cted, an d
orbit al fat an d sept u m are in terposed bet w een th e layers
to preven t re-adh esion . Eversion sh ou ld be ach ieved d u r-
ing skin closu re. Th e in cision site is t aped for a m in im um
of one w eek.
■ Key Technical Points
1. To preven t loss of folds, th e sut ure m ust be t ied
w h ile avoiding th e in t ru sion of soft t issue bet w een
th e levator apon eurosis an d derm is.
2. Correct ion of h igh crease can involve dissect ion
th rough eith er th e pre-apon eurot ic or pre-sept al
layer. Despite th e poten t ial injur y to th e Mü ller
m u scle or levator ap on eu rosis, th e p re-apon eu rot ic
space is associated w ith low er rates of t rip le fold
form at ion an d allow s a ptosis op erat ion .
3. Preven t ion an d correct ion of t riple fold are th e
sam e: Th e su rgeon m u st separate th e an terior an d
posterior lam ellae by all m ean s available—in cluding
th e in terposit ion of orbit al fat in to th is space.
238 III Blepharoplast y

■ Case Studies
Case 1: Triple Fold and Ptosis
A 49-year-old fem ale h ad u n d ergon e a dou ble fold op era-
t ion 11 years previously, w h ich resu lted in t riple fold of
th e righ t upper eyelid 3 m on th s after th e in it ial operat ion .
Recen tly, th e pat ien t h ad un dergon e u pper bleph aroplast y a
to address th e t rip le fold bu t exp erien ced im m ediate post-
operat ive ptosis w ith persisten t t riple fold an d eccen t ric
crease. On exam in at ion , th e pat ien t w as foun d to h ave a
ptot ic u pper eyelid w ith part ial pupil coverage on th e righ t
side (Fig. 18.26a). Th e di eren ce in MRDs w as 2 m m .
Th e pat ien t con sen ted an d un der w en t an open u pper
bleph aroplast y w ith ptosis correct ion of th e righ t eye. Th e
t riple fold w as addressed as described previously, w ith
adh esiolysis an d in terp osit ion of fat bet w een th e an terior b
an d p osterior lam ellae. A bu lky su bcu tan eou s roll w as cre-
ated w ith th e orbicularis oculi m uscle to in crease fold resis- Fig. 18.26 Case 1. Revision of triple fold and ptosis. (a) A 49-year-
tan ce above th e n ew ly establish ed crease. Th e upper ap old female patient presented with eccentric crease and ptosis of the
right upper eyelid after revision upper blepharoplast y. The patient
w as sp lin ted w ith Du oDERM to preven t inw ard folding of
underwent adhesiolysis and interposition of septal fat bet ween the
th e skin . A postoperat ive ph otograph at 6 m on th dem on - anterior and posterior lamellae. A bulky subcutaneous roll was cre-
st rates resolu t ion of th e t rip le fold w ith acceptable sym - ated with orbicularis oculi muscle to increase fold resistance above
m et r y of th e u p per eyelid m argin s (Fig. 18.26b). the newly established crease. (b) Postoperative photograph at 6
months demonstrates resolution of the triple fold with acceptable
symmetry of upper eyelid margins.
Case 2: Triple Fold and Deep Fold
A 46-year-old fem ale w ith a h istor y of m u lt ip le u p per an d
low er bleph aroplast ies presen ted w ith variou s com plica-
t ion s. Her h istor y is m ost relevan t for th e double-eyelid
operat ion 3 m on th s prior, w ith a h igh crease in th e righ t
eye as th e m ajor com plicat ion . Th e pat ien t un der w en t an
u n successfu l revision , an d presen ted 2 w eeks after w ard.
On exam in at ion , th e righ t eyelid w as n ot able for m u lt ip le
creases an d ptosis. Th e left eyelid fold w as deep an d sh ow ed
a sligh tly ect ropic feat u re (Fig. 18.27a). a
The recom m en dat ion w as to correct th e im m ediate
fu n ct ion al p roblem in th e righ t eyelid an d to address th e
deep fold in th e left eye at a later t im e. Du ring th e in t raop -
erat ive explorat ion of th e righ t lid, th e levator ap on eu ro-
sis w as fou n d n ot to be in con t in u it y w ith th e tarsal plate.
Th e adh esion s respon sible for m ult iple creases w ere lysed,
an d th e m edial sept al fat w as m obilized an d in terp osed
bet w een th e an terior an d posterior layers. Th e upper ap
w as sp lin ted w ith Du oDERM CGF u pon skin closu re. Th e b
outcom e w as sat isfactor y. Th e ptosis w as corrected, an d th e
m ajorit y of ext ran eou s folds did n ot reap p ear. Six m on th s Fig. 18.27 Case 2. Revision of triple fold and deep fold. (a) A
later, th e pat ien t un der w en t a su ccessfu l bleph aroplast y of 46-year-old female patient presented with a high, triple fold with
ptosis in the right eye and deep, slightly ectropic left eyelid after
th e left eyelid, w ith resolut ion of th e deep fold an d ect ro-
multiple upper and lower blepharoplasties. In the right eye, the
pion (Fig. 18.27b). adhesions were lysed and the medial septal fat was mobilized and
interposed bet ween the anterior and posterior layers. Correction
of deep fold and ectropion of the left eye was done 6 months after
right eye surgery. (b) Six-month postoperative view shows resolu-
tion of the preoperative problems.
 18
■ Conclusion
Com plicat ion s after bleph aroplast y are too n um erous an d
varied to allow a com p reh en sive discu ssion w ith in th is
ch apter, but th e basic prin ciples of recon st ruct ive surger y
are app licable to a m ajorit y of th ese com p licat ion s. Th e
rst p rin cip le is to u n derst an d th e n orm al an d abn orm al
fu n ct ion an d an atom y of th e eyelid. Th e secon d prin ciple
is to u n do, or decon st ru ct , th e postoperat ive t issu e ch anges
causing th e com plicat ion . Th e th ird prin ciple is to redo th e
in it ial op erat ion w ith out m aking th e sam e m ist ake.
Managem ent of Double-Eyelid Surgery Com plications 239
References
1. Kim YW, Park HJ, Kim S. Secondary correction of unsatisfac-
tory bleph aroplast y: rem oving m ultilam inated septal struc-
t ures and grafting of preaponeurotic fat. Plast Reconstr Surg
2000;106(6):1399–1404, discussion 1405–1406
2. Ch en W P. Th e con cept of a glide zon e as it relates to upper
lid crease, lid fold, an d ap p licat ion in u p per blep h arop last y.
Plast Recon st r Su rg 2007;119(1):379–386
3. Kim YW, Park HJ, Kim S. Revision of un favorable double
eyelid operat ion by reposit ion ing of preapon eurot ic fat . J
Korean Soc Plast Recon st r Su rg 2000;27(2):99–104
4. Ch o IC. Th e Art of Bleph aroplast y. Seou l, South Korea:
Koonja Pu blish ing; 2013:84–124
5. Lew DH, Kang JH, Ch o IC. Surgical correct ion of m ult iple
u pper eyelid folds in East Asian s. Plast Recon st r Surg
2011;127(3):1323–1331
6. Ch ang SH, Ch en W P, Ch o IC, Ah n TJ. Com preh en sive review
of Asian cosm et ic upper eyelid oculoplast ic surger y: Asian
bleph aroplast y an d th e like. Arch Aesth et ic Plast Surg
2014;20(3):129–139
IV
Facial Bone Surgery
19 Zygoma Reduction
Sanghoon Park and Jihyuck Lee
Pearls
• The aim of zygom a reduction is to reduce the w idth
of the cheekbone, thus changing the boxy at facial
shape into a three-dim ensional contour and achieving
a sm ooth, fem inine facial line.
• Bizygom at ic w idth an d volu m e an d th e posit ion
of th e zygom at ic body are th e key variables to be
evaluated, an d th e am ou n t of body ostectom y is
determ in ed during th e surger y.
• Th e zygom at ic body an d arch are usually m oved
m edially, posteriorly, an d som et im es su periorly
during th e surger y; th e poin t of m axim al m alar
project ion is m arked an d it s n ew posit ion carefu lly
plan n ed.
• In zygom a red u ct ion overall facial sh ap e, in clu ding
m an dible p rom in en ce an d facial h eigh t , sh ou ld be
■ Introduction
Asian people ten d to h ave a sh orter an d w ider facial con tour
com pared w ith Western ers. Th e prom in en t m alar com plex
com bin ed w ith th e prot ruding angled part of th e low er jaw
creates a boxy rath er th an oval-sh aped face. W h en view ed
from below, th e at m idface an d w id e ch eekbon es also
create a boxy appearan ce. Th ese facial ch aracterist ics are
t yp ical of th e Mongoloid face (brachyceph alic face), w h ile
th e Caucasian face is slim an d prot ruding in an an terior-
posterior dim en sion (dolicoceph alic face) (Fig. 19.1). Con -
ven t ion al st an dards of beau t y var y across di eren t cu lt u res
an d eth n icit ies. How ever, aesth et ic st an dards in th e cou n -
t ries of East Asia h ave becom e m ore “global” an d in uen ced
by Caucasian st an dards. Asian s seek a slim m er face w ith a
th ree-dim en sion al appearan ce.
Th is discrepan cy in racial ch aracterist ics an d ch anges
in beau t y st an dards led to a rise in in dividu als desiring
to ch ange th eir facial con tou r an d sh ape. In East Asian
coun t ries su ch as Korea, Ch in a, an d Japan , facial con tou r-
ing su rger y is ver y pop ular an d com m on ly perform ed to
at t ain a m ore slen der an d sm ooth facial con tou r. Recen tly,
th is t ren d h as spread to oth er par ts of Asia and am ong th e
Asian s living in Western coun t ries.
However, sim ply ch anging the Mongoloid face in to a Cau-
casian face does not guarantee a satisfactory result in Asian
countries, because Asians have di erent aesthetic goals and
di erent cultural backgrounds. For exam ple, prom inent high
con sidered. Cau t ion sh ou ld be taken for pat ient s
w ith a long face, as th ere is a risk for th e face to
ap pear longer after th e su rger y.
• Reduct ion m alarplast y can be perform ed solely or in
com bin at ion w ith m an dible reduct ion , gen ioplast y,
or foreh ead augm en tat ion .
• Soft t issu e p lays a great role in redu ct ion
m alarp last y. In p at ien ts w ith abu n dan t ch eek fat , th e
slim m ing e ect is less obviou s an d ch eek drooping
is m ore probable.
• Th e follow ing ve factors are con sidered h igh risk
for skin an d soft t issue sagging: (1) over 40 years of
age, (2) abu n dan t ch eek fat , (3) th in skin an d skin
laxit y, (4) class II m an dible or ill-de n ed m an dible
n eck line, (5) deep n asolabial fold or jow l.
ch eekbones are considered a sym bol of youth an d adm ired
in Western countries. How ever, the sam e prom inent cheek-
bones are considered aesthetically unpleasing for Asian
wom en as th is feature gives a h arsh, strong im pression.
Therefore, before the surgery, surgeons should be well aw are
of the goals of zygom a reduction in Asians.
Pat ien t s w h o seek zygom a redu ct ion are th ose w h o
desire a slim an d slen der oval face w h en view ed from th e
fron t . Peop le w ith a brachycep h alic face ch aracterized by
a at foreh ead an d m id face describe th eir face as boxy in
sh ape. Th ey desire a th ree-dim en sion al an d volu m in ou s
face. Peop le w ith prom in en t h igh ch eekbon es com p lain
th at th ey look “too st rong,” “o en sive,” “old,” “t ired,” an d
“m ascu lin e,” an d th ey w an t to ch ange th eir faces to h ave a
m ore “soft ,” “you ng,” an d “fem in in e” app eal.
Th e object ives of zygom a reduct ion are as follow s:
1. Reduct ion of facial w idth for slender facial con tour.
First an d forem ost , th e aim of zygom a reduct ion is
to acquire a m ore slender and n arrow facial contour.
Usually facial w idth is determ in ed by th e bizygom atic
distance w hich links the articular t ubercles on
the t w o sides. Reduction or t ran sposition of the
zygom atic arch is an e ect ive m ethod to reduce
facial w idth . As th e zygom atic body is usually
hypert rophied together, reducing only the zygom atic
arch m ay lead to a boxy appearan ce; th u s, com bin ed
an d h arm on ious reduct ion of arch w idth an d
zygom atic body is essential.
243
244 IV Facial Bone Surgery

■ Patient Evaluation
Direct physical exam in at ion is th e key p rocess to evalu -
ate th e pat ien t’s problem s an d establish a surgical p lan .
Clin ical ph otos are n ecessar y, as is radiologic exam in at ion
in cluding fron t al view, lateral view, subm en tover tex view,
an d Waters’ view. A com p u ted tom ograp hy (CT) scan w ith
3D view is also essen t ial to evaluate th e sh ape of th e zygo-
m at ic com plex.
Th e volum e an d posit ion of th e zygom at ic body, an d
a b th e bizygom at ic w idth are key variables to be con sidered.
Th e volum e of th e zygom at ic body determ in es th e am oun t
Fig. 19.1 Bony facial morphology at the level of the cheekbone
in axial section. Compare the (a) dolicocephalic Caucasian face and of ostectom y requ ired during th e su rger y. If th e volum e is
the (b) brachycephalic Asian face. large, a w ider resect ion of th e zygom at ic body sh ou ld be
plan n ed. How ever, over-zealous reduct ion results in a at
or de cien t look. Th erefore, keeping an adequ ate volum e of
th e zygom at ic body in th e an tero-posterior dim en sion an d
t ran sverse plan e is essen t ial.
Th e posit ion of th e zygom at ic body is m easured both at
2. Ch ange a boxy at facial sh ape in to a th ree- it s m ost lateral m argin and in it s m axim al project ion . Th e
dim en sion al con tour. Even if facial w idth is reduced, outer m argin of th e zygom at ic body is obser ved in conjun c-
th e face can st ill appear squ are.1 Asian faces h ave t ion w ith tem ple an d ch eek. To n arrow th e an terior m id-
a brachyfacial ch aracterist ic w ith a at su borbit al facial w id th , th e lateral m argin of th e ch eekbon e sh ou ld
area. W h en view ed from below, th e lack of m alar
project ion result s in th e suborbit al area an d
zygom at ic arch form ing a 90-degree angle th at len ds
a boxy app earan ce. In th is case, th e face ap p ears
at an d t w o-dim en sion al, an d even w ider th an it
ap pears from th e fron t . Th erefore, ch anges in th e
sh ape an d p osit ion of th e zygom at ic body are n eeded
to create a m idface fu lln ess th at ap pears m ore th ree-
dim en sion al an d youth ful.
3. At t ain a sm ooth facial lin e th at looks m ore fem in in e
an d you ng. An angu lar face lin e n eeds to be m ade
soft . In th e case w h ere th e ch eekbon es prot ru de
out w ardly, th e facial lin e con n ect ing th e tem ple-
zygom a-ch eek-m an dible angle con st it u tes a ver y
convoluted lin e (Fig. 19.2). In th e case of Western ers,
prom in en ce of th e zygom at ic body is a sym bol of
beaut y an d you th fuln ess. How ever, for Asian s this
prom in en ce result s in an obst in ate an d m asculin e
look, w h ich gives a n egat ive im pression . High
ch eekbon es are n ot an ideal look in Asian cu lt ures;
th erefore, reduct ion is n eeded to m ake th e face soft
an d fem in in e. For th ose over th e age of 35, facial
soft t issu e decreases an d skin start s to droop ; m alar
em in en ce looks even m ore pron ou n ced an d cau ses
grooves in th e ch eek an d tem ple, gradu ally resu lt ing Fig. 19.2 Anterior and posterior facial contour lines. The anterior
in a t ired an d aged look. Fat inject ion s to su ch h ollow facial contour line connects the temple, zygomatic body, cheek,
and mandible body (red line), while the posterior facial contour line
areas can be an easy opt ion , bu t th e resu lt is n ot
connects the temple, zygomatic arch, m andible angle, and chin
predict able or perm an en t . Zygom at ic reduct ion is a
(blue line). If the anterior contour line is too convoluted, the patient
good opt ion for th e m idd le-aged w om an w h o desires gives a “strong,” “o ensive,” “old,” “tired,” “m asculine” impression.
a you th fu l, soft , an d fem in in e facial con tou r. The posterior contour line re ects the facial width and facial size.

be t rim m ed or m oved inw ard. If th e outer m argin of th e
ch eekbon e is placed w ide, th e am oun t of n arrow ing an d
m edializat ion sh ou ld be m axim ized an d ostectom y sh ou ld
be com bin ed.
The poin t of m axim al m alar project ion (MMP) is the
point w here the outer contour of the zygom atic com plex
prot rudes m ost in the basal three-quarters view. If the
reduction of th e zygom atic body is perform ed by sh aving, or
the osteotom y is placed lateral to the MMP, this point stays
u n ch anged w h ile th e outer m argin of th e zygom at ic body
is n arrow ed, result ing in an unn at u ral, box-sh aped cheek-
bone. As stated before, the purpose of reduction m alar-
plast y is not resection of th e projection ; therefore, adequate
projection and posit ion of the MMP is the key postopera-
t ive result. The point of MMP is m arked and the surgeon
decides w here to m ove this point three-dim ension ally. The
am oun ts of m edial reposition ing an d ostectom y are closely
related to th e reduct ion of anterior facial w idth .
Th e ideal posit ion of th e MMP m ay var y am ong dif-
feren t eth n icit ies; h ow ever, th e follow ing are t w o sim p le
m eth ods of determ in ing th e ideal posit ion of th e MMP
(Fig. 19.3).
1. Hinderer analysis. Th e MMP is determ in ed at th e
p oin t of in tersect ion of t w o lin es, w h ere th e rst
lin e con n ect s th e lateral can th u s an d th e oral
com m issure, an d th e secon d lin e con n ect s th e n asal
alar base an d th e t ragu s lin e. Th e n ew locat ion is a
p oin t p laced in ju xt ap osit ion to th e crossed lin es in
th e upper outer quadran t .2
2. W ilk inson analysis. A lin e is d rop p ed vert ically
d ow nw ard from th e lateral can th u s to th e in ferior
border of th e m an dible. Th e MMP is located at on e-
th ird th e dist an ce from th e lateral can th us to th e
angle of th e m an dible.3
a b
Fig. 19.3 Determ ining the ideal position of the maximal malar projection (MMP). (a) Hinderer analysis. (b) Wilkinson analysis.
19 Zygom a Reduction 245
On ce th e su rgical variables for th e zygom at ic body are
evaluated, th e bizygom at ic w idth is m easured, an d th e
requ ired am ou n t of arch m edializat ion , w h ich is crit ical in
th e reduct ion of posterior facial w idth , sh ould be decided.
Th e posterior basal por t ion of th e arch , w h ich is posterior
to th e osteotom y, can n ot be m edialized an d sh ou ld be care-
fu lly sh aved to p reven t visible step . Too m u ch arch redu c-
t ion w ith th e rem ain ing zygom at ic body w ill resu lt in a at ,
boxy face. To avoid th is outcom e an d create a full m idface
con tour, th e redu ct ion of th e zygom at ic body an d arch
sh ou ld be coordin ated an d balan ced.
Th ere are m any variables th at n eed con siderat ion dur-
ing surger y, an d th ese sh ould be decided by th e above-
m en t ion ed evalu at ion . Variables of th e zygom at ic body are
(1) am oun t of ostectom y, (2) am oun t of m edializat ion , (3)
am ou n t of setback, an d (4) su p erior or in ferior posit ion -
ing. Variables of th e zygom at ic arch are th e am oun t of arch
m edializat ion an d th e sh aving qu an t it y of th e p osterior
area of th e ar t icu lar t u bercle.
Facial soft t issu e is an im port an t aesth et ic com pon en t
in zygom a redu ct ion an d sh ou ld be con sid ered before an d
during th e surger y. If th e pat ien t h as th in fair skin w ith
m in im al ch eek fat , th e ch anges after bon e su rger y w ill be
obvious an d th e ch an ce of soft t issu e drooping is m in im al.
Th is pat ien t is a good can didate for zygom a reduct ion .
How ever, bony step , especially arou n d th e orbit , m ay be
visible an d th e p late m ay be palp able th rough th e th in skin .
Su rgeon s sh ou ld t ake ext ra e or t to en su re a sm ooth t ran -
sit ion bet w een bony osteotom y. If th e p at ien t h as abu n -
dan t ch eek soft t issu e, or th ick skin , th ere is a h igh risk of
ch eek drooping. Th e pat ien t sh ould be in form ed about th e
possibilit y of ch eek drooping an d appropriate adjun ct ive
m easu res, in clu d ing liposu ct ion or lift ing p rocedu res. If th e
pat ien t h as a th ick m alar fat pad, th e zygom at ic body sh ould
be sligh tly over-corrected to preven t un der-correct ion .
246 IV Facial Bone Surgery
Overall facial shape, in cluding m andible prom inen ce
an d facial length, sh ould be considered (Fig. 19.4). Zygom a
reduction can be perform ed solely or in com bination w ith
m andible reduction. If the patient has a prom inen t m an di-
ble, reduction m alarplast y alone m ay not be able to balance
bigonial and bizygom atic w idth, and com bined m andible
reduction should be recom m ended. If a patient has a long
face w ith prom inent ch eekbones, a reduction in bizygom atic
distance deteriorates the excessively narrow ed long face and
leads to “cucum ber face.” It is advisable to focus on the set-
back of the zygom atic body instead of the m edialization of
body and arch, and selectively create a soft facial contour.
■ Surgical Techniques
Th e surgical tech n ique an d approach for zygom a reduct ion
w as developed in 1983 w h en On izu ka et al4 in t rodu ced th e
ch iseling an d sh aving m eth od for th e protru ding por t ion
of th e m alar bon e via in t raoral in cision . Di eren t surgical
tech n iqu es h ave been devised, such as bone sh aving, in -
fract u re of th e zygom at ic arch ,5 an d osteotom y/ostectom y
of th e zygom at ic body.2,6,7,8,9 Bon e sh aving is th e sim plest
an d m ost st raigh tfor w ard m eth od, an d can be u sed for lim -
ited, localized prot ru sion of a zygom at ic body. How ever,
sh aving of th e zygom at ic body m ay lead to th e exp osu re of
can cellous bon e, result ing in u npredictable resorpt ion an d
p ostop erat ive irregularit y 10 ; th u s, th ere is a lim it at ion on
th e am oun t of resect ion , and th e overall size of th e zygo-
m at ic body can n ot be redu ced w ith th is m eth od. Du e to th e
th ickn ess of th e in st rum en t, th e sh aving m eth od can n ot be
ap plied to th e zygom at ic arch to red u ce th e overall facial
w idth .11 Th e in -fract u re tech n ique 5 is a useful m eth od in
redu cing th e p rot rusion of th e zygom at ic arch . Su rgeon s
u su ally con du ct osteotom y of th e zygom at ic arch , avoid-
ing a full-d epth cut an d m ain tain ing th e con t in uit y of
th e periosteum (green st ick),10 an d push ing th e zygom at ic
segm en ts m edially. Its m ajor advan t ages are sim plicit y
an d sp eed; h ow ever, it carries th e risk of an u n con t rolled
am ou n t of in -fract u ring in th e zygom at ic arch , an d it h as a
lim ited e ect on a prom in en t zygom at ic body.
An L-sh ap ed osteotom y of th e zygom at ic body is th e
preferred m eth od for pat ien ts w ith m oderate to severe
m alar p rot ru sion du e to w ide zygom at ic arch an d prom i-
n en t body. An L-sh aped osteotom y is m ade in th e an terior
part of th e zygom at ic body an d a separate osteotom y is
m ade in th e posterior p art of th e zygom at ic arch . With or
w ithout rem oval of bon e,6 a zygom at ic segm en t is m oved
to th e desired p osit ion an d xed w ith w ires or p lates an d
screw s. Th e L-sh ap ed osteotom y tech n iqu e can ch ange
both th e zygom at ic body an d arch an d h as th e advan tage
of con t rolling th e degree of reduct ion as w ell as th e sh ape
after red u ct ion . As p at ien t s u su ally d esire ch ange in th e
zygom at ic body an d arch , L-sh aped osteotom y is curren tly
th e m ost frequ en tly used an d preferred m eth od in zygo-
m at ic redu ct ion (Fig. 19.5).
Tr
Ft Ft
Zy Zy
Go' Go'
Me'
Zy – Zy
= 70 – 75%
Tr – Me'
Ft – Ft
= 80 – 85%
Zy – Zy
Go' – Go'
= 70 – 75%
Zy – Zy
Fig. 19.4 Evaluation of facial harm ony. Facial harmony should be
considered bet ween midfacial width (Zy–Zy) and lower facial width
(Go′–Go′), and bet ween midfacial width and upper facial width (Ft–
Ft). The ratio bet ween the height (Tr–Me′) and the width of the face
should be in proportion.
Th e approach for zygom a redu ct ion can be sim ply
divided in to t w o part s: th e extern al approach (coron al in ci-
sion , tem p oral in cision , p reau ricu lar in cision ) an d th e in t ra-
oral approach . Th e extern al an d th e in t raoral approach es
h ave th eir resp ect ive advan t ages an d draw backs.11
As zygom at ic reduct ion developed from th e t reat m en t
of zygom at ic fract u re, th e coron al approach w as rst used
to exp ose th e en t ire zygom at ic body an d arch . How ever, it
requ ires a long operat ion t im e, an d it m ay cause bleeding
an d visible scarring. Th e in t raoral ap proach h as th e advan -
tage of h idden scars, lim ited bleeding, an d sh ort operat ion
t im e. How ever, it provides lim ited operat ive exposure,
result ing in di cu lt osteotom y, lim ited space for xa-
t ion, an d th e risk of in fra-orbital n er ve injur y. Side e ect s
in clude ch eek drooping due to w ide dissect ion an d volu m e
reduct ion , w h ich can be avoided by m in im izing th e dissec-
t ion. Th e osteotom ized segm en t sh ould be rigidly xed an d
postoperat ive elast ic dressing provided to preven t ch eek
drooping. Th e in t raoral approach can be u sed solely; h ow -
ever, it is usu ally com bin ed w ith pre-au ricular in cision or
tem ple in cision to m in im ize th e dissect ion an d th e possi-
bilit y of ch eek drooping.

Fig. 19.5 Design of bone cuts in malar reduction. An inverted
L-shaped osteotomy line is marked over the malar eminence. A sec-
ond, parallel line is drawn lateral to the rst line to represent the
strip of bone to be resected. A posterior bone cut is made ~ 2 to 3
cm anterior to the tragus.
As th e in t raoral approach is th e m ost w idely used
m eth od th ese days, zygom a redu ct ion via th e in t raoral
ap proach w ith an L-sh ap ed osteotom y is th e m ost p re-
ferred m eth od to correct facial im balan ce in pat ien t s w ith
prom in en t zygom at ic body and arch .
Anesthesia and Approach
All patien ts are given gen eral an esth esia. Orotrach eal in t u-
bation is preferred at the auth ors’ hospital, but nasotracheal
int ubation can be used. A ~ 3-cm labiobuccal vestibular inci-
sion is m ade on each side of th e m axilla.7 Th rough th is in ci-
sion , th e soft t issues are elevated su periorly an d laterally at
the subperiosteal plane. Dissect ion is lim ited to the area of
the zygom at ic body, th e anterior w all of the m axillar y sinus,
an d th e lateral an d in ferior orbital rim . As th e dissect ion
exten ds superolaterally over th e m alar em in en ce, a portion
of the origin of the zygom at ic m ajor an d zygom at ic-cuta-
neou s ligam ents m ay be partially divided from the bony
su rface.
Anterior Osteotomy
An inverted L-sh aped osteotom y lin e is m arked over th e
m alar em in en ce (Fig. 19.5). Th is lin e gen erally exten ds
m edially from th e lateral border of th e orbital rim to just
below the in fraorbital foram en. Be careful not to start the
osteotom y too low from w here the arch changes from a
vert ical to a h orizon tal direct ion , w h ich m ay result in in suf-
cien t volum e reduct ion in th e zygom atic body. Th e sh ort
lim b of the osteotom y th en t urns at about a 90° angle tow ard
19 Zygom a Reduction 247
the zygom at ico-m axillar y but t ress. Great at tent ion m ust be
paid to avoid injur y to the orbital contents or infraorbital
ner ve. A second, parallel lin e is draw n lateral to the rst line
to represen t th e st rip of bon e to be resected, allow ing in set
of th e fragm ent .12 The distan ce of the second lin e from th e
rst lin e depen ds on th e patien t’s preferen ce an d th e w idth
of the zygom at ic body. A w ider parallel osteotom y can be
m ade for greater reduction ; h ow ever, th e usual w idth of th e
strip at th e au th ors’ h ospital is ~ 3 to 5 m m . Th e sh ort lim b
of the osteotom y m ust be high enough to avoid th e den tal
roots. Carefu l dissect ion is required in the zygom at ic-pter y-
goid space to preven t inju r y to th e vessel, w h ich m ay lead to
profuse bleeding and postoperat ive bruising.
Mu lt ip le ret ractors are p laced an d th e cu ts are m ade
w ith a reciprocat ing saw st ar t ing from th e su perior lateral
lim b of th e osteotom y. Superior m edial lim b an d n ally
in ferior t ran sverse cut s are m ade, an d th e in ter ven ing bon e
fragm en t is rem oved .
Posterior Osteotomy
Up on exp osin g t h e p oster ior p ar t of t h e zygom at ic arch ,
t h e cou rse of t h e fron t al bran ch of t h e facial n e r ve an d
t h e zygom at ic arch is m arked on t h e skin . A ~ 1-cm ve r t i-
cal in cision is m ad e w it h in t h e sid ebu r n ,12 2 to 3 cm an te-
r ior to t h e t ragu s. Th is in cision sh ou ld lie p oster ior to t h e
cou rse of t h e n er ve. Th e arch is id en t i ed after t h e d is-
sect ion of t h e p er iosteu m , an d n e elevators are p assed
over t h e top an d beh in d t h e arch an d as far p oster iorly as
p ossible to en su re t h at t h e oste otom y is st ill an te r ior to
t h e tem p orom an d ibu lar join t . A recip rocat in g saw is u sed
to m ake t h is ver t ical oste otom y. W h en t h e p oste r ior oste-
otom y is com p leted , t h e zygom at ic segm e n t sh ou ld be
fre e to m ove w h ile rem ain in g at t ach ed to t h e m asseter.
Ad d it ion al bon e d ist al to t h e osteotom y m ay be bu r re d if
n ecessar y.12
Fixation
Th e osteotom ized body an d arch are posit ion ed posteriorly
an d m edially as a resu lt of th e osteotom y, an d th e in ter ven -
ing segm en t is rem oved. According to the pat ien t’s desired
outcom e an d preoperat ive plan n ing, th e th ree-dim en sion al
locat ion of th e segm en t is determ in ed w h ile good con t act
of bony surfaces is m ain t ain ed. Six-h ole m in iplates w ith
screw s are placed to x th e an terior port ion of th e segm en t ,
an d t w o- or th ree-h ole m in ip lates w ith screw s are u sed to
x th e zygom at ic arch (Fig. 19.6). Posit ion ing of th e osteot-
om ized segm en t is th e m ost crit ical step for postoperat ive
resu lt s, an d th e n al segm en t posit ion is adjusted based on
pre-exist ing asym m et r y an d in t raoperat ive appearan ce to
ach ieve th e desired n al ou tcom e. An id en t ical p rocedu re
is th en p erform ed on th e con t ralateral side. Stan dard tech -
niqu es are used to close th e in t raoral an d skin in cision s.
248 IV Facial Bone Surgery
Fig. 19.6 Rigid xation of malar complex using t wo miniplates.
(a) Applying a prebending miniplate to the zygomatic arch.
(b) Applying miniplates to the zygoma body.
■ Key Technical Points
Shape of the Osteotomy: “I” versus “L”
Th ere are t w o m ain osteotom y pat tern s used for th e zygo-
m at ic body: I-sh aped osteotom y an d L-sh ap ed osteotom y.11
Baek et al13 described I-sh aped osteotom y as a tech n iqu e to
rem ove th e m alar com plex. Th is osteotom y is placed lat-
eral to th e m axim al m alar p roject ion an d u su ally can n ot
in clude th e volu m e of m alar p roject ion . Th e osteotom ized
segm en t m ay drift dow nw ard as th e m asseter m u scle p u lls
th e fragm ent .
Th e L-sh ap e d osteotom y, w h ich evolved from t h e
I-sh ap ed osteotom y, h as t h e key ad van t age of in clu d in g
t h e volu m e of t h e m alar p roject ion . Fragm en t d isp lace-
m en t is avoid ed an d t h e m asseter m u scle can n ot d rag t h e
fragm en t d ow nw ard becau se of t h e cou n terch e ck of t h e
in fer ior bord er.11 Fu r t h er m ore, t h e L-sh ap ed osteotom y
h as a large r con t act su r face t h an t h e I-sh ap ed osteotom y.
Th e greatest advan t age of t h e L-sh ap e d osteotom y is from
t h e aest h et ic p oin t of view , as t h e osteotom y is e e ct ive
in red u cin g t h e w id t h of t h e zygom at ic body an d rep o -
sit ion in g t h e MMP p oin t . For m a xim izin g t h e d egre e of
red u ct ion , t h e au t h ors ch oose to p osit ion t h e su p e r ior
osteotom y lin e as close to t h e orbit al r im as p ossible. Care
m u st be t aken to avoid inju r y to in t raocu lar an d p er ior-
bit al st r u ct u res.
b
Ostectomy versus Osteotomy
In p at ien t s w ith a oversize zygom at ic body, rep osit ion ing
th e zygom at ic body alon e can n eith er slim th e overall face
n or sm ooth th e m idface con tour. Th erefore, a p at ien t w h o
h as p rom in en t zygom at ic body requires th e approp riate
ostectom y an d reduct ion of bony volum e togeth er. How -
ever, as ostectom y m ay lead to acciden t al bony gap, sur-
geon s m u st t ake great care th at ostectom y is carried ou t in
th e sagit t al dim en sion as m uch as possible an d m axim ize
th e bon e-to-bon e con t act to preven t th e bony gap.
Vector of Transposition
Reposit ion ing of th e osteotom ized zygom at ic com plex is
th e single m ost im por tan t step in reduct ion m alarplast y.
Th e MMP poin t is determ in ed before surger y th rough th or-
ough con su ltat ion an d physical exam in at ion .
If the patient’s chief com plaint is facial w idth, the zygo-
m atic segm ent should be transposed m edially, and if patien ts
seek im provem ent in a prom inent zygom atic body to give
a less harsh im pression, the zygom atic com plex should be
transposed m edially and posteriorly, w ith m ore reduction in
the zygom atic body than in the zygom atic arch. By control-
ling the am ount of transposition of the zygom atic body and
arch, and by com bining the m edial and posterior transposi-
tions, a harm onious and balanced face can be attained.

Fixation
Alth ough xat ion m ay n ot be essen t ial in m alar red u ct ion
u sing th e in -fract u re m eth od, rigid xat ion is n ecessar y
w h en on e or m ore osteotom ies are con ducted. On ly rigid
xat ion to both th e zygom at ic body an d arch can gu aran -
tee precise reposit ion ing an d st abilit y. If rigid xat ion is
n ot u sed after osteotom y, u n der-correct ion , asym m et r y, or
relapse after surger y can occu r. It is a seriou s sh or tcom ing
th at surgeon s are un able to con t rol th e exact degree an d
posit ion of m ovem en t , especially in th e eld of aesth et ic
su rger y. Rigid xat ion is also crit ical to preven t n on u n ion
an d p ostop erat ive p ain .
As th e m asseter m uscle fun ct ion s as a depressor an d
a m edial rot ator for th e zygom at ic segm en t after oste-
otom y, th ree-p oin t xat ion is n ecessar y for th e zygom at ic
body, orbital rim an d zygom at ic arch to preven t th ree-
dim en sion al rot at ion . How ever, xat ion in th e orbit al rim
requ ires addit ion al in cision . To avoid addit ion al in cision
an d xat ion in th e orbit al rim , th e au th ors recom m en d
u sing dou ble-squ are m idplate in th e zygom at ic com plex as
a ver y sim p le an d easy m eth od to p reven t rot at ion w h ile
m in im izing th e in cision s.
■ Complications and
Their Management
Sagging of Soft Tissue
As re d u ct ion m alar p last y involves re d u ct ion of bon e as
w ell as t ran sp osit ion , saggin g of soft t issu e m igh t be
in evit able an d n e e d s to b e ad d resse d d u r in g t h e p ro -
ce d u re. Previou sly, an in fe r iorly p osit ion e d zygom at ic
com p lex or m obile bon e segm e n t w as a m ajor cau se of
soft t issu e saggin g. Th is com p licat ion can be p reve n t e d
by r igid xat ion .
Wid e dissect ion an d excess soft t issu e are poten t ial
reason s for sagging of soft t issue. Min im izing th e dissect ion
an d preser ving th e origin of th e m asseter m u scle in th e
zygom at ic body can m in im ize unw an ted soft t issue prob -
lem s. Th e st at us of soft t issue also plays a role in soft t issue
sagging. High -risk factors for skin an d soft t issu e sagging
in clu de (1) age over 40 years, (2) abun dan t ch eek fat , (3)
th in skin an d skin laxit y, (4) class II m an dible or ill-de n ed
m an dible n eck lin e, an d (5) p red isp osing deep n asolabial
fold or jow l. In th ese h igh -risk groups of p at ien t s, p reopera-
t ive explan at ion s about th e possibilit y of ch eek drooping
are n ecessar y, an d sp ecial at ten t ion sh ou ld be paid before
an d du ring th e p rocedu re to t r y to overcom e th is com p lica-
t ion . Midface lift , th read lift , buccal fat rem oval, an d para-
n asal augm en t at ion are h elpfu l adju n ct ive p rocedures an d
can be com bin ed or perform ed separately.
19 Zygom a Reduction 249
Nonunion
Nonunion is a source of under-correction and cheek drooping,
and is one of the reasons for unidenti ed pain in long-term
follow -up. Though radiology can reveal breakage of xation
m aterial and separation of bony segm ents, exam inations m ay
at tim es be unable to detect de nite signs of m alunion. Partial
separation of bone, especially in the supero-lateral position
of the orbital rim , is often found but is not considered non -
union if one-third of the bone is healed in continuit y. Possible
causes of nonunion are excessive resection of bone, unstable
xation, excessive m ovem ent (e.g., w hen chew ing), m uscle
pull, and traum a in the im m ediate postoperative period. Con-
servative treatm ent can be tried initially to relieve pain and
cam ou age soft tissue depression. Soft tissue depression can
be corrected w ith fat injections, although frequent relapse
can occur. In cases of repeated relapse after fat injection,
onlay Medpor (Stryker) insertion to create continuit y over
the gap is an option. Indications for m ajor surgery include a
severe recurrent pain, and aesthetic problem s such as obvi-
ous bony gap, asym m etry, and sagging of the m alar com plex.
Repositioning of the zygom a com plex is ideal, though very
di cult if bone loss is extensive, and additional bone graft or
alloplastic m aterial m ay be necessary.
Infraorbital Nerve Injury and
Paresthesia
Du ring zygom at ic redu ct ion , inju ries to th e orbit , orbit al
con ten ts, in fraorbit al n er ve, an d tem poral bon e are possi-
ble. To preven t injur y to th ese st ru ct ures, th e surgeon m u st
be carefu l and acutely aw are at all t im es regarding th e loca-
t ion of th e saw.12 Excessive pull by ret ractors are a com -
m on sou rce of paresth esia after su rger y. Plate an d screw s
m ay cau se th e paresth esia if th ey are placed too close to th e
in fraorbit al foram en .
Trismus
Com pression of th e tem poralis m u scle due to inw ard
m ovem en t of th e zygom at ic arch can cau se t rism u s. It w ill
im prove w ith in 1 to 2 m on th s after surger y, an d m outh
open ing exercises are h elpful to relieve th ose sym ptom s.
Asymmetry
As m ost pat ien ts w h o com plain of asym m et r y postopera-
t ively already h ad asym m et r y prior to surger y, a careful
an d th orough p reop erat ive exam in at ion is crit ical, follow ed
by com m u n icat ion regarding th e possibilit y of asym m et r y
an d lim itat ion s of su rger y.
250 IV Facial Bone Surgery
Under-correction
From th e pat ien t’s aesth et ic poin t of view, th e m ost com -
m on com p lain t after zygom at ic redu ct ion is u n der-cor-
rect ion . In adequate reduct ion of th e zygom at ic body or
in ap propriate posit ion ing of th e m axim u m m alar pro-
ject ion is a com m on cau se for dissat isfact ion . Th erefore,
proper pat ien t select ion is required an d pat ien ts’ expect a-
t ion s sh ould be realist ically addressed an d adjusted.
a b
■ Case Studies
Case 1: Zygoma Reduction
A 32-year-old w om an com plain ed of p rom in en t zygom a
an d w ide m idface (Fig. 19.7). An inverted L-sh aped ostec-
tom y w ith a 5-m m redu ct ion of each zygom a w as con du cted
to redu ce th e p rot ru sion of h er zygom a. Th e p osterior p ar t
of th e zygom at ic arch w as divided w ith com plete ostec-
tom y. After th e osteotom ized zygom a w as sh ifted m edially
(5 m m ) an d posteriorly (3 m m ), it w as xed w ith m in i-
plates an d screw s. Th e body of th e zygom a w as xed w ith a
double-bridged plate to provide st abilit y again st th e torque
from th e m asseter m u scle. Th e arch of th e zygom a w as
xed w ith a p re-ben ding p late to ach ieve an accu rate p osi-
t ion as w ell as st abilit y (Fig. 19.8). Th e m alar p rom in en ce
an d m idfacial w idth w ere redu ced m arkedly at 12 m on th s
postoperat ively (Fig. 19.9).
Fig. 19.7 Case 1. Preoperative (a) frontal
and (b) oblique photographs of the patient.
 19 Zygom a Reduction 251

a b

Fig. 19.8 Case 1. (a) Preoperative and (b) postoperative radiographic showing posteromedial repositioning of the zygoma.

Fig. 19.9 Case 1. Twelve-month postopera-

a b
tive (a) frontal and (b) oblique photographs.
252 IV Facial Bone Surgery

Case 2: Combined Zygoma Reduction
and Mandible Contouring
A 28-year-old w om an com plain ed of m alar prot ru sion an d
prom in en t m an dibular angle (Fig. 19.10). Sh e u n der w en t
redu ct ion m alarplast y an d m an dible con touring su rger y
(Fig. 19.11). After com p lete ostectom y w as app lied to th e
an terior an d posterior p ar t of th e zygom a, th e zygom a
w as rep osit ion ed p osteriorly an d m edially. Narrow ing
gen iop last y an d con com itan t m an dible con tou ring su rger y
w ere p erform ed to correct h er squ are low er face. Fou r teen
m on th s after th e op erat ion , th e p at ien t’s facial con tou r
ap pears soft an d slen d er (Fig. 19.12).

a b c

Fig. 19.10 Case 2. Preoperative (a) frontal, (b) oblique, and (c) basal photographs. Zygoma reduction and mandible narrowing surgery
were done simultaneously.

a b

Fig. 19.11 Case 2. Three-dimensional CT images: (a) preoperative and (b) 8 months postoperative

a b
Fig. 19.12 (a–c) Case 2. Fourteen-month postoperative photographs.
References
1. Kang JS, ed. Plast ic Surger y. Seoul, Korea: Koonja; 2004
2. Hinderer UT. Malar im plants for im provem ent of the facial
appearance. Plast Reconstr Surg 1975;56(2):157–165
3. Wilkin son TS. Com plicat ion s in aesth et ic m alar augm en t a-
t ion . Plast Recon st r Su rg 1983;71(5):643–649
4. On izuka T, Watan abe K, Takasu K, Keyam a A. Reduction m a-
lar plast y. Aesth et ic Plast Surg 1983;7(2):121–125
5. Yang DB, Park CG. In fract ure tech n ique for th e zygom at-
ic body an d arch reduct ion . Aesth et ic Plast Surg 1992;
16(4):355–363
6. Ch o BC. Reduct ion m alarplast y using osteotom y an d repo-
sit ion ing of th e m alar com plex: clinical review and com -
p arison of t w o tech n iques. J Cran iofac Su rg 2003;14(3):
383–392
19 Zygom a Reduction 253
c
7. Kim YH, Seul JH. Reduct ion m alarplast y th rough an in -
t raoral in cision : a n ew m eth od. Plast Recon st r Su rg 2000;
106(7):1514–1519
8. Agban GM. Augm en t at ion an d correct ive m alarplast y. An n
Plast Su rg 1979;2(4):306–315
9. Uhm KI, Lew JM. Prom inent zygom a in Orientals: classi cation
and treatm ent. Ann Plast Surg 1991;26(2):164–170
10. Kook MS, Ju ng S, Park HJ, Ryu SY, Oh HK. Red u ct ion m alar-
plast y using m od i ed L-sh aped osteotom y. J Oral Maxillo-
fac Su rg 2012;70(1):e87–e91
11. Hong SE, Liu SY, Kim JT, Lee JH. In t raoral zygom a redu c-
t ion u sing L-sh ap ed osteotom y. J Cran iofac Su rg 2014;
25(3):758–761
12. Morris DE, Moaven i Z, Lo LJ. Aesth et ic facial skelet al
con tou ring in th e Asian p at ien t . Clin Plast Su rg 2007;
34(3):547–556
13. Baek SM, Ch u ng YD, Kim SS. Redu ct ion m alarp last y. Plast
Recon st r Su rg 1991;88(1):53–61
 20 Mandible Reduction
Sanghoon Park and Seungil Chung
Pearls
• “Angle reduct ion ” is th e old n am e for th is procedure
an d rep resen t s a m ajor m iscon cept ion regard ing
w h at th e su rger y is for. Th e pu rpose of m an dible
redu ct ion is to m ake th e low er face appear slim in
th e fron tal view an d to ach ieve a sm ooth con tour in
th e lateral view. Ch anging th e m an dibu lar plan e an d
con touring th e w h ole low er border of th e m an dible
are crit ical step s. On th e oth er h an d, angle red u ct ion
w ith rem oval of t riangular bon e w ill in evit ably leave
an u n n at u ral low er con tou r of m an dible w ith a
secon dar y angle.
• Becau se sh ap ing th e lateral con tour of th e m an dible
alon e m ay resu lt in m in im al im p rovem en t in th e
fron t al view, su rgical tech n iqu es to red u ce th e w idth
of th e low er face via bu rring or ostectom y of th e
lateral cortex sh ou ld u su ally also be don e.
• Th e ch in plays an im port an t role in creat ing a
beaut iful facial lin e an d overall con tour; th erefore,
gen iop last y sh ou ld be con sidered in con t in u it y w ith
m an dible redu ct ion .
• Th e relat ion sh ip bet w een th e m axilla an d th e
m an dible in p ro le view sh ou ld be obser ved. In
class II, or class III pro le, orthogn ath ic surger y
is rst con sidered. How ever, in pat ien t s w ith
m ild deform it y, or in pat ien t s w h o do n ot w an t
or th ogn ath ic su rger y, m an dible reduct ion sh ould
be plan n ed to preven t th e exist ing problem s from
deteriorat ing.
■ Introduction
Th e overall Asian facial st ruct ure is t ypically classi ed as
brachyceph alic or m esoceph alic, w ith a w iden ed m an dibu-
lar arch an d broad low er facial skeleton . In cou n t ries su ch
as Korea, Ch in a, an d Jap an , th ese ch aracterist ics are often
view ed as m ascu lin e an d u n at t ract ive; th u s, both m en an d
w om en often w ish to m ake th eir faces app ear m ore slim
an d slen der.
Th e w idt h of t h e low er t h ird of t h e face is d eter m in ed
by t h e w idt h of t h e m an dible it self, w h ich is su r rou n d ed
by m u scles an d su bcu t an eou s fat t issu es. Gen erally, t h e
cau se of p rom in en t m an d ibu lar an gle in Asian s is t h e
254
• Th e in ferior alveolar n er ve is th e m ost im port an t
st ru ct u re d u ring m an dible redu ct ion , an d it sh ou ld
be carefu lly exam in ed preoperat ively in pan oram ic
view as w ell as in a com p u ted tom ograp hy (CT)
scan . It is t yp ically located at least 20 m m aw ay from
th e upper border of th e m an dible, w h ich sh ould be
kept in m in d w h en design ing an d con du ct ing th e
osteotom y. Th e m ost com m on cause of paresth esia
is n ot a direct cut bu t a blu n t inju r y to th e n er ve
by ret ractors com ing out of th e m en tal foram en .
Osteotom y sh ou ld be con du cted at least 3 m m aw ay
from th e m en tal foram en .
• Th e in cid en ce of m ajor in t raop erat ive h em or rh age
h as d ecreased d u e to advan ces in su rgical
tech n iqu e an d t h e u se of a hyp oten sive an est h et ic
p rotocol. If t h e ret rom an d ibu lar vein or t h e
facial ar ter y is tor n d u r in g a p roced u re, ad equ ate
h em ost asis w it h elect rocau ter y m ay n ot be
easy, an d t h is m ay lead to excessive blood loss.
Ap p licat ion of h em ost at ic su bst an ces an d exter n al
m an u al com p ression for m ore t h an 30 m in u tes can
h elp to stop t h e bleed in g.
• Follow ing th e com plet ion of surger y, th e soft t issu es
of th e ch eek an d th e n eck sh ould be ch ecked for any
sign s of bleed ing or sw elling. Any sign of sw elling or
bleeding n ear th e th roat is a serious com plicat ion
an d sh ou ld be t reated im m ed iately as it m ay cau se
breath ing problem s.
lateral p rot r u sion of t h e m an dibu lar angle rat h er t h an
soft t issu e con t r ibu t ion su ch as hyp er t rop h ied m asseter
m u scle.1,2 An t h rop ologic st u d ies h ave sh ow n sign i can t
qu an t it at ive facial an t h rop om et r ic d i eren ces am ong
d i eren t et h n ic backgrou n d s; on e su ch d i eren ce bein g
t h at Korean s, in com p ar ison to Cau casian s, ten d to h ave a
m ore d evelop ed low er face.3 In ad d it ion , t h e average bigo -
n ial d ist an ce in Cau casian w om en is 105 to 109 m m ,4,5
w h ereas in Korean w om en t h e average d ist an ce is 118 to
125 m m .3 Sin ce Korean s h ave a greater bigon ial d ist an ce
an d m ore ared m an d ibu lar an gle, t h ey often u n d ergo
m an d ible red u ct ion to slen d er ize t h e low er facial con tou r,
w h ereas Cau casian s p refer m an d ible augm en t at ion to
cor rect w eak jaw lin es.6

Resection of the Mandibular Angle
In 1949 Adam s in t rod u ced a su rgical tech n iqu e for resect ing
m an dibu lar bon e an d m asseter m u scle via th e t ran scu t an e-
ous approach , an d Converse perform ed th e sam e procedure
th rough an in t raoral approach in 1959.7 In 1989 Baek in t ro-
d u ced m an dibu lar angle redu ct ion for Asian pat ien ts via
th e in t raoral approach . In 1991 Yang an d Park in t roduced
a su rgical tech n iqu e for con tou ring th e m an dibu lar body
an d th e sym p hysis w ith a sequ en t ial resect ion of th e bon e.
Sin ce th e late 1990s on e-stage, long cur ved ostectom y h as
been w idely used to con tour th e m an dible.8
Narrow ing the Width
Th e conven t ion al ostectom y, w h ich resect s th e in ferior bor-
der of th e m an dibular angle an d body, can bring a sat isfac-
tor y con tou r from th e sid e view ; h ow ever, it fails to sh ow
im p rovem en t in th e fron tal facial con tour du e to it s in abil-
it y to n arrow th e broad low er face. To ach ieve th e desired
ap pearan ce of th e fron t al view facial con tou r, a variet y of
su rgical tech n iqu es w ere develop ed. In 1997, Degu ch i et
al reported th at th e w idth of th e low er face cou ld be n ar-
row ed by a tech n ique th at sh aves th e lateral cor tex an terior
to th e in ferior alveolar n er ve an d sp lit s th e angle p osterior
to th e n er ve.9 In 2001 Han an d Kim e ect ively reduced
th e bigon ial w idth th rough lateral cor tex ostectom y w ith -
out a m an dibular angle reduct ion .10 In 2004, Hw ang et al
in t rodu ced sim u lt an eou s u t ilizat ion of th e t w o di eren t
tech n iqu es.11
Creating an Ideal Shape and
Adding Dimension to a Flat Face
Alth ough th e p reviou sly m en t ion ed m an dible red u ct ion
tech n iqu es h ave m any advan t ages, th ey fail to correct th e
broad an d blun t appearance of th e ch in . Th e ch in is a m ajor
determ in an t of an at t ract ive low er facial con tour. Th u s,
th e auth ors h ave reported th at n arrow ing th e w idth an d
a b
Fig. 20.1 Mandible reduction surgery has evolved from (a) simple resection of the angular portion to (b) contouring of the total man-
dible shape as the desire for a slim and small face has increased. Recently, (c) narrowing genioplast y was introduced to achieve a slim and
oval-shaped jaw using the conventional surgical method.
20 Mandible Reduction 255
m odifying th e sh ape of th e ch in , in conju n ct ion w ith m an -
dible reduct ion , is essen t ial to ach ieve a slim m er an d oval-
sh aped con tou r.12,13,14 Th e au th ors’ cu rren t tech n iqu es for
a p rom in en t m an dible are (1) con t rolling th e slope of th e
m an dibu lar p lan e by resect ing th e m an dibu lar angle an d
con t rolling th e in ferior border of th e body via a long cur ved
resect ion tech n ique, (2) reducing th e w idth of th e low er
face via bu rring or ostectom y of th e lateral cortex, an d (3)
n arrow ing gen iop last y according to th e p at ien t’s speci c
dem an ds. Sin ce th e auth ors in t roduced th e tech n iqu e in
2008, sim ultan eous perform an ce of n arrow ing genioplast y
an d m an d ible red u ct ion h as been w id ely called “V-lin e su r-
ger y” sin ce th e sh ap e of th e con tou red jaw lin e looks like
th e let ter V (Fig. 20.1).
V-lin e su rger y n ot on ly n arrow s th e w idth of th e m an -
dible an d con tours the jaw lin e, but also reduces th e size
an d con t rols th e p osit ion of th e ch in in both th e ver t ical
an d an terior-p osterior d irect ion s, m aking a sm aller an d
m ore fem in in e oval facial con tou r p ossible.
On th e basis of tech n ical perfect ion , th e est ablish m en t
of appropriate surgical in dicat ion s for each tech n ique is
m an dator y to ach ieve aesth et ically p leasing resu lt s. An al-
ysis of th e in dividu al’s en t ire face sh ou ld com e from a
th orough un derst an ding of low er facial t ypes. Th e auth ors
classify th e sh ape of th e low er face according to th e sh ape
of th e ch in , w h ich is h elpfu l in establish ing the t reat m en t
plan (Fig. 20.2).15
■ Patient Evaluation
Diagnosis
Th e con dit ion m ay easily be diagn osed by clin ical n dings
an d rad iologic exam in at ion . Th e degree of p rot ru sion of th e
m an dible, asym m et r y, m asseter m u scle hyper t rophy, an d
am ou n t of th e su bcu t an eou s fat sh ou ld be evalu ated. Th e
degree of hypert rophy of th e m asseter m uscle can be iden -
t i ed by palpat ing th e t igh ten ed versu s relaxed stat us of
th e jaw. Hyperostosis, m ostly aroun d th e m an dible angle,
is n oted in th e radiologic st u dies. Tw o-th irds of th e cases
c
256 IV Facial Bone Surgery

Fig. 20.2 The shapes of the lower face in the frontal view are diverse. Because the chin should be designed based on the individual
patient’s preference, this classi cation system helps patients to compare the shapes of the chin and consult with the surgeon in detail.

sh ow m ild to m oderate in crease in bigon ial dist an ce du e to
lateral aring of the m an dible angle. How ever, th e rem ain -
ing th ird sh ow s tot al m an dibu lar hyper t rophy an d accen t u-
ated square con tour of th e w h ole low er face.
Th e sh ape an d w idth of th e low er face in th e fron t al
view can be classi ed as in Fig. 20.2. Th e p ro le as w ell as
th e h eigh t of th e ch in sh ould be t aken in to con siderat ion .
Th e stat us of soft t issue in cluding m uscle an d fat sh ould be
con sidered as w ell.
be iden t i ed. Th e ideal gon ial angle is w ith in th e range of
105 to 115 degrees, an d th e MP-SN angle is 30 to 40 degrees.
After m easu ring an d u n derst an ding th e accu rate balan ce of
th e upper an d m idface, th e am ou n t of reduct ion , length en -
ing, an d ver t ical/h orizon tal advan cem en t or ret rusion (set-
back) of th e m an dible in th e an terior-posterior direct ion
w ill be determ in ed.
Transverse Plane

Preoperative Evaluation and Th ree-d im en sion al CT or t h e ce r vical-ver tex view is

u sed to id e n t ify t h e t ran sve rse sh ap e of t h e m an d ible
Surgical Planning (Fig. 20.3). Th e an gle of d ive rgen ce an d convexit y of t h e
m an d ible are obser ved . In cases w it h an inw ard -cu rled
The auth or rout inely obtains a pat ient’s ph otographic
an gle w it h a convex t ran sverse sh ap e, sagit t al resect ion
docum entat ion and radiologic exam inat ion that includes
of t h e body w ill h elp to red u ce t h e w id t h of t h e m an d ible
panoram ic view, skull lateral view, postero-anterior (PA)
m ore e ect ively.
cephalogram , and 3D CT im age. For precise surgical planning
an d preven t ion of postoperative asym m etr y, th ree-dim en -
sion al an alysis of th e ph otograph s an d th e radiograph s in
the frontal, sagit tal, an d transverse planes is im portant.
Exam ination of the shape and sym m et r y and understand-
ing the overall balance of the face are m andator y.

Frontal Plane
Using th e PA cep h alogram an d 3D CT, th e degree of p ro-
t rusion or aring of th e m an dible angle, sym m et r y, con -
vexit y of th e body, deviat ion , an d sh ap e of th e ch in sh ou ld
be exam in ed. Th e am oun t of n arrow ing an d lateralizat ion
(con sidering th e degree of asym m et r y), an d th e am ou n t
of angle an d in ferior border resect ion are determ in ed
after ch ecking th e cou rse of th e in ferior alveolar n er ve. A
pan oram ic view is h elpful in determ in ing th e am oun t of
ostectom y of th e m an dibular angle an d body, as w ell as th e
posit ion of its ostectom y lin e.

Sagittal Plane
Using th e lateral ceph alogram , th e gon ial angle, th e m an -
dibular plan e–sellar n asion angle (MP-SN angle), an d th e
ver t ical an d an terior-p osterior p osit ion of th e ch in sh ou ld
Fig. 20.3 Analysis of the transverse plane. The exact region and
amount of sagit tal resection can be determined by thorough eval-
uation of the angle of divergence and convexit y of the mandible
from this view.

Consideration in Surgical Planning
The Chin
The term chin refers to both th e bon e an d the surround-
ing soft tissues. The chin is a very im portant com ponent in
lower facial m orphology, and full at tention should be given
to th e procedure of lower facial contouring surgery. In som e
patients, resection of the m andible alone does not m ake the
face appear slender. Th is is m ain ly attributed to a w ide, at
ch in and a U-shaped lower facial m orph ology. Therefore, to
create a slim and at tractive face, reducing the w idth of the
ch in and m odifying its sh ape and position is n ecessary in
addition to resection of th e m andible. The am ount of central
resection should be individualized depending on the w idth
of the chin and the patient’s n eed. In th e auth ors’ practice,
resection of the central strip ranges from 6 to 12 m m (aver-
age 9.1 m m ). In m ost cases, this am ount of resection pro-
duces the desired shape and w idth of the chin. Advancem ent
or setback (retrusion) of th e chin sh ould also be considered if
a ch ange of pro le is required. The ideal aesthetic chin posi-
tion should be determ ined in the pro le view, considering
the positions of the nasal tip and the upper and low er lip.
However, critical decisions w ith regard to the chin position
are m ade w hen view ing the patient “face to face,” consider-
ing the varying perspectives in repose and w ith broad sm ile.
Abnormal Skeletal Relationship betw een
the Maxilla and Mandible
Th e relat ion sh ip of th e m an dible w ith th e m axilla sh ou ld be
u n derstood, because n ot all pat ien t s h ave a n orm al in ter-
m a xillar y skelet al relat ion sh ip. In cases w ith p rot ru ding
m an dible sh ow ing class III occlu sion , or th ose w ith relat ive
u n derd evelop m en t of th e low er jaw sh ow ing class II occlu-
sion , or th ogn ath ic su rger y m ay be n eeded to im prove th is
disorder. If m an dibular con touring surger y is to be don e
w ith out correct ing class II or class III skelet al problem s, cer-
tain ch aracterist ics sh ould be con sidered to avoid aggravat-
ing th e in term axillar y p roblem s. In cases w ith p rom inen t
m an dible sh ow ing a skelet al class III relat ion sh ip , a long jaw
lin e m ay app ear m ore accen t u ated if th e angle is resected
too m u ch du ring m an dible redu ct ion . Th erefore, th e angle
sh ou ld be con ser vat ively resected an d sagit t al sh aving
sh ou ld be p rop erly p erform ed to m in im ize aggravat ion of
progn ath ic appearan ce. In pat ien t s w ith a ret ruded m an -
dible sh ow ing a class II pro le, excessive resect ion of th e
m an dible angle cau ses a m ore obscu re cer vico-facial lin e.
Th erefore, con ser vat ive m an dible resect ion an d m axim al
sagit t al sh aving of th e body of th e m an dible, com bin ed
w ith advan cem en t gen ioplast y are recom m en ded. In a long
face, angle resect ion sh ou ld be perform ed in a lim ited w ay
to p reven t th e aggravat ion of steep m an dibu lar p lan e.
20 Mandible Reduction 257
Asymmetry
Den t al occlu sion an d overall facial con form at ion sh ou ld
be con sidered to an alyze asym m et r y of th e face. Special
care sh ould be t aken if a m ism atch is obser ved bet w een
th e act ual ph otograph s an d th e radiograph s. If facial asym -
m et r y is du e to skelet al factors, th e degree an d exten t of
asym m et r y sh ou ld be evalu ated . If th ere is can t ing d u e
to m axillar y vert ical d iscrepan cy, th en th e p at ien t sh ou ld
fu lly u n derst an d th e lim itat ion s of m an dibu lar con tou r-
ing su rger y. Man dibular asym m et r y of m ild to m oderate
degree can be im proved by disproport ion ate resect ion of
th e m an dible border an d elaborate th ree-dim en sion al
sh aving. Asym m et ries con n ed to th e ch in relat ive to th e
face are m ost frequ en tly en cou n tered. For in dividu als
w h ose ch in sh ifts to on e side, m an dible reduct ion m akes
th e ch in asym m et r y m ore obvious, an d con com itan t h ori-
zon t al osteotom y of th e ch in an d t ran sverse m ovem en t
m ay be requ ired.
Soft Tissue Contribution
A hyper t roph ied m asseter m u scle, w h ich is a crit ical fac-
tor for determ in ing th e w idth of th e face, sh ou ld be cor-
rected. Gen erally, det ach m en t of th e m asseter from it s
in ser t ion to th e m an dible alon e can redu ce th e volu m e of
th e m u scle, an d addit ion al resect ion of th e m u scle is n ot
recom m en ded . In cases w ith severe hyper t rop hy of t h e
m asseter m u scle, bot u lin u m toxin inject ion or a p ar t ial
resect ion of th e m edial asp ect of th e m asseter m u scle can
be don e. How ever, th is in creases sw elling an d t h e risk of
n er ve inju r y or in am m at ion by n ecrot ic m u scle d ebris.
Bu ccal fat rem oval m ay be com bin ed for excessive ch eek
fat . A lift in g p roced u re is requ ired for skin an d soft t issu e
saggin g, after ch ecking th e p at ien t s’ age an d skin elast icit y.
Th e h igh -risk factors for skin an d soft t issu e sagging are
(1) age over 40, (2) abu n dan t ch eek fat , (3) th in skin an d
skin la xit y, an d (4) class II occlu sion or ill-d e n ed m an -
dible n eck lin e.
Ethnic Variation and Cultural Background
Th e ideal facial sh ap e m ay di er dep en ding on p erson al
preferen ce, as w ell as eth n ic or cu lt u ral backgrou n d. Esp e-
cially w h en con su lt ing p at ien t s w ith di eren t n at ion al or
et h n ic backgrou n d s, carefu l at ten t ion sh ou ld be p aid to
th eir ideal or desirable facial sh ape. For exam p le, Ch in ese
pat ien t s p refer a p oin ted ch in , Japan ese p refer a rou n d
ch in , an d Korean s p refer a m oderately t rap ezoidal ch in . In
th e case of fem in izat ion su rger y for t ran sgen ders, to sat -
isfy th eir special n eed s, m axim izing th e fem in in e ch arac-
terist ics, rath er th an sim p ly redu cing th e w idt h an d size of
th e m an dible, is essen t ial.
258 IV Facial Bone Surgery
■ Surgical Techniques
Approach: Intraoral versus
External Approach
Man dible angle redu ct ion can be d on e u sing th e in t ra-
oral approach or th e extern al approach . Tradit ion ally,
m an dible angle ostectom y h as been p erform ed u sing th e
in t raoral app roach w ith an oscillat ing saw.16 Th is ap p roach
involves m in im al space to w ork along w ith poor visibilit y,
an d it requ ires tech n ical skill in m an ip u lating th e oscil-
lat ing saw. Becau se som ew h at blin d rem oval of th e m an -
dible is requ ired, ostectom y m ay be facilit ated by burring
th e ram u s area or by using in direct m irrors, especially in
pat ien t s w ith inw ardly cur ved angles.
An extern al ap proach w as p reviou sly u sed becau se
it w as easy an d allow ed direct access to th e m an dibu -
lar angle.17 Th e extern al approach can be used w ith ch in
in cision or p ostauricu lar in cision . With th e post auricular
ap proach , scar is h idden an d th e op erat ion t im e is sh or ter.
Becau se p oor visibilit y of th e an terior p ar t of th e m an dible
causes un sat isfactor y outcom es, th is approach sh ould be
ap plied on ly to a lim ited p op u lat ion of pat ien t s w h o h ave
m an dible angle prom in en ce.
Types of Ostectomy: Curved Ostectomy
versus Tangential Ostectomy
See Fig. 20.4 for th e t w o t yp es of osteotom y.
Curved Ostectomy w ith an Oscillating Saw
Th is procedure can be applied to m ost pat ien t s w ith prom -
in en t m an dibu lar angle.8 It redu ces th e p ostero-in ferior
m an dibu lar angle in th e lateral view. Th e an terior exten t
a b
Fig. 20.4 Types of ostectomy for m andible reduction. (a) Curved ostectomy with an oscillating saw. (b) Tangential ostectomy with a
reciprocating saw (lateral cortex ostectomy).
of a cur ved ostectom y m ay be exten ded to just below th e
m en t al foram en dep en ding on a pat ien t’s facial m orp h ol-
ogy. Sim u lt an eou s redu ct ion of th e m an dibu lar angle an d
body can result in a m uch sm aller low er facial con tou r.
Tangential Ostectomy w ith a Reciprocating
Saw (Lateral Cortex Ostectomy)
Th is procedure rem oves th e extern al cortex of th e m an dib -
u lar ram us by m ean s of a reciprocat ing saw. It is perform ed
to n arrow th e bigon ial dist an ce in th e laterally ared angles
of th e m an dible or to reduce th e th ickn ess of th e body of
th e m an dible in th e fron tal view.9,10,11 How ever, th is pro-
cedure is n ot recom m en ded due to the h igh risk of n er ve
inju r y, soft t issu e adh eren ce to th e bony m edulla, an d di -
cult y in sh aping. Th e auth ors recom m end sagit t al resect ion
w ith burring, leaving a th in lm of outer cor tex, in w h ich it
is easy to con t rol th e sh ape of th e m andible an d a n at ural
h ealing p rocess is en su red .
General Procedure
In Korea m ost m an dibu lar angle redu ct ion is perform ed by
long cur ved ostectom y using in t raoral in cision w ith burr-
ing. If p at ien t s w an t a m ore V-lin e ch in , th e auth ors add th e
n arrow ing gen ioplast y p rocedu re.12 Th e gen eral procedure
is as follow s (Fig. 20.5):
1. Man dibular reduct ion is perform ed un der gen eral
an esth esia. Eith er n asot rach eal or en dot rach eal
in t ubat ion can be u sed. Th e auth ors gen erally use
en dot rach eal in t u bat ion w ith a t u be an ch ored in th e
rst p rem olar teeth w ith a 3–0 nylon su t u re.
2. Th e pat ien t is posit ion ed su pine w ith a t ran sverse
roll ben eath th e sh ou lders to exten d th e n eck. Th e
en t ire face is p repp ed w ith betadin e solu t ion . Th e
 20 Mandible Reduction 259

a b c

d e

Fig. 20.5 Operative procedures. (a) The incision line is designed. (b) Subperiosteal elevation with periosteal elevator. The lateral aspect
of the mandibular body is exposed. (c) The desired level of the osteotomy line is marked on the bone with a marking pencil. The marked
line is checked by using dental mirrors. (d) A long curved ostectomy is performed. A 110-degree oscillating saw is used for the ostectomy.
(e) Dividing the at tachment of muscle to the medial part of the mandible. A large elevator or Bovie electrocautery is used to divide any
remaining medial pterygoid muscle bers from the medial surface of the osteotomized segment.

oral cavit y an d th e teeth are brush ed w ith dilute
aqu eou s bet adin e solu t ion . Th e op erat ive eld is
d raped to assist w ith in t raoperat ive evalu at ion of
sym m et r y. Su rger y is p erform ed in th e in t raoral area
in a dark eld; h en ce, w earing a h eadligh t is h elpful
in perform ing th e surgical p rocedu re.
3. A rubber open er is placed bet w een th e upper an d
th e low er teeth . Th e in cision lin e is design ed using a
gen t ian violet solu t ion . A bu ccal vest ibu lar in cision
d esign is m ade from th e ram us exten ding an teriorly
to th e rst m olar or secon d prem olar w h ile leaving
a 7- to 8-m m m u cosal cu . Th is m u cosal cu h elps
to close th e sut ure in an easy m an n er. Th e operat ive
eld is in lt rated w ith 0.25% lidocain e w ith
1:200,000 dilu ted epin eph rin e solut ion .
4. Th rough a subperiosteal elevat ion w ith th e
p eriosteal elevator, th e lateral aspect of th e
m an dibu lar body is exp osed. Th e d issect ion
con t in ues superiorly along th e vert ical ram us
to adequately expose th e area of resect ion . Th e
m asseter bers are st ripp ed from th e low er border
of th e body, angle, an d posterior border of th e ram u s
w ith an angle st ripper to secure a good operat ive
eld. Su bp eriosteal dissect ion p reven ts bleeding
from th e m asseter m u scle. Du ring th e dissect ion th e
m en t al n er ve, th e m argin al m an dibu lar bran ch of
th e facial n er ve, th e ret rom an dibular vein , an d th e
facial arter y sh ou ld be p rotected.
5. Using a specialized angle ret ractor, th e m an dibular
angle is h ooked, an d th e desired level of th e
osteotom y lin e is m arked on th e bon e w ith a
m arking p en cil. Th e m arked lin e is th en ch ecked
w ith den tal m irrors.
6. Usually, a long curved ostectomy is perform ed. A
110-degree oscillating saw is used for the ostectomy.
We use a set of oscillating saws of di erent lengths.
If the ostectomy is done w ith full thickness, the bone
segm ent m oves freely. When patients request angle
reduction, the authors em ploy the curved ostectomy
technique, and for a V-line face, a long curved ostectomy
technique w ith narrow ing genioplasty is perform ed.
7. After th e ostectom y, th e at t ach m en t of m uscle to th e
m edial p art of th e m an d ible u su ally rem ain s. A large
elevator or Bovie elect rocauter y is used to divide
any rem ain ing m edial pter ygoid m u scle bers from
th e m edial su rface of th e osteotom ized segm en t ,
allow ing it s rem oval.
8. Fin ally, a h igh -speed bur is used to rem ove any
addit ion al bon e from th e lateral cor tex an d to m ake
a sm ooth t ran sit ion . Th is p rocedu re preven t s th e
ch an ce of secon dar y angle.
9. An iden t ical procedu re is perform ed on th e
con t ralateral side. Here any preoperat ive asym m et r y
in th e degree of angle prom in en ce sh ou ld be t aken
in to accoun t an d a relat ively greater or lesser am ou n t
of m an dibular bon e resected.
260 IV Facial Bone Surgery
10. Th e bilateral w oun ds are irrigated by salin e an d
h em ostasis secu red. Th e w ou n ds are closed in
t w o layers (periosteu m an d m ucosa) w ith a 4–0
absorbable su t u re. Bilateral su ct ion d rain s are left in
p lace overn igh t . Com p ression w ith a facial ban dage
is u sed .
Combined Narrow ing Genioplasty
Narrow ing gen ioplast y, eith er as a single p rocedu re or in
com bin at ion w ith m an dible reduct ion , m akes th e low er
face ap p ear slen der or p rodu ces a m ore fem in in e ch in con -
tou r.12 Th e soft t issu e at t ach m en t of th e ch in is m ain tain ed
to produce a m axim um n arrow ing e ect an d to m ain t ain
blood ow to th e bony segm en t s. A h orizon tal osteotom y
an d t w o vert ical osteotom ies are design ed as sh ow n in
Fig. 20.6. Th e am ou n t of resect ion in th e cen t ral segm en t is
a 2. Th e surgeon accu rately determ in es th e posit ion an d
b t yp ically in th e range of 10 to 20 m m , w ith length
Fig. 20.6 (a,b) Narrowing genioplast y combined with m andible
reduction is required in patients with wide or blunt chin, and it
greatly improves the slimming e ect in mandible reduction. A hori-
zontal osteotomy and t wo vertical osteotomies are designed. The
central segment is resected, and t wo lateral segments are approxi-
mated centrally and xed with miniplates and screws.
determ in ed preoperat ively, depen ding on the w idth of ch in
an d th e pat ien t’s desire. Th e t w o segm en t s are app roxi-
m ated cen t rally an d xed w ith m icrop lates an d screw s.
Advan cem en t of th e t w o segm en t s is also possible if cor-
rect ion of th e pro le is required. Th e resect ion of th e cen -
t ral st rip ranges from 6 to 12 m m .
Postoperative Care
After th e su rger y, th e pat ien t’s vital sign s are m on itored to
en su re st abilit y 4 to 6 h ou rs p ostop erat ively. Th e p at ien t
m ay drin k w ater after st abilit y h as been con rm ed; th is
progresses to a liqu id diet . To redu ce sw elling or bleed-
ing, th e pat ien t is pu t in a sem i-Fow ler p osit ion . Gen erally,
pat ien t s are h ospit alized for on e n igh t after th e surger y.
Blood drain age t ubes are kept for on e n igh t to drain pos-
sible bleeding from th e op erat ion site.
■ Key Technical Points
1. Im por tan t an atom ic st ruct ures m ust be respected.
Previou s an atom ic st udy h as dem on st rated th at th e
in ferior alveolar n er ve t ypically courses at least 20
m m aw ay from th e u p per border of th e m an d ible,
w h ich sh ou ld be kept in m in d w h en design ing th e
osteotom y. As a rule of th um b, th e osteotom y lin e
sh ou ld be at least 1 in ch (2.5 cm ) aw ay from th e
u pp er border of th e m an dible at th e rst m olar.
quan t it y of m an dibular bon e to be rem oved th rough
a com bin at ion of clin ical assessm en t , exp erien ce,
an d kn ow ledge of m an dibu lar an atom y.
3. Th e superior lim it for resect ion is th e occlusal
plan e; th e an terior lim it is th e convergen ce of th e
m an dibu lar obliqu e lin e w ith th e low er m an d ibu lar
border.
4. Th e resected segm en t t ypically h as an elongated
sem ilu n ar sh ap e in stead of being t riangu lar; w h en
rem oved, it leaves a gen tly cur ved low er m an dibu lar
border. Th e oblique h eigh t of th is segm en t is
ranging 30 to 70 m m .
5. If an osteotom y is too st raigh t an d fails to form a
sm ooth t ran sit ion , it w ill leave a “secon dar y angle.”
Th e secon dar y angle can be palpated or st icks out
extern ally. If secon dar y angle is obviou s, it m ay
require burring or an addit ion al osteotom y.

■ Complications and
Their Management
Hemorrhage and Hematoma
Th e in ciden ce of m ajor in t raoperat ive h em orrh age h as
decreased over th e years, prin cipally because of advan ces
in su rgical tech n iqu e an d th e u se of hypoten sive an es-
th et ic protocols (m ean systolic blood pressure of 65 m m
Hg). Hypoten sive an esth esia cou p led w ith inject ion of local
an esth et ic w ith vasocon st rictor m in im izes blood loss an d
in creases visu alizat ion of th e operat ive eld. If th e ret ro-
m an dibu lar vein or facial ar ter y is torn du ring th e p roce-
dure, at tem pts to secure h em ost asis often fail because
elect rocauterizing th e bleeding vessel is n ot easy. Un su c-
cessful h em ost asis m ay lead to excessive blood loss. Appli-
cat ion of a h em ostat ic subst an ce like Su rgicel (Eth icon ) or
extern al m an u al com pression for at least 30 m in u tes can
h elp to stop th e bleeding.16 Follow ing th e com p let ion of
su rger y, th e soft t issu e of th e ch eek an d th e n eck sh ou ld
be ch ecked for any sign s of bleeding or sw elling. Any sign s
of sw elling or bleeding n ear th e th roat sh ould prom pt
ext rem e aw aren ess an d alarm becau se it m ay cau se a
breath ing problem , possibly leading to a fat al outcom e.
Nerve Injury
If th e cu r ved osteotom y is m ade too h igh on th e m an d ibu -
lar body, th e in ferior alveolar n er ve m ay be inju red. Prior
to su rger y, a p an oram ic X-ray is taken to locate an d ch eck
th e course of th e in ferior alveolar n er ve. Th e surgeon m u st
accu rately de n e th e cou rse of th e in ferior alveolar n er ve
during th e surger y by m easuring its course from th e low er
border of th e m an dible. Th e osteotom y sh ould be at least 3
m m aw ay from th e in ferior alveolar can al an d m en tal fora-
m en .18 Sp ecial care sh ou ld be t aken w h en p erform ing oste-
otom y cut s, an d drilling sh ou ld be accom pan ied by copiou s
irrigat ion to preven t h eat injur y. If it app ears th at th e n er ve
h as been dam aged or am pu t ated, th en a 7–0 nylon n eu ro-
rrh ap hy n eeds to be p erform ed to secu re p ossible recover y
of th e ner ve.
Fracture
Du ring an angle redu ct ion , a precise ostectom y arou n d th e
posterior border of th e m an dible is im por tan t to avoid a
con dylar fract ure. W h en u sing th e oscillat ing saw, adequate
periosteal dissect ion is essen t ial to adequately visualize th e
posterior m an dibu lar border. Th e surgeon m ust n ot allow
20 Mandible Reduction 261
th e osteotom y to becom e ver t ical as it courses posteriorly
up th e ram u s, as th is m ay cause a ram us, su bcon dylar, or
con dylar fract ure. Such fract ures are t reated as described
elsew h ere, u sing open reduct ion w ith in tern al xat ion or
in term axillar y xat ion as in dicated.19
Infection and In ammation
Th ough w oun d in fect ion follow ing surger y is un com m on ,
problem at ic issu es m ay arise due to th e follow ing condi-
t ion s: poor pre- an d postoperat ive oral hygien e, im prop -
erly sealed w ou n d, in su cien t u sh ing, bon e fragm en t s
or du st left beh in d in th e w oun d, dam aged salivar y glan ds,
or periodon t al disease. To preven t th e risks of postopera-
t ive in fect ion , in t raven ous an t ibiot ics are adm in istered on
adm ission . After disch arge, oral an t ibiot ics are p rescribed
to th e pat ien t .
Unfavorable Aesthetic Outcomes
Caution should be taken to avoid rem oving too m uch bone
from th e jaw lin e, or else the con tour m ay appear too sharp
or the cheeks m ay look too h ollow. Prior to surger y, the
design of the osteotom y should be carefully planned, and
accurately m easured and m arked so that the procedure is
perform ed w ithout any com plications.20 Fat grafting m ay be
perform ed to cover and cam ou age any areas of over-correc-
tion. Changes in the skeleton are re ected favorably or unfa-
vorably by th e overlying soft tissues. Careful preoperative
facial analysis of both h ard and soft tissues w ill m axim ize
favorable aesth etic outcom es.21 Other com plications unique
to m an dible reduction are best dealt w ith by prevention .
■ Case Studies
Case 1
A 20-year-old w om an com p lain ed of h er p rom in en t m an -
dibular angles (Fig. 20.7). Sh e desired a slen der an d sm ooth
low er facial con tour. Th e in tergon ial distan ce w as large,
an d th is, in com bin at ion w ith lateral aring of th e angle,
m ade h er low er face app ear broad, squ are, an d st rong. After
a fu ll-th ickn ess ostectom y of a low er border of th e m an -
dibular body-angle region , sh aving of th e ou ter cortex w as
accom plish ed (Fig. 20.8). After th e m an dible con tou ring
su rger y, th e gon ial angle an d th e m an dibu lar plan e angle
in creased (Fig. 20.9). Ten m on th s follow ing th e operat ion ,
th e con tour of h er low er face appeared soft an d slen der
(Fig. 20.10).
262 IV Facial Bone Surgery

Fig. 20.7 Case 1. Preoperative (a) fron-

a b
tal and (b) oblique photographs of the
patient.

b
Fig. 20.8 Case 1. Bone fragments resected by ostectomy.

Fig. 20.9 Case 1. Cephalograms (a) before and (b) after the surgery.

a b
Case 2
A 25-year-old fem ale w ith an angulated low er face w an ted
to m ake h er facial con tour slen der, sm ooth , an d “egg
sh aped” (Fig. 20.11). A com plex gen ioplast y com bin ed w ith
m an dibu lar con touring w as perform ed. Th e com plex gen io-
plast y consisted of 8 m m horizontal reduction, 2 m m verti-
cal reduct ion , and cen tering genioplast y. Absorbable plates
a b
20 Mandible Reduction 263
Fig. 20.10 Case 1. Ten-month postopera-
tive photographs. Postoperative (a) frontal
and (b) oblique.
an d screw s w ere u sed for xation . To obtain a sm ooth cur-
vat ure of th e m an dibular low er border, th e m argin al part
of the m andibular body-angle region w as trim m ed using
an oscillating saw an d bu r (Fig. 20.12). After m an dibu lar
con touring surger y, th e patien t requested correction of h er
m alar prom in en ce an d un der w en t reduction m alarplast y.
Tw ent y m onths follow ing the rst operat ion, the contour of
her low er face appeared soft and slim m er (Fig. 20.13).
Fig. 20.11 Case 2. Preoperative (a) frontal
and (b) oblique photographs of the patient.
264 IV Facial Bone Surgery

a b

Fig. 20.12 Case 2. Bone fragments resected by ostectomy:

(a) mandibular contouring; (b) zygom a reduction.

a Fig. 20.13 Case 2. (a) Frontal and (b) oblique

b
postoperative photographs of the patient at
twenty months after mandible reduction and
eleven months after malar reduction.

Case 3
A 20-year-old w om an requ ested th at h er p rom in en t m an -
dibular angle an d zygom a be corrected (Fig. 20.14). Th e
zygom at ic com p lex w as prot ru ded an d th e m an dible w as
a b
20 Mandible Reduction 265
angu lated, w h ich m ad e h er look m u scu lar. Sh e u n der w en t
m an dible an d zygom a red u ct ion su rger y sim u lt an eou sly.
After th e m an dible con tou ring su rger y, th e gon ial an d m an -
dible plan e angle in creased (Fig. 20.15). Six m on th s follow -
ing th e operat ion , th e con tou r of h er low er face appeared
soft an d slim m er (Fig. 20.16).
Fig. 20.14 Case 3. Postoperative (a)
frontal and (b) lateral photographs of the
patient.
266 IV Facial Bone Surgery

a b

c d

Fig. 20.15 Case 3. Three-dimensional CT scans (a,b) before and (c,d) after the surgery.

a b
References
1. Baek SM, Kim SS, Bin diger A. Th e prom in en t m an dibular
angle: preoperat ive m an agem en t , operat ive tech n ique,
an d result s in 42 pat ien t s. Plast Recon st r Su rg 1989;83(2):
272–280
2. Yang DB, Park CG. Man dibu lar con touring surger y for
pu rely aesth et ic reason s. Aesth et ic Plast Su rg 1991;15(1)
:53–60
3. Park CG, Lee ET, Lee JS. Facial form analysis of th e low er an d
m iddle face in young Korean w om en . J Korean Soc Plast Re-
con st r Su rg 1998;25(1):7–13
4. W h it aker LA, Bartlet t SP. Aesth et ic surger y of th e facial
skeleton. Perspect Plast Surg 1988;1:23–69
5. W h it aker LA. Aesth et ic con touring of th e facial support
system . Clin Plast Surg 1989;16(4):815–823
6. W h it aker LA. Aesth et ic augm en t at ion of th e posterior
m an dible. Plast Recon st r Su rg 1991;87(2):268–275
7. Adam s W M. Bilateral hypert rophy of th e m asseter m uscle;
an operat ion for correct ion; case report . Br J Plast Surg 1949;
2(2):78–81
8. Gui L, Yu D, Zh ang Z, Ch angsh eng LV, Tang X, Zh eng Z. In t ra-
oral on e-stage cur ved osteotom y for th e prom in en t m an -
d ibu lar angle: a clin ical st u dy of 407 cases. Aesth et ic Plast
Surg 2005;29(6):552–557
9. Deguch i M, Iio Y, Kobayash i K, Sh irakabe T. Angle-split t ing
ostectom y for redu cing th e w idth of th e low er face. Plast
Recon st r Su rg 1997;99(7):1831–1839
10. Han K, Kim J. Redu ct ion m an dibu lop last y: ostectom y of
th e lateral cortex arou n d th e m an d ibu lar angle. J Cran iofac
Surg 2001;12(4):314–325
11. Hw ang K, Lee DK, Lee W J, Ch u ng IH, Lee SI. A sp lit ostec-
tom y of m an dibu lar body an d angle redu ct ion . J Cran iofac
Surg 2004;15(2):341–346
20 Mandible Reduction 267
Fig. 20.16 Case 3. Six-month postopera-
tive (a) frontal and (b) lateral photographs
of the patient.
12. Park S, Noh JH. Im portance of the chin in lower facial con-
tour: narrow ing genioplast y to achieve a fem inine and slim
lower face. Plast Reconstr Surg 2008;122(1):261–268
13. Lee TS, Kim HY, Kim T, Lee JH, Park S. Im p or tan ce of
th e ch in in ach ieving a fem in in e low er face: n arrow ing
th e ch in by th e “m in i V-lin e” su rger y. J Cran iofac Su rg
2014;25(6):2180–2183
14. Lee TS, Kim HY, Kim TH, Lee JH, Park S. Con tou ring of th e
low er face by a n ovel m eth od of n arrow ing an d length -
en ing gen iop last y. Plast Recon st r Surg 2014;133(3):
274e–282e
15. Park S. Classi cat ion of ch in in term s of con tou r an d w idth
an d preferen ce in Korean . Paper presen ted at: 61st An n ual
Meet ing of Korean Societ y of Plast ic Su rger y; 2007:355
16. Neligan PC. Prin cip les. In : Neligan PC, ed . Plast ic Su r-
ger y. Vol. 1, 3rd ed. Seat tle, WA: Elesevier Saun ders;
2012:179–183
17. Morris DE, Moaven i Z, Lo LJ. Aesth et ic facial skel-
et al con touring in th e Asian pat ien t . Clin Plast Surg
2007;34(3):547–556
18. Lo LJ, Wong FH, Ch en YR. Th e p osit ion of th e in ferior alveo-
lar n er ve at th e m an dibu lar angle: an an atom ic con sid er-
at ion for aesth et ic m an d ibu lar angle redu ct ion . An n Plast
Surg 2004;53(1):50–55
19. Hw ang K, Han JY, Kil MS, Lee SI. Treat m en t of con dyle frac-
t ure caused by m an dibular angle ostectom y. J Cran iofac
Surg 2002;13(5):709–712
20. Jin H, Park SH, Kim BH. Sagit t al split ram u s osteotom y w ith
m an dible redu ct ion . Plast Recon st r Su rg 2007;119(2):
662–669
21. Hsu YC, Li J, Hu J, Luo E, Hsu MS, Zhu S. Correction of square
jaw w ith low angles using m andibular “V-line” ostectomy
com bined w ith outer cortex ostectomy. Oral Surg Oral Med
Oral Pathol Oral Radiol Endod 2010;109(2):197–202
 21 Aesthetic Orthognathic Surgery
Seong Yik Han and Kar Su Tan
Pearls
• Orth ogn ath ic su rger y is a du al-p ronged op erat ion
th at ful lls both fun ct ion al an d aesth et ic goals
th rough reposit ion ing of th e m a xilla an d/or
m an dible via orth odon t ic an d su rgical m an ip u lat ion .
Fu n ct ion al restorat ion sh ould take preceden ce over
aesth et ic con siderat ion s.
• Th e psych ological im pact of orth ogn ath ic surger y
sh ou ld be em p h asized in th e preoperat ive
evalu at ion . It is recom m en ded th at sign i can t oth ers
at ten d th e p reoperat ive discussion w ith th e p at ien t .
• Un derstan ding of m alocclusion is im port an t for
proper fun ct ion al reh abilit at ion . How ever, restoring
n orm al occlu sion does n ot n ecessarily en sure a good
aesth et ic ou tcom e.
• Pure or th odon t ic com pen sat ion t reat m en t is
som et im es abou t m oving th e teeth in th e opp osite
direct ion to th e surgical m ovem en t . Hen ce, it
is im port an t for th e orth odon t ist to be able to
recogn ize w h ich pat ien ts w ill even t ually require
■ Introduction
“Orth ogn ath ic su rger y” literally m ean s “correctly (or th o-)
posit ion ed jaw (gn ath ic).” It refers to th e surgical correc-
t ion of abn orm al m an dible, m axilla, or both . Abn orm al
den tofacial developm en t or asym m et r y m ay n ot on ly
result in an u n aesth et ic face an d fun ct ion al deteriora-
t ion , but also can lead to psych osocial problem s. Th us th e
object ive of th is su rger y is to restore both fun ct ion an d
aesth et ics. Fu n ct ion al restorat ion refers to rein st at ing th e
fu n ct ion s of occlu sion , m ast icat ion , sw allow ing, tem poro-
m an dibu lar join t (TMJ) fu n ct ion , sp eech , an d p h on at ion .
Aesth et ic im p rovem en t involves th e re-establish m en t of
facial sym m et r y an d h arm ony. Th e form er sh ou ld alw ays
be priorit ized over th e lat ter. Ult im ately, it is h oped th at th e
fu n ct ion al an d aesth et ic im p rovem en t w ill en cou rage th e
resolut ion of any psych osocial issu es.
In th e au th ors’ decades of experien ce w ith m ore th an
3600 orthognathic surgical cases, 96%percen t of th e patients
reported th at they overcam e their inferiorit y com plex fol-
low ing orthognathic surger y. Their new -found con den ce
could be seen on th eir faces a m on th after surger y. Recen tly,
268
su rger y, an d th u s avoid a p ain fu l detou r to a t rial of
or th odon t ics th at produ ce n o ben e t .
• Tem porom an dibular join t posit ion ing sh ould be
assessed rst as th e con dylar posit ion is th e key
referen ce poin t of th e m an dible. Mast icator y m uscle
fu n ct ion an d facial n er ve fu n ct ion sh ou ld also be
ch ecked before t reat m en t .
• High sagit t al su praforam in al osteotom y is su perior
to sagit t al sp lit ram u s osteotom y n ot on ly becau se it
requ ires a sh or ter operat ing t im e, h as less bleeding
ten den cy, an d is less invasive, but also because it h as
th e low est risk of in ferior alveolar n er ve injur y.
• Adequ ate soft t issu e p rotect ion , m et icu lou s
h em ostasis, rigid xat ion , prop er preoperat ive
plan n ing, an d good su rgical skills are th e key ten ets
for a successful facial bon e surger y.
• “Aged appearance” can result from the relaxed m idfacial
soft tissue follow ing LeFort I or bim axillary surgery, and
m ay require additional aesthetic procedures.
there has been an em erging trend of perform ing a t w o-jaw
su rger y (m axillar y Le Fort I operation w ith m an dibu lar
setback) on patien ts w ith n orm al occlu sion for purely cos-
m etic reason s. In th e auth ors’ opin ion th is is un acceptable.
Su rgeon s m ust be w ar y of th e com m ercialization of m edi-
cin e and of th e ne line bet w een ethics and econom ics, and
n ever lose sigh t of th e sacred nat ure of their job.
Du ring or th ogn ath ic su rger y’s h istor y of m ore th an
170 years, m any surgeon s h ave t ried to set th e con cept of
operat ion to ach ieve th ese purposes.1,2 Tech n ically, th e site
an d design of osteotom y, th e ap p roach for th e osteotom y
(ext raoral or in t raoral), th e m eth od for xat ion (w ith w ire
or w ith plates an d screw s), an d th e em ergen ce of th e bon e
exp an sion an d dist ract ion osteogen esis tech n iqu es are
am ong th e in n ovat ion s (Fig. 21.1).3,4,5 Sin ce 1960 or th og-
n ath ic su rger y h as m ade rap id p rogress alongside th e
advan cem en t s in tech n ology su ch as th e xat ion p late an d
screw system for rigid xat ion . In form at ion tech n ology (IT)
d evelopm en t w ith soft w are an d 3D con e beam com p uted
tom ography (CT) an d prin t ing tech n ology also h ave con -
t ributed to th e im provem en t of an alysis an d diagn osis.
To approach or th ogn ath ic surger y, an un derst an ding of
th e basic con cept of occlusion is cru cial sin ce restorat ion
 21 Aesthetic Orthognathic Surgery 269

Blair (1907) Perthes (1924) Schuchardt (1954) Trauner & Obwegeser Obwegeser & Dal Pont
Schlössm ann (1922) (1975) (1958)

Fig. 21.1 The development of the mandibular ramus osteotomy technique. Blair, Schlössmann, and Perthes perform ed osteotomy via
the external oral approach, Schuchardt and Obwegeser used the intraoral approach, and Perthes (1924) is known to be the rst to perform
a sagit tal osteotomy on the ascending ramus. The intraoral sagit tal spit ramus osteotomy was rst performed by Obwegeser (1953), and
Dal Pont modi ed Obwegeser’s procedure to enlarge the contacting surfaces.

to n orm al occlusion is th e overriding priorit y of all or th og-
n ath ic su rgeries. It is th erefore of u t m ost im p or tan ce th at
th e su rgeon rst be w ell in form ed on w h at con st it u tes n or-
m al occlu sion . In n orm al occlu sion , th e m esiobu ccal cu sp
of th e upper rst m olar is received in th e groove bet w een
th e m esial an d dist al buccal cusps of th e low er rst m olar.
An teriorly, th e upper can in e sh ould occlu de bet w een th e
low er can in e an d rst prem olar. Angle classi ed th e m aloc-
clusion in to th ree classes w ith respect to th e den tal align -
m en t an d in terrelat ion sh ip of m axillar y an d m an dibu lar
arch es an d bon es (den to-skelet al) (Fig. 21.2).4 Class I m al-
occlusion is de n ed as h aving a n orm al m olar occlusion
bet w een th e upper rst an d low er rst m olars but prob -
lem s w ith th e oth er teeth , su ch as rot at ion or m alp osit ion -
ing. Class II m alocclu sion involves cases w h ere th e low er
rst m olar is occlu ded dist al to th e u pp er rst m olar. Th is
is su bdivided in to t w o division s: Division 1 is w h ere th e
u pp er in cisors are proclin ed, in creasing th e overjet; divi-
sion 2 is for cases w ith ret roclin ed in cisors, w ith redu ced
overjet . Class III m alocclu sion describes th e low er rst
m olar as being occlu ded m esial to th e u p p er rst m olar.
Accord ing to Angle’s classi cat ion , it w as fou n d th at class
I is th e m ost com m on occlu sion pat tern across all races.
How ever, Japan ese p erson s w ere fou n d to h ave a sign i -
can tly greater percen t age of class II relat ionsh ips (15%),
w h ile class III relat ion sh ips are h igh est am ong th e Ch in ese
p opu lat ion (34%).6
Th e m odern in terpret at ion of Angle’s classi cat ion is
con n ed m ain ly to th e an terior-posterior relat ion s (on th e
sagit t al plan e), om it t ing in form at ion on th e ver t ical an d
t ransverse plan es. In pract ice, th e ideal occlu sion can be
described as h aving (1) class I m olar an d can in e relat ion -
sh ip; (2) n o crow ding, n o sp acing, n o rotat ion ; (3) overjet
~ 2 to 4 m m ; (4) correct crow n angu lat ion an d in clin at ion ;
(5) at an d sligh t upw ard cu r ve of Spee; an d (6) upper an d
low er m idlin es th at are in align m en t . Malocclu sion sh ould
be an alyzed w ith respect to in t ra-arch an d in ter-arch
problem s. In t ra-arch problem s are related to in dividual
teeth—sagit t ally an d vert ically rot ated, or t ran sposit ion ed.
In ter-arch p roblem s are related to th e in term axillar y p rob -
lem s, w h ich occur on th ree plan es: (1) class II or III m aloc-
clusion s in th e sagit t al plan e; (2) cross-bite, scissor bite, or
m idlin e sh ift in th e t ran sverse plan e; an d (3) deep bite or
open bite in th e vert ical plan e.
■ Patient Evaluation
The goal of consultation is to determ ine w hat a patient
wants (chief com plaints) an d h is or her concerns regard-
ing function and aesthetics. Past m edical and dental history
(especially orthodontic treatm ent) is particularly im portant.
The psychological state of the patient should also be evalu-
ated during the inter view. If the patient appears to have
270 IV Facial Bone Surgery
a b
Fig. 21.2 Angle’s classi cation of malocclusion. (a) Class I malocclusion. (b) Class II malocclusion. Mandible is in a retruded position
compared with the maxilla. (c) Class III malocclusion. Protrusion of the mandible with mesial occlusion of the lower teeth is observed.
obsessive-com pulsive tendencies, extra care should be taken
before the surgery. The psychological im pact of orthogna-
thic surgery should be discussed w ith the patient before
surger y. It is recom m en ded that signi cant others, including
fam ily m em bers, also at ten d the preoperative discussion . In
bim axillary protrusion patients, w ho have the greatest risk
of postoperative “aged face,” it is w ise to w arn them about
the possibilit y of additional aesthetic procedures because of
the increased skin redundancy after surgery.
Docu m en t at ion of any tem p orom an d ibu lar join t (TMJ)
sym ptom s su ch as clickin g, deviat ion on m ou t h op en ing,
an d associated h eadach es sh ou ld be record ed . In p ar t icu -
lar, p re-exist in g TMJ dysfu n ct ion p r ior to su rger y sh ou ld
be ad d ressed before or t h od on t ic t reat m en t , as t h e con -
dylar p osit ion is t h e key referen ce p oin t of t h e m an d ible.
Th e range of m ot ion an d any d eviat ion on m ou t h op en -
in g sh ou ld be carefu lly d ocu m en ted . Mast icator y m u scle
fu n ct ion an d facial n er ve fu n ct ion sh ou ld also be ch ecked
before t reat m en t .
Harm ony an d sym m et r y are th e key factors determ in -
ing facial aesth et ics, even th ough it sh ou ld be recogn ized
th at w h at de n es a beaut iful face can di er according to
sociocu lt u ral factors. In th e fron tal view, th e face can be
d ivid ed equ ally in to th e up per th ird (t rich ion to glabella),
m iddle th ird (glabella to su bn asale), an d low er th ird (su b -
n asale to m en ton ) (Fig. 21.3a). Ver t ically th e fron t al p lan e
is com posed of equal fth s (rule of fth s) (Fig. 21.3b).
Th e cen t ral fth is th e dist an ce bet w een th e m edial
can th i (w h ich is equivalen t to th e alar base w idth ). Th e
outer t w o- fth s is th e dist an ce bet w een th e outer can th i
an d th e ou term ost p oin t of th e ear. A vert ical lin e from
eith er ou ter can th u s in d icates th e ideal vert ical p osi-
t ion of th e gon ion (m an dibu lar angle) on both sides. Th e
facial h eigh t-to-w id th rat io (facial in dex) is opt im al w h en
it app roach es 1.35:1 for m ales an d 1.3:1 for fem ales. Th e
c
facial h eigh t is th e dist an ce bet w een th e soft t issu e n asion
an d m en ton . Th e facial w idth is de n ed by th e bizygom at ic
w idth —th e distan ce bet w een th e outerm ost poin t s of th e
soft t issu e zygom at ic arch . Th e bitem poral w idth an d bigo-
n ial w idth sh ou ld ap proxim ate 80 to 85% an d 70 to 75% of
th e bizygom at ic w idth , respect ively (refer to Fig. 19.4).
Lip p roject ion is also a d eterm in ing factor of facial aes-
th et ics. Asian s usu ally h ave dist in ct ive ch aracterist ics of
th e lip due to a com bin at ion of th ickn ess, bim axillar y pro-
t rusion , an d labioversion of th e upper an d low er in cisors.
Th e ideal upper lip sh ould be balan ced w ith th e n ose an d
ch eek, an d th e low er lip sh ould be sligh tly posterior to th e
u pp er lip. Th e am oun t of teeth exp osu re depen ds on th e
ver t ical h eigh t of th e m axilla. W h en both lip s are in repose,
th e verm illion of th e low er lip sh ould be ~ 25 to 30% m ore
exp osed com p ared w ith th e u p p er lip. Th is is esp ecially
im port an t for or th ogn ath ic surger y for a cleft lip -palate
pat ien t . W h en sm iling, th e in cisors sh ould be at least th ree-
quar ters exposed yet n ot exceed 2 m m of gingival sh ow. A
gu m m y sm ile, or excessive gingival sh ow du ring sm iling, is
n ot a reliable in dicator of th e adequ acy of m axillar y h eigh t .
Fin ally, facial sym m et r y can be assessed based on several
relat ion sh ips, involving th e m idsagit t al plan e th rough th e
n asal t ip, m idlin e of th e u pper an d low er in cisors, m idlin e
of th e sym physis of th e ch in , an d th e gon ion posit ion of
eith er sid e. Dyn am ic sym m et r y can be assessed by obser v-
ing th e level of th e oral com m issures an d teeth exposure
on sm iling. Occlusal plan e can t ing sh ould also be assessed.
Cephalom et ric analysis is crucial for ident ifying the
patient’s skeletal and den tal problem s for correct ive surgical
planning and postoperative assessm en t. Standard reference
points on a cephalom et ric X-ray im age and basic propor-
tion s are show n in Fig. 21.4 and Fig. 21.5. Ceph alom etric
data an alysis reveals that there exists som e disparit y in
certain param et ric values bet w een Asian s and Caucasians
 21 Aesthetic Orthognathic Surgery 271

Tr

1/3

G'

1/3

Sn 1/3

1/3
2/3

Me'

a b 1/5 1/5 1/5 1/5 1/5

Fig. 21.3 Aesthetic facial division on frontal view. (a) The face can be divided equally into the upper third (trichion to glabella), middle
third (glabella to subnasale), and lower third (subnasale to menton). (b) Vertically, the face is divided into equal fths (rule of fths).

G'

N
S N'

Por
Or

Ar Pr
ANS
UIA A Sn
PNS
A'
Ls

LIE
UIE
Go

Li
LIA B B'
Pog
Gn Pg'
Me
a M' b

Fig. 21.4 (a,b) The skeletal, dental, and soft tissue reference points in cephalometry (see Table 21.1 for key).
272 IV Facial Bone Surgery

N
N
S

ANS A

E line
B

a Me b

1/2

Sn Fig. 21.5 Basic proportions, angles, and lines in cephalom etric anal-
ysis of the face. (a) The nasion (N)–anterior nasal spine (ANS)/ante-
1/3 rior nasal spine (ANS)–menton (Me) ratio is the most frequently used
1/2
St parameter to assess the adequacy of the vertical height of the chin.
1/2 (b) The “esthetic line” (E-line, Ricket t s line) is drawn from the nasal tip
Li
(pronasale) to the soft tissue pogonion (Pog′) to evaluate lip position.
2/3 1/2 (c) The ideal ratio of the distances Sn–St:St–Me′ is 1:2 and that of the
distances Sn–Li:Li–Me′ is 1:1. S, sella; Me′, soft tissue menton; St, sto-
mion; A, A point, subspinale; B, B point, submentale; G, glabella; Sn,
c Me'
subnasale; and Li, Labrale inferior.

(Fig. 21.6).6,7,8 Th ese di eren ces accoun t for th e ch aracteris-

tics feat ures in facial m orphology obser ved in these eth nic
groups. Im portan t obser vat ion s in Asian s in clude (1) m ore
vert ical grow th ten den cy (dow nw ard grow th ); (2) upper
an d low er in cisors th at are are m ore labially in clin ed, giving
the lip a m ore prot rusive appearance; (3) facial pro les th at
are m ore convex, especially in th e m iddle th ird of th e face
(bet w een points A and B); (4) m ore acute nasolabial angle;
(5) signi can tly sh orter distance bet w een the upper lip and
E-lin e (UL–EL) an d low er lip an d E-lin e (LL–EL). No stat isti-
cally signi cant di erence w as obser ved in reference angles
like sella-nasion -A point angle (SNA), sella-n asion -B point
angle (SNB), A poin t-n asion -B poin t angle (ANB), an d m en -
tolabial angle across all th e eth n ic grou ps (Fig. 21.6).
With th e adven t of n ew tech n ology su ch as con e beam
com puted tom ography (CBCT) an d 3D processing soft w are,
w e are cu rren tly on th e verge of t ran sit ion ing from th e 2D
era in to 3D. Bu t cep h alom et ric an alysis is st ill u sefu l today
Fig. 21.6 Disparit y of parametric values of cephalometry among
an d form s th e fou n dat ion of ou r u n derst an d ing of th e facial
Asians and Caucasians.8 Asians (dotted line) show a higher vertical
m et rics. A den t al m odel is also im p or t an t in p roviding growth tendency and a more convex pro le compared with Cauca-
in form at ion on th e arch form (arch w idth an d arch length ), sians (solid line). The nasolabial angle is more acute in Asians and
teeth posit ion, upper an d low er m olar relat ion , an d teeth the upper incisors are more labially inclined, giving the upper lip a
in clin at ion . It also gives a rough sim ulat ion of p ostoperat ive m ore protrusive appearance. The lower anterior teeth are also labi-
u pp er an d low er jaw relat ion sh ips. ally inclined to the mandibular plane in Asians.
 21 Aesthetic Orthognathic Surgery 273

Table 21.1 Reference point s in cephalometry

Skeletal reference points

N Nasion Most anterior point of nasofrontal suture

S Sella Center of sella turcica

Or Orbitale Most inferior point on orbital m argin

A A point, subspinale Deepest point of anterior border of m axilla

B B point, subm entale Deepest point of anterior border of m entum

Pog Pogonion Most anterior point of mentum

Gn Gnathion Midpoint bet ween Me and Pog

Me Menton The lowest point of symphysis

ANS Anterior nasal spine Most anterior point of nasal oor

PNS Posteror nasal spine Most posterior point on hard palate contour

Ar Articulare Intersection of sphenoidal basis and condylar posterior border

Go Gonion Most inferior, posterior point on mandibular angle

Por Porion Upperm ost point on bony external auditory m eatus

Dental reference points

UIE Upper incisor edge Incisal point of upper incisor

UIA Upper incisor apex End point of root of incisor

LIE Lower incisor edge Incisal point of lower incisor

LIA Lower incisor apex End point of root of lower incisor

Soft tissue reference points

Tr Trichion Hairline at the forehead m iddle line

G′ Soft tissue glabella Median point bet ween eyebrows (most anterior point of forehead)

N′ Soft tissue nasion Deepest point on skin at root of nose

Pr Pronasale Most anterior point of tip of nose

Sn Subnasale Transitional point of nasal septum and upper lip

A′ Soft tissue A point Deepest point bet ween subnasale and upper lip

Ls (UL) Labialis superior (upper lip) Most anterior point of upper lip

St Stomion Middle point bet ween upper and lower lips

Li (LL) Labialis inferior (lower lip) Most anterior point of lower lip

B′ Soft tissue B point Deepest point bet ween lower lip and chin

Pog′ Soft tissue pogonion Most prom inent point of soft tissue chin

Me′ Soft tissue menton Most inferior point of chin

274 IV Facial Bone Surgery

located at th e u pp er part of th e ascen ding ram us sh ou ld be

■ Surgical Techniques
In p at ien t s w ith sligh t m alocclu sion an d n o cosm et ic con -
cern s, it is reason able n ot to o er any t reat m en t . But in
cases of skelet al discrepan cy of th e facial bon es, surger y
m igh t be th e m ost u sefu l m odalit y of t reat m en t . For Asian
pat ien t s, th e auth ors prefer Le For t I osteotom y, h igh sagit-
tal su praforam in al osteotom y (HSSO), an terior segm en tal
osteotom y (ASO), an d gen ioplast y. Table 21.2 su m m arizes
th e appropriate operat ion s for th e respect ive diagn oses.
Typically, th e orth ogn ath ic su rger y is perform ed un der
gen eral an esth esia w ith n asot rach eal in t u bat ion . In ten -
t ion al hypoten sion an d perioperat ive an t ibiot ic coverage in
m ost cases is m an dator y.
Surgery of the Mandible
Sagittal Split Ramus Osteotomy (SSRO)
Am ong the various techniques of m andibular osteotom y
proposed so far, sagittal split ram us osteotom y (SSRO), after
the Obwegeser–Dal Pont m ethod, is the m ost w idely adopted
technique. It is generally indicated in horizontal m andibular
excess or de ciency, or cases of m andibular asym m etry.9
First , m ark th e m idlin e th at run s from th e glabella
along th e n asal dorsu m , d ow n th e ph ilt ru m an d th e m id-
lin e of th e up p er lip an d up per in cisors, th rough th e m id-
lin e of th e low er in cisors to th e m idlin e of th e sym physis.
Th is lin e is h elpful as a referen ce during an d after surger y.
Mu cosal in cision st ar ts from th e bu ccal vest ibu le of th e
low er rst m olar an d con t in u es along th e an terior m argin
of the ascen ding ram us laterally (Fig. 21.7a). Met icu lou s
soft t issu e d issect ion to th e periosteu m w ith p roper h em o-
stasis w ill gu aran tee safe bon e su rger y. Th e bu ccal fat p ad
kept u n less it w ill con st an tly sp ill in to th e su rgical eld for
th e rest of th e su rger y.
Th e periosteu m is in cised w ith diath erm y an d elevated
o th e ascen ding ram us, ret rom olar area, an d rst m olar
region laterally an d buccally. Elevat ion of th e periosteu m
is also don e m edially bet w een th e sigm oid n otch an d lin -
gu la arou n d th e m an dibu lar foram en . Periosteal elevat ion
sh ou ld exten d u p to th e p osterior m argin to allow in st ru -
m en t s to be in serted an d to p rotect th e soft t issu e at th e
posterior m argin during osteotom y. Prior to elevat ion of
th e lingual periosteum of th e ascen ding ram us, in lt rat ion
of epin eph rin e an d lidocain e is h elpful to avoid acciden t al
ru pt u re of n u t rien t vessels em erging from th e bony fora-
m en . After soft t issu e p rotect ion is en su red, bon e cu t t ing
begin s w ith a 3.1- or 4-m m roun d bur at th e an terior bor-
der of th e ascen ding ram u s. Th e cor tex at th e an terior bor-
der is rem oved carefully u p to th e rst m arrow bleeding
poin t . At th is poin t , in lt rat ion of epin eph rin e/lidocain e is
perform ed again before con t in uing th e n ext step.
Lingu al cor tex osteotom y is d on e w ith a 2.7-m m rou n d
bur. Soft t issue protect ion is en sured w ith a n arrow ch an -
n el ret ractor or broad cur ved periosteal elevator. Special
care sh ould be t aken n ot to injure th e in ferior alveolar
n er ve an d vessels. Th e au th ors usu ally keep th e dissect ion
area n arrow to avoid dam age to th e vessel an d n er ve at th e
m an dibu lar foram en . Th e lingu al cortex osteotom y is car-
ried to th e posterior border of th e ascen ding ram u s.
Bu ccal cortex osteotom y sh ou ld be d esign ed d ep en d-
ing on w h eth er th e object ive is to ach ieve setback, advan ce-
m en t , or t ran sverse rot at ion of th e m an dible. Th is can
range from a vert ical osteotom y n ear th e rst m olar area
to an obliqu e lin e ru n n ing from th e secon d m olar to th e
m an dibu lar angle. On ce again , adequ ate p rotect ion is n ec-
essar y to avoid inju r y to th e facial arter y an d th e m argin al
m an dibu lar bran ch of th e facial n er ve.

Table 21.2 Categorization of orthognathic surgery by diagnosis

Diagnosis Appropriate operation

Mandibular protrusion Mandibular setback (SSRO or BVSRO) + genioplast y

Maxillary protrusion Le Fort I

Mandibular vertical excess Genioplast y

Maxillary vertical excess Double jaw surgery

Mandibular retrusion SSRO

Mandibular vertical de ciency SSRO + genioplast y

Open bite Double jaw surgery or Le Fort I only

Bimaxillary protrusion ASO + genioplast y or upper ASO and lower SSRO + genioplast y

Abbreviations: ASO, anterior segmental osteotomy; BVSRO, bilateral vertical sagittal ramus osteotomy; SSRO, sagittal split ramus osteotomy.

After th e cortex of th e an terior ram u s border h as been
rem oved as described earlier, th e au th ors create several
gu ide h oles in th e m edu lla (Fig. 21.7b) dow n to th e poste-
rior border w ith a 1.8-m m rou n d bu r. Care is taken to avoid
th e in ferior alveolar n er ve an d vessels by st aying close to
th e buccal cor tex, especially at the m an dibular body an d
angle area. Ram u s sp lit t ing is com p leted by join ing th ese
gu ide ch an n els w ith a 2-m m ch isel (Fig. 21.7c). Th e separa-
t ion sh ould be perform ed gen tly an d precisely, t aking care
n ot to cau se u nw an ted fract u re of any segm en t .
The tooth-bearing segm ent is referred to as the distal
segm ent w h ile th e segm en t bearing th e con dylar head is the
proxim al segm ent. Once the proxim al and distal segm ents
are separated, th e m andibular body can m ove freely. With
the prefabricated occlusal splint w ired to the upper teeth,
the free-m oving m andibular distal segm ent can be easily
adapted to the upper teeth and splint. Interm axillary xation
(IMF) is then perform ed w ith the m axillary and m andibular
teeth occluded in this new position. The auth ors generally
prefer elastic rubber bands over w ires for this purpose.
Th e n ew m an d ib le p osit ion is ch e cke d w it h t h e
m id lin e d raw n p re op e rat ively t o e n su re fa cia l sym m e -
a b
c
21 Aesthetic Orthognathic Surgery 275
t r y. Th e con d ylar h ea d is ch e cke d t o m a ke su re it is in
a good an d st a b le p osit ion in t h e gle n oid fossa . On ce
eve r yt h in g is con fir m e d t o b e in p osit ion , ost e osyn t h e -
sis is p e r for m e d . Th e re are t w o m et h od s of ost e osyn -
t h esis a ccord in g t o t h e level of fixat ion . Th e fir st , r igid
fixat ion w it h u t ilizat ion of t it an iu m p lat es an d screw s
or lag screw s, resu lt s in a bsolu t e st a b ilizat ion of t h e
t w o b on e se gm e n t s. Th e re is n o m ovab le gap a n d p r i-
m ar y b on e h ea lin g occu rs w it h m in im a l callu s for m a-
t ion . Th e se con d , n on r igid fixat ion w it h w ires, p e r m it s
in t e rse gm e n t a l m ob ilit y. Th e w ire ’s m ain act ion is t o
lim it d ist ra ct ion of t h e t w o se gm e n t s w h ile se con d a r y
bon e h e alin g t akes p la ce. Desp it e b e in g n on r igid , t h is
for m of fixat ion is a cce p t e d a s b e in g fu n ct ion ally st ab le.
Th e au t h or s’ p refe re n ce is t h e r igid fixat ion t e ch n iqu e
be ca u se it is less p ain fu l a n d sh or t e n s h ea lin g t im e. In
ad d it ion , r igid fixat ion can sh or t e n t h e IMF t im e. On ce
ost e osyn t h esis is d on e, t h e IMF is rele ase d t o ch e ck for
n or m al occlu sion as p lan n e d . Th e w ou n d is t h e n ir r i-
gat e d w it h n or m a l salin e, an d a fin a l ch e ck for h e m o -
st asis is d on e before closu re w it h 4 – 0 silk. A 4 - t o 5- cm
sila st ic d rain is a n ch ore d on ea ch sid e.
Fig. 21.7 Sagit tal split ramus osteotomy (SSRO). (a)
Mucosal incision line. (b) Osteotomy is done following
the guide holes created in the medulla down to the
posterior border. (c) Ramus split ting and repositioning
to the proper new occlusion.
276 IV Facial Bone Surgery
High Sagittal Supraforaminal
Osteotomy (HSSO)
High sagit tal su p raforam in al osteotom y (HSSO), also
referred to as supraforam in al h orizon t al oblique osteotom y
(SHOO),10 w as origin ally design ed by W J Höltje,11 an d it
d erived from Sch u ch ardt (Fig. 21.1). HSSO is an esoteric yet
m ore clin ically at t ract ive m eth od th an t radit ion al SSRO11
because of its sh orter operat ing t im e; lesser bleeding
ten den cy an d invasiven ess; low er risk of in ferior alveolar
n er ve inju r y; an d faster recover y.
HSSO begin s w it h a m u cosal in cision st ar t in g at
t h e low est p oin t of t h e asce n d in g ram u s an d p roce e d -
in g lat e rally u p t h e an te r ior b ord e r of t h e ram u s. A
25- t o 30-m m in cision is u su ally su cie n t (Fig. 21 .8a).
Th e p e r ioste u m is elevate d o t h e lat e ral su r face of t h e
asce n d in g ram u s u p to it s p ost e r ior b ord e r. Th e au t h ors
u se a sim p le late ral ret ractor (w id t h 2 0 m m ) to p rote ct
t h e late ral an d p ost e r ior su r face d u r in g t h e ost e ot om y.
Me d ial su r face p e r iosteal elevat ion is d on e b et w e e n t h e
sigm oid n otch an d t h e foram in a above t h e m an d ibu lar
foram e n . As t h is area is h igh ly vascu lar ize d , it t e n d s to
ble e d from t h e m u scu lar an d n u t r ie n t vascu lar bran ch es.
A 5- to 15-m m n ar row t u n n el is u su ally su cie n t to p e r-
for m t h e m e d ial ost e otom y. Th e elevat ion is con t in u e d
u n t il t h e late ral ret ractor from t h e lat e ral sid e is e n cou n -
te re d at t h e p oste r ior bord e r. Th e oste otom y on t h e lat -
e ral cor t ical su r face is 10 to 15 m m low e r t h an t h e m e d ial
oste otom y on t h e asce n d in g ram u s (Fig. 21.8b). Afte r t h e
m e d ial an d late ral ost e otom ies are com p let e d , sp lit t in g
is p e r for m e d . Fixat ion is d on e u sin g a m a xip late w it h
fou r screw s on each sid e for ost e osyn t h esis (Fig. 21 .8 c).
An alt e r n at ive is to u se t w o fou r-h ole m in ip lates w it h
e igh t screw s on each ram u s.
a b
Fig. 21.8 High sagit tal supraforaminal osteotomy (HSSO). (a) The incision line is 25 to 30 mm long and follows the anterior border of
the ramus. A simple lateral retractor (width 20 mm) is applied to protect the lateral and posterior surface during the osteotomy. (b) The
osteotomy on the lateral cortical surface is ~ 10 to 15 mm lower than the medial osteotomy on the ascending ramus. (c) Osteosynthesis
is performed using a maxiplate with four screws on each plate.
Intraoral Vertical Ramus Osteotomy (IVRO)
Th is m eth od is relat ively sim ple an d par t icularly useful
for asym m et ric cases requ iring m an dibular m obilizat ion
(Fig. 21.9). After elevat ing th e lateral periosteu m o th e
ram us from th e sigm oid n otch to th e in ferior border of th e
m an dible (gon ial angle), th e osteotom y is m ade from th e
sigm oid n otch to th e m an dibu lar foram en p osteriorly w ith
an oscillat ing saw. Great care sh ou ld be t aken n ear th e m an -
dibular foram en n ot to dam age th e vascular bun dle, w h ich
can poten t ially cause m assive bleeding. Occasion ally, th e
an t ilingu la on th e lateral su rface can be u sed as a referen ce
to ap proxim ate th e lingu la on th e m edial su rface. After
com plet ing th e vert ical osteotom y, th e prepared splin t is
u sed to guide th e dist al segm en t to n orm al occlusion . Th e
dist al segm en t sh ould be located on th e m edial surface of
th e proxim al segm en t . Osteosyn th esis w ith a m in iplate
is n ot obligator y in th is case, an d in term axillar y xat ion
alon e w ith or w ith ou t in terosseou s w iring n orm ally su f-
ces. Th is in term axillar y xat ion is kept for 6 to 8 w eeks.
Surgery of the Maxilla
Th e m ost w idely perform ed m axillar y orth ogn ath ic su r-
ger y is th e Le For t I osteotom y w ith dow n fract u re.12 Th is
operat ion is relat ively sim ple, but if n ot perform ed cor-
rectly, it can h ave dire con sequen ces such as severe h em or-
rh age, lar yngeal edem a, an d respirator y failure. Lidocain e
an d ep in ep h rin e (1:100,000) is injected in to th e labial
an d bu ccal vest ibu le in clu d ing th e su bp eriosteal area. Th is
hydrodissect ion w ill m ake raising th e m ucoperiosteal ap
easier, as w ell as decrease th e am ou n t of bleeding du r-
ing th e surger y. Th e m idpoin t is m arked w ith a 6–0 nylon
c

Fig. 21.9 Intraoral vertical ramus osteotomy (IVRO). Vertical
ramus osteotomy is useful in case of mandibular asymmetry or
prognathism. The segments are xed with interosseous wiring or
miniplates and screws. The position of the TMJ can be passively
adapted. This m ethod is simple but requires a long period of inter-
maxillary wiring (more than 6 weeks).
su t u re for referen ce later. A m u cosal in cision is m ade 5 to 8
m m above th e m u cogingival ju n ct ion , from th e dist al rst
m olar of on e side to th e oth er. Th e au th ors t yp ically u se a
th in n eedle elect rocauter y for th is pu rpose. Hem ostasis is
p erform ed m et icu lously as th e in cision is deepen ed in lay-
ers. At th e en d, a 5-m m u p -cu t is d on e to p reven t m u cosal
tearing du ring dissect ion of th e pter ygoid process.
Once the bone is reached, periosteal dissection is per-
form ed from the piriform aperture (not entered at this point)
to the zygom atic crest. Dissection should be done carefully
to avoid entering the buccal fat pad. The anterior dissection
extends from the anterior nasal spine up to the infraorbital
foram en. Great care should be taken w hile elevating the nasal
m ucosa from the nasal septum , hard palate, and lateral nasal
wall. A nasal m ucosal tear (especially at the nasal oor) results
in an annoying hem orrhage that can be a challenge to control.
After lifting th e periosteum , th e plan n ed osteotom y
lin es are draw n on th e bone w ith a pencil. Using a diam ond
bur, 5-m m h oles are m ade on the anterior m axillar y w all.
The sinus m ucosa is then lifted o the anterior m axillar y
w all. Using a reciprocating saw, a h orizon tal tran sverse
osteotom y is m ade start ing at the lateral w all of the piriform
fossa an d en ding at th e m axillar y t uberosit y (Fig. 21.10a).
W hen m aking the cut over the anterior m axillar y sinus
w all, th e sin u s m u cosa can be protected w ith a exible peri-
osteal elevator. Once this horizon tal osteotom y is perform ed
on both sides, the low er part of the nasal septal cartilage
an d vom er is detach ed from th e m axilla an d palat in e bon e
u sing a n asal sept u m osteotom e (Fig. 21.10b).
21 Aesthetic Orthognathic Surgery 277
Th e soft palate at th e posterior en d can be protected
w ith a nger during th e separat ion . Next , th e pter ygoid
plate is separated from th e m axilla w ith a cur ved pter ygoid
osteotom e. Th e operator’s nger sh ould be placed on th e
pter ygoid h am ulu s during th e osteotom y at th e pter ygo-
m a xillar y ju n ct ion to preven t inju r y to th e m axillar y ar ter y
an d pter ygoid p lexu s (Fig. 21.10c). On ce det ach m en t of
th e n asal sept um , an terior m axillar y sin us w all, m axil-
lar y t uberosit y, an d pter ygoid process is com p leted, th e
m a xilla is ready to be dow n -fract u red (Fig. 21.10d). Th is
can be don e w ith Row e disim pact ion forceps or m an ually.
With th e Row e forcep s, th e blad e w ith th e large cu r vat u re
protect s th e an terior upper teeth an d th e oth er, sh orter
blade h olds th e n asal oor. Perform th e dow n -fract ure in a
deliberate an d at raum at ic m an n er to preven t un con t rolled
fract u re lin es an d bleed ing. On ce th e d ow n -fract u re is com -
pleted, th e segm en t is h eld dow n w ith a bon e h ook w h ile
bony irregularit ies are sm ooth ed w ith diam on d bu rs or th e
ult rason ic bon e cu t ter. In m axillar y setbacks or u pw ard
displacem en t s, th e posterior sin us w all sh ould also be
t rim m ed to create space for th e desired posterior or supe-
rior m ovem en ts. Avoid inju ring th e descen ding p alat in e
arter y du ring bon e rongeu ring at th e posterior sin u s w all,
as th is can p oten t ially cau se a cat ast roph ic h em orrh age.
On ce th e posterior sin u s w all h as been p repared, th e
m a xilla is m oved in to th e n ew p lan n ed p osit ion u sing th e
prefabricated splin t as a guide. With th is n ew occlusion ,
IMF is ap plied u sing in t raoral elast ic ban ds on th e bracket s.
Measu rem en ts can th en be taken of th e length of th e st itch
at the m edial can th us to th e bracket of th e cen t ral in cisors
to con rm th at th e correct ion as p reop erat ively plan n ed
h as been ach ieved. Fou r L-sh aped, fou r-h ole m in ip lates
are used for osteosyn th esis. On e is placed on each side of
th e piriform rim , an d on e on each of th e lateral bu t t resses
(Fig. 21.10e ). A cin ch su t u re is app lied at th e alar base
before w oun d closu re to preven t splaying of th e alar base
(Fig. 21.10f). For closu re, th e au th ors st ar t by p u t t ing on e
st itch on th e prem arked nylon su t u re in th e m idlin e w ith
4–0 or 3–0 silk (in cisor area). Th e w oun d is th en closed
start ing from th e lateral-m ost edge ( rst m olar area) an d
w orking m edially. At th e m id lin e, a V-Y closu re is fash ion ed
to restore th e n orm al ap pearan ce of th e u pp er lip ; oth er-
w ise it m ay look at an d elongated. Fin ally, t w o passive
silast ic drain s are in serted, on e on each side, an d an ch ored.
Bimaxillary Surgery
Anterior Segmental Osteotomy for
Bimaxillary Protrusion
Bim axillar y prot ru sion is m ost prevalen t in Sou th east an d
East Asia. Th e t ypical ch aracterist ics of bim axillar y prot ru-
sion are p rot ru ded m axilla an d m an dible, ret ru ded sm all
ch in , acu te n asolabial angle w ith /w ith out open bite, an d a
278 IV Facial Bone Surgery

b
a

d e f

Fig. 21.10 Le Fort I osteotomy. (a) Osteotomy starts at the lateral wall of the piriform fossa and ends at the maxillary tuberosit y (red line).
(b) The lower part of the nasal septal cartilage and vomer is detached from the maxilla and palatine bone using an osteotome. (c) The
pterygoid plate is separated from the maxilla with a curved pterygoid osteotome. (d) The m axilla is down-fractured. (e) Four L-shaped,
four-hole miniplates are applied on each side of the piriform rim and lateral but tress. (f) A cinch suture is applied at the alar base before
wound closure to prevent splaying of the alar base.

sm all in terin cisal angle. In dicat ion s for an terior segm en tal
osteotom y (ASO) for pat ien ts w ith bim axillar y prot rusion
in clude
1. Prot rusion of m axillar y teeth an d bon e, causing
sign i can t facial deform it y
2. Orth odon t ically un t reat able prot ru sion , such as
an kylosed teeth , root resorpt ion , or im m ovable/
slow -m oving tooth d u e to th ick bon e stock
3. An terior open bite n ot t reatable w ith orth odon t ic
t reat m en t alon e
4. Un aesth et ic sm all ch in w ith lip excess
First , segm en t al osteotom y of th e m axilla is perform ed.
On th e labial side, th e m argin al gingival in cision ru n s from
th e secon d prem olar of on e side to th at of th e oth er side.
Th e palat al m argin al gingival in cision is sh or ter, from th e
can in e to th e rst prem olar on each side (Fig. 21.11a). Th is
in cision can p reser ve th e vascular su pply to th e bon e sin ce
th ere are n o m ucosal in cision s. On ce th e in cision is m ade,
th e periosteum is elevated to th e an terior n asal spin e on
th e labial side an d to th e coron al m idlin e of th e h ard palate
on th e palat al surface. Ext ract ion of both upper an d low er
rst p rem olars follow s (Fig. 21.11b).
Th e prem olar socket m arks th e osteotom y lin e an d
th e am oun t of posterior setback of th e an terior segm en t .
Th e bon e spicu les at th e edges are sm ooth ed to allow for
proper bon e con tact during osteosyn th esis later. Care m ust
be taken n ot to injure th e can in e an d secon d prem olar by
keep ing th e in ter ven ing socket w all in t act . Th e osteotom y
lin es are m arked on th is prem olar socket w ith a pen cil,
keep ing a distan ce of at least 5 m m p osteriorly an d 3 to 4
m m in feriorly from th e an terior teeth root s, an d ru n par-
allel to th e n asal oor. Th e bu ccal an d p alatal bony w all
at th e ext racted socket is rem oved prim arily w ith a bon e
rongeur. Using a sm all roun d bu r, th e au th ors u sually m ake
sm all port s along th e p lan n ed osteotom y lin e an d in lt rate
ep in ep h rin e an d lidocain e in to th e m arrow p rior to per-
form ing th e osteotom y. Th e au th ors start by deepen ing a
groove along th e p lan n ed osteotom y lin e w ith a 3.8-m m
roun d bur (Fig. 21.11c). Th e diam eter of th e bu r is deter-
m in ed by th e am ou n t of sh orten ing requ ired. Altern at ively,
 21 Aesthetic Orthognathic Surgery 279

Fig. 21.11 Anterior segmental osteotomy (ASO). (a) The palatal marginal gingival inci-
sion is made from the canine to the rst premolar on each side of the maxilla and m andible.
(b) Extraction of both upper and lower rst premolars follows. (c) Osteotomy is performed
by burring out a groove along the planned osteotomy line. (d) The segment is mobilized
and a splint fabricated preoperatively is used as a guide to achieve the desired occlusion.

b c d

a recip rocat ing saw can be u sed. Bleed ing from th e in cisive
foram en d u ring drilling is con t rolled by bon e w ax easily.
Th e m axillar y sin u s can be en coun tered as th e groove is
d eep en ed . Th e sin us m ucosa is kept in t act an d lifted o th e
bon e in stead of being cut th rough .
On ce th e osteotom y is com pleted, th e segm en t is m obi-
lized an d th e preoperat ively fabricated splin t is used as a
gu ide to ach ieve th e d esired occlu sion (Fig. 21.11d). Th e
can in e an d secon d prem olar teeth are ligated w ith w ires
on both sides an d IMF is don e. Th e occlusion is ch ecked
before osteosyn th esis w ith four-h ole, L-sh aped m in iplates
an d screw s. After rigid xat ion is ach ieved, th e sp lin t is
rem oved an d th e m argin al gingival in cision is closed w ith
in terden tal su t u res.
Segm en tal osteotom y of th e m an d ible is ver y sim ilar
to th at of th e m axilla. A m argin al gingival in cision is m ade
from th e secon d p rem olar of on e side to th at of th e oth er
side (Fig. 21.11a). Su bperiosteal dissect ion p roceed s along
th e ch in an d body of th e m an dible. Th e osteotom y lin e is
m arked an d th e rst p rem olars are ext racted on both sides.
Th e bon e is cut in a sim ilar m an n er as described per viously
to create th e an terior segm en t (Fig. 21.11c). Th e splin t is
ap plied n ext to get th e desired align m en t an d occlu sion .
IMF w ith orth odon t ic ru bber elast ics is don e, follow ed by
osteosyn th esis w ith 4-h ole st raigh t plates ben t for proper
t an d adapt at ion . In terru pted in terden t al p ap illar y su t u res
are u sed to close th e in cision an d a silast ic d rain is in serted .
For ASO, th e p refabricated occlusion splin t s are used
p u rely to gu ide th e plan n ed an terior occlusion an d th en
rem oved p rior to ext ubat ion . Postoperat ive IMF is n ot
requ ired, an d th e p at ien t is allow ed to open h is or her
m ou th im m ediately.
Double Jaw Surgery
Dou ble jaw su rger y is also called t w o-jaw su rger y or bim ax-
illar y surger y. Dou ble jaw surgeries sh ould be lim ited to
pat ien t s in w h om (1) th e am oun t of m an dibu lar setback
requ ired is m ore th an 14 m m (in th ese cases, m an dibular
osteotom y alon e is in su cien t to ach ieve n orm al occlusion ,
an d w ill likely h ave a h igh relap se or com p licat ion rate), (2)
sign i can t open bite or seriou s bim axillar y p rot ru sion in
class III m alocclu sion is presen t , or (3) h orizon tal occlusal
can t ing can n ot be adequately corrected or th odon t ically.
Th e m axilla an d m an dible are osteotom ized an d m obi-
lized as described previously in th e sam e set t ing. Opera-
t ion begin s w ith a Le Fort I m axillar y osteotom y an d th e
m a xilla is d ow n -fract u red . Next th e m axilla is align ed w ith
th e h elp of a prefabricated splin t an d xed w ith m in iplates
an d screw s. Man dibu lar osteotom y w ith SSRO or HSSO is
perform ed n ext an d align ed an d xed in a sim ilar m an -
ner. Th e n ew occlu sion is plan n ed p reoperat ively an d t w o
splin t s are n ecessar y: On e is u sed as an in term ed iate sp lin t
after m a xillar y osteotom y to t th e m ovable m axilla to th e
un t reated m an dible, an d th e oth er is for after th e m an dibu -
lar osteotom y, to be u sed as th e n al splin t .
■ Postoperative Care
Day surger y is possible after postoperat ive m on itoring for
~ 4 to 5 h ou rs. Th e n ext visit is on p ostop erat ive day 3, for
rem oving th e silast ic drain an d dressing th e w ou n d. On
postoperat ive day 4 or 5, IMF is released an d t w o m iddle
280 IV Facial Bone Surgery
ring elast ics are u sed on each sid e to en able th e pat ien t to
start early m obilizat ion of th e TMJ w ith sligh t m ou th op en -
ing. On p ostoperat ive day 7 or 8, th e splin t is rem oved an d
th e orth odon t ist begin s postoperat ive or th odon t ic t reat-
m en t . Th e su t u res are u su ally rem oved on postoperat ive
day 10.
An t ibiot ics an d an algesics are prescribed in liquid
form . Th e pat ien t is advised to alw ays carr y arou n d a p air
of sm all scissors to cut o th e ru bber elast ics in case of an
em ergen cy.
■ Key Technical Points
1. Prior to elevat ing th e lingual periosteu m of th e
ascen d ing ram u s, in lt rat ion of epin eph rin e an d
lidocain e is h elpful to avoid acciden t al ru pt ure of
n u t rien t vessels em erging from th e bony foram en .
2. During periosteal elevat ion for lingu al cortex
osteotom y, keep th e dissect ion area n arrow to avoid
dam age to th e vessel an d n er ve from th e m an dibular
foram en .
3. For accurate ram us split t ing, create several guide
h oles in th e m edu lla, dow n to th e posterior border
w ith a 1.8-m m roun d bur. Ram u s split t ing is
com pleted by join ing th ese guide ch an n els w ith a
2-m m ch isel.
4. Rigid xat ion after p recise redu ct ion is key to
sh orten IMF an d bon e h ealing t im e, an d pain less
h ealing.
5. Th e operator’s nger sh ould be placed on th e
pter ygoid ham ulu s during th e osteotom y at th e
pter ygom axillar y jun ct ion to preven t injur y to th e
m a xillar y arter y an d pter ygoid plexu s.
6. After m axillar y bon e su rger y, a cin ch sut ure is
ap plied at th e alar base before w ou n d closu re to
p reven t splaying of th e alar base.
7. During ASO, care sh ould be t aken n ot to injure
th e can in e an d secon d prem olar by keeping th e
in ter ven ing socket w all in t act after ext ract ion of th e
u pp er rst p rem olars. Th e bon e sp icu les at th e edges
are sm ooth ed to allow p rop er bony con t act du ring
osteosyn th esis.
8. Th e osteotom y lin es sh ould be kept at least 5 m m
aw ay from th e an terior teeth root s so as n ot to
d isru pt th e vascular su pply to th e tooth .
■ Complications and
Their Management
Common Complications Follow ing
Facial Bone Surgery
Bleeding du ring SSRO occurs m ain ly from th e bon e m arrow
of th e ram us an d body of th e m an dible. Nut rien t ar teries
from adjacen t soft t issu e also con t ribu te to th e bleeding.
Th ese are m ostly self-lim it ing an d n on -life-th reaten ing.
Severe bleed ing, h ow ever, can resu lt from inju r y to th e in fe-
rior alveolar ar ter y du ring elevat ion of th e periosteu m o
th e lingual cor tex. Hen ce, th e ut m ost care sh ould alw ays be
taken w h en dissect ing n ear th e lingual cor tex, an d proper
soft t issu e p rotect ion w ith broad elevators sh ou ld alw ays
be em ployed to avoid such m ish aps. If severe bleeding is
en cou n tered, p acking th e lingu al t u n n el w ith ep in ep h rin e-
soaked gau ze an d app lying direct digit al pressu re over th e
m an dibu lar foram en rem ain s th e m ost reliable w ay to slow
th e bleeding. Th e pressure sh ould be sust ain ed for ~ 5 to 10
m in u tes. After th e bleeding h as ceased, th e packing is kept
in sit u w h ile th e oth er side is prepared. Th e osteotom ies
m ay p roceed as per u su al if th ere is n o rebleeding. Su rgicel
or brin glue can be applied to th e bleeding area after lin -
gu al cor t ical osteotom ies.
If m assive bleed ing resu lts from facial ar ter y inju r y
during SSRO, th e bleeding site sh ould be packed w ith epi-
n eph rin e gau ze w ith digital com p ression . A 2–0 or 3–0
h em ostat ic su t u re can be app lied over th e bleeding area.
During Le Fort I osteotom ies, the vessels at risk are th e
descending palatine arter y, the m axillar y artery, and the
pterygoid plexus.13,14 The descending palatine artery in the
retrom axillar y region is particularly vulnerable during sepa-
ration of the m axilla from the pterygoid process or dow n-
fract uring of the m axillary segm ent because th is process is
not visualized directly. Thus, placem ent of the osteotom e at
its inferior aspect by palpation is critical to avoid vessel injury
w ithin the pterygopalatine fossa.14,15 Som etim es delayed
secondary h em orrhage (days 1–2 or 7–9) can arise from th e
t uberosit y area. Although the am ount of bleeding is m od-
erate, it should be m anaged prom ptly as it can poten tially
develop into airw ay obstruction. Bleeding from the nasal
oor an d sin us m ucosa can be con trolled spontaneously.
Infection is uncom m on follow ing orthognathic surgery;
the reported incidence is less than 1%.16,17 Nonetheless, if
infection occurs, it is usually associated w ith the m andibu-
lar osteotom y. Follow ing SSRO procedures, m assive irriga-
tion to rem ove bony dust and chips is required.14 Em pirical
antibiotics are routinely prescribed for 7 days after surgery. If
localized infection occurs around the screws, then it is recom -
m ended that they be rem oved. Postoperative pain is usually
m inim al and is easily controlled w ith analgesics such as acet-
am inophen. Severe TMJ pain can occur on the third or fourth
postoperative day and m ay require loosening of the IMF.

Complications Speci c to Maxillary
and Mandibular Orthognathic Surgery
Nerve Injury
Th e in fraorbit al n er ve can be dam aged during m axillar y
su rgeries an d cau se n u m bn ess of th e u p p er lip w ith or
w ith out involvem en t of th e m axillar y teeth , gingiva, an d
alveolar bon e. Gen erally, sen sor y loss in th e in fraorbit al
n er ve dist ribu t ion is tem porar y an d resolves gradually over
a 12- to 18-m on th p eriod.14 Rarely, it develop s in to in fraor-
bital n euralgia in severe cases.
In con t rast to m a xillar y orth ogn ath ic su rger y, m an -
d ibu lar su rger y h as a h igh er rate of tem porar y (60–70%)
or perm an en t (20–30%) n er ve injur y.18,19 Presu m ably, th e
inju r y is su stain ed du ring osteotom y of th e low er lateral
en d of th e body of th e m an dible, or d uring m an dibu lar
split t ing sin ce it often requ ires cu t t ing n ear th e n er ve, an d
som et im es even crossing th e m an d ibu lar can al. Th is is on e
of th e reason s th e au th ors prefer HSSO. Th e low in ciden ce
of n er ve inju r y can be at t ributed to th e fact th at th e areas
of osteotom y an d split t ing are far aw ay from the n er ve du r-
ing HSSO. An oth er danger site is n ear th e m olar or prem o-
lar areas d u ring th e lateral cort ical osteotom y, w h ere th e
ner ve can cou rse laterally n ear th e osteotom y lin es. Th e
pat ien t w h o experien ces such a violat ion w ill com plain of
nu m bn ess over th e corn er of th e m ou th .
Functional Relapse
On e of t h e m ain factors in creasin g t h e r isk of relap se
after or t h ogn at h ic su rger y is an occlu sal d iscre p an cy
t h at in d u ces t h e m an d ible to m ove in an abn or m al d irec-
t ion . Th is occu rs u su ally w it h in a m on t h . Th erefore, it is
ad visable to se n d t h e p at ien t to an or t h od on t ist 5 to 7
d ays after su rger y. An ot h e r con cer n is t h e TMJ factor. An
u n st able TMJ w ill resu lt in an u n st able occlu sion , an d t h is
eve n t u ally lead s to relap se an d recu r re n ce of m alocclu -
sion after su rger y. Th e au t h ors p refe r to get t h e TMJ in a
good con d yle-fossa t before align in g t h e d ist al segm en t .
Abn or m al m u scu lar t ract ion also can lead to fu n ct ion al
relap se. Soft t issu e h as a ten d en cy to ret u r n to it s p re-
op erat ive p osit ion after su rger y. For exam p le, if t h e p os-
ter ior facial h e igh t is lon ger t h an before, t h e m u scles are
st retch ed e ccen t r ically an d ten d to re coil back to t h eir old
p osit ion s. Th is cau ses m an d ibu lar in st abilit y, w it h t h e
m an d ible m ovin g in a rot ator y d irect ion , or back to it s
p reviou s p osit ion . Th e p ter ygom asseter ic m u scle is su s-
p ecte d to be a m ajor con t r ibu tor to t h is p h en om en on . As
a resu lt , t h e p at ien t w ill h ave a relap se of an op en bite or
class III m alocclu sion . Ot h er t h an t h e pter ygom asseter ic
m u scles, t h e ton gu e, lip s, ch eek, an d su p rahyoid m u scles
are also involved in su ch a relap se. On e w ay to cou n ter-
act t h is is to u se a r igid xat ion . Tech n ically, in com p lete
21 Aesthetic Orthognathic Surgery 281
osteotom ies h in d e r t h e segm en t s from m ovin g freely to
t h e n ew p lan n ed p osit ion . As a resu lt , t h e segm e n t s are
in stead brough t in to occlu sion by force, w h ich in evit ably
lead s to relap se. In com p lete osteotom y m ost com m on ly
occu rs at t h e p oster ior ram u s of t h e m an d ible, w h ile t h e
m a xillar y t u berosit y an d p ter ygoid p late are t h e m ost
com m on sites in t h e m a xilla.
Unfavorable Osteotomies
Du ring m a xillar y su rger y, u n con t rolled fract u ring m ay
occur w h en a dow n -fract ure is at tem pted despite in com -
plete osteotom y. To iden t ify th e resist an ce, th e m axillar y
dow n -fract u re sh ou ld be perform ed w ith digit al pressure
on ly, an d Row e disim pact ion forceps sh ould be used on ly
for m obilizat ion after separat ion . Un favorable fract u re sites
during m an dibular surger y are th e con dylar n eck, lingual
plate, an d buccal plate, an d th e in ciden ce rate ranges from
3 to 23%.20,21 If in adverten t fract u re occu rs du ring su rger y,
prom pt m anagem en t for th e fract ure sh ould be un der-
t aken , depending on it s pat tern an d on w h eth er th e dist al
segm en t advan ces or set s back. A prolonged postoperat ive
m a xillar y-m an d ibu lar xat ion is also h elp fu l.14
Condylar Resorption
Con dylar resorpt ion is a late com plicat ion th at usually
occurs 7 to 12 m on th s after th e surger y.14 Th e et iology is
n ot kn ow n yet , bu t cau t ion sh ou ld be paid to pat ien t s h av-
ing class II m alocclu sion , sm all or abn orm al sh ape of th e
con dyle.14,22 Progressive con dyle resorpt ion m ay lead to
open bite an d loss of posterior facial h eigh t . Th e surgeon
m u st w ait at least 6 m on th s u n t il th e resorpt ion is com -
pleted. Th ere is n o e cien t t reat m en t , but in cases of severe
resorpt ion , tot al join t recon st ruct ion m ay be required.
Partial Necrosis of Bone Segment and
Mucosa
Vascular isch em ia an d t issue n ecrosis are caused by un fa-
vorable soft t issu e in cision , excessive st retch ing of th e
palat al soft t issue pedicle, m in u te segm en talizat ion of th e
m a xilla, exten sive hyp oten sion , severan ce of feeding ves-
sels, an d gen eral con dit ion s th at in du ce t ran sien t vascu lar
isch em ia. Usually, vascular com prom ise is t ran sien t but it
can result in devit alizat ion of th e teeth , periodon t al defect s,
an d segm en t al bon e loss. For preven t ion , excessive p erios-
teal st ripping sh ould be avoided an d osteotom y sh ould be
m ade 5 to 6 m m dist an t from teeth root s.23 W h en t issu e
n ecrosis occu rs, u se of recom bin an t bon e m orph ogen et ic
protein 2 (r-BMP2) an d platelet-rich plasm a (PRP) w eekly
for a m on th can be at tem pted. In som e cases, en dodon t ic
t reat m en t is n eeded (Fig. 21.12).
282 IV Facial Bone Surgery

a b

Fig. 21.12 Partial necrosis of bone segment. (a) The X-ray shows that partial necrosis of
the bone segment developed 10 days after surgery. (b) The anterior maxillary bone was
recovered, but root resorption rem ained.

h ad lon g face w it h a h igh ly con cave facial p ro le an d

■ Case Studies a p rot r u sive ch in t h at h e fou n d aest h et ically u n p leas-
in g. He w as classi e d as class III m alocclu sion . Afte r a
Case 1: Mandibular Prognathism 9-m on t h p re op e rat ive or t h od on t ic t reat m e n t , HSSO an d
w ith Long Face ge n iop last y w e re p e r for m e d . Re d u ct ion in t h e am ou n t of
t h e ge n iop last y w as 12 m m , an d t h e am ou n t of set back
A you n g m ale p at ie n t visite d for h abit u al lu xat ion of w as 13.4 m m . Ove r-cor re ct ion w as m an d ator y t o p reve n t
TMJ accom p anyin g ch ew in g d i cu lt y (Fig. 2 1.1 3). He relap se (Fig. 21 .1 4).

a b

Fig. 21.13 Case 1. Mandibular prognathism with long face. (a,b) Preoperative photo-
graphs. (c,d) Preoperative cephalometry and panoram ic view. d

a b
Fig. 21.14 Case 1. (a,b) Two years postoperative photographs. (c,d) Two years postopera-
tive cephalometry and panoramic view.
Case 2: Mandibular Prognathism
w ith Long Face
A you ng m ale pat ien t visited for relat ive ret ru sion of th e
u pp er jaw an d p rot ru sive low er jaw (Fig. 21.15). He sh ow ed
an excessive low er facial th ird , a h igh ly con cave facial p ro-
le, a long an d p rot ru sive ch in , an d a long face w ith ou t a
labiom en tal fold. In fun ct ion al assessm en t , h e w as desig-
n ated as a classi cat ion of class III m alocclu sion skelet al
t yp e w ith accom p anying m ast icator y di cu lt y an d TMJ
fu n ct ion al derangem en t . Preop erat ive orth od on t ic t reat-
m en t w as adm in istered for in t ru sion of m axillar y p osterior
m olars, arrangem en t of m axillar y an d m an dibu lar den t al
arch discrep an cy w ith p alatal exp an sion , decom p en sat ion
of upper an d low er teeth (adjust m en t of teeth in clin a-
21 Aesthetic Orthognathic Surgery 283
d
t ion ), leveling of upper an d low er teeth , tooth align m en t to
restore th e rotat ion s, an d crow ding teeth .
Becau se t h e p at ien t refu sed d ou ble jaw su rger y,
HSSO an d gen iop last y w ere t h e on ly opt ion s at t h e t im e
of t reat m en t p lan n ing. Sin ce t h e ver t ical im p act ion of t h e
u p p er p oster ior teet h w as n ot p ossible w it h or t h od on -
t ic t reat m en t on ly, en dodon t ic p roced u res on t h e u p p er
m olars on each sid e, follow in g p rost h od on t ic t reat m en t ,
w as ad opted ad d it ion ally. On gen iop last y, t h e am ou n t
of ch in red u ct ion w as 13.5 m m , an d t h e d ist al segm en t
w as m oved 3.5 m m backw ard . Con sid erin g t h e p ostop -
erat ive relap se, m an d ibu lar set back w as over cor rected
3 m m . After 3 years, t h e occlu sion w as n or m alized, bu t
1 m m an ter ior d isp lacem en t of t h e m an d ible w as n oted
(Fig. 21.16).
284 IV Facial Bone Surgery

a b

Fig. 21.15 Case 2. Mandibular prognathism with long face. (a,b) Preoperative photo-
graphs. (c,d) Preoperative cephalometry and panoram ic view. d

a b

Fig. 21.16 Case 2. (a,b) Three years postoperative photographs. (c,d) Three years post-
operative cephalometry and panoram ic view. d

References
1. Raym on d GV. Cran iofacial gen et ics an d dysm orph ology. In :
Kolk CAV, Wilkin s EG, eds. Plast ic Su rger y In dicat ion s, Op -
erat ion s, an d Ou tcom es. Mosby; 2000:613–617
2. Steinhäuser EW. Historical developm ent of orthognathic sur-
gery. J Craniom axillofac Surg 1996;24(4):195–204
3. Reu th er J. [Orth ogn ath ic surger y: correct ive bon e op -
erat ion s.] Mun d Kiefer Gesich t sch ir 2000;4(Su ppl 1):
S237–S248
4. Angle EH. Classi cat ion of m alocclusion . Den t al Cosm os
1899;41:248–264
5. Blair VP. Operat ion s on th e jaw -bone an d face. Surg Gyn e-
col Obstet 1907;4:67–78
6. Ow en s EG, Goodacre CJ, Loh PL, et al. A m ult icen ter in -
terracial st u dy of facial ap p earan ce. Part 2: A com parison
of in t raoral param eters. In t J Prosth odon t 2002;15(3):
283–288
7. Ow en s EG, Goodacre CJ, Loh PL, et al. A m ult icen ter in -
terracial st u dy of facial ap p earan ce. Part 1: A com parison
of ext raoral param eters. In t J Prosth odon t 2002;15(3):
273–282
8. Ah n SN. Keph alom et risch e Vergleich st udie von skelet t alen
u n d Weich teil Param etern zw eier eth nisch er Gruppen .
Doctoral dissert at ion . Kieferor th op aedie, ZMK Klin ik, Un i-
versit at Ham bu rg; 1995
9. Obw egeser HL, ed. Man dibular Grow th An om alies. Berlin ,
Heidelberg, Germ any: Sp ringer-Verlag; 2001
10. Kadu k W M, Podm elle F, Lou is PJ. Revisit ing th e su p rafo-
ram in al h orizon t al obliqu e osteotom y of th e m an dible. J
Oral Maxillofac Su rg 2012;70(2):421–428
11. Scheuer HA, Höltje WJ. [Stability of the m andible after high
sagittal supraforam inal osteotomy. Roentgen cephalom etric
study.] Mund Kiefer Gesichtschir 2001;5(5):283–292
12. LeFort R. Et u de experim en tale su r les fract u res d e la m a-
ch oire su p erieu re. Rev Ch ir 1901;23:208–227
21 Aesthetic Orthognathic Surgery 285
13. Bell W H. Le Forte I osteotom y for correct ion of m axillar y
deform it ies. J Oral Su rg 1975;33(6):412–426
14. Morris DE, Lo LJ, Margu lis A. Pitfalls in orth ogn ath ic su r-
ger y: avoidan ce an d m an agem en t of com plicat ions. Clin
Plast Su rg 2007;34(3):e17– e29
15. Lan igan DT, West RA. Man agem en t of postop erat ive h em -
orrh age follow ing th e Le Fort I m axillar y osteotom y. J Oral
Maxillofac Su rg 1984;42(6):367–375
16. Ruggles JE, Han n JR. An t ibiot ic p rop hylaxis in in t ra-
oral orth ogn ath ic surger y. J Oral Maxillofac Surg 1984;
42(12):797–801
17. Gallagher DM, Epker BN. Infection follow ing intraoral sur-
gical correction of dentofacial deform ities: a review of 140
con secutive cases. J Oral Surg 1980;38(2):117–120
18. Posn ick JC, Al-Qat t an MM, Step n er NM. Alterat ion in fa-
cial sen sibilit y in adolescen t s follow ing sagit t al split an d
ch in osteotom ies of th e m an dible. Plast Recon st r Su rg
1996;97(5):920–927
19. Lindquist CC, Obeid G. Com plications of genioplast y done
alone or in com bination w ith sagittal split-ram us osteotom y.
Oral Surg Oral Med Oral Pathol 1988;66(1):13–16
20. Van d e Perre JP, Stoelinga PJ, Blijdorp PA, Brou n s JJ, Hop -
pen reijs TJ. Perioperat ive m orbidit y in m axillofacial ortho-
paedic surger y: a ret rospect ive st u dy. J Cran iom axillofac
Surg 1996;24(5):263–270
21. van Merkesteyn JPR, Groot RH, van Leeuw aard en R,
Kroon FH. In t ra-operat ive com plicat ion s in sagit t al an d
vert ical ram u s osteotom ies. In t J Oral Maxillofac Su rg
1987;16(6):665–670
22. Merkx MA, Van Dam m e PA. Con dylar resorpt ion after or-
th ogn ath ic su rger y. Evalu at ion of t reat m en t in 8 p at ien t s. J
Cran iom axillofac Su rg 1994;22(1):53–58
23. Bell W H, Fon seca RJ, Ken n eky JW, Levy BM. Bon e h ealing
an d revascu larizat ion after tot al m axillar y osteotom y. J
Oral Su rg 1975;33(4):253–260
 22 Genioplasty
Seong Yik Han and Kar Su Tan
Pearls
• Gen ioplast y has n o e ect on occlusion an d can thus
be considered a w holly aesthet ic procedure aim ed
at m odifying the form and appearance of th e bony
m en t um .
• Gen iop last y is m ost com m on ly don e as an
adju n ct ive p rocedu re of an terior segm en tal
osteotom y, angle redu ct ion surger y, m an dibular
sh aving, zygom at ic su rger y, an d rh in oplast y to
yield syn ergist ic e ects in m aking an aesth et ically
pleasing face.
• Proper evaluat ion an d docum en tat ion in th e form
of facial ph otography, sim ulat ion m odeling, an d
radiograp h ic invest igat ion s (pan oram ic view, lateral
an d p osterior-an terior [PA] cep h alogram , an d/or 3D
com puted tom ography [CT] scan ) are im perat ive
prior to surger y.
• Th e object ive is to ach ieve facial h arm ony th rough
su rgically m odifying th e m en t u m an d m an dibu lar
sym p hyseal areas, recreat ing ap p ropriate facial
propor t ion s an d sym m et r y of th e low er th ird of
th e face.
■ Introduction
Th e ch in is vital in creat ing a sen se of sym m et r y an d pro-
port ion of th e face. Th e feat ures of im por tan ce in th e ch in
in clu de (1) th e cur vat u re from th e in ferior verm illion to
th e ch in t ip, (2) th e volum e of th e ch in bon e, an d (3) th e
posit ion of th e ch in t ip. In terest ingly, th e ch in h as a sig-
n i can t im pact on th e p at ien t socially. Many p at ien t s w ith
m icrogn ath ia or m an dibu lar hyp op lasia reveal a lack of
con den ce, in t roversion , an d an in feriorit y com plex. In th is
sen se, th e role of aesth et ic su rgeon s exten d s beyon d sim ple
aesth et ic en h an cem en t s an d augm en tat ion s.
Th e con cept of beaut y borrow s h eavily on th e in di-
vidu al’s cu lt u ral backgrou n d an d exp osu re. In East Asian
t radit ion s, a roun d an d volum in ous ch in w as preferred as
th e ideal. Now adays, h ow ever, m any fem ale pat ien t s w an t a
sm all face w ith a V-sh ap ed ch in in stead of th e big U-sh aped
ch in of previous t im es. Most m ale pat ien ts also prefer a n ar-
row er, sligh tly longer an d m oderately p rom in en t ch in . We
286
• Th e ideal ch in posit ion varies am ong in dividuals,
an d is determ in ed by taking in to con siderat ion both
th e h ard an d soft t issue ceph alom et r y referen ce
poin t s.
• Gen ioplast y can be perform ed in t w o w ays:
(1) osseou s gen ioplast y an d (2) augm en tat ion
gen iop last y u sing im p lan ts. Th e au th ors p refer
osseous gen ioplast y because it provides a m ore
reliable outcom e.
• Osseou s gen iop last y is don e in t raorally u n der
gen eral an esth esia. Horizon t al bon e cu t s are m ade
bicort ically w ith an oscillat ing saw, t aking care
n ot to injure th e m en tal n er ve, an d th e m obilized
segm en t is xed w ith pre-ben t m in iplates.
• Alth ough gen iop last y is a relat ively safe operat ion
w ith ver y low com plicat ion rates, m en t al n er ve
inju r y, m alun ion /n on u n ion , irregularit y of bon e
su rface, lip droop ing or skin dim p ling, ch in ptosis,
an d asym m et r y m ay develop .
can safely assum e th at th is t ren d w ill con t in ue to evolve,
an d su rgeon s w ill h ave to st ay cu rren t w ith th e t im es an d
m odify th eir tech n iqu es to su it th e requ irem en t s of th e
con tem porar y aesth et ic preferen ce.
Gen iop last y, w h ile seem ingly a relat ively st raigh tfor-
w ard procedu re, h as a sign i can t im pact on overall facial
h arm ony an d at t ract iven ess. Th is surger y is gen erally con -
sidered an adjuvan t su rger y, p erform ed to en h an ce an d
com plem en t oth er facial bon e surgeries such as sagittal
split ram us osteotom y (SSRO), anterior segm ental osteotom y
(ASO), m andibular angle reduct ion surgery, an d m alarplast y.
The m ost com m on indications for genioplast y are (1)
sm all chin w ith class II m alocclusions (w ith or w ithout open
bite or bim axillary protrusion) and (2) big chin w ith class III
m alocclusion and an excessively long face. These problem s are
often a result of congenital syndrom es (e.g., Treacher-Collins
syndrom e) or hereditary m alocclusion, chin hypoplasia sec-
ondary to childhood osteom yelitis, chin deviation due to soft
tissue contractures (e.g., burns), and anterior chin or tem poro-
m andibular joint grow th center disruptions from traum a.
 22 Genioplast y 287

t ion of th e xat ion m eth od, th is tech n ique is st ill w idely

■ Historic Background of used today. Fur th er advan ces in th e osteotom y design s
Genioplasty in th e h orizon t al, ver t ical, an d sagit t al p lan es resulted in
greater con t rol over th e n al ap pearan ce of th e ch in .
Historically, gen ioplast y is p erform ed in on e of t w o w ays:
th e use of on lay augm en tat ion over th e m en t um sur-
face, an d th e rep osit ion ing of th e ch in via osteotom ies. G. ■ Essential Cephalometric Data
Au frich t in 1934 described th e u se of th e excised n asal
h u m p as an au tograft m aterial “recycled” from rh in o- for Genioplasty
plast y.1 In 1948, K. H. Th om a described th e use of t it an ium
Th e im por t an t n orm s for ch in posit ion in ceph alom et ric
m esh for gen iop last y. Nu m erou s m aterials h ad been exper-
an alysis are su m m arized in Table 22.1. Th e di eren ces in
im en ted w ith th rough ou t h istor y w ith var ying success, but
ceph alom et ric n orm s am ong various eth n ic groups h ave
as im p lan t tech n ologies advan ced, so did th e ou tcom es.
been w ell docum en ted th rough various com parat ive st ud-
Som e exam p les of th ese in clu d e acr ylic, w ax, silast ic ch in
ies.4,5,6 Th e m ajor di eren ce in ch in ceph alom et ric param -
im plan t (Brow n et al 1953), expan ded polytet ra uoroeth -
eters is th e length of th e low er face. In Korean s, Sp ′–Gn
ylen e (e-PTFE, or Gore-Tex [W. L. Gore]) syn th et ic im p lan t s,
(m m ) is longer th an it is, for exam ple, in Germ an s (65.91
ceram ics an d hydroxyapat ite, an d dem in eralized gran u -
m m versu s 63.27 m m , respect ively). Th u s, th e rat io N–ANS/
lated tooth (Auto BT) w ith BMP.
ANS–Me (79.5%) is low er in Korean s. Th is valu e is a u sefu l
Th e con cept of osseous gen ioplast y w as rst presen ted
gu ide for th e calcu lat ion of th e ideal ver t ical length of th e
by O. Hofer in 1942. He ut ilized a th ree-step tech n ique:
ch in . Oth er variables also sh ow ed sign i can t di eren ces
segm en tal osteotom y, relocat ion , an d xat ion of th e ch in
(see Chapter 21, Fig. 21.4 an d Fig. 21.5).
bon e to th e n ew posit ion .2 Hofer d escribed rst creat ing
a h orizon tal osteotom y of th e an terior p ar t (m en t u m ) of
th e m an dible via an ext raoral subm en t al in cision to correct
p rogn ath ism an d m icrogn ath ia (Fig. 22.1a). H. Obw egeser ■ Patient Evaluation
(1957) later described advan cem en t sliding gen ioplast y
via an in t raoral approach to avoid visible ch in scars Patient Consultation
(Fig. 22.1b).3
After osteotom izing th e low er port ion of th e an terior It is im p ort an t to in qu ire abou t th e p at ien t’s m edical an d
m an dible, th is segm en t w as p u lled for w ard, p edicled on th e fam ily h istor y. Som et im es pat ien t s m ay w ith h old sign i -
gen iohyoid m u scle. He xed th e segm en t u sing p erim an - can t det ails, such as previou s ller inject ion or ch in im plan t
dibular Supram id (S. Jackson ) th read over th e acr ylic splin t . su rger y, on ly to be revealed du ring rou t in e p reop erat ive
Later Obw egeser sw itch ed to direct bon e w iring. He also radiologic exam in at ion s. Th is h igh ligh t s th e im port an ce
described m odi cat ion s of h is tech n ique for asym m et ric of a com plete preoperat ive assessm en t in clu ding X-rays. It
ch ins, by m odifying th e arc of th e segm en t . With th e excep - is also im port an t to listen at ten t ively an d t ake n ote of th e

a b

Fig. 22.1 Early genioplast y techniques. (a) Anterior sliding advancement genioplast y was rst described by O. Hofer in 1942. It was
performed via an extraoral submental approach. (b) Genioplast y surgery described by Obwegeser. This sliding advancement genioplast y
was performed intraorally, xed with perimandibular Supramid thread on each side over an acrylic dental splint.
288 IV Facial Bone Surgery
Table 22.1 Important norms of chin position by cephalometric analysis (adapted from Dr. SN Ahn 4)
Variables a Norms (Asian)
N–Me (mm ) 118.8 ±4.5
N–ANS (mm) 52.9 ±2.7 (45% from N–Me)
ANS–Me (mm ) 65.9 ±4.5 (55–56% from N–Me)
N–ANS/ANS–Me (%) 80.5 ±5.7
S–N–A (°) 82.0 ±3.9
S–N–B (°) 79.4 ±3.5
G–Sn:Sn–Me′ 1:1
Sn–St:St–Me′ 1:2
a
See Chapter 21, Table 21.1 for a guide to variables.
p at ien t’s desires an d exp ect at ion s. Th e param eters dis-
cussed usually in clude (1) th e volu m e an d sh ape of th e ch in
(sm all/large, broad/n arrow, sh arp/oval), (2) posit ion ing of
th e ch in t ip on th e sagit t al plan e (prot rusion or ret ru sion ),
(3) vert ical h eigh t of th e ch in (length ening/sh or ten ing),
an d (4) sym m et r y (in all th ree plan es).
Occasion ally, th e su rgeon m ay en cou n ter a pat ien t h av-
ing good ch in sh ape, p osit ion , h eigh t , an d sym m et r y but
w h o requests su rger y. In th is sit u at ion , th e surgeon n eeds
to con sider th e p at ien t ju diciou sly.
Th e pat ien t’s occlusion is also exam in ed during th e
con su ltat ion . Th is is especially crucial in pat ien t s w h o h ave
h ad p reviou s orth odon t ic t reat m en t or jaw surgeries. Gen -
erally, sim ple gen iop last y alon e is su cien t for a pat ien t
w ith n orm al class I occlusion . How ever, it w ill n ot su ce
for p rop er aesth et ic correct ion for pat ien t s w ith class II or
III occlu sion s. In th is case, orth odon t ic t reat m en t or su r-
ger y (su ch as an terior segm en t al osteotom y or sagit tal split
ram u s osteotom y) sh ould precede gen ioplast y to correct
m alocclu sion .
■ Patient Assessment
For preoperat ive assessm en t , an alysis of facial ph oto-
graph s, in clu ding fron tal, 45 degrees obliqu e, lateral, basal,
an d h elicopter view s, an d sm iling an d pou t ing view s, is th e
rst step . It is cru cial to obt ain sm iling an d pou t ing p h oto-
graph s sin ce som e problem s, su ch as skin dim p ling, m ay
ap pear on ly du ring p ou t ing or sm iling.
To determ in e th e ideal soft t issue vert ical dim en sion of
th e low er th ird of th e face, various referen ces m ay be used,
su ch as (1) th e Ricket ts lin e (E-lin e), (2) th e ru le of th irds,
(3) soft t issue division s from th e su bn asale (Sn ) to th e soft
t issue m en ton (Me′) an d from th e glabella to th e soft t issu e
Norms (Caucasian)
115.7 ±4.5
52.4 ±3.0 (45% from N–Me)
63.3 ±5.5 (54–55% from N–Me)
83.2 ±6.2
81.1 ±4.1
79.0 ±3.5
m en ton (see Ch apter 21, Fig. 21.5), an d (4) th e con cept of
th e “zero-m eridian ” (Gon zalez-Uloa, 1962).
Th e “esth et ic” lin e, or E-lin e, can be draw n from th e
n asal t ip (pron asale) to th e soft t issue pogon ion (Pog′)
to evalu ate lip p osit ion (Fig. 22.2). Th e m ean dist an ce of
th e upper lip to th e E-lin e is 0.41 m m in Asian s an d 4.72
m m in Cau casian s; w h ile th e m ean d ist an ces for th e low er
lip are 1.27 m m an d 3.14 m m for Asian s an d Caucasian s,
resp ect ively.4 Using th ese m easu rem en t s, th e p osit ion of
th e pogon ion can be ext rapolated. On e pitfall to n ote is th at
th is m eth od relies h eavily on th e pat ien t’s h aving a n or-
m ally p rojected pron asale (n asal t ip ). Usu ally th e pron asale
is in adequately projected in Asian s; th u s, u sing th is poin t as
a referen ce in su ch p at ien ts can lead to an erron eou s con -
clusion in iden t ifying a ret ruded pogon ion posit ion .
Th e rule of th irds is also applied in th e an alysis of facial
p ropor t ion s. Th e face is divided in to th ree equ al vert ical
sect ion s: Th e p ort ion from th e t rich ion (Tr) to th e glabella
form s th e u pper th ird, from th e glabella to th e su bn asale
th e m iddle third, an d from th e su bn asale to th e m en ton th e
low er th ird (see Ch apter 21, Fig. 21.3a). Asian s are kn ow n
to h ave a longer low er th ird th an Caucasian s by ~ 2 to 3%.
Th is m eth od of propor t ion al an alysis m ay be used to deter-
m in e th e ideal p osit ion of th e soft t issu e m en ton (Me′)
(Fig. 22.3a). In addit ion , fu rth er an alysis of th e low er th ird
can be m ade by st udying th e posit ion s of th e subn asale
(Sn ), stom ion (St), low er lip (LL), an d soft t issue m en ton .
Th e rat io of th e dist an ces Sn –St:St–Me′ is 1:2, an d th at of
th e dist an ces Sn –LL:LL–Me′ is 1:1 (Fig. 22.3b). In p at ien t s
w ith sm all chin s, th e Sn –LL:LL–Me′ rat io w ill be m ore th an
1. Using th ese rat ios of th e low er facial th ird, th e opt im al
p osit ion of the soft t issue m en ton can be calculated.
Th e con cept of zero-m eridian w as described by Gon -
zalez-Ulloa in 1962.8 From th e soft t issue N poin t , a lin e
p erp en dicu lar to th e Fran kfort h orizon t al lin e (FH lin e), th e
 22 Genioplast y 289

Fig. 22.2 Esthetic line (E-line,
Ricket ts’ line). The “esthetic” line,
or “E-line,” is drawn from the nasal
tip (pronasale, Pn) to the soft tis-
sue pogonion (Pog′) to evaluate lip
position.
Pn
UL to E line
LL to E line
Pog'
lin e from th e upper rim of th e extern al auditor y can al to
th e low er rim of th e orbit , is draw n . Th is is kn ow n as th e
zero-m eridian . Th e soft t issu e pogon ion is located along
th e zero-m eridian (Fig. 22.3c).
Im aging an alysis in clu ding X-ray (p an oram ic view,
Ceph alo PA, Ceph alo Lat) or 3D CT scan is also a n ecessit y.
In th e p lan n ing of th e ideal p osit ion of th e ch in t ip (Me or
Pog), it is u sefu l to bear in m in d th at p roport ion is m ore
im port an t th an th e act ual length . Lateral cep h alom et r y
is perh aps th e single m ost in form at ive tool in assessing
an d d eterm in ing th e posit ion of th e ch in . Th e an terior-
posterior ch in project ion (Pog) is determ in ed on th e sag-
it tal plan e by locat ing it bet w een th e SNA an d SNB lin es.
Th e n asion (N)–an terior n asal spin e (ANS)/an terior n asal
spin e (ANS)–m en ton (Me) rat io is th e m ost frequ en tly u sed
param eter to assess th e adequacy of th e ver t ical h eigh t of
th e ch in (Fig. 22.4). Th ese p aram eters are th e n orm s for
referen ce; h ow ever, depen ding on th e pat ien t’s preferen ce,
th e n al ch in posit ion m ay be adjusted to w ith in 6% of th is
referen ce gure safely.

G Fig. 22.3 Proportional analysis by

facial thirds to determine the vertical
dimension of the chin. (a) Normal ver-
1/2 tical dimension (left); vertical de ciency
N
of lower third (middle); vertical excess of
lower third (right). (b) Distance ratio Sn–
Sn Frankfort line St:St–Me′ is 1:2, and the distance ratio
1/3 Sn–LL:LL–Me′ is 1:1. (c) Zero-meridian
1/2
St line: from N′ (soft tissue nasion) perpen-
Li 1/2 dicular to the Frankfort horizontal line
2/3 1/2 (upper rim of the external auditory canal
Pg
to lower rim of the orbit). Pog′ (soft tis-
sue pogonion) should be located along
Me'
b c this line. Otherwise the chin is retruded
0-Meridian or protruded.
290 IV Facial Bone Surgery
S N NSL
N-ANS
ANS
NL
ANS-Me
Go
Me
ML
Fig. 22.4 Cephalometric analysis of chin position. The ratio N–
ANS/ANS–Me is the best parameter for determining the ideal ver-
tical chin length. The N–ANS/ANS–Me index is 80% ± 6 in Asians
as opposed to 83% ± 6 in Caucasians. The N–ANS length averages
51 to 53 mm in every ethnic group. However, the ANS–Me length
is signi cantly di erent, averaging 66 mm in Asians and 63 mm
in Caucasians. ANS, anterior nasal spine; S, sella; N, nasion; NSL,
nasion-sella line; NL, nasal line; Go, gonion; Me, menton; ML, man-
dibular line. (See Fig. 21.4 and Table 21.1 for the de nition of ref-
erence points.)
In pract ice, it is im p ort an t to rem em ber th at th e soft
t issue does n ot m ove at th e sam e m agn it u de as its un derly-
ing rep osit ion ed bon e. For exam ple, a 5-m m advan cem en t
of th e ch in bon e usually result s in soft t issue advan cem en t
of ~ 75% of th at . In vert ical length en ing an d sh or ten ing of
th e ch in , h ow ever, soft t issue follow s bon e m ore closely, on
th e order of ~ 90%.
■ Surgical Techniques
Th ere are essen t ially ve kin ds of gen ioplast y, depen ding
on th e direct ion of ch in m obilizat ion : (1) sagit tal augm en -
tat ion , (2) sagit tal reduct ion , (3) vert ical augm en t at ion , (4)
ver t ical redu ct ion , an d (5) t ran sverse correct ion (Fig. 22.5).
Alth ough osseou s gen ioplast y is a relat ively sim ple
operat ion , it is bet ter to perform it using gen eral an esth esia
as th e n oise an d vibrat ion of th e bony w ork can be u n set-
tling an d dist ressing to th e pat ien t . Nasal in t ubat ion is th e
m eth od of ch oice for secu ring th e air w ay. Th is also allow s
th e ch in sh ape an d posit ion to be ch ecked in closed occlu-
sion du ring su rger y. Recen tly, osseou s gen ioplast y u sing an
u lt rason ic bon e cu t ter h as becom e feasible w ith local an es-
th esia un der IV sedat ion (Fig. 22.8).
1. Th e m idlin e of th e face (run n ing th rough th e dorsum
of th e n ose an d ph ilt rum , bet w een th e t w o m edial
in cisors to th e m idpoin t of th e ch in ) is draw n w ith
a m arking p en preoperat ively. Th is ser ves as an
in t raop erat ive gu ide.
2. Su bp eriosteal in lt rat ion of local an esth esia w ith
1:100,000 epin eph rin e from th e rst prem olar to th e
con t ralateral side w ill n ot on ly provide h em ost asis
but also ease hydrodissect ion for periosteal elevat ion
over th e ch in . In lt rat ion in to th e labial m u cosa is
also h elpfu l in redu cing m u cosal bleeding.
3. Th e in t raoral approach is preferred, especially in
Asian s, sin ce th e in cision al scar on the skin ten ds to
be m ore prom in en t th an in Caucasian s. Th ere are
t w o w ays of m aking th e in t raoral in cision , via eith er
a labial m u cosal in cision or a m argin al gingival
in cision (Fig. 22.6).
a. Labial m ucosal incision: Th e m id lin e is h atch ed
w ith a scalpel for referen ce. Th en a labial in cision
is m ade 5 m m aw ay from th e labiogingival
groove, leaving an edge for easier sut uring
during closure. It exten ds from th e rst prem olar
of on e side to th at of th e oth er. From th e
su p er cial m u cosa, th e in cision is m ade to th e
periosteu m w ith diath erm y. Take n ote to avoid
excessive disru pt ion of th e m en talis m u scle
bers to p reven t ch in ptosis.
b. Marginal gingival incision: An in cision is m ade
along th e gingival m argin from th e secon d
prem olar of on e side to th at of th e con t ralateral
side w ith a n o. 12 or n o. 15 scalpel dow n to
th e bony alveolar crest . Next th e periosteum
is directly lifted an d th e m ucogingival ap is
developed to expose th e bony surface of th e ch in .
Th e advan t ages of th is in cision in clude sparing
of th e m en talis m uscle an d th e absen ce of a
m u cosal scar.
4. Th e dissect ion sh ou ld exten d to th e in ferior m argin
of th e m an dible on th e labial m an dibular surface,
an d sh ou ld be w ide en ough for th e osteotom y.
Un n ecessarily w ide dissect ion aroun d th e sym physis
area sh ou ld be avoided. Th e ap sh ou ld n ot exten d
to th e lingual su rface; this is n ecessar y to preven t
ch in ptosis, dim pling, an d un easin ess of low er lip
m ovem en t after su rger y. Bleeding from n u t rien t
vessels en cou n tered du ring d issect ion m ay be
easily con t rolled w ith bon e w ax. Iden t ifying th e
m en t al n er ve is n ot m an dator y, bu t it w ill be safer.
If gen iop last y is to be com bin ed w ith m an dibu lar
sh aving or angle redu ct ion su rger y, it is m ore
conven ien t to skeleton ize th e m en tal n er ve to allow
m ore sp ace for op erat ion .
5. Th e m idlin e of th e ch in is m arked w ith a sm all
rou n d bu r, n orm ally from th e lin e bet w een th e low er
cen t ral in cisors to th e m idlin e of th e ch in t ip. Th is
m arking is u sed for app roxim at ion of th e m idlin e of
th e ch in segm en t later. Th e h orizon tal cut t ing lin e is
m arked as design ed (Fig. 22.7).
With a m icrom otor d rill, t w o or th ree ver y sm all
h oles are m ade along th e p lan n ed osteotom y lin e,
 22 Genioplast y 291

a b
Fig. 22.6 Operative incisions for osseous genioplast y. (a) Labial
a
mucosal incision. (b) Marginal gingival incision.

Fig. 22.7 Bony marking for genioplast y. The midline of the chin
is marked with a small round bur or saw. Marking the horizontal
cut ting line is done with a pencil or marking pen as designed. A
long groove is created at the t wo ends of the planned osteotomy to
prevent slippage during sawing.
c

an d local an esth et ic w ith ep in ep h rin e is in lt rated

d
e m in d th at it is often easier to create a m ore n at u ral-
Fig. 22.5 Five t ypes of genioplast y. (a) Sagit tal augmentation
(anterior advancement). (b) Sagit tal reduction (posterior reduc-
tion). (c) Vertical augmentation with bone graft. (d) Vertical reduc-
tion. (e) Transverse correction in facial asymmetry.
in to th e m edulla via th ese por ts to redu ce bleeding
during th e m en t al osteotom y. A 5-m m -long groove
is created at th e t w o en ds of th e plan n ed osteotom y
w ith a 1.8-m m bur, to create a leading groove for
th e saw blade to preven t slippage during saw ing.
Th e osteotom y lin e sh ould be at least 5 m m aw ay
from th e m en tal foram in a in feriorly. A recip rocat ing
saw w ith a rou n d-t ip blade is u sed to m ake th e
h orizon tal osteotom y. Th e rst cut is from on e lateral
edge to th e m idlin e, an d th is is repeated on th e
con t ralateral side. During th e osteotom y, th e m en tal
n er ves sh ould alw ays be protected w ith in st ru m en t s
to p reven t in adver ten t inju ries to th e n er ves. Bear in
looking m an dibular lin e w h en th e osteotom y lin e
start s m ore p osteriorly.
Th e progress of th e cu t t ing can be felt as th e saw
cut s th rough th e ou ter cortex an d m edulla to engage
th e in n er lingual cor tex. On ce both cort ices h ave
been engaged, it m ay be m ore expedit ious to cut
bicort ically. Perisym physeal bleeding can be reduced
if prior in t ram edu llar y in lt rat ion w as p erform ed
as described earlier. Du e to it s at rau m at ic n at u re,
292 IV Facial Bone Surgery

th e ult rason ic bon e cu t ter reduces t raum a to th e

t issue, bony h em orrh age, an d postoperat ive sw elling
(Fig. 22.8). How ever, it exten ds th e operat ion t im e by
30 to 40%. Th is tech n ique is part icularly useful w h en
em ployed n ear th e m en t al n er ve or facial arter y.
6. On ce th e osteotom y is com pleted an d h em ost asis
secu red , th e distal osteotom ized m en t u m segm en t is
m obilized . Th e an terior belly of th e digast ric m u scle
is at tach ed to th e d igast ric fossa on th e lingual
su rface of th is segm en t , an d it is n ot n ecessar y to
det ach th is st ruct ure. How ever, in cases of vert ical
redu ct ion , th e m u scle at tach m en t to th e reducing
bon e sh ould be rem oved w ith an elect ric cauter y.
7. Th e m obilized segm en t is th en xed in th e n ew
posit ion according to preoperat ive plan s w ith
t w o pieces of t w o- or th ree-h ole m in iplate an d
screw s. Pre-ben t p rot ru sion /ret ru sion m in ip lates
are available (Fig. 22.9). Du ring xat ion , alw ays
refer to th e m arked m idlin e to en sure th e cen t ral
posit ion of th e ch in . In vert ical sh orten ing of th e
ch in , a bony step is form ed at each en d of th e ch in
segm en t w h ere th e origin al m an dibu lar lin e h as
been disrupted. Ut m ost care sh ould be taken w h en
t rim m ing th e step to restore a sm ooth m an dibular a
lin e, as th e m en tal n er ve is often in close proxim it y.
8. Th e m ucosa is th en closed w ith in terrupted 4–0
Vicr yl (Eth icon ) or silk. Th e m idlin e is rst iden t i ed
an d op posed u sing th e p reviou sly h atch ed m u cosal
poin t s, an d th e rest of th e in cision is closed from
lateral to m edial. Th e im p or t an ce of prop er closu re
can n ot be overem ph asized sin ce poorly m atch ed
closu re can result in facial asym m et r y, discom for t ,
an d fu n ct ion al dist u rban ce p ostop erat ively, desp ite
perfect bony align m en t an d xat ion . For th is reason ,
m argin al gingival in cision is m ore conven ien t , b
as it can be ret u rn ed to it s origin al posit ion
Fig. 22.8 The ultrasonic bone cut ter is e ective for sensitive
w ith out m ucosal or m uscu lar m ism atch . Closing
areas. (a) Equipment. (b) Bone cut ting with ultrasonic bone cut ter
of th e m argin al gingival in cision can be don e w ith during genioplast y.
in terden t al papillar y m at t ress su t u res. Silast ic drain s
3 to 4 cm in length are in serted prior to put t ing in
th e n al st itch es on both sides.
9. After n ish ing th e sut ures, com pressive dressing is
ap plied w ith elast ic t aping to th e ch in , giving it a
m ild lift . Gen iop last y is alw ays d on e as a day su rger y,
an d h osp it alizat ion is n ot n ecessar y in m ost cases.
Pat ien t s are p rescribed an t ibiot ics an d an algesics.

Fig. 22.9 The mobilized segment is xed in the new position

according to preoperative plans with pre-bent four-hole miniplate
and screws.

■ Key Technical Points
1. A preoperat ively draw n m idlin e of th e face from th e
d orsu m of th e n ose to th e m idp oin t of th e ch in w ill
ser ve as a ver y u sefu l in t raop erat ive gu ide.
2. In lt rat ion of su bperiosteal local an esth esia from
th e rst prem olar to th e con t ralateral side provides
hydrodissect ion as w ell as h em ostasis to ease lift ing
of th e periosteum over th e ch in later.
3. An in t raoral in cision is preferred over th e extern al
ap proach in Asian s sin ce th e in cision al scar on th e
skin ten d s to be easily n ot iceable com p ared w ith
Cau casian .
4. A labial in cision is m ade 5 m m aw ay from th e
labiogingival groove, leaving an edge for sut u ring
d u ring closure. Margin al gingival in cision h as th e
advan t ages of sp aring th e m en talis m u scle an d th e
absen ce of a m u cosal scar.
5. W h ile m aking an in cision , care sh ould be t aken to
avoid detach m en t of m en t alis m uscle bers, w h ich
can lead to ch in ptosis.
6. Th e exten t of subperiosteal ap dissect ion sh ou ld be
lim ited to th e in ferior m argin of th e m an dible on th e
labial m an dibular su rface sin ce u n n ecessarily w ide
d issect ion aroun d th e sym physis area can result in
in adver ten t ch in ptosis or dim pling an d u n easin ess
of low er lip m ovem en t after surger y.
7. Iden t ifying th e m en tal n er ve is n ot alw ays n ecessar y,
but it is m ore conven ien t to skeleton ize it w h en
gen iop last y is to be com bin ed w ith m an d ibu lar
sh aving or angle redu ct ion su rger y.
8. With a m icrom otor drill, t w o or th ree ver y sm all
h oles are m ade along th e lin e of th e p lan n ed
osteotom y to in lt rate epin eph rin e in to th e m edulla,
w h ich can h elp reduce bleeding during th e m en t al
osteotom y.
9. Osteotom y cut s are m ade from lateral to m idlin e.
Grooves m ay be m ade on th e bon e w ith a sm all
bur to preven t saw slippage w h en perform ing th e
osteotom y.
10. It is bet ter to m ake a h orizon tal osteotom y lin e
m ore p osteriorly to create a m ore n at u ral-looking
m an dibu lar lin e.
22 Genioplast y 293
■ Complications and
Their Management
General Complications
Gen ioplast y is a relat ively safe operat ion w ith ver y low
com plicat ion rates. Gen eral com plicat ion s in clude h em or-
rh age, in fect ion , sw elling, an d pain . Most of th e postopera-
t ive bleeding is from th e m arrow of th e osteotom ized bon e
an d can be con t rolled in t raop erat ively w ith h em ostat ic
product s such as h em ostat ic collagen (CollaTape, Zim m er
Den t al, or Helist at , Moore Medical), gelat in agen t s (Gel-
foam , P zer), bon e w ax, or cellu lose m aterials (Surgicel,
Eth icon ). Mu cosal bleed ing can be con t rolled w ith an elec-
t ric cauter y. In fect ion risks are m it igated w ith judicious
in t ra- an d postoperat ive an t ibiot ic use, en suring sterile
operat ive procedures an d environ m en t an d m et iculous
hem ostasis. For t un ately, in fect ion rates in gen ioplast y are
ver y low. Postoperat ive edem a is th ough t to be related to
th e degree of surgical t rau m a sust ain ed in t raoperat ively.
Th e at rau m at ic n at ure of th e ult rason ic bon e cut ter h as
redu ced postoperat ive sw elling sign i can tly. Edem a usu -
ally p eaks on p ostop erat ive days 3 an d 4 before su bsiding.
Gen ioplast y is a relat ively pain less su rger y. Postoperat ive
pain can usually be easily con t rolled w ith acet am in oph en .
Mental Nerve Injury
Inju r y to th e m en t al n er ve p resen t s w ith low er lip pares-
th esia, especially at th e corn ers of th e m outh . Th is is pre-
ven ted w ith carefu l p rotect ion of th e n er ve du ring su rger y.
In cases w h ere a w ide operat ive eld is requ ired , th e n er ve
sh ou ld be dissected an d m obilized to avoid excessive t rac-
t ion on it . If th e n er ve is severed during surger y, re-an as-
tom osis sh ou ld be at tem pted w ith a 9–0 or 10–0 su t u re.
Th e n er ve fun ct ion can be assessed postoperat ively w ith a
pin ch test at th e corn er of th e m outh . Tract ion injuries on
th e n er ve often recover w ith in 1 to 3 w eeks. Sm all bran ch es
m ay be cu t d u ring labial m u cosa in cision . Th e loss of lip
sen sat ion is m ore p rom in en t at th e m edian area rath er
th an th e corn ers of th e m outh . In such cases, sen sat ion usu-
ally ret u rn s w ith in a m on th .
Bony Malunion or Nonunion
Th e risk of m al- or n on un ion is h igh er w ith w ire xat ion .
Th e developm en t of th e m in iplate osteosyn th esis system
en abled rigid xat ion of th e segm en ts. Malu n ion or n on -
un ion is ver y rare in gen ioplast y as long as th ere is con -
tact bet w een th e bon e segm en ts. Tw o m in iplates w ith four
screw s are often su cien t to obt ain rigid xat ion in th e
sym p hyseal region .
294 IV Facial Bone Surgery

Irregularity of Bone Surface
Irregu larit y of th e in ferior border of th e m an dible is a
com m on com plicat ion , par t icu larly in vert ical ch in h eigh t
redu ct ion surgeries. After m aking parallel h orizon t al oste-
otom ies, th e m iddle segm en t is rem oved; th e cau dal seg-
m en t is th en p laced to th e m ain m an dibu lar body. At th e
lateral en ds of th e bon e edges, a t riangular bony prot u ber-
an ce w ill be p rod u ced du e to th e m isalign ed m an dibu lar
lin e (Fig. 22.10).
If th is p rot u beran ce is n ot sh aved o du ring th e su rger y,
pat ien t s w ill com plain of irregu larit y an d som et im es pain
at th e m an dibular border. It m ay also be seen in aggressive
n arrow ing of th e ch in t ip. In th is case u sing ar t i cial bon e
w ith BMP can h elp sm ooth out th e steps.
Lip Drooping, Chin Ptosis, and
Skin Dimpling
Ch in ptosis is de n ed as th e drooping of ch in soft t issue
over th e in ferior border of th e m an dible. Lip droop ing is
de n ed as low er-posit ion ed lip w ith dim pled skin during
lip closure. Ch in ptosis an d lip droop ing are due to prob -
lem s w ith th e m en talis an d depressor m u scles of th e low er
lip. Th e m en talis m uscle origin ates from th e in cisive fossa
of th e m an dible an d in sert s in to th e derm is of th e ch in skin .
It h as t w o fu n ct ion s: (1) to su pp ort , elevate, an d prot ru de
th e low er lip; an d (2) elevat ion an d w rin kling of th e skin
of th e ch in . Failure to re-at tach th e m en t alis m uscle after
division an d m uscular brosis after in fect ion or rem oval of
a large im p lan t are kn ow n to be th e m ain cau ses of th is
ph en om en on .9 Pat ien t s h aving a h istor y of ch in im plan t
su rger y h ave a h igh er risk of exacerbat ion of ch in ptosis
after revision osseou s gen iop last y for th is reason . Th u s, it
is im port an t to obt ain preoperat ive ph otograph s for docu-
m en t at ion . To preven t th e aesth et ic an d fu n ct ion al com pli-
cat ion s m en t ion ed previously, preser vat ion of th e m en t alis
an d it s p rop er re-at t ach m en t d u ring su rger y are essen t ial.
W h en it is u sed, revision surger y is aim ed at re-an ch oring
th e m en t alis m uscle to th e in cisive fossa, an d to repose th e
dragged periosteum an d ch in pad superiorly.
Asymmetry
Asym m et r y m ost frequ en tly results from errors in plan -
n ing an d/or surgical execu t ion . Correct ive gen ioplast y for
asym m et ric ch in s sh ou ld be p lan n ed m et icu lou sly. Failu re
to m ark th e m idlin e p rior to perform ing th e osteotom y w ill
lead to asym m et r y. Also, it m ust be kept in m in d th at th e
m agn it u de of soft t issu e m ovem en t correspon ds to on ly 75
to 90% of th e m agn it u de of bony t ran slat ion s. For exam p le,
if th e bon e segm en t is m oved 5 m m t ran sversely, th e cor-
resp on ding soft t issu e posit ion w ill on ly m ove bet w een
3.75 an d 4.75 m m . Th erefore, in correct ion of th e asym -
m et ric ch in , over-correct ion of th e bon e is often requ ired
to ach ieve soft t issu e sym m et r y. On ce it is establish ed th at
th ere is postoperat ive asym m et r y as a resu lt of m alposi-
t ion ing, revision is advised w ith in 2 w eeks.
Allograft-Related Complications:
Chin Drooping, Distortion,
Irregular Skin
Ch in drooping an d distort ion occu r after im plan tat ion of
an allograft su ch as silicon e or Gore-Tex. Th ere is invari-
ably erosion of th e cort ical ch in bon e by in ser ted im p lan ts,
an d in som e p at ien t s th is is cou p led w ith an osteop hyt ic
react ion along th e p erim eter of th e im plan t , creat ing a cra-
ter-like bony defect (Fig. 22.11). Occasion ally th is erosion
can exten d th rough th e an terior alveolar bon e to reach th e
root s of th e fron t al teeth .
A peau d’orange appearan ce of th e ch in is an oth er
frequ en tly en cou n tered p roblem follow ing ch in im p lan ts,

a b

Fig. 22.10 (a,b) Treatment of bony irregularit y after osseous genioplast y. Triangular bony irregularities at both lateral ends following
vertical or sagit tal reduction genioplast y. This bony edge needs to be removed to prevent postoperative inconvenience. It is usually located
near the mental foramen, and thus extra caution should be taken during the removal.

a b
Fig. 22.11 Osteolytic crater on chin bone by alloplastic chin implant. (a) Identi cation of previously inserted Gore-Tex chin implant. (b)
Crater-like erosion of the chin bone near the root of anterior teeth is observed during removal of the chin implant.
esp ecially Gore-Tex. Th is m ay be du e to disru pted m u scle
bers failing to re-align an d re-at t ach to th e cort ical bon e
su rface du e to th e presen ce of th e in terp osit ion ed im plan t .
An oth er possibilit y m ay be im plan t m igrat ion . Th ese allo-
p last ic im plan t s h ave also been fou n d to adh ere to over-
lying m u scle bers an d derm is, result ing in skin th in n ing
over t im e. Care sh ou ld be t aken in perform ing revision
su rger y in su ch cases, as p erforat ion of th e skin can occu r
d u ring im plan t rem oval.
■ Case Studies
Case 1
A 23-year-old wom an presents w ith a bim axillary protrusion
and a severely retruded sm all chin (Fig. 22.12 and Fig. 22.13).
Problem List
1. Aesth et ic: un favorable facial aesth et ics, h igh ly
convex facial pro le, ret ruded ch in , beak-like lip
sh ape, fu lln ess of m ou th w ith gu m m y sm ile
2. Fun ct ion al: in tern al TMJ derangem en t , m u scle st rain
arou n d lip s, crow ding of low er an terior teeth
3. Ceph alom et ric an alysis:
a. Severe proclin at ion of low er an terior teeth (L1
in clin at ion ): 37.3 degrees (m ean 25 degrees ± 2)
b. Ext rem ely sm all in terin cisal angle: 99.8 degrees
(m ean 124.0 degrees ± 8.3)
c. Position of Pog too posterior from N-perpendicular
(Pog to N-perp): –12.5 m m (m ean, –5 m m ± 1)
d. High degree of facial convexit y: 16.5 degrees
(m ean 3.6 degrees ± 4.6)
e. Sh or t m an dibu lar body length : 66.7 m m (m ean
78 m m ± 4.3)
22 Genioplast y 295
f. Low er an d u p p er lip p rot ru sion : u p per lip to
E-lin e, 3.7 m m (m ean –1.02); low er lip to E-lin e,
7.2 m m (m ean 2.03)
Treatment Plan
1. Con ser vat ive tem porom an dibular join t (TMJ)
t reat m en t w ith an occlusal stabilizing applian ce.
Th e aim is to set up th e opt im al an d stable con dylar
posit ion
2. Orth odon t ic t reat m en t: teeth align m en t for an terior
crow ding, leveling of den tal arch es, in t rusion of
u pp er posterior m olars.
3. Operat ion : an terior segm en tal osteotom y (ASO) of
m a xilla, sagit t al sp lit ram u s osteotom y (SSRO) of
m an dible, gen iop last y.
Notes
1. Th e rst aim of th is operat ion w as TMJ st abilizat ion
an d th en n orm alizat ion of th e occlu sion .
2. For aesth et ic im provem en t , advan cing gen ioplast y
alon e cou ld n ot fu l ll th ese goals; th erefore,
m a xillar y an terior segm en t al osteotom y (ASO) w as
ap plied in com bin at ion .
3. After su rger y, upper an d low er an terior teeth
in clin at ion , th e zero-m eridian an d Pog′ relat ion sh ip ,
an d th e E-lin e to u pp er an d low er lip dist an ces w ere
n orm alized. Lip m u scle st rain an d gu m m y sm ile
w ere also im proved.
4. Most im p or tan t , th e p at ien t’s con den ce an d sm ile
w ere restored, an d sh e recovered from th e in feriorit y
com plex an d depression sh e h ad experien ced before
t reat m en t .
296 IV Facial Bone Surgery

Fig. 22.12 Case 1. Pre- and postoperative

a b
photos. Frontal and lateral views show-
ing improvement of chin projection. (a,b)
Before the surgery; (c,d) After the surgery.

c d
 22 Genioplast y 297

Fig. 22.13 Case 1. Cephalogram. (a) Measure-

ments of angles and lengths were marked on the
cephalogram and lateral photograph. (b) Measure-
ment drawings overlapped on lateral photograph. (c)
Postoperative cephalogram showing bone cuts and
miniplates.

b c
298 IV Facial Bone Surgery
Case 2
A 26-year-old w om an presen ted w ith t yp ical bim axillar y
prot rusion an d a ret ruded ch in (Fig. 22.14).
Problem List
1. Aesth et ic: un sat isfactor y facial con tour, convex facial
p ro le, u pper lip prot ru sion w ith excessive up per
an terior teeth labioversion , sm all ch in , n on ideal
cer vical cu r vat ure
2. Fun ct ion al: m uscle st rain surroun ding lips,
hyperton ic m en t alis m uscle, lip incom peten ce
3. Ceph alom et ric an alysis:
a. Bim axillar y p rot ru sion (Angle’s class I occlu sion )
b. Ch in ret rusion :
– Pog to N-p erp : –40.9 m m (m ean , –5 m m ± 1)
– SNB: 69.4 degrees (m ean , 79.1 degrees ± 3)
– Y-axis to SN (angle N–S–Gn ): 80.2 degrees
(m ean 70.3 degrees ± 2.4)
– Pog′ to A′B′: –6.91 m m (m ean 3.0 m m ± 2.0)
c. Proclin at ion of upper an d low er lips:
– Nasolabial angle: 89.9 degrees (m ean , 100
degrees ± 2)
– Up per lip to E-lin e: 3.7 m m (m ean , –1.0 m m
± 2.0)
– Low er lip to E-lin e: 7.17 m m (m ean , 2.0 m m
± 3.0)
d. Prot ru sion an d proclin at ion of upper an d low er
an terior teeth :
– In ter-in cisal angle: 110.4 degrees (m ean ,
124.0 degrees ± 8.3)
– UIE to facial plan e: 16.61 m m (m ean , 6.0 m m
± 1.5)
– LIE to facial plan e: 12.6 m m (m ean , 4.6 m m ±
1.7)
– FMIA (angle FH lin e): 32.1 degrees (m ean ,
59.8 degrees ± 6.4)
e. Sh or ter m an dibu lar body length : 65.7 m m
(m ean , 78.0 m m ± 4.3)
Treatment Plan
1. Orth odon t ic t reat m en t: teeth align m en t for an terior
crow ding, leveling of den tal arch es.
2. Operat ion : (1) an terior segm en t al osteotom y (ASO)
of m axilla an d m an dible; (2) gen ioplast y.
Notes
1. Th e m ain object ives of th e surger y w ere (1) to
correct th e proclin at ion of th e upper an d low er
an terior teeth , an d (2) to restore th e p osit ion of th e
ch in an d soft t issue pogon ion .
2. Th e correct ion of u pper an d low er an terior teeth
proclin at ion can be easily ach ieved. But for m ore
aesth et ically pleasing resu lt s, th e osteotom ized
m a xillar y segm en t is m obilized u pw ard an d th e
m an dibu lar segm en t dow nw ard. Oth er w ise th e
orth odon t ist m ay h ave di cult ies postoperat ively
t r ying to ach ieve adequ ate im pact ion of th e an terior
teeth .
3. Gen erally, th e m an dibular body can be length en ed
via body osteotom y in class II p at ien t s. In th is
case, th e pat ien t h ad class I occlu sion ; h en ce,
advan cem en t of th e ch in w ith sliding gen iop last y
alon e w as su cien t .
4. All surgeries w ere perform ed in a single stage as a
day surger y.
 22 Genioplast y 299

a b
c

d e
f

Fig. 22.14 Case 2. Pre- and postoperative photos and cephalogram. (a,b) Preoperative facial photographs show slightly protruding lips
with retruded chin. (d,e) Postoperative photographs show increased chin projection and improved lip position. (c,f) Pre- and postopera-
tive lateral cephalograms.
300 IV Facial Bone Surgery
References
1. Aufrich t G. Com bin ed n asal plast ic an d ch in plast ic: correc-
t ion of m icrogen ia by osteocart ilagin ou s t ran sp lan t from
large h u m p n ose. Am J Su rg 1934;25:292
2. Hofer O. Operat ion del Progn ath ie un d Microgen ie: Die
Op erat ive Beh an d lu ng d er alveolaren Ret rakt ion des Un -
terkiefers u n d ih re Anw en du ngsm oglich keit fu r Prog-
n ath ie un d Mikrgen ie. Dt sch Zah n Mun d Kieferh eilk
1942;9:121–132
3. Obw egeser H. Surgical procedures to correct m an dibu-
lar p rogn ath ism an d resh ap ing of th e ch in . In : Trau n er R,
Obw egeser H, eds. Th e su rgical correct ion of m an dibu lar
p rogn ath ism an d ret rogn ath ia w ith con siderat ion of gen io-
p last y. Oral Su rg Oral Med Oral Path ol 1957;10:677–689
4. Ah n SN. Keph alom et risch e Vergleich st udie von skelet t alen
u n d Weich teil Param etern zw eier eth nisch er Gruppen .
Doctoral Dissert at ion . Kieferorth op aedie, ZMK Klin ik, Un i-
versit at Ham bu rg; 1995
5. Hw ang HS, Kim WS, McNam ara JA Jr. Ethn ic di eren ces in
th e soft t issu e pro le of Korean an d Eu rop ean -Am erican
adult s w ith n orm al occlusions an d w ell-balan ced faces.
Angle Orth od 2002;72(1):72–80
6. Ioi H, Nakat a S, Nakasim a A, Coun t s AL. Com parison of
ceph alom et ric n orm s bet w een Jap an ese an d Cau casian
adult s in antero-posterior an d vert ical dim en sion . Eur J
Or th od 2007;29(5):493–499
7. Ricket t s RM. Esth et ics, environ m en t , an d th e law of lip re-
lat ion . Am J Orth od 1968;54(4):272–289
8. Gon zalez-Ulloa M. Quan t it at ive prin ciples in cosm et ic sur-
ger y of th e face (pro leplast y). Plast Reconst r Surg Tran s-
plan t Bu ll 1962;29:186–198
9. Zide BM, McCarthy J. Th e m en talis m uscle: an essen t ial
com p on en t of ch in an d low er lip posit ion . Plast Recon st r
Surg 1989;83(3):413–420
V
Facial Skin and Hair Rejuvenation
23 Management Strategies for the Aging Asian Face :
Philosophy and Evolution
Samuel M. Lam
Pearls
• Th e prin cipal m an ifestat ion of aging for m ost
East Asian s (an d all oth er peoples for th at m at ter)
is volum e loss. Ju diciou s volu m izat ion u sing fat
graft ing an d/or llers can p rovide w on derfu l
rejuven at ion th at is n at ural an d im pactful.
• Hair restorat ion can be a vit al com p on en t to global
facial rejuven at ion an d can p rovide an im p or tan t
fram e to th e u p per face to m ake it ap p ear m ore
you th fu l an d at t ract ive.
• Th e aging Asian eyelid is a com plicated su bject .
Th e t reat m en t algorith m is based on w h ich t ype of
eyelid a pat ien t possesses: a n at u ral eyelid crease,
an eyelid w ith ou t a crease, or an eyelid w ith a
previously surgically created crease.
■ Introduction
Th e aging East Asian face bears rem arkable sim ilarit ies to
th e aging faces of oth er peoples, but also h as dist in ct at t ri-
butes th at separate it from th e rest of th e w orld. Th is ch ap -
ter w ill explain both th e sim ilarit ies an d di eren ces of th e
Asian face regarding th e aging process an d h ow to approach
it in a cu lt u rally sen sit ive, e ect ive, an d safe m an n er. Th e
focu s of th e ch apter w ill be h eavily biased th rough th e l-
tered len s of m y w orldview, w h ich I h ope w ill in crease th e
pragm at ism of th e con ten t rath er th an be con sidered overly
sim p list ic or p reju diced .1,2,3 Th e m ajor topics th at w ill be
covered in clude h air restorat ion , facial volum izat ion , Asian
bleph aroplast y,4 an d facelift ing. To cover each of th ese top -
ics su rgically w ou ld t ake a textbook to do th e subject m at-
ter just ice. In stead, th is ch apter w ill focus on th e relevan t
aging process of th e Asian face on a global scale an d tou ch
on th e ph ilosophy of w h at ages th e Asian face an d h ow in
gen eral term s to m an age th is problem . I believe th at th is
ch apter w ill be helpful both for th e surgeon w h o is n ew to
w orking w ith th e East Asian face an d for th e su rgeon w h o
h as great exp erien ce in th is eld.
• Typically, low er facial rejuven at ion for th e East
Asian is n ot n ecessar y un t il m uch later in life w h en
com pared w ith the Caucasian . Neurom odulators can
be used in th e plat ysm a to reverse early aging an d
to delay th e n eed for a facelift . A ch in im p lan t can
be an im port an t adjun ct to im prove th e sh ape of
th e Asian face as w ell as to en h an ce a facelift result .
Lipocon touring of th e n eck sh ou ld be don e sh arply
w ith scissors in a con ser vat ive fash ion un der direct
vision rath er th an w ith a su ct ion can n u la.
• Man agem en t of th e skin sh ou ld be an in tegral
part of ever y con sult at ion an d st rategy for global
rejuven at ion . How ever, it is advisable to alw ays
be m ore con ser vat ive w h en it com es to ablat ive
tech n iqu es ow ing to th e in creased risk an d t im e of
convalescen ce for th e Asian pat ien t .
■ Patient Assessment and
Philosophy of Aging
Th e Asian face h as been con sidered relat ively resistan t to
th e aging process, at least com pared w ith th e fairer races,
w h o are m ore subject to th e w eath ering e ect s of solar
exp osu re. Th e u n iqu e n at u re of th e Asian’s skin st an ds as
a barrier to th e det rim en tal e ect s of solar rays an d h elps
keep th e face from th e accelerated aging th at is a com m on
an d early feat u re of m any Cau casian faces.5 Never th eless,
aging does occur both subtly an d profoun dly but perh aps
n ot so aggressively as in th e Cau casian . Part of th is p ro-
t racted youth fuln ess in th e Asian can be at t ributed to th e
cult ural proclivit y to avoid th e sun for t w o prin cipal rea-
son s. First , su n spots an d freckles th at m ay be con sidered
ch arm ing in th e Occiden t are often deem ed un at t ract ive
in Asia. Secon d, th e darker skin th at an Asian bears m ay
relegate th e in dividual to a lesser societ al stat u s, w h eth er
overtly or su bcon sciou sly. Th is bias tow ard fairer com plex-
ion reign s in m any cult ures th rough ou t Eu rope, Africa, an d
m any oth er sectors of th e w orld. I believe th at su n exp o-
303
304 V Facial Skin and Hair Rejuvenation

su re can act u ally be w orse for aging th an sm oking or oth er
n icot in e u se, an d th at su n an d n icot in e togeth er can be n eg-
at ively syn ergist ic. Fu rth er, Asian s w h o rem ain in Asia t yp i-
cally h ave h ealth ier diets th an th ose Asian s w h o m igrate to
th e West , w h ich can fur th er m ain tain th eir youth fu l m ien .
All bet s are o w h en th e Asian decides to t ravel to th e West
to set tle an d th en adopts Western h abits of sun bath ing
an d con su m pt ion of processed an d h eavily adip ose-laden
foods. Never th eless, th e gen et ic n at u re of th e Asian skin
t yp e can p rovide relat ive protect ion again st aging d esp ite
th e adopt ion of such adverse lifest yle ch anges.
■ Volume Loss and
w h en lling an Asian face n ot to do so as robustly in m any
cases as for th e ver y gaun t faces th at are often seen in oth er
races. In fact , lling areas aroun d th e periorbital an d ch in
region s can m ake a face act u ally appear slim m er if don e in
a ju diciou s fash ion (Fig. 23.1). A fu r th er w ord of cau t ion is
th at in m any Korean faces, lling th e m alar region can be
deem ed m asculin izing sin ce it can squ are o a w ide face;
in fact , m any Korean s pay to h ave th eir m alar bon es sur-
gically redu ced an d collap sed inw ard. Th is cu lt u ral sen si-
t ivit y sh ould be verbally addressed an d h eeded to avoid a
m iscalcu lated ou tcom e.
Th ere are t w o prin cipal m ech an ism s for volu m izing a
face, fat graft ing (a su rgical m odalit y) an d inject able ll-
ers (an in -o ce procedu re). Fat graft ing is ver y e ect ive

Volume Restoration as a d u rable, long-last ing resu lt bu t su ers from a few

draw backs. First , absorpt ion is relat ively u npredictable.
Th ere can be variable loss of th e t ran splan ted fat , th ough
Even th ough Asian s age relat ively less th an th eir fairer-
in gen eral th ere sh ould be a large percen t age th at rem ain s.
skin n ed coun terparts, th ere are still un m istakable sign s of
Accord ingly, I do n ot like to u se fat graft ing to t r y to x on e
aging in the Asian face. It w ould be quite rare to look at a
area of th e face sin ce th e absorpt ion rate m ay com p ro-
70-year-old Asian and unw it t ingly assum e that she is on ly
m ise th e in ten ded ou tcom e. Conversely, if th e en t ire face is
30 years old. If her skin (like that of m any of m y octogen arian
t reated, su cien t fat graft ing can sur vive so th at th e en t ire
aun ts) is relat ively w h ite, u n blem ish ed, an d alm ost w rin kle
face ap p ears bet ter. Su ch an in st an ce, w h en en ough of th e
free, w hy is it so obvious th at sh e is in deed m uch older? To
t ran splan ted fat is left to con t ribute to an im proved look of
m e, th e an sw er is readily apparen t . It is th e u n iversal sign
th e face, m ay be called an im provem en t in on e’s “blin k”;
of volum e loss that a ects all races in relat ive degrees but is
th at is on e looks bet ter in th e blin k of an eye to an on looker
the predom inan t feat ure of the aging Asian face.6
even th ough th e m in ut iae of th e face m ay n ot be en t irely
Volu m e loss is obser ved as a lin ear loss of fat from birth
corrected in ever y w ay. I use llers to touch up alm ost any
u n t il death . A 1-year-old h as con siderably m ore facial fat
fat graft to ach ieve im p roved ou tcom es.
th an a 5-year-old. Sim ilarly, a 5-year-old’s face h as m ore
fat th an a 10-year-old’s. In an adu lt if body w eigh t is h eld
th e sam e, ever y 5 years represen t s in elu ctable, progressive
volum e loss an d skeleton izat ion of th e face. Accordingly,
th e sen escen t sh adow s th at develop across th e face an d th e
loss of glorious, youth fu l h igh ligh t s sh ould be th e prin cipal
a b
target s in revolum izing th e face. Furth er, th ere is an im m e-
diate “blin k” e ect: We pret t y m uch kn ow w h o is you ng
an d w h o is old in a n an osecon d, based on facial sh ap e. A
you ng face is ver y rou n d, w h ich w e h ave a special term for:
baby fat . Baby fat is n oth ing special. It just represen ts th e
exu beran t fat of you th th at grad u ally d issip ates. As you th
regresses, th e sh ape of th e face becom es a m ore angelic
oval by 30 years of age, w h ich is ch erish ed by m any w om en
w h o fear looking fat as th e ideal age of beaut y. By 40 years of
age, as th e fat con t in ues to skeleton ize an d th e m alar bon es
begin to be part ially exposed, th e face becom es squared
o in appearan ce. Fur th er volum e loss an d possibly som e
w eigh t gain con t ribu te to an inversion of th e facial feat u res,
w h ere th e low er face in creasingly becom es th e dom in an t
at t ribu te. Accordingly, a prim ar y focu s for th e aging Asian
face is to restore balan ce an d sh ape to th e face to m ake it Fig. 23.1 A Chinese patient who underwent single facial fat graft-
look m ore you th ful. I believe th at lling th e tem ple, perior- ing procedure along with a conservative skin-only upper blepharo-
plast y. (a) Before the procedure. (b) One year after the surgery. The
bital region , m alar area, an d perioral area can be as h elpful
patient’s face appears narrower by selective targeting of the peri-
for th e Asian face as it is for oth er eth n ic an d n on eth n ic orbital and perioral regions for volumization and by avoiding the
faces, w ith a few caveat s. buccal area. The upper blepharoplast y was helpful since the eyelid
First , Asian faces in gen eral ten d to be fu ller to begin skin had de ated near the ciliary margin. However, the principal
w ith th an m any w h ite faces. Th erefore, it is im port an t method of rejuvenation of the eyelid was facial fat grafting.
 23 Managem ent  
Strategies 
for 
the 
Aging 
Asian 
Face: 
Philosophy 
and 
Evolution 305

If llers can be so accu rate in rejuven at ing th e face, w hy a

is th is m eth od n ot preferred over fat graft ing? Th e sim ple
reason is cost . Fat is free; it can be h ar vested w ith ou t paying
for each syringe except for th e labor th at is involved . Fill-
ers, especially d u rable llers like p oly m ethyl m eth acr ylate,
can be costly w h en m ult iple syringes are used to con tour
ever y detail of th e face. Today, w ith th e adven t of dispos-
able m icrocan n u las, I h ave h ad an exp on en t ial in crease in
th e use of llers because m any pat ien t s do n ot prefer th e
up -fron t cost , th e n at ure an d t im e of th e recover y process,
an d th e variable absorpt ion of fat graft ing. W h en ap proach - b
ing a face w ith eith er llers or fat graft ing, I prefer to t arget
a lit tle bit of ller or fat at alm ost ever y sm all area of th e
face, in clu ding th e tem ple, brow /u pp er eyelid, low er eyelid,
n asojugal groove, an terior ch eek, lateral ch eek, su bzygo-
m at ic recess, bu ccal area (as deem ed ap p ropriate), can in e
fossa an d n asolabial groove, p rejow l su lcu s, an terior ch in ,
an d lateral m an dible (as deem ed ap prop riate). By lling all
of th ese areas, th e face appears balan ced an d rejuven ated.
Th e degree an d dist ribut ion of th e ller are based on art-
ist r y, ju dgm en t , an d exp erien ce an d lie beyon d th e scope of Fig. 23.2 A Chinese patient who underwent hair restoration.
th is ph ilosoph ically based ch apter. (a) Before the procedure. (b) After the procedure. Hair restoration
provides a stronger frame to his face.

■ Hair Loss and Hair Restoration

Hair restorat ion occu p ies a large p ar t of m y clin ical p rac- w ill fram e th e back of th e h ead. All of th ese elem en t s can
t ice, an d I h ave exten sive experien ce w orking w ith th e provide im provem en t for th e Asian pat ien t . Even w om en
Asian pat ien t . I w ill speak h ere again in term s th at are spe- lose th eir facial fram e an d can ben e t from h air restorat ion
ci c to th e Asian , an d also presen t som e un iversal con cept s as part of a global st rategy of rejuven at ion (Fig. 23.5).
th at can be h elpful for anyon e w h o is con tem plat ing en ter- Today, h air t ran splan t su rger y can produce results as
ing th e eld of h air t ran splan t surger y. Fu rth er, to elaborate in credibly n at ural as any oth er t ype of facial procedure.
on ever y tech n ical aspect of h ow to perform h air restora- Many su rgeon s st ill recall th e u n n at u ral ap p earan ce of plug
t ion w ould be n early im possible in a span of a few pages,
an d any cu rsor y t reat m en t of th e p rocedu re w ou ld n ot do it
ju st ice. Never th eless, th e ar t ist ic an d ph ilosoph ical poin ts
are w ell w orth exp loring even in th e form at of th is ch apter. a b
First of all, w h at is th e en d object ive of p erform ing h air
t ran splan t surger y? I w ould like to st ate th at goal at th e
out set , w h ich is to provide a st rong aesth et ic fram e to th e
u pp er face. Sim ilarly, fat graft ing aroun d th e eyes can h elp
w ith providing an eye fram e, lling th e tem ple an d outer
ch eek can provide an outer facial fram e, an d facelift ing/
ch in im plan t s/volu m izat ion can provide a low er face fram e.
W h en th e h airlin e h as been re-est ablish ed for eith er a m an
or a w om an , th e face looks m ore at t ract ive an d youth ful
in st an tly. Th e fram e of th e u pper face is com p rised of t w o
com pon en t s: th e cen t ral h airlin e an d th e tem ple h airlin e.
Not ever y p erson n eeds both h orizon t al (cen t ral) an d vert i-
cal (tem ple) h airlin es im proved, but it is w orth w h ile for th e
reader to u n derst an d th e im por t an ce of con sidering th ese
opt ion s (Fig. 23.2).
Fig. 23.3 An Indian patient who underwent eyebrow hair trans-
Oth er exam p les of facial fram ing w ith h air restorat ion plant. (a) Before the procedure. (b) After the procedure. An eye-
in clu de an eyebrow h air t ran splan t (Fig. 23.3) th at w ill brow hair transplant brightens the eyes and provides an improved
fram e th e eye, an d a crow n h air t ran splan t (Fig. 23.4) th at frame to the eyes.
306 V Facial Skin and Hair Rejuvenation
a b
Fig. 23.4 A Vietnamese patient who underwent crown hair trans-
plant. (a) Before the procedure. (b) After the procedure.
graft s th at t ran sform ed a pat ien t in to a doll’s h ead. How -
ever, n o longer is th at th e case. Using n at u rally occu rring
clusters of h air kn ow n as follicular un its, t ran splan ts can
be perform ed an d bring in credible n at u raln ess. W h at gives
m e absolu te pleasu re in w orking w ith h air t ran splan t at ion
is th e art ist r y th at can be exercised during any procedure,
from design ing a h airlin e or eyebrow to allocat ing grafts
w ith th e den sit y gradien t th at is opt im al for a part icular
p at ien t . Th e tediu m th at m any surgeon s associate w ith
th e surgical procedure lies in th eir ign oran ce of h ow m uch
enjoym en t can be h ad w h en perform ing it .
Th e Asian pat ien t h as a few ver y salien t di eren ces
from oth er races th at sh ou ld be con sidered before p erform -
ing a procedu re on h im or h er. First , th e h airs t ypically are
ver y dark, ver y coarse, an d ver y st raigh t an d are set again st
a p aler to m oderately dark skin . Th is is perh ap s th e w orst
com bin at ion of ch aracterist ics to h ave w h en on e w an t s
to ach ieve n at uraln ess. Th e darker, coarser, an d st raigh ter
h air, esp ecially w h en set again st a scalp th at is fairer in
com plexion , can m ake a graft look un n at ural if n ot per-
fectly execu ted . It is, h ow ever, ext rem ely easy for th e tech -
n ician team to dissect an d t ran sp lan t th ese graft s becau se
th ey are so dark, coarse, an d st raigh t . Th e surgical team
m u st t ake steps to en su re th at th e resu lt ap pears absolu tely
n at u ral in ever y w ay. To en su re th is ou tcom e, I alm ost
alw ays p erform an in creased n u m ber of single-h air grafts
along th e fron tal h airlin e so th at th e h airlin e looks n at u ral.
For exam p le, I m ay use on ly 150 to 200 single-h air graft s in
a ligh t-skin n ed, ligh t-colored, n e- an d cu rly-h aired in di-
vidual. In con t rast , I m ay use t w ice th at n um ber of single-
h air grafts for an Asian p at ien t before I even con tem plate
start ing w ith t w o-h air grafts becau se I w an t th e h airlin e to
ap pear ver y soft in n at u re. Th e recip ien t sites th at are m ad e
to accom m odate th ese graft s form w h at is kn ow n as th e
“m icro” h airlin e. Th e “m acro” h airlin e refers to th e act u al
in it ial lin e draw n on th e scalp in to w h ich th ese recipien t
sites w ill be p laced . Th e m acro h airlin e draw n on th e t yp i-
cal Asian also can look quite di eren t from th at in th e Cau-
casian pat ien t . Th e m acro h airlin e is t ypically rou n der in
sh ap e w ith less su p pression or con cavit y along th e lateral
exten t of th e h airlin e, w h ich m atch es th e rou n der sh ap e of
a b
Fig. 23.5 A Filipina patient who underwent hair transplant.
(a) Before the procedure. (b) After the procedure. A hair transplant
improves the frontal fram e to her face.
m any Asian faces. A ver y n arrow h airlin e often w ill n ot look
quite righ t on an Asian pat ien t because th e h airlin e sh ape
w ill n ot m atch th e face or w ill n ot m atch a h airlin e th at
exist s in th is race. St u dying n at u ral, n on balding h airlin es in
Asian s can be a good guide to t rain ing on e’s aesth et ic eye
w ith real-w orld exam ples before begin n ing to operate on
th ese in dividuals.
Th ere are t w o t ypes of don or h ar vest ing th at are cu r-
ren tly o ered. Th e t radit ion al m eth od of graft h ar vest ing is
kn ow n as follicular un it t ran splan t , or FUT, w h ich involves
a lin ear st rip from th e back of th e h ead. Th e n ew er m eth od,
w h ich involves sm all pun ch es an d avoids th e lin ear in ci-
sion , is kn ow n as follicu lar u n it ext ract ion , or FUE. FUT st ill
plays a ver y sign i can t role for m any of m y pat ien t s for
several reason s. First , graft s th at are taken th rough a lin ear
h ar vest an d th en dissected are u n qu est ion ably h ealth ier
an d th ereby h ave an in creased su r vival rate after t ran sp lan -
tat ion . Even th e ver y best FUE grafts are m ore fragile an d,
even w ith th e m ost assid uou s h an dling an d t ran splan t at ion
of th em , are st ill less viable relat ive to FUT. Secon d, FUE
m ay n ot be th e best w ay to opt im ize th e u se of th e don or
h air region , in th at grafts m ust be t aken ver y broadly across
th e en t ire expan se of th e back of th e h ead, an d th at m ay
cause several problem s. First , th ere can be don or deple-
t ion if you t ake m ore th an 20% of th e graft s, leading to a
m oth -eaten ap p earan ce or dim in ish ed d en sit y in th e don or
area. Secon d, FUE is n ot a scarless procedu re an d can lead
to pu n ctate w h ite d ot s correlat ing w ith w h ere th e p u n ch es
h ave taken th e graft s. Th ird, because h ar vest ing m ust occu r
in a w ide expan se, th e h ar vest can approach or exceed th e
de n ed safe don or area; th at is, fut u re h air loss can prog-
ress in to th e areas w here h ar vest ing occu rred, leading to
loss of t ran splan ted grafts in a h aph azard fash ion . FUE
scars are m ore visible as w ell in p at ien t s w ith greater p ig-
m en t at ion sin ce th e scars are t yp ically hypopigm en ted in
n at ure. FUT, h ow ever, is n ot w ith out risk eith er, p ar t icularly
in th e Asian . Becau se Asian s ten d to create m ore exuberan t
 23 Managem ent  
Strategies 
for 
the 
Aging 
Asian 
Face: 
Philosophy 
and 
Evolution 307

scar form at ion th an Cau casian s, at t im es a th icker scar m ay
d evelop in th e don or area. Fu rth er, because th e don or h air
is ver y dark black an d ver y st raigh t , th e w h ite lin e of a scar
can be m ore visible th an in m any oth er races. Th ese con sid-
erat ion s are m ean t to ser ve on ly as gu idelin es for a p hysi-
cian w h o is in terested in perform ing a h air t ran splan t in an
Asian pat ien t , an d are n ot in ten ded to frigh ten or m islead
eith er a prosp ect ive su rgeon or p at ien t .
Recen tly, th ere h as been a rise in th e use of regen era-
t ive m edicin e tech n iqu es th at I like to refer to as “fert ilizers”
sin ce th ese adju n ct ive m easu res h elp t ran sp lan ted h airs
grow m uch bet ter, faster, an d m ore con sisten tly. Th e don or
scar can be h elp ed w ith th ese p rodu ct s as w ell. Th e th ree
m ajor p rodu ct s th at w e u se are Mat riStem (ACell), p latelet-
rich p lasm a (PRP), an d aden osin e t rip h osp h ate (ATP). It lies
beyon d th e scope of th is ch apter to discuss h ow an d w hy
each of th ese p rodu ct s is u sed . Su ce it to say th at I believe
th ese produ cts are in dispen sable for ever y h air t ran splan t
p rocedu re th at I p erform an d can be ver y h elpfu l to ach ieve
bet ter outcom es w h eth er th e pat ien t is Asian or n ot .
■ Aging Asian Eyelids and
th e crease to be too h igh an d th ereby ren der th e appear-
an ce u n n at u ral in m y op in ion . Sim ilarly, brow lift ing can
m ake a su prat arsal crease too h igh in an Asian , esp ecially
if p erform ed in conju n ct ion w ith eyelid skin rem oval. Con -
versely, fat graft ing an d llers m ain tain or low er th e eyelid
crease. Accordingly, if skin is rem oved or a brow lift per-
form ed, I alm ost alw ays use som e level of lling to bring
th e eyelid crease h eigh t back dow n as n eeded (Fig. 23.6).
On e oth er p oin t th at sh ou ld be st ressed is th at an eye-
lid crease, un fort un ately, is not an all-or-n on e proposi-
t ion . Th ere are par t ial creases, an d a pat ien t can h ave a fu ll
crease on on e side an d a part ial crease on th e oth er side.
Typically, th e side w ith th e par t ial crease h as a n arrow er
palpebral apert ure th at resem bles t rue ptosis. W h en I
speak of an Asian born w ith an eyelid crease, I am speaking
on ly of Asian s w h o h ave 100%com plete full creases bilater-
ally. Part ial creases of any degree really beh ave abou t th e
sam e as n o creases at all an d sh ou ld be p laced in to th at cat-
egor y, w h ich I w ill discu ss n ext .
Th e tem ptat ion w ith th e Asian w h o is born w ith out a
crease is sim ply to perform a st an dard bleph aroplast y in
w h ich eyelid skin is rem oved an d n o xat ion is perform ed
to create a crease. Sin ce th ere is n o crease, w h ere does th e

Brow s, and Eyelid Rejuvenation su rgeon m ake th e in cision ? Th ere is n o good an sw er. I h ave
not iced th at w h en on e sim ply rem oves th e skin in th ese
pat ien t s, th ere is n o discern ible result , th at is, n o im prove-
I h ave w rit ten abou t th is topic before in oth er textbooks,
m en t . In stead, a visible scar m ay becom e ap p aren t sin ce
an d I believe I h ave com e to a good u n derstan ding of h ow
th e skin can n ot fold over a crease th at doesn’t exist . If th e
to h elp a su rgeon t r ying to m an age th e com plex top ic of
su rgeon con cu rren tly t ries to rem ove fat from th e p ost sep -
th e aging Asian eyelid. I h ave divided th e aging Asian eye-
lid in to th ree categories: Asian s born w ith a n at u ral supra-
tarsal eyelid crease, Asian s w h o do n ot h ave a crease, an d
Asian s w h o h ave h ad a previou sly surgically created crease.
By ap proach ing an Asian p at ien t in th is fash ion , th e su r-
a b
geon sh ou ld be able to n avigate th is issu e safely to develop
th e best outcom es for a part icular in dividu al.
Let u s begin w ith Asian s w h o are born w ith a n at u ral
eyelid crease. Th ese in dividu als are perh ap s th e easiest
categor y to m an age. Becau se of th e crease, th eir eyelid
beh aves alm ost iden t ically to a Caucasian on e, an d accord-
ingly th e sam e opt ion s are available. If th e eyelid skin h angs
over th e ciliar y m argin , I recom m en d a con ser vat ive u p p er
bleph aroplast y, rem oving skin on ly. I alm ost alw ays recom -
m en d ad ding som e kin d of volu m e to th e u p per eyelid an d
brow sim ult an eously or in a st aged procedure. As I h ave
th orough ly discu ssed, de at ion of th e brow an d upper eye-
lid is th e p rin cipal m ech an ism by w h ich aging occurs in all
races. Th erefore, I believe th at eyelid skin rem oval is on ly
a su pp ort to re-in at ion of th e eyelid an d brow. Fu r th er,
I believe th at brow lift ing is u n n ecessar y an d det rim en - Fig. 23.6 A Chinese patient who has ptosis on her right side and
what appears to be too high a supratarsal crease even though she
tal. On e caveat is w orth issuing h ere: I rem ove skin on ly
has never had a previous eyelid surgery. The height of her crease
w h en it appears to be h anging at or over th e ciliar y m ar-
is high most likely from volume loss as well as acquired ptosis. She
gin . If th ere is st ill a ver y visible dist an ce of 1 to 3 m m of had full facial fat grafting that improved her eyelid position and
exp osed su p ratarsal crease w h en th e p at ien t h as h is or h er contour, thereby rejuvenating her upper eyelid. She also underwent
eyes op en on for w ard gaze, th en I do n ot recom m en d any a transconjunctival blepharoplast y. (a) Before the surgery. (b) After
addit ion al skin rem oval becau se su ch rem oval w ou ld cau se the surgery.
308 V Facial Skin and Hair Rejuvenation

t al t issue w ith out crease xat ion sut u res, th en th e eyelid

apert u re u n fort u n ately st ill looks n arrow, w ith ou t su bst an -
t ive ch ange. Even w orse, th ere can be variable xat ion in
w h ich creases are on ly par t ially xed but n ot u n iform ly or a b
even ly so. In m y opin ion it is in advisable in an Asian p at ien t
w h o does n ot h ave a crease (or w h o h as a part ial crease) to Fig. 23.7 This 53-year-old Korean man wanted eyelid rejuvena-
tion and he is shown in the “before” photograph without a true
sim ply rem ove skin . It w ill n ot w ork an d w ill lead to poor
supratarsal crease. He underwent a formal Asian blepharoplast y
outcom es.
to create a supratarsal crease and seems more rejuvenated in his
So, th en , w h at can be don e for an Asian w ith ou t a appearance. (a) Before the procedure. (b) After the procedure.
crease? In m y opin ion , th ere are t w o opt ion s: create a
crease an d/or use llers or fat graft ing in th e upper-eyelid/
brow region (Fig. 23.7 an d Fig. 23.8). To create a su prat ar-
sal crease is an ap p aren tly st raigh tfor w ard p rocess bu t
carries w ith it som e im por t an t lim itat ion s th at sh ould be a p art ial crease, th at crease sh ou ld be con sid ered n on exis-
conveyed to th e pat ien t before surger y is con tem plated. ten t an d t reated accordingly.
First , a crease does ch ange th e look of an in divid ual, m ak- A great opt ion is to perform both a supratarsal crease
ing th e eyelid sh ape roun der an d m ore op en . Th is is usually an d volu m izat ion of th e brow. How ever, I t yp ically do n ot
n ot a big issu e for a teen ager or you ng adu lt w h o com es to like perform ing both p rocedures at th e sam e t im e, as I am
th e physician for th e express purpose of creat ing a crease. alw ays con cern ed th at th e fat w ill disru pt th e secu rit y of
How ever, it can be m ore of an issu e for som eon e w h o h as th e crease xat ion . Also, I gen erally do n ot like to do th e
lived , say, 50 or 60 years an d n ow w ou ld like to h ave a reju- fat graft rst an d later th e crease xat ion becau se th is m ay
ven at ive p rocedu re. Th is p oin t sh ou ld be com m u n icated in terfere w ith th e crease xat ion at a later date. Accord-
to a prospect ive pat ien t expressly an d clearly. Furth er, th e ingly, if I w ere to perform both procedu res, in an ideal
m eth od th at I p refer to u se to create a crease is th e fu ll-in ci- w orld I w ou ld p erform th e su prat arsal crease xat ion rst
sion m eth od th at I learn ed from m y late m en tor, Dr. Joh n follow ed 4 to 6 m on th s later w ith fat graft ing or llers.
A. McCu rdy. Th e tech n ique o ers th e m ost durable results
but su ers from a prot racted recover y t im e. Th e crease
can look ver y abn orm al at a w eek an d can appear sligh tly
u n n at u ral even for a few m on th s follow ing th e procedure.
Th is is m uch m ore di cu lt for m en because th ey can n ot
w ear cam ou aging eye m akeu p an d can th erefore look
m ore u n n at u ral w ith a h igh er crease th an w om en do. Th is
h igh er crease w ill even t u ally becom e sm aller an d sm aller
u n t il it becom es com p letely n at ural in app earan ce several
m on th s to a year dow n th e road. I also recom m en d th e u se
of th icker-fram ed rect angular glasses th at can rest approxi-
m ately at th e su prat arsal crease or sligh tly above to dist ract
an on looker’s eyes from th e tem p orarily elevated crease a
h eigh t . If th e in dividu al does n ot w ear glasses n orm ally,
I recom m en d th at h e or sh e start w earing su ch glasses
before th e surger y to h abit uate on lookers to th e presen ce
of eyeglasses on th e face.
For th e in dividu al w ith ou t a n at ural crease, th e oth er
suggested altern at ive is lling th e u p p er-eyelid/brow com -
p lex w ith llers or fat graft ing. Alth ough th is tech n ique
m ay ap pear n ot to m ake m u ch sen se sin ce th e brow often
already looks too fu ll, recall th at in fact th e eyelid is de ated
an d on ly app ears to be dep en den t an d h anging. If th ere is b
any qu est ion as to th e pat ien t’s persp ect ive on w h eth er
Fig. 23.8 A Vietnamese wom an who had fat grafting to her eye-
th is w ould be a suitable opt ion , I recom m en d a test using
lids and face. She has a partial eyelid crease and accordingly has
a tem p orar y, reversible p roced u re like adm in ist rat ion of
t wo options only: create a supratarsal crease and/or volumize the
hyaluron ic acid to determ in e if th e aesth et ic is in align - brow. I performed only a single session of fat grafting to her eye-
m en t w ith th e p at ien t’s goals. If so, th en a m ore p erm an en t lids. (a) Before the procedure. (b) One year after the procedure.
opt ion can be un der taken . Also, recall th at if th e person h as The de ated brow appears lifted only because it has been lled out.
 23 Managem ent  
Strategies 
for 
the 
Aging 
Asian
The nal categor y is the Asian patient w ho has had a pre-
viously surgically created crease. You could potentially treat
this patient just like an individual born w ith a natural crease.
However, the reason this is a separate category has a lot to
do w ith how high the previous crease w as m ade and how
long ago. Back in the 1980s, a procedure know n as West-
ern ization w as in vogue, in w hich a lot of skin and fat w as
rem oved and a high crease created. Over tim e, as the patient
ages, the skin around the crease continues to de ate, m aking
the crease look m uch sm aller than it w as originally. How -
ever, this low er crease cannot be treated as a norm ally low
crease. The reason for this is that if skin is further rem oved
from this patient, the previously abn orm ally high crease w ill
ret urn and the patient m ay experience lagophthalm os. The
way th at the physician can determ ine if th e crease w as m ade
too high is sim ply to lift up th e eyelid skin and look at w h ere
the crease w as fashioned. Just by doing this sim ple m aneu-
ver during the consultation, the surgeon can easily deter-
m ine if th e crease w as m ade very h igh and the eyelid tissue
excavated (i.e., already excessively rem oved). Another option
is just to look at the patient. With previous surgery the eyelid
w ill look som ew hat unnatural but it m ay not be apparent
w hy to the surgeon since the crease height can be relatively
low. The reason for this is that the crease prim arily consists
of thick brow skin that has been folded over, m aking the eye-
lid look deep set and bizarre. I believe that the only w ay to
im prove this situation is w ith volum ization using either fat
grafting or llers. I w ould contend that any oth er m eth od
would com prom ise the desired outcom e by return ing the
patient to the m ore unnat ural state of m any years ago.
■ Low er Facial Aging and
Rejuvenation
Fort u n ately, for m any Asian s th e low er face does n ot age
as m u ch as in Cau casian s. Th eir th icker an d solar-resist an t
skin h elps th em to keep th eir n eck posit ion bet ter for a
m u ch longer p eriod th an for Cau casian s. How ever, aging
st ill w ill sh ow u p in th e Asian , even th ough it m ay do so
a decade or t w o later th an in oth er races. A preven t at ive
m an euver th at I u se in all races to delay th e n eed for a face-
lift is rout in e applicat ion of n eu rotoxin to th e p lat ysm al
bands (using ~ 10 to 15 un it s of bot ulin um toxin ). Pat rick
Trevidic, from Paris, Fran ce, h as presen ted convin cing evi-
den ce th at in dividuals w h o h ad st rokes m any years prior
su er n o n eck aging on th e a ected/st roked side. I h ave
seen clin ical evid en ce of ongoing im p rovem en t in th e n eck
w ith con t in uous n eurotoxin used to ret urn th e n eck to a
m ore you th fu l st ate. Obviou sly, if th e n eck h as already
con siderably advan ced in aging, it w ill be di cult to ele-
vate th e n eck t issu e w ith ou t a form al rhyt idectom y. Even
in th ese cases, I like o ering n eurom odu lator t reat m en t s
 
Face: 
Philosophy 
and 
Evolution 309
as a preven t ive m easu re again st recu rren ce an d as a rst
at tem pt to see h ow m uch im provem en t can be h ad sh or t
of surger y. Th ere really is n o di eren ce in m y facelift tech -
niqu es for an Asian n eck an d a Caucasian n eck. I t ypically
use sh or t in cision s th at on ly circum scribe th e ears an d do
not exten d in to th e h air-bearing area, along w ith an in ci-
sion in th e su bm en t al region , w h ich I believe can be u n iver-
sally accept able n o m at ter th e race. Becau se th e Asian skin
is th icker an d m ore elast ic th an th at of m any fairer-skin n ed
races, often I do n ot rem ove a lot of skin during th e su rger y,
but th at is n ot th e poin t of a facelift anyw ay.
An oth er procedu re th at can be ver y h elpful for m any
Asian s, w h eth er a facelift is perform ed or n ot , is an allo-
plast ic ch in im plan t . (I use th e exten ded an atom ic Con -
form im plan t m an ufact u red by Im plan tech .) Many Asian s
have a ret ruded ch in along th e in ferior border as w ell as
prem axillar y de cien cy. Adding a ch in im plan t can provide
im proved skelet al project ion an d ren der th e face less fu ll
an d rou n d in asp ect . In add it ion , I believe a ch in im plan t
in an Asian can be h elpful in im proving a facelift resu lt for
th ree reason s. First , th e n eck length is in creased, m aking
th e n eck appear im proved w ith out th e n eed to perform a
lift ing procedure in m any cases of early t issue descen t . Sec-
on d, th e ch in im plan t can provide a fulcrum aroun d w h ich
th e lift ing of th e t issues is im proved, as w ou ld be th e case
in any in dividual w ith w eaker skeletal support . Fin ally, th e
ch in im plan t can disrupt th e m an dibular ligam en t , a retain -
ing st ruct u re th at lim it s th e abilit y to lift th e t issues e ec-
t ively. William Bin der, w h o lect ures on th e subject , believes
th at th e perm an en t in terposit ion of th e ch in im plan t w ill
bet ter m ain tain th e posit ion of th e jaw lin e sin ce th e m an -
dibular ligam en t n ever re-adh eres.
As far as neck adiposit y is con cerned, for the younger or
older pat ient I prefer to open the neck t issues sharply w ith
scissors an d th en select ively rem ove ju st th e righ t am ou n t of
adipose tissue, taking care to leave en ough fat on top of th e
plat ysm a that plat ysm al dehiscen ce does not show up after-
w ard if a facelift is n ot being sim u ltan eously perform ed. I
believe that judicious an d selective rem oval of pre-plat ys-
m al adipose tissue w ith ou t a con curren t rhyt idectom y can
be undertaken in som e Asian s even into their 50s, unlike in
fair-skin n ed in dividuals, in w h om I gen erally am con cern ed
about doing so after ~ 40 to 45 years of age for fear th at th e
plat ysm al bands w ill becom e m ore eviden t if no con curren t
tighten ing procedure is undertaken. I alm ost never perform
liposuction using a cannula anym ore because I believe that
it overskeletonizes a neck that can already be skeletonized
in appearance from aging. Accordingly, m y liposuct ion
m ach in e gen erally sits in th e corn er of m y operat ing room
collect ing dust. A com bin at ion of judicious lipocon touring,
ch in augm en tation , an d rhyt idectom y often can provide far
bet ter results th an any one procedure alone, but obviously
m ust be un dertaken in th e righ t can didate w h o w ould ben -
e t from all th ree of th ese treat m en t st rategies.
310 V Facial Skin and Hair Rejuvenation
■ Skin Aging and
Rejuvenation Methods
I am con den t th at Asian skin th erapy is far bet ter t reated
elsew h ere in th e book th an I h ave don e h ere. I h ave a great
reluct an ce to perform ablat ive resurfacing, w h eth er frac-
t ion al or oth er w ise, in an Asian due to th e pigm en t ar y
risks—both hyper- an d hyp opigm en t at ion —an d th e p ro-
longed recover y t im es th at en su e. Accordingly, I p refer to
u se top ical th erap ies su ch as grow th factors, an t i-oxidan ts,
an d brigh ten ers to h elp p at ien t s, an d lim ited n on ablat ive
ph ototh erapies like erbium an d ph otofacial t reat m en t s to
im p rove skin qu alit y. I kn ow th at m y m ore exp erien ced col-
leagu es ach ieve excellen t ou tcom es by m ean s of aggressive
skin resu rfacing w ith lim ited m orbidit y, so I h u m bly defer
a m ore com preh en sive discu ssion of th e su bject to th em .
■ Conclusion
Th e aging process in th e Asian , albeit delayed an d less
profoun dly eviden t th an in th e fairer-skin n ed races, n ev-
er th eless does occu r an d m u st be t reated for opt im al ou t-
com es. For m e, th e prin cipal approach to h elp rejuven ate
m ost Asian s lies in u n derstan ding volu m e restorat ion . For
Asian s w ith lim ited volum e loss, I prefer in -o ce inject -
able llers becau se th ey do n ot n eed ver y m u ch volu m e
an d allow m ore accu racy in accom p lish ing th e righ t level
of volum izat ion . Fat graft ing st ill h as a sign i can t role in
m y p ract ice tow ard ach ieving th ese goals, bu t I reser ve th is
in ter ven t ion for som eon e w h o h as a greater degree of vol-
u m e loss du e to m ore advan ced aging.
I believe th at h air restorat ion can be a ver y im p ort an t
asp ect to rejuven at ion for both th e Asian m ale an d fem ale
pat ien t but is overlooked because m any surgeon s do n ot
perform th is procedure. W h en an in dividual h as a w eak
h airlin e bu t h as been rejuven ated th rough ou t th e rest of
th e face an d n eck area, I con ten d th at th e overall result is
com prom ised an d th e pat ien t sh ould con sider h aving h air
restorat ion if it is applicable to an d ben e cial for h im or
h er. Even if su rger y is n ot an opt ion for w h atever reason ,
th ere are m any poten t and e ect ive m edical solut ion s such
as n asteride, m in oxidil, an d low -level laser th erapy th at
can part ially coun teract early to m oderate h air loss. Even
top ical cam ou aging p rodu ct s can be u sed to tem p orarily
restore th e h air for social even ts or even on a daily basis if
th e in dividual forgoes a surgical opt ion .
I perform far few er low er facial rejuven at ion s in Asian s
th an I do in Caucasian s, even th ough for th e m id- an d upper
face I p erform alm ost th e sam e frequ en cies of in ter ven t ion .
I believe th at Asian s sim p ly d o n ot su er as m u ch from
low er facial descen t an d sh ould n ot be n eedlessly su bjected
to rejuven at ion in th is area. As st ressed earlier in th e ch ap -
ter, I believe th at n eurom odulators an d ch in im plan ts are
ver y e ect ive adju n ct s to m an agem en t of th e low er face,
particularly in th e Asian pat ien t w h o m ay ben e t from
th ese in ter ven t ion s.
Th e com plicated subject of th e aging Asian eyelid is
presen ted in an algorith m ic fash ion th at I believe can h elp
alm ost any p hysician steer clear of p roblem s, esp ecially
th e surgeon w h o h as lim ited experien ce w orking w ith th e
Asian pat ien t or w h o does n ot perform Asian eyelid sur-
ger y in gen eral. Breaking dow n pat ien t s in to th e broad
categories of th ose born w ith a n at u ral crease, th ose w h o
do not h ave a crease, an d th ose w h o h ave previou sly h ad a
su rgically created crease can be ver y h elp fu l in design ing a
proper t reat m en t plan th at is both e ect ive and safe.
Alth ough I h ave on ly brie y m en t ion ed th e m an age-
m en t of th e Asian skin an d th e fact th at I do n ot often p er-
form aggressive skin th erapy, I believe th at in m ost Asian s
skin th erapy can be h igh ly e ect ive as part of a global
st rategy. I h ave alm ost ever y aging Asian p at ien t on n eu -
rom odulator th erapy an d on a com preh en sive topical skin
regim en . Helping th e skin look m ore polished can m ake
anyon e look bet ter an d sh ou ld n ot be overlooked in any
in dividual of any race.
References
1. Lam SM, Glasgold MJ, Glasgold RA, eds. Com plem en t ar y Fat
Graft ing. Ph iladelph ia, PA: Lippin cot t , William s & Wilkin s;
2006
2. Glasgold MJ, Glasgold RA, Lam SM. Volum e restorat ion
an d facial aesth et ics. Facial Plast Surg Clin North Am
2008;16(4):435–442, vi
3. Lam SM, Glasgold RA, Glasgold MJ. Lim it at ion s, com plica-
t ion s, an d long-term sequ elae of fat t ran sfer. Facial Plast
Surg Clin North Am 2008;16(4):391–399, v
4. Karam AM, Lam SM. Managem ent of the Asian upper eyelid.
Facial Plast Surg Clin North Am 2010;18(3):419–426
5. McCurdy JA Jr, Lam SM, eds. Cosm et ic Su rger y of th e Asian
Face. New York, NY: Th iem e Medical Pu blish ers; 2005
6. Lam SM. A n ew paradigm for th e aging face. Facial Plast
Surg Clin North Am 2010;18(1):1–6
24 Facial Fat Grafting
Kyoung-Jin (Saf ) Kang
Pearls
• Reducing th e in it ial excessive expect at ion s of th e
pat ien t by adequate coun seling is im port an t .
• Th e st ruct u ral an d fun ct ion al relat ion sh ip of
th e aging an d soft t issue fou n dat ion s un der th e
in u en ce of gravit y sh ould be con sidered to avoid an
u n n at u ral facial con tou r after fat graft ing.
• Fat graft ing ach ieves volum et ric lift ing by
st rength en ing soft t issu e fou n dat ion s an d restoring
volu m e de cien cy.
• Com m on fat h ar vest ing sites are th e abdom en an d
lateral th igh , follow ed by th e m edial th igh an d an k.
• Fat graft ing of th e face sh ould be perform ed
sequ en t ially from th e p ostero-su p erior to th e
an tero-in ferior area an d from th e deep layer to th e
su p er cial layer.
• Pressing or m assaging after fat inject ion m ust be
avoided sin ce it can dam age m at ure adipocytes.
■ Introduction
Au tologou s fat t ran sfer h as been w idely u sed to im p rove
w rin kles, folds, an d depression s caused by aging an d to
t reat part ial congen ital facial hypoplasia. In 2000, Fourn ier
in t rodu ced a lipo- lling tech n ique as a good solut ion for
reversing th e aging process via volum e surger y. Also, h e
w as th e rst u ser of th e syringe-n eedle u n it or syringe-can -
n u la un it to com p letely block con t act w ith air.1 Sin ce th en ,
com plem en tar y fat graft ing h as been frequently used as
an adju n ct ive t reat m en t to restore volu m e de cien cy th at
can n ot be im proved by conven t ion al rhyt idectom y.2
At p resen t , fat graft ing is don e n ot on ly for volu m e
recover y, bu t for facial con tou r im provem en t as w ell.
Despite th e su rgeon’s at tem pt s to ach ieve su ccessfu l fat
graft ing, an u n n at u ral facial con tou r su ch as a at , broad,
an d sagged app earan ce can occu r w h en th e fat is injected
on ly for th e correct ion of volu m e deplet ion , w ith n o con -
siderat ion of th e st ru ct u ral an d fu n ct ion al relat ion sh ip of
th e aging an d soft t issue foun dat ion s.3 Sp ecial st ru ct u res
th at m ain t ain soft t issu e con tours by rest rict ing or xing
th e m ovem en t of facial soft t issue are classi ed according
to th ree m orp h ologic form s: ret ain ing ligam en t , sept u m ,
an d adh esion . How ever, w ith aging as w ell as after years
of m u scular act ivit ies and th e pu ll of gravit y, th e ligam en -
tou s xat ion s becom e disten ded, elongated, an d th in n ed
due to th e decrease of collagen ber an d loss of in t ra- an d
• Using an ideal grip tech n iqu e is im port an t in
in creasing sur vival an d redu cing th e com plicat ion s
of fat graft ing.
• Fat inject ion s m ust alw ays be perform ed as th e
syringe or can n u la is being d raw n back to p reven t
vascu lar occlu sion .
• W h en inject ing fat in to th e foreh ead area, th e
su rgeon is st rongly recom m en d ed to inject
bot ulin um toxin before th e procedu re for bet ter fat
su r vival, w ith th e except ion of pat ien t s w h o h ave
eyelid ptosis.
• Fat inject ion is n ot a procedure w ith ou t
com plicat ion s. Serious com plicat ion s such as
in fect ion an d vascular occlu sion alw ays n eed both
th e surgeon’s an d th e pat ien t’s at ten t ion .
peri-ligam en t al fat . Even t u ally, th e soft t issue fou n dat ion s
becom e w eak an d laxit y of face en sues. Autologous fat
can be injected in to th e in t ra- an d peri-ligam en t al space,
th ereby st rength en ing th e at ten uated ligam en tou s xat ion
to p rovide solid soft t issu e fou n dat ion s.
Th us, to ach ieve a successful outcom e in fat inject ion ,
a system at ic ap proach con sid ering th e roles of variou s
st ru ct u res related to facial con tou r, th e st ru ct u ral ch anges
im posed by th e aging process, an d th e in uen ce of gravit y
is n ecessar y. Con sidering all th ese factors, th e w h ole face is
divided in to several zon es, an d th e autologous fat is grafted
according to a sp eci c sequ en ce of inject ion s.
■ Patient Evaluation
Th e physician sh ould evaluate th e facial proport ion s,
degree of aging, an d th e facial sh ape of th e pat ien t (oval,
roun d, h ear t , square, rect angle, inverted t riangle, t riangle,
an d d iam on d sh ap es). According to th e facial sh ap e an d
degree of aging, th e physician can recom m en d th e best
ap proach for fat graft ing th at can m ake th e p at ien t’s face
look younger, sm aller, an d m ore beaut iful. For exam ple, fat
graft ing for an terior p roject ion is recom m en ded in a broad
an d at face. Volu m et ric lift ing u sing fat graft ing is rec-
om m en ded in a sagged, t riangular, or rect angular face. An
asym m et ric face or facial exp ression sh ou ld be evalu ated
311
312 V Facial Skin and Hair Rejuvenation
p rior to th e procedu re. According to th e degree of asym m e-
t r y, th e am oun t of fat an d level of placem en t sh ould di er.
To predict th e tot al am oun t of fat to be injected, it is
n ecessar y to id en t ify th e areas w h ere th e p at ien t w an ts
graft ing, an d to con rm oth er areas n ecessar y to create
n at u ral con tou r w ith ou t sagging, even if th e p at ien t does
n ot w an t to p erform fat graft ing in th ose areas. Addit ion -
ally, th e th ickn ess an d elast icit y of th e skin an d su bcu t an e-
ous t issue sh ou ld be ch ecked to adjust th e am ou n t of fat
an d level of p lacem en t .
Du ring th e con su ltat ion , th e im p or tan ce of environ -
m en t al factors th at can decrease th e su r vival rate an d lon -
gevit y of grafted fat sh ou ld be exp lain ed to th e p at ien t .
Th e physician m ust precisely ch eck th e pat ien t’s surgical
h istor y, in clu ding all facelift ing procedu res, previous fat
graft ing, allograft im p lan tat ion , an d any inject ion s of art i-
cial llers in clu ding foreign bodies (silicon e or p ara n ).
Oth er ch ecking poin t s in clu de th e h em orrh agic ten den -
cies of curren tly taken drugs, h ealth foods, an d n ut rit ion al
su p p lem en t s, su ch as asp irin , ibu profen , deer an tler, red
gin seng, licorice, ep h edra, garlic, on ion liqu id , vit am in
E (α -tocoph erol), an d om ega-3 fat t y acids. Sm oking an d
d rin king sh ou ld be stopped 1 or 2 w eeks prior to th e p roce-
d u re an d at least 2 w eeks to a m axim u m of 3 m on th s after
th e procedure because th ey in crease th e in ciden ce of h em -
orrh age, edem a, in am m at ion , an d delayed w oun d h ealing.
Gen erally, th e t u rn over of grafted fat occu rs w ith in 2 to 3
m on th s after th e p rocedu re du e to t ran sien t reperfu sion
isch em ia, bu t it can occu r after u p to 6 m on th s.4 Th erefore,
it w ould be good to m ain tain th e pat ien t’s body w eigh t
u n t il 6 m on th s after th e procedu re. It is advisable to in form
th e pat ien t in advan ce th at if th ere is a n eed for addit ion al
fat graft ing, it sh ou ld be don e w ith in 3 m on th s after th e
rst p rocedu re, as su ch t im ing is safer an d is associated
w ith bet ter e ects. W h en th e pat ien t h as asym m et ric facial
m ovem en t , bot u lin u m toxin can be injected 2 w eeks prior
to th e plan n ed procedure.
Becau se facial fat graft ing brings dram at ic ch anges in
facial app earan ce as t im e passes, p re- an d p ostoperat ive
p h otograph ing is ver y im port an t to evalu ate th e e ects.
A sky-blue backgrou n d is preferred because skin color is
exp ressed bet ter an d it can h ave sh ad ow th in n ing e ect s.
A st robe ash is a good ligh t source sin ce it is close to n at u -
ral ligh t . Use of a stan dard len s th at h as a 50-m m dist an ce
bet w een th e cam era an d th e len s is recom m en ded.
■ Procedural Techniques
Instruments and Solutions
In st ru m en t s for h ar vest ing fat in clu de a t u m escen t in lt ra-
tor (1.8 m m [d iam eter] × 25.0 cm [length ]), stan dard su c-
t ion can n ula (3.0 m m × 25.0 cm ), an d syringe (Lu er lock
disposable syringe, 10.0 m L). In st rum en ts for fat inject ion
in clu de a t u m escen t in lt rator (0.9 m m × 15.0 cm ), injec-
a
b
Fig. 24.1 Cannulas of various sizes for (a) fat harvesting and
(b) injection.
t ion can n ula (Colem an Type I, Men tor, 1.2 m m × 7.0 cm ;
Type II, 1.0 m m × 7.0 cm ), an d syringe (Luer slip disposable
syringe, 1.0 m L) (Fig. 24.1).
For local inject ion , lidocaine (1,000 m g/L) con tain -
ing epin eph rin e (1.0 m g/L) is m ixed w ith bicarbon ate (10
m Eq/L). Modi ed Klein solu t ion s for don or an d recipien t
sites are as follow s: lidocain e (2,400 m g/L) con t ain ing ep i-
n eph rin e (2.0 m g/L) is m ixed w ith bicarbon ate (15 m Eq/L).
Anesthesia
For fat graft ing, local an esth esia com bin ed w ith oral pre-
operat ive m edicat ion s (ceph alexin , acet am in oph en , an d
diazepam ) or in t ravascular sedat ion (propofol) is usually
ap plied. Th e au th or p refers to do fat graft ing u n der seda-
t ion , but gen eral an esth esia can also be applied according
to th e dem an d of th e pat ien t an d th e an esth et ic p hysician’s
requ irem en t according to th e m edical st at u s of th e pat ien t .
A n on steroidal, long-last ing an t i-in am m ator y drug su ch
as d iclofen ac sodiu m can be given before su rger y for p re-
em pt ive an algesia.
Preparation of Fat for Injection
Liposuction
In d on or site select ion , th e rst preferen ce is th e abdom en
an d lateral th igh . Th e secon d is th e m edial th igh an d an k.
Th e th ird is th e su pra-pubic, an terior th igh , an d supra-kn ee
region . How ever, any body area th at is possible for liposu c-
t ion can be a don or site for fat graft ing.
For h ar vest ing fat , th e en t r y site is an esth et ized by
m odi ed Klein solu t ion for region al an esth esia u sing an
in lt rator at t ach ed to a 10-m L Luer lock syringe, an d a
3- to 4-m m -long in cision is m ade at th e en t r y site w ith
 24 Facial Fat Grafting 313

a su rgical blade. Th e app ropriate in lt rated volu m e of

t um escen t solut ion is in a rat io of 1 to 2 m L for each 1 m L
of th e expected fat h ar vest .5 A st an dard su ct ion can n u la
con n ected to a Luer lock syringe is in t roduced for m an ual
liposuct ion . For th is procedu re, th e plu nger of th e syringe
sh ou ld be gen tly h an dled to provide ~ 1 or 2 m L of n ega-
t ive pressure space in th e barrel of th e syringe w h ile th e
can n ula is push ed th rough th e h ar vest site. A h igh vacuum
(m ore th an 2 m L) m ay dam age fat cells during th e proce-
dure. Th e applicat ion of skin protector or th e pat ien t’s ow n
oil from th e fat aspirates to th e in cision site is h elpful in
preven t ing frict ion burn an d hyper t roph ic scar. All in cision
sites sh ou ld be closed w ith nylon 6.0 in terru pted su t u res. a

Separation of Aspirates
After h arvesting, th e fat aspirate is centrifuged at 1,200 g
for 3 m in utes.6 Free oil should be rem oved by holding the
syringe diagonally and pouring the oil out. Th e contam in ated
portion can be absorbed or w iped by m oist gauze w ith ster-
ile saline. After elim inating the free oil, the low er fraction,
w hich contains blood and t um escent solution, is discharged
an d th e puri ed fat is then transferred from the 10-m L Luer
lock syringe to a 1.0-m L disposable syringe (Fig. 24.2).
b
Fig. 24.2 Separation and transfer of fat. (a) Lipo-aspirate before
the centrifugation (left), fractionated lipo-aspirate after centrifuga-
tion, separated into three layers (supranatant oil layer, middle real
fat layer, and infranatant layer, which is composed of blood, tissue
uid, tumescent solution, and puri ed fat after removing suprana-
tant and infranatant layers (right). (b) Direction of fat transfer from
10-mL Luer lock syringe to 1.0-mL Luer slip disposable syringe.

Fat Injection
Region al in lt rat ion of an esth esia w ith a 1% lidocain e w ith
ep in ep h rin e (1:100,000) m ixt u re is injected in to th e en t r y
site of fat inject ion for sen sor y n er ve block. Th e su p raor-
ce

Zone I
n
e

bital, suprat roch lear, in fraorbit al, m en tal, buccal, zygo-

u
q
e

m at icotem p oral, zygom at icofacial, greater au ricu lar, an d

S

Line 1
n
io

au ricu lotem p oral n er ves are t arget s of sen sor y n er ve block.

ct
je

Tu m escen t in lt rat ion can be u sed for preven t ion of bleed -

In

1
Line 2 3 Zone II
ing, pain , an d vascu lar em bolizat ion in th e tem ple, orbital,
buccal, an d pre-auricular area. Line 3 8
2
To ach ieve a successful outcom e in fat inject ion , appro- 13 9 5
Line 4 10 6 Zo n e
priate design an d sequen t ial inject ion are im port an t . Th e 14 4 III
20 11
au th or in t rod u ced th e sequ en t ial au tologou s fat inject ion 17 7
g

15
in
g

(SAFI) tech n ique, w h ich w as developed to apply fat using a

it k in
a

12
h

18
s

system ic ap proach . 16 Zo n e IV
f
w
o
in n

19
g
o t io

21
p
c
d ir e
ro

Face (Temporal, Midface, and

D

Low er Face Regions)
For SAFI, four lin es divide th e lateral face in to ve zon es
(Fig. 24.3). Each zon e h as several areas for fat graft ing. Th e
areas n u m bered 1, 3, 6, 9, 11, 13, 14, 15, 17, 18, 19, an d 21
are th e areas w h ere m ost of th e pat ien t s w an t fat graft ing.
Th e oth er n um bered areas are th e sites w h ere th e physi-
cian sh ould inject fat for providing st rong skelet al support ,
st rength en ing th e soft t issu e fou n dat ion , an d p reven t ing
gravit at ion al descen t . Th e p lacem en t an d injectable vol-
u m e of each SAFI area are described in Table 24.1.
Zo n e
V
Fig. 24.3 Four SAFI lines and possible areas for injection. The four
SAFI lines that divide the face into ve zones are (1) Line 1, con-
necting the temporal hairline and the anterior auricular border; (2)
Line 2, connecting the orbital ligament, the posterior border of the
orbital process of the zygoma, the zygomatic retaining ligament,
and the posterior border of the super cial masseter muscle; (3)
Line 3, connecting the zygomatico-maxillary suture, the anterior
inferior prominence of the maxilla, and the anterior border of the
super cial m asseter muscle; (4) Line 4, connecting the nasolabial
fold and the labio-m andibular fold.
314 V Facial Skin and Hair Rejuvenation

Table 24.1 Areas, placement, and volume of fat grafting in the face

Zone Area Area and subarea Purpose Placement Volume*

I 1 Temporal scalp area within
5 cm from the hairline
2 Sideburn and its posterior
temporal area
Augm ent and strengthen
soft tissue foundations
The space bet ween super cial 2.0–3.0
temporal fascia (STF) and
deep temporal fascia (DTF),
subcutaneous super cial fat layer, 1.0–2.0
and inferior temporal septum

II 3 Temporal hollow Strengthen soft tissue Orbital ligament and inferior 2.0–4.0
foundations temporal septum

Augm entation Subcutaneous super cial fat layer,

and the space bet ween STF and DTF

4 Pre-auricular area Augmentation Sub-SMAS and super cial fat layer 2.0–3.0
(Super cial temporal fat pad)

5 Zygom atic arch Strengthen soft tissue Zygom atic retaining ligam ent 0.5–1.5
foundations

Augmentation Subcutaneous super cial fat layer

6 Lateral cheek depression Augmentation Deep lateral cheek fat, SMAS, and 1.0–2.0
subcutaneous super cial fat layer

7 Parotid gland area Augm entation Subcutaneous super cial fat layer 1.0–2.0

III 8 Lateral canthal area Augm entation On the periosteum and under the 0.5–1.0
orbicularis oculi muscle

9 Palpebro-malar groove
(lateral trough deform it y)
Strong skeletal support
and augmentation
Under the orbital retaining 0.5–1.5
ligament, on the periosteum of
anterior area to arcuate m arginalis,
above the orbital retaining
ligament, and SOOF

10 Malar em imence Strong skeletal support Supra-periosteal layer(pre- 1.0–4.0

(hypoplasia or at m ala) and augmentation zygomatic space), SOOF, and
super cial fat layer

Strengthen soft tissue Zygomatic ligam ents and bucco-

foundations maxillary retaining ligament

11 Lateral subarea of Augmentation Deep lateral fat, interm ediate 2.0–4.0

subm alar hollow lobe of buccal fat pad, SMAS,
and super cial fat layer

Strengthen soft tissue Masseteric cutaneous ligament

foundations

12 Lower part of the Augm entation Masseter m uscle and 1.0–2.5

masseter muscle subcutaneous fat layer

Fig. 24.4 sh ow s th e locat ion of en t r y sites, inject able
areas, an d advan cing direct ion s for th e can n u la in perform -
ing SAFI. Th e arrow s from each en t r y site in dicate th e d irec-
t ion s an d approach able areas for th e can n u la. How ever, th e
select ion of th e en t r y sites d ep en ds on th e st at u s of th e
pat ien t s an d th e preferred post ure or conven ien ce of th e
physician .
Fat injection is perform ed in a system at ic m anner: (1) in
the sequence of zones I, II, III, IV, and V; (2) from the postero-
su perior area to th e an tero-in ferior area w ith in th e sam e
zone (Fig. 24.3); an d (3) in th e sequen ce of deep, m iddle,
an d super cial layer w ith in an area or its subarea (Fig. 24.5).
For exam ple, th e subm alar h ollow is divided in to t w o
su bareas (an terior an d lateral) becau se th is area is relat ively
 24 Facial Fat Grafting 315

IV 13 Tear trough deformit y Strong skeletal support On the periosteum of the inferior 1.0–2.0
and augm entation orbital rim, under orbital retaining
and bucco-maxillary ligam ent,
SOOF, and preorbital subcutaneous
super cial fat layer

14 Midcheek furrow Strong skeletal support Bucco-maxillary ligam ents, above 2.0–4.0
and augm entation the periosteum and under the lip
levator muscles (deep medial cheek
fat, a part of SOOF), and super cial
medial cheek fat.

15 Anterior subarea of Strong skeletal support, On the periosteum of zygom a 2.0–6.0

subm alar hollow strengthen soft tissue and maxilla, m asseteric cutaneous
foundations, and fullness ligament, and atrophied buccal fat
pad

Augm entation Peripheral of buccal fat pad, under

the bucco-maxillary ligam ent
and lip elevator m uscles, and the
subcutaneous super cial fat layer

16 Jowl (hypoplasia) Deep and super cial fat layer 1.0–2.0

V 17 Nasolabial fold Augmentation Whole layer of depressed part 1.0–2.0

18 Labio-mandibular fold Augmentation Whole layer of depressed part 1.0–2.0

(m arionet te line)

19 Pre-jowl sulcus Augmentation On the periosteum of m andibular 1.0–2.0

bone, and deep and super cial fat

20 Pre-maxillary and upper Strong skeletal support On the periosteum of the piriform 1.0–2.0
lip area and augm entation area and deep fat

21 Sm all chin Strong skeletal support On the periosteum of mandible, 2.0–5.0

and augm entation deep and submental fat layer, and
super cial fat layer

Total injectable volum e 26.5 to

57.5

Abbreviations: DTF, deep temporal fascia; SMAS, super cial musculoaponeurotic system ; SOOF, suborbicularis oculi fat; STF, super cial
temporal fascia.
*Volume: Injectable fat (mL/one side of face)

w ide an d h as a h igh risk of sagging due to th e w eak soft t is-
su e fou n dat ion . Fat is sequ en t ially injected in to th e su pra-
p eriosteal layer of th e zygom a an d m axilla for in creasing
skelet al su p p or t , in to th e m asseteric cu tan eou s ligam en t
for st rength en ing th e soft t issu e fou n dat ion , an d in to th e
at roph ied bu ccal fat p ad for in creasing fu lln ess (Fig. 24.6).
Th e n asolabial fold con sists of t w o part s: th e lateral
bulging caused by volum e-depleted pseu do-ptosis an d th e
m edial dep ression cau sed by th e loss of volu m e. To correct
th e lateral bulging, fat is injected to th e m alar, m idch eek
fu rrow, an d su bm alar area. To correct th e m edial depres-
sion , inject ion in to th e w h ole layer of th e d ep ressed area
is n ecessar y.
Forehead Region
Th e foreh ead also can be divided in to ve zon es based on
th e st ru ct ures related to th e m orphology an d aging of th e
foreh ead . Fat is injected in th e sequen ce of zon es I, II, III,
IV, an d V as sh ow n in Fig. 24.7. W h en p erform ing foreh ead
fat graft ing, fat sh ou ld be rst injected in to area above th e
316 V Facial Skin and Hair Rejuvenation

Skin Skin Skin

B
B
B
o
o
o
n
n
n
e
e
e
a

Skin
Skin

1
1 5 5
8 8 2

B
2 6 10 10 6

o
n
B
9 9 3

e
o
3 7

n
7

e
4 4

Possible entry sites ( ) and directions ( ) of injection b

Fig. 24.4 Possible entry sites and directions of injection. The
arrows from each entry site indicate the directions of injection and
approachable areas for the cannula.
Fig. 24.5 Sequential depth of fat injection. (a) As the fat is
injected closer to the underlying skeleton, the e ect of the sup-
porting skeleton is stronger and the chance of gravitational descent
is less. (b) As the fat is injected more into the deep level, the pos-
sibilit y of injected fat descending inferiorly becomes less.

Upper
Lower depressed
depressed area
area

Skin a
Retaining ligament
Muscle

Fig. 24.6 Sequential fat injection in t wo abut ting areas of the face. When
injecting t wo depressed areas that are abut ting (a), fat should be injected into
the upper depressed area rst followed by the lower area, including soft tissue
and retaining ligament (b). This technique helps to decrease the volume of c
injected fat in lower areas and skin becomes more tense. Eventually, it can also
prevent soft tissue sagging induced by gravitational descent. Injecting fat in
the reverse order (c) is not recommended.
 24 Facial Fat Grafting 317

areas. App roach ing zon es I to III is also easy from en t r y site
Zone I B. Zon e IV in cludes th e m ost depressed area in th e fore-
head. If deep h orizon tal foreh ead w rin kles are presen t in
Zone II zon e IV, en t r y at site C along th e w rin kles is selected.
Irregu larit ies an d lu m ps occu r frequ en tly in foreh ead
fat graft ing. Mold ing th e irregu lar areas is often perform ed
Zone III
for a sm ooth an d even su rface, bu t it is n ot usually recom -
m en ded . Ad dit ion ally, it is st rongly recom m en ded to inject
Zone IV bot ulin um toxin before th e procedure for bet ter fat sur-
vival, except in pat ien t s w h o h ave eyelid ptosis. Th e bou n d-
aries of th e zon es an d th e am ou n ts of fat to be injected are
Zone V
described in Table 24.2.

Fig. 24.7 The ve zones, possible entry sites, and directions of

injection for forehead fat grafting. The t wo blue lines indicate the
superior temporal line. The t wo black dot ted circles show the fron-
tal eminences. The blue circles (A, B, C) are the possible entry sites,
and the white arrows show the directions of injection.
fron t al h air lin e (zon e I) ben eath th e galea ap on eu rosis
an d fron talis m u scle for t igh ten ing th e fron t alis m u scle to
redu ce p hysical st ress on th e grafted fat . Alth ough en t r y
site A is a good ch oice for graft ing zon es II an d III, it is dif-
cu lt to m ove th e can n u la an d inject fat even ly becau se th e
su bcu tan eou s layers of zon es II an d III are relat ively th in ,
d en se, an d st i . Care is n eeded to avoid un expected com -
p licat ion s su ch as lu m p an d irregu larit y in th ese zon es.
Korean s ten d to p refer a m ore p rojected an d rou n d
m idforeh ead (zon e III). Sequ en t ial fat graft ing from zon es
I to III t igh ten s soft t issu es w ith volu m et ric lift ing in th ese
Baton Grip Technique
Syringe grip an d inject ion m eth ods are im por tan t factors
in th e success rate an d p reven t ion of com plicat ion s in fat
graft ing p roced u res. Ben e t s from ideal syringe grip are
n esse, accu racy, easy adju st m en t of th e fat volu m e, an d
less t raum a. Th e proper grip is called “baton grip” because
it is sim ilar to th e grip of th e baton u sed by th e con ductor
of an orch est ra. Th e posit ion s of th e ngers for th is tech -
niqu e are sh ow n in det ail in Fig. 24.8. Th e t ip of th e can -
nu la is p ush ed in to th e t arget area w ith th um b an d in dex
nger exten d ed . Th e graft ing fat volu m e is n ely adju sted
w ith th um b an d in dex nger w h ile th e can n ula is draw n
back w ith con st an t speed by using th e h an d an d th e en t ire
arm . Th e force is p assed dow n to th e th u m b rest ing on
th e plunger suppor ted by th e hypoth en ar em in en ce. Fat
is p assed th rough th e can n ula by pulling th e barrel of th e
syringe an d com es ou t of th e can n u la in a th read-like sh ape
(Fig. 24.9).

Table 24.2 The boundary of SAFI zones, purposes, placement, and volume of fat grafting in the forehead

Zone Boundary Purpose Placement Volume*

I Area to 7 cm above the Tightening of frontalis Subgaleal space 3–5

frontal hairline muscle

II Upper third of forehead Anterior projection and Subgaleal space, super cial fat layer 1–2
natural lateral contour

III Middle third of forehead Anterior projection and Subgaleal space, super cial fat layer 1–3
natural frontal em inence

IV Lower third of forehead Strong skeletal support Supraperiosteal layer or subgaleal space, 2–4
intramuscular, galeal fat pad, super cial fat layer

V Brow area below zone IV Volum e recovery and Supraperiosteal layer or subgaleal space, 1–2
strong skeletal support glabella fat pad, brow fat pad (ROOF),
super cial fat layer

Total injectable volume 8 to 16

Abbreviation: ROOF, retro-orbicularis oculi fat.

*Volume: Injectable fat (mL/one side of face).
318 V Facial Skin and Hair Rejuvenation

Fig. 24.8 Baton grip technique for fat grafting. The barrel of the
syringe is positioned bet ween the tip of the thum b and the distal
interphalangeal joint of the index nger. The rest of the plunger is
positioned in the junction bet ween the hypothenar eminence and
the medial side of the palm . Other ngers hold the barrel of syringe
as if they were grabbing an egg. (a) Lateral view of the exion state.
(b) Lateral view of the extension state.

Application of Platelet-Rich Plasma b

and Adipose -Derived Stem Cells
Various at tem pts have been m ade to increase the sur vival rate
an d longevit y of grafted fat. Am ong them , the application of
platelet-rich plasm a (PRP)7,8 an d adipose-derived stem cells
(ADSC)4 are the m ost popular, and positive research results
h ave been published on these applications. How ever, m ore
research is still required for m ore evidence in im provem ent
of fat sur vival and longevit y by these applications.
Postoperative Care and Treatment
Im m ediately after fat grafting, Microfoam (3M) tape should be
placed on the in ltrated area and left in place w ith application
of an ice pack for 3 or 4 days. This is for m inim izing the form a-
tion of edem a, and for preventing m igration of in ltrated fat
and protecting the skin. The entry site sutures are rem oved
after 3 days, and then Steri-Strip (3M) is applied for 2 days
m ore. Facial m uscle m ovem ent should be restricted, and liq-
uid food such as porridge is recom m ended over this period of
tim e. Three days after the procedure, it is better to replace ice
packs w ith hot packs to elim inate edem a and bruising.
Part icular at ten t ion sh ould be paid to avoid pressure on
th e in lt rated area during sleep un t il 3 m on th s after th e
procedure. Pat ien ts sh ould also be in st ructed to keep th eir
face above th eir h ear t du ring sleep . Warn p at ien t s to m ake
su re th at th ey an d oth ers do n ot tou ch or pu t p ressu re on
Fig. 24.9 Fineness of baton grip technique. The thread-like fats
extruded from t wo kinds of cannulas, with inner diameters of (a) 15
mm and (b) 12 mm, using the baton grip technique.
th e in lt rated area. Ligh t exercise is allow ed, but st ren uou s
exercise sh ou ld be avoid ed for a m on th as it m ay h ave a
n egat ive im pact on th e early sur vival rate of th e injected
fat .9 Addit ion al fat graft ing can alw ays be perform ed.
Th e opt im al t im e for an addit ion al procedure is at least 3
m on th s after th e rst fat graft ing. How ever, if th e pat ien t
st rongly dem an d s it , th e p rocedu re m ay be p erform ed at
least 1 m on th after th e rst on e using fresh or frozen fat .
■ Key Technical Points
1. Fat injection is perform ed in a system atic m anner: (1)
in the sequence of zones I, II, III, IV, and V; (2) from the
postero-superior area to the antero-inferior area w ithin
the sam e zone; (3) in the sequence of deep, m iddle,
and super cial layers w ithin an area or subarea.
2. Applicat ion of a skin protector or pat ien t’s ow n oil
from th e fat aspirates to th e in cision site is h elp fu l in
preven t ing frict ion bu rn an d hypert roph ic scarring.

3. Tu m escen t solut ion sh ould n ot be injected sudden ly
in a h uge volum e w ith h igh pressu re; th is could
cause th e developm en t of a lake in th e t issu e, w h ich
could lead to in su cien t an d un even liposuct ion .
4. The baton grip tech n ique of using th e syringe in fat
inject ion h elps to in crease th e sur vival of grafted fat
an d to decrease com p licat ion s.
5. W h en correct ing tear t rough deform it y, th e en d
p oin t of fat graft ing is a st at us th at is sligh tly un der-
corrected in th e supin e posit ion .
6. In foreh ead fat graft ing, fat is injected in to th e
area above th e fron t al h airlin e ben eath th e galea
ap on eu rosis an d fron t alis m u scle to t igh ten th e
fron t alis m u scle an d th u s h elp to redu ce p hysical
st ress on th e grafted fat .
7. Inject ing bot ulin um toxin before graft ing in creases
th e sur vival of grafted fat in th e foreh ead.
■ Complications and
Their Management
Edema, Bruising, or Hematoma
Edem a or persisten t edem a (longer th an 2 w eeks) m ay
occur due to t issue dam age during pre-t un n eling an d injec-
t ion , hypo-osm olarit y due to th e t um escen t uid, an d sev-
eral oth er system ic diseases. To avoid or m in im ize edem a,
adequ ate tap ing is m ost im p ort an t . Prolonged edem a
sh ou ld n ot be con fu sed w ith hyp er-correct ion , h em atom a,
in am m at ion , or factors due to system ic diseases. Gen er-
ally, a m edical device th at accelerates lym p h at ic circu lat ion
can be h elpfu l to reduce edem a.
Th e m ajor cause of bruising or h em atom a is vascu lar or
m u scu lar dam age cau sed by th e can n u la du ring inject ion . A
precise inject ion grip tech n ique sh ould be applied, an d th e
bleeding ten den cy of th e pat ien t sh ould be ch ecked before
th e procedu re.
Irregularity, Lump, and Bump
Th e occu r ren ce of ir regu lar it y, lu m p , an d bu m p u su ally
d ep en d s on t h e p hysician ’s gr ip tech n iqu e, exp er ien ce,
an d aest h et ic se n se. Mold in g of t h e ir regu lar areas is
ofte n p e r for m ed for a sm oot h an d even su r face d u r in g
t h e p roced u re, alt h ough it s e ect is lim ite d . If t h e lu m p is
seen or felt d u r in g or w it h in 2 w eeks afte r t h e p roced u re,
it sh ou ld be rem oved p rop erly w it h lip olysis-assisted or
m an u al lip osu ct ion . Also, if any ir regu lar it y is se en afte r
rem oval of t h e lu m p , it is advisable to cor rect it im m e-
d iately w it h ad d it ion al fat graft in g. Som et im es, t w o or
t h re e inject ion s of cat abolic steroid solu t ion can h elp to
red u ce t h e size of lu m p an d bu m p . Desp ite all at tem p t s, if
24 Facial Fat Grafting 319
any lu m p an d bu m p st ill exist s, excision is recom m en d e d .
Th ese com p licat ion s can be p reven te d if an ad e qu ate vol-
u m e of fat is p laced at t h e op t im al laye r u sin g a p recision
syr in ge gr ip tech n iqu e.
Asymmetry and Hyper- and
Hypo -Correction
Occasion ally, som e p at ien ts com p lain of asym m et r y im m e-
diately after fat graft ing. Edem a or in appropriate correc-
t ion is th e m ost com m on cau se of asym m et r y. Th is can be
im proved w ith adju st m en t of volum e by perform ing eith er
liposuct ion or addit ion al fat graft ing at least 1 m on th after
th e procedu re.
Migration and Gravitational Descent
Early m igrat ion is m ain ly caused by direct pressure on th e
in lt rated site or act ive m ovem en t of th e m im ic m u scle. It
m igh t be im p roved by m olding w ith gen tle d igit al pressu re
or preven ted by pret reat m en t w ith bot ulin um toxin . Late
m igrat ion u su ally occu rs in th e areas of th e n asolabial folds,
ch eeks, an d jow ls an d is caused by gravit at ion al descen t
due to th e w eigh t of th e injected fat . Th e prin ciple of correc-
t ion is to do proper liposuct ion of th e descen t area rst an d
th en do volum et ric fat graft ing in to th e depressed area. But
som et im es facelift su rger y is n ecessar y for p at ien t s w h o
have severe laxit y of skin . It is suggested th at applicat ion of
th e SAFI tech n ique an d pret reat m en t w ith bot u lin u m toxin
are reliable ap proach es to p reven t th ese com p licat ion s.
Resorption of Fat
Resorpt ion of grafted fat is th e m ost seriou s com m on com -
plain t by pat ien t s. Many environ m en t al an d tech n ical fac-
tors are related to th e su r vival rate of injected fat . To redu ce
th is com plicat ion , applying ADSC, pret reat m en t w ith bot-
ulinu m toxin , even placem en t of fat using th e baton grip,
cessat ion of sm oking, postoperat ive lim it at ion of facial an i-
m at ion , an d on e or t w o session s of addit ion al fat graft ing
are requ ired .
Hyperpigmentation and Scar
Hyperp igm en t at ion is frequ en tly fou n d in th e orbit al an d
periorbit al area w ith bruising after fat graft ing. Th e sur-
geon sh ou ld app ly su n block cream an d p rescribe 2 to 4%
hydroqu in on e cream on e or t w o t im es per day if it becom es
w orse. In th e pat ien t w ith sen sit ive skin , h alf-st rength
hydroqu in on e cream is applied. Th e applicat ion of in ten se
pulsed ligh t an d Q-sw itch Nd: YAG laser m igh t also be
helpfu l to im prove hyperpigm en tat ion . Dam age of approxi-
320 V Facial Skin and Hair Rejuvenation

m ated ep ith eliu m cau sed by som e frict ion of th e can n u la is

th e m ain cause of scar form at ion . It is h elpful to t reat scars
w ith th e applicat ion of an t iscar oin t m en t , steroid oin t m en t
or inject ion , an d laser resurfacing. Th e auth or recom m en ds
th at ent r y be m ade w ith an 18-gauge n eedle an d th at th e
site is su t u red for preven t ion of scar.

Acneiform Eruption
Acn eiform eru pt ion is cau sed by excessive oil form at ion
from dest royed fat cells after fat graft ing. It frequ en tly
develops in pat ien ts w ith oily skin an d previous acn e h is-
a
tor y. It can be im p roved by adequ ate clean sing of th e face
an d adm in ist rat ion of drugs for ~ 7 days.

In ammation and Abscess Formation

Bacterial in fect ion after fat graft ing is accom p an ied by pain ,
sw elling, an d er yth em atou s in du rat ion , w h ich last s 2 or 3
days to several w eeks after th e procedu re. Abscess com -
m on ly form s if th e in fect ion is n ot con t rolled at an early
stage (Fig. 24.10).10,11 On ce it occu rs, an aggressive t reat-
m en t su ch as in cision an d drain age is n eeded sin ce it can
spread to th e su rrou n ding t issu e, cau sing severe com p lica-
t ion s such as cellulit is.10,12 Th e m ain causes of in fect ion are
in ad equ ate sterilizat ion of su rgical in st ru m en ts, con t am i-
n ated frozen fat , in t raop erat ive con tam in at ion of fat an d b
can n ula, an d in fect ion through th e en t r y site. At ten t ion
sh ou ld be given to th e pat ien t’s h istor y sin ce an im m u n e- Fig. 24.10 Abscess formation after fat injection. (a) A female
com prom ised pat ien t h as a m uch h igh er possibilit y of patient who developed left cheek swelling after whole face fat
injection. (b) About 30 mL of pus was aspirated from her left cheek.
in fect ion . To preven t in fect ion , w ash ing th e in side of th e
can n ula th orough ly an d com plete sterilizat ion of surgical
in st ru m en t s are m an dator y. All uids in clu ding t um escen t
solu t ion s sh ou ld be sterile, an d st rict hygien e con t rol du r-
ing h ar vest ing, separat ing, an d rech arging of th e fat is n ec-
essar y. Th e perioral area an d n asal cavit y sh ou ld be avoided
as en t r y sites of inject ion , an d ad equ ate p re- an d p ostop -
erat ive an t ibiot ics sh ou ld be adm in ist rated . Con t in u ou s
ap plicat ion of ice p acks m ay preven t sp reading of in fect ion
to th e su rroun ding area in th e early stages. Th e basic goal of
su rgical t reat m en t is to rem ove con tam in ated fat an d su r-
rou n d ing t issu e. Add it ion al fat graft ing is p ossible at least
6 m on th s after com plete recover y from th e in fect ion , an d
on ly fresh fat sh ould be used. Fig. 24.11 Skin necrosis of the nasolabial area after fat injection.

Vascular Embolization
Alth ough th e occu rren ces of vascu lar occlu sion from fat
graft ing h ave sign i can tly decreased w ith th e u se of th e
blu n t can n ula, it st ill exists. It is kn ow n to occur frequen tly
after facial fat graft ing at th e region s of th e glabella, n asola-
bial folds, n ose, an d tem poral area (Fig. 24.11).
Region al com p licat ion s such as skin n ecrosis 13 an d
blin dn ess 14,15 can be cau sed by occlu sion of an en d bran ch
or surroun ding bran ch es of an ar ter y w h en fat is acciden tly
injected in to th e ar ter y. If a large am oun t of fat is injected
in to th e ar ter y w ith h igh pressure, th e fat can be re u xed
in to th e in tern al carot id ar ter y. Even t ually, a seriou s com -
plicat ion su ch as st roke m ay occur.15,16 Blin dn ess occurs
con cu rren tly w ith sudden orbit al or periorbit al pain du ring
or im m ediately after th e fat graft ing. No in st an ces of visual
restorat ion h ave been reported after fat graft ing–in du ced
 24 Facial Fat Grafting 321

blin dn ess, but sym ptom s of brain in farct ion h ave partly accom pan ied by volu m e redu ct ion of th e tem p oral, m alar
resolved in a few cases as t im e passed.14,15,16,17 an d su bm alar areas, an d th e lateral ch eek. Six m on th s after
On th e oth er h an d, if th e fat is injected in to th e vein , fat graft ing, th e overall facial con tou r ch anged to an oval
it goes th rough th e h ear t an d th en blocks th e pu lm on ar y or reversed t riangle sh ape, an d asym m et r y sign i cantly
arter y. Su dden sw eat ing, dyspn ea, an d t achyp n ea can be im proved in th e fron t al view (Fig. 24.13). Th is su ccessfu l
m an ifested as t ypical sym ptom s of n on th rom bot ic pu lm o- volu m e red ist ribu t ion m ade th e face look lifted n at u rally in
n ar y em bolism du ring fat graft ing.18 th e postero-superior direct ion also. Th e m ost rem arkable
It app ears th at th e m obilit y of th e vessel is sign i can tly ch ange is th e ogee cur ve in th e m idface. Th e com pletely
redu ced after th e rst fat graft ing du e to brosis an d fu ll- isolated ogee cur ve becam e con n ected an d roun d by th e
n ess of th e in lt rated area. Th u s, in spite of u sing th e blu n t an terior p roject ion th rough fat graft ing.
can nula, th e vessels m ay h ave a m u ch h igh er ch an ce of
being pen et rated w ith re-inject ion of th e previou s in lt ra-
t ion site th an w ith th e prim ar y fat inject ion . Even w h en
th e fat is injected for th e rst t im e, fulln ess due to over-
correct ion can also reduce th e m obilit y of th e vessels, th u s a b
in creasing th e p ossibilit y of pen et rat ion .
Th ese serious com plicat ion s can be preven ted by avoid-
ing over-correct ion an d u sing a cau t iou s ap proach in th e
secon d an d th ird session s of fat graft ing. It is im port an t to
inject fat n ot w h en th e can n u la is pu sh ed ah ead, bu t w h en
th e can n ula is being draw n back. Avoid inject ing fat parallel
to th e cou rse of a vessel an d u se ep in ep h rin e for con st rict-
ing vessels. Add it ion ally, em ergen cy care m u st alw ays be
ready an d th e p at ien t m ust be t ran sferred im m ediately to
th e secon dar y or tert iar y care cen ter for fu rth er appropri-
ate treat m en t w h en vascu lar occlu sion occu rs.

Complications of the Donor Site Fig. 24.12 Case 1. Whole face volume recovery with fat grafting.
(a,b) The patient before the procedure (unpowdered state).
Severe com p licat ion s from lip osu ct ion occu r rarely sin ce
on ly a relat ively sm all am oun t of fat is n eeded for facial
fat graft ing. Th e possible com p licat ion s from lip osu ct ion
in clu de depression or irregu larit y, bleeding an d h em atom a,
brosis, hyp erp igm en tat ion , p aresth esia an d p ain , in am -
a b
m at ion , serom a, scar, n ecrosis, fat em bolism , th rom boem -
bolism , an d toxic sh ock syn drom e.

■ Case Studies
Case 1: Whole Face Fat Grafting
A 30-year-old w om an w an ted to im prove h er angu lar face
(Fig. 24.12). Sh e h ad dark circles w ith in fraorbit al h ollow s,
deep n asolabial folds, volu m e de cien cies of th e lateral
ch eek, tem poral h ollow s, an d a at foreh ead. A tot al of
65 m L of puri ed fat w as u sed for inject ion in to th e face
an d foreh ead. A p reop erat ive view sh ow s a long, rect an -
gu lar, asym m et ric face w ith a sagging ap p earan ce d u e to Fig. 24.13 Case 1. (a,b) Six m onths after the procedure (unpow-
th e developm en t of n asolabial folds an d jow ls, w h ich is dered state).
322 V Facial Skin and Hair Rejuvenation

Case 2: Low er Lid Rejuvenation Using
Fat Graft
A 33-year-old w om an com plain ed of orbit al fat p rot ru sion
an d tear t rough deform it y (Fig. 24.14). Using th e baton
grip tech n iqu e, ~ 15 m L of p u ri ed fat w as injected to
th e m alar, palpebro-m alar groove, tear t rough deform it y,
an d m idch eek fu rrow to in crease skeletal su p port an d to
restore volum e de cien cy. Postop erat ively, th e lid-ch eek
jun ct ion w as sign i can tly sh orten ed, an d in fraorbital h ol-
low n ess an d deep m idch eek fu rrow im proved rem arkably
(Fig. 24.15). In creased skelet al su pp ort an d restorat ion of
soft t issu e m ade th e fat p rot ru sion less p rom in en t .

Fig. 24.14 Case 2. Skeletal supporting and volume recovering e ect Fig. 24.15 Case 2. The patient 18 months after the procedure.
of SAFI on lower lid rejuvenation. The patient before the procedure. The lid-cheek junction was signi cantly shortened and infraorbital
hollowness and deep midcheek furrow rem arkably improved after
fat injection.

Case 3: Forehead Fat Grafting

A 24-year-old w om an w an ted to h ave a rou n d an d con -
vex foreh ead (Fig. 24.16). In t w o session s of fat graft ing
5 m on th s apart , 18 m L an d 10 m L of puri ed fat w ere
injected, resp ect ively. Tw en t y un it s of bot ulin um toxin
w ere injected in to th e fron talis an d corrugator m u scle 10
days before th e procedu res (Fig. 24.17).

Fig. 24.16 Case 3. Forehead fat grafting and pretreatment with bot-
ulinum toxin. The patient before the procedure (unpowdered state).

a b

Fig. 24.17 Case 3. (a) Five months after the rst procedure (unpowdered state). A second procedure was performed at this time. (b) Five
years after the rst procedure, and 4 years and 7 months after the second procedure (powdered state).

References
1. Fourn ier PF. Fat graft ing: m y techn iqu e. Derm atol Surg
2000;26(12):1117–1128 Com m en t in Derm atol Surg
2003;29:898
2. Am ar RE. [Adipocyte m icroin lt rat ion in th e face or t issue
rest ruct u rat ion w ith fat t issu e graft .] An n Ch ir Plast Esth et
1999;44(6):593–608
3. LaTren t a GS. Atlas of Aesth et ic Face an d Neck Surger y. 1st
ed. Ph iladelph ia, PA: Sau n ders, Elsevier; 2004:52–59
4. Yoshim ura K, Sato K, Aoi N, Kurita M, Hirohi T, Harii K. Cell-
assisted lipotransfer for cosm etic breast augm entation: sup -
portive use of adipose-derived stem /strom al cells. Aesthetic
Plast Surg 2008;32(1):48–55, discussion 56–57
5. Kuh bier JW, Weyan d B, Radtke C, Vogt PM, Kasper C, Re-
im ers K. Isolat ion , ch aracterizat ion , di eren t iat ion , an d ap -
p licat ion of adipose-d erived stem cells. Adv Bioch em Eng
Biotech n ol 2010;123:55–105
6. Colem an SR. St ruct ural Fat Graft ing. St Louis, MO: Qualit y
Medical Pu blish ing; 2004:55–73
7. Cer velli V, Palla L, Pascali M, De Angelis B, Curcio BC, Gen -
t ile P. Au tologou s p latelet-rich plasm a m ixed w ith p u ri ed
fat graft in aesth et ic plast ic surger y. Aesth et ic Plast Surg
2009;33(5):716–721
8. Abu zen i PZ, Alexan der RW. En h ancem en t of au tologou s
fat t ran splan t at ion w ith platelet rich plasm a. Am J Cosm et
Surg 2001;18:59–70
9. Niech ajev I. Lip en h an cem ent: surgical altern at ives an d
h istologic aspect s. Plast Recon st r Surg 2000;105(3):
1173–1183, discussion 1184–1187
24 Facial Fat Grafting 323
10. Beeson WH, Slam a TG, Beeler RT, Rachel JD, Picerno NA.
Group A streptococcal fasciitis after subm ental tum escent
liposuction. Arch Facial Plast Surg 2001;3(4):277–279
11. Galea LA, Nicklin S. Mycobacterium abscessus infection
com plicating hand rejuvenation w ith structural fat grafting.
J Plast Reconstr Aesthet Surg 2009;62(2):e15–e16
12. Villan i F, Caviggioli F, Gian n asi S, Klinger M, Klinger F. Cu r-
ren t applicat ion s an d safet y of au tologous fat grafts: a re-
port of th e ASPS Fat Graft Task Force. Plast Recon st r Surg
2010;125(2):758–759, auth or reply 759
13. Dan esh -Meyer HV, Savin o PJ, Sergot t RC. Case rep ort s an d
sm all case series: ocular an d cerebral isch em ia follow ing
facial inject ion of autologous fat . Arch Oph th alm ol 2001;
119(5):777–778
14. Teim ou rian B. Blin dn ess follow ing fat inject ion s. Plast Re-
con st r Su rg 1988;82(2):361
15. Dreizen NG, Fram m L. Su dden u n ilateral visu al loss after
autologous fat inject ion in to th e glabellar area. Am J Oph -
th alm ol 1989;107(1):85–87
16. Th au n at O, Th aler F, Loirat P, Decroix JP, Bou lin A. Cerebral
fat em bolism in duced by facial fat inject ion . Plast Recon st r
Surg 2004;113(7):2235–2236
17. Yoon SS, Ch ang DI, Ch u ng KC. Acu te fat al st roke im m edi-
ately follow ing au tologou s fat inject ion in to th e face. Neu -
rology 2003;61(8):1151–1152
18. Jiang X, Liu DL, Ch en B. Midd le tem p oral vein : a fatal h az-
ard in inject ion cosm et ic surger y for tem ple augm ent at ion .
JAMA Facial Plast Surg 2014;16(3):227–229
 25 Endoscopic Forehead and Brow Lift
Tee Sin Lee and Stephen S. Park
Pearls
• Th e aging upper on e-th ird of th e face is assessed as a
u n it , an d all aesth et ic u n it s are in terrelated.
• Th e aging brow can h ave a dram at ic im pact on
gen eral facial exp ression , creat ing a t ired or fat igu ed
ap pearan ce.
• Ptosis of th e aging brow can sim ulate
derm atoch alasis of th e upper eyelid.
• Th e approach es to foreh ead an d brow lift can be
divided in to open an d en doscopic. Open approach es
in clu de t ran s-bleph aroplast y, direct , m idforeh ead,
t rich ophyt ic, an d coron al.
• Th e prin ciples of en doscopic foreh ead an d brow lift
(EFBL) are th e m aking of sm aller, w ell-cam ou aged
in cision s; m axim al release of m u scu lar an d
periosteal at tach m en t s; ceph alic rot at ion of th e
■ Introduction
Foreh ead an d brow lift is an im por tan t com pon en t of upper
face rejuven at ion . Th is often com p lem en ts th e resu lt s of
u pper bleph arop last y, an d th e reverse is also t rue. Fore-
h ead lift resu lt s in a sm ooth er con tou r w ith resolu t ion or
im p rovem en t of foreh ead an d glabellar rhyt ids, w h ile brow
lift aim s to elevate th e brow s to an aesthet ically pleasing
posit ion an d also to sculpt an aesth et ically pleasing sh ape.
In th e p rocess of ach ieving th is, in cision s h ave to be m ade
in th e foreh ead an d scalp or along th e h airlin e, w h ere th ey
m ay be too con spicu ou s for p at ien ts to accept . Hen ce, th e
con cept of th e m in im ally invasive procedure w as devel-
oped. an d th e en doscopic foreh ead an d brow lift (EFBL) w as
popu larized.
Th is w as rst described by Vascon ez et al1 in 1994 in th e
Un ited St ates, w h ere th ey detailed th e use of en doscopes to
gu ide th e release of th e su p raorbital an d glabellar t issu es.
Th e dissect ion w as in th e subgaleal plan e, but th e xat ion
w as n ot w ell d escribed. Su bsequ en tly, m u lt ip le variat ion s
in dissect ion an d xat ion tech n iqu es h ave been rep or ted.
In gen eral, EFBL h as been sh ow n to p rodu ce excellen t
resu lt s; h ow ever, it h as n ot been proven to be superior to
th e open tech n iques. A st udy in 2002 by Puig an d LaFerri-
324
scalp , foreh ead, an d brow com p lex; an d xat ion of
th e com plex at th e desired h eigh t .
• W h en a com bin ed approach to dealing w ith th e
brow s an d eyelids is plan n ed, EFBL is don e rst to
set th e h eigh t of th e eyebrow s an d determ in e th e
am ou n t of skin to be excised .
• Th e advan t ages of EFBL over th e coron al approach
are cam ou aged in cision s, sh orter recover y t im e,
an d less risk of alop ecia an d scalp n u m bn ess.
• Th e disadvan t ages of EFBL are th at th e h airlin e
can be raised, redun dan t foreh ead skin can n ot
be excised, less con t rol in asym m et rical brow s,
in creased cost du e to m ore soph ist icated
in st ru m en t s being used, an d learn ing cur ve.
• EFBL h as been sh ow n to be e ect ive w ith last ing
outcom es. Di eren t xat ion m eth ods are available.
ere 2 com pared th e results of open approach es versus EFBL.
They foun d n o st at ist ical di eren ce in th e m easu rable
result s bet w een th ese procedures. In a system at ic review
of open versus en doscopic tech n iqu es publish ed in 2011,
th ere is n o clear eviden ce to in dicate th at open m eth ods
are in ferior to th e en doscop ic ap proach es.3 How ever, EFBL
d oes o er som e advan tages over th e open tech n iques. Th e
in cision s are sm aller an d w ell h idden w ithin th e h airline.
It resu lts in less blood loss an d also redu ced scalp hypo-
esth esia. Disadvan tages in clu de th e in creased cost for th e
m ore sop h ist icated in st ru m en t s an d also a learn ing cu r ve
to overcom e. Th e ideal xat ion m eth od is st ill con t roversial
but m any di eren t tech n iques seem to w ork w ell.
■ Relevant Anatomy
Facial propor t ion s are divided in to h orizon t al th irds an d
ver t ical fth s. Th e u pp er face occu p ies th e u p p er th ird an d
start s from th e t rich ion to th e glabella. Th e tem p oral region
is also im por tan t w h en dealing w ith th e lateral brow posi-
t ion . Hen ce, kn ow ing th e an atom y of th e foreh ead an d tem -
poral region is of param oun t im port an ce to en sure a safe
an d com p licat ion -free foreh ead an d brow lift .
 25 Endoscopic Forehead and Brow Lift 325

Th e foreh ead is m ade u p of ve layers. From super cial Plane of dissection

to deep , th ey are skin ; su bcu t an eou s fat; galea apon eu ro-
t ica, w h ich split s to envelop th e fron talis m uscle; loose are- Deep tem poralis fascia
olar t issue; an d periosteum . At th e brow area is th e subbrow
fat pad or th e ret ro-orbicu laris fat p ad, fou n d ju st below th e Tem poroparietal
orbicularis ocu li m uscle but above th e periosteu m . As for fascia
th e tem poral region , th e layers are skin , subcut an eous fat ,
tem poropariet al fascia, deep tem poralis fascia, an d n ally
th e tem poralis m uscle. Th e deep tem poralis fascia split s Superficial fat pad
in to su p er cial an d deep layers to envelop th e super cial
tem poral fat pad ~ 2 cm above th e zygom at ic arch . Th e
su p er cial layer at t ach es to th e su p er cial su perior m argin Superficial
temporal vessels
of the zygom at ic arch , an d th e deep layer at t ach es to th e
deep su perior m argin . Deep to th e deep layer lies th e deep Frontal branch
tem poral fat pad, w h ich represen t s a su perior exten sion of of facial nerve
Zygom atic
th e buccal fat pad. arch
Th e fron t al bran ch of th e facial n er ve courses w ith in
SMAS
th e tem poroparietal fascia (Fig. 25.1) along th e Pit anguy
lin e.4 Th is is a lin e th at ru n s from 0.5 cm below th e t ragu s Deep fat pad
to 1.5 cm above th e lateral eyebrow (Fig. 25.2).
A loose areolar p lan e sep arates th e tem poroparietal
fascia from th e deep tem p oralis fascia. Th is is a relat ively Fig. 25.1 The frontal branch of the facial nerve courses within the
avascular plan e, an d it is deep to th e fron tal bran ch of th e temporoparietal fascia. SMAS, super cial musculoaponeurotic system.
facial n er ve, an d h en ce is an ideal plan e of dissect ion du r-
ing EFBL (Fig. 25.3). How ever, th e m edial zygom at ico-tem -
poral vein or th e sen t in el vein can be foun d t raversing th is
plan e (Fig. 25.4). Th e vein can be fou n d ~ 1 cm lateral to
th e fron tozygom at ic sut ure lin e, and th e fron tal bran ch is
usu ally fou n d ju st ceph alad to it . Trin ei et al5 m ap p ed ou t
a zon e of cau t ion based on th e locat ion of th is vein an d it s
p roxim it y to th e fron t al bran ch , an d foun d that th e n er ve
w as alw ays w ith in a 10-m m radiu s of th is vessel. A m ore
recen t st u dy by Sabin i et al foun d th is radiu s to be m uch
closer, w ith in 0 to 2 m m .6 Ext rem e care sh ould be taken in
th is area sin ce a disru pt ion of th e vein can lead to bleeding,
im paired visu alizat ion , elect rocauter y, an d th en injur y to
th e facial n er ve.
Th e supraorbital n otch or foram en t ran sm it s th e su pra- 1.5 cm
orbit al n er ve, a bran ch of th e oph th alm ic n er ve. Th is can be
located ~ 27 m m lateral to th e glabellar m id lin e, or t ypically
w ith in 1 m m of a lin e draw n in a sagit tal plan e t angen t ial
to th e m edial lim bu s (Fig. 25.5). As it em erges from th e
foram en or n otch , it divides in to a deep an d a su per cial
bran ch . Th e deep bran ch run s superolaterally, parallel an d 0.5 cm
~ 0.5 to 1.5 cm m ed ial to th e su p erior tem p oral lin e in th e
loose areolar t issu e bet w een th e galea an d periosteum . Th e
su p er cial bran ch u su ally divides in to m u lt iple bran ch es,
piercing th e fron t alis m uscle an d run n ing super cial to it .
Th e deep lateral bran ch supplies sen sat ion to th e lateral
posterior foreh ead an d scalp w h ile th e super cial m edial
bran ch supplies sen sat ion to th e foreh ead along th e m id-
lin e an d fron t al scalp .
Th e suprat roch lear n er ve, also a bran ch of th e oph -
th alm ic n er ve, can be foun d ~ 17 m m lateral to th e gla- Fig. 25.2 The frontal branch of the facial nerve follows the Pitan-
bellar m idlin e or at an average of 9 m m m edial to th e exit guy line.
326 V Facial Skin and Hair Rejuvenation

Fig. 25.3 Cadaveric dissection demonstrating temporal anatomy. Fig. 25.4 Intraoperative endoscopic view of the sentinel vein
A: Temporoparietal fascia on the ap side. B: Deep temporalis fascia (asterisk) seen traversing bet ween the temporoparietal fascia
demonstrating the glistening white fascia. C: A small window cre- (above) and deep temporalis fascia (below).
ated in the deep temporalis fascia to demonstrate the temporalis
muscle. Bet ween A and B: loose areolar tissue and plane of surgical
dissection.

of th e supraorbit al n er ve th rough a n otch (Fig. 25.5). Th e

n er ve pen et rates th e corrugator an d fron t alis m u scles as it
courses superiorly along a lin e t angen t ial to th e m edial en d
of th e brow. It supplies sen sat ion to a cen t ral ver t ical st rip
of foreh ead an d th e m edial u pper eyelid. Th e in frat roch lear
n er ve exit s ju st below th e su p rat roch lear n er ve arou n d th e
m edial orbit al rim , an d it p rovides sen sat ion to th e u p p er
n ose an d m edial orbit .
It is im p or t an t to kn ow th at th ere is brou s ligam en -
tous th icken ing aroun d th e orbit al rim an d tem poral area
th at xates th e brow an d foreh ead com plex. Th ese rm
at t ach m en t s n eed to be released for th e brow an d foreh ead
to be adequately an d e ect ively lifted. Th e arcus m argin alis
is an area of localized th icken ing of th e ap on eurosis at th e Fig. 25.5 Supraorbital and supratrochlear neurovascular bundles.
su p erior orbit al rim w h ere th e orbit al sept u m at t ach es to On the right side of the skull, the supraorbital neurovascular bundle
is seen exiting ~ 27 mm from the midline. The deep branch runs
th e orbit al bon e. An oth er area of th is th icken ing is th e con -
superolaterally while the super cial branch situates medially. On
join t ten don or th e zon e of xat ion at th e tem poral fu sion the left side of skull, the supratrochlear neurovascular bundle is
lin e (Fig. 25.6). Th is is an area of fu sion bet w een th e galea, seen exiting ~ 17 m m from the midline.
tem poropariet al fascia, an d deep tem poralis fascia an d th e
p eriosteu m of th e fron t al bon e. It also m arks th e t ran sit ion
bet w een foreh ead an d tem ple. Fin ally, th ere is th e orbital
ret ain ing ligam en t cen tered over th e fron tozygom at ic
su t u re th at h old s th e lateral p ar t of th e brow dow n .
Th e m usculat ure also plays an im port an t role in th e th e fron t al an d zygom at ic bran ch es of th e facial n er ve. Th e
p osit ion an d sh ape of th e brow. Th is is divided in to th e depressors of th e brow n eed to be adequately dealt w ith
brow elevators an d depressors. Th e elevators are th e fron - to ach ieve an e ect ive lift . Th ey are u su ally in a balan ced
t alis m uscle an d are supplied by th e fron t al bran ch of th e state m ain t ain ing th e posit ion of th e brow. Any over- or
facial n er ve. Th e depressors are th e p roceru s, corrugator u n der-act ivit y of eith er w ill cause th e brow s to be raised
su p ercilii, an d th e orbicu laris ocu li m u scles, su pp lied by or low ered.
 25 Endoscopic Forehead and Brow Lift 327

For m ales, the brow s should be positioned at or near

the supraorbital rim w ith m inim al arching and be m ore
horizontal. Creating the arch in a m an w ill be unattractive.
For fem ales, the brow s should be positioned slightly supe-
rior to the supraorbital rim w ith a subtle arch as described
previously.

Aging Process
As w e age, th e brow un dergoes descen t due to gravit at ion al
forces an d loss of skin elast icit y. Th e m edial brow h eigh t
is m ain tain ed by th e balan ce bet w een brow elevator (fron -
talis) an d depressors (corrugator supercilii an d procerus).
How ever, as th e fron t alis stop s at th e tem p oral fu sion lin e,
th e lateral brow receives u n opposed depression from th e
lateral par t of th e orbicularis ocu li du e to lack of fron t alis
act ion . Hen ce, th e lateral brow d escen ds earlier an d m ore
severely th an th e m edial brow.
Fig. 25.6 Conjoint fascia and brow m uscles. A: Conjoint fascia. B:
Orbital retaining ligament. The conjoint fascia requires complete As t h e lateral brow descen ds, it creates h ooding of th e
transection from the vertex to the orbit. This is approached from lateral p ar t of th e eyelid, w h ich m ay cau se obst ru ct ion of
lateral to medial (direction shown in C), and then released anterior th e visu al eld. Ptot ic brow s can por t ray th e ap pearan ce of
to posterior (as in direction D). anger, sad n ess, w orr y, an d w earin ess d esp ite th e absen ce
of em ot ion al in ten t or cau sat ive p hysical con dit ion .
Foreh ead an d glabellar rhyt ids develop as a result of
rep eated m u scu lar con t ract ion during facial expression
an d also th e p rocess of aging, w h ich produ ces skin th in n ing
an d loss in elast icit y.
■ Considerations
Brow Aesthetics
a b
Before assessing th e pat ien t , th e surgeon n eeds to kn ow
w h at th e ideal brow posit ion an d sh ape are, an d also to
u n derst an d th e p roblem th at is being addressed. Th e ideal
brow posit ion an d sh ape var y w ith sex, age, race, cult ure,
an d fash ion t ren d s. Hen ce, it is im port an t to u n derst an d
th e pat ien t’s n eeds an d con cern s before em barking on sur-
ger y. Th ere is n o on e st an dard su rger y for all p at ien ts.
Th e brow can be an alyzed in term s of its sh ape, posi-
t ion , m obilit y, an d sym m et r y w ith th e con t ralateral side.
Th e m edial brow sh ou ld begin at a ver t ical lin e draw n from
th e alar facial crease to th e m edial can th us, an d at ~ 1 cm
above th e m edial can th u s (Fig. 25.7). It sh ou ld p rogress
laterally in a clu b -like con gurat ion , gradu ally t apering
tow ard it s lateral en d. It sh ou ld ascen d su periorly to th e
ap ex an d th en t u rn in feriorly. Th e lateral brow sh ou ld en d
at an obliqu e lin e from th e alar facial crease to th e base of
th e lateral can th us. Th e h igh est poin t , or apex, of th e brow
sh ou ld be at th e lateral lim bu s. How ever, som e believe th at
th is h igh poin t sh ould be m ore lateral th an th e lateral lim - Fig. 25.7 Ideal brow position. The medial brow should begin at a
vertical line drawn from the alar facial crease to the medial canthus.
bus an d closer to th e lateral can th us. Fin ally, th e m edial an d
The lateral brow should end at an oblique line from the alar facial
lateral en ds sh ou ld lie at abou t th e sam e h orizon t al plan e.
crease to the base of the lateral canthus. The highest point of the
Th e sh ape of th e brow can be described as at , arch ing, brow should be at the lateral limbus (a) or some believe that it should
dow nw ard slan t ing, or upw ard slan t ing. Most im port an t , be more lateral, closer to the lateral canthus (b). Finally, the medial
th e brow s on th e t w o sides sh ould be in sym m et r y. and lateral ends should lie at about the same horizontal plane.
328 V Facial Skin and Hair Rejuvenation
Relationship w ith the Eyelid
An alysis of th e brow w ou ld n ot be com p lete w ith ou t th e
an alysis of th e eyelid, as th ey both con t ribu te to th e u pp er
face aesth et ics an d u n dergo a sim ilar aging p rocess. Ver y
often, brow ptosis an d derm atoch alasis con t ribute to lat-
eral h ood ing. Hen ce, p erform ing a brow lift or bleph aro-
plast y alon e m ay n ot adequately deal w ith th e problem .
Com bin ing a brow lift w ith a bleph aroplast y allow s a m ore
con ser vat ive resect ion of th e upper eyelid skin an d is a
com m on procedure.
W h en assessing a pat ien t for a bleph aroplast y, it is
im p erat ive to assess th e brow posit ion as w ell. If th e brow s
are ptot ic to begin w ith , p erform ing a blep h arop last y m ay
exacerbate th is an d create an u n n at u ral ap p earan ce. In
th is scen ario, it is best to rst raise an d stabilize th e brow s
before an upper bleph aroplast y.
An oth er sit uat ion is w h en a pat ien t presen t s w ith an
asym m et ric brow posit ion secon dar y to over-act ivit y of
th e fron talis on on e side. Th is can occur from un ilateral
u pper eyelid ptosis w h ere th e p at ien t h abit u ally raises on e
brow in an at tem pt to im prove th e visual eld. Hen ce, th e
brow s n eed to be assessed w ith th e fron t alis at rest to avoid
in ter ven t ion in w h at is a physiologic con dit ion rath er th an
an an atom ic on e. Th e correct m an agem en t in th is sit u at ion
w ou ld be to correct th e ptosis rath er th an th e brow p osi-
t ion . With over-act ivit y of th e fron talis due to brow ptosis,
eyelid ptosis, or derm atoch alasis, dyn am ic foreh ead rhyt ids
w ill gradu ally becom e stat ic, requiring a foreh ead lift .
Indications
Th e th ree m ain in dicat ion s to lift th e foreh ead an d brow are
foreh ead an d glabellar rhyt idosis, brow ptosis, an d brow
asym m et r y.
Foreh ead an d glabellar rhyt idosis can be occasion ally
t reated w ith bot u lin u m toxin inject ion in to th e depres-
sor m u scles, a ch em ical brow lift . Bot u lin u m toxin m ay
h ave a st ronger in dicat ion in a prophylact ic role. Deeper
rhyt ids can be addressed w ith soft t issue llers, occasion -
ally in com bin at ion w ith bot u lin u m toxin . How ever, th ese
m eth ods are tem p orar y an d requ ire repeated t reat m en t s to
m ain t ain th e desired ou tcom e.
In a su rgical foreh ead lift , th e w rin kles are m ech an i-
cally pulled u pw ard an d at ten ed. Th e m u scular elevator
an d depressors can be resected, sep arated, or w eaken ed
su rgically to ach ieve sim ilar e ect s. Th ese resu lt s are
deem ed m ore perm an en t th an the use of bot ulin um toxin
an d injectable llers. How ever, th e longevit y is qu est ion -
able as th e m u scle bers ten d to regen erate an d re-estab -
lish th e con n ect ion , resu lt ing in som e ret urn of m u scle
fu n ct ion an d h en ce th e rhyt ids. Som e argu e th at th e ret u rn
of fun ct ion is m in im al an d th e n eed for bot ulin um toxin is
overst ated .
Special Considerations in
East Asian Patients
In gen eral, th e d ist an ce bet w een th e brow an d lash es of
th e upper eyelid is greater in Asian s th an in Caucasian s. In
addit ion , Asian s ten d to h ave a sh allow er su perior orbit al
su lcu s com p ared w ith Cau casian s.
Horizon t al foreh ead rhyt ids are also less com m on in
Asian s becau se of in creased derm al th ickn ess as w ell as th e
presen ce of m ore abun dan t adipose t issue in th e supraga-
leal p lan e. Th is h olds t ru e for glabellar rhyt idosis as w ell.
Eyebrow t at tooing or m icrop igm en tat ion is ver y pop -
u lar in Asia an d m ust be recogn ized at th e preoperat ive
evaluat ion ; it is im p or t an t to locate th e posit ion of th e
act u al brow, w h ich m ay h ave been plu cked or rem oved .
Su bsequ en t t at tooing can be u t ilized for scar cam ou aging
if n ecessar y.
■ Patient Evaluation
History and Examination
It is u n com m on for p at ien ts to p resen t w ith com p lain t s of
droopy brow s an d speci cally request a brow elevat ion .
More frequ en tly, th eir gen eral com plain t is looking t ired,
fat igu ed, solem n , or older, w h ile th eir en ergy an d m ood do
n ot correlate. It is n ot un com m on for th em to ask to “h ave
th eir eyes don e” as th ey pin ch th e h ooded skin of th e upper
lids. In m ore severe cases, th ey m ay com plain of su perior
visu al eld obst ru ct ion du e to th e h ood ing or fron t al ten -
sion h eadach e secon dar y to fron t alis over-act ivit y in an
at tem pt to raise th e upper lid to see bet ter. Deep st at ic fore-
h ead rhyt ids frequen tly co-exist after m any years of fron -
talis hyperact ivit y. If th e m edial brow drops, th e pat ien t
m ay com p lain th at it creates th e im p ression of stern n ess
or anger.
It is im p ort an t to iden t ify th e speci c et iology of th e
u nw an ted appearan ce an d dem on st rate th is to th e pat ien t .
Th is leads to th e m ost direct surgical t reat m en t . On e
m u st dist ingu ish bet w een derm atoch alasis, brow ptosis,
deh iscen ce of th e levator apon eurosis, hyperfu n ct ion ing
fron t alis, facial n er ve inju r y, an d oth er esoteric variables.
Frequen tly a com bin at ion of m an euvers provides th e best
opt ion , w ith EFBL being a cen t ral st aple in upper facial
rejuven at ion .
As w ith all cosm et ic pat ien t s, it is im por tan t to iden t ify
th ose w ith h idden agen das or psych iat ric issues during th e
con su ltat ion process. If th eir expectat ion s are un reason -
able or if th ey h ave u n realist ic dem an ds, it m ay be bet ter
n ot to operate on th em .
After un derstan ding a pat ien t’s n eeds an d con cern s,
th e n ext par t of th e con sult at ion is to est ablish th e path ol-
ogy an d severit y. Th e w h ole face h as to be exam in ed for

propor t ion an d h arm ony, in cluding th e aging process of th e
low er face. After rejuven at ion of th e upper face, th e low er
jow ls an d m arion et te lin es w ill appear m ore dram at ic in
con t rast . Th e face can be in dish arm ony.
It is crit ical to give pat ien t s a m irror du ring th e con -
su ltat ion for th em to poin t ou t th eir exact con cern s. You
can th en use th e m irror to con rm w h at th ey desire an d
also to dem on st rate w h at you can ach ieve for th em . It is
im port an t for th e su rgeon an d pat ien t to h ave sim ilar goals
an d exp ectat ion s.
Th e exam in at ion sh ould st ar t from top to bot tom .
1. Hairlin e: Th e h airlin e is im p or t an t as it d eter m in es
t h e st ar t in g p oin t of t h e u p p er face an d can be
altered d u r in g a brow lift . If t h e h airlin e is h igh ,
it m akes t h e foreh ead ap p ear lon ger, an d fu r t h er
elevat ion m ay be u n d esirable. Conversely, a low
h airlin e le n d s it self w ell to a brow lift p roce d u re. A
reced in g h airlin e is a m ajor factor in d eter m in in g
t h e p rop er su rgical opt ion sin ce scar exp osu re in
t h e fu t u re is clearly a p roble m . Even w om en , as
t h ey age, can sh ow sign s of t h in n in g h air in t h e
fron t al area.
2. Height and shape of forehead: Th e h eigh t an d sh ape
of th e foreh ead determ in es if th e EFBL m eth od can
be used. If th e foreh ead is too long an d convex, th e
en doscop ic in st ru m en t s m ay n ot be able to reach th e
su p raorbit al rim an d arcu s m argin alis adequ ately,
m aking th e p rocedu re tech n ically ver y d i cu lt . A
at ter foreh ead w ith a relat ively low h airlin e is ideal
for EFBL.
3. Forehead and glabellar rhyt ids: Foreh ead an d
glabellar rhyt ids are assessed to determ in e if th ey
are dyn am ic or st at ic. Mu scu lar hyp eract ivit y is n ot
un com m on , an d e ort s to relax th e m uscles are
requ ired to bring th e brow s back to th eir n at u ral
posit ion . Th is is an im port an t step before assessing
th e act ual posit ion of th e brow s an d th e am oun t of
redu n dan t u pper lid skin .
4. Posit ion, shape, and sym m et ry of eyebrow s: Th e
d esired h eigh t an d sh ap e of t h e brow is d eter m in ed
w it h t h e p at ie n t in fron t of a m ir ror. It can be
d iscu ssed in on ly gen eral ter m s, or a p recise
calcu lat ion can be m easu red . Th e foreh ead is rst
rela xed an d brow s are elevated to t h e d esired
p osit ion an d sh ap e. A skin m arker is t h en p laced
at t h e ap ex of t h e brow at t h e d esire d h e igh t .
Next , t h e brow is released an d t h e skin m arker is
allow ed to slid e u p on to t h e skin of t h e foreh ead .
Th e d ist an ce m arked is t h e am ou n t of brow
elevat ion requ ired . Th e sam e is t h e n d on e on t h e
con t ralate ral sid e. Any baselin e asym m et r y sh ou ld
also be p oin te d ou t .
5. Am ount of redundant upper eyelid sk in: With th e
brow s h eld at th e desired h eigh t by an assist an t , th e
25 Endoscopic Forehead and Brow Lift 329
am ou n t of redu n dan t u p p er lid skin is determ in ed by
pin ch ing an d th en m arking w ith a skin m arker. Th e
am ou n t of skin to be resected sh ou ld be ju st en ough
to evert th e lid lash es to 90 degrees bu t n ot cau se
lagoph th alm os.
6. Presence of eyelid ptosis: It is ext rem ely im port an t
to assess for eyelid ptosis, as it can be th e m ajor
con t ribu tor to th e t ired appearan ce an d visual eld
de cit . Th e m argin al re ex dist an ce can be used. Th e
ptosis m ay secon darily give rise to an asym m et ric,
relat ive, u n ilateral brow ptosis as th e ip silateral
fron t alis at tem pts to com pen sate an d elevates th e
brow. Moreover, a st an dard brow lift w ill n ot correct
th e com pen sator y brow asym m et r y.
7. Absence of Bell’s phenom enon and lagophthalm os:
Any baselin e lagoph th alm os sh ou ld be d etected
as it w ill likely be exacerbated follow ing EFBL an d
u pp er bleph aroplast y. Bell’s ph en om en on is a
n orm al p rotect ive m ech an ism for th e corn ea an d
sh ou ld be p resen t , especially if a sm all am ou n t of
lagoph th alm os occurs postoperat ively.
8. Low er t w o-thirds of the face: Again , th e rest of th e
face sh ou ld be assessed to en su re facial h arm ony. If
sign i can t aging co-exist s in th is region of th e face,
th e discrepan cy can be m ore dram at ic follow ing
su rger y.
Methods and Patient Selection
Th ere are m any m eth ods to elevate th e foreh ead an d brow ;
th ese can be divided in to open an d en doscopic approach es.
Th e various in cision s available for di eren t t ypes of brow
lift are sh ow n in Fig. 25.8. Th e open app roach es in clu de
1. Coron al approach
2. Modi ed coron al ap p roach
a. Trich op hyt ic
b. Pret rich ophyt ic
3. Direct brow lift
4. In direct brow lift or m idforeh ead brow lift
5. Tran s-bleph aroplast y brow lift
Th e m ain disadvan tage of th e open tech n ique is th e prob -
lem w ith th e surgical scar an d n um bn ess from t ran sect ion
of th e supraorbit al an d suprat roch lear n er ves. Th e scar
can be too visible or result in alopecia along th e in cision .
Going across th e sku ll or h airlin e causes scalp hypoesth e-
sia, w h ich can be discon cert ing to som e p at ien ts. Alth ough
th e t ran s-bleph aroplast y approach avoids th e m ajor issue
of th e surgical scar, it does n ot allow a great deal of lift an d
sh ou ld be regarded m ore as a brow st abilizer th an as an
elevator. Th e en doscopic ap proach rem edied th ese issu es
an d h as becom e th e tech n iqu e of ch oice for m ost su rgeon s.
330 V Facial Skin and Hair Rejuvenation

The incisions of the endoscopic approach are sm aller and

run parallel to th e n er ves, th us sparing th em . Th is approach
a raises th e hairline superiorly and should not be perform ed
b for som eone w ith a high hairline to begin w ith. Another fac-
tor to con sider is th e convexit y of th e foreh ead. If th e fore-
c h ead is h igh and ver y convex, th e EFBL instrum en ts w ill n ot
reach the inferior m argin of dissect ion; the forehead con -
d vexit y in h ibits th e rigid in strum en ts. Fin ally, th is approach
is not feasible for patients w ith a receding h airline or bald-
n ess, as the frontal in cisions w ill not be w ell cam ou aged.
e
f
■ Surgical Techniques
Instruments
The instrum ents fundam ental to EFBL are show n in Fig. 25.9.

Fig. 25.8 Incisions available for di erent t ypes of brow lift. a, cor-
onal; b, trichophytic; c, pre-trichophytic; d, indirect brow or mid-
forehead; e, direct brow; f, trans-blepharoplast y.
Th e en doscopic approach does h ave som e disadvan -
tages an d lim itat ion s, an d h en ce pat ien t select ion is im por-
tan t . It s advan t ages in clude
• Redu ct ion in length of in cision s
• Well-cam ou aged in cision s
• Less edem a an d sw elling
• Less blood loss an d su rgical t rau m a
• Faster recover y
• Less scalp paresth esia
Disadvan t ages in clu de
• Learn ing cu r ve
• Raised h airlin e
• In creased cost d u e to in st ru m en t s an d m on itor
• Poten t ial com p licat ion s from im p lan ts
Preoperative Preparation
Preoperat ive ph otograph s sh ould be taken w ith th e pat ien t
in th e up righ t posit ion an d w ith ou t any m akeup. Skin
m arkings sh ou ld also be don e in th e u prigh t posit ion an d
th e am oun t of brow elevat ion recorded. Th e course of th e
fron t al bran ch of th e facial n er ve, th e su praorbit al n otch /
foram en , an d su prat roch lear n otch can be m arked out on
th e skin .
Incisions
EFBL can be don e u n der eith er gen eral an esth esia or con -
sciou s sedat ion . On e percen t xylocain e w ith 1:100,000
ep in ep h rin e is u sed to in lt rate th e p lan n ed in cision s.
Tu m escen ce solut ion can be used to inject in th e sub -
periosteal plan e at th e foreh ead an d scalp to facilit ate th e
dissect ion .
Scalp in cision s can var y. Gen erally, ve or six in cision s
are u sed (Fig. 25.10). On e (or t w o) m idlin e an d t w o m ore

Fig. 25.9 Endoscopic forehead and brow lift instruments.


Fig. 25.10 Incisions used in the endoscopic forehead and brow
lift approach. The rst incision is placed in the midline; the second
incision is more lateral, usually centered at the apex of the brow
or the lateral canthus; the third incision is the most lateral and is
placed perpendicular to a line traversing the alar-facial groove and
the lateral canthus over the temporalis fascia. These incisions are
placed ~ 1.5 to 2.0 cm posterior to the hairline.
lateral ver t ical in cision s are p laced ~ 2 cm beh in d th e h air-
lin e. Each in cision sh ou ld be ~ 2 cm . Th e lateral in cision s
sh ou ld be placed at th e apex of th e brow s or w h ere th e
m axim al elevat ion sh ou ld be. Th is is u su ally cen tered on
th e lateral can th us. Ver t ical in cision s are used as th ey are
p arallel to th e cou rse of th e sup raorbit al an d su prat roch -
lear n er ves an d th u s reduce th e risk of scalp p aresth esia.
Th e direct ion of closure also m in im izes skin ten sion an d
h en ce redu ces th e risk of alop ecia. Tw o coron al tem po-
ral in cision s are m ade 2 cm beh in d th e h airlin e, over th e
tem poralis fascia. Th ese in cision s are m ade parallel to th e
tem poral h airlin e w ith th e cen ter of th e in cision s perpen -
dicular to a lin e draw n from th e alar facial crease to th e
lateral can th u s. It can be conver ted to an ellipt ical excision ,
allow ing som e skin excision to aid in th e lateral brow lift .
Th ese in cision s are in ten t ion ally beveled in th e direct ion of
th e h air so as to m axim ize th e preser vat ion of h air follicles
an d redu ce th e risk of alop ecia.
Dissection
On ce th e m idlin e an d lateral in cision s are m ade, sh arp d is-
sect ion is t aken d ow n d irectly to th e sku ll bon e to en ter
th e su bperiosteal plan e. Blin d dissect ion is rst m ade pos-
teriorly to th e ver tex an d th en an teriorly to 2 cm above
th e supraorbit al rim to protect th e n eurovascu lar bun dles.
Cen t rally th e dissect ion can be m ade to th e n asofron t al
su t u re at th e n asal radix, as th is area lies in bet w een th e
25 Endoscopic Forehead and Brow Lift 331
su p rat roch lear n er ves. Lateral dissect ion is m ade u p to th e
conjoin t ten don or th e lin ea tem poralis.
Th rough th e tem poral in cision s, dissect ion is m ade
th rough th e tem poropariet al fascia dow n to th e deep tem -
poralis fascia. Th e deep tem poralis fascia can be iden t i ed
by its glisten ing w h ite fascia th at is st rong an d st riated.
A sm all cu t th rough th is fascia to reveal th e u n derlying
tem poralis m uscle can be u sed to con rm th e righ t layer
(Fig. 25.3). Blin d dissect ion along th is plan e can be don e
su p erior to th e cou rse of th e fron t al bran ch of th e facial
ner ve an d to th e conjoin t ten don .
Th e conjoin t ten don can be dissected th rough to con -
nect th e cen ter an d tem p oral pockets from lateral to m edial
using a periosteal elevator in a sw eeping m an n er (Fig. 25.6).
As th is is den se an d adh eren t fascia, a reason able am oun t
of force is required. Going from lateral to m edial en sures
th at th e correct plan e is ach ieved an d can be don e un der
direct visualizat ion from th e cen t ral pocket .
Release of Muscular and
Ligamentous Attachment
Th e rest of th e dissect ion sh ould be don e w ith th e aid of
a 30-degree en doscope to visu alize th e n eu rovascu lar
bun dles. Th e en doscope w ith a ret ract ion arm is in serted
th rough th e m idlin e in cision an d a cur ve periosteal eleva-
tor th rough th e lateral in cision on th e side of dissect ion .
Th e subperiosteal dissect ion is recom m en ded, as th e w h ite
of th e skull bon e o ers excellen t opt ics w ith th e en doscope.
With th e h elp of th e ret ract ion arm , an opt ical cavit y is
m ain t ain ed for visu alizat ion .
The objective of the rem aining dissection is to free up
periosteal and m uscular at tachm ents to allow cephalic rota-
tion of the forehead and brow. The rst st ruct ure is the con -
join t ten don, w hich h as already been freed as m entioned
previously. Th e second st ruct ure is the arcus m arginalis, in
w hich the dissect ion is done under endoscopic guidance. If
the supraorbital neurovascular bundle exits from a notch,
it can be freed by push ing it inferiorly into the orbital cav-
it y. The arcus m arginalis can then be released ent irely. If the
supraorbital bu n dle exits from a foram en , it w ill be en cou n -
tered earlier in th e dissection an d care h as to be taken n ot
to tran sect or overly stretch th e n er ve. In th is circu m stan ce,
dissect ion is perform ed circum ferent ially around the fora-
m en . On ce th e arcu s m argin alis is com pletely dissected, th e
inst rum ent can enter the upper eyelid.
Th e t h ird st r u ct u re is t h e orbit al ret ain in g ligam en t
fou n d at t h e fron tozygom at ic su t u re. It lim it s late ral brow
m ovem en t by in d ire ct ly at t ach in g t h e late ral brow skin
to t h e late ral orbit al r im . Th is is u su ally ap p roach ed from
t h e tem p oral in cision w it h t h e en d oscop e t h rough t h e lat -
eral in cision . Ext rem e cau t ion m u st be exercised d u r in g
d isse ct ion at t h e area lateral to t h e late ral orbit al r im an d
fron tozygom at ic su t u re region , as t h e sen t in el vein an d
t h e fron t al bran ch of t h e facial n er ve can be vu ln erable.
Th e sen t in el vein can be id en t i ed by ten t in g t h e tem -
332 V Facial Skin and Hair Rejuvenation

p orop ar iet al fascia u p (Fig. 25.4) u p , an d it can be seen

t raversin g t h is sp ace ~ 1 cm lateral to t h e fron tozygom at ic
su t u re. In adver ten t inju r y to t h is vein m ay cau se u n n ec-
essar y blee d in g t h at obscu res you r su rgical eld . It can
also be d i cu lt to con t rol t h e h em ost asis e n d oscop ically
an d m ay p u t t h e fron t al bran ch of t h e facial n e r ve at r isk
if excessive cau te r y is u sed . It is u n n ecessar y to rou t in ely
cau ter ize t h e ve in if it is n ot breach e d , as som e st u d ies
h ave sh ow n t h at t h is resu lt s in t h e d evelop m e n t of su p er-
cial ret icu lar vein s at t h e te m p le area .7 Th e d en se fascia
at t h e lateral orbit al r im can t h en be d issected free, t ak-
in g care n ot to d isr u pt t h e lateral can t h al ten d on . It is n ot
n ecessar y to d issect t h e zygom at ic arch u n less t h ere is a
p lan for a m id face lift .
Next , th e periosteu m is released across th e su perior
Fig. 25.11 Illustration of the forehead and glabellar anatomy
orbit al rim s an d across th e n asal radix. Th is w ill provide under endoscopic view.
addit ion al m obilit y an d release of th e foreh ead an d brow
com plex to facilit ate elevat ion . As th e periosteu m is in cised,
th e galeal fat pad m ay be exposed (Fig. 25.11). Ad dit ion al
h orizon tal p eriosteal in cision s m ad e m ore su periorly
u n der th e fron talis m uscle can be don e if th e pat ien t h as
Fixation Method
deep h orizon t al foreh ead rhyt ids. Th is m an euver can jeop -
On ce th e foreh ead an d brow com p lex is m axim ally released
ardize th e n er ves an d dim in ish brow elevat ion .
an d m obilized, it h as to be su rgically st abilized in th e
Th e fou r t h st r u ct u re to be released is t h e brow d e p res-
desired posit ion w h ile w ait ing for th e n at ural h ealing an d
sor. Releasin g t h e brow d ep ressors can also d eal w it h t h e
xat ion p rocess to t ake p lace. Perm an en t xat ion of th e
h or izon t al an d obliqu e glabellar rhyt id s cau sed by t h e
brow is ach ieved by re-adh eren ce of th e periosteum to th e
p rocer u s an d cor r ugator su p ercilii m u scles, resp ect ively.
sku ll bon e at th e desired p osit ion . Rom o et al8 an d Scla-
Myectom y, com p lete m ytotom y, or p ar t ial d isr u pt ion of
fan i et al9 foun d th at th is adh eren ce took 6 to 12 w eeks to
m u scle bers can be d on e, an d t h e p refer red m et h od
occur. More recen tly, th ere are st udies report ing th at th e
rem ain s con t rove rsial. On ce t h e cor r ugator m u scle is
re-adh eren ce is com plete w ith in 2 w eeks.10,11 Hen ce, a xa-
en cou n te red an d isolate d , it can be excised an d rem oved
t ion m eth od th at can last long en ough for the n at ural re-
to t h e exten t p ossible. How ever, excessive rem oval m ay
adh eren ce to t ake p lace is n ecessar y to h old th e brow s in
resu lt in a visible d ep ression in t h e glabellar area, sp lay-
th e desired posit ion .
in g of t h e m ed ial brow s, an d an u n n at u ral an im at ion . In
t h is sit u at ion , a glabellar im p lan t or au tologou s fat m ay
be requ ired to ll in t h e d efe ct . Alter n at ively, t h e m u scle Temporal Fixation
can be p ar t ially d isr u pted by in cisin g it or by blu n t d is-
sect ion w it h e n d oscop ic force p s. Care is n e ed e d to p ro - In the tem poral area, the lateral part of the brow is raised and
tect t h e su p raorbit al an d su p rat roch lear n e u rovascu lar xated by securing the undersurface of the ap to the tem po-
bu n d les w h ile d oin g so. Th e su p raorbit al vessels an d roparietal fascia, and then to the deep tem poralis fascia, w ith
n er ves can be see n beh in d t h e t ran sverse h ead of t h e cor- a 2–0 polypropylene or polydioxanone suture (Fig. 25.12).
r ugator at t h e su p er ior orbit al r im level. Med ially w h ere Altern at ively, th e sut ure can be placed th rough th e
t h e obliqu e h ead of t h e cor r ugator is, t h e su p rat roch lear tem poral in cision an d brough t out th rough th e skin n ear
vessels an d n e r ves t rave rse t h rough t h e su bst an ce of t h e th e brow but just an terior to th e h airlin e. Th is is to redu ce
m u scle an d sh ou ld be ad equ ately p reser ved . Th e p roce r u s th e possible ten sion from th e in cision lin e to decrease th e
can be d ealt w it h in a sim ilar m an n er. W h ich ever m et h od risk of alop ecia. A st ab in cision is th en m ade w ith a n o. 15
is u se d , t h ere m ay be a ten d en cy for t h e cu t en d s of t h e blade th rough th e epiderm is at th e exit poin t of th e sut u re.
m u scle to ad h ere to on e an ot h er, resu lt in g in u n n at u ral Th e sut ure is th en passed back th rough th e st ab in cision
glabellar m ovem en t s. an d an ch ored to th e deep tem p oralis fascia to ach ieve th e
An altern at ive t reat m en t for th e brow depressors is th e desired tem poral lift .12
u se of a n eu rotoxin given p reop erat ively. Paralysis of t h e
d ep ressors can ach ieve t w o object ives. It resu lt s in fu r t h er
m obilizat ion of th e brow s an d h en ce allow s m ore com - Forehead and Brow Fixation
p lete elevat ion . Secon d , th e lack of m ovem en t from th e
d ep ressors p ostop erat ively facilit ates th e xat ion of th e As for th e cen t ral foreh ead area, th e dissect ion is su bperios-
foreh ead an d brow com p lex to th e bon e, opt im izin g t h e teal an d h en ce th ere is absen ce of soft t issue for sut ures to
resu lt s of EFBL. an ch or to. Th is leads to a w ide variet y of xat ion m eth ods

a b
Fig. 25.12 Temporal xation for temporal lift during a cadaveric dissection. (a) The rst bite of the suture, securing the temporoparietal
fascia at the distal ap. (b) The second bite of the suture, taking the deep temporalis fascia at the proximal ap. (c) Sutures tied to achieve
temporal lift.
on w h ich n o o cial con sen sus exist s. Fixat ion is th rough
each of th e fron t al scalp in cision s. On e m u st be m in dfu l of
th e sagit t al sin us if a bon e drilling tech n iqu e is used.
No Fixation
Som e h ave advocated th at th e release an d m obilizat ion of
th e foreh ead an d brow com plex is th e m ost crucial part
of EFBL, ren dering th e xat ion un n ecessar y. Troilius 13
rep orted in h is 20 su bp eriosteal en doscopic brow lift
w h ere th e surgeon does n ot use scalp xat ion at all, relying
on ly on ch anging th e balan ce of m uscle vectors aroun d th e
eyebrow s. He con clu ded th at good resu lt s can be ach ieved
w ith out scalp xat ion if n ot m ore th an 4 m m of elevat ion
is requ ired.
Fixation w ith Fibrin Glue
Fixat ion can be ach ieve d w it h t issu e sealan t or br in glu e.
After t h e brow h as been elevated to t h e d esire d p osit ion ,
br in glu e is sp rayed u n d er n eat h t h e raised ap t h rough
t h e t w o lateral in cision s an d t h e ap is h eld d ow n for 5
m in u tes. Th is m et h od o e rs t h e ad d it ion al advan t age of
obliterat in g t h e p oten t ial d ead sp ace bet w ee n t h e sku ll
bon e an d foreh ead ap in ad d it ion to t h e xat ion of t is-
su e. Th is p reve n t s h e m atom a an d se rom a for m at ion ,
an d h e n ce n egates t h e u se of d rain s p ostop erat ively. In a
rep or t of 80 p at ien t s, t issu e glu e w as sh ow n to be e e c-
t ive an d safe in m ain t ain in g brow p osit ion d u r in g EFBL
for u p to 1 year.14
Fixation w ith Monocortical Screw s
A m ore rigid form of xat ion u ses m on ocort ical screw s as
th e poin t of an ch or. Th is requires drilling in to th e outer
table of th e calvarium . In a st udy by Harirch ian et al,15 th e
average skull th ickn ess for m ales w as foun d to be 5.96
m m versu s 6.16 m m in fem ales, w ith th e cran ial th ick-
n ess in creasing m edially an d p osteriorly. Th ey reported n o
relat ion sh ip bet w een age an d sku ll th ickn ess. In gen eral,
25 Endoscopic Forehead and Brow Lift 333
c
4 m m is con sidered a safe depth as deep drilling m ay result
in cerebrospin al uid leak. Th e safest area to drill is along a
parasagit tal lin e at th e m idpu pil or lateral lim bus lin e an d
just an terior to th e coron al sut ure. Hen ce, th is can be safely
don e at th e lateral in cision s. Drilling of th e bon e in th e m id-
lin e of th e calvarium sh ould be avoided as it h as a risk of
inju ring th e sagit t al sin us, w h ich is foun d in th e m idlin e
of th e in n er skull. Nu m erous ven ous lakes can also be fre-
quen tly foun d in th e m idlin e. Fixat ion sh ould also n ever be
don e over th e squam ous port ion of th e tem poral bon e as it
is th e th in n est port ion of th e tem poral bon e.
Th e locat ion at w h ich to place th e screw is determ in ed
by th e am oun t of lift desired. Th is sh ould h ave been m ea-
su red p reop erat ively w h en assessing th e p at ien t . On e
cen t im eter sh ou ld be added to th is m easu rem en t to com -
pen sate for th e distan ce bet w een screw an d brow an d for
som e descen t in th e u p righ t p osit ion . Th is dist an ce is th en
m easu red from th e m arking on th e sku ll bon e m ade at th e
lateral in cision ceph alically to determ in e th e placem en t of
th e screw.
Th e screw s used can be perm an en t or resorbable.
Resorbable screw s are th readless screw s m ade of poly-L-
lact ic acid th at w ill dissolve in 12 to 24 m on th s. Th ey are
gen erally ~ 2 m m in d iam eter, an d th ey h ave a low p ro le
an d h en ce n ot easily p alp able th rough th e scalp. Th ey are
in ser ted w ith an aid of a carrier in to a bur h ole created by
a 4-m m self-lim it ing drill. Th e screw ts in w ith a t igh t
frict ion grip , an d th e p resen ce of a cen t ral t u n n el allow s
an ch oring su t u res to pass th rough . In th is case th e m ea-
su rem en t is m ade from th e cau dal border of th e in cision
ceph alically to determ in e th e placem en t . On ce th e screw s
are in , 2–0 p olypropylen e or p olydioxan on e can be u sed
to secu re th e cau dal border of th e lateral in cision , t aking
th e su bderm al t issues an d galea apon eurot ica to th e screw
(Fig. 25.13).
Th e advan t age of using th e resorbable screw s is th at
th ey o er a st rong an ch oring poin t to suspen d th e brow s.
How ever, th e d isadvan tages are th e in creased cost of th e
im plan t , im plan t palpabilit y, in fect ion , an d risk of cerebro-
spin al u id leak w h en drilling th e calvariu m .
334 V Facial Skin and Hair Rejuvenation
b c
Fig. 25.13 Fixation with monocortical screws and sutures. (a) Monocortical screw. (b) Monocortical hole drilled in the skull bone. The
amount of brow lift is determined by the distance of the hole drilled from the caudal border of the incision. (c) Placem ent of monocortical
screw into the hole. (d) Sutures secured bet ween the screw and the caudal margin of the incision, resulting in desired brow lift.
Altern at ively, longer t it an iu m screw s can be u sed.
How ever, th ey p rot ru de from th e sku ll an d requ ire rem oval
in 2 w eeks. In th is m eth od, th e am ou n t of lift requ ired is
m easu red from th e cep h alic border of th e lateral in cision
ceph alically. As th e scalp is rotated superoposteriorly to
ach ieve th e desired elevat ion , th e screw is in serted an d
skin st ap les are p laced cau dal to th e screw to m ain tain th e
elevat ion (Fig. 25.14).16
Fixation w ith Cortical Bone Tunnels
An oth er xat ion m eth od, d escribed by McKin n ey et al,17 is
by creat ing cort ical bon e t u n n els in th e calvarium to allow
an ch oring (Fig. 25.15). Th e bon e bridge is created w ith a
1.1-m m bur w ith a safet y guard of 4 m m . Tw o opposing bur
a b
Fig. 25.14 Fixation with monocortical screws and staples.
(a) Monocortical screw inserted and brow lifted in the superior
direction. (b) Skin staples are placed caudal to the screw to m ain-
tain the desired brow elevation.
d
h oles are created at 45 degrees, m ade ~ 4 m m apart . Th ey
can be orien ted h orizon t ally or vert ically to th e brow s.
Altern at ively, a bon e t u n n el gu idan ce device (Brow lift Bon e
Bridge System , Medt ron ic Xom ed, Jacksonville, Florida) can
be used to create th e bon e t u n n el. On ce th e t un n el is cre-
ated, a device design ed to pu ll a sut ure th rough th e bon e
t un n el is used to engage th e sut ure. Eith er 2–0 polypropyl-
en e or p olydioxan on e can be u sed for an ch oring in a sim ilar
fash ion as for th e resorbable screw s. Fig. 25.16 sh ow s th e
resu lt s for a pat ien t w h o un der w en t EFBL u sing th e cor t ical
bon e t u n n el xat ion m eth od.
Th e advan tages of th is m eth od are it s low cost an d th ere
is n o risk of im plan t p alpabilit y. Cor t ical t u n n el su t ure xa-
t ion h as been sh ow n to be sim ple, st able, an d reproducible
in m ain t ain ing brow posit ion in EFBL w ith low m orbidit y.18
Jon es et al19 com p ared t w o xat ion m eth od s, brin glu e
versu s p olydioxan on e su t u res t ied th rough bon e t u n n els,
in h is review of 538 pat ien t s. He foun d th at xat ion w ith
p olydioxan one sut ures t ied th rough bon e t un n els produ ces
a sign i can tly m ore st able resu lt th an brin glu e alon e,
w ith out greater risk.
Fixation w ith Endotine Forehead Device
Fixat ion of th e elevated brow s can also be don e w ith th e
u se of th e En dot in e Foreh ead device (Coapt System s, Palo
Alto, Californ ia) (Fig. 25.17). Ch ow dh u r y et al20 rep orted
th at th is device is e ect ive, safe, an d easy to use w ith h igh
p at ien t sat isfact ion . Th is is a resorbable t riangular device
w ith spikes or t in es on on e side th at are oriented at an
angle. Th ese spikes are able to skew er or grab tissu es so
th at th ey can be h eld in th e desired posit ion after lift ing.
Th is device is com posed of a bioabsorbable copolym er of
lact ic an d glycolic acids an d com pletely dissolves w ith in 6
to 12 m on th s.
 25 Endoscopic Forehead and Brow Lift 335

a b c

d e

f g
Fig. 25.15 Fixation with cortical bone tunnels. (a) Bone tunnel guid-
ance device (Browlift Bone Bridge System, Medtronic Xomed, Jackson-
ville, Florida) and drill. (b) Demonstrating the engagement of drill in
the guidance device. (c) Using the guidance device to create cortical
bone tunnel. (d) A device designed to pull suture through the bone
tunnel is used to engage the suture. (e) Successful engagement of
suture in the bone tunnel. (f) Needle introduced to engage the caudal
margin of the lateral incision. (g ) Sutures are then tied to achieve the
desired brow lift.

a b

Fig. 25.16 A 45-year-old female who had endoscopic forehead lift, lower blepharoplast y, rhinoplast y, rhytidectomy, and fat injection of
upper and lower face. (a) Before the surgery. (b) Two months after the surgery. (Courtesy of Dr. In-Sang Kim.)
336 V Facial Skin and Hair Rejuvenation
a b
c
Fig. 25.17 Fixation with Endotine Forehead device. (a) Endotine Forehead device with multiple tines shown. (b) Placement of the device
in a monocortical hole created in the skull bone. (c) Lifting of the forehead superiorly to achieve the desired brow lift and redraping the
ap over the device. (d) Finger pressure applied over the device to ensure adequate penetration of the periosteum by the tines so that the
brow can be held at the desired position.
Tw o m on ocor t ical w ells are created w ith a drill
equ ip ped w ith th e En dot in e drill bit an d sleeve at th e cau -
dal m argin s of th e lateral in cision s. Th e En dot in e Foreh ead
d evice is th en in serted w ith th e aid of an in sert ion device
in to th e w ell. On ce th e device is rm ly xated, th e foreh ead
an d scalp can be lifted an d red raped over th e t in es an d be
h eld at th e desired p osit ion . Digital p ressu re over th e t in es
is n ecessar y to en sure adequ ate p en et rat ion of th e perios-
teu m by th e t in es. Th e sym m et r y an d h eigh t of th e brow s
are ch ecked . If th e h eigh t is in adequ ate or if th ere is any
asym m et r y, th e ap can be released from th e device an d
redraped again to ach ieve th e desired ou tcom e.
Th e advan t age of using th is device is th at th e im plan t
resorbs. In add it ion , th e En dot in e Foreh ead device provides
m u lt iple poin t s of con t act w ith th e elevated t issu e an d can
th eoret ically create a w ider dist ribut ion of h olding st rength
th at does n ot rely on a single sut u re.5 It also elim in ates th e
con cern of un due ten sion on th e scalp in cision .
Th ere is st ill a risk of im plan t extrusion an d in fect ion .
Th e device m ay be palpable or ten der, an d it in creases th e
cost of th e su rger y.
Closure and Dressing
Th e in cision s can be closed w ith skin staples, w h ich are
rem oved in 10 days. Th e h air an d scalp are w ash ed w ith
hydrogen peroxide an d n orm al salin e. A pressure dressing
is th en ap plied to th e foreh ead an d rem oved after 24 h ours.
Sequence of the Combined Approach
If an u p per bleph aroplast y is plan n ed for th e sam e set t ing,
it is u su ally don e after th e EFBL. In th is sequ en ce, an accu -
rate brow lift can rst be ach ieved an d th e residu al h ooding
d
can be m ore accu rately determ in ed. Th is w ill allow a m ore
con ser vat ive bleph aroplast y, reducing th e risk of lagoph -
th alm os postoperat ively. If th e upper eyelid skin is rem oved
rst , th e correct brow lift m ay resu lt in lagop h th alm os.
■ Postoperative Care
Th e pat ien t is advised to sleep w ith h ead elevated 30
degrees to m in im ize sw elling an d bru ising. Fur th erm ore,
ice packs to th e exposed areas an d eyes can h elp m in im ize
edem a. Th e p at ien t sh ou ld n ot engage in any vigorou s exer-
cise or act ivit y for 1 w eek.
■ Botulinum Toxin
Bot u lin u m toxin can ser ve as an adju n ct to EFBL. Inject ion
in to th e p roceru s an d corrugators ser ves to elevate th e
m edial brow, an d som e su bst it u te th is tech n iqu e for sec-
t ion ing of th e m uscles. Bot ulin um toxin injected in to th e
brow depressors preoperat ively can also facilitate th e reat-
tach m en t of th e brow s in th e elevated posit ion during th e
h ealing process.
■ Key Technical Points
The principles behind endoscopic forehead and brow lift are
1. Use of a m in im al n um ber of in cision s, w h ich are
sm all, sh ort , an d w ell cam ou aged
2. Dissect ion in a safe an d bloodless plan e
3. Release of all brous, ligam en tous, an d m uscu lar
at t ach m en t s of th e brow s to allow m axim al
m obilizat ion
 25 Endoscopic Forehead and Brow Lift 337

4. Separat ion of th e depressors an d fron talis to Intracranial Injury

overcom e th e rhyt id osis
5. Ceph alic rot at ion of th e en t ire scalp to ach ieve
d esired brow posit ion an d t igh t n ess of th e foreh ead
6. Fixat ion of the brow s, foreh ead, an d scalp com plex
7. Postoperat ive care
In t racran ial inju r y su ch as cerebrosp in al u id leak an d
hem orrh age can h ap pen during th e m on ocort ical drilling
process for th e screw s, cor t ical t un n els, or En dot in e devices.

Wound Problems
Th e in cision s m ay h eal w ith hypert roph ic scars or keloids,
■ Complications and esp ecially if closed u n der ten sion . In t ralesion al steroids or
Their Management scar revision m ay be requ ired .

Seroma or Hematoma
Implant Problems
Serom a an d h em atom a can occu r in th e p oten t ial space of
Th e screw s an d En dot in e devices m ay cause discom fort an d
th e foreh ead an d scalp. Th is risk is m in im ized by careful
irrit at ion to th e pat ien t . Rarely are th ey palpable or visible.
dissect ion in th e correct plan e, h em ost asis at th e in cision s,
an d u se of a rm p ressu re d ressing over th e foreh ead. Fibrin
sealan t can fu rth er redu ce th e risk of bleed ing.
Alopecia
Th e scalp in cision sites can h ave alopecia. Th is occurs m ost
Edema and Ecchymosis
often if closed u n der ten sion , if cauter y w as used on h air
follicles, or if gross m ism atch of skin edges exist s.
Th ere w ill in evit ably be som e edem a an d ecchym osis
w ith in th e rst 48 h ou rs. EFBL m ay involve less edem a th an
th e open coron al an d t rich ophyt ic approach es.
Raising Hairline
Th is is n ot a com plicat ion as m uch as a con sequen ce of
Infection
EFBL. For th is reason , p at ien t s w ith a pre-exist ing h igh
hairlin e are n ot ideal can didates for th is t ype of brow lift .
Woun d site in fect ion is ver y un com m on due to th e robust
blood supply of th e scalp. Postoperat ive an t ibiot ics are usu-
ally n ot n ecessar y.
Over- and Under-Correction
Over- an d u n der-correct ion are p ossible ou tcom es.
Nerve Injury
Un der-correct ion can be im proved w ith a revision or bot-
ulinu m toxin inject ion in the brow depressors. Over-cor-
Th e fron t al bran ch of th e facial n er ve can be injured dur-
rect ion , w ith th e un desirable resultan t facial expression , is
ing th e tem poral dissect ion . It can also be injured by th er-
ext rem ely d i cu lt to reverse.
m al inju r y w h en at tem pt s at arrest ing bleeding from th e
sen t in el vein are d on e w ith elect rocau ter y. Th e n er ve can
also be st retch ed du ring th e dissect ion , resu lt ing in tem p o-
rar y n eu rop raxia. If th is occu rs, th e n er ve m ay take several
Relapse
m on th s to recover.
As th e pat ien t con t in ues to age, th e brow s w ill again
Th e sen sor y ner ves, su praorbit al, an d suprat roch lear
descen d. Longevit y varies according to m any variables,
n er ves, can be inju red du ring th e subperiosteal dissect ion
in cluding skin elast icit y, sun exposure, sm oking, an d pos-
n ear th e su praorbit al rim , an d th is w ill resu lt in p araesth e-
sibly th e xat ion m eth od u sed.
sia in th e foreh ead an d scalp areas.

Suture Extrusion and Granulomas ■ Conclusion

In con clu sion , EFBL re p rese n t s t h e u se of ad van ce d t e ch -
If p erm an en t su t u res are u sed for an ch oring, su t u re gran u -
n ology in facial cosm et ic su rge r y. Th e d esire to h ave
lom as or ext rusion can occu r. On occasion , th is w ill requ ire
sm alle r an d w ell-cam ou age d in cision s, less p ostop e ra-
su rgical rem oval to alleviate sym ptom s.
338 V Facial Skin and Hair Rejuvenation
t ive e d e m a, sh or te r re cove r y t im es, an d , m ost im p or t an t ,
less ve r tex n u m b n ess h as le d to it s w id e acce p t an ce an d
p op u lar it y. Th e key factors in EFBL are w id e u n d e r m in -
in g in t h e cor re ct p lan e, com p lete p e r iost eal release, an d
e e ct ive xat ion . Carefu l scu lpt in g of t h e brow sh ap e is
im p e rat ive to creat e an aest h et ic an d n at u ral-ap p ear in g
exp ression .
References
1. Vasconez LO, Core GB, Gam boa-Bobadilla M, Guzm an G,
Askren C, Yam am oto Y. Endoscopic techniques in coronal
brow lifting. Plast Reconstr Surg 1994;94(6):788–793
2. Puig CM, LaFerriere KA. A ret rospect ive com parison of
open an d en doscopic brow -lift s. Arch Facial Plast Surg
2002;4(4):221–225
3. Grah am DW, Heller J, Kurkjian TJ, Sch au b TS, Roh rich RJ.
Brow lift in facial rejuven at ion : a system at ic literat u re re-
view of open versus en doscopic tech n iqu es. Plast Recon st r
Surg 2011;128(4):335e–341e
4. Pit anguy I, Ram os AS. Th e fron t al bran ch of th e facial
n er ve: th e im port an ce of it s variat ions in face lift ing. Plast
Recon st r Su rg 1966;38(4):352–356
5. Trin ei FA, Jan uszkiew icz J, Nah ai F. Th e sen t in el vein: an
im p ort an t referen ce p oin t for su rger y in th e tem poral re-
gion . Plast Recon st r Surg 1998;101(1):27–32
6. Sabin i P, Wayn e I, Quatela VC. An atom ical guides to pre-
cisely localize th e fron t al bran ch of th e facial n er ve. Arch
Facial Plast Su rg 2003;5(2):150–152
7. Win slow CP, Burke A, Bartels S, Cook TA, Wax MK. Bipo-
lar scissors in facial plast ic su rger y. Arch Facial Plast Su rg
2000;2(3):209–212
8. Rom o T III, Sclafan i AP, Yung RT, McCorm ick SA, Cocker
R, McCorm ick SU. En d oscopic foreh eadp last y: a h isto-
logic com p arison of p eriosteal re xat ion after en doscop ic
versu s bicoron al lift . Plast Recon st r Su rg 2000;105(3):
1111–1117, discussion 1118–1119
9. Sclafan i AP, Fozo MS, Rom o T III, McCorm ick SA. St rength
an d h istological characterist ics of periosteal xat ion to
bon e after elevat ion . Arch Facial Plast Surg 2003;5(1):
63–66
10. Kim JC, Craw ford Dow n s J, Azu ola ME, Devon Grah am H III.
Tim e scale for periosteal readh esion after brow lift . Lar yn -
goscope 2004;114(1):50–55
11. Kriet JD, Yang CY, Wang TD, Cook TA. Evalu at ion of p eri-
cran ial skull adh eren ce during h ealing in th e rabbit m odel.
Arch Facial Plast Su rg 2003;5(1):67–69
12. Holzap fel AM, Mangat DS. En doscop ic foreh ead -lift u s-
ing a bioabsorbable xat ion device. Arch Facial Plast Su rg
2004;6(6):389–393
13. Troiliu s C. Su bp eriosteal brow lift s w ith ou t xat ion .
Plast Recon st r Su rg 2004;114(6):1595–1603, discu ssion
1604–1605
14. Sidle DM, Loos BM, Ram irez AL, Kabaker SS, Maas CS. Use of
BioGlue surgical adhesive for brow xation in endoscopic
brow plasty. Arch Facial Plast Surg 2005;7(6):393–397
15. Harirch ian S, Ku peran AB, Sh ah AR. Safet y of cran ial xa-
t ion in en d oscopic brow lift s. Am J Otolar yngol 2013;
34(6):690–694
16. Pu t term an AM. In t raop erat ively con t rolled sm all-in ci-
sion foreh ead an d brow lift . Plast Recon st r Su rg 1997;
100(1):262–266
17. McKin n ey P, Celet t i S, Sw eis I. An accu rate tech n iqu e
for xat ion in en doscopic brow lift . Plast Recon st r Surg
1996;97(4):824–827
18. Malat a CM, Abood A. Exp erien ce w ith cor t ical t u n n el xa-
t ion in en doscopic brow lift: th e “bevel an d slide” m odi -
cat ion. In t J Surg 2009;7(6):510–515
19. Jon es BM, Grover R. En doscop ic brow lift: a p erson al review
of 538 pat ien t s an d com parison of xat ion tech n iques.
Plast Recon st r Su rg 2004;113(4):1242–1250, d iscu ssion
1251–1252
20. Ch ow dh u r y S, Malh ot ra R, Sm ith R, Arn stein P. Pat ien t an d
su rgeon experien ce w ith th e En dot in e Foreh ead d evice
for brow an d foreh ead lift . Oph th al Plast Recon st r Surg
2007;23(5):358–362
26 Facial Rejuvenation Using Energy Devices
Un-Cheol Yeo
Pearls
• Collagen den at urat ion is on e of th e m ech an ism s for
n on ablat ive rejuven at ion laser t reat m en t .
• Cooling during n on ablat ive facial rejuven at ion is
ver y im p or tan t for th e skin of East Asian s.
• En ergy devices th at do n ot use ligh t m ay be safer
in Asian skin . Pigm en t at ion in th e epiderm is of
Asian skin h in ders e ect ive deliver y of ligh t in to
th e derm is an d causes com plicat ion s su ch as
hyperpigm en t at ion . En ergy devices th at do n ot use
ligh t h ave n o in teract ion w ith epiderm al m elan in .
• En ergy device em ission s oth er th an ligh t can bypass
ep id erm al m elan in t issu e, bu t Asian skin react s
im m ediately to in am m at ion caused by skin dam age
an d m ay develop hyperpigm en t at ion even w h en a
ligh t sou rce is n ot u sed for rejuven at ion .
• Dep en d ing on th e n at u re of th e en ergy device,
su rgeon s can target d i eren t depth s for
rejuven at ion . Som et im es m ult ilayer th erapy is
possible w ith th e com bin ed u se of th ese devices.
■ Introduction
Skin rejuven at ion is an aesth et ic p rocedu re to cou n teract
or reverse sign s of th e aging process su ch as pigm en tat ion ,
vascu lar ectasia, w rin kle, an d loss of elast icit y. Skin reju -
ven at ion can be d ivided in to t w o t yp es. Type I rejuven a-
t ion reverses skin problem s such as dyspigm en tat ion an d
vascu lar ch anges, w h ile t ype II rejuven at ion aim s to redu ce
w rin kles an d restore skin elast icit y. Ablat ive versus n on -
ablat ive rejuven at ion is a con cept d i eren t from t yp e I an d
t yp e II rejuven at ion . Ablat ive rejuven at ion is used to t ar-
get ph oto-dam aged skin th at p rogressively w orsen s w ith
age. Th rough th e ablat ion of th e ep iderm is an d port ion s
of th e super cial derm is, as w ell as th e in duct ion of col-
lagen rem odeling in th e deeper derm is, ablat ive resurfacing
can reduce w rin kles, dysch rom ia, skin la xit y, an d vascu-
lar ch anges. On th e oth er h an d, n on ablat ive rejuven at ion
delivers h eat to th e epiderm is, derm is, an d su bcut is w ith -
out epiderm al dam age, th ereby in ducing collagen denat ur-
at ion . Eith er an ablat ive or a n on ablat ive m eth od could be
eith er t yp e I or t ype II rejuven at ion .
• In lt rat ive radiofrequ en cy (RF) can t arget di eren t
depth s by ch anging th e length s of th e n eedles, th u s
facilitat ing m u lt ilayer th erapy.
• In ten se p u lsed ligh t (IPL) is ver y u sefu l for t yp e I
rejuven at ion . Bu t it sh ou ld be used w ith caut ion
as it h as a large spot size an d com plicat ion s can be
catast roph ic.
• Am ong th e t yp es of fract ion al laser t reat m en t ,
su p er cial t reat m en t lasers su ch as th e th u liu m
fract ion al laser give im m ediate e ect ive resu lts.
Becau se it target s th e su rface, th e ch anges are
readily visible. Th is ph en om en on doesn’t im ply th at
sh allow t reat m en t is bet ter th an deep t reat m en t .
• To reverse aging beyon d th e depth of th e skin , h igh -
in ten sit y focused ult rasoun d (HIFU), in lt rat ive
RF w ith long n eed les, or in terst it ial lasers can be
ap plied.
• HIFU w as origin ally in t rod u ced to t igh ten th e
su p er cial m u scu lo-apon eu rot ic system (SMAS) an d
m ay dest roy fat w h en d elivered to th e fat layer. Th is
can be used ver y e ect ively for ch ubby ch eeks.
■ General Principles
Principles of Nonablative Rejuvenation
Th e aim s of n on ablat ive reju ven at ion (NAR) are to red u ce
w r in kles an d to in crease elast icit y. NAR in clu d es n ot on ly
t yp e II reju ven at ion w it h ou t ablat ion of t h e skin , bu t
also t yp e I reju ven at ion , w h ich can be ach ieved by IPL,
Q-sw itch ed laser, or d ye laser. NAR d elivers h eat to t h e
ep id er m is, d e r m is, an d su bcu t is u sin g lasers or rad iofre-
qu en cy. Sin ce NAR t reat m e n t d oes n ot cau se ep id er m al
dam age, it is safe an d allow s a rap id recove r y, w it h less
ch an ce of t h e hyp e r p igm e n t at ion an d p rolon ged er y-
t h em a t h at is associated w it h lase r p eelin g. NAR in clu d es
var iou s lasers an d rad iofre qu en cies. Base d on t h e ch ro -
m op h ores t h at in te ract w it h each laser, t h e NAR lasers
can be classi ed in to t h ree categor ies: (1) dye lasers,
w h ich u se h em oglobin as a ch rom op h ore; (2) Nd :YAG
lase rs, w h ich u se h e m oglobin , m elan in , an d w ater as
ch rom op h ores; an d (3) m id in frared lasers, w h ich u se
w ater as a ch rom op h ore.
339
340 V Facial Skin and Hair Rejuvenation

Most lasers for NAR u se w ater as a ch rom op h ore to Concept of Type I and Type II
gen erate h eat in th e skin . Wavelength s bet w een 1,300 an d
1,600 n m are used for th is purpose. With in th is range, th e
Rejuvenation
w avelength th at h as h igh absorpt ion to w ater can pen et rate
For t ype I rejuven at ion of Asian skin , IPL, Q-sw itch ed lasers,
th e skin m ore sh allow ly th an th e w avelength th at h as low
ch em ical peeling, an d m edical skin care, in clu ding vitam in
absorpt ion to w ater. Using th ese ch aracterist ics, app rop ri-
C ion toph oresis, can be used. Alth ough m edical skin care
ate w avelength s can be ch osen to h eat th e exact depth of
requ ires long-term t reat m en t , it is safest an d ver y usefu l
th e skin . Fract ion al t reat m en t , a non ablat ive t ype, also uses
w h en com bin ed w ith oth er t reat m en t . Vit am in C ion toph o-
a w avelength bet w een 1300 an d 1600 n m , an d determ in es
resis is often u sed before an d after laser t reat m en t . Pat ien t s
it s depth of p en et rat ion according to th e w avelength . Th e
w ith sen sit ive skin can get t ype I rejuven at ion safely w ith
key m ech an ism of NAR is collagen den at u rat ion , w h ich
IPL as op p osed to ch em ical p eeling. Norm al skin t reated
result s in regen erat ion of n ew collagen . Gen erally, collagen
w ith ch em ical peeling m ay respon d posit ively, sh ow ing
exposed for m ore th an 1 secon d to 60°C sh ow ed den at ur-
im provem en t in both pigm en tat ion an d w rin kling. Th e
at ion . Bu t w h en it w as exposed to a tem perat ure less th an
Q-sw itch ed laser is th e stan dard laser for p igm en tat ion
50°C, act ivated h eat sh ock protein (HSP) in creases th e col-
problem s. It t arget s speci c lesion s an d h as a sm all t reat -
lagen syn th esis rath er th an den at u rat ion .1,2 In th e case of
m en t beam size, w h ereas IPL h as a ver y big spot size.
dye laser t reat m en t , collagen bers sh ow ed ch anges after
For type II rejuvenation aim ed at improving the appear-
2 w eeks an d in creased collagen bers appeared after 4
ance of w rinkles, various kinds of lasers and energy devices
w eeks. After 5 w eeks, an in creased n u m ber of broblast s
can be applied. To reverse epiderm al aging, ablative or nonab-
w as con sp icu ou s.3 A ligh t-em it t ing diode (LED) w as also
lative fractional lasers and in ltrative fractional RF can be used.
able to dem on st rate in creased act ivit y of broblast w ith -
In Asian skin, the ablative lasers are subject to com plications
out collagen den at urat ion .4 CO2 lasers, dye lasers, an d NAR
such as hyperpigm entation, and so the nonablative fractional
t reat m en t s are also kn ow n to increase m at rix m etallopro-
laser is safer. For derm al reform , LED, pulsed dye laser, NAR and
tein ases (MMPs), w h ich rem ove ph oto-dam aged collagen s
fractional lasers, and in ltrative fractional RF can be used. In l-
an d resu lt in th e act ivat ion of broblast s, th u s con t ribu t ing
trative fractional RF bypasses the epiderm is w ith cold penetra-
to th e reversal of th e aging process.5,6 Collagen syn th esis
tion needling, so it could be a good option for Asian skin, w hich
w as app aren t in 1 to 2 m on th s an d th e resu lt p ersisted u p
easily develops hyperpigm entation. The sam e factor renders RF
to 1 year.7 On th e oth er h an d, th e e ect of t reat m en t w ith
useful for patients w ho have sensitive skin. Reduction of fat vol-
ablat ive fract ion al CO2 laser w as m ain tain ed from 3 m on th s
um e in the subcutaneous fat and tightening of SMAS are pos-
to u p to 2 years.8,9 Th is im p lies th at ablat ive laser is m ore
sible w ith m onopolar RF, HIFU, and interstitial lasers.
e ect ive an d th e e ect is longer-last ing com p ared w ith th e
n on ablat ive laser in term s of collagen syn th esis.
Commonly Used Devices in
Principles of Ablative Rejuvenation Facial Rejuvenation
Beyon d t issu e ablat ion , sh ort-pu lsed, h igh -en ergy, rapidly Devices u sed in facial rejuven at ion can be d ivid ed in to fou r
scan n ed CO2 lasers are able to t igh ten th e skin by m ean s grou p s based on en ergy sou rce: ligh t , radiofrequ en cy, u lt ra-
of t w o m echan ism s: con t rolled in st an t an eous h eat ing an d sou n d, an d p n eu m at ic. Ligh t-based devices in clu d e th e dye
w ou n d h ealing.10 Precise h eat ing of collagen lead s to im m e- laser, IPL, Nd:YAG laser, m idin frared laser, fract ion al laser,
diate con t ract ion an d visible skin t igh ten ing from dest ru c- an d in terst it ial laser. Rad iofrequ en cy d evices are divided
t ion of th e hydrogen bon ds w ith in th e collagen t riple h elix in to m on opolar, bipolar, an d in lt rat ive t ypes using th e
w ith out dest roying th e collagen m olecule. Th e ideal tem - elect rical curren t th rough a t reat m en t t ip. Recen tly, ult ra-
perat u re h as been sh ow n to be 63°C. As tem perat u re rises, sou n d an d m icrojet inject ion by p n eu m at ic com pression
m ore an d m ore cross-lin k bon ds are broken u n t il d en a- are being u sed as n on invasive m eth ods.
t urat ion an d loss of st ruct ure occur. Den at ured collagen
slough s in th e rst few days after th e procedu re w ith fu ll
re-epith elializat ion w ith in 1 w eek. Over th e en suing 3 to ■ Rejuvenation by Light Devices
6 m on th s, th is process st im ulates n ew collagen deposit ion
an d broblast p roliferat ion . Th e w ou n d h ealing respon se Dye Laser
in du ces con t ract ion th rough broplasia. Th is ablat ive frac-
t ion al t reat m en t h as a h igh er risk of com plicat ion s, but th e The pulsed dye laser uses the w avelength of 585 to 595
e ect of t reat m en t is su perior. Modern fract ion al ablat ive n m . It targets hem oglobin in th e capillaries of th e derm is,
tech n ology allow s for ablat ion of a por t ion of th e epiderm is indirectly stim ulat ing th e derm is. The convent ion al pulse
w h ile leaving adjacen t , un t reated skin to act as a reser voir durat ion of 0.45 m s produced purpura, but low -energy
for h ealing, resu lt ing in a sh or ter d ow n t im e an d low er risk treatm ent w ith an NLite laser (Clem son Eye) w ith pulse
for com plicat ion s. durat ion of 0.35 m s sh ow ed e ectiveness w ith no purpura.11

Intense Pulsed Light
In ten se p u lsed ligh t , or IPL, is broadban d ligh t , as op posed
to a a laser, th at em it s ligh t w ith a single w avelength . Th e
spect ral d ist ribu t ion is bet w een 550 an d 1200 n m . Variou s
w avelength s in teract w ith variou s ch rom op h ores in th e
skin , an d gen erally longer w avelength s p en et rate deep er.
Becau se broadban d ligh t h as d iverse e ect s on th e skin ,
select ivit y tow ard a cert ain t arget is low com p ared w ith
laser. Th ere are various kin ds of IPL w ith di eren t spect ral
dist ribut ion s, spot sizes, etc. The param eter sh ow n on th e
com puter screen , h ow ever, m ay n ot be th e real IPL beam
param eter. Th erefore, using th e sam e param eter bet w een
di eren t IPL devices is un reliable an d sh ould be avoided.
Type I Rejuvenation w ith IPL
Treat ing a vascu lar lesion w ith IPL risks h eat ing m elan in
pigm en t s at th e sam e t im e due to th e broad spect rum of
th e ligh t . W h en using IPL to t reat vascular lesion s, blisters
an d cru st s are seen before th e develop m en t of p u rp u ra.
Blisters an d cru st s are m an ifest at ion s of ep iderm al h eat
dam age. Mult iple pulses of IPL can gen erate h eat aroun d
th e vessels. Th erefore, epiderm is m ust be given t im e to cool
dow n . Th is can be ach ieved by allow ing a longer th erm al
relaxat ion t im e th an th e in ter val bet w een subpulses of IPL.
As for t reat m en t of pigm en t at ion , IPL h as a long pulse
durat ion , w h ich leads to m ild ch anges after t reat m en t .
It h eat s u p an d p rod u ces m ild ch anges in a m elan ocyt ic
lesion w ith out m elan osom al dest ru ct ion . By select ing th e
ap prop riate lter, th e opt im al set t ing for each skin ph oto-
t yp e can be ach ieved. W h en IPL is u sed for th e t reat m en t
of m elasm a, special adjust m en t of th e param eters is n eces-
sar y. Th e p aram eter u sed for th e t reat m en t of m elasm a is
low er com pared w ith oth er pigm en t at ion problem s. In ad-
ver ten t h igh u en ce irradiat ion on m elasm a can lead to
aggravat ion of th is con dit ion . Th is ph en om en on t yp ically
m an ifest s in th e case of invisible m elasm a or m ild m elasm a
a b
Fig. 26.1 IPL treatment for freckles. (a) Before treatment. (b) Immediately after treatment with IPL. The freckles became darker and the
treated area shows di use erythema, which indicates a treatment end point. (c) Ten days after treatment freckles are e ectively removed,
and the skin appears bright.
26 Facial Rejuvenation Using Energy Devices 341
m asked by oth er p igm en t at ion problem s. Sin ce IPL t reat-
m en t u ses a ver y large sp ot size com p ared w ith lasers, it
is su itable for obscu ring th e dyspigm en tat ion in th e w h ole
face an d ach ieving gen eral im provem en t (Fig. 26.1).
Dep en d ing on th e site of th e face, h ow ever, th e opt im al
set t ing can var y dram at ically. Areas su ch as th e foreh ead,
m an dibu lar lin e, an d zygom a sh ou ld be t reated cau t iou sly.
Th ese areas overlying th e facial bon es are pron e to er y-
th em a an d pain . Th e foreh ead sh ould be t reated w ith a u -
en ce at least 2 J/cm 2 low er th an th e set t ings u sed to t reat
th e ch eek. During IPL t reat m en t , cooling gel is useful to
preven t form at ion of air space bet w een th e t reat m en t t ip
an d skin su rface. Filling th e sp ace w ith gel can h elp p ropa-
gate ligh t even ly in to th e skin . Th e gel can also h elp to cool
dow n th e t reat m en t t ip, w h ich becom es h ot w ith con t in u-
ous ring of IPL. Depen ding on th e th ickn ess of th e gel, th e
at ten uat ion of ligh t can be ch anged. More th an 10%at ten u -
at ion is expected w ith th e use of gel. Hen ce, it’s essen t ial
to kn ow th e th ickn ess of th e gel app lied. It is m ore likely
to n d cu r ved areas su ch as th e n ose an d foreh ead bet ter
covered by th e gel. W h en th e assum pt ion is th at th e gel is
too th ick an d th e param eter is adju sted to com p en sate for
th e at ten uat ion by the gel, overly h igh uen ce m ay be deliv-
ered. If th e at ten u at ion is n ot as expected , th is m ay becom e
dangerous to th e pat ien t . It is th erefore safer to set th e
param eter w ith th e assum pt ion th at th e layer of gel is th in .
Som e operators m ay at tem pt to pu sh th e cr yst al closer to
th e skin surface. Th is w ou ld n ot in crease th e uen ce deliv-
ered to th e skin , th ough any p ossible com p licat ion w ou ld
be n egligible. In any case, th e th ickn ess of th e gel sh ou ld be
kept con stan t at all t im es.
Im m ed iately after irrad iat ion , th e p igm en ted lesion
m ay becom e darker, w h ich in dicates adequ ate t reat m en t .
Th e t reat m en t en d poin t sh ould be con t rolled carefully.
Im m ed iately after IPL irradiat ion , th e skin sh ow s m ild
er yth em a. Th at is gen erally regarded as a t reat m en t en d
poin t . W h en th e redness is di u sed, it is n e; but th e sit u -
at ion is dangerous if th e redn ess is in ten se an d sh ow s th e
m ark of th e t reat m en t t ip . Th is ill-de n ed er yth em a u su-
c
342 V Facial Skin and Hair Rejuvenation

ally su bsides in several m in u tes. Th e er yth em a is n ot th e

on ly sign al for com pleted t reat m en t . To predict th e opt im al
t reat m en t en d poin t , variou s factors sh ould be t aken in to
accou n t su ch as p ain , color ch ange in p igm en t after t reat-
m en t , skin t yp e of p at ien t , ou tdoor act ivit y, p at ien t’s gen -
eral con dit ion , an d gen der.
On e of th e com m on com p licat ion s of IPL t reat m en t are
rect angu lar crust s. Th e m ild cases spon t an eously subside.
A crust is a problem w h en it becom es big an d visible. After
th e crust falls o , redn ess persist s for several m on th s. Gen -
erally, th e m ost seriou s com p licat ion s of IPL t reat m en t are
blisters, crust s, long-last ing er yth em a, an d hyperpigm en -
t at ion (Fig. 26.2).
Fig. 26.2 Complications of IPL treatment. Rectangular mark with
crusts and swelling and redness after IPL treatment. These prob-
lems resolve with tim e although redness and hyperpigmentation
Type II Rejuvenation w ith IPL may persist in the area for many months after the crust peels o .

Th e e cacy of IPL for t ype I rejuvenat ion is w ell accepted.

IPL is in ferior to NAR in t yp e II rejuven at ion for w rin kles
an d elast icit y. In th e begin n ing IPL w as kn ow n to h ave du al an d 1,540 n m (Aram is, Qu an tel) are frequ en tly u sed for
e ect s th rough vascu lar h eat ing by sh ort-w avelength ligh t NAR. Th ese w avelength s are called “m idin frared.”
an d w ater h eat ing by long-w avelength ligh t . It is kn ow n Water absorpt ion of ligh t ranges from 1,200 to 1,450
th at sh orter w avelength s th at w ork th rough th e vascular n m . At aroun d 1,450 n m it reach es th e peak an d th ereafter
path w ay con t ribute to t issue rejuven at ion . it decreases. To m odify m idderm is requires select ion of th e
opt im al w avelength —n eith er too h igh n or too low —w ith in
th e w ater absorpt ion range. So th e opt im al w avelength for
Nd:YAG Laser skin rejuven at ion is 1,200 to 1,600 n m .
Th e low absorpt ion coe cien t w ith regard to m ela-
Th e Q-sw itch ed Nd:YAG laser h as been used as a basic t reat- n in m ean s less react ion w ith epiderm is, safer u se, an d less
m en t m eth od for pigm en t at ion p roblem s. Th e Q-sw itch ed ch an ce to develop hyperpigm en t at ion . Th e w avelength of
Nd:YAG laser 12 an d long-pu lsed Nd :YAG laser h ave also 1,540 n m h as a low er absorpt ion rate by m elan in com pared
been used in NAR to reduce w rin kling. W h en Q-sw itch ing w ith 1,450 n m . Th is w orks favorably for t ype II skin . Th e
stop s, th e lasers are in w h at is called “free ru n n ing” m ode depth of t reat m en t an d absorpt ion by w ater m olecu les
w ith a 0.3-m s pulse durat ion . Using th is pulse durat ion an d di er am ong product s. Th e absorpt ion by w ater is h igh -
a 5-m m h an dp iece, con t in u ou s irradiat ion of 14 J/cm 2 an d 7
Hz is called th e “gen esis tech n iqu e.” It delivers 1,000 sh ot s
to each ch eek, m aking th e su rface gradually go from w arm
to h ot . Th is tem perat ure elevat ion is believed to result in 10,000
)
d erm al rem odeling. Th e gen esis tech n iqu e is perform ed
l
1
–
l
o
1,000
w ith brush ing an d n o con tact .13 For skin rejuven at ion , pu lse
m
HbO2 Melanin
1
–
m
100
durat ion s from n an osecon ds to m illisecon ds are used. Th e
t
n
c
Water
(
e
i
n
c
Q-sw itch ed Nd:YAG laser w ith th e n an osecon d set t ing
i
10
i
n
f
f
a
e
l
e
o
could be ablat ive or n on ablat ive depen ding on th e in ten sit y
M
C
1
n
,
2
o
of t reat m en t . Th e gen esis tech niqu e u sing th e m illisecon d
O
i
t
b
0.1
p
H
r
pulse durat ion is a kin d of n on ablat ive rejuven at ion .
o
;
s
)
¹
b
–
A
0.01
m
c
(
r
0.001
e
t
Midinfrared Laser
a
W
0.0001
0.1 1.0 10
Wavelength (µm )
Wavelength s bet w een 1,300 n m an d 1,800 n m are w ell
absorbed by w ater an d u sed for h eat ing th e derm is dif- Fig. 26.3 Absorption coe cients of various chromophores
(water, hemoglobin, melanin) in skin. Midinfrared wavelengths of
fu sely. Th ese w avelength s h ave w ater absorpt ion coe -
1,300 to 1,800 nm are absorbed by water and useful in di usely
cien t s of 20/cm to 80/cm (Fig. 26.3). W h en a w avelength
heating up the dermis. It is used for NAR. The sam e wavelengths
in th is range is app lied to skin , th e depth of 0.2 to 0.4 m m are used for nonablative fractional lasers. The thulium fractional
below th e skin surface is t argeted an d h eated. Am ong th ese, laser uses 1,927 nm , the Er:YAG laser uses 2,940 nm, and the CO2
1,320 n m (CoolTouch ), 1,450 n m (Sm ooth beam , Can dela), laser uses 10,600 nm.

est at 1,450 n m for Sm ooth beam ) an d th e t reat m en t depth
for Sm ooth beam is 0.2 m m , by far th e sh allow est . Aram is
(1,540 n m ) h as a t reat m en t depth of 0.3 to 0.7 m m w ith
a m oderate rate of absorpt ion by w ater an d it t arget s th e
u pp er d erm is. Th is depth of t reat m en t is u sefu l for w rin kle
redu ct ion an d acn e t reat m en t (Fig. 26.4). CoolTou ch (1,320
n m ) h as th e low est absorpt ion by w ater bu t p en et rates th e
d eep est , at 1.4 m m . Deep pen et rat ion does n ot n ecessar-
ily m ean a bet ter t reat m en t . Th erm age (Solt a Medical) is a
p roduct th at pen et rates deep like CoolTouch .
Deep t reat m en t is good for reversing laxit y or in creas-
ing elast icit y, w h ile sh allow t reat m en t is good for n e
w rin kle reduct ion . Th e surgeon n eeds to select t reat m en t
d epth according to th e p at ien t’s n eeds. Th e absorpt ion by
w ater is n ot th e on ly factor th at regu lates th e p en et ra-
t ion depth of t reat m en t w ith th e m idin frared laser. Longer
w avelength s are associated w ith low er scat tering ch arac-
terist ics an d pen et rate deeper. Large spot size is h elpful in
in creasing pen et rat ion depth as w ell.
Fractional Lasers
CO2 lasers h ave been used for a long t im e for resurfacing
but are com prom ised by long dow n t im e. To overcom e th is
d em erit , th e Er:YAG laser w as in t roduced. It h as less dow n
t im e, but is also less e ect ive th an th e CO2 laser. On e tech -
n iqu e to circu m ven t th is p roblem w as to deliver th e en ergy
in a fract ion al w ay. Fract ion al t reat m en t targets a port ion of
th e en t ire skin . Fract ion al t reat m en t spares n orm al, un in -
jured t issu e in bet w een irradiated colum n s of coagulat ion ,
to ser ve as a regen erat ion sou rce du ring th e regen erat ion
period. Advan tages of fract ion al t reat m ent are less dow n
t im e an d relat ively h igh e cacy. Th e depth of t reat m en t
depen ds on th e laser being used.
Nonablative Fractional Laser
Th e Fraxel fract ion al laser irradiates w ith 1,550-n m -w ave-
length ligh t an d scan s th e skin w ith t iny dot s (80 to 180
µm ). Th ese dot s form n um erous (375 to 4,000 per square
cen t im eter) m icroth erm al zon es (MTZs). A MTZ is a col-
u m n -sh aped coagulat ion zon e from th e skin su rface to th e
derm is. Sixt y m in utes after applicat ion of th e topical an es-
th et ics, th e Fraxel laser scan s th e skin m u lt iple t im es an d
covers ~ 10 to 20% of th e skin su rface. Th e n on irradiated,
h ealthy skin part icipates in regen erat ion an d th e recover y
is ver y easy. Th e proced ure causes sw elling for 1 to 3 days.
Th e er yth em a after t reat m en t su bsides w ith in 3 to 7 days
in 85% of th e pat ien t s. It m ay last u p to 3 w eeks in som e
pat ien t s. Th is t reat m en t is repeated biw eekly to m on th ly,
u su ally for th ree to ve session s. Un like oth er form s of
NAR, th is fract ion al t reat m en t can m odify th e epiderm is
an d su p er cial derm is safely. Th is t reat m en t to th e su per-
cial port ion of th e skin im p roves w rin kles an d elast icit y
26 Facial Rejuvenation Using Energy Devices 343
a
b
Fig. 26.4 Non ablative rejuvenation for periorbital wrinkles using
the m idinfrared laser Aramis. (a) Before treatm ent. (b) After four
treatments with Aramis the periorbital wrinkles decreased.
an d avoid s th e app earan ce of scar. Th e Mosaic fract ion al
laser,14,15 w h ich u ses th e sam e tech n ology as th e Fraxel, h as
been in troduced in South Korea an d is w idely u sed. Th is
t reat m ent m eth od delivers NAR in a fract ion al w ay w ith out
cooling.
Ablative Fractional Laser
After th e adven t of n on ablat ive fract ion al lasers su ch as
th e Fraxel, curiosit y regarding th e usage of th e CO2 laser
or Er:YAG laser in a fract ion al w ay su rged. In ablat ive frac-
t ion al laser t reat m en t , th e tem perat ure of th e core of th e
coagulat ion colum n is over 100°C. Th is m ean s vaporizat ion
of w ater an d evaporat ion of skin . As th e w ater vaporizes, it
rem oves th e t issue th at h arbors w ater in to th e air, produc-
ing a real h ole in th e skin . Th is ablat ive fract ion al t reatm en t
causes m ore dow n t im e an d h eigh ten s th e risk of com plica-
t ion s, bu t th e e ect of t reat m en t is superior (Fig. 26.5).
Thulium Fractional Laser
Th e th ulium fract ion al laser, w ith a 1,927-n m w avelength ,
has a w ater absorpt ion coe cien t bet w een th ose of th e CO2
laser an d th e n on ablat ive fract ion al laser, such as th e Fraxel
or th e Mosaic (Lut ron ic). In oth er w ords, its ch aracterist ics
posit ion it bet w een ablat ive fract ion al an d n on ablat ive
fract ion al laser t ream en t . Becau se of th is, th e th u liu m frac-
t ion al laser can provide eith er t ype of t reat m en t depen ding
on th e param eter.
Fract ion al laser t reat m en t using th ulium h as h igh
absorpt ion by w ater com p ared w ith n on ablat ive fract ion al
lasers, so it s pen et rat ion in to th e skin is ver y sh allow bu t
344 V Facial Skin and Hair Rejuvenation
a
b
Fig. 26.5 Facial rejuvenation using the Edge ablative fractional
laser (Jeisys Co., South Korea). (a) Before treatment. Periorbital
wrinkles and infraorbital fat bulging are observed. (b) After four
treatments with the Edge (30 mJ, 30 W, 300 dots/cm 2 used for
each treatment), improvement of periorbital wrinkles and removal
of infraorbital fat bulging can be seen.
th e react ion is in ten se. As a result , it is used for w rin kle
redu ct ion . Th e ch anges cau sed by th u liu m fract ion al t reat-
m en t are m ostly su p er cial an d th u s are easily recog-
n ized by obser vers. Becau se of th e in ten se dam age th at
occurs in th e epiderm is, th e th ulium fract ion al laser can
also be a good m odalit y for p igm en tat ion problem s. Th u s,
th ulium fract ion al lasers can be used in t ype I an d t ype II
rejuven at ion .
Interstitial Lasers
Th e laser t reat m en ts for skin rejuven at ion discu ssed so far
u se on ly extern al irradiat ion w ith laser beam s. Now a n ew
m eth od is available th at involves in sert ing opt ical ber in to
th e skin an d h aving th e irradiat ion don e un der th e skin
su rface. It is called in terst it ial laser. Som e exam ples are
Sm artlipo (Cyn osu re), a 1,064-n m laser, an d Accu scu lpt
(Lut ron ic), w ith a 1,444-n m w avelength ; both w avelength s
are absorbed by fat t issu e. Opt ical ber is in serted in to th e
fat layer an d u sed for lip olysis. After in sert ion th e opt ic
ber is orien ted u pw ard w h ile it irradiates an d is grad u ally
w ith draw n . It is aim ed at dam aging th e un dersurface of th e
derm is for rem odeling an d regen erat ion . In terst it ial laser
t reat m en t not on ly can safely be u sed for lipolysis but also
can be u sed in com bin at ion w ith liposu ct ion . After in ter-
st it ial laser t reat m en t , it is easier to do liposu ct ion as th e
fat t issu e h as already been d est royed part ially by th e laser.
A w avelength of 1,927 n m is th e latest t reat m en t opt ion
available as an altern at ive for lipolysis an d derm al rem od-
eling (Fig. 26.6). After in terst it ial t reat m en t w ith a 1,927-
n m laser for subderm al rem odeling, an in creased am oun t
of collagen in th e t argeted derm is can be n oted (Fig. 26.7).
In terst it ial t reat m en t bypasses th e epiderm is an d is associ-
ated w ith less risk for hyperp igm en t at ion , w h ich m akes it
u sefu l for Asian skin .
■ Rejuvenation by
Radiofrequency Devices
Radiofrequ en cy (RF) d evices u t ilize elect ricit y in th e fre-
quen cy range 3 kHz to 300 MHz to ach ieve skin rejuven a-
t ion . W h en th e elect rical curren t goes th rough th e skin , it
creates frict ion w ith in th e t issue. Th is frict ion causes h eat-
ing. Th e h eated t issue is a good m edia for elect ric curren t
because t issu es w ith h igh er tem perat ure h ave low er im ped-
an ce. Th e RF cu rren t follow s th e less resist an t p ath w ay.
RF devices h ave m on opolar an d bipolar t reat m en t t ips.
Recen tly, in sulated n eedles h ave been used for RF. After
m u lt iple in su lated n eedles are in ser ted in to th e skin ,
µa , cm –1
12
2300–2400
1927
1759
6 1724
425
1424
1210
555
2129
0
500 1500 2500 nm
Fig. 26.6 Optical properties of the subcutaneous adipose tis-
sue in the spectral range 400 to 2,500 nm. Spectral dependence
of the absorption coe cient of the subcutaneous adipose tissue
calculated from the experimental data by the inverse adding-dou-
bling method. The vertical lines indicate the standard deviation.
The arrows and numerals indicate the absorption band m axima.
(Adapted with permission from Bashkatov AN, Genina A, Kochubey
VI, et al. Optical properties of the subcutaneous adipose tissue
spectral range 400–2500 nm. Opt Spectrosc 2005;99:836–842.)

Fig. 26.7 Subdermal remodeling after 1927-nm thulium intersti-
tial laser (Xlender-Y, Wontech Co., South Korea) treatm ent. After
subdermal irradiation using the Xlender-Y, localized subdermal
coagulation is observed. It can be used e ciently for subsurface
resurfacing because it does not involve super cial dermis and epi-
dermis (a total 3,850 J was delivered over 100 cm 2 , 4.8 W/40 Hz /
Dut y 40%/120 mJ of pulse energy).
th e n on in su lated dist al t ip delivers RF curren t . Usually
it em ploys bip olar n eedles an d th e elect ric curren t run s
bet w een th e n eedles. Th is is called in lt rat ive RF t reat m en t
in a fract ion al w ay.
Monopolar RF
In m on op olar RF t reat m en t th e ret u rn p ad is u su ally
at t ach ed to th e back or abdom en of th e pat ien t an d th e
t reat m en t elect rode is used on th e face or body. Th e rst
m on opolar device u sed for aging skin w as th e Th erm age
Th erm aCool TC system . It w as in t roduced for facial rejuve-
n at ion in 2001. Th erm age uses RF for h eat p rod uct ion in
th e derm is for rem odeling an d rejuven at ion . W h ile elect ric
curren t is em it ted from th e square, at m em bran e, cr yo-
gen is sprayed on to th e su rface of th e m em bran e. In it ially
Th erm age w as used to t reat th e foreh ead an d tem ple, an d
to lift th e u p p er eyelid an d eyebrow. Th erm age is also u sed
for lift ing an d t igh ten ing th e ch eek an d th e perioral an d
m an dibu lar lin e. To d eliver m u lt ip le passes in a sh ort t im e,
bigger t ips an d faster t ips are developed, in cluding th e big
t ip (1.5 cm 2 ) an d th e superbig t ip (3.0 cm 2 ). As experien ce
h as grow n , Th erm age h as com e to be u sed to t reat oth er
p art s of th e body, in clud ing th e abdom en , arm , an d dorsu m
of th e h an ds. Using it in com bin at ion w ith oth er t reat m en ts
can h ave a syn ergist ic e ect .
Com for t Pulse Tech n ology (CPT) is a n ew version of
Th erm age. Th e upgraded version gives pat ien t s a m ore
com for table t reat m en t w ith m in im al pain . CPT tech n ology
feat u res th ree u pgrades. First , it h as a vibrat ing h an dp iece
th at allow s th e pat ien t to feel less pain . Secon d, th ere is a
26 Facial Rejuvenation Using Energy Devices 345
ch ange in th e en ergy deliver y m eth od. Un like previou s gen -
erat ion s, CPT divides th e en ergy in to 5 p u lses an d du ring
th e in term ission , cr yogen is sprayed, w h ich con t ributes to
th e decreased pain . Th ird, th e CPT Th erm age uses a fram ed
t ip. Th e m em bran e of th e t ip is covered w ith a fram e so th at
RF can p ass th rough th e m em bran e even ly, an d n ot th rough
th e edge. In addit ion , th e e cien cy of en ergy deliver y is
in creased 25% an d deeper h eat gen erat ion is possible.
The selection of the proper patient is im portant. Patients
w ith m ild to m edium laxit y w ho are bet ween 35 and 60
years old m ight be the best candidates for Therm age. Since RF
doesn’t interact w ith the m elanin and preserves epiderm is
w hen properly used, it can be used safely in people of color.
Bipolar RF w ith Light
In bip olar RF t reat m en t , an elect ric circu it is form ed
bet w een t w o closely sit uated elect rodes. RF is an altern at-
ing curren t; th e cu rren t m oves for w ard an d back bet w een
th e t w o elect rodes, exer t ing frict ion an d h eat .
From th e begin n ing, bipolar RF w as developed in com -
bin at ion w ith th e u se of ligh t . In bipolar RF w ith ligh t , th e
skin area th at is in con tact w ith th e RF is di eren t from th e
skin area th at com es in to con t act w ith th e ligh t . As th e ligh t
goes th rough th e skin perpen dicu larly, an elect ric cu rren t is
created bet w een t w o elect rodes. Th e t w o form s of en ergy
cross in th e derm is at a poin t w h ere st rong h eat is exer ted
on a focal area of th e derm is w ith m in im al surface h eat ing.
Th is tech n ology w as in t roduced as elect ro-opt ical syn ergy
(ELOS). Th e com m ercial product s for th is tech n ology are
Polaris an d Au rora (Syn eron ), an d th ey h ave progressed
to E-laser an d E-ligh t . In Korea, th e sam e p rin cip le is u sed
w ith th e An t ila x (bipolar RF + in frared (IR):1,100–1,800
nm ) an d Arn eb (bipolar RF + diode: 635, 915 n m ).
In ltrative Fractional RF
In lt rat ive fract ion al RF u ses in su lated slen der n eedles.
Mu lt ip le n eedles are in serted in to th e skin . Th e n on in su -
lated dist al t ip of each n eedle em it s RF after in ser t ion . Th e
proxim al part of th e n eedle is in sulated; th e epiderm is an d
su p er cial d erm is are n ot th erm ally inju red, w h ich m ean s
it is a kin d of m icro n eedling or cold pen et rat ion tech n ique.
By circum vent ing th e sup er cial part , in lt rat ive fract ion al
RF can safely d eliver in ten se en ergy in to th e deep derm is.
Gen erally, in lt rat ive fract ion al RF h as a low er den sit y of
needles th an th e m icro n eedling tech n iqu e an d fract ion al
laser t reat m en t , so it cau ses less epiderm al dam age. Th e
dam age in th e super cial part h eals w ith in a few days an d
th e derm al coagu lat ion recovers w ith in several m on th s.
Moreover, di eren t depth s can be t argeted w ith th e correct
select ion of n eedles.
In lt rat ive fract ion al RF is u sed to t reat variou s con di-
t ion s in Korean an d Asian pat ien t s. It is used for rejuven at ion
(Fig. 26.8), scar t reat m en t , an d p ore size redu ct ion .16,17,18,19
346 V Facial Skin and Hair Rejuvenation
a
b m m , or 1.5 m m from t h e skin su r face w it h t h e resp ect ive
Fig. 26.8 Periorbital rejuvenation by in ltrative fractional RF
(Intracel, Jeisys Co., South Korea). (a) Before rejuvenation. (b) The
full face was treated with one pass (bipolar, level 2, needle 1.5 mm),
and additional treatments in the periorbital area used t wo or three
passes (bipolar, level 2, needle 0.8 mm or 1.5 mm). Sixt y days after
treatment the patient shows improved periorbital wrinkles. (Cour-
tesy of Dr. Takashi Takahashi, Tokyo, Japan.)
Th e in lt rat ing n eedles can also t arget an d dest roy seba-
ceous glan ds an d im prove acn e problem s. Repor ts suggest
th at it is e ect ive for act ive acn e.19 In lt rat ive fract ion al RF
can be used w ith a com bin at ion of di eren t n eedle length s
in on e session . Th is result s in m u ltilayer t reat m en t .
■ Rejuvenation by High-Intensity
Focused Ultrasound
Th e h igh -in ten sit y focu sed u lt rasou n d (HIFU) d evice
em it s u lt rasou n d , w h ich p en et rates t h rough skin an d
focu ses t h e sign al on a sm all p oin t below t h e skin su r face.
Table 26.1 Types of cartridges that should be used for targeting di erent HIFU penetration depths in various
conditions
Thin skin and fat Thin skin, normal fat
Dermis
Fat layer A t ype A, B t ypes
SMAS B t ype B, C t ypes
A t ype cartridge: 2 mm penetration in normal-t ype skin and subcutis.
B t ype cartridge: 3 mm penetration in normal-t ype skin and subcutis.
C t ype cartridge: 4.5 mm penetration in normal-t ype skin and subcutis.
D t ype cartridge: 6 m m penetration in normal-t ype skin and subcutis.
Th e m et h od relies on t h e d eliver y of con cen t rated u lt ra-
sou n d en ergy from t h e u lt rasou n d t ran sd u cer. Th e HIFU
m et h od is n ot on ly u sed for lysin g fat in t h e body bu t also
for t arget in g t h e SMAS in t h e face. Ult h era w as t h e rst
d evice claim ing to t arget t h e SMAS u n d er t h e skin . HIFU
d elivers u lt rasou n d en ergy to t h e SMAS an d d en at u res
collagen an d st im u lates regen erat ion . Ult h era u ses 4-, 7-,
an d 10-Mh z t ran sd u cers an d t arget s a sp ot 4.5 m m , 3.0
t ran sd u cers. Th e focu sed coagu lat ion area is called t h e
t h er m al coagu lat ion zon e (TCZ). After 12 w eeks t h e TCZ
is rep laced by n ew collagen syn t h esis.20,21,22 Th e sh ap e of
t h e TCZ is an “inver ted con e” or cylin d er, an d t h e size is
~ 1 m m . TCZs are m ad e fract ion ally in lin e by t h e scan n er
of t h e t ran sd u cer. Th is is called t h e “t reat m en t lin e.” Each
t reat m en t lin e is 2.5 cm an d is com p osed of 17 to 23 TCZs;
t h e in ter val bet w een TCZs in t h e lin e is 1.1 to 1.5 m m .
Even t h ough it is rep or ted t h at a 4-MHz, 4.5-m m t ran s-
d u cer h as a TCZ at t h e 4.5 m m d ept h , t h e d ept h of t h e TCZ
w ill d i er dep en d ing on w h et h er it is p h an tom , fat t is-
su e, skin , d e-ep it h elialized skin , etc. W h en HIFU t raverses
low -im p edan ce t issu e su ch as fat , it resu lt s in a d eep TCZ.
W h en HIFU t raverses h igh -im p edan ce t issu e su ch as skin ,
it for m s TCZ at a sh allow d ept h . Th e d ept h of TCZ is n ot
xed accord in g to t h e t ran sd u cer. Th u s, it sh ou ld be t aken
in to accou n t w h en clin ically ap p lied . W h en w e t reat t h e
t h in -skin n ed p at ien t w it h HIFU, t h e TCZ m ay be deep er
t h an exp ected , becau se t h in skin w ill n ot absorb HIFU
m u ch . On t h e ot h er h an d , w h en w e t reat t h ick-skin n ed
p at ien t s w it h HIFU, too m u ch en ergy m ay be absorbed in
it s early p rop agat ion , for m in g t h e TCZ at a sh allow d ept h .
Th ese factors sh ou ld be con sid ered in t h e t reat m en t p ro -
tocol (Table 26.1).
Good can didates for this procedure are those w ho have
a fat t y ch eek. Th ey m ay be satis ed w ith th e shru n ken ch eek
after HIFU treat m en t. Conversely, th ose w ith a th in ch eek
w ould com plain about a sun ken ch eek appearan ce after
HIFU t reatm en t . Som et im es focal depression is obser ved
after HIFU t reatm en t , w h ich is regarded as fat atrophy.
Normal skin and fat Thick skin and fat
A t ype A, B t ypes
B t ype B, C t ypes
C t ype D t ype
 26 Facial Rejuvenation Using Energy Devices 347

■ Rejuvenation by a

Pneumatic Devices
Skin rejuven at ion tech n ology u sing pn eu m at ic en ergy is a
n on invasive p rocedure delivering m icro-jet u id in to th e
derm al or subderm al layer w ith out th e use of a n eedle.14,15
Micro-jet u id is broken dow n in to m icro-bu bbles in skin
t issue an d spreads th rough th e derm is even ly, form ing a
vor tex an d accelerat ing collagen boost ing in collagen -rich
derm al t issu e by h igh pressure. Th is can be used for facial
lift ing, scar t reat m en t (acn e scars, su rgical scars, an d keloid
b
scars), w rin kles, etc. Variou s u id s can be u sed, su ch as
salin e solu t ion , dilu ted n on -cross-lin king hyalu ron ic acid
(HA) solut ion, 20% glu cose solut ion , an d poly-deoxy ribo-
n u cleot ide (PDRN) accord ing to th e sp eci c requ irem en ts.
W h en using a pn eum at ic energy–based device, su cien t
pressure an d speed are n eeded. How ever, th e pressure an d
volu m e of u id sh ou ld be adju sted to variou s skin con di-
t ion s su ch as th ickn ess, elast icit y, exibilit y, an d st rength .
An im m ediate skin rejuvenation e ect is achieved by ll-
ing the em pt y space bet ween skin tissue cavities w ith m icro-
bubbles and perform ing skin tightening by physical injection.
Facial w rinkles caused by collapse of skin tissue can be c
im proved by injection of diluted non-cross-linking HA solu-
tion into the appropriate skin structure. Right after injection,
the injection site w ill appear like a balloon w ith bleaching
seen. This w ill rem ain from m inutes to hours depending on
the t ype and viscosit y of uid injected. As the injected uid is
absorbed, the bleaching balloon form ed at the injection site
subsides slow ly and occasionally rem ains erythem atous.
A prolonged skin rejuven at ion e ect is n ow possible
due to dam aged skin t issue regen erat ion w ith n ew colla-
gen syn th esis. Du e to th e n ew collagen syn th esis, p at ien ts
can feel con t in uous skin ch anges such as im provem en t Fig. 26.9 Neck wrinkle treatment with Innojector (Amorepaci c
of skin text ure an d th e facial con tou rs. Th ese ch anges are Co., South Korea). (a) Before treatment of neck transverse line. (b)
m an ifested th ree m on th s after th e t reat m en t . Th ree to ve Single treatment using needle-less tip (150 µL saline per shot, pres-
t reat m en t s biw eekly can resu lt in aesth et ic im provem en t sure level 3, distance bet ween injection sites ~ 1.0 cm). Swelling is
(Fig. 26.9). observed immediately after injection. (c) One m onth after treat-
ment. (Courtesy of Dr. Beom -Joon Kim, Seoul, South Korea.)

References
1. Desm et t re T, Maurage CA, Mordon S. Heat sh ock protein
hyperexpression on ch orioret in al layers after t ran spu-
p illar y th erm oth erapy. Invest Oph th alm ol Vis Sci 2001;
42(12):2976–2980
2. Souil E, Capon A, Mordon S, Din h -Xuan AT, Polla BS, Bach -
elet M. Treat m en t w ith 815-nm diode laser in duces long-
last ing expression of 72-kDa h eat sh ock p rotein in n orm al
rat skin . Br J Derm atol 2001;144(2):260–266
3. Om i T, Kaw an a S, Sato S, Hon da M. Ult rast ruct ural ch anges
elicited by a n on -ablat ive w rin kle redu ct ion laser. Lasers
Surg Med 2003;32(1):46–49
4. Lee SY, Park KH, Choi JW, et al. A prospective, random ized,
placebo-controlled, double-blinded, and split-face clinical
study on LED phototherapy for skin rejuvenation: clinical,
pro lom etric, histologic, ultrastructural, and biochem ical
evaluations and com parison of three di erent treatm ent set-
tings. J Photochem Photobiol B 2007;88(1):51–67
5. Orringer JS, Kang S, Joh n son TM, et al. Con n ect ive t is-
su e rem odeling in du ced by carbon dioxide laser resu r-
facing of p h otodam aged h u m an skin . Arch Derm atol
2004;140(11):1326–1332
6. Orringer JS, Voorhees JJ, Ham ilton T, et al. Derm al m at rix
rem odeling after n on ablat ive laser th erapy. J Am Acad Der-
m atol 2005;53(5):775–782
7. Dain ich i T, Ueda S, Fu m im ori T, Kir yu H, Hash im oto T.
Skin t igh ten ing e ect using fract ion al laser t reat m en t II:
a p ilot an im al st u dy on skin rem odeling. Derm atol Su rg
2010;36(1):71–75
348 V Facial Skin and Hair Rejuvenation
8. Ort iz AE, Trem ain e AM, Zach ar y CB. Long-term e -
cacy of a fract ion al resu rfacing device. Lasers Su rg Med
2010;42(2):168–170
9. Man u skiat t i W, Fit zpat rick RE, Gold m an MP. Long-term
e ect iven ess an d side e ect s of carbon dioxide laser re-
su rfacing for p h otoaged facial skin . J Am Acad Derm atol
1999;40(3):401–411
10. Ort iz AE, Goldm an MP, Fit zpat rick RE. Ablat ive CO2 lasers
for skin t igh ten ing: t radit ion al versus fract ion al. Derm atol
Su rg 2014;40(Su pp l 12):S147–S151
11. Bjerring P, Clem en t M, Heicken d or L, Egevist H, Kiern an
M. Select ive n on -ablat ive w rin kle red u ct ion by laser. J Cu -
t an Laser Th er 2000;2(1):9–15
12. Goldberg DJ, W h it w or th J. Laser skin resu rfacing w ith th e
Q-sw itch ed Nd :YAG laser. Derm atol Su rg 1997;23(10):
903–906, discu ssion 906–907
13. Schm ults CD, Phelps R, Goldberg DJ. Nonablative facial rem od-
eling: erythem a reduction and histologic evidence of new col-
lagen form ation using a 300-m icrosecond 1064-nm Nd:YAG
laser. Arch Derm atol 2004;140(11):1373–1376
14. Mit ragot ri S. Cu rren t st at u s an d fu t u re prosp ects of n ee-
d le-free liqu id jet injectors. Nat Rev Drug Discov 2006;
5(7):543–548
15. Baxter J, Mit ragot ri S. Need le-free liqu id jet inject ion s:
m ech an ism s an d app licat ion s. Exp ert Rev Med Devices
2006;3(5):565–574
16. Lee HS, Lee DH, Won CH, et al. Fract ion al rejuven at ion u s-
ing a n ovel bip olar radiofrequ en cy system in Asian skin .
Derm atol Su rg 2011;37(11):1611–1619
17. Seo KY, Yoon MS, Kim DH, Lee HJ. Skin rejuven at ion by
m icron eedle fract ion al radiofrequ en cy t reat m en t in Asian
skin : clin ical an d h istological an alysis. Lasers Surg Med
2012;44(8):631–636
18. Kim JE, Lee HW, Kim JK, et al. Object ive evalu at ion of th e
clin ical e cacy of fract ion al rad iofrequ en cy t reat m en t for
acn e scars an d en larged pores in Asian skin . Derm atol Surg
2014;40(9):988–995
19. Lee KR, Lee EG, Lee HJ, Yoon MS. Assessm en t of t reat m en t
e cacy an d sebosu ppressive e ect of fract ion al radiofre-
quency m icron eedle on acn e vulgaris. Lasers Surg Med
2013;45(10):639–647
20. W h ite W M, Makin IR, Barth e PG, Slayton MH, Gliklich RE.
Select ive creat ion of th erm al injur y zon es in th e su per -
cial m usculoapon eurot ic system using inten se ult rasoun d
th erapy: a n ew t arget for n on invasive facial rejuven at ion .
Arch Facial Plast Su rg 2007;9(1):22–29
21. W h ite W M, Makin IR, Slayton MH, Barth e PG, Gliklich R.
Select ive t ran scu t an eou s deliver y of en ergy to porcin e soft
t issu es u sing In ten se Ult rasou n d (IUS). Lasers Su rg Med
2008;40(2):67–75
22. Lau bach HJ, Makin IR, Barth e PG, Slayton MH, Man stein D.
In ten se focused ult rasoun d: evaluat ion of a n ew t reat m en t
m odalit y for precise m icrocoagu lat ion w ith in th e skin .
Derm atol Su rg 2008;34(5):727–734
27 Hair Transplantation in East Asians
Sungjoo (Tommy) Hwang
Pearls
• Th e East Asian sku ll ten ds to be rou n der in
circum feren ce an d to h ave a larger an d w ider
foreh ead com pared w ith it s Cau casian coun terp ar t ,
w h ich result s in roun ded fron totem poral angles an d
a at ter h airlin e.
• Asian s h ave few er h airs an d a low er m ult i-h air
follicular u n it (FU) cou n t th an Caucasian s. Th e
follicle length from epid erm is to derm al papilla is
longer an d th e average h air sh aft diam eter is th icker.
• Asian s are pron e to keloid an d hyper t roph ic
scarring, w h ich is m ore com m on in you nger p at ien t s
due to th eir h igh er rate of collagen syn th esis.
• Even after p at ien t s receive h air t ran splan t at ion ,
th e loss of exist ing h air con t in ues as t im e goes on .
Th erefore, addit ion al m edical t reat m en t is n ecessar y
to p reven t or lim it fu rth er h air loss.
• “Depth -con t rolled t ran sp lan t at ion ” according to
graft length can h elp to yield a su p erior resu lt an d
h elp to m in im ize com p licat ion s su ch as folliculit is,
pit t ing, an d poor sur vival.
■ Introduction
In h air t ran splan t at ion , th e term Asian en com passes in di-
vidu als from a w ide area located geograp h ically from w h at
European s call th e Middle East to th e Far East . Eth n ic groups
h ave di eren t h air an d facial ch aracterist ics depen ding on
th eir coun t r y of origin . In th is ch apter, th e w ord Asian w ill
m ain ly be u sed in referen ce to th e p eop les of East Asia, su ch
as th e Korean s, Japan ese, an d Han Ch in ese.
Historically, Asians have been concern ed less about m ale
pat tern hair loss (MPHL) than Caucasians. This is m ainly
because MPHL was associated w ith w ealth, the w isdom due
to age, and the upper classes.1,2 In today’s societ y, Asians are
becom ing m ore concerned about their external features and
appearan ce th an they h ave been in the past. For exam ple, it
is becom ing m ore di cult for Korean m ales w ith a Norw ood
t ype IV or greater level of baldness to get m arried or obtain
em ploym ent because th ese individuals look older than th eir
actual age. This can lead to feelings of insecurit y and sh am e.
To overcom e this, m ore and m ore Asians are becom ing inter-
ested in hair transplantation surger y.
• Ap p lying th e vibrator an d ice p ack du ring local
an esth esia can be ver y h elp fu l in redu cing p ain .
Allow ing th e pat ien t to grasp th e assistan t’s h an d or
arm can also h elp to m in im ize th e react ion to p ain .
• Vit am in E, om ega-3, an d h erbal m edicat ion s sh ould
be avoided for at least t w o w eeks prior to surger y to
redu ce bleeding during h air t ran splan t at ion .
• Preoperat ive oral diazepam m ay lim it th e in ciden ce
of syn cope an d fain t ing. Taking a break an d
con su m ing cookies an d juice w ould be h elpful to th e
pat ien t in redu cing discom for t during th e h ours-
long op erat ion .
• Follicular u n it ext ract ion (FUE) sh ould be perform ed
w ith care in Asian s because of th eir idiopath ic
t issue brosis, low er FU den sit y an d h air-graft rat io,
h igh h air-skin color con t rast , an d a h igh er risk of
t ran sect ion du e to th eir longer h air follicle.
• Several factors sh ou ld be evalu ated du ring
con su ltat ion . Th ese in clu de th e age of th e pat ien t ,
don or den sit y, don or h air th ickn ess, exten t of h air
loss, an d th e pat ien t’s exp ect at ion s.
Hair t ran sp lan tat ion am ong East Asian s an d Cau casian s
is sim ilar in m any asp ects, but th ere are several di eren ces
th at m ust be discussed.
■ Characteristics of the
Asian Scalp and Hair
Shape and Hairline
Th e sh ape of th e Asian skull appears roun der in circu m fer-
en ce th an th e u su ally ovoid Cau casian sku ll. Th e foreh ead
area of th e Asian sku ll also ten ds to be larger an d w ider
th an it s Cau casian coun terpart (Fig. 27.1). Th ese di er-
en ces resu lt in rou n ded fron to-tem p oral angles an d a h ead
th at is at ter across th e h airlin e in East Asian s.3
Clin ical con sultat ion s w ith Asian m ales h ave fou n d
th at m ost prefer a low, st raigh t h airlin e w ith a roun ded
fron totem p oral angle. Su rgeon s occasion ally recom m en d a
fron t al recession to p at ien ts for a bet ter cosm et ic resu lt , as
it is som et im es n ecessar y to m odify th e pat ien t’s desired
349
350 V Facial Skin and Hair Rejuvenation
a b
h airlin e to p rodu ce an aesth et ically accept able cosm et ic
resu lt . For pat ien t s w ith Nor w ood class VI or VII h air loss,
a fron t al forelock design con n ect ing th e tem ple areas w ill
p roduce aesth et ically accept able results for m ost Asian
p at ien t s, alth ough t ru e isolated fron tal forelocks are n ot
w ell accepted by th e m ajorit y of Asian s.
Hair Characteristics
Com pared w ith Caucasian s, Asian h air is coarser, h as a
larger caliber, an d is u sually st raigh ter. Th e average h air
sh aft diam eter of an Asian is ~ 100 m m , versu s a m axim u m
of ~ 70 m m for th at of Caucasian s.1,2 Th e larger-caliber h air
sh aft con t ribu tes to th e ap pearan ce of greater h air den sit y.
Fu rth erm ore, th e color con t rast bet w een black h air an d
ligh t skin is h igh . Skin color varies from w h ite to dark across
Asia (e.g., Korean s an d Japan ese tend to h ave w h ite skin ,
w h ereas Malaysian s an d In dian s tend to h ave darker skin ).
Th is h igh skin /h air color con t rast also m akes it ver y di -
cult to ach ieve th e illusion of fulln ess, because th e scalp can
be clearly seen th rough th e st raigh t black h air. As a result ,
th e h igh color con t rast coupled w ith th e larger-caliber h air
m akes a t ran sp lan t m ore n ot iceable w h en m in i or p u n ch
graft s are u sed . Th erefore, follicu lar u n it t ran sp lan t at ion
(FUT) is th e m eth od of ch oice for Asian s for produ cing a
m ore n at u ral look.4,5
Th e follicle length from epiderm is to derm al papilla is
5.5 m m on average in Asian s com pared w ith ~ 4.5 m m in
Cau casian s. Th is resu lt s in a h igh er risk of t ran sect ion of
graft s du ring don or h ar vest ing an d graft dissect ion .6
Fig. 27.1 (a,b) Comparison of Asian and
Caucasian skull shapes. The East Asian skull
is rounder in circumference and has a larger
and wider forehead compared with the Cau-
casian counterpart.
Hair Density
The hair densit y of the donor area of an Asian m ale is usually
low er than that of Caucasian m ales. Caucasian s have h air
densit y of an average of 200 hairs/cm 2 in the donor area,7
w h ereas Koreans have ~ 137 h airs/cm 2 in the occipital area
an d 118 h airs/cm 2 in th e tem poral area.1 Ezaki est im ates
that the average hair densit y in Japanese m en is 130 hairs/
cm 2 , w h ile Path om van ich reports th at Th ai m en h ave 170
hairs/cm 2 in the occipital an d 127 h airs/cm 2 in the parietal
area.8,9 In gen eral, m ales in th e Far East of Asia h ave a low er
h air den sit y th an th ose in th e Middle East or Sou th east Asia.
The occipital follicular units of Koreans are ~ 37% single-
haired, 38% t wo-haired, and 25% three-haired. According to
Im agawa, the scalp hairs of Japanese m en are m ade up of 30%
single-hair, 50 to 55%t wo-hair, and 15 to 20%three-hair FUs
on average.1 Pathom vanich states that the scalp hair of Thai
m en has 24% single-hair, 64% t wo-hair, and 13% three-hair
FUs.9 In addition, Thai m en have 90 FU/cm 2 or 170 hairs/cm 2
in the occipital area w hile in the parietal zone, they have 70
FU/cm 2 or 127 hairs/cm 2 . This represents 1.8 hairs/FU. Ber-
nstein found that Caucasian m en have an average of 25%
one-hair FUs, 50% t wo-hair FUs, and 25% three-hair FUs.4,5
Caucasians have a sim ilar densit y of FUs, but have 2.3 hairs/
FU, resulting in a greater total num ber of hairs.
In gen eral, h air t ran splan t at ion doctors cou n t th e
n u m ber of “graft s” t ran splan ted. How ever, Korean doctors
coun t th e n um ber of “h airs” t ran splan ted. Th is is because
th e rat io of single-h air FUs to m u lt i-h air FUs varies greatly
am ong p at ien t s, an d th e resu lt s are depen den t on th e n u m -
ber of h airs an d n ot on th e n um ber of graft s.

Scar Formation
Th e Asian scalp is th icker an d less elast ic th an th e Cau ca-
sian scalp an d su ers a h igh er in ciden ce of keloid or hyper-
t roph ic scarring at th e don or site.1,2,9 Th ese scars occur less
com m on ly in Asian s th an th ose from African descen t , but at
a h igh er rate th an in Cau casian s.1,2 Th ese scars occur in th e
don or area an d are ver y rare in th e recipien t area. Th e m ain
cause for hypert roph ic scarring in Asian s is gen et ic, an d
th e problem occurs m ore com m on ly in younger pat ien ts,
due to th eir h igh er rates of collagen syn th esis. Th ese scars
can also be aided by excessive ten sion du ring don or site
closu re. Th e risk in creases if m ult iple h air t ransplan t at ion
session s are n ecessar y, so su rgeon s sh ou ld avoid th e u se of
w ide st rips an d m in im ize ten sion during closure.
The Importance of Medications
in Asians
Com pared w ith Caucasian s, usu ally few er h airs on th e East
Asian h ead are available for h ar vest ing.1 Also, a h igh er rate
of scarring on th e don or site lim its th e n u m ber of proce-
d u res available to East Asian s.9 Even after p at ien ts receive
hair t ran splan t at ion , th e ongoing loss of h air con t in ues as
t im e goes on . Th erefore, it is essen t ial to m ain t ain exist-
ing h air in East Asian pat ien t s w ith m edicat ion s like oral
n asteride an d topical m in oxidil, w h ich can slow fu t u re
hair loss.10,11,12,13 In ad dit ion , by m ain t ain ing exist ing h air
To evaluate w h eth er a pat ien t is a good can didate for
th rough th e use of m edicat ion , a pat ien t’s self-esteem can
h air t ran splan t at ion , w e n eed to t ake several factors in to
be greater due to th e h air’s h igh er den sit y.
con siderat ion .2
■ Patient Evaluation
Th e follow ing poin ts sh ould be discussed during con sult a-
t ion w ith pat ien ts.2
1. Pat ien t s n eed to be in form ed about th e procedure,
exp ected cou rse after th e p rocedu re, an d p ossible
com plicat ion s.
2. Realist ic expectat ion s regarding th e n um ber of h airs
an d areas to be t ran sp lan ted n eed to be exp lain ed, as
w ell as ach ievable long-term resu lt s.
3. It is h elpfu l to draw th e ach ievable h airlin e w ith a
colored pen cil to sh ow th e pat ien t .
4. It is h elpfu l to grade expected result s based on th e
age, severit y, fam ily h istor y, an d den sitom eter result
of th e pat ien t .
5. It is im port an t to explain th e n ecessit y of m edical
t reat m en t to preven t furth er h air loss.
6. Discu ssion about fut ure h airst yle can aid pat ien t
sat isfact ion . A sh ort h airst yle can resu lt in low er
p at ien t sat isfact ion , w h ile p art ing can be m ore
sat isfactor y cosm et ically.
27 Hair Transplant ation in East Asians 351
7. Pat ien t s w h o h ave been w earing w igs sh ould be
in form ed th at th e h air t ran splan t w ill n ot result in
th e sam e appearan ce as th at of don n ing a w ig.
8. In th e even t th at a pat ien t received an un sat isfactor y
procedu re from an oth er clin ic, it is im port an t n ot to
crit icize th e previous clin ic. It is m ore ben e cial for
th e pat ien t to receive a det ailed explan at ion about
th e im provem en t s ach ievable from an addit ion al
procedu re.
9. Sin ce th e aim of a procedu re can di er bet w een a
doctor an d a pat ien t , it is ben e cial to sh ow before
an d after p h otos of p reviou s pat ien t s.
10. Th ough pat ien t s prefer to h ave th e m axim u m
n u m ber of h airs to be t ran sp lan ted , t ran sp lan t able
h air n u m bers sh ou ld be based on scalp elast icit y,
fam ily h istor y, an d likely fu t u re p rogression .
11. Many Asian s rout in ely con su m e various h erbs
su ch as gin seng, garlic, an d on ion , as w ell as oth er
su p p lem en t s. Th ese h erbs an d su p plem en t s m ay
in crease bleeding during h air t ran sp lan t at ion
su rger y an d th erefore sh ou ld be avoided for at least
2 w eeks prior to surger y.14
12. A com plete blood coun t , a rout in e u rin alysis,
test s for h epat it is B an d C an t igen an d h um an
im m un ode cien cy virus (HIV), an d test s for liver
an d kidn ey fu n ct ion sh ou ld be p erform ed before th e
su rger y.
1 . Age: Am on g a ll age grou p s, p at ie n t s u n d e r t h e
age of 2 5 ye a r s a re t h e m ost d ifficu lt t o sat isfy.
Exp e r ie n ce d h a ir su r ge on s u su a lly avoid or
d elay h a ir t r a n sp la n t at ion for yo u n g p at ie n t s.
Ma le - p at t e r n h a ir loss st a r t s a ft e r a d olesce n ce .
Th e refore , m a n y p at ie n t s w it h a d va n ce d h a ir
loss in t h e ir 2 0 s re qu est h a ir t r a n sp la n t at ion .
In seve re ca ses, p e r for m in g t h e t ra n sp la n t is
in evit a b le . If t h e h a ir lo ss is n ot ve r y a d va n ce d ,
it is a d visa b le t o d elay t h e t r a n sp la n t a s lo n g a s
p o ssib le , a n d t h e d on o r sit e sh o u ld b e p rese r ve d
a s m u ch a s p ossib le for fu r t h e r t r a n sp la n t at ion
in t h e fu t u re , eve n if t h e t r a n sp la n t is p e r for m e d .
Do n or sit e sca r r in g is m o re co m m o n in you n ge r
p at ie n t s, so it is n e cessa r y t o d iscu ss sca r r in g.
Also, sp e cia l con sid e rat ion n e e d s t o b e give n
co n ce r n in g closu re , in clu d in g sm a lle r w id t h s a n d
in t e r n a l su t u res. Mid d le - age d or o ld e r p at ie n t s,
h ow eve r, r a rely d evelo p sign ifica n t sca r r in g o n
d on o r sit es, a n d t h e ir e xp e ct at ion s a b ou t t h e
t ra n sp la n t t e n d t o b e low e r. Th e refore , t h e ir
sat isfa ct ion t e n d s t o b e gre at e r a n d t h ey a re m ore
su it a b le for t h e t r a n sp la n t .
352 V Facial Skin and Hair Rejuvenation
2. Donor densit y: Th e h air d en sit y of th e p at ien t’s don or
area sh ou ld be evalu ated u sing a den sitom eter.15 Th is
procedure assesses th e n um ber of single-, t w o-, an d
th ree-h air FUs th at w ill be obtain ed from th e donor
area. Korean s h ave an average of 130 h airs p er squ are
m eter on th e occipit al scalp . Greater h air n u m ber
w ith h igh er den sit y ten ds to h ave 2- an d 3- h air FU,
resu lt ing in a bet ter outcom e after th e t ran splan t . If
th e den sit y is m uch low er th an average in pat ient s
w ith severe h air loss, h air t ran splan t at ion sh ould
be avoided because th e pat ien t w ill n ot be sat is ed
w ith th e result s.
3. Hair thick ness: Th icker h airs on th e don or site resu lt
in greater volum e an d bet ter cosm esis after th e
t ran splan t . It is h elpful, th erefore, to m easure th e
th ickn ess of th e h air during th e con sult at ion . If th e
h air th ickn ess is less th an 60 m m , th e ou tcom e of th e
h air t ran sp lan t at ion w ill n ot be as good an d pat ien t s
usually w ill n ot be able to ach ieve th e exp ected
fu lln ess.
4. Pat ient’s expectat ions: Pat ien ts w ith early m ale-
pat tern h air loss ten d to h ave h igh er expect at ions,
resu lt ing in low er pat ien t sat isfact ion . Also,
th e progression of alopecia an d th e sur vival of
t ran splan ted h airs can resu lt in u n usu al an d
un accept able h air pat tern s. In con t rast , advan ced
m ale-pat tern h air loss pat ien t s ten d to h ave low er
exp ectat ion s, resu lt ing in h igh er sat isfact ion . It is
ver y im p or tan t to assess th e p at ien t’s exp ect at ion s
from th e su rger y. Un realist ic expect at ion s w ill resu lt
in u n h appy p at ien ts. It is im por tan t to adjust th e
pat ien t’s expectat ion s prior to th e surger y, an d it is
w ise to delay th e su rger y if th e expectat ion s do not
ch ange.
5. Scalp laxit y: A th ick an d im m obile scalp is described
as “t igh t scalp,” an d it can be di cu lt to close th e
don or site w oun d if th e w idth is greater th an 1 cm . It
is safer to operate m ult iple t im es w ith sm all w idth s
in cases of t igh t scalp sin ce a w idth of 1.5 cm can
resu lt in n ecrosis an d severe scarring. With t igh t
scalp , th e w id th sh ou ld be sm all an d th e n u m ber
of h ar vested h air follicles low er th an usu al, or else
sat isfact ion w ith th e ou tcom e of t ran sp lan t at ion also
w ill be low. Th erefore, a scalp th at is too t igh t is a
con t rain dicat ion for h air t ran splan t at ion .
6. Past history and fam ily history regarding scarring:
East Asian s are gen et ically suscept ible to abn orm al
don or area scarring, w h ich a ect s th eir suitabilit y
for h air t ran splan t at ion . In part icular, th ey are
pron e to keloid scarring, w h ich occurs w h en the
brou s t issu e exp an ds beyon d th e bou n daries of th e
in cision al scar, an d hypert roph ic scarring, w h ich
is ch aracterized by exuberan t brous grow th th at
does n ot cross th e w oun d m argin . Th ese problem s
occur m ore com m on ly in younger pat ien t s, due to
th eir h igh er rates of collagen syn th esis. Du ring the
con su ltat ion , East Asian pat ien t s sh ould be carefully
screen ed for th ese p roblem s, an d old w ou n d s sh ou ld
be exam in ed. Pat ien ts w ith a person al h istor y of
keloid scar form at ion are n ot good can didates for
h air restorat ion surger y, w h ile th ose w ith a fam ily
h istor y of keloid scarring, or a person al h istor y of
hypert roph ic scarring, sh ould be cau t ion ed on th e
in creased risk of abn orm al h ealing.
■ Surgical Techniques
Preparation on the Day of Surgery
W h en th e pat ien t arrives for surger y, the auth or begin s
by t aking preoperat ive ph otograph s. If a pat ien t h as h igh
blood pressure, th is can lead to excessive bleeding during
su rger y. Tran sien t h igh blood pressu re m ay be cau sed by
em ot ion al st ress, so p reop erat ive sedat ives su ch as diaze-
pam an d/or sublingual n ifedipin e are useful in reducing or
n orm alizing th e pat ien t’s blood p ressure. Assistan t s sh ou ld
sh am p oo th e scalp before d on or h ar vest ing to redu ce th e
bacterial colony cou n ts in th e scalp, th us h elping to preven t
or reduce in fect ion s th at m ay be associated w ith surger y.
Hairline Design
Th e sh ape of th e scalp is gen erally roun d an d w ide am ong
East Asian s. Th e h airlin e design in East Asian s sh ou ld be
a w ide arc w ith less cen t ral convexit y, an d fron totem p o-
ral recession sh ou ld be less p rom in en t com pared w ith th e
Cau casian’s rou n d, convex h airlin e.3
Th e design of th e fron tal h airlin e is m ade using st an -
dard dist an ces an d an atom ical lan dm arks. Th e prin ciple of
th ree equal dist an ces is th e balan ce bet w een ch in an d n asal
t ip, nasal t ip an d glabella, an d glabella an d m idfron tal poin t
of the h airlin e. In gen eral, th e distan ce bet w een th e glabella
an d th e m idfron t al p oin t of th e h airlin e ranges from 6.5 to
8.5 cm .16 A 7.0 to 7.5 cm h airlin e w orks w ell in th e m ajor-
it y of pat ien t s, an d th is is w h ere th e auth or places m ost
h airlin es. W h en design ing th e h airlin e it is im port an t to
rem em ber th e h airlin e con sists of th e fron t al h airlin e an d
tem ples. Th e fron t al h airlin e h as to balan ce w ith th e tem -
ples to ach ieve a balan ced, n at ural look. If th e tem ples are
receded an d h air t ran splan t at ion on th e tem ple area is n ot
in dicated becau se of in su cien t don or h air, th en a h igh er
h airlin e, w ith an u p slop e, w ill create balan ce.
Gen erally, in pat ien ts w ith m ild h air loss an d bet ter
don or h air on average, placing th e fron t al h airlin e at 7 to 8
cm is safe. If th e pat ien t does n ot object , th e auth or gen er-
ally prefers to design in a sm all am ou n t of u pslope, th u s
m aking it easier to t ie th e top h airlin e to th e tem p les w ith -
out h aving it exten d too far in to th e tem ple area. Younger
pat ien t s w ill often push for a low er h airlin e or a dow n -
slop ing (juven ile) h airlin e. On an ad u lt Asian th is design
looks odd, is di cu lt to correct , an d sh ou ld be avoided.

Hair sh afts of East Asian s are coarse, dark, an d st raigh t .
It is u su ally n ot easy to m ake a soft an d n at u ral-looking
h airlin e in East Asian p at ien t s. Th erefore, Asian s requ ire
m ore single-h air u n it s to create a n at u ral-looking h airlin e.
Th e au th or prefers to place a m in im u m of 400 single-h air
FUs at th e fron tal h airlin e.
Th e rout in e th at th e auth or uses to create th e h airlin e is
sim p le an d is as follow s (Fig. 27.2):
1. Note th e distan ce bet w een th e ch in an d n asal t ip,
bet w een th e n asal t ip an d glabella, an d bet w een
th e righ t an d left tem ples. Using th e referen ce,
m ark a sh ort h orizon t al lin e 6.5 to 8.5 cm above th e
m idbrow level.
2. Mark a poin t on th is lin e dividing th e face in to equal
left an d righ t h alves. Th is can be don e easily by
h old ing th e m arking pen over th e n ose an d bisect ing
th e face in to equal h alves.
3. From th is m idpoin t draw th e top h airlin e laterally,
keep ing it on a h orizon t al p lan e or a sligh t u pslop e
w h en view ed from th e fron t .
4. Ch eck from th e fron t to m ake su re th e t w o sides
are even an d from th e side to see if th e lin e th at h as
been draw n balan ces th e exist ing tem ples. If th e
fron t al h airlin e looks low w h en view ed from th e
sides, you w ill h ave to m ove th e top lin es u p sligh tly
an d red raw th e top lin e w ith a sligh t u p slope.
5. Th e st raigh t lin e looks un n at ural. Add a zigzag
pat tern lin e on th e st raigh t h airlin e an d im plan t th e
single-h air FUs on th e zigzag lin e to m ake a n at u ral-
ap pearing h airlin e.
Fig. 27.2 Hairline design in Asian male with male-pat tern hair
loss. A new hairline is designed considering the vertical and hori-
zontal facial harmony. A zigzag pat tern is more natural-looking
than a straight line.
27 Hair Transplant ation in East Asians 353
Donor Harvesting
Strip Surgery
St rip h ar vest ing is perform ed by th e m ajorit y of h air resto-
rat ion su rgeon s th rough out th e w orld. ISHRS 2013 cen sus
resu lt s sh ow ed 68%for st rip h ar vest ing com pared w ith 32%
for follicular un it ext ract ion .17
La xit y of scalp can be assessed easily by m oving th e
scalp vert ically w h ile h olding h airs from th e don or site. It
can be classi ed in to hyperelast ic, n orm al, an d t igh t scalp.
Th ere are oth er m eth ods to m easure th e scalp laxit y: May-
er’s scalp elast icit y scale 18 an d Moh ebi’s la xom eter.19 Th ere
are di eren t op in ion s abou t ideal w idth s for d on or sites.
Th e opt im al w idth of th e don or st rip in Asian s is 1.5 cm
or less.1,2,6 It can be di cult to close using a 1-cm w idth in
pat ien t s w ith a t igh t scalp, so it is advisable to m in im ize
w idth s. It can be easy to close a hyperelast ic scalp w ith
w idth s of m ore th an 2 cm ; h ow ever, excess scarring can
result from th e st retch -back ph en om en on .20 Th erefore, it is
advisable to in cise w ith in a 1.5-cm w idth in p at ien t s w ith
hyperelast ic scalp. Wide scars ten d to occur m ore readily
in younger pat ien ts sin ce th e rate of collagen syn th esis is
greater. In you ng p at ien ts, th erefore, a long an d n arrow
don or st rip is safer th an a sh or t , w ide st rip.
On ce th is is determ in ed, th e h air is t rim m ed in th e
don or area, w h ich is located in th e m idocciput , exten ding
sligh tly in to th e tem p oral region . Th e h air is t rim m ed to
~ 2 m m in length w h en em ploying th e Western m eth od,
an d 5 to 10 m m in length for th e im plan ter tech n iqu e.21
Som e doctors p refer to u se th e t u m escen t tech n iqu e to
an esth et ize th e d on or area, w h ile oth ers favor a bu ered
solu t ion of 1% lidocain e w ith 1:100,000 epin ep h rin e w ith -
out t um escen ce.2 Allow ing th e pat ien t to h old th e assis-
tan t’s h an d or arm during local an esth esia can also h elp to
sooth e th e p ain . Ap p lying an ice p ack an d vibrator n ear th e
inject ion site during local an esth esia can be ver y h elpful
to red u ce p ain (Fig. 27.3).22 Pat t ing th e p at ien t’s back is a
useful m eth od to m ake th e pat ien t feel com for table during
don or h ar vest ing, especially in th e pron e posit ion .
To m inim ize the num ber of t ransected follicles, the
incision should be parallel to the direct ion of the hair fol-
licles. This is im portant because the length of hair follicles is
greater in Asian s th an in Caucasian s, an d th u s th e probabil-
it y of t ransect ion is higher am ong Asian s. For th is reason,
the single-blade knife technique is safer for m aking an inci-
sion th an th e m u lt i-blade kn ife tech n ique. More accurate
incision al m eth ods include the open technique suggested
by Path om van ich : Four skin h ooks an d t w o assistan ts are
required to gain m ore exposure and to potent ially cut
faster.6 He m in im ized th e follicular t ran sect ion at 1%or less.
In addit ion , bleeding n eeds to be con t rolled com p letely
before w ou n d closure. Arterial bleeding n eeds to be con -
t rolled w ith a h em ostat . Sm aller vessels can be con t rolled
w ith a h em ost at , bu t a larger vessel n eeds ligat ion w ith 4–0
Vicr yl (Eth icon ). It is recom m en ded th at th e surgeon avoid
or reduce th e degree of elect ro-cauterizat ion to con t rol
354 V Facial Skin and Hair Rejuvenation
Fig. 27.3 Applying an ice pack and vibrator near the injection site
helps to reduce injection pain.
bleeding in th e don or area sin ce it dam ages th e t issue an d
in terferes w ith w ou n d h ealing. It is best to rem ove all th e
dam aged follicles to preven t folliculit is or cyst s.
Th e w ou n d m ay be closed th rough a variet y of m eth -
ods. How ever, it is st ill con t roversial w h eth er t w o-layer
closure h as m ore ben e t th an single-layer closure, un der-
m in ing versu s n on u n derm in ing, staple versu s su t u re, an d
oth er opt ion s.16 Th e m ajorit y of surgeon s use absorbable
st itch es (Vicr yl or Mon ocr yl, Eth icon ) for deep -layer clo-
su res an d close th e skin w ith eith er st ap les or ru n n ing n on -
absorbable or absorbable st itch es.
Dam kerng repor ted th at t w o-layered closu re from h is
exp erien ce failed to m in im ize scarring, an d in stead h e
closes th e w ou nd w ith 3–0 nylon as reten t ion st itch es ~ 1.5
cm apart an d a 1-cm bite aw ay from th e in cision. Th e skin
is th en closed w ith ru n n ing 4–0 Vicr yl Rapide (Eth icon ).16
He reported it produ ced good resu lt s in Asian pat ien t s.
Th e auth or also h ad good result s w ith th e reten t ion su t u re
m eth od bu t p refers nylon su t u re over Vicr yl Rap id e becau se
absorbable su t u re m aterial h as m ore t issu e react ion an d a
ten den cy to leave a w orse scar in East Asian s (Fig. 27.4).
Reten t ion st itch es are u sually rem oved at 3 to 5 days post-
operat ive an d skin st itch es are rem oved at 10 days postop.
Trich op hyt ic closure is h igh ly recom m en ded in East
Asian pat ien t s to reduce th e don or scarring, especially
in you nger p at ien ts or pat ien t s w ith hyp er-elast ic scalp.
Th ere m igh t be som e con t roversy regarding t rim m ing of
th e superior or in ferior edge, bu t th ere h as been n o vis-
ible di eren ce in th e ap pearan ce of scarring. Trich ophyt ic
closure m ay im prove th e scar’s appearan ce, but pat ien ts
m ay also exp erien ce a sligh tly h igh er in ciden ce of cyst or
ingrow n h air form at ion on th e closure site.23,24,25,26
To avoid sign i can t scarring in th e don or area, risk
factors su ch as ten sion an d sm oking m u st be redu ced as
m u ch as p ossible; great care m u st be exten ded in p erform -
ing m et icu lou s surgical tech n iqu es. Despite th ese e ort s, a
sm all p ercen t age of pat ien t s w ill develop sign i can t scar-
ring, u su ally d u e to gen et ic di eren ces in skin t ype.
Follicular Unit Extraction
In 1988 Masum i Inaba in Japan in t roduced the use of a
1-m m punch for extract ing individual follicular units. Body
h air tran splan tat ion u sing a pun ch w as reported by Woods
in 1998. In 2002 Rassm an and Bernstein further re ned the
procedure an d nam ed it follicular unit ext raction.16,27 Harris
later in troduced the SAFE system using a blunt punch to free
the follicle.28 Isolat ing the follicles one by one using a m anual
punch w as ver y tim e-consum ing. Motorized FUE m achin es
w ere developed to in crease th e speed of ext raction .29 The
latest developm ent , from Robot ics, is an interact ive, com -
puter-assisted system using im age-guided robot ics to har-
vest follicu lar u n it grafts.30 Th e follicu lar u n its obtain ed by
strip surger y an d th e FUE m eth od are th e basic bu ilding
blocks of follicular unit transplantat ion (FUT).
In FUE, th e p hysician rem oves follicu lar u n its on e at
a t im e from th e don or site u n t il th ere are en ough for a
t ran splan t session . W h en using th e FUE roun d pun ch , th e
0.75- to 0.80-m m size sh ould be reser ved for on e-h air FUs.
The 1.0-m m size can be used for m ost t w o- an d th ree-
h air graft s. Th e larger, 1.2-m m pu n ch , w ith th e poten t ial
to leave a scar an d t ran sect adjacen t follicles, sh ould be
avoided. Th e en t ire don or site sh ould be t rim m ed, leav-
ing beh in d 0.3 to 0.5 cm of h air above th e skin to guide th e
p un ch . FUE is a tech n iqu e th at requ ires special skill on the
p art of th e physician an d ben e t s th e p at ien t w ith less visi-
ble don or-site scarring, although sm all polka-dot scars m ay
ap pear at sites of follicu lar u n it ext ract ion . FUE p rocedu res
u su ally requ ire few er su rgical st a m em bers, less su rgical
exp erien ce on th e p ar t of th e p hysician , an d n o n eed to
rem ove sut ures.
FUE cau ses sm all, p olka-d ot-like, w h ite scars in th e
d on or area.16,29 Both th e th ousan ds of sm all rou n d scars
from FUE an d th e long lin ear scar from th e st rip h ar vest
Fig. 27.4 Using retention sutures with nylon in closing the donor
site wound helps to minimize suture scarring by reducing tension.
 27 Hair Transplant ation in East Asians 355

are often h ard to detect w h en h air in th e don or area is at a

n orm al length an d th e ext ract ion is p erform ed by a skilled
su rgeon . How ever, th e d on or den sit y is m u ch low er in East
Asian s th an in Caucasian s, so to get en ough h airs, w ith FUE
th e follicles are h ar vested from a m uch greater area of th e
d on or zon e com p ared w ith st rip h ar vest , an d th e ch an ce
of get t ing h air from a n on safe don or area is h igh er.16,27
Becau se of th e h igh h air-skin color con t rast , em pt y sp ot s,
sn ail t racks, an d m ot tling occu r w h en adjacen t follicles are
ext racted in East Asian s.
Another draw back is transection (Fig. 27.5). Because the
hair follicle is longer in Asians than in Caucasians, the punch
has to score m ore deeply to free the follicle, w ith a higher
risk of tran section. Therefore, th e FUE technique should be
perform ed ver y carefully to avoid transection in Asians.16
A p roblem of bu ried graft s can occu r du ring th e FUE Fig. 27.5 Transection of follicle by follicular unit extraction occurs
techn iqu e w h en th e graft is pu sh ed in to fat an d m ust be more commonly in Asians because the hair follicle is longer.
rem oved th rough a sm all in cision . FUE can also be m ore
exp en sive an d take longer to p erform th an FUT, so graft s
are u su ally ou t of th e body longer, risking su bopt im al
grow th .27
graft d epth in th e recip ien t area can occu r. For exam ple, if
a single p at ien t h as 6-, 5-, 4-, an d 3-m m -length graft s in
Graft Dissection and th e don or area, an d all in cision s are m ade at a 6-m m depth ,
Graft Preservation th en a 6-m m graft w ill t in th e slit adequately. But a 3-m m
graft w ill be located 3 m m d eep er th an th e p roper depth
A graft can be prep ared by slivering from th e st rip . Slivers an d cou ld resu lt in follicu lit is, cyst , p it t ing, an d p oor su r-
are fu rth er dissected in to follicu lar u n it graft s w ith a d ou - vival (Fig. 27.7).2,34,35
ble-edge razor blade or n o. 20 blade. Tran sect ion of th e graft s can som et im es occu r during
Graft d issect ion is u su ally accom p lish ed u n der a 3× graft p reparat ion w ith FUT an d FUE. Tran sected follicles
m agn i ed lou p e, bin ocu lar stereo m icroscop e, Man t is sh ould also be p laced at th e p rop er level to avoid deeper
m icroscope (New Vision Engin eering), or digital m on i- locat ion in th e recipien t site. Th erefore, to preven t th e
tor m icroscope w ith ~ 10× p ow er m agn i cat ion .31,32,33 com plicat ion s m en t ion ed, a surgeon n eeds to group th e
East Asian h airs are larger in caliber an d h ave h igh skin / graft s in th e sam e in dividu al by length an d m ake prop er
h air color con t rast; th erefore, th is step can be don e w ith in cision d epth s according to each grou p. In pract ical term s,
th e n aked eye. But m agn i cat ion is qu ite h elpful in prepar- it takes a lot of t im e to m easu re th e length s of 2,000 to
ing grafts for East Asian s, par t icular for th e gray h airs. On e 3,000 h air follicles. To reduce th is t im e, th e auth or devel-
com m on problem en coun tered is gray or w h ite h air th at is
di cult to visualize an d coun t on direct in spect ion . Gen -
t ian violet an d m ethylen e blue h ave been used in th e past
to dye th e h air, bu t th is is m essy an d n ot really e ect ive.
Th e best solut ion is to h ave th e pat ien t dye th e h air 2 to 3
n igh t s before su rger y or, p referably, h ave th e h air colored
before surger y if th e pat ien t h as n o allergic react ion to dye-
ing m aterial. Make su re th e color st ain s th e h air close to
th e skin .16 Th ere are m any h air-coloring p rodu ct s available
on th e m arket . An in st an t h air coloring preparat ion w orks
quickly and is th e best do-it-you rself ch oice. Because it is
ver y di cu lt to dist ingu ish th e follicle an d skin in th e case
of gray color, th e colored h air can be a guidelin e for graft
p rep arat ion . With out dyeing th e h air, it is alm ost im pos-
sible to dissect th e h air follicles accu rately (Fig. 27.6).
Th e auth or reported th at th ere is a sign i can t di er-
en ce in graft length s in th e sam e in dividu al, especially in
th e East Asian com pared w ith th e Cau casian , an d if w e Fig. 27.6 Gray hair should be dyed before surgery. Dyed hair
m ake th e exact sam e in cision depth th rough ou t , im p rop er helps for bet ter visualization of the gray hair follicle.
356 V Facial Skin and Hair Rejuvenation
Fig. 27.7 A deeply transplanted graft may cause folliculitis on
the recipient site.
oped a board for graft length m easurem en t . As sh ow n in
Fig. 27.8, a fu rrow on th e board is m ade an d th e en d of th e
graft is p laced on th e ledge of th e fu rrow ; th en in dividu al
h air follicles are grou ped by length . Using th is device, th e
au th or’s assistan ts w ere able to m easu re th e length s m ore
e cien tly an d redu ce th e t im e of m easu rem en t . With th e
“depth -con t rolled t ran sp lan tat ion ” tech n iqu e, th e au th or
h as redu ced or preven ted follicu lit is, cyst , an d pit t ing in
m ost of h is p erson al cases.34
Con t rol of th e tem perat ure an d preven t ion of desic-
cat ion is im por t an t . Com m on ly used solut ion s are ch illed
n orm al salin e or lact ate Ringer, an d graft s sh ou ld be
im m ersed in th e solut ion but ju st put on w et gau ze.36 Stor-
age of prepared graft s on gau ze or Telfa pads (Ken dall) can
in crease th e in tegrit y of th e h air graft s as com pared w ith
su bm erged p reser vat ion . Su r vival of p reser ved h air graft s
Fig. 27.8 Hwang’s board for graft length measurement. The
length of each follicle was measured on Hwang’s board; 3- to 4-mm,
4- to 5-mm , 5- to 6-mm, and 6- to 7-mm grafts were grouped.
is bet ter at 4°C th an at room tem perat u re.36 Even th ough
ch illed salin e is used, it is best to im plan t th e graft s w ith in
a 6-h ou r period. Recen tly, a variet y of n ew storage solu -
t ion s an d m aterials, such as Plasm a-Lyte (Baxter Health -
care), HypoTh erm asol-ATP (BioLife Solu lt ions), ACell, an d
p lasm a-rich protein (PRP), h ave been prom oted for im prov-
ing graft sur vival, but n o st udy h as est ablish ed th e best
storage solu t ion .37,38,39,40
Recipient Site
In Asian countries, both the im planter and Western tech -
niques of im plantation are used. The m ain di erence
bet w een these techniques is that w ith the Western tech-
nique, m ost of the recipient site incisions are prem ade by
the doctor, and grafts are planted later by the assistant nurse.
As a variation of this, the doctor m akes a ne slit and im m e-
diately places the FU in sit u. The im planter techniques w ere
rst developed in Korea in the 1990s and are w idely used
there but are not as popular in other countries. Historically,
Mr. Paek, a Korean m edical assistan t, developed an in stru-
m ent for eyebrow h air transplan tation for a patient w ith
m adarosis in the 1960s.41 Then Choi m odi ed this instru-
m ent an d developed th e Choi im planter in th e 1990s.21 Many
t ypes of im planters have since been m anufactured. This is
w hy the im planter technique is so popular in Korea, and it
has recently becom e m ore popular in Western countries.
The im planter is shaped like a pencil w ith a hollow nee-
dle at the tip. There are four sizes (0.6, 0.8, 1.0, an d 1.2 m m )
that correspon d to one-, t w o-, and three-h air follicular unit
grafts (Fig. 27.9). A single graft is placed in side th e hollow
en d of each device. Th e sh arp en d of th e device can then be
injected into the recipient site, w here it sim ultaneously cre-
ates a slit and inserts the graft in side the slit . On w ithdraw al
of the needle, the graft is left inside the in cision site.2
Fig. 27.9 Various t ypes of implanters. The sizes of an implanter’s’
needles (0.8, 1.0, and 1.2 m m from left to right) correspond to
one-, t wo-, and three-hair follicular unit grafts.
 27 Hair Transplant ation in East Asians 357

Hair t ran sp lan t at ion sh ou ld be directed like a nger

of a palm laid on th e crow n . Also, angles of t ran splan t a-
t ion sh ould be carefu lly ch osen an d varied according to th e
angle of th e foreh ead an d scalp (Fig. 27.10).
Each tech n ique h as advan t ages an d disadvan t ages, an d
n eith er m eth od is su p erior to th e oth er for h air t ran splan -
tat ion in Asian pat ien t s. It is a fact , h ow ever, th at m ost doc-
tors in South Korea an d m ore th an h alf of th e doctors in
Japan p erform th e im p lan ter tech n iqu e, w h ile doctors in
th e oth er Asian cou n t ries prefer th e Western m eth od. With
th e Western tech n ique, t um escen t an esth esia in th e recipi-
en t area h as th e advan tage of con t rolling bleeding from
th e prem ade slit s bet ter th an sim ple in lt rat ion . Th ere is
n o n eed to u se t u m escen t an esth esia w ith th e im p lan ter
tech n ique becau se th e im m ediately t ran splan ted graft s
preven t m ost of th e bleeding th at w ou ld oth er w ise occur
from th e in cision sites. Th is au th or u ses a solu t ion of 2%
lidocain e w ith 1:100,000 epin ep h rin e as a ring block along
th e an terior h airlin e an d 0.5%lidocain e w ith 1:100,000 epi- Fig. 27.10 Angles of transplantation should be changed accord-
n ep h rin e as a eld block. Don or site h ar vest ing t akes on ly ing to the angle of the scalp.
~ 30 to 60 m in u tes. Th e graft p lacem en t , h ow ever, u su ally
takes 2 to 4 h ours. It is di cult to sust ain th e e ect of local
an esth et ics longer th an 1 h ou r on th e scalp. Th erefore, it sh ow ed th at su r vival rates w ere h igh er at 20 to 30 graft s/
is advisable to inject areas th at w ill be t ran splan ted in th e cm 2 com p ared w ith th e h igh er t ran sp lan ted den sit ies of 40
n ext 30 to 40 m in u tes, rath er th an th e w h ole scalp at on ce. to 50 grafts/cm 2 . Th e recip ien t area den sit y suggested for
Th is also h elps to m in im ize bleeding at th e recipien t site. th e im plan ter is 30 grafts/cm 2 .2,44,45
Because of the large hair caliber of Asians, hair t ran s- Becau se th e don or supp ly is lim ited in Asian s com -
plantat ion looks un nat ural if t w o- or three-hair follicular pared w ith Caucasian s, a “den sit y gradien t” is advisable. If
unit grafts are im planted in the anterior feathering zon e. th e pat ien t w an t s to use a part ing, th en m ore den sit y on
Therefore, three to ve row s of single-hair follicular un its are th e fron t al area an d part side is n ecessar y. Less den sit y is
appropriate to give th e pat ien t a n at u ral-looking h airlin e.1,2 n eeded on th e p osterior area an d n onp ar t side of th e scalp .
A st u dy don e to assess th e su r vival rate of on e- an d t w o- Th erefore, it is desirable to im plan t t w o- an d th ree- h air
h air follicu lar u n it graft s u sing th e im p lan ter revealed graft FUs in th e p art site an d fron t al scalp an d on e-h air FUs in th e
grow th of 92.0% after 6 m on th s an d 90.4% after 1 year.42,43 posterior area an d n onpart side of th e scalp. With th is t ype
Th ere is con t roversy regarding th e opt im al den sit y for h igh of den sit y gradien t , com bing th e h air from th e part side
su r vival rate. Graft su r vival at di eren t t ran splan ted den - produces a “layering e ect ,” m aking th e h air appear fuller
sit ies w as also st u died in Korean p at ien ts, an d th e resu lt s (Fig. 27.11). With th is e ect , th e ligh t d oes n ot pen et rate

Fig. 27.11 More grafts on the part side

a b
makes the hair fuller by a layering e ect. (a)
With this t ype of densit y gradient, comb-
ing the hair from left to right produces a
“layering e ect,” making the hair appear
fuller. (b) Combing the hair from right to
left reduces the layering e ect.
358 V Facial Skin and Hair Rejuvenation
th e scalp as easily an d th e low er-den sit y areas becom e less
obvious. A proper den sit y gradien t an d layering are crit ical
elem en t s in th e aesth et ics of h air restorat ion in East Asian s.
■ Postoperative Care
Sh am pooing is u su ally resu m ed 24 h ou rs after su rger y an d
th e don or sut ures are rem oved 10 days follow ing surger y.
Folliculit is on th e recipien t site, w h ich is m ore com m on
in Asian s th an in Cau casian s, can occu r bet w een 1 an d 3
m on th s after su rger y. Th is con dit ion u su ally resolves it self
w ith in 6 m on th s postoperat ively. An addit ion al h air t ran s-
plan t at ion session , if n ecessar y, can be perform ed as early
as 6 m on th s follow ing th e in it ial session . How ever, it is u su -
ally recom m en ded to w ait at least 1 year. By th at t im e, th e
su rgeon w ill h ave a bet ter idea w h eth er ad dit ion al su rger y
is n ecessar y, w h ich don or area w ill be available, an d w h ich
recipien t site w ill receive th e t ran splan ted h airs for th e best
result s.
■ Key Technical Points
Depth-Controlled Transplantation
(DCT) According to Graft Length
1. Th ere are sign i can t di eren ces am ong graft length s
in th e sam e in dividual, especially in th e East Asian
com pared w ith th e Caucasian .
2. It is n ecessar y to sort th e grafts according to th eir
length an d to m ake th e proper in cision depth
according to th e graft length .
3. Th is “depth -con t rolled t ran splan t at ion ” tech n ique
can h elp to m in im ize com plicat ion s such as
follicu lit is, pit t ing, an d poor graft su r vival.34
Optimal Density for Best Survival Rate
• Den se packing u sing m ore th an 40 FUs/cm 2 m ay
result in poor h air grow th .
• A den sit y of 30 to 40 FUs/cm 2 or less is ap p rop riate
for Asian s an d p erm its th e best h air su r vival
rate.42,43,44,45
Density Gradient and Layering E ect
• If th e p at ien t ch ooses to u se a part ing, th en a h igh er
den sit y on th e fron t al area an d th e parted side is
n ecessar y.
• With a part , less den sit y is n eeded on th e p osterior
area an d on th e n onp ar t side of th e scalp .
• With th is t yp e of den sit y gradien t , com bing th e h air
from th e parted side an d fron t p rodu ces a “layering
e ect ,” m aking th e h air ap p ear fu ller.
Preparation of Gray Hair Follicle
• Becau se it is ver y di cult to dist inguish th e follicle
from th e skin in th e case of gray h air, coloring th e
h air can gu ide graft p reparat ion .
• With ou t dyeing th e h air, it is alm ost im possible to
dissect th e h air follicles accurately.
Scar Revision w ith W-plasty
• In case of a lin ear scar, sim ple excision an d closu re
can be done, but th e scar usually reappears at th e
sam e size or w ider du e to th e stretch -back e ect .
• In stead of lin ear closu re, W-p last y m ay be th e
t reat m en t of ch oice.
• W-plast y can preven t scar st retch ing. It can n ot
redu ce th e w idth of th e n ew scar, but it m ay
m ake th e scar look less n ot iceable th an it s lin ear
coun terpart due to its zigzag pat tern (Fig. 27.12).
■ Complications and
Their Management
For e ect ive h air t ran splan t at ion , it is im por tan t to kn ow
n ot on ly h ow to produ ce good result s, but also h ow to pre-
ven t su rgical com p licat ion s.
Necrosis and Dehiscence
Large an d w ide don or site in cision can resu lt in a w ou n d
w h ich can n ot be closed, or in a w oun d closu re w ith too
m u ch ten sion . Th is w ill in terfere w ith circu lat ion , resu lt ing
in com p licat ion s su ch as n ecrosis an d deh iscen ce.1,46 Appro-
priate w idth is im port an t to preven t th ese com plicat ion s,
an d w id th s bet w een 1 an d 1.5 cm are gen erally acceptable.
In cases w h ere th ere is di cu lt y in closing th e w oun d, it is
bet ter to let th e w oun d h eal by secon dar y in ten t ion after
part ial closu re w ith m oderate ten sion .
Pain, Numbness, Hypoesthesia,
Hyperesthesia, and Neuralgia
Many pat ien t s experien ce p ain on th e don or site after
th e t ran splan t . In m ost cases, th e pain su bsides w ith in 2
days. Occasion ally, sen sat ion can be redu ced or lost at th e
don or site or in areas above th e don or site.1,47 Cases u su ally

a b
Fig. 27.12 Revision of linear scar using W-plast y. (a) Scar on the donor site. (b) W-plast y postop. (c) Six m onths postoperative.
resolve w ith in a few m on th s, bu t persist for m ore th an 1
or 2 years in rare cases. Also in rare cases, a pat ien t m ay
com plain of n eurologic or elect rical pain . Th ese result from
n er ve dam age du ring n er ve h ar vest ing or abn orm al n er ve
h ealing. Gen erally, th ese com p licat ion s occu r after FUE.
Undesirable Scar
Scar r in g can d i e r d u e to a p at ie n t ’s race an d age.
Asian s an d you n ge r p e op le t e n d to d evelop m ore scars.
You n ge r age a e ct s scar r in g d u e t o t h e p e rson ’s h igh e r
h ealin g act ivit y. Sm alle r w id t h s, d ou b le- laye r closu re,
an d t r ich op h yt ic closu re can h elp to m in im ize scar-
r in g. Pat ie n t s w it h a t e n d e n cy to d evelop hyp e r t rop h ic
or keloid scars sh ou ld be t reate d m ore carefu lly. Scars
can b e h elp e d by t ran sp lan t in g h airs on t h e scar it self or
u sin g W- p last y to re m ove t h e scars. Th e sim p le excision
of scars is kn ow n to be u n h elp fu l. FUE also leaves a rou n d
hyp op igm e n t e d scar.
Temporary Hair Loss
Areas arou n d th e w ou n d closu re can develop tem p orar y
alop ecia begin n ing 2 w eeks after th e procedu re.1,48 Sh ed-
ding of exist ing h air also can develop in th e recipient area.
It is specu lated th at th is resu lt s from p oor vascu larit y. Most
cases resolve w ith in 3 to 6 m on th s.
Scalp Pruritus
Com plicat ion s on th e t ran splan ted site var y from m ild to
severe p ru rit u s. Som e of th ese can be secon dar y to n er ve
dam age, crust s, folliculit is, or seborrh eic derm at it is. Mild
prurit us can be con t rolled w ith topical steroids, but severe
cases m ay require oral an t ih ist am in es. Scalp prurit us usu-
ally disap p ears in a cou ple of w eeks.
27 Hair Transplant ation in East Asians 359
c
Facial Sw elling
Facial sw elling is a com m on com plicat ion, w h ich can last
from 3 to 6 days an d can in terfere w ith social act ivit ies.49,50
Oral or in t ram u scu lar cort icosteroids or addit ion of t riam -
cin olon e to th e local an esth et ics for th e recipien t site can
redu ce facial sw elling. Also, “gravit y posit ion ,” as n am ed by
th e au th or, can h elp. Previou sly it h ad been assum ed th at
h ead elevat ion to 45 degrees h elp s to m in im ize facial sw ell-
ing. How ever, research by th e auth or sh ow ed th at a supin e
or lateral decu bit us posit ion w ith out h ead elevat ion (grav-
it y posit ion ) can preven t lym ph at ic accu m ulat ion in th e
foreh ead , th u s p reven t ing facial sw elling.51 It is h elpful to
m ain t ain gravit y posit ion for 1.5 days (op erat ion day p lu s
1 day after surger y) so th at th e lym ph at ic ow s dow nw ard
due to gravit y an d th e lym ph at ics accum ulate tow ard th e
occipital an d tem poral scalp in stead of th e foreh ead, w h ich
can h elp to preven t upper eyelid sw elling. If th ere is fore-
h ead sw elling, m assaging from th e glabella to th e lateral
eyebrow can preven t up per eyelid sw elling. If upper eyelid
sw elling occu rs, th ere is n o t reat m en t . Th e p at ien t h as to
w ait 2 or 3 days for it to resolve.
Unnatural Hairline
Un n at ural h airlin e can result from t ran splan t at ion of t w o-
or th ree- h air FUs on th e fron t al h airlin e, or t ran splan t ing
th e fron t al h airlin e as a st raigh t lin e w ith on e-h air FUs. Th is
can be corrected by fur th er surger y, but it is best to m ake a
nat ural-looking h airlin e using single- h air FUs an d a zigzag
hairlin e in th e rst t ran splan t .
Folliculitis
Hair follicles tran splanted too deeply can cause in am m a-
tion. The reported incidence rate varies from 1 to 20%. Also,
increased sebum production and inappropriate w ashing of
360 V Facial Skin and Hair Rejuvenation
the hair can result in secondary folliculitis, w hich can be pre-
vented by appropriate w ash ing using sh am poos. Topical ste-
roids can relieve sym ptom s, but oral antibiotics are required
for severe cases. Transplanting to the appropriate depth is
the m ost im portant factor to prevent this. The author largely
prevented folliculitis after transplantation w ith use of the
depth-controlled transplantation (DCT) technique.34
Pitting
Pit t ing resu lt s from th e t ran splan t being seated too deeply.
Th is can be preven ted w ith th e DCT tech n ique.
Poor Survival and Loss of
Transplanted Hair
Th e sur vival rate of t ran splan ted h air is usually 90% or
above, bu t an exp erien ced p hysician can h ave cases w h ere
m ost of th e t ran sp lan ted h airs do n ot su r vive du e to an
u n kn ow n factor or X factor. A case of t rich orreh exis n odosa
seen on h air sh aft exam in at ion w as rep or ted in a p at ien t
w ith poor sur vival of th e t ran splan ted h air. Th is is ver y
rare, an d th e cau se of t rich orreh exis n odosa is un kn ow n .
Th e sur vival rate can also be low ered by dam age don e
during follicle dissect ion , t ran sect ion w ith FUE, dehydra-
t ion , dam age in curred du ring th e in ter val bet w een dis-
sect ion an d im plan t at ion , ben ding of follicles d u ring
t ran splan tat ion , an d t ran splan t s th at are too deep or too
sh allow.
Arteriovenous Fistula
Ar terioven ou s (AV) st u la develop s on th e don or or recip i-
en t sites ver y rarely.1 Pu lsat ion is n oted in th ese cases. Most
cases spon t an eou sly resolve w ith in 6 m on th s, but ligat ion
of th e vessel can be perform ed if rupt ure is a con cern or if
t reat m en t is required for cosm et ic reason s.
Syncope
Occasion ally, syn cop e can resu lt du ring or after th e p roce-
dure. Vasovagal react ion s are probably th e m ost com m on
em ergen cy even t to occu r in th e h air restorat ion p ract ice.1
Preoperat ive oral diazepam m ay lim it th e in ciden ce of th is
react ion by decreasing th e pat ien t’s an xiet y an d fear of
inject ion or surger y. Sin ce pat ien t s lie on th e bed for m any
h ours during th e t ran sp lan t , th e auth or recom m en ds per-
form ing leg exercises for 1 m in ute before sit t ing on th e bed
to p reven t p ost u ral hyp oten sion . Taking a break an d eat ing
cookies an d juice can be h elpful to reduce th e pat ien t’s dis-
com for t during th e hours-long operat ion .16
Hiccups
Th e cause an d physiology of h iccups are n ot know n . It is
specu lated th at th is occu rs du e to con du ct ion of st im u li
from dam aged n er ves on th e don or site to th e p h ren ic
n er ve.52 Hiccu p s u su ally occu r w ith in 6 to 24 h ou rs an d
can last up to 2 days before spon tan eously resolving. Ch lor-
p rom azin e 50 m g t w ice daily is kn ow n to h elp ease th e d is-
com fort caused by con t in uou s h iccu ps.
■ Case Studies
Hair t ran sp lan t at ion can be app lied n ot on ly to m ale-p at-
tern h air loss but also to fem ale-pat tern h air loss, fem ale
h airlin e correct ion , eyebrow /eyelash h air t ran sp lan tat ion ,
pubic h air t ran splan t at ion , an d beard t ran splan tat ion . Th e
au th or sh ares t w o cases: On e is abou t h air t ran splan t at ion
in a p at ien t w ith m ale-pat tern h air loss, an d th e secon d on e
is abou t fem ale h airlin e correct ion .
Case 1
A 47-year-old m ale p at ien t presen ted w ith m ale-pat tern
h air loss, Nor w ood t ype V (Fig. 27.13a). He w an ted to
cover th e h airless area w ith as m uch h air as possible. He
h ad ver y good don or d en sit y an d ver y th ick h air on th e
occipital scalp. Th e excised st rip size w as 1.5 cm × 30 cm .
Th e don or site w as closed w ith a on e-layer closure using
reten t ion sut u res. Th e reten t ion st itch es w ere rem oved at 4
days postop, an d th e skin st itch es w ere rem oved at 10 days
postop. Th e h airlin e w as m ade at th e h eigh t of 8.5 cm above
th e m idbrow level. A single-h air FU graft w as im plan ted on
th e h airlin e area in a zigzag pat tern ; a four- an d th ree- h air
FU graft w as t ran splan ted on th e fron t al scalp an d righ t-
side part area; an d a t w o-h air FU graft w as im p lan ted on
th e posterior scalp an d coun ter-part area to create m axim al
fu lln ess. Th e n u m ber of t ran splan ted h airs is 6,636 (497
single-h air FU grafts, 1,425 t w o-h air FU graft s, 863 th ree-
h air FU grafts, an d 175 fou r-h air FU graft s) (Fig. 27.13b).

a b
Case 2
A 28-year-old fem ale presen ted w ith an M-sh ap ed h airlin e
(Fig. 27.14a). Sh e w an ted to m ake th e h airlin e rou n der.
Sh e h ad n orm al h air den sit y an d th ickn ess on th e occip i-
tal scalp. Th e excised st rip size w as 1.5 cm × 18 cm . Th e
don or site w as closed w ith a double-layer closu re an d a
t rich ophyt ic closure w as perform ed. Th e skin st itch es w ere
a b
27 Hair Transplant ation in East Asians 361
Fig. 27.13 Case 1. Male hair transplanta-
tion. (a) Before the surgery. (b) One year
after surgery.
rem oved at 10 days postop. Th e h airlin e w as m ade at th e
heigh t of 7 cm above th e m idbrow level. A single-h air FU
graft w as im p lan ted on th e h airlin e area in a zigzag p at tern ,
t w o-h air FU grafts w ere im plan ted posterior to th e h air-
lin e, an d th ree-h air FU grafts w ere im plan ted posterior to
th e t w o-h air FU grafts t ran splan ted. Th e n um ber of t ran s-
plan ted h airs is 3,120 (680 single-h air FU grafts, 905 t w o-
hair FU grafts, an d 210 th ree-h air FU grafts) (Fig. 27.14b).
Fig. 27.14 Case 2. Female hair transplan-
tation. (a) Before the surgery. (b) One year
after surgery.
362 V Facial Skin and Hair Rejuvenation
■ Conclusion
Hair t ran splan t at ion for East Asian s p resen t s several
ch allenges seldom seen in Caucasian s. Th ese in clude an
in creased risk of scarring, a lim ited n u m ber of don or h airs,
h igh skin /h air color con t rast , low er h air den sit y, an d a
u n ique fron t al h airlin e. In spite of th ese ch allenges, w ith
th e select ion of good can didates an d use of appropriate
operat ive tech n iques, excellen t results can be produced in
Asian s. Hair t ran splan t at ion tech n iques sh ould alw ays be
adju sted depen ding on th e in dividu al being t reated. Hair
ch aracterist ics, h ead sh ape, h air an d skin color, an d oth er
feat u res speci c to Asian s n ecessit ate cer tain m odi cat ion s
in h air t ran splan t at ion procedures an d t reat m en t s.
References
1. Unger W P, Sh apiro R, Unger R, Unger M, eds. Hair Tran s-
p lan t at ion . New York, NY: Marcel Dekker; 2004:568–576,
591–595, 892–897
2. Unger W P, Shapiro R, Unger R, Unger M, Eds. Hair Trans-
p lan t at ion , Lon don , UK: In form a Health care; 2011:63–75,
76–81, 235–237, 404–406, 408, 423, 428–430
3. Vong V. Norm al h airlin e or Nor w ood class 0, 1. Hair Tran s-
p lan t Forum In t 1999;6:178–181
4. Bern stein RM, Rassm an W R, Szaniaw ski W, Halperin
A. Follicular t ran splan t at ion . In t J Aesth et ic Rest Surg
1995;3:119–132
5. Bern stein RM, Rassm an W R. Follicular t ran splan t at ion .
Pat ien t evaluat ion an d surgical plan n ing. Derm atol Surg
1997;23(9):771–784, discussion 801–805
6. Path om van ich D. Don or h ar vest ing: a n ew approach to
m in im ize t ran sect ion of h air follicles. Derm atol Surg
2000;26(4):345–348
7. Arn old J. 6th ann u al m eet ing of th e In tern at ion al Societ y
of Hair Restorat ion Su rger y. Hair Tran splan t Forum In t’l
1998;6:4
8. Ezaki T. Advan t ages an d disadvan t ages of h air t ran splan t
su rger y on t reat m en t of m ale baldn ess. Jp n J Aesth et Plast
Surg 1997;19:99–117
9. Haber R, Stough D, eds. Hair Tran splan tat ion. Seat tle, WA:
Elsevier Sau n d ers; 2006:149–156
10. Kau fm an KD, Roton da J, Sh ah AK, Meeh an AG. Long-term
t reat m en t w ith n asterid e 1 m g decreases th e likelih ood
of developing furth er visible h air loss in m en w ith an dro-
gen et ic alopecia (m ale pat tern h air loss). Eu r J Derm atol
2008;18(4):400–406
11. Fin asteride Male Pat tern Hair Loss St u dy Grou p. Long-term
(5-year) m u lt in at ion al experien ce w ith n asteride 1 m g
in th e t reat m en t of m en w ith an drogen et ic alopecia. Eu r J
Derm atol 2002;12(1):38–49
12. Lee WS, Lee HJ, Ch oi GS, et al. Gu idelin es for m an agem en t
of an drogen et ic alopecia based on BASP classi cat ion —th e
Asian Con sen su s Com m it tee gu idelin e. J Eu r Acad Derm a-
tol Ven ereol 2013;27(8):1026–1034
13. Avram M, Rogers N. Con tem p orar y h air t ran sp lan t at ion .
Derm atol Su rg 2009;35(11):1705–1719
14. Makh eja AN, Bailey JM. An t ip latelet con st it u en t s of garlic
an d onion . Agen t s Act ion s 1990;29(3–4):360–363
15. Bern stein R, Rassm an W. Den sitom eter an d video-m icros-
copy. Hair Tran sp lan t Foru m In t 2007;17(2):49–51
16. Path om van ich D, Im agaw a K, eds. Hair Restorat ion Su rger y
in Asian s. New York, NY: Sp ringer; 2010:37–39, 91–93,
105, 125–129, 133–140
17. Leon ard R, Ch arles G, Dorin R, et al. In tern at ion al Societ y of
Hair Restorat ion Surger y. 2013 Pract ice Cen sus Resu lt s
18. Mayer M, Pau ls T. Scalp elast icit y scale. Hair Tran sp lan t Fo-
ru m In t 2005;15:122–123
19. Moh ebi P, Pak J, Rassm an W. How to assess scalp laxit y.
Hair Transplan t Foru m In t 2008;18:161, 167
20. Bern stein RM, Rassm an W R. Th e scalp laxit y p aradox. Hair
Tran splan t Forum In t 2002;12:9–10
21. Ch oi YC, Kim JC. Single h air t ran sp lan t at ion u sing th e Ch oi
h air t ran splan ter. J Derm atol Surg On col 1992;18(11):
945–948
22. Kakigi R, Sh ibasaki H. Mech an ism s of pain relief by vi-
brat ion and m ovem ent . J Neu rol Neurosu rg Psych iat r y
1992;55(4):282–286
23. Marzola M. Trich op hyt ic closu re of th e don or area. Hair
Tran splan t Forum In t 2005;15:113–116
24. Frech et P. Min im al scars for scalp su rger y. Derm atol Su rg
2007;33(1):45–55, discussion 55–56
25. Rose P. Ledge closu re. Hair Tran sp lan t Foru m In t 2005;
15:113–116
26. Kim D. Plan n ing o in ferior edge in th e Frech et an d
Rose t rich op hyt ic closu res. Hair Tran splan t Forum In t
2008;18(6):211
27. Rassm an W R, Bern stein RM, McClellan R, Jon es R, Worton
E, Uyt ten daele H. Follicu lar un it ext ract ion : m in im ally
invasive su rger y for h air t ran sp lan t at ion . Derm atol Su rg
2002;28(8):720–728
28. Harris JA. Follicu lar u n it ext ract ion : th e SAFE system . Hair
Tran splan t Forum In t 2004;14:157–164
29. On da M, Igaw a HH, In ou e K, Tan in o R. Novel tech n iqu e
of follicular un it ext ract ion h air t ran splan t at ion w ith a
pow ered pu n ch ing device. Derm atol Su rg 2008;34(12):
1683–1688
30. Bu n agan MJ, Ban ka N, Sh ap iro J. Hair t ran splan t at ion u p -
date: p rocedu ral tech n iqu es, in n ovat ion s, an d app licat ion s.
Derm atol Clin 2013;31(1):141–153
31. Kim C, Kim H, Kim D. Follicu lar u n it t ran splan t at ion : com -
parison of video m icroscopic vs. com bin at ion m eth ods.
Arch Aesth et ic Plast Su rg 2014;20(1):61–64
32. Lim m er B. Bob Lim m er d oes it all on e h air at a t im e. Hair
Tran splan t Forum In t 1991;1:8–9
33. Keen e SA, Gibson GH. New cost-e ect ive, ergon om ic w ay
to m agn ify d on or h air du ring follicu lar u n it graft dissec-
t ion : LCD m on itor w ith video m agn i cat ion . Hair Tran s-
plan t Forum In t 2003;13:9
34. Hw ang S. In t ra-pat ien t graft length d i eren ces in u en c-
ing depth con t rolled in cision s. Hair Tran sp lan t Foru m In t
2012;22:117, 122–123

35. Cooley JE. Dilem m as in hair restorat ion . Hair Tran splan t
Forum In t 2005;15:207–208
36. Hw ang SJ, Lee JJ, Oh BM, et al. Th e e ect s of dehydrat ion ,
p reser vat ion tem p erat ure an d t im e on th e h air graft s. An n
Derm atol 2002;14:149–152
37. Krugluger W, Moser K, Moser C, Laciak K, Hugen eck J.
En h an cem en t of in vit ro h air sh aft elongat ion in follicles
stored in bu ers that preven t follicle cell apoptosis. Der-
m atol Surg 2004;30(1):1–5, d iscu ssion 5
38. Uebel C. A new advan ce in baldn ess surger y using platelet-
d erived grow th factor. Hair Tran splan t Foru m In t 2005;
15(3):77–84
39. Cole J. Th e opt im al h olding solut ion an d tem perat ure
for h air follicle grafts. Hair Tran splan t Forum In t’l 2012;
22:17–21
40. Cooley JE. Bio-en han ced h air restorat ion . Hair Tran splan t
Forum In t 2014;24(4):121, 128–130
41. Ah n S. We salute you , Mr. Paek. Hair Tran splan t Forum In t
2000;10:151
42. Lee SJ, Lee HJ, Hw ang SJ, et al. Evaluat ion of sur vival rate af-
ter follicu lar u n it t ran sp lan t at ion u sing th e KNU im p lan ter.
Derm atol Su rg 2001;27(8):716–720
43. Beeh n er ML. A com parison of h air grow th bet w een follic-
u lar-u nit grafts t rim m ed “skin ny” vs. “chu bby”. Derm atol
Su rg 1999;25(4):339–340
27 Hair Transplant ation in East Asians 363
44. Seager D, ed. Den se packing tech n iqu es. In : Unger W P, Sh a-
piro R, Unger R, Unger M, eds. Hair Tran splan t at ion . 6th ed.
Lon don , UK: Elsevier Saun ders; 2006:127–131
45. Lee W, Lee S, Na G, Kim D, Kim M, Kim J. Su r vival rate ac-
cording to grafted den sit y of Korean on e-h air follicu lar
u n it s w ith a h air t ran splan t im plan ter: experien ce w ith
four pat ien t s. Derm atol Surg 2006;32(6):815–818
46. Hah ler B. Su rgical w ou n d deh iscen ce. Med su rg Nu rs
2006;15(5):296–300, quiz 301
47. Stough D, ed . Hair Rep lacem en t: Su rgical an d Medical. St .
Louis, MO: Mosby Year Book; 1996:105–110
48. Tru e RH, Dorin RJ. A protocol to p reven t sh ock loss. Hair
Tran splan t Forum In t 2005;15:197
49. Neidel F. Preven t ing p ost-operat ion sw elling. Hair Tran s-
plan t Forum In t’l 2003;13:50
50. Gh olam ali A, Sep ideh P, Su san E. Hair t ran splan t at ion :
preven t ing post-operat ive oedem a. J Cut an Aesth et Surg
2010;3(2):87–89
51. Hw ang S. Gravit y posit ion to preven t facial ed em a in
h air t ran splan t at ion . Hair Tran splant Forum In t’l 2009;
77:81–82
52. Arn old J. A n eu rological explan at ion for h iccu ps follow ing
h air t ran splan tat ion. Hair Tran splan t Forum In t’l 1995;5:23
 28 Aesthetic Laser Hair Removal for the Asian Face
Wooseok Koh
Pearls
• Wom en of all races seek h air rem oval because
visible h air on th e face is aesth et ically u n desirable,
darken s th e skin , an d in terferes w ith m akeup
ap plicat ion . Men seek h air rem oval for a clean er
ap pearan ce, to avoid th e in conven ien ce of daily
sh aving, an d to avoid skin dam age from sh aving an d
follicu lit is.
• A n arrow foreh ead is on e of th e m ajor in d icat ion s for
laser facial h air rem oval in Korea. More t radit ion ally
m in ded Korean s an d Ch in ese believe th at a
sm all foreh ead is aesth et ically u n desirable; th is
con t ribu tes to th e popu larit y of facial h air rem oval.
• You ng w om en in Korea d esire m en w ith a h airless
face; th is h as sign i can tly in creased th eir in terest in
laser facial h air rem oval.
• Many factors are involved in th e su ccess of laser
facial h air rem oval; am ong th em , a doctor’s
kn ow ledge from experien ce perform ing th e
procedure is m ost im por tan t .
• Con sult at ion before th e t reat m en t is ver y im port an t
in set t ing reason able goals for facial laser h air
rem oval, especially if it involves w iden ing th e
foreh ead .
■ Introduction
Perm an en t laser h air rem oval becam e available in clin i-
cal pract ice in 1996 w ith th e adven t of th e ruby laser,
w h ich h ad a pulse durat ion in th e m illisecon d (m s) range
an d a skin cooling system .1,2 Alexan d rite,3,4 800 to 810 n m
d iode,5,6 an d Nd:YAG lasers 7,8 en tered th e h air rem oval m ar-
ket soon after. Th e ru by laser w as later w ith draw n becau se
of it s in st abilit y an d h igh risk in th e Asian popu lat ion ; oth er
lasers are st ill in use today. Most of th e h air rem oval lasers
curren tly available w ere developed in th e late 1990s, w ith
m odi cat ion s in pow er den sit y, u en ce, or sp ot size; h ow -
ever, th eir basic sp eci cat ion s h ave n ot ch anged. Recen tly
in t roduced diod e lasers in clude th e 755-n m ,9 940-n m ,10
980-n m (e.g., LEDA EPI 980 from Alm a Lasers an d Lin Scan
808/980 from GME), an d 1060-n m (e.g., Ligh t Sh eer INFIN-
ITY from Lu m en is) m od els. Vacu u m -assisted lasers 11,12 an d
364
• An 800- to 810-n m diode laser (e.g., Ligh t Sh eer XC,
Lum en is) w ith pulse durat ion of 3 to 30 m s an d
an en ergy den sit y of 23 to 40 J/cm 2 can be u sed
for facial h air rem oval. Th e ch an ces of obt ain ing a
p osit ive outcom e dw in dle w ith a pulse durat ion
exceeding 30 m s for Asian m ale facial h air rem oval.
• Usu ally, slow t reat m en t w ith h igh er u en ce is m ore
e ect ive in facial h air rem oval. Low ering th e skin
tem perat ure before t reat m en t is ver y im por tan t to
redu ce th e side e ect s of laser h air rem oval.
• In ad dit ion to decreased facial h air, an aesth et ic
im provem en t of skin in cluding brigh ter an d soft
skin ton e, im provem en t of follicu lit is/acn e, an d
decreased hyperpigm en t at ion associated w ith
sh aving can be ach ieved w ith facial laser h air
rem oval.
• A n ew foreh ead h airlin e n eeds to be design ed
con sidering th e pat ien t’s w ish es, gen der, an d facial
outlin e. Act ively guiding th e pat ien t in regards to th e
opt im al design an d e cacy is im port an t because
pat ien t s ten d to ch oose an excessively h igh or low
h airlin e. Th e design ing of th e foreh ead h airlin e is n ot
design ing a beaut iful h airlin e, bu t redesign ing on e-
th ird of th e n at ural facial outlin e.
lasers w ith radiofrequen cy,13,14 w ith a low u en ce, an d w ith
a h igh repet it ion rate 15,16,17 h ave also becom e available.
Desp ite th e developm en t of lasers for h air rem oval,
t reat m en t guidelin es h ave n ot been est ablish ed, an d con -
t roversy exists over th e ver y possibilit y of perm an en t h air
rem oval.18,19 Many physician s w h o perform h air rem oval
procedures h ave n ot obser ved su cien t e cacy an d
believe th at perm an en t h air rem oval is n ot possible.
My clin ic, sp ecializing in gen eral laser h air rem oval
procedures for 14 years, focuses on facial hair rem oval for
m en an d w om en . Wom en seek h air rem oval becau se vis-
ible h air on th e face is aesth et ically u n desirable, darken s
th e skin , an d in terferes w ith m akeup applicat ion . Men seek
h air rem oval for a clean er app earan ce, to avoid th e in con -
ven ien ce of daily sh aving, an d to avoid skin dam age from
sh aving an d follicu lit is. Recen tly, m ale celebrit ies w ith
h airless faces h ave becom e pop u lar in Sou th Korea, lead -
ing th e t rend tow ard sm ooth an d h airless faces in m en .
 28 Aesthetic Laser Hair Rem oval for the Asian Face 365

My su r vey of 100 Korean w om en revealed th at on ly 16%

regarded facial h air in m en as an at t ract ion . It also sh ow ed
th at w om en in th eir 40s (44.5%) sh ow ed m ore preferen ce
to facial h air in m en th an w om en in th eir 20s (10.2%) or 30s
(16.7%). In addit ion , n early 80% of respon den t s an sw ered
th at th ey w ould be w illing to recom m en d laser h air rem oval
to th eir m ale rom an t ic p ar t n ers if th e resu lt w as as good as
sh ow n in th e p h otograp h p resen ted in th e su r vey. For th is
reason , m en are in creasingly seeking facial h air rem oval in
Korea. How ever, th e facial h air of East Asian m en is den ser
an d h as th icker sh aft s th an in oth er areas of th eir bodies, or
in relat ion to th e h air of Caucasian s 20 ; th erefore, p erm an en t
rem oval is ver y di cult , even w ith repeated t reat m en t s.
In Korea a sm all foreh ead is con sidered u n at t ract ive.
Cert ain facial feat u res are associated w ith fort un e in Korea
an d Ch in a, an d a sm all or n arrow foreh ead is often associ-
ated w ith bad fort u n e. In addit ion , a n arrow foreh ead dis-
t urbs th e balan ce of th e face, con t ribut ing to an un at t ract ive
rst im pression . Rem oving excess h air from th e foreh ead to
lift th e h airlin e creates a rou n ded an d at t ract ive foreh ead in
fem ales. Un like Cau casian s, w h o ten d to h ave a w ide fore-
h ead, m any Asian s h ave a n arrow foreh ead. Th erefore, laser
h air rem oval for h airlin e correct ion is a p opu lar p roced u re
in m y clin ic.21
In th e skin , laser radiat ion is absorbed by th e m elan in
presen t in th e h air sh aft , raising th e tem perat ure of th e Fig. 28.1 ABC staining using CD8/144B antibody for detecting
area an d part ially dest roying follicu lar cells. How ever, it hair stem cells in vertical section of hair follicle. Hair stem cells
is st ill u n clear w h eth er th e m ost e ect ive t arget for h air (brown cells, arrows) are located at the outermost part of the outer
rem oval is th e h air stem cell or th e papilla cell or both .22 root sheath in the hair follicle.
In th is ch apter, I w ill discu ss m y clin ical exp erien ce an d
kn ow ledge in ach ieving perm an en t h air rem oval or aes-
th et ic im provem en t by m odifying th e den sit y of h air in th e
oth er t arget s, in clu ding vessels an d m elan ocytes, or n on -
East Asian face.
speci c dam age to th e h air follicle are also con sidered as
possible m ech an ism s. How ever, th e exact m ech an ism of

■ Mechanisms of Laser Hair
Removal
Th e rst h air rem oval laser w as based on th e con cept of
“select ive p h ototh erm olysis.”1,23 Years later, th is con cept
w as exp an ded as th e “exten ded th eor y of select ive p h oto-
th erm olysis.”24 According to th ese th eories, th e m ain ch ro-
m op h ore is eu m elan in in th e h air sh aft an d h air bu lb. Heat
from laser absorpt ion in th e m elan in p igm en ts of th e h air
follicle di u ses ou t to dam age th e h air follicle, in terfering
w ith regen eration of th e visible term in al h air. Recently,
low - uen ce, h igh -frequen cy lasers h ave been foun d to pro-
duce result s sim ilar to th ose of h igh -pow er, low -frequen cy
lasers.15,16,17
To rem ove h air perm an en tly, th e targets sh ould be cells
th at are biologically n ecessar y for regen erat ion of th e h air
follicles. Based on th is hyp oth esis, th e biological targets
sh ould be eith er th e h air stem cell (Fig. 28.1) or p ap illa cell,
or both .22 How ever, alth ough th is hypoth esis is plausible,
n o data su p p or t ing th is h ave been p u blish ed. Dam age to
laser h air rem oval is st ill un clear, even th ough th e p roce-
dure w as developed 20 years ago.
■ Factors That Improve the
E cacy of Permanent Hair
Removal
Many factors, in clu ding u en ce, p u lse du rat ion , w ave-
length , spot size, an d t reat m en t in ter val, a ect th e suc-
cess of laser h air rem oval.25 In addit ion , th e kn ow ledge an d
exp erien ce of th e p hysician in u en ce th e resu lt s. Opt im al
factors th at im prove th e su ccess rate are as follow s:
1. Proper w avelength: 755 nm or 800 to 810 nm 26,27,28,29,30
2. Proper pulse durat ion : 20 to 80 m s (from person al
exp erien ce)
3. Proper uen ce: as h igh as possible w ith out causing
adverse e ects 6,31
4. Proper spot size: as large as possible, if applicable 32,33
366 V Facial Skin and Hair Rejuvenation
5. Proper epiderm al cooling: en ough con t act cooling,
cold room tem perat ure 34,35,36,37,38,39
6. Proper coverage rate: 100 to 120% w ith out skipped
areas, depen ding on h air den sit y an d th ickn ess an d
laser beam qualit y 40,41,42
7. Proper t reat m en t in ter val: 4 to 8 w eeks, depen ding
on th e t reated area 43
8. Proper care of adverse e ect s: post in am m ator y
hyper- or hypopigm en tat ion , scabbing, persisten t
er yth em a, u rt icarial react ion , th e Koebn er
p h en om en on , laser-in duced cat aract , an d iris
at rophy 44,45,46,47,48,49,50,51,52,53
9. Proper physician : on e w ith opt im al kn ow ledge an d
scru p u lou sn ess 42
10. Proper evaluat ion of result s: at least 6 m on th s after
th e n al t reat m en t 54,55
■ Patient Evaluation
Con sult at ion is an im port an t ph ase in th e laser facial h air
rem oval process, especially for m ales seeking w iden ing of
th e foreh ead. In m ale facial h air rem oval by laser, det ailed
exp lan at ion s abou t th e p ossibilit y of tem p orar y side e ects,
in clu ding crust , er yth em a, an d hyperpigm en tat ion , before
th e rst t reat m en t session are m an dator y, because usually
h igh er u en ces are u sed com pared w ith gen eral laser h air
rem oval of oth er areas or in fem ale facial h air rem oval.
In design ing to w iden a foreh ead, I con sider th e jaw
lin e, sh ape of th e h ead , an d gen der of th e pat ien t to deter-
m in e th e exten t of foreh ead exp an sion . Am ong th ese con -
siderat ion s, d eterm in ing th e foreh ead h eigh t th at is m ost
ap prop riate for th e p at ien t’s face is esp ecially im p ort an t .
Th e usual h eigh t of th e foreh ead is on e-th ird of th e facial
h eigh t; h ow ever, th e n al rat io sh ou ld be decided accord -
ing to th e doctor’s or pat ien t’s aesth et ic sen se. In design ing
th e h airlin e, guiding th e pat ien t in regards to th e opt im al
design an d e cacy is im por tan t because pat ien t s ten d to
ch oose an excessively h igh or low h airlin e. I alw ays in form
th e pat ien t s th at design ing th e foreh ead h airlin e is rede-
sign ing on e-th ird of th e facial ou tlin e, n ot ju st redesign ing
th e h airlin e.
In facial h air rem oval by laser, ch ecking th e facial skin
color, recen t h istor y of sun exposure, daily h air rem oval
m eth od, th ickn ess of h air, color of h air, an d p resen ce of co-
exist ing facial skin disease is cru cial for deciding th e exact
t reat m en t param eters an d plan n ing th e sch edu le. Taking
th e pat ien t’s ph otograph s before and after each t reat m en t
to assess th e ou tcom e is im p or tan t , an d th e n eed m u st be
exp lain ed to th e p at ien t .
Carefu l an d fran k evalu at ion of th e n al resu lt is
requ ired for both th e pat ien t an d doctors, bu t it is n ot
alw ays easy in laser h air rem oval. Th e n al ou tcom e sh ou ld
be assessed at least 6 m on th s after th e n al t reat m en t .
■ Procedural Techniques
Facial Hair Removal in
Female East Asians
East Asian w om en receive h air rem oval t reat m en t s to
create a m ore fem in in e appearan ce, to brigh ten th e skin
ton e, an d to en able th em to ap p ly m akeu p m ore easily.
For reason s th at are un clear, th e facial h air of East Asian
w om en resp on ds m ore poorly to laser rem oval th an does
axillar y or leg h air, even w ith opt im ally adju sted u en ce
an d w avelength . Th erefore, m ore th an n in e t reat m en t s are
n ecessar y in m any cases. I recom m en d set t ing th e u en ce
based on th e pat ien t’s curren t skin color rath er th an th e
Fit zpat rick skin t ype. Skin color can ch ange w ith ult raviolet
(UV) ligh t exposure, an d t w o people w ith th e sam e Fit z-
pat rick skin t ype can presen t di eren t skin colors depen d-
ing on th e degree of sun exposure. I h ave divided th e skin
color by gross exam in at ion in to n in e t ypes, an d I refer to
th e m elan in in dex w h en gross exam in at ion is n ot de n i-
t ive (Fig. 28.2). Becau se of overseas t ravel, m any p eop le are
exp osed to st rong UV ligh t du ring th e w in ter as w ell as in
th e sum m er. Th erefore, skin color sh ould be closely exam -
in ed regardless of th e season .
Technique
As facial h airs are th in in East Asian w om en , long-pu lse-
durat ion laser does n ot su cien tly rem ove th e hairs u n less
th e uen ce is ver y h igh . Th erefore, an opt im al ou tcom e
depen ds on a balan ce bet w een uen ce an d pulse durat ion .
I p refer to u se a h igh u en ce d esp ite th e possibilit y of cau s-
ing pain , except in pat ien ts ver y sen sit ive to pain . W h en th e
u en ce is set low to avoid p ain , th e ch an ce of perm an en t
h air rem oval declin es an d th e th erap eut ic goal can n ot be
ach ieved . It is h elp fu l to clearly com m u n icate to th e p at ien t
th at th e t reat m en t m ay be pain ful an d th at topical an es-
th et ic is available.
From m y experien ce, pulse durat ion of 3 to 30 m s an d
an en ergy den sit y of 23 to 40 J/cm 2 u sing an 800-n m d iode
laser are e ect ive. Bu t th e ch an ce of obt ain ing a posit ive
outcom e dw in dles w ith a pulse durat ion exceeding 30 to
40 m s.
1. Based on th e skin color, I u se a h igh er u en ce in
ligh ter skin . I st ar t th e t reat m en t at 30 m s an d 22 to
28 J/cm 2 w h en u sing an 800-n m Ligh t Sh eer XC laser.
W hen a pat ien t h as dark skin due to su n exposure, I
u se a low er u en ce or p ost p on e th e n ext t reat m en t
to 2 to 3 m on th s.
2. After th e rst t reat m en t , I in crease th e param eters
by 5 to 10% if n o adverse e ect s h ave been obser ved
an d th e skin h as n ot darken ed .

Fig. 28.2 A device for measuring melanin index. (Courage +
Khazaka electronic GmbH, Germ any.)
3. I w ait for 4 w eeks bet w een th e t reat m en t s for th e
rst fou r session s an d in crease th e in ter val after th e
fth t reat m en t dep en ding on th e ou tcom e. W h en th e
skin is darken ed, th e risk of adverse e ect s in creases
w ith h igh er uen ce, an d th e n ext t reat m en t sh ould
be post pon ed or th e u en ce sh ould be low ered.
4. I apply laser irradiat ion s th orough ly so th at n o t arget
area is m issed.
5. I prolong con tact cooling t im e or in crease coolant
spray t im e in areas w ith th icker an d den ser h airs.
6. Low ering th e am bien t room tem perat ure h elps to
low er th e skin tem p erat u re. A top ical an esth et ic is
ap plied in p at ien ts p ar t icu larly averse to p ain .
E ects
A brigh ter skin ton e an d sm ooth er skin can be exp ected
after laser h air rem oval. Th e overall skin ton e im p roves an d
th e face appears m ore fem in in e after t reat m en t (Fig. 28.3).
Ver y few st u dies discu ss th e p ercen tage of Korean
w om en in w h om p erm an en t facial h air rem oval is ach ieved
or th e n um ber of t reat m en t s required for perm an en t h air
a b
28 Aesthetic Laser Hair Rem oval for the Asian Face 367
rem oval. Because th e e cacy of laser h air rem oval varies
depen ding on th e race of th e pat ien t an d th e t reat m en t
area, a direct com p arison of p aram eters or devices is in ad -
equ ate for clarifying th e e cacy in a cert ain t reat m en t
site or race. At th is t im e, th ere are n o st u dies th at clearly
describe th e e ect on th e t reat m en t outcom e of th e di er-
en t t yp es of laser, t reat m en t tech n iqu e, u en ce, in ter val
an d frequ en cy, t reated area, or race of th e p at ien t .
Facial Hair Removal in Male East Asians
Th e goals of facial h air rem oval in East Asian m en are as
follow s: (1) to elim in ate th e in conven ien ce of daily sh av-
ing (in m en w ith folliculit is or hyperpigm en t at ion due to
excessive, qu ickly grow ing facial h airs th at n eed frequ en t
sh aving); (2) aesth et ic im provem en t (Asian s ten d to h ave
th ick h air an d m ay st ill appear dish eveled after sh aving);
(3) sm ooth er, m ore you th ful-looking skin ; an d (4) a gen -
eral dislike of facial h air (by p at ien t s w h o do n ot h ave
excess h air bu t st ill dislike facial h air an d ch oose laser h air
rem oval as an altern at ive to using t w eezers).
Male facial h air h olds di eren t m ean ings across cu l-
t ures an d t im es. Am ple facial h air is en couraged in m en
in m any cult ures th rough out th e w orld. How ever, in Korea
today m any pop u lar m ale celebrit ies p resen t a clean , h air-
less face an d use cosm et ics, an d w om en ten d to p refer
th is t ype of fem in ized appearan ce in m en. I believe th is is
th e m ain reason m any Korean m en are seeking facial h air
rem oval.
East Asian m en ten d to h ave th icker facial h air th an
do Caucasian s. Un like h air rem oval in w om en , facial h air
rem oval in East Asian m en requ ires con siderable experi-
en ce an d kn ow ledge of adverse e ect s, p ar t icu larly w h en
using a h igh u en ce. Th e risk of adverse e ect s in m ale
facial h air rem oval in creases w ith in exp erien ced d octors
because th e den se an d th ick h airs m ay t rigger an overlap -
ping respon se to laser th erapy.24 Th erefore, it is im p or t an t
to preven t adverse e ects an d m in im ize derm al dam age.
A con t act-t ype skin cooling system m ay be useful for pre-
ven t ing adverse e ects.34,35,36
Fig. 28.3 E ect of facial hair removal
in women. (a) Before the treatment.
(b) After three treatments, the overall skin
tone improved and the face appears more
feminine.
368 V Facial Skin and Hair Rejuvenation
Technique
I u se a p u lse du rat ion of 30 to 50 m s, becau se m ost h airs
h ave th ick sh aft s. I set th e u en ce based on th e curren t skin
color, as w ith fem ale facial h air rem oval.
1. I set th e u en ce as h igh as p ossible. I start th e
t reat m en t at 30 m s an d 24 to 35 J/cm 2 w h en u sing an
800-n m Ligh t Sh eer XC.
2. Avoid overlap of irradiat ion , but do n ot om it any
t arget area during t reat m en t . Caut ion is n eeded, as
rep eated irradiat ion of th e sam e area m ay lead to
scarring an d oth er seriou s adverse e ects.
3. I use on ly a con t act-t ype skin cooling system .
Rem oving den se an d th ick h airs w ith a h igh
u en ce can cau se n on sp eci c d erm al dam age, an d
p rotect ing deeper layers w ith con t act cooling h elps
p reven t adverse e ect s. To allow su cien t cooling,
in crease th e con t act t im e of th e cooling system from
0.5 to 1 secon d in areas w ith th ick an d den se h airs.
4. Frequ en tly ch eck for h airs adh ering to th e t ip of th e
con tact-t ype h an dpiece.
5. Var y th e u en ce u n d er th e n ose an d on th e ch in ,
ch eeks, an d sideburn s, depen ding on th e den sit y
an d th ickn ess of th e h air sh aft s. Use a relat ively low
u en ce for den ser an d th icker h air sh aft s.
a b
a b
E ects
Aesthetic Im provem ent and Skin Brightening
Accord ing to m y su bject ive assessm en t , th e facial skin
ap pears to im p rove in m ost Asian m ale p at ien ts after laser
h air rem oval, alth ough th e im p rovem en t h as n ot been sci-
en t i cally m easu red. Th e p at ien t s th em selves feel th at th eir
skin h as im p roved after t reat m en t , an d m ost of th e gen eral
popu lat ion also see an im provem en t in th e “before” an d
“after” ph otograph s of pat ien t s (Fig. 28.4). Fu rth er research
is n eeded to clarify w h eth er th is im provem en t is du e to th e
ap pearan ce of less h air or to th e w h iten ing or rejuven at ing
e ect s of th e laser.56
Reduced Hyperpigm ent ation
Many Asian m en seeking laser h air rem oval p resen t w ith
hyperpigm en t at ion of th e skin . Post in am m ator y hyper-
pigm en t at ion is suspected to arise from sh aving-related
skin dam age, follicu lit is, or aftersh ave-related d erm at it is.
Asian m en , w h o h ave th icker facial h air, apply m ore pres-
su re to th e skin du ring sh aving th an do Cau casian s; h en ce,
th ey are m ore likely to experien ce skin irrit at ion . Asian skin
is also m ore su scept ible to p ost in am m ator y hyp erpig-
m en t at ion .57 E ect ive h air rem oval redu ces th e frequ en cy
of sh aving and skin irritat ion during sh aving. Th is result s in
a grad u al im provem en t of hyp erp igm en tat ion (Fig. 28.5).
Fig. 28.4 Aesthetic improvement of skin
tone after facial laser hair removal. (a)
Seven years after ve treatments in another
clinic. (b) Six months after additive seventh
treatments in my clinic.
Fig. 28.5 Improvement of shaving-related
hyperpigmentation after laser hair removal.
(a) Before the treatment. (b) Three months
after six treatm ents. E ective hair removal
reduced the frequency of shaving and
related skin irritation, thus reducing the
hyperpigmentation.
 28 Aesthetic Laser Hair Rem oval for the Asian Face 369

Fig. 28.6 Improved facial acne after laser

a b
hair removal. (a) Before the treatment.
(b) Three m onths after sixth treatments
shows improved folliculitis and acne of the
areas not treated by laser.

Im provem ent of Folliculitis and Acne
I see con sisten t an d rep eated ou tcom es of im p roved follicu -
lit is or acn e after laser facial h air rem oval in Korean m en , as
h ave oth ers.58 After th ree or fou r t reat m en t s, th e frequ en cy
of shaving decreases, an d sh aving-related folliculit is an d
acn e im p rove. In som e cases, follicu lit is an d acn e of th e
areas n ot t reated by laser also sh ow im p rovem en t , bu t th e
reason s are n ot u n derstood (Fig. 28.6). I believe th at th e
t yp e of sh aving cream m ay p lay a role an d sh ou ld be inves-
t igated fur th er.59
Forehead Widening in East Asians
Excess hairs of the forehead are rem oved to im prove the fore-
head shape in patients w ith a narrow forehead, wom en w ith
a m asculine forehead shape, or m en w ith a fem inine forehead
shape. For Koreans and Chinese, hairline correction to w iden
the forehead is a com m on aesthetic procedure because a
narrow forehead is considered unat tractive. The goals of
this treatm ent are to expand the forehead area, im prove the
physiognom ic balance of the face, and create a fem inine or
m asculine forehead shape, depending on the gender.
Forehead Hairline Design
Th e n al design sh ould be con rm ed th rough m ult iple con -
su ltat ion s (an average of t w o or th ree). Pat ien t s n eed su f-
cien t t im e to th in k over th e opt im al design w h ile looking
in th e m irror. Th e doctor sh ou ld lead th e design ph ase but
sh ou ld ask for pat ien t s’ op in ion s, begin n ing w ith th e sec-
on d t reat m en t . Th is h elps to in crease pat ien t sat isfact ion .
Hairlin e d esign is based on th e follow ing factors:
Th e follow ing tech n iqu es are u sed to create an irregular
hairlin e (Fig. 28.7):
1. Use di eren t u en ces du ring t reat m en t .
2. Com bin e various w avelength s an d pulse durat ion s
during t reat m en t .
3. To avoid form ing a dist in ct lin e, do n ot set a lin ear
boun dar y for laser irradiat ion .
Technique
The hairline generally includes som e thick hairs, w hereas
the forehead surface is covered w ith ne hairs. Therefore, the
param eters should be set di erently for the two areas. As
explained previously, the wavelength, uence, and pulse dura-
tion should be varied to avoid form ing a distinct line at the hair-
line. The frequency of treatm ent di ers between individuals,
but at least six treatm ents are typically needed.
1. For th e rst t reat m en t , test variou s u en ces (e.g.,
Ligh t Sh eer XC, 10–28 J/cm 2 ) an d spot sizes (e.g., 5–12
m m ), an d u se at least t w o w avelength s (e.g., 800 n m
an d 1,064 n m ).
2. Adjust th e t reat m en t in ter val (8 to 10 w eeks) based
on th e degree of h air rem oval desired.
Laser spot
12 m m 9 mm 5 mm 7 mm 10 m m 12 m m
Treatment diagram

1. Basic design : Th e sh ape sh ould be rect angular in

m en , rou n d to oval in w om en .
2. Rat io: Approxim ately one-th ird of th e facial length is
H
a
an app rop riate foreh ead length .
i
r
l
i
n
e
3. Reciprocal design : Con sider th e jaw lin e.
4. Irregularit y: Mim ic a n at ural h airlin e, w h ich is
Fig. 28.7 Diagram used to explain how to make irregular hair-
irregularly irregular. Leave ran dom n e h airs in place line using t wo di erent wavelengths and multiple spot sizes and
according to th e p at ien t’s w ish es. shapes. Blue 12 m m; LightSheer XC, Blue 9 mm; LightSheer ET,
5. Fin e tou ch : Leave som e n e h airs at th e tem poral Orange 5 mm, 7 mm, 10 mm; CoolGlide Excel, Yellow 12 mm; Nd-
p art of th e fem ale h airlin e. YAG of GentleMax (Candela).
370 V Facial Skin and Hair Rejuvenation

■ Key Technical Points

1. For East Asian facial hair rem oval, I choose the
uen ce based on th e cu rren t skin color (e.g., 5–30 m s,
10–45 J/cm 2 of Ligh t Sh eer XC).
2. Apply th e laser th orough ly so that n o t arget area is a
m issed.
3. Prolong con tact cooling t im e or in crease coolan t
spray t im e in areas w ith th icker an d den ser h air.
Low er th e am bien t room tem perat u re to low er th e
skin tem p erat u re. For East Asian m ale facial h air
rem oval, u se con tact-t ype epiderm al cooling an d
in crease th e con t act t im e of th e cooling system from
0.5 to 1 secon d in areas w ith th ick an d den se h air to b
allow su cien t skin cooling.
Fig. 28.8 Seborrheic dermatitis after laser hair removal. (a) Seb-
4. Take a ph otograph before each t reat m en t to assess orrheic dermatitis aggravated 4 days after rst treatment. (b) Five
th e outcom e an d use a h igh er uen ce in areas w ith weeks after rst treatment. The erythem a resolved within a week
lit tle ch ange. without any treatment.
5. For w iden ing of th e foreh ead, devote su cien t t im e
to con su ltat ion before t reat m en t (10–20 m in u tes).
Th e n al design sh ould be con rm ed th rough m any
con su ltat ions. Pat ien t s n eed to be carefu l to avoid UV exp osu re an d
skin irrit at ion before an d d u ring t reat m en t . Skin darken ing
6. For th e rst t reat m en t to w iden th e foreh ead, test
due to UV exposure m ay reduce th e e ect of th e t reat m en t
variou s u en ces (e.g., Ligh t Sh eer XC, 10–28 J/cm 2 )
an d in crease th e risk of adverse e ects. Advise pat ien t s to
an d spot sizes (e.g., 5–12 m m ) an d u se at least t w o
avoid t an n ing if possible, an d to avoid sh aving or excessive
w avelength s (e.g., 800 n m an d 1,064 n m ).
cleansing of t reated areas for 7 to 10 days after t reat m en t to
7. Th e n al outcom e sh ould be evaluated at least 6 reduce th e pigm en t at ion resp on se of th e skin an d in crease
m on th s after th e last t reat m en t . th e e cacy of th e n ext t reat m en t .

■ Complications and ■ Case Studies

Their Management
I h ave obser ved th e follow ing adverse e ect s of facial h air
rem oval in m en an d w om en ; persisten t er yth em a, hyper-
pigm en t at ion , depigm en tat ion , aggravat ion of seborrh eic
derm at it is (Fig. 28.8), an d follicu lit is. I h ave also seen rare
cases of idiopath ic hyper t rich osis in th e ch eek, jaw lin e,
an d n eck areas in w om en . Most adverse e ect s resolve n at-
u rally w ith ou t t reat m en t . If idiopath ic paradoxical hyper-
t rich osis is suspected, in crease th e u en ce 20 to 30% above
th at of th e previous t reat m en t an d perform at least th ree
addit ion al t reat m en ts.60 Th is ap p roach gen erally resolves
th is adverse e ect .
Case 1
A 27-year-old m ale p at ien t con su lted for laser h air rem oval
from h is face an d n eck (Fig. 28.9a). He h ad sh aved ever y
day for 5 years an d su ered from irregular, bum py, dark
skin . He received seven t reat m en ts w ith 800-n m Ligh t-
Sh eer XC (30 m s, 12 × 12 m m , 26 J/cm 2 × 4, 28 J/cm 2 , 29 J/
cm 2 , 33 J/cm 2 ; t reat m en t in ter vals of 5, 5, 6, 8, 10, an d 12
w eeks). Except for a few occasion al regrow n h airs, a ver y
sat isfactor y resu lt w as obt ain ed 8 m on th s after th e seven th
t reat m en t (Fig. 28.9b). He applied a topical steroid cream
t w ice because of th e er yth em a react ion after t reat m en ts.

a b
Case 2
A 34-year-old fem ale pat ien t con su lted con cern ing h er n ar-
row foreh ead for w iden ing (Fig. 28.10a). Sh e received ve
t reat m en t s, an d th e t reat m en t schedu le an d param eters
w ere as follow s:
• First t reat m en t: 10/20/25 J/cm 2 30 m s (Ligh t Sh eer
XC) + 24 J/cm 2 15 m s (CoolGlide Excel, Cu tera,
10 m m ) + 10 J/cm 2 3 m s (CoolGlide Excel, 10 m m )
in ter val; 8 w eeks
• Secon d t reat m en t: 10/20/26 J/cm 2 30 m s
(Ligh t Sh eer XC) + 25 J/cm 2 15 m s (CoolGlide Excel,
10 m m ) + 10 J/cm 2 3 m s (CoolGlide Excel, 10 m m )
in ter val; 8 w eeks
a b
28 Aesthetic Laser Hair Rem oval for the Asian Face 371
Fig. 28.9 Case 1. Laser hair removal in East
Asian male face. (a) Before the treatment.
(b) Eight months after the seventh treatment.
• Th ird t reat m en t: 10/20/27 J/cm 2 30 m s (Ligh t Sh eer
XC) + 23/28 J/cm 2 15 m s (CoolGlid e Excel, 10 m m )
+ 10 J/cm 2 3 m s (CoolGlide Excel, 10 m m ) in ter val;
10 w eeks
• Fou rth t reat m en t: 12/25/26 J/cm 2 30 m illisecon ds
(Ligh t Sh eer XC) + 25 J/cm 2 15 m s (CoolGlide Excel,
10 m m ) + 8/9/10 J/cm 2 3 m s (Coolglide Excel, 10
m m ) in ter val; 14 w eeks
• Fifth t reat m en t: 25 J/cm 2 30 m s (Ligh t Sh eer XC)
+ 25 J/cm 2 15 m s (CoolGlide Excel, 10 m m ) +
8 J/cm 2 3 m s (CoolGlide Excel, 10 m m ) +
5 J/cm 2 2 m s
Five m on th s after th e ve t reat m en t s, th e pat ien t w as sat is-
ed w ith a n at u ral-looking, w iden ed h airlin e (Fig. 28.10b).
Fig. 28.10 Case 2. Widening of a female’s
forehead. (a) Before the treatment. (b) Five
months after the fth treatment.
372 V Facial Skin and Hair Rejuvenation
a b
Case 3
A 35-year-old m ale pat ien t con su lted abou t w iden ing h is
n arrow foreh ead (Fig. 28.11a). He received th ree t reat-
m en t s; th e t reat m en t sch ed u le an d param eters w ere as
follow s:
• First t reat m en t: 20/26 J/cm 2 30 m s (Ligh t Sh eer XC) +
38 J/cm 2 20 m s (CoolGlide Excel, 10 m m ) + 29 J/cm 2
15 m s (CoolGlide Excel, 10 m m ) in ter val; 10 w eeks
• Secon d t reat m en t: 16/26 J/cm 2 30 m s (Ligh t Sh eer
XC) + 43 J/cm 2 20 m s (CoolGlide Excel, 10 m m )
in ter val; 8 w eeks
• Th ird t reat m en t: 16/25 J/cm 2 30 m s (Ligh t Sh eer XC)
+ 47 J/cm 2 20 m s (CoolGlid e Excel, 10 m m ) + 19 J/
cm 2 7 m s (CoolGlid e Excel, 10 m m )
Eigh t m on th s after th e th ree t reat m en t s, h e w as sat is-
ed w ith th e resu lt (Fig. 28.11b).
References
1. Grossm an MC, Dierickx C, Farin elli W, Flot te T, Anderson
RR. Dam age to h air follicles by n orm al-m od e ru by laser
p ulses. J Am Acad Derm atol 1996;35(6):889–894
2. Dierickx CC, Grossm an MC, Farinelli WA, An derson RR.
Perm an en t h air rem oval by n orm al-m ode ruby laser. Arch
Derm atol 1998;134(7):837–842
3. Nan n i CA, Alster TS. Long-pulsed alexan drite laser-assisted
h air rem oval at 5, 10, an d 20 m illisecon d pulse durat ion s.
Lasers Surg Med 1999;24(5):332–337
4. Görgü M, Aslan G, Aköz T, Erdoğan B. Com parison of al-
exan drite laser an d elect rolysis for h air rem oval. Derm atol
Surg 2000;26(1):37–41
5. Or t RJ, An derson RR. Opt ical h air rem oval. Sem in Cut an
Med Su rg 1999;18(2):149–158
6. Cam pos VB, Dierickx CC, Farinelli WA, Lin TY, Manuskiat ti
W, Anderson RR. Hair rem oval w ith an 800-n m pulsed diode
laser. J Am Acad Derm atol 2000;43(3):442–447
Fig. 28.11 Case 3. Widening of a male’s
forehead. (a) Before the treatment. (b)
Eight months after the third treatm ent.
7. Alster TS, Br yan H, William s CM. Long-pulsed Nd:YAG
laser-assisted h air rem oval in pigm en ted skin : a clin ical
an d h istological evaluat ion . Arch Derm atol 2001;137(7):
885–889
8. Goldberg DJ, Silapun t S. Histologic evaluat ion of a m il-
lisecon d Nd:YAG laser for h air rem oval. Lasers Su rg Med
2001;28(2):159–161
9. Paasch U, Wagn er JA, Paasch HW. Novel 755-n m diode laser
vs. convent ional 755-nm scanned alexandrite laser: side-
by-side com parison pilot st udy for thorax an d axillar y hair
rem oval. J Cosm et Laser Ther 2015;17(4):189–193
10. Hu ssain M, Suw an ch in da A, Ch aruw ich t rat an a S, Gold-
berg D. A n ew long pulsed 940 n m diode laser used for
h air rem oval in Asian skin t ypes. J Cosm et Laser Th er
2003;5(2):97–100
11. Xia Y, Moore R, Ch o S, Ross EV. Evalu at ion of th e vacu u m -
assisted h an dpiece com pared w ith th e sapph ire-cooled
h an dpiece of th e 800-n m diode laser system for th e
u se of h air rem oval an d reduct ion . J Cosm et Laser Th er
2010;12(6):264–268
12. Zh ou ZC, Gu o LF, Gold MH. Hair rem oval u t ilizing th e
Ligh t Sh eer Duet HS h an d piece an d th e Light Sh eer ET: a
com parat ive st udy of t w o diode laser system s in Ch in ese
w om en . J Cosm et Laser Th er 2011;13(6):283–290
13. Sadick NS, Laugh lin SA. E ect ive ep ilat ion of w h ite an d
blon d h air u sing com bin ed radiofrequen cy an d opt ical en -
ergy. J Cosm et Laser Th er 2004;6(1):27–31
14. Sadick NS, Shaoul J. Hair rem oval using a com bination of con-
ducted radiofrequency and optical energies—an 18-m onth
follow -up. J Cosm et Laser Ther 2004;6(1):21–26
15. Brau n M. Perm an en t laser h air rem oval w ith low u en ce
h igh repet it ion rate versus high uen ce low repet it ion rate
810 nm diode laser—a split leg com parison st udy. J Drugs
Derm atol 2009;8(11, Su p pl):s14–s17
16. Pai GS, Bh at PS, Mallya H, Gold M. Safet y an d e cacy of
low - u en ce, h igh -repet it ion rate versu s h igh - u en ce, low -
repet it ion rate 810-n m diod e laser for perm an en t h air re-
m oval—a split-face com parison st udy. J Cosm et Laser Th er
2011;13(4):134–137
17. Barolet D. Low u en ce–h igh rep et it ion rate diode laser
h air rem oval 12-m on th evaluat ion: reducing pain an d

risks w h ile keeping clin ical e cacy. Lasers Surg Med
2012;44(4):277–281
18. Fern an dez AA, Fran ça K, Ch acon AH, Nouri K. From in t ra-
zors to lasers: a t im elin e of h air rem oval m eth ods. J Cosm et
Derm atol 2013;12(2):153–162
19. Wim m ersh o MB, Sch erer K, Loren z S, Lan dthaler M, Ho-
h en leut n er U. Hair rem oval using a 5-m sec long-pulsed
ru by laser. Derm atol Su rg 2000;26(3):205–210
20. Vogt A, Mc Elw ee KJ, Blum e-Peyt avi U. Biology of th e h air
follicle. In : Blum e-Peyt avi U, Tost i A, W h it ing DA, Trueb R,
eds. Hair Grow th an d Disorders. Leipzig, Germ any: Spring-
er; 2008:8–9
21. Koh W, Hw ang J. New clinical applicat ion of laser h air re-
m oval; w iden ing of n arrow foreh ead. Lasers Su rg Med
2003;32S15:67
22. Ibrah im i OA, Avram MM, Han ke CW, Kilm er SL, An der-
son RR. Laser h air rem oval. Derm atol Th er 2011;24(1):
94–107
23. An derson RR, Parrish JA. Select ive ph ototh erm olysis: pre-
cise m icrosurger y by select ive absorpt ion of pulsed radia-
t ion . Scien ce 1983;220(4596):524–527
24. Alt sh uler GB, An derson RR, Man stein D, Zen zie HH,
Sm irn ov MZ. Exten ded th eor y of select ive p h ototh erm oly-
sis. Lasers Su rg Med 2001;29(5):416–432
25. Koh W. Laser hair rem oval. In : Park S, Yeo U, eds. Laser Der-
m atology Plast ic Su rger y. Seou l: Koonja; 2014:253–275
26. Sadighha A, Mohaghegh Zahed G. Meta-analysis of hair re-
m oval laser trials. Lasers Med Sci 2009;24(1):21–25
27. Erem ia S, Li CY, Um ar SH, New m an N. Laser h air rem oval:
long-term resu lt s w ith a 755 n m alexan drite laser. Derm a-
tol Su rg 2001;27(11):920–924
28. Han drick C, Alster TS. Com parison of long-pulsed diode
an d long-pulsed alexan drite lasers for h air rem oval: a
long-term clin ical an d h istologic st u dy. Derm atol Su rg
2001;27(7):622–626
29. Bouzari N, Tabatabai H, Abbasi Z, Firooz A, Dow lat i Y. Laser
h air rem oval: com parison of long-pu lsed Nd:YAG, long-
p u lsed alexan drite, an d long-pu lsed diode lasers. Derm atol
Su rg 2004;30(4 Pt 1):498–502
30. Li R, Zhou Z, Gold MH. An e cacy com parison of hair rem oval
utilizing a diode laser and an Nd:YAG laser system in Chinese
wom en. J Cosm et Laser Ther 2010;12(5):213–217
31. Polderm an MC, Pavel S, le Cessie S, Grevelin k JM, van Leeu-
w en RL. E cacy, tolerabilit y, an d safet y of a long-p u lsed
ru by laser system in th e rem oval of u nw an ted h air. Derm a-
tol Su rg 2000;26(3):240–243
32. Nou ri K, Ch en H, Sagh ari S, Ricot t i CA Jr. Com paring 18-
versu s 12-m m sp ot size in h air rem oval u sing a Gen tle-
LASE 755-n m alexan drite laser. Derm atol Su rg 2004;30(4
Pt 1):494–497
33. Bäum ler W, Sch erer K, Abels C, Ne S, Lan dth aler M,
Szeim ies RM. Th e e ect of di eren t sp ot sizes on th e ef-
cacy of hair rem oval u sing a long-pulsed diode laser. Der-
m atol Surg 2002;28(2):118–121
34. Alt sh uler GB, Zen zie HH, Erofeev AV, Sm irn ov MZ, An der-
son RR, Dierickx C. Con t act cooling of th e skin . Phys Med
Biol 1999;44(4):1003–1023
35. Zen zie HH, Alt sh uler GB, Sm irn ov MZ, An derson RR. Evalu -
at ion of cooling m eth ods for laser derm atology. Lasers Su rg
Med 2000;26(2):130–144
28 Aesthetic Laser Hair Rem oval for the Asian Face 373
36. Nelson JS, Majaron B, Kelly KM. Act ive skin cooling in con -
jun ct ion w ith laser derm atologic surger y. Sem in Cut an
Med Su rg 2000;19(4):253–266
37. Ram R, Rosen bach A. E ect s of am bien t room tem p erat u re
on cold air cooling during laser h air rem oval. J Cosm et Der-
m atol 2007;6(3):203–206
38. Klavuhn KG, Green D. Im portance of cutaneous cooling dur-
ing ph ototherm al epilat ion : theoret ical and pract ical con -
siderat ion s. Lasers Surg Med 2002;31(2):97–105
39. Goldberg DJ. E ect of tem p erat u re-con t rolled cooling on
ligh t-based skin t reat m en t s. J Cosm et Laser Th er 2006;
8(3):155–156
40. Moren o-Arias GA, Castelo-Bran co C, Ferran d o J. Side-
e ect s after IPL ph otodep ilat ion . Derm atol Su rg 2002;
28(12):1131–1134
41. Bern stein EF. Hair grow th in du ced by d iode laser t reat-
m en t . Derm atol Su rg 2005;31(5):584–586
42. Noh S, Koh WS, Lim HW, et al. Tool to visu alize an d evalu -
ate op erator p ro cien cy in laser h air-rem oval t reat m en t s.
Biom ed Eng On lin e 2014;13:40
43. Bou zari N, Tabat abai H, Abbasi Z, Firooz A, Dow lat i Y. Hair
rem oval u sing an 800-n m diode laser: com parison at dif-
feren t t reat m en t in ter vals of 45, 60, an d 90 days. In t J Der-
m atol 2005;44(1):50–53
44. Lan da N, Corron s N, Zabalza I, Azp iazu JL. Urt icaria in d u ced
by laser ep ilat ion : a clin ical an d h istop ath ological st u dy
w ith extended follow -up in 36 pat ien t s. Lasers Surg Med
2012;44(5):384–389
45. Helou J, Maatou k I, Mou t ran R, Obeid G. Fox-Fordyce-like
disease follow ing laser h air rem oval appearing on all t reat-
ed areas. Lasers Med Sci 2013;28(4):1205–1207
46. Bech ara FG, Georgas D, San d M, et al. E ect s of a long-
pulsed 800-n m d iode laser on axillar y hyp erh idrosis: a
ran dom ized con t rolled h alf-side com p arison st u dy. Der-
m atol Surg 2012;38(5):736–740
47. Desai S, Mah m ou d BH, Bh at ia AC, Ham zavi IH. Paradoxical
hypert rich osis after laser th erapy: a review. Derm atol Surg
2010;36(3):291–298
48. Willey A, Torron tegu i J, Azp iazu J, Lan da N. Hair st im u la-
t ion follow ing laser an d in ten se p u lsed ligh t p h oto-epila-
t ion : review of 543 cases an d w ays to m an age it . Lasers
Surg Med 2007;39(4):297–301
49. Dosh i SN, Levy ML, Marku s R. Koebn erizat ion of react ive
perforat ing collagen osis in du ced by laser h air rem oval. La-
sers Surg Med 2003;32(3):177–179
50. Moreno-Arias GA, Cam ps-Fresneda A. Long-lasting hypopig-
m entation induced by long-pulsed alexandrite laser photo-
epilation . Derm atol Surg 2003;29(4):420–422
51. Weisberg NK, Green bau m SS. Pigm en t ar y ch anges af-
ter alexan drite laser h air rem oval. Derm atol Su rg 2003;
29(4):415–419
52. Lan igan SW. In cid en ce of sid e e ect s after laser h air re-
m oval. J Am Acad Derm atol 2003;49(5):882–886
53. Brilakis HS, Hollan d EJ. Diode-laser-in du ced cat aract an d
iris at rop hy as a com p licat ion of eyelid h air rem oval. Am J
Op h th alm ol 2004;137(4):762–763
54. Davou di SM, Beh n ia F, Gorou h i F, et al. Com p arison of long-
pulsed alexan drite an d Nd:YAG lasers, in dividu ally an d in
com bin at ion , for leg h air redu ct ion : an assessor-blin d ed,
ran dom ized t rial w ith 18 m on th s of follow -u p . Arch Der-
m atol 2008;144(10):1323–1327
374 V Facial Skin and Hair Rejuvenation
55. Lou W W, Qu in t an a AT, Geron em u s RG, Grossm an MC. Pro -
sp ect ive st u dy of h air red u ct ion by diode laser (800 n m )
w ith long-term follow -u p. Derm atol Su rg 2000;26(5):
428–432
56. Dang Y, Liu B, Liu L, et al. Th e 800-n m diod e laser irrad ia-
t ion in d u ces skin collagen syn th esis by st im u lat ing TGF-β/
Sm ad sign aling p ath w ay. Lasers Med Sci 2011;26(6):
837–843
57. Davis EC, Callen der VD. Post in am m ator y hyp erpigm en ta-
t ion : a review of th e epidem iology, clin ical feat u res, an d
t reat m en t opt ion s in skin of color. J Clin Aesth et Derm atol
2010;3(7):20–31
58. Manuskiatti W, Dierickx CC, González S, et al. Laser hair re-
m oval a ects sebaceous glands and sebum excretion: a pilot
study. J Am Acad Derm atol 1999;41(2 Pt 1):176–180
59. de Groot AC. Con t act allergy to cosm et ics: cau sat ive ingre-
dien t s. Con tact Derm at 1987;17(1):26–34
60. Uyar B, Saklam az A. E ect s of th e 755-n m alexan d rite la-
ser on n e dark facial h air: review of 90 cases. J Derm atol
2012;39(5):430–432
VI
Minimally Invasive Facial Plastic Surgery
29 Aesthetic Facial Use of Botulinum Toxin in East Asians
Kyle Seo
Pearls
• Th e t reat m en t st rategy beh in d bot ulin um toxin
t yp e A (BTA) in East Asian s, regarding dosages an d
inject ion p oin ts, sh ou ld be based on th e follow ing
con siderat ion s: th e pat ien t’s m uscle m ass, m uscle
sh ape, an d p at tern of m u scle act ivit y; eth n ic
di eren ces bet w een East Asian s an d Caucasian s;
an d aesth et ic ap prop riaten ess in th e con text of th e
pat ien t’s overall facial st ruct ure.
• Com pared w ith Caucasian s, East Asian s h ave
relat ively w ide, roun d, an d at faces. Th e use of
BTA for th e t reat m en t of m asseter hyp ert rop hy an d
en larged parot id glan d, in w h ich a squ are-sh ap ed
face can be sm ooth ed by d ecreasing th e facial w idth
an d ach ieving a “V” sh ap e in th e fron t p ro le, is
popu lar am ong East Asian s for th is reason .
• BTA inject ion for th e p u rposes of w iden ing th e
palpebral apert u re (i.e., th e eye open ing) by inject ion
of th e low er eyelid is con t rain dicated in East Asian s
because it m ay rem ove th e pret arsal bulge. How ever,
East Asian s do con sider th e w iden ed palpebral
ap er t u re a h allm ark of fem ale beau t y (kn ow n as th e
“ch arm ing roll”).
• Eyebrow “sh aping” w ith BTA, pop u lar in Cau casian s,
is also n ot recom m en ded for East Asian s because
prom in en tly arch ed brow s m ay look especially
u n n at u ral in an Asian face, w h ich is relat ively w ide.
• Asian s gen erally ten d to h ave a sm aller m ass, an d
less hyp erdyn am ic act ivit y, of facial m uscle th an
Cau casian s. Th erefore, low er doses of BTA m ay
be required in East Asian pat ien t s com pared w ith
Cau casian s. Gen erally, in Asian s an in it ial d ose of 3
to 6 U is recom m en d ed for foreh ead h orizon tal lin es
an d 10 U for glabellar frow n lin es.
■ Introduction
Sin ce Carruth ers et al1 rst app lied bot u lin u m toxin t yp e A
(BTA) for th e t reat m en t of glabellar frow n lin es in 1987, BTA
inject ion h as gain ed w orld-w ide popularit y as a dyn am ic
w rin kle redu ct ion t reat m en t because of it s easy applica-
t ion , conven ien ce, and safet y. How ever, m ore recen tly,
th e applicat ion of BTA for aesth et ic purposes h as gon e far
beyon d sim ply reducing w rin kles. Its applicat ion h as been
exp an ded in to correct ion of facial con tou rs cau sed th rough
• Most p hysician s u se clin ical equ ivalen ce at
a conversion rat io of 1:1 for aesth et ic u se of
on abot ulin um toxin A an d oth er BTA product s, except
abobot u lin u m toxin A, for w h ich th e conversion rat io
is believed to be 1:2.5 for on abot ulin um toxin A to
abobot u lin u m toxin A.
• Th e m ain target of BTA w h en resh aping a square jaw
is th e low er cen t ral belly of th e m asseter m u scle.
Deep inject ion , su cien t to tou ch th e m an d ibu lar
bon e, is ver y im por tan t to avoid em barrassing
facial expression (e.g., an u n n at u ral asym m et ric
sm ile cau sed by su p er cial inject ion w eaken ing th e
rizoriu s in th e an terior p art of th e m asseter). Fou r
to six inject ion poin t s (IPs) w ith 5 U p er inject ion
site are recom m en ded dep en ding on th e p at ien t’s
m u scle volu m e.
• Inje ct ion of BTA in to an en larged or p rot r u d in g
p arot id glan d can red u ce t h e w id t h of t h e low er
face by blockin g t h e act ion of acet ylch olin e as
a n eu rot ran sm it te r in t h e salivar y glan d s. Dee p
in t raglan d u lar inject ion at t h e m ost p rot r u d in g
p ar t of t h e p arot id glan d arou n d t h e m an d ibu lar
an gle is requ ire d w it h ve or six IPs an d 5 U p e r
inject ion site.
• The use of m ultiple intraderm al injections of BTA
(intraderm al BTA), under various nam es such as
“m esobotox,” “derm atoxin,” and “m icrotoxin,” has
been w idely adopted in Asia. The treatm ent is used
not only to reduce dynam ic facial w rinkles but also
to reduce static w rinkles and pore size. An additional
action is creating the so-called perceived lifted e ect
or pseudolift. Thus, intraderm al BTA can be considered
to produce a full range of anti-aging e ects.
disuse at rophy of th e m asseter m uscle,2,3 correct ion of th e
body con tour th rough disuse at rophy of calf m u scles, an d
also t reat m en t of focal hyp erh idrosis.4
Several papers an d con sensus publications have pro-
vided guidelin es for the aesth etic use of BTA.5,6,7,8 How ever,
m ost of these publications have focused exclusively on Cau-
casian subjects, except for recent consensus recom m enda-
tions by Korean experts for the aesthetic use of BTA in Asians.9
This chapter focuses on the ethnic di erences bet w een East
Asians and Caucasians for the aesthetic use of BTA in term s
of an atom y, th e applicable dose, injection m ethods, and
377
378 VI Minim ally Invasive Facial Plastic Surgery
indications of BTA, thereby providing som e practical sugges-
tions for the aesthetic use of BTA in East Asians.
■ Patient Evaluation
Each pat ient should be exam ined individually. Individual-
ized assessm ent and treat m ent are necessar y because there
is sign i cant variabilit y am ong individuals w ithin the sam e
East Asian populat ion in the shape and function of m any
target m uscles. Dosages and IPs should be based on the sub-
ject’s m u scle m ass, m uscle sh ape, pat tern of m uscle act iv-
it y, and judgm ent of w hat is aesth etically appropriate in the
con text of th e in dividual patien t’s overall facial st ruct ure.
How ever som e crit ical eth n ic di eren ces bet w een East
Asians and Caucasians should be kept in m in d in developing
a treatm en t st rategy for East Asian s u sing BTA.
Di erences in Aesthetic Ideals
Com pared w ith Caucasian s, East Asian s h ave a relat ively
w ide, rou n d, an d at face. For th is reason , East Asian s con -
sider a sm aller, n arrow er, an d m ore th ree-dim en sion al face
to be m ore at t ract ive, an d m ay w ish to ach ieve th is ideal
u sing bot u lin um toxin . On e of th e m ost t yp ical exam ples
of th is is t reat m en t for m asseter hypert rophy using bot u li-
n u m toxin , w h ich is n ot popu lar in Western cou n t ries even
th ough it w as rst developed in Western cou n t ries m ore
th an 20 years ago.2 Th is n ovel t reat m en t w ith BTA h elp s
th ose East Asian s w ith a square-looking face to ach ieve a
d ecreased facial w idth an d a “V” sh ape to the face in fron t
p ro le as w ell. In a sim ilar con text , bot u lin u m toxin t reat-
m en t for th e p arot id glan d is gain ing p op u larit y am ong
East Asian s as a w ay of decreasing facial w idth .
BTA inject ion for w id en ing th e p alp ebral ap ert u re (th e
eye open ing) is an oth er t ypical exam p le of th e di eren ce
in t reat m en t ap proach es bet w een Asian s an d Caucasian s.
BTA inject ion can rem ove th e p ret arsal bu lge an d sligh tly
low er th e in ferior ciliar y m argin to w iden th e palpebral
ap er t u re.10 How ever, it is im port an t n ot to dim in ish th e
pret arsal m uscu lar bulge in East Asian s, w h o con sider it
a h allm ark of fem ale beau t y (th e “ch arm ing roll”). Th ey
m ay also believe th at th e “ch arm ing roll” brings th e opt ical
illu sion of a “big eye” (like double-eyelid surger y does in
Asian s w ith in h eren tly sm aller eyes). Th e roll can even be
en h an ced by th e inject ion of hyalu ron ic acid ller. In su ch a
con text , BTA inject ion for w iden ing th e palpebral apert u re
is th erefore a con t rain dicat ion in East Asian s.
Anatomic Di erences betw een
East Asians and Caucasians
Asian s gen erally h ave a sm aller m uscle m ass an d less hyper-
dyn am ic act ivit y com pared w ith Caucasian s. Speci cally,
Asian s ten d to h ave sh orter corrugator m u scles th an Cau-
casian s. Th e sm aller m uscle m ass of Asian s seem s to com e
n ot on ly from gen et ic d i eren ces 11 bu t also from cult ural
d i eren ces, sin ce Asian s ten d to u se th eir facial expression
m u scles less th an do Cau casian s.12 Moreover, Asian s h ave
been described as developing few er age-related w rin kles
th an Caucasian s. Th is m ay be because, in com parison w ith
Cau casian s, Asian s h ave a th icker d erm is,13 in creased fat
above an d deep to th e su per cial m u scu lar ap on eu rot ic
system , an d den ser fat an d brou s con n ect ion s bet w een
th e super cial m uscu lar apon eurot ic system an d deep
(p arot idom asseteric) fascia.14 Th erefore, low er doses of BTA
m ay be requ ired in East Asian p at ien ts th an in Cau casian s.
■ Procedural Techniques
Commercial Products of
Botulinum Toxin Type A
Com m ercially available BTA produ cts in Asia are on a-
bot ulin um toxin A (Botox/Vistabel, Allergan In c., Ir vin e,
Californ ia), abobot u lin u m toxin A (Dysp or t , Ip sen , Bou logn e-
Billan cour t , Fran ce/Medicis/Valean t , Bridgew ater, NJ; also
licen sed as Azzalure to Galderm a, Lausan n e, Sw it zerlan d),
an d in cobot u lin u m toxin A (Xeom in /Xeom een /Bocou t u re/
XEOMIN Cosm et ic); bot u lin u m toxin t ype A (150 kDa) free
from com plexing p rotein s (Merz Ph arm aceu t icals Gm bH,
Fran kfurt , Germ any). Oth er BTA product s th at h ave been
ap proved for u se in Asia are Neu ron ox (Medytox In c., Seou l,
Sou th Korea; also m arketed as Bot u lift , Cu n ox, Meditoxin ,
an d Siax), Prosign e (CBTX-A; Lan zh ou Biological Produ cts
In st it u te, Lan zh ou , Ch in a) an d Regen ox (Hugel Ph arm a,
Sou th Korea; also m arketed as Bot u lax an d Zen tox).
An oth er Korean toxin , Nabot a (Daew oong Ph arm aceu t ical
Co. Ltd., Seoul, South Korea), is licen sed an d un der invest i-
gat ion in th e Un ited States an d Eu rop e as Evosyal (Alph aeon
Corp., New por t Beach , Californ ia).
In each p rodu ct labeling, th e m an u fact u rer states th at
dosage u n it s are n ot in terch angeable becau se di eren t
assays are u sed to m easu re th e poten cy of di eren t bot u -
lin um toxin t ype A p roduct s. How ever, several con sen sus
papers an d clin ical st udies suppor t clin ical equivalen ce at a
conversion rat io of 1:1 for aesth et ic use of on abot ulin um -
toxin A an d oth er BTA p rod u ct s except abobot u lin u m -
toxin A.5,8,15,16 Variou s dose conversion rat ios h ave been
suggested for on abot u lin u m toxin A an d abobot u lin u m tox-
in A. Based on available dat a an d clin ical experien ce, m ost
p hysician s apply a rat io for on abot ulin u m toxin A to abob -
ot ulin um toxin A of 1:2.5 for aesth et ic u se.17,18
Dilution and Storage of
Botulinum Toxin Type A
Lyophilized BTA pow der should be recon stituted w ith
preservative-free saline to avoid possible reductions in the
potency of BTA. However, som e advocates for preservative
con taining saline insist that it reduces the pain experienced
 29
by patients from th e injection of BTA w ithout in uencing
the potency of BTA.19,20 Various volum es of n orm al saline
have been used for the reconstitution of BTA pow der, from
1 to 10 m L, w ith 2.5 m L and 3.3 m L being popular dilutions,
w ith respective concentrations of 4 U/0.1 m L and 3 U/0.1 m L.
Variou s resu lt s h ave been suggested for th e e ect of
refrigerator storage on th e poten cy of BTA follow ing th e
recon st it u t ion of BTA. Based on available dat a an d clin ical
exp erien ce, h ow ever, m ost p hysician s store th e recon st i-
t uted BTA in th e refrigerator for up to 4 w eeks.21,22,23
Landmark of Injection
The determ ination of BTA injection sites should be based on
m uscular and bony landm arks, rather than on cutaneous ones.
The eyebrows are a particularly unreliable cutaneous landm ark.
This is especially so in older people w ith eyebrow sagging, and
in wom en, due to their propensity to m odify the eyebrow
shape by tweezing, plucking, etc. Exam ination of the overlying
soft tissues—fat and skin—m ay be useful as an adjunct.
Injection Levels
W h ile in t raderm al inject ion h as th e ben e t of less bruis-
ing, p recise inject ion in to th in derm is, su ch as th at foun d in
th e low er eyelid, is di cult . Moreover, in t raderm al injec-
t ion is m uch m ore pain ful th an su bderm al or in t ram uscu-
lar inject ion . Th erefore, it is m ore realist ic to describe th e
placem en t of BTA required for deep m uscles, su ch as th e
m asseter an d corrugator, as su bderm al or in t ram u scu lar.
■ Site -Speci c Techniques
Forehead Horizontal Lines
Th e t arget m uscle is th e fron t alis (Fig. 29.1). Con sid erat ion
poin t s are as follow s:
1. Screening for th ose at risk of eyebrow ptosis, (e.g.,
p at ien t s w ith ptosis, or people w h o congen itally
open th eir eyes w ith th e fron talis) is a prerequisite
a b
Aesthetic Facial Use of Botulinum Toxin in East Asians 379
because eyebrow ptosis is a fairly em barrassing side
e ect from th e aesth et ic view p oin t in Asian s, w h o
h ave a w ider distan ce bet w een th e eyebrow an d th e
palpebral ssu re com pared w ith Caucasian s. Typical
at-risk pat ien ts for eyebrow ptosis are older people
(i.e., in th eir 50s an d above); th ese p at ien t s requ ire a
low in it ial dose from 2 to 3 U.
2. Many Asian s require low er doses of BTA sin ce Asian s
h ave a sm aller m uscle m ass an d less hyperdyn am ic
act ivit y th an Cau casian s.
Th e m icrodroplet tech n ique at th e in t raderm al level m ay
be of value to preser ve expressivit y. Gen erally, t w o row s
of six or seven IPs are recom m en ded (Fig. 29.2a). Altern a-
t ives in clu de th ree row s of inject ion s for people w ith a h igh
foreh ead (Fig. 29.2b). Low in it ial doses from 3 to 6 U are
recom m ended an d n o m ore th an 12 U in tot al becau se of
th e risk of eyebrow ptosis.
Glabellar Frow n Lines
Th e t arget m uscles are the corrugators an d procerus (an d
som et im es th e orbicu laris ocu li) (Fig. 29.3). Th e con sid er-
at ion poin t s are as follow s:
1. Asians have shorter and narrower corrugator m uscles
com pared w ith Caucasians.11 Asians also have
less hyperdynam ic activit y than Caucasians 12 and
consequently require lower doses of BTA. Therefore, a
four-point injection pattern (rather than the standard
ve-point pattern for Caucasians), w ith injection of
the procerus and the m edial corrugators (but not the
lateral corrugators), is generally appropriate for Asian
fem ales. Of course, a ve-point injection pattern could
be appropriate for Asian m ales and other subjects w ith
a greater m uscle m ass. To prevent “sam urai eyebrow ”
(a weird expression especially seen in Asians w ith a
w ide face), an additional injection of 0.5 U BTA into
the frontalis at 2 cm above the eyebrow in line w ith a
lateral canthal line can be of bene t in subjects aim ing
to achieve a standard Caucasian pattern.
2. St retch test s w ill h elp to iden t ify subject s for w h om
th e com bin at ion of BTA w ith a soft t issue ller,
versu s BTA alon e, is th e m ost ap prop riate strategy.
Fig. 29.1 BTA injection for forehead horizontal
lines. (a) Before the injection. (b) Two weeks
after injection.
380 VI Minim ally Invasive Facial Plastic Surgery

a b

Fig. 29.2 Injection points and dose of BTA for forehead horizontal lines. (a) Injection points and dose of BTA for t wo rows with six to seven
IPs. (b) Alternatives include three rows of injections for people with a high forehead. (Used with perm ission from Seo KK. Botulinum Toxin
for Asians [in Korean]. Seoul: Seoul Medical Books & Publishing; 2014.)

Fig. 29.3 BTA injection for glabellar frown

a b
lines. (a) Before the injection. (b) Two weeks
after injection.

Intram usclular injection into four IPs should be used (2 U in
two IPs in the procerus and 4 U in two IPs in the m edial part of
the corrugator) (Fig. 29.4a). The standard Caucasian pattern for
glabellar frow n lines requires an additional 1 to 2 U at the m id-
pupillary line for the lateral part of the corrugator (Fig. 29.4b).
Occasion ally, an addit ion al inject ion of 1 U at th e lateral
can th al lin e im m ediately above th e eyebrow is n ecessar y
for th ose pat ien t s w ith a hyp eract ive orbicu laris ocu li.
To avoid ptosis, on e of th e m ost serious an d u n com for t-
able adverse e ects of BTA, t ake th e IP for th e corrugator
h ead above th e bony orbit al rim by palp at ing th e bony rim ,
an d th en inject it slow ly w ith a n on dom in an t nger, com -
p ressing th e bony orbit al rim so as to p reven t th e spread of
BTA in to th e orbit al p ar t below.
Lateral Canthal Rhytides
(Crow ’s-Feet)
Th e t arget m uscle is th e orbicu laris oculi (Fig. 29.5). Con -
siderat ion p oin ts are as follow s:
1. It is im port an t to preser ve th e expression lin es at
th e lateral can th al lin es to som e exten t to m ain t ain a
n at u ral look.
2. It is also im port an t , prior to inject ion , to dist inguish
bet w een orbicu laris act ivit y an d zygom at icu s
act ivit y as th e cau se of w rin kles arou n d th e lateral
can th al area. Horizon t al lin es un der th e eyes an d
descen ding lin es at th e lateral m alar area are cau sed
 29 Aesthetic Facial Use of Botulinum Toxin in East Asians 381

a b

Fig. 29.4 Injection points and dose of BTA for glabellar frown lines. (a) Intramusclular injection into four IPs should be used (2 U in t wo
IPs in the procerus, and 4 U in t wo IPs in the medial part of the corrugator). (b) The standard Caucasian pat tern for glabellar frown lines
requires an additional 1 to 2 U at the midpupillary line for the lateral part of the corrugator. (Used with permission from Seo KK. Botulinum
Toxin for Asians [in Korean]. Seoul: Seoul Medical Books & Publishing; 2014.)

Fig. 29.5 BTA injection for lateral canthal

a b
rhytides. (a) Before the injection. (b) Two
weeks after injection.

by zygom at icus act ivit y an d, con sequ en tly, are n ot
in dicat ion s for BTA. Th is sh ould be com m u n icated
in advan ce to pat ien ts prior to t reat m en t so th at
expect at ion s are ap p ropriate.
3. Follow ing BTA for crow ’s-feet , Asian s w ith
p rom in en t zygom a an d abu n dan t prem alar fat above
th e n asojugal groove ten d to readily sh ow m ore
p rom in en ce of th e lateral m alar area, w h ich Asian s
gen erally h ate. In th ese p at ien t s, inject ion at a low er
p ar t is un n ecessar y; altern at ively, a low er dose (i.e.,
on ly 0.5 U of BTA) is required.
To avoid bruising, subderm al inject ion tech n ique is useful
for th is t reat m en t area as th e area h as abu n dan t u n d erly-
ing vessels. At least th ree IPs w ith 2 to 3 U per IP sh ould be
used, w ith an opt ion al on e or t w o IPs, dep en ding on th e
w rin kle pat tern (Fig. 29.6).
Eyebrow s (Brow Lifting and Shaping )
Th e t arget m u scles are brow depressors (corrugators,
procerus, orbicularis ocu li). Con siderat ion poin ts are as
follow s:
1. It is im port an t to preser ve or ach ieve a n at u ral
eyebrow posit ion becau se eyebrow s ten d to droop
w ith aging in Asian s.
382 VI Minim ally Invasive Facial Plastic Surgery

Infraorbital Wrinkles
The target m uscle is the lower part of the orbicularis oculi,
preseptal and orbital part. Consideration points are as follows:

1. Th e in fraorbit al area sh ould n ot be injected in th ose

pat ien t s w h o h ave poor skin elast icit y.
2. It is im portant not to inject the pretarsal part of the
orbicularis oris close to the low er ciliary m argin
because injection of BTA into this area dim inishes the
pretarsal m uscular bulge in East Asians, w ho consider
it a hallm ark of fem ale beaut y (the “charm ing roll”).
3. Caut ion sh ould be t aken w h en inject ing pat ien t s
w ith in fraorbit al fat bu lging becau se of th e risk of
deteriorat ion of th e fat bulge.
IPs are u su ally recom m en ded bet w een th e preseptal part
an d th e orbital part of th e orbicu laris oris. On e row of ve
or six IPs per eye, w ith a tot al dose of less th an 2 U, is rec-
om m en ded (Fig. 29.7).

Fig. 29.6 Injection points and dose of BTA for lateral canthal rhyt-
ides. At least three IPs should be used with an optional additional
Infraorbital Eye Opening
one or t wo IPs (purple) above and/or below these depending on the
wrinkle pat tern. (Used with permission from Seo KK. Botulinum Th e t arget m uscle is th e orbicu laris oculi, pretarsal part .
Toxin for Asians [in Korean]. Seoul: Seoul Medical Books & Publish- Con siderat ion poin ts are as follow s: BTA inject ion w ou ld
ing; 2014.) rem ove th e pret arsal bulge an d sligh tly low er th e in ferior

2. Eyebrow “lifting” w ith bot ulin um toxin, by leveraging

the m ech anism of bot ulinum rebalancing and
w eaken ing depressor m u scles su ch as th e corrugator,
procerus, and orbicularis, has been described as a
rejuvenative procedure.24 W h ile you th ful eyebrow s
in Caucasian s rarely sit high on the foreh ead, and
eyebrow s often becom e elevated w ith age due to
partial com pensat ion for upper eyelid ptosis,25
eyebrow lifting w ould m ake sense in Asians w ho
have a w ider distan ce bet w een th e eyebrow s and the
palepebral ssure than in Caucasian s, and w ho show
brow drooping w ith aging.
3. Eyebrow “shaping” w ith botulinum toxin has been
described extensively in the Caucasian literature.26
However, prom inently arched brow s m ay look
especially unnatural in Asians since their faces are
relatively w ide. The preferred Asian fem ale brow shape
is usually atter and lower in the lateral t wo-thirds
than that described for Caucasians. This does not
detract from facial harm ony and, in fact, m ay enhance
it. Asian subjects in their native countries, and m ost Fig. 29.7 Injection points and dose of BTA for infraorbital wrin-
Asian im m igrants in other countries, especially dislike kles. One row of ve or six IPs per eye, with a total dose of less than
the laterally elevated “Sam urai eyebrow.” 2 U is recommended bet ween the preseptal part and the orbital
part of the orbicularis oris. (Used with permission from Seo KK.
Typical sch em es involve com bin at ion t reat m en t w ith BTA Botulinum Toxin for Asians [in Korean]. Seoul: Seoul Medical Books
at th e glabella an d orbicu laris ocu li. & Publishing; 2014.)
 29 Aesthetic Facial Use of Botulinum Toxin in East Asians 383

ciliar y m argin to w iden th e palpebral aper t ure (eye open -

ing).10 How ever, it is im port an t n ot to dim in ish th e pret ar-
sal m uscu lar bu lge in Korean an d Taiw an ese su bject s an d
oth er Asian s w h o con sider it a h allm ark of fem ale beau t y
(th e ch arm ing roll). Th ey also believe th at th e ch arm ing
roll is resp on sible for th e opt ical illusion of a “big eye,” like
double-eyelid surger y is in Asian s w ith in h eren tly sm aller
eyes. Th e ch arm ing roll is even en h an ced by th e inject ion of
hyaluron ic acid ller. Hen ce, in th is con text , BTA inject ion is
a con t rain d icat ion in th ese East Asian s.
On e poin t per eye, 1 to 2 m m below th e in ferior ciliar y
m argin in th e m id pu p ilar y lin e, is su cien t . A d ose of 2 U
per eye is recom m en ded (Fig. 29.8).

Nasal Tip Lifting
Th e t arget m u scles are th e depressor sept i n asi an d n asalis
(an d som et im es th e levator labii su perioris alaequ e n asi).
Con siderat ion poin t s are as follow s:
Fig. 29.8 Injection point and dose of BTA for an infraorbital eye
opening. One point per eye 1 to 2 mm below the inferior ciliary mar-
gin in the midpupillary line is su cient. A dose of 2 U per eye is rec-
ommended. (Used with permission from Seo KK. Botulinum Toxin for
Asians [in Korean]. Seoul: Seoul Medical Books & Publishing; 2014.)

1. Nasal t ip elevat ion is u su ally p erform ed by ller

inject ion in stead of by bot ulin um toxin alon e
in Asian cou n t ries. How ever, bot u lin u m toxin
inject ion com bin ed w ith n ose ller can result in an
im m obilizing e ect on th e n ose, th u s m aking th e
ller rem ain longer.
2. It is ben e cial to t reat th e n asalis or levator labii
su p erioris alaequ e n asi in conju n ct ion w ith
th e depressor sept i n asi if th ere is sign i can t
recruit m en t of th e n asalis an d levator labii superioris
alaequ e n asi du ring an im at ion .
For n asal t ip t reat m en t , on e inject ion w ith 4 U at a poin t
at th e subn asale (n asolabial ju n ct ion ) deep in to th e n asal
spin e w h ere th e d ep ressor sept i n asi origin ates is recom -
m en ded, com bin ed w ith t reat m en t for th e n asalis w ith 4 U
at t w o IPs (Fig. 29.9).

a b

Fig. 29.9 Injection points and dose of BTA for nasal tip lifting. One injection with 4 U at the subnasale (nasolabial junction) deep into the
nasal spine is recommended, combined with treatment for the nasalis with 4 U at t wo IPs. (a) Frontal view. (b) Lateral view. (Used with
permission from Seo KK. Botulinum Toxin for Asians [in Korean]. Seoul: Seoul Medical Books & Publishing; 2014.)
384 VI Minim ally Invasive Facial Plastic Surgery

Bunny Lines
Th e target m uscles are th e levator labii su perioris alequae
n asi an d n asalis. Con siderat ion poin ts are as follow s: Cen -
t ral ver t ical bun ny lin es are caused by th e n asalis, an d can
be dim in ish ed com pletely w ith BTA. How ever, bun ny lin es
lateral to th e dorsu m of th e n ose, w h ich are produced by
th e levator labii su perioris alaeque n asi an d th e m edial
band of th e orbicularis oculi, can n ot be en t irely im proved,
sin ce com pletely p aralyzing th e levator labii su perioris
alaequ e n asi is n ot recom m en ded.
As w ith all subject s, keeping th e IPs m edial to th e n aso-
facial groove can avoid in adver ten t com p lete p aralysis of
th e levator labii superioris alaeque n asi. Th ree IPs w ith 2 U
per IP are recom m en ded (Fig. 29.10).

Gummy Smile
Th e t arget m uscle is th e levator labii superioris alaeque
n asi. Con siderat ion poin t s are as follow s:
Fig. 29.10 Injection points and dose of BTA for bunny lines. Three
1. Th e m ech an ism for th is in dicat ion is w eaken ing of IPs with 2 U per IP are recommnended. (Used with permission from
hyperact ivit y of th e elevator m uscles of th e upper Seo KK. Botulinum Toxin for Asians [in Korean]. Seoul: Seoul Medi-
lip to im prove excessive gingival display (“gum m y cal Books & Publishing; 2014.)
sm ile”).
2. It is im port an t to inject BTA on ly in to th e levator labii
su p erioris alaequ e n asi becau se p aralysis of oth er lip
levator m uscles result s in a w eird-looking sm ile.
3. Bot u lin u m toxin inject ion sh ould be perform ed
caut iously in Asian pat ien t s w ith a long ph ilt rum
an d p rot ru ding u p per lip , becau se th is m ay lead to
elongat ion of th e ph ilt rum .

In t ram u scu lar inject ion is recom m en ded at ju st lateral to

th e ala n asi. Inject ion sh ould n ot be too lateral, or else th e
facial expression m ay ch ange du ring sm iling. Tw o IPs w ith
2 to 4 U per IP are recom m en ded (Fig. 29.11).

Perioral Rhytides
Th e target m uscle is th e orbicularis oris. Con siderat ion
poin t s are as follow s:

1. A low er in it ial dose is bet ter for preser ving th e

closing act ion of th e orbicularis oris. Several m uscles
im p ort an t for facial expression are located adjacen t
to th e orbicularis oris, an d th erefore care m ust be
t aken to avoid in adverten t inject ion in to adjacen t
m u scles.
Fig. 29.11 Injection points and dose of BTA for gummy smile.
2. Bot u lin u m toxin inject ion sh ould be perform ed Intramuscular injection is recommended just lateral to the ala nasi
caut iously in Asian pat ien t s w ith a long ph ilt rum with 2 to 4 U per IP. (Used with permission from Seo KK. Botulinum
an d p rot ru ding u p per lip , becau se th is m ay lead to Toxin for Asians [in Korean]. Seoul: Seoul Medical Books & Publish-
elongat ion of th e ph ilt rum . ing; 2014.)
 29 Aesthetic Facial Use of Botulinum Toxin in East Asians 385

At least t w o IPs p er side on th e u p per lip verm illion border
are recom m en ded. Occasion ally th is m ay be exten d ed to
in clu de t w o to four poin t s on th e low er lip . A dose of 1 U
p er IP is recom m en ded (Fig. 29.12).
bot ulin um toxin sh ould be injected in to th e low er
part of th e depressor angu li oris to avoid th e
poten t ial for in adver ten t di usion in to oth er m u scles
resp on sible for m ovem en t of th e corn er of th e
m ou th .

Mouth Corner Elevation Su bderm al inject ion can be p erform ed to avoid in adverten t
di usion in to th e depressor labii in ferioris. On e IP w ith a
(Marionette Lines) dose of 2 to 4 U in th e low er on e-th ird of th e depressor
angu li oris is recom m en d ed (Fig. 29.13).
Th e t arget m uscle is th e depressor anguli oris. Con sider-
at ion p oin t s are as follow s:

1. Treat m en t for a pre-exist ing m arion et te lin e is Cobblestone Chin

u su ally m an aged by ller inject ion w ith bot u lin u m
toxin in stead of bot ulin um toxin alon e. Th is is
because bot ulin um rebalan cing (i.e., w eaken ing th e
d ep ressor anguli oris w ith BTA) resu lts in elevat ion
of th e m outh corn er. Hen ce BTA is a w idely used
adju n ct to ller inject ion .
2. Th e depressor anguli oris is th e m ost super cial
m u scle above th e depressor labii in ferioris. If th e
d ep ressor labii in ferioris is a ected by bot u lin um
toxin , asym m et r y of th e low er lip during an im at ion
or in abilit y to low er th e lip m igh t occur.
3. Th e m odiolus, on w h ich m any m uscles aroun d
th e corn er of th e m outh (in cluding th e depressor
angu li oris) converge, is low er th an th e in terch eilion
h orizon tal lin e in 58.4% of Asian s.27 Th erefore,
Th e t arget m uscle is th e m en talis. Con siderat ion poin t s are
as follow s:
1. A “cobbleston e” appearan ce of th e ch in du e to
ch ron ic hyperact ivit y of th e m en talis can w orsen
w ith aging an d can be im proved by BTA inject ion
in to th e m en talis.
2. BTA sh ould n ot be injected too close to th e depressor
labii in ferioris to avoid th e risk of asym m et r y caused
by in adver ten t di usion of BTA in to it .
In t ram u scu lar inject ion w ith 4 U in to t w o IPs 1 cm apart
from cen t ral lin e at th e low er border of th e ch in is recom -
m en ded . Tw o m ore inject ion s w ith 2 U p er IP above th ese
are requ ired su bderm ally (Fig. 29.14).

a b

Fig. 29.12 Injection points and dose of BTA for perioral rhytides. (a) At least t wo IPs per side with 1 U per IP on the upper lip vermillion
border are recommended. (b) Occasionally this may be extended to include t wo to four points on the lower lip. (Used with permission
from Seo KK. Botulinum Toxin for Asians [in Korean]. Seoul: Seoul Medical Books & Publishing; 2014.)
386 VI Minim ally Invasive Facial Plastic Surgery
Fig. 29.13 Injection point and dose of BTA for mouth corner ele-
vation (marionet te line). One IP with a dose of 2 to 4 U in the lower
one-third of the depressor anguli oris is recommended. (Used with
permission from Seo KK. Botulinum Toxin for Asians [in Korean].
Seoul: Seoul Medical Books & Publishing; 2014.)
Platysmal Bands
Th e t arget m uscle is th e plat ysm a. Con siderat ion poin t s are
as follow s:
1. BTA inject ion for th e plat ysm a is used to reduce
p lat ysm al ban ds. Decu ssat ion of th e plat ysm al ban d
is m ore frequ en t in Asian s th an in Cau casian s.28
Hen ce, th e so-called gobbler n eck deform it y is rarely
fou n d in Asian s.
2. BTA inject ion to th e plat ysm a m ay result in a
d ecrease in rest ing m uscle ton e, w h ich brings about
th e pseudo-lift ing e ect ach ieved by th e m ech an ism
of bot ulin um rebalan cing.
In t ram u scu lar inject ion along th e p lat ysm a ban d from th e
in ser t ion area aroun d th e jaw lin e to th e origin at ing area
n ear th e clavicle is p erform ed w ith IPs 2 cm ap art . A dose
of 2 to 4 U per IP, an d n o m ore th an 80 U in on e session , is
recom m en ded (Fig. 29.15).
a b
Fig. 29.15 (a,b) Injection points and dose of BTA for plat ysmal band. Intramuscular injection with a dose of 2 to 4 U per IP along the
plat ysma band from the insertion area around the jaw line to the originating area near the clavicle is performed with IPs 2 cm apart.
Fig. 29.14 Injection points and dose of BTA for cobblestone chin.
Intram uscular injection with 4 U into t wo IPs 1 cm apart from the
central line at the lower border of the chin is recommended. Two
more injections with 2 U per IP above these are required subder-
mally. (Used with permission from Seo KK. Botulinum Toxin for
Asians [in Korean]. Seoul: Seoul Medical Books & Publishing; 2014.)
Square Jaw (Masseter Hypertrophy)
Th e t arget m uscle is th e m asseter (Fig. 29.16). Con sider-
at ion poin t s are as follow s:
1. Th e m ain ben e t from th is n ovel in dicat ion for BTA
inject ion is to en h an ce the sh ape of th e low er face by
m odifying th e squ are jaw com m on in Asian s. Anyon e
can ach ieve a reduced facial con tour to som e exten t
by reducing th e th ickn ess of th e m asseter m uscle
provided th ey h ave su cien t m u scle volu m e.
2. Th e m ech an ism of act ion of BTA in th e t reat m en t
of square jaw is a t ype of disuse m uscular at rophy.
Th erefore, th is t reat m en t result s in a t im e lag in
both th e on set an d peak of act ion th at di ers from
conven t ion al t reat m en t s for w rin kles, w h ere th e
on set of act ion begin s after just 2 to 3 days an d th e
peak e ect is reached 1 to 2 w eeks post inject ion .
In clin ical p ract ice, th e e ect of BTA u sed in th e
m asseter h as an on set t im e of 2 w eeks post inject ion ,
 29
a b
an d th e p eak e ect develops at 2 to 3 m on th s
post inject ion .3,29
3. Six m on th s later, th e m uscle volum e w ill usu ally
h ave ret u rn ed to som e exten t , an d by 10 to 12
m on th s p ost inject ion , th e m u scle volu m e can be
ap proach ing it s previou s st ate. Th is is becau se
m u scle at rop hy is reversible, w ith recover y occu rring
after 3 to 6 m on th s. How ever, th e d u rat ion of th e
e ect is variable an d depen ds on th e in dividu al’s
p erson al h abit s, such as bru xism , u n con sciou s jaw
clen ch ing, an d excessive ch ew ing. Th ere h ave also
been m any report s th at th e e ects of BTA in th e
t reat m en t of m asseteric hypert rophy can last for
m ore th an 1 or 2 years, even after on ly on e session of
inject ion s.30 Th is exten ded du rat ion of th e e ect of
BTA is p art icu larly n oted in th ose su bjects w h o h ave
th e acquired form of m asseteric hyper t rophy, as long
as th ey avoid eat ing tough foods an d do n ot h ave th e
h abit of jaw clen ch ing.
4. A person w ith a square jaw in th e fron t view th at
is m ain ly due to th e m asseter m u scle is th e best
can didate for this n ovel in dicat ion for t reat m en t .
5. Factors th at con t ribu te to m asseteric hypert rophy
in clu de jaw clen ch ing an d bru xism , an d th e h abit ual
ch ew ing of gu m or dried, h ard food.31 On e-sided
ch ew ing can lead to asym m et ric m asseteric
hypert rophy.
6. Fem ales w ith a prom in en t zygom a tend to w ish
th e zygom a to n ot appear even m ore prom in en t;
th erefore, reduct ion of th e low er par t of th e
m asseter, rath er th an th e w h ole m u scle, is m ost
ap prop riate.
Aesthetic Facial Use of Botulinum Toxin in East Asians 387
Fig. 29.16 Injection for square jaw (mas-
seter hypertrophy). (a) Before the injection.
(b) Three months after the injection.
7. In dividuals w ith a pre-exist ing sun ken ch eek sh ould
be in form ed in advan ce of th e risk of aggravat ion
of th e sun ken ch eek w ith th e disappearan ce of th e
m u scle volu m e follow ing th is p rocedu re.
8. Pat ien t s in th eir 40s an d above w ith a pre-exist ing
sagging jow l gen erally sh ow aggravat ion of th e
sagging follow ing th is p roced u re.
9. Mild tem p orar y m u scle w eakn ess, su ch as di cu lt y
ch ew ing, w ill occur after BTA inject ion s in a
propor t ion of su bjects. How ever, th is gen erally
passes an d ch ew ing ret urn s to n orm al forcefuln ess
w ith in 3 m on th s.32
The lower central belly of the m asseter m uscle is the m ain target
when reshaping a square jaw using botulinum toxin. Deep injec-
tion su cient to touch the m andibular bone, rather than injec-
tion at a m edium depth, is very important. Super cial injection
can weaken the rizorhius attached super cially to the anterior
part of m asseter, causing an em barrassing change of facial
expression (e.g., an asym m etric, unnatural sm ile). To reduce the
risk of adverse change of facial expression w hen treating m as-
seteric hypertrophy, physicians should start by injecting at least
1 cm inside the anterior m argin of the m asseter m uscle in addi-
tion to deep injection.
For th e cosm et ic p urpose of resh aping a low er facial
con tour, th e low er part of th e m asseter m uscle un der th e
im agin ar y lin e con n ect ing th e t ragu s to th e m ou th corn er
is th e m ain t arget . A safe an d e ect ive inject ion zon e for
squ are jaw can be delin eated by th e u p per m argin being
an im agin ar y lin e con n ect ing th e t ragu s to th e m ou th cor-
ner, th e low er m argin as th e m an dibu lar bony border, an d
th e an terior an d posterior m argin s as th e an terior an d pos-
terior borders of each m asseter m uscle. IPs are located at
388 VI Minim ally Invasive Facial Plastic Surgery
least 1 cm in side from th e bord er, to avoid unw an ted di u -
sion of BTA in to oth er facial m u scles.
Fou r to six IPs of 5 U are recom m en ded dep en ding on
th e m uscle volum e (Fig. 29.17).
Reduction of the Parotid Gland
Th e t arget is th e parot id glan d. Con siderat ion poin t s are as
follow s:
1. En larged parot id glan ds can con t ribute to a
squ are-sh aped low er face app earan ce. Becau se
acet ylch olin e, th e n eu rot ran sm it ter in th e salivar y
glan ds, can be blocked by BTA, inject ion of BTA in to
th e parot id glan d can resu lt in at rophy of th e parot id
glan d in h u m an s.33 In deed, inject ion of BTA in to an
en larged or p rot ru ding parot id glan d can redu ce th e
w idth of th e low er face.
2. Inject ing BTA in to th e parot id glan d seldom result s
in a dr y m ou th as 71% of salivar y produ ct ion com es
from th e su bm an d ibu lar glan d.34
Th e m ost prot ruding part of th e parot id glan d aroun d th e
m an dibu lar angle is th e m ost e ect ive inject ion site. Deep
in t raglan du lar inject ion is requ ired . Five to six IPs w ith 5
U p er inject ion site are recom m en ded dep en d ing on th e
parot id glan d volum e (Fig. 29.18).
a b
Fig. 29.17 Injection points and dose of BTA for square jaw. Depending on the muscle volum e, IP numbers can vary. (a) Four IPs. (b) Six
IPs. (Used with permission from Seo KK. Botulinum Toxin for Asians [in Korean]. Seoul: Seoul Medical Books & Publishing; 2014.)
Intradermal Botulinum Toxin
Con siderat ion poin t s are as follow s:
1. Mult iple in t raderm al inject ion s of BTA (in t raderm al
BTA) h ave been w idely adopted in Asia, u n der
variou s n am es su ch as “m esobotox,” “d erm atoxin ,”
an d “m icrotoxin .” Th e t reat m en t is ap plied w ith
th e expect at ion of n ot on ly redu cing dyn am ic facial
w rin kles bu t also reducing stat ic w rin kles an d pore
sizes, as w ell as creat ing th e so-called perceived
lifted e ect or pseudolift— even th ough act u al lift ing
e ect s h ave n ot been object ively veri ed. Th erefore,
in t raderm al BTA can be con sidered to produce a full
range of an t i-aging e ect s.
2. Th e sam e dyn am ic w rin kle reduct ion th at is
delivered by th e conven t ion al in t ram uscular
inject ion of BTA can also be ach ieved by di usion
of BTA in to un derlying facial expression m u scles,
because BTA spreads in a th ree-dim en sion al
m an n er from th e derm is an d becau se several
facial expression m u scles also h ave in t racu t an eou s
in ser t ion s.
3. Th e hypoth esized e ects of th e im provem en t of
stat ic w rin kles an d t igh ten ing of p ores, w h ich
im p art s a sh in e an d a t igh ter look to th e skin ,
involves derm al edem a resu lt ing from th e t ran sien t
 29
Fig. 29.18 Injection points and dose of BTA for enlarged parotid
gland. Five to six IPs with 5 U per injection site are recommended
depending on the parotid gland volume. (Used with permission
from Seo KK. Botulinum Toxin for Asians [in Korean]. Seoul: Seoul
Medical Books & Publishing; 2014.)
an d m ild lym p h at ic in su cien cy in du ced by
u n derlying m u scu lar paralysis. Derm al edem a m igh t
im prove th e n e st at ic w rin kles an d dilated pores.
4. In som e an ecdotal repor t s, in t raderm al BTA h as been
described as reducing sebum product ion an d pore
prom in en ce.35,36,37 Acet ylch olin e receptors h ave been
rep orted to be presen t in sebaceou s glan ds,38 an d a
p ossible e ect of BTA is to redu ce th e act ivit y of th e
sebaceou s glan d an d th e p ore size, th u s im p roving
a b
Fig. 29.19 Injection points and dose of BTA for intradermal BTA. The white dots indicate intradermal injection sites and the gray dots
indicate intramuscular injection sites. (a) Frontal view. (b) Lateral view. (Used with permission from Seo KK. Botulinum Toxin for Asians [in
Korean]. Seoul: Seoul Medical Books & Publishing; 2014.)
Aesthetic Facial Use of Botulinum Toxin in East Asians 389
th e skin by giving it a sm ooth appearan ce. Recen tly,
th e reduct ion of sebum product ion an d pore size
by in t raderm al BTA in pat ien t s w ith oily skin w as
object ively elucidated.39
5. Th e pseudo-lift e ect is in fact n ot t rue lift ing but a
kin d of opt ic illusion . Th e e ect can be ach ieved by
th e reduct ion of th e low er face con tou r by reducing
th e volum e of th e m asseter m uscle an d by giving a
sh arp er d e n it ion to th e ch in lin e by w eaken ing th e
m en t alis an d plat ysm a m u scles.
Com bin ing m ult iple in t raderm al inject ion s w ith th e con -
ven t ion al in t ram u scu lar inject ion is u su ally recom m en ded.
Conven t ion al in t ram u scular inject ion s can be u sed for
sup p lem en t at ion in areas w ith deep m u scles su ch as th e
corrugator, m en t alis, an d m asseter. Areas for in t raderm al
inject ion are th e foreh ead, ch eek, an d an terior m alar area
(Fig. 29.19).
■ Complications and
Their Management
To date, th ere is n o e ect ive an t idote for BTA. Th erefore,
on ce it is adm in istered, th ere is n o w ay to reverse an adverse
e ect of BTA for at least 2 to 3 m on th s. Adverse e ect s are
th erefore best preven ted. Hen ce, a screen ing assessm en t of
risky pat ien t s is m ost im p or tan t , an d a carefu l an d m et icu -
lou s inject ion tech n iqu e is also recom m en ded. Com p lica-
t ion s of BTA an d speci c in dicat ion s for BTA t reat m en t h ave
already been described in depth in th e previou s sect ion s.
390 VI Minim ally Invasive Facial Plastic Surgery
References
1. Carruth ers JD, Carruth ers JA. Treat m en t of glabellar frow n
lin es w ith C. bot u lin u m -A exotoxin . J Derm atol Su rg On col
1992;18(1):17–21
2. Sm yth AG. Bot ulin um toxin t reat m en t of bilateral m asse-
teric hyp ert rop hy. Br J Oral Maxillofac Su rg 1994;32(1):
29–33
3. Kim HJ, Yum KW, Lee SS, Heo MS, Seo K. E ect s of bot u -
lin u m toxin t yp e A on bilateral m asseteric hyp er t rop hy
evaluated w ith com puted tom ograph ic m easurem en t .
Derm atol Su rg 2003;29(5):484–489
4. Grun feld A, Murray CA, Solish N. Bot ulinu m toxin for hy-
p erh idrosis: a review. Am J Clin Derm atol 2009;10(2):
87–102
5. Carruth ers A, Kan e MA, Flyn n TC, et al. The convergen ce
of m edicin e an d n eurotoxin s: a focus on bot ulin um toxin
t ype A an d it s applicat ion in aesth et ic m edicin e—a global,
eviden ce-based bot ulin um toxin con sen sus educat ion in i-
t iat ive: p art I: bot u lin u m toxin in clin ical an d cosm et ic
p ract ice. Derm atol Su rg 2013;39(3 Pt 2):493–509
6. Carruth ers J, Fou rn ier N, Kersch er M, Ruiz-Avila J, Trin dade
d e Alm eida AR, Kaeu p er G. Th e convergen ce of m edicin e
an d n eurotoxin s: a focus on bot ulin um toxin t ype A an d
it s ap p licat ion in aesth et ic m edicin e—a global, eviden ce-
based bot ulin um toxin con sen sus educat ion in it iat ive: part
II: in corporat ing bot u lin um toxin in to aesth et ic clin ical
p ract ice. Derm atol Su rg 2013;39(3 Pt 2):510–525
7. Asch er B, Talarico S, Cassuto D, et al. In tern at ion al con -
sen sus recom m en dat ion s on th e aesthet ic usage of bot u -
lin u m toxin t yp e A (Speyw ood Un it)—Part I: Up per facial
w rin kles. J Eur Acad Derm atol Ven ereol 2010;24(11):
1278–1284
8. Loren c ZP, Ken kel JM, Fagien S, et al. Con sen su s pan el’s as-
sessm en t an d recom m en dat ion s on th e use of 3 bot ulin um
toxin t yp e A prod u ct s in facial aesth et ics. Aesth et Su rg J
2013;33(1, Suppl):35S–40S
9. Ahn BK, Kim YS, Kim HJ, Rho NK, Kim HS. Consensus recom -
m endations on the aesthetic usage of botulinum toxin t ype
A in Asians. Derm atol Surg 2013;39(12):1843–1860
10. Flyn n TC, Carru th ers JA, Carru th ers JA. Bot u lin u m -A
toxin t reat m en t of th e low er eyelid im p roves in fraorbit al
rhyt ides an d w iden s th e eye. Derm atol Su rg 2001;27(8):
703–708
11. Yang HM, Kim HJ. Anatom ical st udy of the corrugator super-
cilii m uscle and its clinical im plication w ith bot ulinum toxin
A injection. Surg Radiol Anat 2013;35(9):817–821
12. Tzou CH, Giovan oli P, Plon er M, Frey M. Are th ere eth n ic
d i eren ces of facial m ovem en t s bet w een Eu ropean s an d
Asian s? Br J Plast Su rg 2005;58(2):183–195
13. Lee Y, Hw ang K. Skin th ickn ess of Korean ad u lt s. Su rg Ra-
d iol An at 2002;24(3-4):183–189
14. Sykes JM. Man agem en t of th e aging face in th e Asian p a-
t ien t . Facial Plast Su rg Clin North Am 2007;15(3):353–360,
vi–vii
15. Pou lain B, Trevidic P, Clave M, et al. Clin ical equ ivalen ce
of conven t ion al on abot ulin um toxin A (900 kDa) an d in -
cobot u lin u m toxin A (n eu rotoxin free from com plex-
ing p rotein s—150 kDa): 2012 m u lt idisciplin ar y Fren ch
con sen su s in aesth et ics. J Drugs Derm atol 2013;12(12):
1434–1446
16. Sat tler G, Callan der MJ, Grablow it z D, et al. Non in ferior-
it y of in cobot u lin u m toxin A, free from com plexing p ro-
tein s, com p ared w ith an oth er bot u lin u m toxin t yp e A
in th e t reat m en t of glabellar frow n lin es. Derm atol Su rg
2010;36(Suppl 4):2146–2154
17. Karsai S, Rau lin C. Cu rren t eviden ce on th e u n it equ iva-
len ce of d i eren t bot u lin u m n eu rotoxin A form u lat ion s
an d recom m en dat ion s for clin ical pract ice in derm atology.
Derm atol Su rg 2009;35(1):1–8
18. Kan e M, Don ofrio L, Asch er B, et al. Exp an d ing th e u se of
n eurotoxin s in facial aesth et ics: a con sen sus pan el’s as-
sessm en t an d recom m en dat ion s. J Drugs Derm atol 2010;
9(1, Suppl)s7–s22, quiz s23–s25
19. Alam M, Dover JS, Arn dt KA. Pain associated w ith injec-
t ion of bot u lin u m A exotoxin recon st it u ted u sing iso-
ton ic sodiu m ch loride w ith an d w ith ou t p reser vat ive: a
dou ble-blin d , ran dom ized con t rolled t rial. Arch Derm atol
2002;138(4):510–514
20. Sarifakioglu N, Sarifakioglu E. Evalu at ing e ect s of p re-
ser vat ive-con t aining salin e solut ion on pain percept ion
during bot u lin u m toxin t ype-A inject ion s at di eren t lo-
cat ion s: a prosp ect ive, single-blin ded, ran d om ized con -
t rolled t rial. Aesth et ic Plast Su rg 2005;29(2):113–115
21. Yang GC, Ch iu RJ, Gillm an GS. Qu est ion ing th e n eed to u se
Botox w ith in 4 h ou rs of recon st it ut ion : a st u dy of fresh
vs 2-w eek-old Botox. Arch Facial Plast Surg 2008;10(4):
273–279
22. Hexsel DM, De Alm eida AT, Ru tow it sch M, et al. Mu lt i-
cen ter, dou ble-blin d st udy of th e e cacy of inject ion s w ith
bot ulin um toxin t ype A recon st it uted u p to six con secu-
t ive w eeks before ap p licat ion . Derm atol Su rg 2003;29(5):
523–529, discussion 529
23. Liu A, Carru th ers A, Coh en JL, et al. Recom m en dat ion s
an d curren t pract ices for th e recon st it ut ion an d storage of
bot ulin um toxin t ype A. J Am Acad Derm atol 2012;67(3):
373–378
24. Hu ilgol SC, Carru th ers A, Carru th ers JD. Raising eye-
brow s w ith bot ulin um toxin . Derm atol Surg 1999;25(5):
373–375, discussion 376
25. Sundaram H, Kiripolsky M. Nonsurgical rejuvenation of the up-
per eyelid and brow. Clin Plast Surg 2013;40(1):55–76
26. Su n daram H, Carru th ers J, eds. Th e glabella an d cen t ral
Brow. In : Carru th ers J, Carru th ers A, eds. Procedu res in
Cosm et ic Derm atology: Soft Tissu e Augm en t at ion . 3rd ed.
New York, NY: Elsevier Saun ders; 2013:88–99
27. Hu KS, Yang SJ, Kw ak HH, et al. Locat ion of th e m od iolou s
an d th e m orph ologic variat ion s of th e risorius an d zygo-
m at icus m ajor m uscle related to th e facial expression in
Korean s. Korean J Phys An th rop ol 2005;18:1–11
28. Kim HJ, Hu KS, Kang MK, Hw ang K, Ch u ng IH. Decu ssa-
t ion p at tern s of th e p lat ysm a in Korean s. Br J Plast Su rg
2001;54(5):400–402
29. Yu CC, Ch en PK, Ch en YR. Bot u lin u m toxin A for low er fa-
cial con touring: a prospect ive st udy. Aesth et ic Plast Surg
2007;31(5):445–451, discussion 452–453
30. Kim NH, Ch u ng JH, Park RH, Park JB. Th e u se of bot u lin u m
toxin t ype A in aesth et ic m an d ibu lar con tou ring. Plast Re-
con st r Su rg 2005;115(3):919–930
31. Man d el L, Th arakan M. Treat m en t of u n ilateral m asseter-
ic hyp ert rophy w ith bot u lin u m toxin : case rep ort . J Oral
Maxillofac Su rg 1999;57(8):1017–1019
 29
32. Kim KS, Byu n YS, Kim YJ, Kim ST. Mu scle w eakn ess after
rep eated inject ion of bot u lin u m toxin t yp e A evaluated
according to bite force m easurem en t of h um an m asseter
m u scle. Derm atol Su rg 2009;35(12):1902–1906
33. Bae GY, Yu n e YM, Seo K, Hw ang SI. Bot u lin u m toxin in -
ject ion for salivar y glan d en largem en t evalu ated u s-
ing com p u ted tom ograp h ic volu m et r y. Derm atol Su rg
2013;39(9):1404–1407
34. Flin t P, Haugh ey B, Lu n d V. Physiology of th e salivar y glan ds.
In : Cum m ings CW, Fredrickson JM, Harker LA, Krau se CJ,
Sch u ller DE, eds. Otolar yngology—Head an d Neck Surger y.
Vol 2, 5th ed. St Lou is, MO: Mosby Elsevier; 2010
35. Ch ang SP, Tsai HH, Ch en W Y, Lee W R, Ch en PL, Tsai TH. Th e
w rin kles sooth ing e ect on th e m iddle an d low er face by
Aesthetic Facial Use of Botulinum Toxin in East Asians 391
in t raderm al inject ion of bot ulin um toxin t ype A. Int J Der-
m atol 2008;47(12):1287–1294
36. Rose AE, Goldberg DJ. Safet y an d e cacy of in t rad erm al
inject ion of bot u lin um toxin for th e t reat m en t of oily skin .
Derm atol Surg 2013;39(3 Pt 1):443–448
37. Sh ah AR. Use of in t raderm al bot u lin u m toxin to redu ce
sebu m p rodu ct ion an d facial p ore size. J Drugs Derm atol
2008;7(9):847–850
38. Ku rzen H, Wessler I, Kirkpat rick CJ, Kaw ash im a K, Gran d o
SA. Th e n on -n euron al ch olin ergic system of h um an skin .
Horm Met ab Res 2007;39(2):125–135
39. Li ZJ, Park SB, Soh n KC, et al. Regu lat ion of lip id prod u ct ion
by acet ylch olin e sign alling in h um an sebaceous glan ds. J
Derm atol Sci 2013;72(2):116–122
 30 Facial Contouring Using Fillers
Jongseo Kim
Pearls
• Con touring or augm en t at ion of th e facial skeleton
w ith llers is on e of th e m ost su btle bu t pow erful
n on surgical t reat m en t s.
• An E-plan e, w h ich is a lin e draw n from th e t ip of th e
n ose to th e t ip of th e ch in , is an im port an t gu idelin e
for con tou ring th e lateral pro le. In th e fron t al view,
a h eart-sh ap ed face is th e p referred facial con tou r.
• To t reat n e w rin kles, volum e replacem en t ju st
u n der th e derm is w ith soft ller th at h as low er
elast icit y is e ect ive.
• For st ruct ural facial con touring, a larger volum e of
ller is requ ired in m ost cases. Hard ller gels su ch
as CaHA ller, PCL ller, an d p ar t icle t yp e HA ller
are p referred.
• W h en a pat ien t is n ot su re about th e proper ller
t yp e an d it s e ect at in it ial con su ltat ion , use of
n orm al salin e or HA ller is recom m en ded. If th e
pat ien t is sat is ed w ith th e result s of ller inject ion
but w an t s to avoid repeated inject ion s, long st an ding
ller can be app lied.
• Sp ecial cau t ion sh ou ld be taken w h en inject ing ller
in to th in -skin areas su ch as th e eyelid, periorbit , an d
n e w rin kles on th e ch eek area becau se of p ossible
■ Introduction
Filler is u sed in th e East Asian face for diverse aesth et ic p ur-
poses: facial con touring, in cluding augm en t at ion of cert ain
facial areas; t reat m en t of aging lin es su ch as w rin kles an d
prom in en t crease 1 ; an d derm al hyd rat ion . Many Asian s
h ave sm all ch in s, at n oses, an d dep ressed foreh eads com -
p ared w ith Caucasian s.2 To augm en t th ose areas, in sert ion
of im plan t s such as silicon , Gore-Tex (W. L. Gore), Medpor
(St r yker), cart ilage, bone, or fat graft s is com m on ly used.
Becau se m any p at ien t s w an t a sim p le an d safe p roced u re
in stead of surgeries, ller can be an altern at ive opt ion to
augm en t th ose areas.
In m ost cases, t h e augm en t at ion resu lt s from ller
are sim ilar to t h ose from im p lan t su rger y except for it s
lon gevit y. Becau se ller inject ion ch an ges t h e soft t is-
su e st r u ct u res an d n ot t h e bony st r u ct u res, t h e size an d
t h e sh ap e of t h e facial skeleton an d t h ickn ess of soft t is-
392
n odu le form at ion an d color ch ange. In th is case, it is
bet ter to inject a sm all am oun t m ult iple t im es or u se
soft ller by can u la.
• Th e foreh ead, tem ple, ch eek, ch in , n ose, n asolabial
fold, an d jaw lin e are com m on ller inject ion sites
for facial con touring.
• For foreh ead con touring, 1.5 to 3.0 m L of ller is
injected u n der th e m uscle layer using th e radial
fan n ing tech n iqu e th rough on e en t r y p oin t m idw ay
bet w een th e eyebrow s.
• Com m only used llers for nasal augm entation are
CaHA ller, Rest ylane (Galderm a), and Perlane (Merz).
Subm uscular injection using the linear threading
technique and subcutaneous injection using the serial
puncture technique are usually com bined.
• In aged p at ien t s, m ore exten sive volu m et ric
replacem en t is n eeded an d oth er, con com it an t
lift ing procedures su ch as ult rasoun d lift ing or
su rgical face lift ing w ou ld be h elpfu l.
• Hydro lift ing, in w h ich hyalu ron ic acid is directly
injected in to th e derm is layer of th e skin , is usefu l in
people w h o h ave serious dr y skin or w h o w an t m ore
elast ic an d hydrated skin .
su es are fu n dam en t al con sid erat ion factors for su ccess-
fu l resu lt s. W h en con sid er in g augm en t at ion of cer t ain
facial areas, t h e “est h et ic p lan e” (E-p lan e) is an im p or t an t
gu id elin e for a p leasin g facial p ro le.3,4 Th e E-p lan e is a
lin e d raw n from t h e t ip of t h e n ose to t h e t ip of t h e ch in .
To h ave a p leasing facial p ro le for t h e average Cau casian
face, t h e low er lip sh ou ld be 2 m m beh in d t h e lin e, an d
t h e u p p er lip 4 m m beh in d t h e lin e, w it h var iat ion s being
n or m al for p at ien t s of d i eren t et h n ic backgrou n d s. Many
p hysician s, h ow ever, feel t h at t h e id eal E-p lan e of an Asian
face is qu ite d i eren t from t h at of a Cau casian face. For
an Asian face, t h e low er lip an d u p p er lip sh ou ld be n ear
t h e E-p lan e. Th e jaw is also im p or t an t to com p lem en t t h e
w h ole face. If t h e jaw is p u lled in or is exten d ing too m u ch ,
it d isr u pt s t h e overall h ar m ony of t h e aest h et ic st an dard .
If t h e p at ien t ’s p ro le ap p ears ver y convex, t h e ch in an d
t h e foreh ead area can be augm en ted by llers; for a con -
cave p ro le, llers can be p laced in t h e n ose, t h e p aran asal
area, an d t h e an ter ior ch eek.

W h ile th e E-plan e is a guidelin e for con touring th e
facial pro le, a h eart sh ap e is con sidered th e preferred
facial con tou r by Asian s in th e fron t al view. It is ch aracter-
ized by h igh er an d fuller ch eeks, raised n asal p ro le, an d
sm aller ch in con t ribu t ing to a sm ooth facial convexit y. Tra-
dit ion ally, it is con sidered ideal w h en th e rat io bet w een th e
upp er, m id-, an d low er face is equal or represen ted as 1:1:1.
Recen tly, h ow ever, th e “baby face,” in w h ich th e low er face
part’s rat io is a lit tle sh or t of 0.8, h as been receiving at ten -
t ion in th e rejuven at ion of th e Asian face.
Derm al llers can be an opt ion for t reat m en t of rhyt id es
as w ell as for facial scu lpt ing. Un d erst an d ing th e aging pro-
cess is crucial to at t ain opt im al resu lt s w ith facial rejuven a-
t ion by ller inject ion . Facial aging is th e result of decreased
th ickn ess an d elast icit y of th e skin , absorpt ion of fat , an d
resorpt ion of th e bony skeleton . In addit ion , decreased
adh eren ce bet w een th e skin an d su bcu t an eou s t issu e, m u s-
cle alterat ion , an d sagging of soft t issues are presen t . Th us,
ju st t igh tly ret ract ing th e facial skin th rough su rgical in ter-
ven t ion m ay be in ap prop riate in som e p at ien ts becau se it
can produce an un n at ural-looking appearan ce. Replen ish -
ing facial volu m e an d lling n e w rin kles w ith injectable
llers w ou ld be a bet ter ap proach in th ese pat ien t s.
Recen tly, facial rejuven at ion using th e hydro lling
e ect of hyalu ron ic acid (HA) ller h as been em p loyed for
im p rovem en t of skin text ure. Sin ce th e con cen t rat ion of HA
in skin decreases w ith aging, th e skin’s elast icit y an d abilit y
to h old w ater are decreased, leading to an in creased ten -
d en cy tow ard w rin kling an d skin laxit y, part icularly in th e
facial skin . Becau se of th eir hydroph ilic n at u re, HA llers
p lay a role as a derm al reser voir of hyd rat ion , by d raw ing
w ater in to th e ext racellu lar m at rix in th e d erm is, resu lt ing
in hydrat ion in th e derm is an d im provem en t of skin surface
rough n ess an d n e w rin kles.
■ Patient Consultation
Du ring con su ltat ion , th e p at ien t w ill be in form ed of th e
poten t ial risks w ith th e ller inject ion . A detailed m edical
h istor y sh ou ld be t aken , in cluding prior inject ion proce-
Table 30.1 Types of llers
Action Type Duration
Volum izer Hyaluronic acid 6–12 m onths
Calcium hydroxylapatite > 1 year
Stim ulator Poly-L-lactic acid (PLLA) > 1 year
Polycaprolactone (PCL) 1–4 years
30 Facial Contouring Using Fillers 393
dures. Aspirin or Coum adin (Bristol-Myers Squibb) n eeds
to be stop p ed before th e procedu re to p reven t bleeding an d
bruising. Any pat ien t s w ith im m un ologic diseases such
as lu pu s or scleroderm a sh ou ld take ext ra precau t ion s as
people w ith facial soft t issue at rophy can h ave problem s.
Th e con sult at ion an d assessm en t sh ould in clude th e
follow ing:
1. Discu ssion of th e pat ien t’s expectat ion s (durat ion of
llers, inject ion am ou n t of llers, p at ien t’s aim an d
purpose)
2. Medical an d surgical h istor y, m edical con dit ion s, an d
drug allergies
3. Radiologic assessm en t (com puted tom ography [CT]
scan s or facial X-rays)
4. Preoperat ive an d postoperat ive ph otography for
evalu at ion an d com p arison
5. Com puter-assisted sim ulat ion if available
In m ost cases, bot u lin u m toxin an d inject able llers are
in ext ricably lin ked. Con com itan t bot ulin um toxin inject ion
is ben e cial as it preven t s unw an ted m igrat ion of injected
ller by rest rict ing excessive m u scle m ovem en t , an d also
ch anges facial sh ape favorably.5 Th erefore, it is essen t ial to
h elp th e p at ien t u n derst an d th e ben e t s of com bin ed bot u -
lin um toxin inject ion .
■ Filler Materials
A w ide variet y of ller m aterials are cu rren tly avail-
able, w ith a seem ingly en dless ow of n ew an d em erging
product s. Table 30.1 sh ow s detailed in form at ion on ller
m aterials cu rren tly available. Am ong th ese llers, th e best
an d th e safest p rodu ct s are hyalu ron ic acid (HA) llers.
Th ere are t w o t ypes of HA in term s of rh eology or it s par-
t icle sh ape: On e is biph asic HA ller (Rest ylan e) an d th e
oth er is m on op h asic HA ller (Juved erm , Belotero). With a
m on op h asic HA ller su ch as Juved erm , it is easy to inject
w ith out lum ps or irregu larit y, but it is h ard to use w h en
con touring to form a sh ape w ith a n arrow base an d t all
Longevity Product(s)
Temporary Rest ylane
Juvederm
Belotero
Temporary Radiesse
Temporary Sculptra
Temporary Ellanse (Aqtis)
394 VI Minim ally Invasive Facial Plastic Surgery
h eigh t . With a biph asic HA ller su ch as Rest ylan e, it is easy
to lay bricks (“brickw ork”) in to a form w ith a n arrow base
an d t all h eigh t , bu t th ere is a h igh risk of lu m p s or irreg-
u larit y. Molding is m u ch m ore d i cu lt w ith biph asic HA
llers bu t th ey can last longer an d are m ore du rable th an
th e m on oph asic HA llers. Over t im e, th e injected HA gel
is slow ly absorbed in to th e su rrou nd ing t issu es an d disap -
p ears by a p rocess called isovolum et ric degradat ion .
Sim ilar to HA-based prod uct s, calcium hydroxylapa-
t ite (CaHA, Radiesse, Merz) is also relat ively in ert , is ver y
safe, an d requ ires n o skin test ing prior to inject ion . In com -
parison to HA-based llers, h ow ever, CaHA is n ot recom -
m en ded for th e t reat m en t of ver y su per cial w rin kles an d
creases. CaHA is m ore com m on ly used to augm en t deep
creases an d folds as w ell as con touring th e ch eek, ch in ,
an d foreh ead. Ap proxim ately 9 m on th s after an inject ion ,
CaHA begin s to u n dergo gradu al en zym at ic digest ion , w ith
com plete disappearan ce of th e aesth et ic e ect bet w een 12
an d 18 m on th s. From th e au th or’s exp erien ce, th e volu m e
st art s to decrease w ith in 1 m on th after CaHA inject ion .
Poly-L-lact ic acid (PLLA; Sculpt ra, Derm ik Laboratories)
an d p oly-cap rolacton e (PCL; Ellan se, AQTIS Medical) w ork
by providing a delayed long-last ing volum izing e ect .6
How ever, m u lt ip le t reat m en t s (t w o or th ree session s) are
n eeded to ach ieve com plete correct ion . Act u ally, Scu lpt ra is
n ot a volu m izing ller, bu t a st im u lator. Th e augm en t at ion
or con touring e ect s of Sculpt ra are n ot predictable eith er;
th erefore, it is n ot recom m en ded for con touring purposes.
■ Procedural Techniques
Anesthesia
Th e topical an esth et ic is n ot adequate; h en ce, it is recom -
m en ded th at th e su rgeon block th e n er ve locally or u se
t um escen t solut ion for an esth esia before ller inject ion .
Th e auth or prefers both . Epin eph rin e in th e an esth et ic solu -
t ion h elps to reduce bruising an d prolong th e an esth et ic
e ect for a few h ou rs. Lidocain e (m ixed w ith ep in ep h rin e)
is u sed for local n er ve block. For a m idface local block, th e
n eedle can be placed th rough an in t raoral app roach just
above th e can in e arou n d th e in fraorbit al n er ve area. Th e
m icro–n er ve block tech n iqu e can be u sefu l for an inject ion
of th e lip area. For th e m icro–n er ve block tech n ique, sm all
aliqu ot s of an esth et ic solu t ion are injected along th e m u co-
sal bord er of th e lip n ear th e gingival su lcu s. Micro-blocks
h ave th e advan t age of n ot producing a deep region al an es-
th esia. How ever, th is tech n ique m ay t ake longer to perform
an d th e poten t ial for in com p lete an esth esia is greater. Th e
au th or p refers t u m escen t solu t ion , w h ich is p repared by
m ixing 100 m L of n orm al salin e w ith 20 m L of 2%lidocain e
an d 1 m L of 1:100,000 ep in ep h rin e.
Selecting Needles
Derm al llers m ay be injected u sing eith er a sh arp n eedle
or a blun t-t ip m icrocan n u la (Fig. 30.1). A blu n t-t ip m icro-
can n ula (also called a sm ooth -t ip m icrocan n ula or a blun t-
n eedle can n u la) is a sm all t u be (18- to 30-gauge), w ith an
edge th at is n ot sh arp , design ed for th e at rau m at ic su bder-
m al inject ion of llers. Depen ding on th e in n er diam eter,
it can be used eith er for fat t ran sfer, or for th e inject ion of
llers su ch as HA, PCL, PLLA, CaHA, etc.
Each physician h as speci c preferen ces for inject ion
in st rum en t s depen ding on th e t ype of procedu re being per-
form ed. For exam ple, n eedles m ay be preferred for delicate
correct ion of lin es an d w rin kles, w h ile can n ulas m ay be
preferred for volum e correct ion . Needles h ave th e advan -
tages of ext rem e precision of m ovem en t , th e possibilit y of
deep in t raderm al inject ion , an d conven ien ce w h en sm aller
inject ion volum e is required. Disadvan t ages in clu de pain ,
bruising, an d possible vessel lacerat ion . Can n ulas cause
less t raum a, pain , an d bru ising an d allow a large area to be
t reated at th e ch osen inject ion depth . Speci c t rain ing is
required to m aster the tech n iques of inject ion , an d th is is
con sidered a disadvan t age.
Usually a 50-m m -length, 27-gauge needle is used for the
injection of Restylane. The author prefers a 70-m m 23-gauge
m icrocannula since it can also be used to inject Ellanse,
Restylane Sub-Q (large-particle HA), and m onophasic HA llers
such as Juvederm and Teosyal (Teoxane Laboratories) as well.
a
b
Fig. 30.1 Needles for ller injection. (a) Sharp needle with 1-mL
ller syringe. (b) Blunt-tip micro cannula.
 30 Facial Contouring Using Fillers 395

Fig. 30.2 Two techniques for nasal augm en-

tation using ller. (a) Linear threading tech-
nique. (b) Serial puncture technique (“Kisses”
technique).

a b

Injection Techniques Self-Pistol Technique

Linear Threading, or Tunneling
Lin ear th reading is a tech n iqu e in w h ich th e n eedle is
in ser ted in to th e skin an d th e ller is deposited in a lin ear
fash ion along th e t rack as th e n eed le is slow ly w ith draw n .
Becau se th is creates essen t ially a t u n n el of ller, th is is also
com m on ly called th e t un n eling tech n ique. Applied w ith a
can n ula, th is is th e m ost frequen tly u sed tech n ique for th e
augm en tat ion of th e n ose (Fig. 30.2a).
Th e inject ion area is draw n w ith a pen cil an d th e in ser-
t ion poin t s are selected in th e cen ter of th e area to be aug-
m en ted . After bolu s inject ion u n der th e fascia, m olding is
ap plied by sim p le com p ression on th e injected area. Th is
m eth od is com m on ly u sed in tem p oral depression . Assess-
m en t is easy becau se it is n ot n ecessar y to pre-inject w ith
lidocain e solut ion in th is tech n ique.

Serial Puncture
a b
Serial pu n ct u re involves m u lt iple inject ion s posit ion ed
adjacen tly along th e length of th e w rin kle or crease. Th is
tech n iqu e m akes m any “ch ocolate Kisses”–like st ruct ures
on th e n ose (Fig. 30.2b). It is im p erat ive th at th ese injec-
t ion s rem ain su cien tly close to form a relat ively sm ooth ,
con t in uou s lin e of augm en t at ion (Fig. 30.3). In cases w h ere
th ere is a n ot iceable separat ion bet w een th e inject ion sites,
post t reat m en t m assage m ay h elp blen d th e ller.

Fanning Technique
Th e fan n ing tech n iqu e is perform ed for augm en t at ion of
a w id e area su ch as th e foreh ead , m alar, an d jow l region s
(Fig. 30.4). Radial fan n ing is an exten sion of th e lin ear
th reading tech n ique.7 Th e ller is deposited in a lin ear lin e
as th e n eedle is w ith d raw n w ith a fan sh ap e m ovem en t .
Before th e n eedle is act u ally rem oved from th e skin , it Fig. 30.3 Correction of mild hump nose with ller. (a) Pro le view
is redirected an d advan ced along a n ew radial lin e. Mu l- shows a mild hump nose. (b) After injection of 0.5 m L of Rest ylane
t iple st rokes w ill be n eeded to preven t irregularit y after using a 29-gauge sharp needle with serial puncture (“Kisses”) tech-
inject ion . nique, the pro le became smooth.
396 VI Minim ally Invasive Facial Plastic Surgery
Fig. 30.4 Fanning technique of ller injection.
Facial Contouring
Forehead
Th ere are ve layers on th e foreh ead, com posed of skin ,
su bcu tan eou s t issu e, ap on eu rosis, loose con n ect ive t is-
su e, an d p eriosteu m , collect ively called SCALP (Fig. 30.5).8
W h en inject ing llers to th e foreh ead, th e t arget layer dif-
fers according to th e pu rp ose of ller inject ion . To t reat
w rin kles, injectable llers can be in t roduced to th e derm al
an d th e su bderm al layers. How ever, to ch ange th e foreh ead
con tour, a deeper inject ion in to th e supraperiosteum an d
su bm u scu lar layer is p referred . In ller inject ion , a deep
inject ion h as a low er risk of lu m ps an d irregularit ies. To
preven t m igrat ion of ller gels, bot ulin um toxin is injected
togeth er w ith th e ller in m ost cases.
W h en using a blun t n eedle, th e en t r y poin ts sh ould
be m ade before an inject ion . Th e auth or prefers to m ake
on e en t r y poin t m idw ay bet w een th e eyebrow s.9 Occasion -
ally, th e au th or m akes on e en t r y p oin t at th e cen ter of th e
foreh ead (Fig. 30.6) sin ce th e m idlin e ap proach is safer by
avoiding dam age to th e blood vessels. Som e doctors prefer
to m ake t w o en t r y poin ts on each side of th e eyebrow, but
th is is n ot safe due to risk of inju r y to th e supraorbit al n er ve
an d blood vessels. Also, th e en t r y p oin t s on th e eyebrow
h ave a h igh risk of bacterial con t am in at ion from h air folli-
cles of th e eyebrow s. For foreh ead con touring, 1.5 to 3.0 m L
of ller is injected using th e radial fan n ing tech nique. Th e
fan n ing m eth od is ap p ropriate for placem en t of th e prod-
u ct in th e su praperiosteal layer in stead of th e su bderm is
1 2 3
5
1. Skin
2. Subcutaneous tissue
3. Musculo-aponeurotic layer
4. Retaining ligaments and space
5. Periosteum and deep fascia
3
45
1 2
Fig. 30.5 Soft tissue layer of the face. There are ve tissue layers
on the face composed of skin, subcutaneous tissue, aponeurosis,
loose connective tissue, and periosteum , which are collectively
called SCALP.
or subcut an eous t issues because th e bon e can be a guide
to con t rol th e inject ion depth .9 For con touring of th e Asian
foreh ead , CaHA an d PCL llers are p referred an d 3 m L is
u sed for th e rst session . Molding im m ediately after ller
inject ion is easy an d essen t ial because it is h ard to m old
after th e ller h as set tled dow n . For m olding, a roller is
u sed in th is region .
Temple
The tem poral fossa is a critical area for volum e restoration
of the aging face.7 Tem ple contouring is also perform ed for
patients w ho h ave a big m alar bone. The tem poral fossa is
a sh allow depression on th e side of th e skull bou n ded by
the tem poral lines and term inat ing above the level of th e
zygom atic arch (Fig. 30.7). To con rm inject ion depth dur-
ing ller inject ion w ith a cann ula, a blunt needle can be
passed through the zygom at ic arch . If the cannula goes
through under the zygom at ic arch , it m eans that the can -
nula is posit ioned under a deep tem poral fascia or m u scle
layer. If the cannula is blocked again st the zygom atic arch,
it is posit ioned bet w een the deep and super cial tem po-
ral fasciae. To contour or augm ent the tem poral fossa, it is
essen t ial to inject th e ller into various layers according to
 30 Facial Contouring Using Fillers 397

Fig. 30.6 Forehead ller injection through

a b
one m idline entry point. (a,c) Before the pro-
cedure. (b,d) Immediately after injection.
Through one midline entry point, supra-perios-
teal injection to forehead with 3 mL of biphasic
HA (Rest ylane) was performed.

c d

Plane of dissection an d bruising. After ller injection , th e tem poral area m ay

sh ow sw elling for a few days. Th e sw elling w ill gradu ally
Deep tem poralis fascia resolve as the t um escent solution is absorbed. It is im por-
tant to determ ine the proper volum e of t um escent solution
Tem poroparietal
needed for the tem poral area contouring. Irregularit y after a
fascia su bderm al inject ion is com m on w ith Rest ylan e or Perfecth a
(Laborator y Obvieline), and to avoid this com plication Juve-
derm , Teosyal, or Belotero (Merz Aesthetics) can be used.
Superficial fat pad Th e self-pistol tech n iqu e is com m on ly used in th is area
also. Usu ally, on e st roke ben eath th e tem poralis fascia is
adequ ate w ith th e deep inject ion tech n iqu e. If th e resu lt is
Superficial not sat isfactor y after th e in it ial inject ion an d m olding, an
temporal vessels
addit ion al inject ion can be m ad e to th e in su cien t area.
Frontal branch
of facial nerve
Zygom atic
arch Cheek
SMAS As aging progresses, th e bony m idface “collapses,”10 lead-
ing to in ferior orbital rim rem odeling w ith loss of an te-
Deep fat pad
rior project ion an d sagging of th e soft t issu e fat pads, th u s
m aking th e m idface h ollow an d d roop ing. Th is cau ses th e
Fig. 30.7 Various layers and their boundaries in temporal fossa. m idface to lose ver t ical h eigh t , an d th e p iriform apert u re
Temporal fossa is bounded by the temporal lines and level of the to recess posteriorly, m aking four crescen t aging lin es
zygomatic arch. Understanding of super cial and deep temporal (Fig. 30.8).10,11,12,13,14 Th e au th or suggest s correct ing th ese
fascia is important for selection of the injection layer. fou r crescen t aging lin es w ith ller u sing th e “Reteen age”
m eth od (Fig. 30.9).
Volu m e rep lacem en t ju st u n der th e su bderm is is e ec-
t ive in t reat ing n e w rin kles but in adequate to ch ange facial
th e t ype of ller.The auth or prefers to inject CaHA beneath con tour. To ch ange con tou r, deep inject ion w ith a h ard ller
th e deep tem poral fascia or bet w een the deep and super - gel su ch as CaHA ller, PCL ller, an d p ar t icle-t yp e HA ller
cial tem poral fasciae to prevent irregularit y and to ensure is n ecessar y. To determ in e th e inject ion site, th e p at ien t
e ect ive treat m en t. But th e ller can be injected in to th e is asked to sm ile before th e inject ion . If th e volum e of th e
su bderm al layer also w ith HA an d th e fan n ing tech n iqu e m idface is n ot en ough , inject ion in to th e su praperiosteal
for augm entat ion . Th e fann ing tech n ique in th is area begin s layer is preferred, and in oth er cases inject ion in to th e sub -
w ith the inject ion of t um escent solut ion to reduce pain cu tan eous fat plan e is don e.
398 VI Minim ally Invasive Facial Plastic Surgery
a b
Fig. 30.9 The correction of the four crescent aging lines with ller
is referred to as the “Re-teenage” m ethod by the author. (a) Before
the procedure. (b) Immediately after injection. Two milliliters of
Rest ylane was injected on each cheek area into a deep medial fat
pad and medial super cial fat pad, and 0.5 mL of Rest ylane was
injected in the nasolabial area. Additionally, 1.5 mL of the Perfecta
Subskin product was injected on each side of the prejowl sulcus. A
total of 8 m L of the HA ller was used for the whole face.
Fig. 30.8 Blue “four crescent aging lines” are
deformities that disturb a natural facial S-line.
The four crescent aging lines are the tear
trough, midcheek groove, nasolabial line, and
pre-jowl sulcus.
Local an esth esia begin s w ith a bilateral in fraorbit al
n er ve block w ith 0.2 to 0.4 m L of 2%lidocain e. Som e p hysi-
cians prefer to m ix th e ller w ith a solut ion con t ain ing 2%
lidocain e an d 1:100,000 epin eph rin e.
Medial and Lateral Cheek
Ch eek inject ion is perform ed sequen t ially from m edial
to lateral. Th e rst inject ion is p laced m edial to th e in fra-
orbit al n er ve, en tering perpen dicular to th e skin ~ 2 cm
ben eath th e m edial can th us. Th e n eedle is th en “w alked”
m edially an d in feriorly, dep osit ing ller. Ad dit ion al dep os-
it s are p laced close to th e orbit al rim , as w ell as laterally
an d in feriorly. Th e n on dom in an t in dex nger is u sed to
est ablish th e in ferior orbit al rim locat ion so as to preven t
deposit ion of m aterial in to th e orbit al area. Th e secon d
inject ion is given lateral to th e in fraorbital n er ve an d th e
th ird is at th e m alar em in en ce. Any ller to be injected
w ith in th e boun daries of th e m alar sept um sh ould be
placed im m ediately on to th e periosteum , th e so-called
preperiosteal bolu s inject ion tech n ique. For th is m eth od, a
29-gauge sh arp n eedle is in ser ted at an angle of 90 degrees
to th e skin su rface. Th is tech n iqu e n ot on ly resu lt s in n at u -
ral an d aesth et ically pleasing app earan ce, bu t also cau ses
few er bruises an d low ers th e em bolic poten t ial sin ce th e
m aterial is p laced in an avascu lar space.
Th is pre-periosteal bolu s inject ion tech n ique also can
be accom plish ed u sing eith er a t ran soral or t ran scut an eous
ap proach w ith a can n u la. For a large volu m e inject ion in th e

ch eek, th e auth or prefers a t ran scut an eou s approach w ith
a can n u la after m aking an en t r y poin t 1 cm lateral from th e
corn er of th e m outh . Th ere is less risk of in fect ion an d bio-
lm creat ion w ith t ran scu t an eou s inject ion . Besides, u sing
a can n u la is tech n ically less d em an ding, easier to teach ,
an d h as less risk of in fraorbit al n er ve inju r y an d vascu lar
inju r y com p ared w ith n eedle inject ion . W h en perform ing a
t ran soral approach , th e use of an t ibiot ics is recom m en ded
to preven t bio lm form at ion as th ere is a risk of con t am i-
n at ion w h en th e can n u la is m oving for w ard an d backw ard
th rough th e en t r y poin t . An oth er approach is to place th e
m on op h asic an d less refract ive HA in th e su bderm al p lan e.
Tear Trough
For t reat ing th e tear t rough , th e lin ear th reading or serial
pun ct ure tech n ique is used w ith a 30-gauge sh arp n eedle
or can n ula. Tem porar y, long-last ing, or perm an en t llers
can be used e ect ively to augm en t th e un derlying soft t is-
su e. In p at ien t s w ith th in n er skin , h ow ever, ller can create
a lu m p or Tyn dall e ect , resu lt ing in a m ore aggravated tear
t rough . Th e au th or prefers to use Belotero am ong HA llers
to t reat tear t rough becau se th e Tyn dall e ect is less.
Pre-inject ion of lidocaine, w hich is called the “Baiser
Voler” tech nique,15 is needed to cont rol pain and ecchy-
m osis. It is often h elpfu l to keep th e patien t in an uprigh t
posit ion during the procedure to accurately visualize the
ongoing contouring process. The needle is inserted from lat-
eral to m edial just in ferior to th e deepest m argin of th e tear
t rough. The plane of injection is supra-periosteal to m axi-
m ize th e soft tissue cush ion ing of th e ller below th e tear
t rough ligam ent . W hen using a cannula, touching the tear
t rough ligam ent can be a guide to an appropriate plane. On
average 0.5 m L of ller is placed on each side, depending on
the degree of rejuvenat ion desired.
Nose
Nose augm en tat ion by ller inject ion can be don e for cos-
m et ic p u rposes an d for correct ion of st ru ct u ral abn orm ali-
t ies. Sim ple dorsal augm en tat ion , in creasing t ip project ion ,
h u m p or deviated n ose correct ion , an d n ost ril reduct ion
are com m on in d icat ion s for n ose con tou ring u sing ller.
Inject able llers are also qu ite u sefu l in pat ien t s w h o h ave
already u n dergon e rh in op last y an d n oted p ersisten t post-
operat ive con tour irregularit ies or depression s. Th is sim ple
inject ion m eth od h as gain ed in creasing pop ularit y an d is
often referred to as m edical rh in oplast y.
Th e lin ear th reading tech n ique w ith a blu n t can n ula is
th e m ost frequen tly used tech n ique for n asal augm en t at ion
to p reven t em bolism an d blin dn ess, alth ough even w ith a
blu n t n eedle, blin dn ess can occu r in rare cases. Can n ulas
of 23, 25, an d 27 gauge can be u sed. Th e auth or prefers
23-gauge for CaHA ller an d 27-gauge for Rest ylan e or Per-
lan e. It is h ard to inject Juvederm w ith a 27-gauge can n ula
30 Facial Contouring Using Fillers 399
because it is n ot a par t icle-t ype HA gel. To inject Juvederm
or Teosyal, 23 gauge is recom m en ded. Th e inject ion is don e
at th e sup ra-periosteal layer, subm u scular layer, or both .
For a m ajor augm en tat ion , th e auth or prefers t w o-layer
inject ion s (Fig. 30.10), rst in to th e su bm u scu lar layer w ith
th e lin ear th reading tech n ique an d th en in to th e subcu ta-
neous layer w ith th e serial p un ct ure tech n ique.
Th e auth or prefers th e serial pun ct ure tech n ique
using HA ller (especially Rest ylan e lidocain e), Ca ller
(Radiesse), an d PCL ller (Ellan se) for n asal augm en tat ion .
Th e usual am oun t of inject ion is ~ 0.5 m L in Asian s. How -
ever, in som e cases up to 1 m L is adm in istered by adding
an oth er 0.5 m L a m on th later. Avoid u sing m ore th an 1 m L
in on e session to p reven t m igrat ion of th e ller m aterials.
Th e angles of inject ion ch ange according to th e sh ape
of th e n ose. Th e auth or prefers to inject rst at 10 to 20
degrees along th e ver t ical a xis an d th en ch ange th e angle to
90 degrees. Th en m ult iple “Kisses” inject ion s are applied,
esp ecially on th e d orsu m an d th e colu m ella area.
On follow -u p , m old ing of th e n ose area can be p er-
form ed to reduce irregularit y an d deviat ion . Molding is
don e im m ediately after inject ion if a visible con tour irregu -
larit y is n oted becau se it is h ard to m old a few w eeks later.
A gen tle p in ch -an d -roll tech n iqu e is u sed. A cold com press
is h elpfu l on th e rst day to m in im ize sw elling an d ecchy-
m osis. Special care sh ou ld be t aken to avoid u n du e p res-
su re th at cou ld cau se u nw an ted d isp lacem en t of th e ller.
a b
Fig. 30.10 Nasal dorsal augmentation using ller. (a) Before injec-
tion. After making an entry point at the nasal tip with a 23-gauge
needle, a 50-mm , 27-gauge cannula was inserted through the
entry point to the nasion (bet ween the medial canthi) under the
muscle layer. Rest ylane ller (0.8 mL) was injected while withdraw-
ing the cannula in a single motion from the nasion to the tip. For
further augmentation, subcutaneous injection using the serial
puncture technique was added. (b) After injection.
400 VI Minim ally Invasive Facial Plastic Surgery
Follow -u p is n eeded on th e n ext day to ch eck th e sh ape of
th e n ose an d exam in e for adverse e ects, especially if th e
p at ien t feels pain on th e n ose. Tou ch -up t reat m en ts can be
adm in istered if n ecessar y.
Nasolabial Folds
Nasolabial folds are form ed bet w een th e n ose an d lips,
an d a dyn am ic fold occu rs w h en rep et it ive m ovem en t of
th e facial m u scles creates a skin crease. W h eth er th e ller
w ou ld be injected at th e d erm al, su bcu tan eou s, or su p ra-
periosteal level is determ in ed by th e an atom y of th e fold.
For inject ion , eith er th e lin ear or fan n ing tech n ique is used
(Fig. 30.11).
Fillers injected in t h e d erm al layer in a lat t ice p at tern
give p ersisten ce an d a n at u ral e ect to sm iling. For injec-
t ion in th e derm is layer or low er, m olding is n eeded, bu t
m old ing is n ot n ecessar y w it h inject ion in th e su p ra-p eri-
osteal layer. W h en t h e prim ar y cau se is th e u n der-devel-
opm en t of th e u pp er jaw bon e, it is best to inject in to th e
su p ra-p eriosteal layer.16,17 In Asian s, th e n asolabial folds
are often created by a w eaken ed u p p er jaw an d t h e ller
is injected ju st above th e p eriosteu m of th e u p p er jaw to
create volu m e. W h en a n asolabial fold is cau sed by ch ange
of locat ion of th e m alar fat p ad, it is recom m en ded th at
t h e inject ion be m ade to th e su bderm al layer of both th e
n asolabial fold an d th e n asojugal groove (tear t rough ) to
get lift an d p roject ion .
Lips
Lip augm en tat ion by ller is a sim ple procedure to im prove
th e appearan ce of th e lips an d to m ake a h arm on ious
relat ion sh ip w ith th e n ose an d th e ch in by in creasing th e
fu lln ess of th e lips. Th e aging p at ien t t yp ically requ ires su b -
m u cosal inject ion along th e en t ire length of th e lip rath er
th an ju st th e cen t ral port ion . Som e pract it ion ers prefer to
address th is by inject ing th e in divid u al lin es sep arately.
Care sh ou ld be t aken n ot to create u nw an ted ver t ical ridges
or beading due to in adverten t over correct ion of th e der-
m is. Precise correct ion of th ese th in su p er cial lin es is h ard
to ach ieve by deep derm al inject ion . A bet ter altern at ive is
to sim p ly add m ore volu m e d u ring th e verm illion inject ion ,
w h ich ten ds to st retch th e vert ical lip lines as they exten d
from th e m u cosal lip, resu lt ing in decreased visibilit y.
An oth er opt ion is to u se on ly collagen -based tem porar y
llers for inject ion of th e in d ividu al lin es becau se collagen
is bet ter su ited for su per cial derm al p lacem en t .
Lip en h an cem en t in th e you nger p op u lat ion involves
st raigh tfor w ard volu m e en h an cem en t . Most of th ese
pat ien t s requ ire volu m e en h an cem en t on ly along th e cen -
t ral th ree- fth s of th e lip. Inject ion is t ypically don e w ith
th e lin ear th reading or serial pun ct ure tech n iqu e, proceed-
ing from m edial to lateral. Along th e red lip , the targeted
Fig. 30.11 Determination of the depth of injection in the nasola-
bial fold. The dynamic fold formed by repetitive movement of the
facial muscles is corrected by injection into the derm is layer. In case
the cause is innate under-development in the upper jaw bone, it is
best to inject into the supra-periosteal layer.
layer for a ller p lacem en t is th e su bm u cosa just above th e
orbicularis oris m uscle. In m any cases, a layered dist ribu-
t ion h elps to provide fu ller, m ore un iform en h an cem en t .
For in creased verm illion de n it ion , th e n eedle is carefully
in ser ted w ith in th e p oten t ial space bet w een th e red an d
w h ite lips. W h en don e properly, inject ion of th e ller can
be seen to plum p out th e verm illion border even w ith out
advan cem en t of th e n eedle. If th is is n ot th e case, th e n ee-
dle sh ould be reposit ion ed un t il th ere is low resist an ce to
ow. Many you nger pat ien t s w ill also ben e t from a vol-
u m e en h an cem en t along th e ph ilt ral colum n s. Th is usu -
ally involves a m idderm is ller inject ion w ith in th e base of
each colu m n , w h ich h elps to fu r th er ou tlin e an d d e n e th e
lips. A tot al of 1 to 2 m L is usually su cien t to ach ieve th e
desired size an d sh ape.
For lip augm en tat ion , HA gels are com m on ly used .
Oth er ller gels, su ch as PCL an d CaHA llers, are n ot p re-
ferred on th e lips sin ce w h ite n odules are visible an d pal-
pable. Moreover, PCL an d CaHA ller gels can m igrate after
an inject ion on th e lip s by st rong m u scle m ovem en t . Colla-
gen ller h as a risk of cau sing redn ess an d im m u n e-related
problem s an d is n ot used at presen t for lip con touring, but
som e allo-t ran sp lan t at ion of h u m an derm is (su ch as Allo-
derm , LifeCell) is used for lip augm en t at ion .
Chin
In Asia, con tou ring th e ch in along w ith n ose augm en tat ion
is a popular procedure because m any Asian s h ave sm all
ch in s. Derm a llers can be a t reat m en t opt ion for a sm all
ch in correct ion in stead of surger y or graft im plan tat ion .
Inject ion of ller w ith a sh arp n eedle is th e sim p lest
m eth od for ch in augm en t at ion (Fig. 30.12). Th is procedu re
can be perform ed w ith in 1 m in ute. For th is sim ple injec-
 30 Facial Contouring Using Fillers 401

a b
Jaw
Age-associated volum e loss is kn ow n to play an im port an t
role in th e st ru ct ural ch anges of th e low er face lin e. In th e
low er face, th is m an ifest s as drooping of th e corn ers of
th e m outh an d jow l, leading to a loss of th e oval jaw lin e
of youth . Jaw lin e resh aping by volum e replacem en t h as
th erefore becom e an in dispen sable com pon en t of m odern
facial rejuven at ion an d con tou ring.

Jowl Contouring
CaHA, PCL gel, or h ard HA gels can be injected in to th e fol-
low ing locat ion s.21 To correct th e roun d sh ape of th e low er
jaw lin e, CaHA or PCL ller sh ou ld be placed at th e deep
derm is u sing a 70-m m , 23-gauge can n ula. Inject ion s can
be delivered using th e fan n ing tech n ique (Fig. 30.14). Th e
ch oice of inject ion depth w ill depen d on w h eth er a n eedle
or can n ula is used an d also on th e th ickn ess of the der-
Fig. 30.12 Chin augmentation using ller. (a) Before the proce-
dure. (b) Immediately after injection of 1.5 mL of Radiesse. m is. Recom m en ded in sert ion p oin t s are at th e m an dibu lar
angle an d p rejow l su lcu s. Pat ien ts w h o h ave severe sag-
ging on th e low er face lin e m ay n ot ach ieve th e ben e t s
w ith derm al ller procedures on ly. Th e m ajorit y of doc-
tors advocate u se of injectable llers in su bject s w h o are
w ait ing for su rger y, or in th ose w h o do n ot w an t su rger y
t ion , Rest ylan e m ixed w ith lidocain e can be used w ith a
or in w h om surger y is con t rain dicated, an d as a pow erful
29-gauge n eedle. Th is sh arp n eedle is in cluded in th e box
adju n ct in augm en t ing or com p lem en t ing a su rgical resu lt .
w ith th e ller. Juvederm also can be used for ch in con -
Cogged th read in ser t ion or h igh -in ten sit y focused u lt ra-
touring u sing th e sam e m eth od. Th ese HA llers can be
sou n d (HIFU) can be p erform ed for con tou ring th e low er
injected in to th e su bderm al layer, alth ough su pra-p erios-
face for th ese in dividu als in stead of u sing inject ion llers. It
teal or su bm uscular inject ion is preferred. In t ram u scular
is bet ter to com bine ller inject ion w ith th ese procedures.
inject ion sh ou ld be avoided because of discom for t in th e
m en t alis m u scle du ring facial expression . W h en m aking a
h eart lin e ch in , th e p rocedu re m u st be don e even ly from
Marionet te Lines
th e upper layer of th e periosteum to th e subderm al layer
Volu m e en h an cem en t of m arion et te lin es is u su ally don e
bet w een th e ch in’s cen t ral lin e an d th e m en talis m us-
w ith on e of th e th ree inject ion tech n iques m en t ion ed pre-
cle.18,19,20 Th e injected p rodu ct can easily m ove to th e low er
viou sly. Nearly all categories of llers can be safely u sed
part of th e ch in because th ere is n o barrier t issue w ith in
th e subcut an eous fat layer below th e ch in . To be success-
fu l, th e n on inject ing h an d sh ou ld be u sed as a barrier or
gu ide w h en inject ing to en su re th e p rodu ct rem ain s w h ere
it is in ten d ed . Th e blu n t n eedle tech n ique is p referred for
inject ion of CaHA an d PCL ller. For a can n u la m eth od, t w o
en t r y p oin t s are u sed in th e p re-jow l su lcu s area of th e
low er border (Fig. 30.13).
Prior to m arking th e en t r y poin t s, a sm all am oun t of
lidocain e is injected, follow ed by th e in sert ion of a sh arp
23-gauge n eedle or a 70-m m , 23-gauge can n ula. To reduce
pain during th e procedure, t um escen t solut ion can be
injected p rior to CaHA an d PCL ller inject ion th rough th e
sam e can n u la. Pat ien t s sh ou ld be n ot i ed th at th e am ou n t
of augm en t at ion by CaHA an d PCL ller w ill be reduced 1
m on th after th e inject ion . Mu scle relaxan ts su ch as Botox
(Allergan ), Dysport (Galderm a), an d Xeom in (Merz) are
also u sed con com itan tly to soften th e ch in (preven t ing a Fig. 30.13 Contouring of the lower face line by llers. Entry points
cobbleston e appearan ce) an d to im prove th e con tour. and fanning technique of injection for rejuvenation of jaw lines.
402 VI Minim ally Invasive Facial Plastic Surgery
a b
Fig. 30.14 Lower face contouring using ller. (a) Before the procedure. Sagging skin and underlying bone resorption contribute to forma-
tion of the jowl with aging. (b) Immediately after an injection to the lower jawline with Ellanse M. (c) One month after injection. (d) After
t wo sessions of injections for the lower jawline.
for th is pu rp ose. Th e inject ion layer is a com bin at ion of
th e deep derm al an d subcut an eous plan es. In m any cases,
th ere is n ot on ly a deep lin e exten ding from th e com m is-
su re, bu t also a loss of volu m e in th e su rrou n ding area. In
th ese cases, a cross-h atch ing tech n ique can be used to add
m ore volu m e. Dist ribu t ion of th e ller often en d s u p follow -
ing th e sh ap e of an inverted t riangle w ith th e lateral m ar-
gin based on th e d eep est m arion et te lin e. Prejow l su lcu s
en h an cem en t by exten ding th e ller inject ion dow n to th e
low er m an dibu lar border is often an adju n ct to m arion et te
lin e correct ion . In th in -skin n ed pat ien t s, longer-last ing an d
p erm an en t llers can be placed over th e periosteum w ith
a h igh er safet y m argin . Du e to disp lacem en t of th e jow l
w h en su pin e, it is recom m en ded th at pat ien t s be injected
in th e u p righ t posit ion for m ore accurate correct ion . Th e
ller is dist ribu ted along th e low er m argin of th e m an dible
an d in som e cases ju st below th e m an d ibu lar border if th e
jow ling is severe. Th is inject ion exten ds from th e an terior
m argin of th e jow l tow ard th e m idlin e of th e ch in to h elp
restore a m ore you th fu l t ran sit ion bet w een th ese poin ts.
Bet w een th e m arion et te lin es an d p rejow l su lcu s, a tot al
volu m e of 2 to 3 m L of ller is com m on ly u sed to ach ieve
adequ ate correct ion .
Dermal Hydration Using
Hyaluronic Acid
Skin text u re is a ver y im port an t factor from th e persp ec-
t ive of beaut y an d an t i-aging. A stabilized hyalu ron ic acid
(S-HA) ller gel h as been m ain ly used to t reat folds an d
w rin kles associated w ith facial aging sin ce it can be m ain -
tain ed for a longer t im e an d yields bet ter e ect s th an oth er
c d
llers.22 Par t icle-t ype S-HA can im prove skin text ure as
w ell as skin rough n ess.
Before th e t reat m en t , a 9% lidocain e topical an esth et ic
cream is applied to th e inject ion area an d covered w ith
plast ic w rap for 40 m in utes. Pat ien t s can be injected w ith
1m L of S-HA (Rest ylan e Vit al, Belotero Soft , Belotero Basic,
Juvederm Vobella) th at is divided in to 1,000 sh ot s u sing
th e injector (Derm aQueen , Woorhi Medical Group or Vit al
Injector). Th is d evice h as ve n eed les an d th e dist ribu t ion
of th e m icrodroplet inject ion s provides a m ore regular area
of coverage th an m an ual inject ion . Part icle-t ype S-HA or
biph asic (Rest ylan e Vit al), m on oph asic (Juvederm Vobella),
or polyph asic (Belotero Basic) llers can be injected in to th e
derm is. Th e inject ion depth can be con t rolled by a touch
pan el on th e injector (0–2 m m ). Th e recom m en ded injec-
t ion depth is about 1 m m . Th is m eth od w as inven ted by th e
au th or an d w as n am ed th e “Reteen age m eth od .”23 Because
th ere is a bevel in th e t ip of th e n eedle, th e act ual depth
of th e inject ion w ill be less th an 1 m m . During th is proce-
dure, th e inject ion depth sh ou ld be reduced if subst an t ial
bleeding is n oted, w h ich m ean s th e inject ion pen et rated
th e subderm al plexus. After th e inject ion s, cold com pres-
sion is p erform ed to spread th e S-HA an d to redu ce pain
an d ecchym osis.
■ Key Technical Points
1. For con tou ring a w ide area, a can n ula is preferred to
a n eedle to redu ce com p licat ion s du ring inject ion .
2. In ch anging th e foreh ead con tour, a deeper inject ion
su ch as at th e su p ra-p eriosteal an d su bm u scu lar
layers is preferred to reduce irregu larit y.
 30 Facial Contouring Using Fillers 403

3. Becau se t um escen t solut ion can in terfere w ith th e To prevent intra-arterial ller injection, the needle tip
d eterm in at ion of th e prop er volu m e of ller to be should always be kept in the m idline and never placed paral-
injected in to th e su bderm al tem p le region , th e lel to the dorsal nasal artery. If side wall injection is inevitable
volu m e e ect of t u m escen t solu t ion sh ou ld alw ays due to correction of a deviated nose, the needle tip should be
be con sidered. m oved obliquely after m idline injection. Severe pain during
4. In t ram uscular inject ion during ch in augm en t at ion the procedure and geographic pale skin color change are clues
sh ou ld be avoided becau se of m en talis m u scle of arterial injection. But skin necrosis by venous congestion
d iscom for t during facial expression . is m ore com m on and occurs w hen a large volum e of ller is
5. The linear threading technique w ith a cannula is the injected into the supratip area. To avoid this, a sm all am ount of
m ost frequently used technique for nasal augm entation ller should be injected to the deep layer. If a vascular problem
to prevent arterial em bolism and blindness. is suspected, stop the injection and aspirate the injected ller
to reduce volum e. Hyaluronidase injection and hyperbaric
6. HA gels are com m on ly preferred for lip
oxygen therapy m ust be applied as soon as possible. Antibiot-
augm en tat ion . Oth er ller gels, su ch as PCL an d
ics should be adm inistrated to prevent secondary infection.24
CaHA ller, are n ot ap prop riate in m ost cases du e to
Th e m idface region h as a relat ively loose subcut an e-
visible an d palpable w h ite n odules.
ous fat plan e, an d th ere can be pressu re-in duced m igra-
7. Due to displacem en t of th e jow l w h en supin e, th e t ion of th e ller. Th e auth or does n ot recom m en d rm
p hysician is advised to inject pat ien t s in th e u prigh t m assages w ith in 3 w eeks after inject ion , an d it is bet ter
p osit ion for m ore accurate correct ion . to inject ller w ith h igh er coh esiven ess to p reven t m igra-
t ions. Malar edem a can arise from inject ion s w ith HA, Juve-
deram , or Rest ylan e Vit al, as th ese llers h ave th e pow er
■ Complications and to at t ract w ater. Malar edem a can p ersist as long as a few
Their Management m on th s after an inject ion . Low er eyelid edem a also can
develop after ch eek con touring. During con touring of th e
Irregularit y, asym m etr y, and un even shape are com m on ch eek or tear t rough correct ion , a ller can be in ciden tally
com plicat ion s after ller injection regardless of region . injected in to th e orbital fat th rough th e orbit al sept u m ,
These com plications can be prevented by choosing the w h ich causes a prolonged edem a on th e low er eyelid. A
appropriate t ype of ller according to inject ion layers an d large am ou n t of ller in to th e subderm al layer of th e low er
postoperat ive m olding. Retouching is recom m ended 1 to 3 eyelid can also m ake a prolonged edem a. Th erefore, w h en
m on th s after th e rst injection if th ese com plicat ion s occur. inject ing th e subderm al layer on th e low er eyelid to t reat
Region-related speci c com plicat ion s are m ent ioned later.
Su p raorbit al n er ve dam age can be avoided by u sing
th e m idlin e on e-en t r y-poin t tech n ique. Inject ing CaHA an d
PCL w ith t um escen t solut ion to reduce pain h as th e pos-
sibilit y of u n dergoing su dden volu m e loss after 1 m on th ,
w h ich sh ould be explain ed to pat ien ts before th e proce-
dure. Bruising or skin n ecrosis by ar terial em bolism is rela-
t ively rare in th e foreh ead region .
In contouring of the tem ple, irregularit y is the m ost com -
m on after a fanning technique injection into a subderm al
layer and m igration m ay occur after the self-pistol technique
into a deep layer. Pain and hem atom a are com m on com plica-
tions after an intram uscular injection (self-pistol technique).
To prevent intra-arterial injection, a negative pressure test
(regurgitation) should be done before injecting ller.
In con tou ring of th e n ose, blin d n ess is th e m ost seri-
ous an d irreversible com plicat ion , alth ough it is rare. It can
occur w h en ller is injected in to th e dorsal n asal arter y,
su p rat roch lear ar ter y, or angu lar ar ter y arou n d th e n asal
an d p eriorbit al region . Th ese arteries an astom ose w ith th e
oph th alm ic ar ter y. To preven t th is, th e n eedle sh ould be Fig. 30.15 Skin necrosis after nasal ller injection. Nasal skin
kept in th e m idlin e an d m oved back an d forth con t in u ou sly necrosis with crust formation developed in a 25-year-old woman
during inject ion . Skin n ecrosis is th e secon d m ost serious who had a nasal HA ller injection 1 month previously. She was
com plicat ion (Fig. 30.15). In t ra-ar terial em bolizat ion or treated with hyaluronidase and hyperbaric oxygen therapy, but the
ven ou s congest ion can lead to th is problem . necrosis progressed.
404 VI Minim ally Invasive Facial Plastic Surgery
n e w rin kles, inject ing a sm all am ou n t of ller over t w o or
th ree session s is recom m en ded over a single large-volum e
inject ion . In addit ion , a soft-t yp e ller is ch osen to preven t
lu m py h ard n ess at th e in fraorbital area.
For con touring of th e n asolabial fold, it is im por tan t to
avoid inject ing in to th e lateral n asal arter y. Because th e lat-
eral n asal ar ter y ru n s 4 m m above th e su pra-alar groove,
avoid inject ing above th e groove (Fig. 30.16). Inject slow ly
an d carefu lly an d p ay at ten t ion to any ch ange of skin color.
A sm all am ou n t of inject ion (~ 0.05 m L per inject ion ) is rec-
om m en ded to preven t vascular com plicat ion s.25
References
1. Bran dt FS, Cazzan iga A. Hyaluron ic acid gel llers in th e
m an agem en t of facial aging. Clin In ter v Aging 2008;
3(1):153–159
2. McCurdy JA, Lam SM, eds. Cosm et ic Surger y of th e Asian
Face. New York, NY: Th iem e Medical Pu blish ing; 2011
3. Ricket t s RM, ed. Orth odont ic Diagn osis an d Plan n ing:
Th eir Roles in Preven t ive an d Reh abilit at ive Dent ist r y. Vol.
2. Denver, CO: Rocky Moun t ain /Orthodon t ics; 1982
4. Ricket t s RM. Esth et ics, environ m en t , an d th e law of lip re-
lat ion . Am J Orth od 1968;54(4):272–289
5. Carruth ers JD, Glogau RG, Blit zer A; Facial Aesth et ics Con -
sen sus Group Facu lt y. Advan ces in facial rejuven at ion :
bot ulin um toxin t ype a, hyaluron ic acid derm al llers,
an d com bin at ion th erapies—con sen sus recom m en da-
t ion s. Plast Recon st r Su rg 2008;121(5, Su p pl):5S–30S, qu iz
31S–36S
6. Mikos AG, Th orsen AJ, Czer w on ka LA, et al. Preparat ion
an d ch aracterizat ion of poly (L-lact ic acid) foam s. Polym er
1994;35(5):1068–1077
7. Buck DW II, Alam M, Kim JY. Inject able llers for fa-
cial rejuven at ion : a review. J Plast Recon st r Aesth et Surg
2009;62(1):11–18
8. Men delson BC, Mu za ar AR, Adam s W P Jr. Surgical an at-
om y of th e m idch eek an d m alar m ou nds. Plast Recon st r
Surg 2002;110(3):885–896, discu ssion 897–911
9. Kim JA. Clin ical experien ce w ith Ca ller in o -label u se in
foreh ead, n eck fold, n ose an d tear t rough . Paper presen ted
at: 2014 join t m eet ing of Aesth et ics Asia an d th e 1st Aes-
th et ic an d An t i-Aging Med icin e Asian Congress; Septem -
ber 25–27, 2014; Singpore, Marin a Bay San ds
10. Sh aw RB Jr, Kat zel EB, Kolt z PF, et al. Aging of th e facial skel-
eton : aesthet ic im plicat ions an d rejuven at ion st rategies.
Plast Recon st r Su rg 2011;127(1):374–383
11. Rich ard MJ, Morris C, Deen BF, Gray L, Woodw ard JA. An al-
ysis of th e an atom ic ch anges of th e aging facial skeleton u s-
ing com p u ter-assisted tom ograp hy. Oph th al Plast Recon st r
Surg 2009;25(5):382–386
12. Zadoo VP, Pessa JE. Biological arch es an d ch anges to th e
cu r vilin ear form of th e aging m axilla. Plast Recon st r Su rg
2000;106(2):460–466, discussion 467–468
13. Pessa JE, Desvigne LD, Lam bros VS, Nim erick J, Sugunan B, Za-
doo VP. Changes in ocular globe-to-orbital rim position w ith
age: im plications for aesthetic blepharoplast y of the lower
eyelids. Aesthetic Plast Surg 1999;23(5):337–342
14. Dou al JM, Ferri J, Lau de M. Th e in u en ce of sen escen ce on
cran iofacial an d cer vical m orph ology in h um an s. Surg Ra-
d iol An at 1997;19(3):175–183
Fig. 30.16 Course of lateral nasal artery at the alar groove. To
prevent intra-arterial injection in nasolabial fold correction, avoid
injecting above the alar groove because the lateral nasal artery runs
4 mm above the alar groove.
15. Kim JA, Van Abel D. Neocollagen esis in h u m an t issu e in -
jected w ith a polycaprolacton e-based derm al ller. J Cos-
m et Laser Th er 2015;17(2):99–101
16. Em re IE, Cakm ak O. Ageing face, an over view —aet iol-
ogy, assessm en t an d m an agem en t . Otorh in olar yngologist .
2013;6(1):160–166
17. Zim bler MS, Kokoska MS, Th om as JR. An atom y an d p ath o-
physiology of facial aging. Facial Plast Su rg Clin Nor th Am
2001;9(2):179–187, vii
18. Colem an SR, Grover R. Th e an atom y of th e aging face: vol-
um e loss an d ch anges in 3-dim en sion al topography. Aes-
th et Su rg J 2006;26(1S):S4–S9
19. Roh rich RJ, Pessa JE. Th e fat com p art m en t s of th e face:
anatom y and clin ical im plicat ion s for cosm et ic surger y.
Plast Recon st r Su rg 2007;119(7):2219–2227, discu ssion
2228–2231
20. Hu r MS, Kim HJ, Ch oi BY, Hu KS, Kim HJ, Lee KS. Morph ol-
ogy of th e m en t alis m u scle an d it s relat ion sh ip w ith th e
orbicularis oris an d in cisivus labii inferioris m uscles. J Cra-
n iofac Su rg 2013;24(2):602–604
21. Dallara JM, Basp eyras M, Bu i P, Cart ier H, Ch aravel MH,
Du m as L. Calciu m hydroxylap at ite for jaw lin e rejuven a-
t ion : con sen su s recom m en dat ion s. J Cosm et Derm atol
2014;13(1):3–14
22. Mat arasso SL, Carru th ers JD, Jew ell ML; Rest ylan e Con -
sen su s Grou p . Con sen su s recom m en dat ion s for soft-t is-
su e augm en t at ion w ith n on an im al st abilized hyalu ron ic
acid (Rest ylan e). Plast Recon st r Surg 2006;117(3 Su ppl):
3S–34S; discussion 35S–43S
23. Kim AJ. E ect of injection depth and volum e of stabilized
hyaluronic acid in hum an derm is on skin texture, hydration,
and thickness. Arch Aesthet Plast Surg 2014;20(2):97–103
24. Colem an SR. Avoidance of arterial occlusion from injection of
soft tissue llers. Aesthet Surg J 2002;22(6):555–557
25. Roh rich RJ, Rios JL, Fagien S. Role of n ew llers in facial
rejuven at ion : a caut ious ou tlook. Plast Recon st r Surg
2003;112(7):1899–1902
31 Management of Facial Filler Injection
Complications
Hyoung Jin Moon and Jong Sook Yi
Pearls
• Skin th ickn ess varies across di eren t an atom ic
region s. Sin ce th e eyelids, periorbit al area, an d
n asal dorsu m are kn ow n to h ave a ver y th in derm is,
special care sh ou ld be t aken w h ile inject ing in to
th ese region s n ot to create lum pin ess, n odules, or
gran u lom as.
• Th e glabellar an d n asolabial region s are regarded as
h igh -risk facial u n it s in w h ich su rger y can lead to
seriou s vascu lar com p licat ion s.
• Fillers sh ou ld be placed in th e app ropriate layer of
skin . Too su per cially injected llers can resu lt in
un even n ess an d visibilit y. Too deeply injected llers
can be un der e ect ive at ch anging sh apes.
• Given th at m ost faces are sligh tly asym m et ric, it is
im p ort an t to visually ch eck w h eth er th e t w o sides of
th e face are sym m et ric during inject ion .
• Massage is gen erally su cien t to at ten an d
disperse excessive, super cial, or un aesth et ically
placed ller causing visibilit y.
• Bilateral com pression an d releasing of th e su perior
n asal corn er of th e orbit al rim s du ring inject ion is a
■ Introduction
A ller is any m aterial th at can augm en t volu m e w h en
injected in to th e body, an d is usually available in an inject-
able form . Well-kn ow n llers in clu de hyalu ron ic acid p rod-
u ct s, collagen , para n , an d liquid silicon e. Alth ough m ost
of th e llers in th e m arket are kn ow n to h ave a good safet y
pro le, com plicat ion s can occur occasion ally sin ce th ey
are art i cial im plan t s th at can in du ce a foreign -body reac-
t ion . Because inject ion is a blin d procedure, th e physician
is u n able to see exactly w h ere th e ller is placed. Accord -
ing to a st udy of 286 pat ien t s injected w ith hyaluron ic acid
gel, th ere w as a com plicat ion rate of ~ 5%.1 How ever, m ost
com plicat ion s can be preven ted by select ing safe product s
an d p erform ing th e procedu re in an app rop riate m an n er.
Alth ough llers can be injected in to any region of th e body
th eoret ically, each ller h as a speci c n ich e in term s of it s
purpose. For in stan ce, h u m an collagen s and th e m edium
hyaluron ic acid product s such as Rest ylan e (Galderm a) an d
Juvederm Ult ra (Allergan ) are app ropriate for correct ing
n e rhyt ides in th in -skin areas w h ile h eavier llers su ch as
n ew m an euver th at can redu ce orbital com p licat ion s
by in creasing in t ralum in al pressure.
• Severe pain an d blan ch ing of th e skin are w arn ing
sign s of in t ravascu lar inject ion of ller an d requ ire
em ergen t m easu res. Th ese in clu de stopp ing
inject ion , aspirat ing as m u ch injected ller as
possible, an d inject ing a h igh dose of hyaluron idase
in case of hyaluron ic acid ller.
• Low -m olecu lar-w eigh t h eparin , h ot p acks an d soft
m assage, 2% n it roglycerin p aste p atch , an d inject ion
of prostaglan din E1 are addit ion al m easu res to
en h an ce vasodilat ion an d in h ibit ion of p latelet
aggregat ion in case of vascular occlusion by ller.
• On ce esch ar h as form ed, ap prop riate w et dressing
is required w ith an t ibiot ics to preven t secon dar y
in fect ion . St art ing hyperbaric oxygen th erapy also
h elps to im prove h ealing.
• W h en addressing an in ter ven t ion to com plicated
cases such as skin n ecrosis, m ore con ser vat ive an d
less invasive t reat m en t sh ould be at tem pted before
recom m en ding a radical solut ion .
calcium hydroxyapat ite an d poly-L-lact ic acid are excellen t
for th eir volu m et ric e ect .2
An u n derst an ding of facial an atom y, esp ecially skin
th ickn ess an d vessels, is also cru cial to reduce com plica-
t ions. Skin th ickn ess varies am ong di eren t an atom ic
region s, an d requires di eren t tech n iques depen ding on
ller t yp e. Gen erally, h u m an collagen sh ou ld be placed
in th e m idderm is, an d m ed iu m -length hyaluron ic acid
product s sh ould be placed in th e deep derm is. Calcium
hydroxyapat ite is injected at th e derm al subcut an eous bor-
der, w h ile poly-L-lact ic acid an d fat are injected in to th e
su bcu t is.2 Sin ce th e eyelids, periorbit a, an d n asal dorsum
are kn ow n to h ave a ver y th in d erm is, sp ecial care sh ou ld
be taken w h en inject ing in to th ese region s n ot to in t ro-
du ce lum pin ess, n odules, or poten t ial gran ulom as. For th e
n ovice, som et im es it is bet ter to err on th e side of ller
placem en t th at is too deep rath er th an too sup er cial even
th ough the augm en tat ion e ect m ay n ot be as apparen t .2,3
The rich net work of blood vessel in the face is by and
large a blessing, but it can increase the chances of bruising,
hem atom a, or em bolism -related com plications. The glabellar
and nasolabial regions are regarded as high-risk facial units
405
406 VI Minim ally Invasive Facial Plastic Surgery
that can be associated w ith serious com plications, includ-
ing em boli and resulting necrosis because their m ain arter-
ies, the supratrochlear artery and the angular lateral nasal
artery, respectively, are vulnerable to em bolism by ller
(Fig. 31.1).2,3,4 Augm enting the chin w ith heavy llers can
potentially lead to vascular com prom ise if too m uch of the
product is injected at once by com pressing the blood vessels.
It is n ot clear w h ich t ype of inject ion tech n iqu e, th e
m u lt iple serial pu n ct u re or th e lin ear th reading tech n iqu e,
causes few er com plicat ion s. Th e m ult iple pun ct ure tech -
n iqu e m akes it easier to con t rol p lacem en t bu t can lead
to un even n ess. Th e lin ear th reading tech n ique ten ds to
requ ire m ore exp erien ce, an d can resu lt in over-inject ion
to a given area. Th e fan n ing tech n iqu e h as been repor ted
to in crease the likelih ood of bleeding even in experien ced
h an ds.2,5 Ult im ately, th e p ract it ion er can u t ilize th ese tech -
n iqu es to su p p lem en t th e w eakn esses of on e an oth er.
■ Patient Evaluation
Th e pat ien t w ith com plicat ion s after ller inject ion sh ould
be in ter view ed th orough ly about previous m edical proce-
dures. If th e pat ien t is in an im m u n osuppressed state, it
is n ot a con t rain dicat ion , but th e h igh er risk of in fect ion
sh ou ld be d iscu ssed. In th ose p at ien ts w ith im m u n ologic
diseases such as lupu s or scleroderm a, it is best to con sult
w ith th e derm atologist or rh eum atologist before proceed-
ing w ith any addit ive procedu res. Previou s ller-related
issu es, in clu ding t yp e an d dose of llers, n u m ber of injec-
t ion s, an d injected areas, sh ould be evaluated.
If a p at ien t is dissat is ed w ith a p reviou s ller t yp e,
th e physician sh ould n ot re-adm in ister th at product . In th is
a b
sit u at ion , it is best to at tem pt an altern at ive t reat m en t or
product , or sim ply n ot to t reat at all. To set u p an accurate
t reat m en t plan , th e physician sh ould ask about th e on set
an d progress of sym ptom s an d sign s. Gen erally, t ran sien t
sw elling or ten dern ess can be seen 24 to 72 h ou rs after
inject ion becau se of th e p hysical im posit ion an d su bse-
quen t volu m e displacem en t on th e skin from an im plan t .2
Th ese adverse e ect s w ill dim in ish over a relat ively sh ort
period of t im e. But if th ere is an irregularit y due to a sem i-
perm an en t or perm an en t ller, it w ill require som e form of
in ter ven t ion . W h en th e physician determ in es it is n eces-
sar y to do som e kin d of in ter ven t ion , th e p at ien t n eeds to
be in form ed th at th e t reat m en t plan m ay require m u lt iple
session s, w h eth er it is a sm all com plicat ion or a devast at-
ing on e. A discu ssion regarding th e poten t ial for any per-
m an en t scars from th ese in ter ven t ion s sh ou ld be in clu ded
in th e in it ial con su lt at ion . Th is step is really im port an t in
m ain t ain ing a good doctor-pat ien t relat ion sh ip sin ce th e
pat ien t is usually in a ver y an xious st ate. More con ser va-
t ive an d less invasive t reat m en t is often recom m en ded as a
rst at tem pt for a com plicated pat ien t rath er th an a radical
solu t ion .
■ Complications and
Their Management
Th e best w ay to m an age com plicat ion s is to preven t th em
by ch oosing th e appropriate tech n ique an d ller t ype.
At t ain ing a con sisten tly excellen t ou tcom e an d avoiding
poor resu lt s begin before th e act ual inject ion . Marking th e
inject ion poin t s prior to th e act ual inject ion s con sidering
adjacen t an atom y is h elpfu l to reach th ese goals.
Fig. 31.1 Dermal necrosis after ller injec-
tion at glabellar and nasolabial regions.
The glabellar and nasolabial regions are
regarded as high-risk facial unit s. Embo-
lism of the supratrochlear artery and lateral
nasal artery caused skin necrosis of the
(a) glabella and (b) nasal tip, respectively.
 31 Managem ent of Facial Filler Injection Com plications 407

Early Onset
Minor Form
Bruising is a com m on com plication of ller injections, and
it is caused by vascular dam age from a needle. All patients
sh ould be in form ed not to take blood th in ners such as aspirin
1 w eek before the procedure. During the procedure, pierc-
ing of m uscular layers m ust be m inim ized. The injection
site should be cleaned w ith an alcohol sw ab, and the pro-
cedure should be perform ed in a room w ith adequate light- Fig. 31.2 Cannula for ller injection. For safet y reasons, facial ller
ing. Im m ediately applying an ice pack to the injection site injection is best done using a thin, blunt cannula instead of a sharp
m ay help to m inim ize bruising. Special needles or cann ulae needle.
can be used to m inim ize vascular injury as w ell (Fig. 31.2).
If bleeding occurs during the procedure, the injection site
sh ould be covered w ith gauze and pressed for several m in -
utes to prevent hem atom a form ation. Usually bruising is Th e facial arter y t akes a tort u ous course along th e n aso-
on ly tem porary and does not a ect the n al therapeutic labial crease (Fig. 31.3), w h ere it becom es en dangered by
e ect. It can darken in the days follow ing the injection, but an inject ion in ten ded to soften an d redu ce th e p rom in en t
w ill gradually disappear after 10 days in m ost cases.6 n asolabial fold . Th e fron t al bran ch of th e su p er cial tem -
Occasion ally, th ere m ay be hyp ersen sit ivit y to th e ller poral arter y gives o descen ding bran ch es to an astom oses
ingred ien t s. Th e m ain sym ptom s are pain an d er yth em a, w ith th e supraorbit al an d th e suprat roch lear ar teries from
accom pan ied by pru rit u s an d fever.7 In th e vast m ajorit y th e oph th alm ic arter y. To preven t com plicat ion s, a sm all-
of pat ien t s, fort un ately, th ese sym ptom s resolve in 2 to 3 bore n eedle t ip is recom m en ded w ith sm aller syringes,
days as th e cau sat ive su bst an ce disappears. In severe cases, preferably 0.5 to 1 m L, so th at less pressure is required on
adm in istering cor t icosteroid p rodu ct s an d w arm com pres-
sion m ay h elp alleviate th e sym ptom s. V-beam laser t reat-
m en t can be u sed for persisten t er yth em a.8

Major Form
Th e serious com plicat ion s th at occur after ller inject ion
are blin dn ess an d derm al n ecrosis. Vascu lar com prom ise
can be largely divided in to in t ra- an d ext ravascular causes.
In t ra-ar terial inject ion of ller is rare bu t can be disast rou s.
Ext ravascu lar causes in clude extern al ven ous com pres-
sion d u e to excessive volu m e of inject ion , an d edem a an d
in am m ator y respon se cau sed by a com pon en t of th e ller.

Intra-arterial Embolism
In t ra-ar terial em bolism h as a relat ively low in ciden ce,
but its con sequen ces are devastat ing. Blin dn ess follow ing
cosm et ic ller inject ion is th e m ost serious com plicat ion .
Most cases of ocu lar com plicat ion s occu r du ring m u lt ip le-
site inject ion s, bu t som e facial u n its dist ingu ish ed by th e
fat com p ar t m en ts an d th e ret ain ing ligam en t s m ay h ave a
h igh er risk com p ared w ith oth ers.9,10,11 Th e n asolabial an d
th e fron totem poral un its are kn ow n to be danger zon es
due to large-core cutan eous arteries suscept ible to acci-
dent al can n ulat ion , the facial an d th e super cial tem poral Fig. 31.3 The tortuous course of the facial artery. The facial
arteries.12 You ng p at ien t s m ay h ave h igh er risk of blin d- artery runs along the nasolabial crease and anastomoses with the
n ess because h ealthy skin h as abu n dan t cu t an eou s ar terial descending nasal artery. The t wo facial arteries communicate with
an astom oses. each other in the nasal supratip region.
408 VI Minim ally Invasive Facial Plastic Surgery

th e plunger. Th e n eedle t ip sh ould be m oved back an d for th
con t in uously during inject ion sin ce m ost com plicat ion s
occur w h ile inject ing ller m aterials in th e st at ic state w ith
h igh pressu re. Previou sly t rau m at ized areas, su ch as a blu n t
t raum a site or bleph aroplast y site, sh ou ld be avoided. Dur-
ing ller inject ion at th e tem ple area, th e n eedle t ip can be
d eviated su p er cially from th e deep inject ion plan e by a
bony cur ve of th e fron t al bon e an d en coun ter th e fron t al
bran ch of th e super cial tem poral arter y. Th us, special care
sh ou ld be taken n ot to lose th e ap p ropriate p lan e. Recen tly,
eviden ce h as em erged of persisten t an astom oses bet w een
th e oph th alm ic arter y an d th e facial ar terial system at th e
su p erior n asal corn er of th e orbital rim .12 Based on th is
kn ow ledge, th e auth or h as in t rodu ced an e ect ive safet y
m an euver th at bilaterally com p resses th e su p erior n asal
corn ers of th e orbit al rim s during th e inject ion m om en t
an d releases th em soon after w ard . Th is tech n iqu e creates a
tem porar y collapse of th e an astom ot ic pathw ays using th e
h an d of an assist an t (Fig. 31.4).
W h en an assist an t is u n available, an altern at ive m eth od
is to com press th e t issue on th e course of th e core arter y
bet w een th e inject ion site an d th e eye w h ile st retch ing
th e skin for an inject ion procedure u sing th e n on dom in an t
h an d. Th is m eth od cou ld in crease th e lu m in al pressu re
en ough to block any ller th at w as acciden tally injected
in to th e m ain arter y u n d ern eath from t raveling to th e globe.
Th e target areas for com pression are th e oral com m issure,
u pp er n asolabial fold, alar crease, side of th e n ose, m ed ial
can th us, superior n asal orbit al rim , an d glabella. With th e
in dex an d long ngers cou n teract ing w ith th e th um b, th e
inject ion areas can be st retch ed an d im m obilized.
If th e p at ien t com plain s of su dden ocu lar p ain or visu al
loss, h ow ever, inject ion m ust cease im m ediately. An oph -
th alm ologist sh ould be con tacted for m easu rem en t of
visual acu it y an d fu n d oscopy.
Th e goal of t reat m en t is rapid restorat ion of perfusion
to th e ret in a an d opt ic n er ve h ead . Ret robu lbar inject ion
of 2 to 4 m L (150 to 200 U/m L) of hyaluron idase is recom -
m en ded w ith in 60 to 90 m in u tes.13 Th is m igh t be th e single
m ost e ect ive opt ion to dissolve th e in t raorbital in t ravas-
cular hyalu ron an in a t im e-sen sit ive m an n er.14 Ocu lar m as-
sage (rep eated, in creasing pressu re ap p lied to th e globe for
10- to 15-secon d in ter vals over 3 to 5 m in utes) m ay low er
in t raocu lar pressu re an d in crease ar teriolar ow, poten -
t ially m oving th e ret in al vascular em bolus periph erally.15
In t raven ou s m an n itol an d diu ret ics (500 m g of acet azol-
am id e) m ay in crease ret in al blood ow an d rapidly redu ce
in t raocular pressure. Topical an d in t raven ous an t ibiot-
ics an d subsequ en t adm in ist rat ion of h igh -dose cor t ico-
steroid (m ethylp redn isolon e 1 g/day in t raven ou sly for 3
days, an d dose tapering w ith oral adm in ist rat ion ) can be
at tem pted.15,16 In fact , n o safe, feasible, an d reliable t reat-
m en t exists for iat rogen ic ret in al em bolism . Non eth eless,
th erapy sh ou ld th eoret ically be applied as soon as possible
to in crease th e ch an ce of recover y.
Inject ion rh in oplast y is also th e m ain p roced u re th at
can in du ce in tra-ar terial em bolism by inject ing th e dorsal
n asal ar ter y directly. Th e dorsal n asal ar ter y, as it s n am e
suggest s, ru n s along th e dorsu m of th e n ose, ~ 3 m m aw ay
from th e m id lin e (Fig. 31.5). It is a fairly im m obile blood
vessel xed to th e su rrou n ding t issu e, an d th e n eed le t ip
can be in ser ted safely if it is in ser ted in parallel w ith th e

a b

Fig. 31.4 Anastomotic channel blockage by compression. Blocking the anastomotic channel bet ween the ophthalmic artery and the
other facial arterial system prevents blindness by embolism. Orbital rims at the superior nasal corners are compressed using the index and
long ngers during ller injection at the (a) nasolabial area and (b) superciliary ridge.
 31 Managem ent of Facial Filler Injection Com plications 409

Fig. 31.5 Arterial supply of the external nose.

Supraorbital a. The dorsal nasal artery runs along the dorsum
Supratrochlear a. of the nose, ~ 3 mm away from the midline. The
dorsal nasal artery anastom oses with the ophthal-
mic, infratrochlear, and angular arteries, causing
Dorsal nasal a. the spread of embolism through the connected
blood vessels, manifesting as skin necrosis in a
geographic pat tern.

External nasal branch

of anterior ethm oidal a.

Infraorbital a.

Lateral nasal a.

Colum ellar branch

Septal branch
Angular a.

Superior labial a.

Facial a.

blood vessel. Th e dorsal n asal arter y an astom oses w ith
th e oph th alm ic, in frat roch lear, an d angular arteries, an d a
w idespread em bolism th rough th e con n ected blood vessels
m an ifest s as skin n ecrosis in a geograp h ic p at tern .
If arterial inject ion is su sp ected, h ow ever, p rom pt
m an agem en t sh ou ld be don e accord ing to th e t reat m en t
p rotocol of in t ra-arterial em bolism . On ce ller is injected
in to th e ar terial bloodst ream , th e pat ien t exp erien ces
severe p ain im m ediately, an d m ay com p lain of a sen sa-
t ion of som eth ing spreading ou t from th e inject ion site.
Th e area su pplied by th e blood vessel w h ere ller em bo-
lism h as occu rred becom es pale du e to isch em ia. Th e isch -
em ic area develops edem a w ith in several h ou rs, an d soon
ap pears m ot tled an d p u rplish d u e to ven ou s congest ion as
a rebou n d p h en om en on . After ~ 24 h ou rs, m u lt ip le u lcer-
at ive lesion s accom p an ied by esch ar an d er yth em a, w ors-
en ing over t im e, resu lt in d esqu am at ion of th e t issu e w ith in
several days (Fig. 31.6).3,4 Th ese large areas of n ecrosis h eal
an d redu ce over t im e, even t u ally leading to scar form at ion
w ith con t ract ion of t issue (Fig. 31.7).
To preven t th is com plicat ion du ring n asal augm en t a-
t ion w ith llers, th e n eedle t ip m ust alw ays be located in
th e m idlin e to avoid inject ing in to th e dorsal n asal ar ter y.
If ller h as to be injected in to th e sid e of th e n asal dorsu m ,
for exam ple, for correct ion of a d eviated n ose, th e n eedle
sh ou ld n ever m ove in parallel w ith th e direct ion of th e
blood vessel. After in sert ing th e n eedle in to th e m idlin e,
th e n eedle t ip sh ould m ove to th e side. Becau se th e dor-
sal n asal ar ter y is located in th e su p er cial fat t y layer an d
SMAS, th e inject ion sh ou ld be in to th e deep fat t y layer to
preven t em bolizat ion to th e dorsal n asal ar ter y. Aspirat-
ing th e n eedle before inject ion an d inject ing ller w h ile
w ith draw ing th e n eedle are t ips for safe inject ion . Using a
blu n t can n ula also h elps to preven t in ciden tal pun ct ure of
th e vessel an d is recom m en ded to physician s w h o are n ot
fam iliar w ith th e inject ion tech n iqu e.
If the patient com plains of severe pain and blanching of
the skin is observed along the area of the blood vessel dur-
ing the ller procedure, the injection should im m ediately
stop and as m uch ller should be aspirated as possible. If
hyaluronic ller has been injected, injection of hyaluronidase
to the lesion is recom m ended (Fig. 31.8). The optim al tim e
of hyaluronidase injection in case of vascular com plications
has not been determ ined yet, but it is w ise to use high doses
of hyaluronidase (at least 200 U) as early as possible. Som e
experts recom m end dilution w ith saline to increase disper-
sion or lidocaine to aid vasodilation. Additional hyaluronidase
should be injected if im provem ent is not seen w ithin 60 m in-
utes.17 According to an experim ental study, the degradation
ratio of cross-linked HA w ith 100 IU of hyaluronidase after
24 hours was 50%, and it depended on the am ount of hyal-
uronidase.18,19 Recently, there has been som e evidence that if
hyaluronidase is injected subcutaneously, it w ill di use into
the obstructed vessels and degrade the HA ller to prevent
410 VI Minim ally Invasive Facial Plastic Surgery

a b c d

Fig. 31.6 Intra-arterial embolism by ller injection. The ischemic area develops edema within several hours, and soon a purplish, mot tled
area appears due to venous congestion occurring as a rebound phenomenon. After ~ 24 hours, multiple ulcerative lesions accompanied by
eschar and erythema appear and worsen over time, resulting in desquamation and ulceration of the tissue within several days. (a) Before
injection. (b) Four hours after injection. (c) One day after injection. (d) Three days after injection.

im pending necrosis caused by intra-arterially injected HA
ller.17 Low -m olecular-weight heparin therapy can decrease
throm bosis and em bolism , but it m ay be di cult to obtain
and adm inister in an outpatient clinic setting. It is very im por-
tant to supply enough oxygen to the area of ischem ia. For this
purpose, hot packs, soft m assage, and 2% nitroglycerin paste
can be applied for vasodilation. Injection of prostaglandin E1 is
e ective by the action of vasodilation and inhibition of plate-
let aggregation. A regim en of 10 m g a day for 3 to 7 days is
recom m ended. Appropriate dressing should be applied once
desquam ation and pustule form ation occur after a day. The
physician should adm inister appropriate antibiotics to pre-
vent secondary infection, apply wet dressing for faster wound
healing, and continue to adm inister antibiotics.2,3,4

a b c

Fig. 31.7 Skin contracture after nasal ller injection. (a) Treatment was delayed after intra-arterial ller injection, and necrosis pro -
gressed even with hyperbaric oxygen chamber treatment. (b,c) Two months later, the size of the necrotic area has decreased, but her right
alar area shows slight contracture.
 31
a b
Start ing hyperbaric oxygen th erapy is also h elpful. It
is kn ow n to im p rove n eovascu larizat ion an d post isch em ic
t issue sur vival by elevat ing cellu lar oxygen levels. Th e pro-
tocol di ers am ong pract it ion ers, bu t th e auth ors recom -
m en d 90 m in u tes of t reat m en t t w ice per day for 7 to 30
days w ith 100% oxygen at 0.2 MPa. This yields a m ore th an
20% in crease in ar terial blood oxygen con ten t .20
Venous Congestion
Derm al n ecrosis du e to ven ou s com pression from exces-
sive ller volu m e is m ore com m on th an derm al n ecrosis
by direct in t ra-arterial inject ion . In it ially, both th e vein an d
arter y su pp lying th e injected site are com p ressed by th e
excess ller volu m e, so th e p at ien t feels severe p ain an d th e
skin in th at area becom es p ale. Un like arterial com p ression ,
w h ich can be reperfu sed by h igh lling pressu re an d col-
lateral circulat ion , ven ou s congest ion often persist s. In th is
case, th e pat ien t con t in ues to feel dull pain an d th e skin
darken s w ith t im e. Th e skin t urn s dark violet after 24 h ours
an d desqu am at ion or p u st u les can be obser ved. De n it ive
sign s of derm al n ecrosis su ch as esch ar form at ion occu r
gradu ally, an d th e skin recovers th rough th e w ou n d h eal-
ing p rocess (Fig. 31.9).1–4
Th e skin color an d pain sh ould be closely m on itored
w h ile inject ing a sm all am ou n t at a t im e.
If vascu lar com pression is su spected from blan ch ing of
th e injected area righ t after inject ion , th e inject ion sh ould
be stopped im m ediately, an d su cien t m assage an d a h ot
Managem ent of Facial Filler Injection Com plications 411
Fig. 31.8 Hyaluronidase treatment of ller
embolization. A woman had hyaluronic acid
ller injection on both nasolabial folds.
Immediately after injection, she felt a burn-
ing sensation and pain. Treatment with
ller aspiration and hyaluronidase injection
started 1 day after injection. (a) She devel-
oped redness on the right cheek and nasal
dorsum. (b) Within a week, redness on the
cheek and nasal dorsum decreased.
pack sh ould be applied to th e a ected area. Th e skin sh ould
be pu n ct ured at th e site of ller inject ion an d squeezed to
rem ove ller. If hyaluron ic acid–t ype ller w as u sed, inject
hyaluron idase rst an d th en t r y rem oving injected ller.
Adm in ister an t ibiot ics an d p rostaglan din E1 as m en t ion ed
previously. Tw o percen t n it roglycerin paste can be applied
for vasodilat ion . Hyperbaric oxygen th erapy is also recom -
m en ded. Un like in t ra-arterial em bolism , ven ou s com p res-
sion can be resolved w ith ou t sequ elae if t reated p roperly
in it ially. How ever, if th e in it ial t reat m en t w as n ot provided
or w as in appropriate, it progresses to derm al n ecrosis due
to ven ou s congest ion , and after a day th e skin t u rn s dark
violet . W h en th is h appen s, th e physician sh ou ld apply
a w et dressing for faster w ou n d h ealing an d con t in u e to
adm in ister an t ibiot ics.4,6
Aft e r t h e act ive w ou n d st age, n e crot ic a rea s ch a n ge
in t o ch ron ic st age w it h re m ain in g scar s. Scar s w ill n eve r
d isap p ea r b u t can b e re d u ce d . Th e Fra xel Xe n a la se r
(Solt a Me d ica l), p lat elet - r ich p lasm a (PRP), st e m cell fat
graft in g, d iam on d p e elin g, a n d car boxy t h e rapy can b e
ad d resse d w h e n t h e sca rs b e com e p e r m a n e n t . Su r gica l
t reat m e n t of scar t issu e can b e at t e m p t e d if seve re skin
d efor m it y re m a in s re gard less of t h ese m ea su res. Sin ce
su rgica l t reat m e n t h a s t h e r isk of m akin g a n ew sca r, a
t h orou gh d iscu ssion sh ou ld t a ke p lace w it h t h e p at ie n t
before t h e su r ge r y. Accord in g t o t h e size an d locat ion
of t h e w ou n d an d t h e p refe re n ce of t h e su r ge on , a local
rot at ion a l fla p , n a sola b ial flap , or foreh ea d flap ca n b e
u se d .
412 VI Minim ally Invasive Facial Plastic Surgery
4 Hrs 24 Hrs
72 Hrs 5 Days
Delayed Onset
Mild Form
In am m ator y respon se an d edem a can occu r du e to a p ro-
tein com pon en t su ch as en dotoxin con t ain ed in th e ller,
result ing in injur y to th e skin . Th is is caused m ostly by
hyaluron ic acid ller, an d sym ptom s such as er yth em atou s
edem a, derm al hyp ert rop hy, an d p u st u les ap p ear several
days after inject ion . Sym ptom s can occur at all sites of ller
inject ion an d u sually can be t reated w ell w ith appropriate
an t ibiot ic t reat m en t an d d ressing.9,21
Inject ing ller too su p er cially (close to th e skin su r-
face) m ay resu lt in u n even n ess of th e injected site or visi-
bilit y of th e ller. Part icularly w h en sem i-perm an en t llers
are injected too su p er cially, th e lu m p in ess m ay rem ain
for several m on th s.1,2,3 Gross u n even n ess after soft t issu e
augm en tat ion is cert ain ly n ot accept able. To avoid th is, th e
ller sh ou ld be injected in to th e ap p rop riate layer accord-
ing to it s ch aracterist ics. If ller visibilit y or un even n ess of
th e skin occurs, m assaging th e ller in to th e deeper layer
m ay im p rove th e ap pearan ce. If a blu ish ridge develop s
due to th e Tyn dall e ect (Fig. 31.10), hyalu ron idase can be
injected an d excessive ller can be replaced.22
Fig. 31.9 Venous congestion by ller injec-
tion. As the process of venous congestion con-
tinues, the skin darkens with tim e, such that it
turns dark violet after ~ 24 hours and desqua-
mation or pustules can be observed. As time
passes, de nitive ndings of dermal necrosis
such as eschar formation occur gradually, and
then the skin recovers through the wound heal-
ing process.
48 Hrs
3 Wks
Asym m et r y is th e m ost com m on com plicat ion of ller
inject ion , especially after inject ion rh in oplast y. But m any
pat ien t s h ave asym m et r y at th e baselin e already. If th e
qualit y of facial asym m et r y seem s u n likely to be corrected
w ith ller inject ion , th is sh ould be discu ssed before any
procedure and th e pat ien t sh ould be m ade aw are of th e
lim itat ion s of th e procedu re.1,2,3,4
To preven t asym m et r y during inject ion rh in oplast y,
th e needle t ip m ust be placed precisely in th e m idlin e, an d
th e direct ion of th e bevel sh ou ld be tow ard th e m edian
plane. W h en inject ing ller in to a pat ien t w ith a deviated
n ose, it is p ru den t to w atch th e sh ape of th e n ose closely
w h ile slow ly inject ing sm all am oun t s of ller. Main ten an ce
of sym m et r y is im port an t regardless of th e am oun t of
m aterial delivered. Th ere are t w o w ays to m ain t ain sym -
m etr y: m easu ring th e am ou n t of inject ion an d visible
correct ion . W h en using th e t radit ion al 1-m L syringe, th e
injector sh ou ld en sure th at approxim ately equal am ou n t s
are delivered to corresp on d ing st ru ct u res, su ch as th e lip s
or the n asolabial folds on th e t w o sides of th e face. Given
th at m ost faces are often sligh tly asym m et rical, it is m ore
im port an t to visually ch eck th at th e sides of th e face are
sym m et ric. Altern at ing sm all aliqu ot inject ion s bet w een
th e sides m ay perm it th e ach ievem en t of sym m et r y.
 31
a b
Major Form
Bu m ps can be form ed after any t yp e of ller inject ion ;
th ese can be due to eith er gran ulom a or n odule form a-
t ion , alth ough th e et iology is n ot clear. A gran ulom a is
an im m u n e resp on se to an injected foreign body an d is
form ed by accu m u lat ion of im m un e respon se–related cells
su ch as lym ph ocytes to elim in ate th e foreign body.23,24,25 It
is ver y rare an d u sually results from th e inject ion of sem i-
p erm an en t or perm an en t ller. Treat m en t opt ion s in clu de
cort icosteroid inject ion an d surgical rem oval. Alth ough the
in t ralesion al steroid inject ion is e ect ive, it sh ou ld be used
ju diciou sly in a w eak con cen t rat ion (n o greater th an 10
m g/m L) sin ce it can resu lt in adjacen t skin at rophy.2 Nod -
u les are rou n d an d solid, an d th ey are essen t ially collec-
t ion s of injected ller w ith ou t an in am m ator y respon se.
Th e t reat m en t is hyaluron idase inject ion , if th e used ller
is hyalu ron ic acid, or su rgical rem oval.4,5
Late-on set in fect ion is u su ally cau sed by less com -
m on bacteria, su ch as m ycobacteria.22 Fluct uan t n odules
w ith er yth em a, w arm th , an d ten dern ess are th e key sign s
of in fect ion in con t rast to gran ulom a. Lim ited in cision
an d drain age or dressing ch anges u su ally fail to eradicate
th ese in fect ion s, even w h en accom panied by appropriate
an t ibiot ic th erapy. Su ccessfu l t reat m en t requ ires aggres-
sive debridem en t of all in fected su bcu tan eou s t issu es an d
skin .26 Large defect s can be covered w ith split-th ickness
skin graft ing.
Migrat ion of llers can occu r u p to several years after
th e inject ion . Sem i-perm an en t an d perm an en t im plan t s
are both p ron e to m igrate. It is kn ow n th at an in fect ion or
d elayed gran u lom a m ay t rigger m igrat ion .27 If th e un derly-
ing con dit ion is con t rolled, hyaluron idase inject ion or su r-
gical rem oval are t reat m en t opt ion s for m igrated llers.
Managem ent of Facial Filler Injection Com plications 413
Fig. 31.10 Visibilit y of ller due to super-
cial injection. (a) Too super cial injection
of ller caused a bluish discoloration of the
nasal dorsum by the Tyndall e ect. (b) After
7 months, the ller resorbed and the nasal
dorsum looks norm al.
References
1. McCracken MS, Kh an JA, Wulc AE, et al. Hyaluron ic acid gel
(Rest ylan e) ller for facial rhyt ids: lesson s learn ed from
Am erican Societ y of Op h th alm ic Plast ic an d Recon st ru c-
t ive Su rger y m em ber t reat m en t of 286 p at ien ts. Op h th al
Plast Recon st r Su rg 2006;22(3):188–191
2. Gladstone HB, Cohen JL. Adverse e ects w hen injecting facial
llers. Sem in Cutan Med Surg 2007;26(1):34–39
3. Andre P, Lowe NJ, Parc A, Clerici TH, Zim m erm ann U. Ad-
verse reactions to derm al llers: a review of European expe-
riences. J Cosm et Laser Th er 2005;7(3-4):171–176
4. Low e NJ, Maxw ell CA, Pat n aik R. Adverse react ions to
derm al llers: review. Derm atol Surg 2005;31(11 Pt 2):
1616–1625
5. Dayan SH, Bassich is BA. Facial derm al llers: select ion
of appropriate products an d tech n iques. Aesth et Surg J
2008;28(3):335–347
6. Glaich AS, Cohen JL, Goldberg LH. Injection necrosis of the
glabella: protocol for prevention and treatm en t after use of
derm al llers. Derm atol Surg 2006;32(2):276–281
7. Mat arasso SL, Her w ick R. Hypersen sit ivit y react ion to n o-
n an im al st abilized hyaluron ic acid. J Am Acad Derm atol
2006;55(1):128–131
8. Lupton JR, Alster TS. Cut an eou s hypersen sit ivit y react ion
to inject able hyalu ron ic acid gel. Derm atol Su rg 2000;
26(2):135–137
9. Alam M, Dover JS. Man agem en t of com plicat ion s an d se-
quelae w ith tem porar y inject able llers. Plast Recon st r
Surg 2007;120(6, Su ppl):98S–105S
10. Gierlo M, Stöh ring C, Bu der T, Wiltfang J. Th e su bcu t an e-
ous fat com part m en t s in relat ion to aesth et ically im por-
t an t facial folds and rhyt ides. J Plast Recon st r Aesth et Surg
2012;65(10):1292–1297
414 VI Minim ally Invasive Facial Plastic Surgery
11. Algh oul M, Codn er MA. Ret ain ing ligam en t s of th e face: re-
view of an atom y an d clin ical ap p licat ion s. Aesth et Su rg J
2013;33(6):769–782
12. Tan sat it T, Moon HJ, Apin u n t rum P, Ph et udom T. Veri ca-
t ion of em bolic channel causing blin dness follow ing ller
inject ion. Aesthet ic Plast Surg 2015;39(1):154–161
13. Carruth ers JD, Fagien S, Roh rich RJ, Wein kle S, Carruth ers
A. Blin dn ess cau sed by cosm et ic ller inject ion : a review
of cause and th erapy. Plast Recon st r Surg 2014;134(6):
1197–1201
14. Fagien S. Paper presen ted at: 2013 Allergan ALFA execut ive
con su lt an t s m eet ing; Novem ber 23, 2013; New York, NY
15. Lazzeri D, Agost in i T, Figus M, Nardi M, Pan t alon i M, La-
zzeri S. Blin dn ess follow ing cosm et ic inject ion s of th e face.
Plast Recon st r Su rg 2012;129(4):995–1012
16. Sung MS, Kim HG, Woo KI, Kim YD. Ocu lar isch em ia an d
isch em ic ocu lom otor n er ve p alsy after vascu lar em boliza-
t ion of inject able calciu m hydroxylapat ite ller. Op h th al
Plast Recon st r Su rg 2010;26(4):289–291
17. Coh en JL, Biesm an BS, Dayan SH, et al. Treat m en t of Hy-
aluron ic acid ller-in duced im pen ding n ecrosis w ith hy-
alu ron idase: Con sen su s recom m en dat ion s. Aesth et Su rg J
2015;35(7):844–849
18. Kim DW, Yoon ES, Ji YH, Park SH, Lee BI, Dh ong ES. Vascular
com plicat ion s of hyalu ron ic acid llers an d th e role of hy-
alu ron idase in m an agem en t . J Plast Recon st r Aesth et Su rg
2011;64(12):1590–1595
19. Lam bros V. Th e u se of hyalu ron idase to reverse th e e ect s
of hyaluron ic acid ller. Plast Recon st r Surg 2004;114(1):
277
20. Klein KC, Gu h a SC. Cu t an eou s w ou n d h ealing: cu rren t
con cept s an d advan ces in w ou n d care. In dian J Plast Su rg
2014;47(3):303–317
21. Sh a r R, Am ir A, Gu r E. Long-term com p licat ion s of facial
inject ion s w ith Rest ylan e (inject able hyalu ron ic acid). Plast
Recon st r Su rg 2000;106(5):1215–1216
22. Hirsch RJ, Naru rkar V, Carru th ers J. Man agem en t of in -
jected hyalu ron ic acid in duced Tyn dall e ect s. Lasers Su rg
Med 2006;38(3):202–204
23. Fern án dez-Aceñ ero MJ, Zam ora E, Borbujo J. Gran u lo-
m atous foreign body react ion again st hyalu ron ic acid:
report of a case after lip augm en t at ion . Derm atol Surg
2003;29(12):1225–1226
24. Rau lin C, Greve B, Hart sch u h W, Soegding K. Exu dat ive
gran ulom atous react ion to hyaluron ic acid (Hylaform ).
Con t act Derm at 2000;43(3):178–179
25. Sidw ell RU, Dh illon AP, Bu tler PE, Ru st in MH. Localized
gran ulom atous react ion to a sem i-perm an ent hyaluron ic
acid an d acr ylic hydrogel cosm et ic ller. Clin Exp Derm atol
2004;29(6):630–632
26. Plau s W J, Herm an n G. Th e su rgical m an agem en t of su per-
cial infect ion s caused by at ypical m ycobacteria. Su rger y
1991;110(1):99–103
27. Jordan DR, Stoica B. Filler m igrat ion : a n u m ber of
m ech an ism s to con sid er. Oph th al Plast Recon st r Surg
2015;31(4):257–262
Index
Note: Page nu m bers follow ed by f an d t in dicate gures an d tables, respect ively.

A – skin qu alit y an d, 100 – in rh in oplast y – for ptosis surger y, 216, 216f

– surger y –– calci cat ion , secon dar y – for zygom a reduct ion , 247
ablat ive rejuvenat ion , 339
–– in aesth et ic rh in oplast y for rhin oplast y for, 139, 140f Angle classi cat ion , of
– lasers for, 340, 343, 344f
South east Asians, 116 –– com plicat ion s of, 135–148 m alocclusion , 269, 270f
– principles of, 340
–– case st u dies, 105–106, 106f, –– deviated, secon dar y an terior segm ent al osteotom y, for
abscess, facial fat graft ing an d,
107f rhin oplast y for, 138–139 bim a xillar y prot rusion , 274t,
320, 320f
–– for cleft n ose, 103, 104f –– infectious com plications of, 141 277–279, 279f
ACell. See Mat riStem
–– com plicat ion s of, 104–105, –– in am m at ion caused by, 140 – an d gen ioplast y, 286, 295,
acn e, facial, im provem ent , laser
105f –– m obile, secon dar y rhin oplast y 296f–297f, 298, 299f
hair rem oval an d, 369, 369f
–– excision design , 102, 102f for, 139 Aqu am id. See polyacr ylam ide gel
acn eiform erupt ion, facial fat
–– key techn ical poin ts in, –– pat ien t evaluat ion, 136–138 arcus m argin alis, 326, 331
graft ing an d, 320
103–104 –– pearls, 135 arteriovenous st u la, h air
aden osin e t riph osph ate (ATP), in
–– n asal obst ruct ion after, 105 –– prot rusion , secondar y t ransplan tat ion an d, 360
hair t ran splant procedures,
–– pearls, 99 rhin oplast y for, 139 Artesense. See polym ethyl
306
–– poor h arm ony of alar base –– visible, secon dar y rh in oplast y m ethacr ylate
adipose-derived stem cells, in fat
w ith nasal dorsum an d t ip for, 139 Asian (s)
graft ing, 318
after, 105 – in septorhin oplast y, 135–136, – de n it ion of, 3
ADSC. See adipose-derived stem
–– scarring after, 104–105, 105f 143 – facial aesthet ic procedures u sed
cells
–– tech niques for, 101–103 –– pearls, 135 in , 3, 4f
aesth et ic facial plast ic surger y, in
–– t ypes of, 102, 102f – an d sh ort n ose deform it y, 122 ASO. See an terior segm en t al
East Asian s
– su rgical an atom y of, 101, 101f – skin an d m ucosal dam age osteotom y
– pearls, 3
– w idth of, 99, 100 caused by, 22 ATP. See aden osin e triph osph ate
– t ren ds in , 3–10
alar bat ten grafts, 39 alopecia. See also h air loss (ATP)
aging. See also bleph aroplast y,
alar-colum ellar disproport ion, – en doscopic forehead an d brow augm en tat ion rhin oplast y. See
aging-related
correct ion of, 53–54, 54f lift an d, 337 also n asal dorsal augm en tat ion
– of Asian face, m an agem en t of,
alar facial groove, 101 – tem porar y, after h air – alar bat ten graft s in , 39
303–310
alar lift , sail excision for, 109–110, t ran splant at ion , 359 – alar rim graft s in , 39
–– pearls, 303
110f–111f an atom y – an esth esia for, 16, 28
– low er eyelid, 196–197, 197f
alar rim – of alar base, 101, 101f – an d base reduct ion , 39
– periocular, 196–197, 197f
– excessively th ick, 99 – of Asian eyelid, 6, 211 – brow lift w ith , 15
– periorbit al ch anges related
– hanging, 99 – of Asian face, 6, 7f, 8f – case st udies, 40–43, 40f–45f
to, 174
alar rim graft(s), 39, 54–55 – of Asian n ose, 6, 26, 27f, 61–62 – cau dal septal extension graft in,
– skin , solar exposure an d,
– in correct ive rh in oplast y for – of East Asian eyelid, 162–163, 34, 34f, 40, 41f
303–304
sh or t con t racted n ose, 128, 163f – closure for, 21, 39
ala (pl., alae)
128f – of facial arter y, 407, 407f – com plicat ion s of, 22–23
– asym m et ric, 14, 15
alar w edge resect ion , 102, 102f – of facial bon es, 6 – defat t ing for, 18, 18f
– East Asian , ideal sh ap e of, 100,
– large, V-Y advan cem en t for, 103 – of forehead, 324–326, – an d glabellar augm en tat ion , 39
100f
– and sill excision , com bin ed, 102, 325f–327f, 331–332, 332f – incision s for, 17, 21
– aring of, 99, 101, 101f
102f, 103f, 105–106, 106f, 107f – of glabella, 324–326, 325f–327f, – key techn ical point s, 21–22, 40
– h anging, 100, 101, 103
AlloDerm , in rh in oplast y, 135 331–332, 332f – an d low n asal bridge, 21
–– sail excision for, 109–110,
– com plicat ion s of, 138, 138f, 140 – of intern al n asal valve, 87 – open , in cision s for, 17
110f–111f
allograft , in genioplast y, – of lateral n asal ar ter y, 404f – open ing nose for, 28
– h ooding, 101
com plicat ion s of, 294–295, – n egat ive vector, 197f, 198, 207, – osteotom y in , 19
– physical exam in at ion of,
295f 207f – pat ien t evaluat ion for, 14–15,
99–100, 100f
alloplast ic im plan t s. See also – posit ive vector, 198 14f, 15f
– resect ion, 9, 15
Gore-Tex; Medpor; silicone – of tem poral region , 324–326, – pearls, 13
– w ide, 9
im plan ts 325f–327f – posit ion ing for, 16
alar base
– advant ages of, 13 – of upper eyelid, 152–153, 153f, – postoperat ive care, 39–40
– de n ition of, 99
– in Asian aesth et ic surger y, 14 162 – principles of, 13
– of East asian n ose, 99
– calci cat ion of, 22 an esthesia – release of ligam en tous
– eth n ic variat ions in , 99
– capsule form at ion w ith, 22 – for augm en tat ion rhin oplast y, at tachm en ts in , 18
– illu sions an d, 100
– for chin 16, 28 – septal cart ilage h ar vest in ,
– m odi cat ion
–– com plicat ion s of, 294–295, – for blepharoplast y, 178 18–19, 19f
–– in dication s for, 99
295f – for double-eyelid surger y, 166 – silicon e im plant s for, 13–25
–– patient evaluat ion for, 99–101
–– in facial rejuven at ion , 309 – for en doscopic forehead an d –– case st udies, 23–24, 24f, 25f
–– pearls, 99
– com plicat ion s of, 13, 14, 22–23, brow lift , 330 –– closu re tech n ique for, 21
– poor h arm ony w ith n asal
28, 28f – for facial fat graft ing, 312, 313 –– com plicat ions of, 22–23
dorsum and t ip, after alar base
– in fect ion w ith , 23, 24, 25f – for ller inject ion in facial –– derm al fat graft w ith , 22, 23f
surger y, 105
– in h eren t physical characterist ics con touring, 394 –– displacem en t an d m ovem en t
– skin of, 101
of, problem s cau sed by, 22–23 – for gen ioplast y, 290 of, 23

415
416 Index
augm en tat ion rhin oplast y
(cont inued)
– silicon e im plant s for (cont inued)
–– ext rusion of, 23
–– in fect ion w ith , 23, 24, 25f
–– in sert ion of, 19, 19f
–– key tech nical poin ts in , 21–22
–– pearls, 13
–– periosteal pocket for, 17–18,
18f
–– p rep arat ion of, 16–17, 16f,
17f
–– splin t ing, 21
– skin ap elevat ion, 17, 17f
– skin m arking for, 15–16, 16f
– spreader graft placem en t in ,
32–33, 33f, 40, 41f
– stacked on lay graft for, 19–20,
20f
– surgical tech niques for, 28–39
– t ip contouring in , 37–39, 38f
– an d t ip -to-sept um h eigh t
di erence w ith lateral crural
in clin at ion , varian t techn ique
for, 21, 21f
– un i ed graft an d im plan t hybrid
in sert ion in , 20
– varian t techn iques for, 20–21
– vert ical lin e for, 16, 16f
– w ing graft placem en t in , 20, 20f
autoim m un e disease, an d saddle
n ose, 89
autologous grafts, 8–9
B –– orbit al fat prolapse an d, 177
backstop graft , in aesth et ic
rh inoplast y for South east
Asian s, 113
beaut y
– Asian ideal of, 5
– cult ural beliefs about , 5
– Eurocen t ric, 5
– Korean de nit ion of, in uence
of, 5
Bell’s ph enom enon , preoperat ive
evaluat ion, 177, 181, 214, 329
Belotero. See hyaluronic acid
bigonial dist an ce, 254, 270, 271f
– increased, 255–256
– reduct ion of, 255
bilateral vert ical sagit t al ram us
osteotom y, m an dibular, 274t
bim axillar y advan cem ent/
reduct ion, 9, 295, 296f–297f,
298, 299f
bim axillar y prot rusion , an terior
segm en tal osteotom y for, 274t,
277–279, 279f
– an d gen ioplast y, 286, 295,
296f–297f, 298, 299f
bim axillar y surger y. See anterior
segm en tal osteotom y; double
jaw surger y
bitem poral w idth, 270, 271f
bizygom at ic w idth, 244–246
Blaskovics’ m eth od, for aesthet ic
lateral can th oplast y, 190–191,
191f
bleph aroplast y, 7f, 307, 307f. See
also double-eyelid su rger y
– aging-related (upper), 173–183,
328
–– an esth esia for, 178
–– asym m et r y after, 181
–– bleph aroptosis an d, 175, 176f
–– brow posit ion an d, 175–176
–– case st udies, 182–183,
182f–183f
–– com plicat ions of, 180–181
–– corneal protect ion m ech an ism
an d, 177
–– deep superior sulcus an d,
175, 175f
–– derm atoch alasis an d, 175,
176f
–– eyelid crease design in , 178
–– eyelid crease form at ion in ,
179, 180f
–– eyelid w rin kles an d, 177
–– fat rem oval in , 179, 179f, 181
–– goals of, 173–174
–– key tech n ical poin ts in , 180
–– lacrim al gland injur y in , 181
–– lacrim al gland posit ion an d,
177
–– lagoph th alm os after, 181
–– levator fu nct ion an d, 175,
175f, 176f
–– an d nat ural eyelid crease
creat ion , 182, 182f
–– an d not iceable eyelid crease
creat ion , 183, 183f
–– an d orbit al h em orrhage, 181
–– pat ien t dissat isfact ion w ith ,
180
–– pat ien t evaluat ion for,
175–178
–– pearls, 173
–– postoperat ive care, 180
–– skin closure, 179, 180f
–– skin excision in , 178, 178f, 181
–– skin text ure and thickn ess
an d, 178
–– an d su perior sulcus, 181
–– tear secret ion and, 177
–– tech n iques for, 178–179
–– too-h igh double-lid fold after,
181
–– t ren ds in , 173–174
–– under-correct ion in, 180
–– unn at ural eyelid con tou r
after, 181
–– upper eyelid crease an d, 177
–– w ith out eyelid crease creat ion,
182, 182f
– Asian , 162. See also double-
eyelid su rger y
– com plicat ion s of, 225–239
– dem an d for, am ong East asian s,
196
– an d epicanth oplast y, com bin ed,
8 – versu s derm atoch alasis, 175,
– fat preser vat ion m eth od,
197–198, 202–203
–– in dicat ion s for, 198
– fat t ran sposit ion , 199, 202–203
–– com plicat ions of, 206
–– subperiosteal, 202–203
–– supraperiosteal, 203, 203f
– goals of, 173–174
– low er, 196–209
–– in Asian pat ien ts, surgical
con siderat ion s, 199
–– asym m et r y after, 205
–– case st udies, 206–207, 207f
–– com plicat ions of, 205–206
–– conjun ct ival ch em osis after,
206
–– diplopia after, 206
–– ect ropion after, 205, 205f
–– eyelid ret ract ion after, 205
–– globe posit ion an d, 198
–– h orizont al laxit y correct ion
procedures, 204
–– in ferior orbital rim an d, 197f,
198
–– key tech n ical poin ts in , 204
–– an d lateral tarsal st rip
procedure, 204
–– low er eyelid laxit y an d,
198–199
–– an d m in im ally invasive lateral
can th oplast y, 204
–– n egat ive vector anatom y an d,
197f, 198, 207, 207f
–– an d orbicu laris oculi
suspension, 204, 206, 207f
–– orbicularis-retain ing ligam ent
release and orbitom alar
suspension in , 203
–– an d orbit al h em orrh age, 206
–– pat ien t evaluat ion for,
197–199
–– pearls, 196
–– w ith pin ch skin excision , 199,
201, 201f
–– posit ive vector an atom y an d,
198
–– postoperat ive care, 201
–– an d prom in en t lateral fat
pad, 205
–– an d SOOF lift , 198, 199, 203,
207, 207f
–– surgical tech n iques for,
199–204
–– t ransconju nct ival approach,
197, 199
–– t ransconju nct ival fat excision
procedure, 199–201, 199f,
200f
–– t ranscu tan eous approach , 197,
199, 201, 202f
– upper
–– an d en doscopic foreh ead an d
brow lift , 336
–– skin -on ly, 304f
blepharoptosis, 162, 174, 174f
– cau ses of, 210
– correct ion , 153, 154
176f
– after double-eyelid surger y,
236–237, 237f
– evalu at ion , 175, 176f
– involut ion al
–– clin ical presen tat ion of, 175,
175f
–– an d deep superior sulcus,
175, 175f
– pat ien t evaluat ion , 211–214
– versu s ptosis, 174, 175f
– upper eyelid fu nct ion in, 153
blindn ess
– fat graft em bolizat ion an d, 320
– after ller inject ion , 10, 403
–– preven t ion of, 407–408, 408f
blood, as ller, propert ies of, 393t
bot ulinum toxin
– as adjun ct to en doscopic
foreh ead an d brow lift , 336
– aesth et ic facial use of, 377–391
–– inject ion levels, 379
–– landm arks for, 379
–– pat ien t evaluat ion for, 378
–– pearls, 377
– for brow lift ing an d shaping,
336, 381–382
– for bu nny lin es, 384, 384f
– for cobbleston e ch in , 385, 386f
– com m ercial form ulat ion s, 378
– com plicat ion s of, 389
– for crow ’s-feet , 380–381, 381f,
382f
– dilut ion of, 378–379
– dosage of, 378
– for forehead an d glabellar
rhyt idosis, 328
– for forehead h orizon t al lin es,
379, 379f, 380f
– for glabellar frow n lin es,
379–380, 380f
– for gum m y sm ile, 384, 384f
– for infraorbital eye open ing,
382–383, 383f
– for infraorbital w rin kles, 382,
382f
– int raderm al inject ion, 388–389,
389f
– for m arion et te lines, 385, 386f
– for m asseter m uscle
hypert rophy, 386–388, 387f,
388f
– for m outh corn er elevat ion ,
385, 386f
– for n asal t ip lift ing, 383, 383f
– for parot id glan d reduct ion,
388, 389f
– for perioral rhyt ids, 384–385,
385f
– for plat ysm al ban ds, 386, 386f
– for squ are jaw, 386–388, 387f,
388f
– storage of, 378–379
breast augm en tat ion , an d cost al
cart ilage h ar vest , 28–29, 29f
brow lift . See also en doscopic
foreh ead an d brow lift
– w ith augm en tat ion rh in oplast y,
15
– an d blepharoplast y, 176
– botulinum toxin for, 336, 381–382

– incision s for, 329, 330f
– indicat ion s for, 15
brow t ip aesthet ic line, 72–73, 73f
bruising
– facial fat graft ing an d, 319
– ller inject ion an d, 407
bun ny lin es, bot ulin um toxin for,
384, 384f
BVSRO. See bilateral vert ical
sagit t al ram us osteotom y
C of, 287, 288t, 289, 290f, 295,
calci cat ion, of alloplast ic
im plan ts, 22
calcium hydroxylapat ite, 394, 405
– propert ies of, 393t
cart ilage
– auricular, advan tages of, 24
– autologous, for nasal t ip
augm en tat ion , 13
– con ch al
–– in corrective rhinoplast y for
short contracted nose, 124f, 125
–– har vest of, 17, 109
– costal. See cost al cart ilage
– as dorsal im plan t , 114
– septal, har vest of, 18–19, 19f, 62
cart ilage grafts, 6
– in rhinoplast y, 8
caruncle. See lacrim al carun cle
Caucasians, as beau t y ideal,
historical perspect ive on , 5
Caucasoids, 3
ceph alom et r y
– eth n ic di erences and,
270–272, 272f, 290f
– for gen ioplast y, 287, 288t, 289,
290f, 295, 297f, 298
– param et ric values, disparit y
am ong Asians an d Caucasians,
270–272, 272f
– preoperat ive, in orth ogn athic
surger y, 282f–284f
– referen ce poin t s in , 270, 271f,
272f, 273t
ch arm ing roll, 378, 383
ch eek
– ller inject ion in, 397–399, 398f
– four crescen t aging lin es,
397–399, 398f
ch eekbones
– Asian , 6, 7f
– prom in en t (high ), 243, 244
ch em ical peeling, in facial
rejuvenat ion , 340
ch em osis, conjun ct ival, after
low er bleph aroplast y, 206
ch in
– aesth et ics of, 286
– alloplast ic im plan t for, 309
– asym m et r y, and low er facial
con touring, 257
– augm ent at ion , 40–43, 42f
–– in facial rejuvenat ion , 309
–– ller inject ion for, 400–401,
401f
– cobblestone, bot ulin um toxin
for, 385, 386f
– de n it ion of, 257
– drooping/distor t ion , after
gen ioplast y, 294
– ideal, ch aracterist ics of, 286
– on lay augm en tat ion, h istorical
perspect ive on , 287
– peau d’orange on , after
gen ioplast y, 294–295
– in plann ing for low er facial
contouring, 257
– posit ion , ceph alom et ric an alysis
297f
– psychosocial sign i can ce of, 286
– ptosis, after gen ioplast y, 294
– resect ion, in low er facial
con touring, 257
ch in im plan t , 9
cobbleston e ch in , bot ulinu m toxin
for, 385, 386f
cocain e abuse, and saddle n ose,
89–90
collagen , inject ion, depth of, 405
colum ella
– Asian , 26, 27f
– lengthen ing aps for, 9
– ret ract ion of, 100
– ret rusion of, 99
– sh or t , 9
– w ide base of, 99
colum ellar base, too-w ide,
correct ion of (n arrow ing of),
103, 104f
Com fort Pulse Tech n ology
(Th erm age), 344
com pu ted tom ography
– con e beam , 272
– preoperat ive
–– for gen ioplast y, 289
–– for m an dibular reduct ion , 256
–– for secon dar y rh inoplast y, 136
conjoin t fascia, 326, 327f, 331
conjoin t ten don , 331
conjunct ival ch em osis, after low er
blepharoplast y, 206
conjunct ival prolapse, after ptosis
correct ion , 221
conjunct ival tarsal Mü llerectom y,
211
conjunct ivo-Mü llerectom y. See
Mü ller m u scle conjun ct iva
resect ion (MMCR)
con t act len s–in du ced ptosis,
214, 214f
con t ract ion , nasal, postoperat ive,
24, 25f
corneal protect ion m ech an ism ,
preoperat ive evaluat ion , 177
corneal ulcer, 177
correct ive rh in oplast y, 72–86
– approach for, select ion of, 75
– bleeding/hem atom a after, 81
– case st udies, 81–83, 82f–85f
– closure, 80
– com plicat ion s of, 81
– dorsal irregularit y/deviat ion
after, 81
– dressing, 80
– edem a after
–– late (persisten t), 81
–– m anagem en t of, 81
– en don asal approach for, 75
– extern al approach for, 75
– key tech n ical poin ts in , 80–81
– n asal sept al st raighten ing in,
77–78, 78f
– osteotom y in , 76–77
– pat ien t select ion , 74–75
– pearls, 72
– postoperat ive m an agem en t, 80
– preoperat ive pat ien t in ter view
for, 74
– for saddle n ose, 87–98
–– pearls, 87
– sept al exten sion graft in , 79–80,
80f
– for sh ort con t racted nose,
122–134, 141–142, 142f
–– case st udies, 131–133,
132f–133f
–– closure, 129
–– com plicat ion s of, 130–131
–– com posite graft for, 124f, 125,
129, 130f
–– dorsal augm en tat ion in , 129,
129f
–– elongat ion of fram ew ork in ,
127, 128f
–– graft car ving for, 126, 126f,
127f
–– graft m aterial h ar vest ing for,
125–126, 125f
–– key tech n ical point s in , 130
–– m ovabilit y of costal cart ilage
graft after, 130–131
–– n asal obst ru ct ion after, 131
–– pat ien t evaluat ion , 122–123,
123f
–– pearls, 122
–– pneum oth orax du e to, 130
–– skin dam age in, 130
–– skin un derm in ing, 127
–– st rategies for, 123–125, 124f
–– techn iques for, 123–129
–– t ip graft s in , 127–128, 128f
–– t ip problem s after, 131
–– t ip reposit ion ing in , 127–128,
128f
–– w arping of costal cart ilage
graft after, 130, 131f
– spreader graft in , 78–79, 79f
– surgical plann ing, 74
– tech n iques for, 75–80
corrugator supercilii m uscle,
326–327
costal cart ilage
– advant ages of, 27–28
– age and, 28
– car ving
–– for augm ent at ion rh in oplast y,
31, 43, 44f
–– for dorsal on lay graft , 126,
126f, 127f
–– for at st raigh t piece, 126, 127f
– disadvan tages of, 13
– graft splint ing techn ique, 31, 32f
Index 417
– h ar vest of, 125–126, 125f
–– an atom ical con siderat ion s in ,
29, 29f
–– in cision for, 28–29, 29f
–– an d pn eum oth orax, 130
–– an d scar, 28, 29f, 31
–– tech niqu e for, 28–31, 30f, 40,
41f, 43, 44f
– for n asal dorsal augm en tat ion ,
8, 26–46, 30f, 41f, 43, 44f
–– pearls, 26
– n asal dorsal onlay graft
–– m ovabilit y of, 130–131
–– w arping of, 130, 131f
– for n asal t ip graft ing, 26–46,
30f, 41f
–– pearls, 26
– problem s w ith , 13
coun seling, preoperat ive, for
rh in oplast y, 27–28
CPT. See Com fort Pulse
Tech n ology
Crohn’s disease, an d saddle
n ose, 89
crow ’s-feet
– bot ulin um toxin for, 380–381,
381f, 382f
– preoperat ive evaluat ion , 177
cu cum ber face, 246
D
deep tem poralis fascia, 325, 325f,
326f
den t al m odel, 272
depigm en tat ion , after laser facial
h air rem oval, 370
derm al hydrat ion , u sing
hyaluron ic acid, 402
derm atoch alasis, 174, 174f, 210,
328
– versu s blep h aroptosis, 175,
176f
– brow ptosis w ith , 176
– evaluat ion , 175
digital im aging
– m orphing w ith , 27
– in rh inoplast y plan n ing, 27, 40,
40f, 43, 43f
diplopia, after low er
blepharoplast y, 206
dist ract ion test (for w ard t ract ion
test), for eyelid laxit y,
198–199
dorsal nasal arter y, ller inject ion
in , prevent ion of, 403,
408–409, 409f
double eyelid, 151–152, 152f, 162,
163, 174
– form at ion
–– extern al-in cision techn ique,
153
–– n on in cision sut ure ligat ion
for, 153
– h eigh t for, 165, 166f
– open ing ph ase, 153f
– rest ing ph ase, 153f
– too-high , after aging-related
(upper) bleph aroplast y, 181
418 Index
double-eyelid surger y, 162
– asym m et r y after, 233
– bleph aroptosis after, 236–237,
237f
– com plicat ion s of, 158–160, 170,
225–239
–– case st udies, 238, 238f
–– key tech nical poin ts for, 237
–– pat ient evaluat ion , 225
–– pearls, 225
–– surgical tech n iques for,
226–237
– deep fold after, 228
– ect ropion after, 228, 230f
– an d epicanth oplast y, 185–186,
186f
– an d exoph th alm os, 154
– incision al, 162–172
–– an esth esia for, 166
–– asym m et r y after, 170
–– case st udies, 170–171, 171f
–– closu re, 169, 169f
–– com plicat ions of, 170
–– for correct ion of h igh crease to
low crease, 171, 171f
–– for correct ion of sh ort in side
crease to out side crease, 170,
171f
–– crease design , 165–166, 166f
–– crease disappearance after,
170
–– disadvan tages of, 163
–– xat ion sut ure of eyelid crease
in , 168, 168f
–– in dicat ion s for, 163, 163f
–– key tech nical poin ts in , 169
–– an d levator advan cem en t ,
169, 169f
–– m ult iple folds caused by, 166,
167, 168f
–– orbicularis m uscle rem oval in ,
166–167, 167f
–– orbit al fat rem oval in, 167,
167f
–– pat ient evaluat ion for,
163–164
–– pearls, 162
–– postoperat ive care, 170
–– ROOF rem oval in , 167, 167f
–– skin bulging after, 168, 169f
–– skin excision in , 165, 166–167,
166f, 167f
–– skin in cision in , 166, 167f
–– skin su t ure in, 169, 169f
–– tech n iques for, 165–169
– inclusion cyst after, 226, 227f
– m ult iple folds caused by, 166,
167, 168f, 233–236, 234f, 235
– n onin cision al sut u re tech n iques
–– case st udies, 161, 161f
–– com plicat ions of, 158–160
–– an d irregular fold, 159
–– key tech nical poin ts in , 158
–– an d knot exposu re, 160
–– an d lid m argin tension
eversion, 160, 160f
–– n eedle ch oice, 156
–– pearls, 151
–– procedu res for, 156–157,
156f–158f
–– an d relapse, 158–159
–– an d scar, 159, 160f
–– an d st itch abscess, 160
–– an d st rangulat ion , 160
–– sut u re m aterial, 155–156
– part ial in cision al tech nique, 163
– pat ien t evaluat ion for, 154
– pret arsal fullness after,
232–233, 233f
– ptosis after, 238, 238f
– an d pu y eyelid, 154
– rem oval of surgically created
eyelid fold after, 237
– revision case, 154–155
– scar after, 226, 226f, 227f
– shallow fold after, 227–228, 228f
– sim ple sut ure tech n ique, 163
– su nken eyelid after, 236, 236f
– t ran sconjunct ival Mü ller
t ucking in, 158, 159f, 161, 161f
– t riple fold caused by, 166, 167,
168f, 232, 233–236, 234f, 235f,
238, 238f
– an d w eak levator fun ct ion, 154
double jaw surger y, 274t, 279
dr y eye syn drom e, 177, 181, 214
E in , 337
East Asian s, 3
– facial aesth et ic procedures used
in, 3, 4f
– ph en ot ypic feat ures of, 6
ecchym osis, after en doscopic
forehead an d brow lift , 337
ect ropion , 8, 198
– after dou ble-eyelid surger y,
228, 230f
– after low er bleph aroplast y,
205, 205f
– after ptosis correct ion , 221
eczem a, lateral can th al, 174
edem a
– after en doscopic foreh ead an d
brow lift , 337
– facial fat graft ing an d, 319
– after ller inject ion , 403, 412
EFBL. See en doscopic foreh ead
an d brow lift
E-lin e. See esth et ic lin e (E-lin e)
en doscopic foreh ead and brow
lift , 324–338
– advant ages an d disadvan tages
of, 324, 330
– alopecia caused by, 337
– an atom ical con siderat ion s in,
324–326, 325f–327f, 331–332,
332f
– an esthesia for, 330
– an d bot ulin um toxin , 336
– closure, 336
– com bin ed approach , sequen ce
of, 336
– com plicat ion s of, 337
– dissect ion , 331
– dressing, 336
– ecchym osis after, 337
– edem a after, 337
– exam in at ion for, 328–329
– xat ion m eth od, 332–336
–– w ith cort ical bone t un nels,
334, 335f
–– w ith En dot in e Forehead
device, 334–336, 336f
–– w ith brin glue, 333
–– w ith m onocort ical screw s,
333–334, 334f
– forehead an d brow xat ion in ,
332–333
– gran ulom a form at ion after, 337
– h airlin e elevat ion after, 337
– h em atom a caused by, 337
– h istorical perspect ive on , 324
– h istor y-taking for, 328–329
– an d im plan t problem s, 337
– incision s for, 330–331, 331f
– indicat ion s for, 328
– an d infect ion, 337
– inst rum en t s for, 330, 330f
– an d int racran ial inju r y, 337
– key tech n ical poin t s in , 336–337
– n er ve injur y in, 337
– n o xat ion in , 333
– an d open tech n iques,
com parison of, 324, 329
– over- and un der-correct ion
– pat ien t evaluat ion for, 328–330
– pearls, 324
– plan e of dissect ion for, 325,
325f, 326f, 331
– postoperat ive care, 336
– preparat ion for, 330
– relaps after, 337
– release of m uscular an d
ligam en tous at tach m en t in,
331–332, 332f
– serom a after, 337
– sut u re ext rusion after, 337
– techn iques for, 330–336
– tem poral xat ion in, 332, 333f
– an d w oun d problem s, 337
En dot ine Foreh ead device,
334–336, 336f
en t ropion , 162
– correct ion of, 168
– after ptosis correct ion , 221
epican th al fold(s), 164–165,
173, 184
– recon st ruct ion , 194, 194f
– thirds of, 185
– t ypes of, 184–185, 185f
– un der-corrected, 188–189
epican th oplast y, 184–189
– an atom ical considerat ion s in , 6
– com plicat ion s of, 187–189
– an d dog-ear, 185–186
– double-fold operat ion an d,
185–186, 186f, 187f
– Fuen te’s t ran sposit ion ap for,
187, 188f
– Jordan’s deep t issue approach
m ethod, 188f
– Mat sun aga’s m odi ed M-plast y
m ethod, 188f
– m edial, 8, 165
– m odi cat ion an d re nem ent for
Asian s, 8
– m odi ed Uch ida m ethod, 187,
188f
– palpebral m argin in cision
m eth od, 8
– Park’s Z-plast y m eth od, 187,
188f
– pat ien t evaluat ion for, 185
– pearls, 184
– reconst ruct ive, 189, 189f, 190f
–– back-cut design in, 189, 189f
–– rotat ion ap in , 189, 190f
–– V-Y advancem en t ap for, 189,
189f, 190f
– reverse Fuente’s design , 186f,
187
– Roveda m ethod, 186
– scar after, 187–189
– sim ple skin excision m ethod, 186
– skin excision in, 185
– skin redraping m ethod, 187, 188f
– surgical techn iques for,
186–187
– V-Y advan cem en t m ethods,
186–187, 187f
– W-plast y m eth od, 186
– Wu’s square- ap m eth od, 188f
– Yoon’s on e-arm ed ju m ping m an
m eth od, 188f
– Z-plast y ap m ethod, 186–187,
188f
epicanth us inversus, 184, 185f
– iat rogen ic, 187–189
– preven t ion of, 189, 189f, 190f
epicanth us palpebralis, 184, 185f
epicanth us supraciliaris, 184,
185f
epicanth us tarsalis, 184, 185, 185f
E-plan e. See esth et ic plan e
(E-plane)
ePTFE. See Gore-Tex
er yth m a
– after ller inject ion, 407
– after laser facial h air rem oval,
370
esthet ic line (E-line), 272, 272f,
288, 289f
esthet ic plane (E-plane), 392
exoph th alm os, dou ble-eyelid
surger y and, 154
expan ded
polytet ra uoroethylen e. See
Gore-Tex
exposure kerat it is, 177, 181
external n asal valve
– collapse, 100–101
– sten osis, after alar base surger y,
100
eyebrow (s). See also brow lift;
en doscopic foreh ead an d brow
lift; ptosis
– aesth et ics of, 327, 327f
– age-related ch anges in , 174,
175–176, 327
– asym m et r y of, 328
– depressor m uscles, 326, 332

– elevat ion, in com pen sat ion for
bleph aroptosis, 174, 174f, 175,
175f, 210, 211, 212f, 221, 222f
– elevator m uscles, 326
– h air t ran splant for, 305, 305f
– ideal posit ion of, 327, 327f
– posit ion of, evaluat ion ,
175–176, 329
– rejuvenat ion of, 307–308, 307f,
308f
– sh ape, evaluat ion , 329
– sh aping, bot ulin um toxin for,
336, 381–382
– sym m et r y, evaluat ion , 329
– t at tooing, 328
– volum izat ion of, 308, 308f
eyelash (es)
– direct ion of, 215, 215f
– upp er, dow nw ard angulat ion ,
164
eyelash ptosis, 162, 215, 215f
– correct ion of, 168, 218–219
– evaluat ion of, 164
eyelid(s). See also lid lag; lid
m argin
– age-related ch anges in , 174, 328
–– m an agem ent of, 307–309, 307f
– Asian
–– an atom y of, 6, 162–163, 163f,
211
–– characterist ics of, 173, 196
– asym m et r y
–– after dou ble-eyelid surger y,
233
–– preoperat ive, 233
– Caucasian , an atom y of, 163f
– East Asian , an atom y of,
162–163, 163f
– low er
–– age-related changes in,
196–197, 197f
–– Asian, characterist ics of, 196
–– asym m et r y, after low er
bleph aroplast y, 205
–– fat graft ing for, 322, 322f
–– u id accu m u lat ion in , 198
–– horizon tal laxit y correct ion
procedures for, 204
–– laxit y, 198–199
–– loss of skin elast icit y, 198
–– ret ract ion, after low er
bleph aroplast y, 205
– ptosis, 328
–– evaluat ion , 329
– redu ndan t skin of, evaluat ion ,
329
– rejuvenat ion of, 307–308, 307f,
308f
– skin of, 164
– sun ken, 236, 236f
– upp er. See also double eyelid;
single eyelid
–– an atom y of, 152–153, 153f, 162
–– anterior lam ella, 152–153
–– eth n ic variat ions, 152
–– fat pockets in, 177
–– low er-posit ioned t ran sverse
ligam en t in , 167, 168f
–– m iddle lam ella, 152
–– opening process of, 152–153,
153f
–– orbital fat of, 164
–– posterior lam ella, 152–153
–– pu y, 177
dou ble-eyelid surger y an d, 154
–– ret ractors, 210
–– st ruct ure-fun ct ion
relat ion ships, 151
– w rin kles
–– correct ion , 177
–– preoperat ive evaluat ion , 177
eyelid crease. See also eyelid
fold(s)
– aging an d, 307–308, 307f, 308f
– deep, after double-eyelid
surger y, 228
– design
–– in aging-related (upper)
bleph aroplast y, 178
–– in double-eyelid surger y,
165–166, 166f
– duplicated, 177
– evaluat ion , 177
– xat ion sut ure of, in double-
eyelid surger y, 168, 168f
– form at ion , in aging-related
(u pper) blepharoplast y, 179,
180f, 182, 182f, 183, 183f
– heigh t , 165, 166f, 177, 213
–– ideal, 163
–– preoperat ive sim ulat ion , 163
– high
–– correct ion of, 229–232,
231f–233f
–– after double-eyelid surger y,
170, 229–232, 230f
– in side, 164, 164f
– low , after dou ble-eyelid
su rger y, 170, 228–229, 228f,
229f
– nasally t apered, 164
– outside, 164, 164f
–– fan -parallel t ype, 164
–– fan t ype, 164, 164f
–– h igh er, 164, 165f
–– parallel t ype, 164, 164f
– parallel, 164
– part ially high , after double-
eyelid surger y, 232
– postoperat ive disappearan ce,
after double-eyelid surger y,
170, 226–227
– sem ilun ar, 164
– sh allow, after double-eyelid
surger y, 227–228, 228f
– sh ape of, 164
– su rgically created, 308
–– age-related ch anges an d, 177
–– aging an d, 309
– too-h igh, after aging-related
(upper) blepharoplast y, 181
– w ebbing of, 165, 165f
eyelid fold(s). See also eyelid
crease
– deep, after double-eyelid
surger y, 228, 238, 238f
– in /out (n eut ral), 154, 155f, 156
– in side, 154, 155f, 156
– irregular, n onin cision al dou ble-
eyelid surger y an d, 159
– m ult iple, caused by double-
eyelid surger y, 166, 167, 168f,
233–236, 234f, 235
– out side, 154, 155f, 156
– sh allow, after double-eyelid
surger y, 227–228, 228f
– surgically created, rem oval
of, 237
– t riple
–– after double-eyelid su rger y,
166, 167, 168f, 232, 233–236,
234f, 235f, 238, 238f
–– p r im ar y, cor re ct ion , 236,
236f
eye surger y, aesth et ic. See also
bleph aroplast y
– an atom ical con siderat ion s in , 6
F – Asian , an atom y of, 6
face(s)
– Asian , 243, 244f
–– aesth et ic ideals an d, 378,
392–393
–– aging, m an agem en t of,
303–310, 311
–– anatom ical con siderat ions, 6,
7f, 8f, 378
–– ch aracterist ics of, 272, 272f
– brachyceph alic, 243, 244f, 254
– Caucasian, 243, 244f
– cult ural beliefs about , 5
– dolich oceph alic, 243, 244f
– fem ale, at t ract ive com posites,
3, 4f
– at , adding dim en sion to, 255,
255f, 311
– fron tal plane, ver t ical division s
( fth s), 270, 271f, 324
– fron tal view, aesthet ic divisions
in , 270, 271f
– ideally sh aped, creat ion of, 255,
255f, 256f
– low er
–– aging of, 309
–– rejuven at ion of, 309
–– sh ape, classi cat ion of, 256,
256f
–– w idth
classi cat ion of, 256, 256f
narrow ing, 255
– m esocephalic, 254
– sh ape
–– cult ural factors a ect ing, 257
–– eth nicit y an d, 257
–– an d fat graft ing, 311
– th irds of (rule of th irds), 270,
271f, 288, 289f, 324
– volum e loss in , 304–305, 304f,
311
– volum e restorat ion in , 304–305,
304f, 311–312
facelift , 309
– h igh -frequen cy focused
ult rasoun d in , 10
Index 419
– laser in , 10
facial an alysis, 14, 14f, 74, 75f,
244–246, 255–256, 270
– for en doscopic forehead an d
brow lift , 329
– for fat graft ing, 311–312
– for gen ioplast y, 288–290
facial arter y, an atom y of, 407,
407f
facial asym m et r y
– causes of, 73
– an d fat graft ing, 311–312
– after ller inject ion , 412
– after genioplast y, 294
– an d low er facial con touring,
257
– preoperat ive, 14, 73
– t ransverse correct ion
genioplast y for, 290, 291f
facial bones
– age-related ch anges in , 174,
178
facial bone surger y. See
also m an dible; m axilla;
orth ognath ic surger y
– com plicat ions of, 280–281
facial con touring
– llers for, 392–404
–– pearls, 392
– surger y for, 243. See also
m an dible, reduct ion
(con touring)
–– plann ing for, 256–257, 256f
facial con tour lin e(s)
– an terior, 244f
– posterior, 244f
facial h air
– in m en, 364–365
– in w om en, 364–365
facial h arm ony, evaluat ion , 246,
246f
facial m idlin e, 72–73, 73f
facial n er ve
– fron tal bran ch of, 325, 325f,
326, 331
–– inju r y in en doscopic foreh ead
and brow lift , 337
– palsy, an d un ilateral ptosis, 174,
175f, 176
– zygom at ic bran ch , 326
facial rejuvenat ion , 9. See also
endoscopic foreh ead an d
brow lift
– hyaluron ic acid for, 393
– ligh t devices for, 340–344
– n on surgical, 10
– u sing en ergy devices,
339–348
–– devices com m on ly used in ,
340
–– pearls, 339
– volum e restorat ion in , 304–305,
304f
facial sw elling, after hair
t ran splant at ion , 359
facial sym m et r y, an alysis of, 270
Fasan ella-Ser vat procedure, 211
420 Index
fat graft ing, 9
– facial, 304–305, 304f, 311–323
–– an d abscess form at ion , 320,
320f
–– an d acn eiform eru pt ion , 320
–– addit ion al procedures, 318
–– an esth esia for, 312, 313
–– areas, 313–317, 313f,
314t–315t
–– asym m et r y after, 319
–– baton grip tech nique, 317,
318f
–– bruising after, 319
–– can nulas for, 312, 312f
–– case st udies, 321–322, 321f,
322f
–– com plicat ions of, 319–321
–– direct ion of inject ion , 314,
316f
–– donor-site com plicat ions, 321
–– edem a after, 319
–– en t r y sites for, 314, 316f
–– fat preparat ion for, 312–313,
313f
–– fat resorpt ion in , 319
–– in foreh ead region , 315–317,
317f, 317t, 322, 322f
–– graft gravitat ional descen t
in , 319
–– graft h ar vest for, 312–313
–– graft m igrat ion in , 319
–– h em atom a caused by, 319
–– h istor y-t aking for, 312
–– hyperpigm en tat ion after, 319
–– hypo- an d hyper-correct ion
in , 319
–– an d in am m at ion , 320
–– inject ion tech n iques, 313–317
–– in st rum en ts for, 312, 312f
–– irregularit y after, 319
–– key tech nical poin ts in ,
318–319
–– in low er face, 313–315, 313f,
314t
–– for low er lid rejuvenat ion ,
322, 322f
–– lum p/bum p cau sed by, 319
–– in m idface, 313–315, 313f,
314t
–– pat ien t evaluat ion for,
311–312
–– pearls, 311
–– placem en t , 313–317,
314t–315t
–– postoperat ive care, 318
–– preparation for, 312
–– scar after, 319–320
–– sequen t ial autologous fat
inject ion (SAFI) techn ique for,
313, 313f, 314t–315t, 316f,
317t
–– sequen t ial depth of inject ion ,
314, 316f
–– sequen t ial inject ion in
abut t ing areas, 314–315, 316f
–– an d skin n ecrosis, 320, 320f
–– tech n iques for, 312–318
–– in tem poral region , 313–315,
313f, 314t
–– vascu lar em bolizat ion of fat
after, 320–321, 320f
–– volum e used, 313–317,
314t–315t
–– w h ole face, 321, 321f
– for su nken eyelid, 236, 236f
– in upper-eyelid/brow com plex,
308, 308f
ller inject ion , 10
– aesthet ic uses of, 392
– bruising after, 407
– bum ps caused by, 413
– in ch in , 400–401, 401f
– com plicat ion s of, 10
–– delayed onset , 412–413
–– early on set , 407–411
–– pat ien t evaluat ion , 406
– danger zon es, 407
– depth of, 405
– edem a after, 412
– er ythm a after, 407
– facial con tou ring using,
392–404
–– an esth esia for, 394
–– can n ulas for, 407, 407f
–– in ch eek, 397–399, 398f
–– com plicat ion s of, 403–404,
403f, 405–414
–– in foreh ead, 396, 397f
–– key techn ical point s in ,
402–403
–– m aterials for, 393–394, 393t
–– n eedles for, 394, 394f, 407,
407f
–– pat ien t assessm ent for, 393
–– pat ien t con su ltat ion for, 393
–– pearls, 392
–– Reteen age m eth od, 397–399,
398f
–– techn iques for, 394–402
–– in tem ple, 396–397, 397f
– in facial volu m e restorat ion ,
304–305, 393t, 405
– fan n ing tech n ique, 395, 396f,
406
– ller m igrat ion after, 413
– llers for, 10, 393t
– for foreh ead and glabellar
rhyt idosis, 328
– gran ulom a after, 413
– high -risk areas, 405–406
– hypersen sit ivit y react ion to,
407
– in fect ion after, 413
– in am m at ion after, 412
– in t ra-arterial, 403, 409, 410f
–– m anagem en t of, 409
–– prevent ion of, 407–408, 408f
– for jaw line resh aping, 401, 402f
– for jow l con touring, 401, 402f
– linear threading (t un n eling)
techn ique, 395, 395f, 406
– in lips, 400
– for low er face contouring,
400–401, 401f, 402f
– lum piness after, 412, 413
– for m arion et te lin es, 401–402
– for nasal augm ent at ion , 395,
395f, 399–400, 399f
– in nasolabial folds, 400, 400f
– pain after, 407
– self-pistol tech niqu e, 395
– serial pun ct ure (“kisses”)
tech niqu e, 395, 395f, 406
– skin n ecrosis after, 403, 403f,
406, 406f, 409, 410f, 411, 412f
– skin th ickn ess an d, 405
– for sun ken eyelid, 236, 236f
– super cial, ller visibilit y after,
412, 413f
– in tear t rough, 399
– for tear t rough depression, 197
– techn iques for, 395
– in upper-eyelid/brow com plex,
308, 308f
– ven ous congest ion cau sed by,
411, 412f
nasteride, 351
follicular un it ext ract ion , for h air
restorat ion , 306, 354–355,
355f
follicular un it t ransplan t , for h air
restorat ion , 306, 350, 354, 355
folliculit is
– facial, im provem en t , laser h air
rem oval and, 369, 369f
– in hair t ran splan tat ion , 355,
356f, 359–360
– after laser facial h air rem oval,
370
foreh ead. See also en doscopic
foreh ead an d brow lift
– age-related ch anges in , 327
– an atom y of, 324–326,
325f–327f, 331–332, 332f
– augm en tat ion, 15
– ller inject ion in , 396, 397f
– h air rem oval from , 9, 365, 369,
369f, 371–372, 371f, 372f
– h eigh t , evaluat ion, 329
– h orizon t al lin es in , bot ulin um
toxin for, 379, 379f, 380f
– layers of, 325, 396, 396f
– preoperat ive exam in at ion of,
14–15, 14f
– resh aping, by h air reduct ion ,
9, 365, 369, 369f, 371–372,
371f, 372f
– rhyt idosis, 328
–– evaluat ion, 329
– sh ape, evalu at ion , 329
– size, cu lt u ral beliefs about , 365
– w iden ing, laser hair rem oval
for, 365, 369, 369f, 371–372,
371f, 372f
four crescent aging lines,
397–399, 398f
Fox’s m eth od, for aesthet ic lateral
can th oplast y, 191, 191f
Frankfort h orizon tal line,
288–289, 289f
fron t alis m uscle, 210, 326
– in t raderm al bot ulin um toxin
inject ion and, 388–389, 389f
– overact ivit y of, 328
–– un ilateral, 328
– ptosis surger y an d, 210, 211,
215, 219–220, 220f
– sling, 211, 215, 219–220, 220f
FUE. See follicular un it ext ract ion
FUT. See follicular unit t ran splant
G
galeal fat pad, 332, 332f
gen ioplast y, 274, 274t, 282–283,
282f–284f, 286–300
– advan cem en t sliding via
int raoral approach , historical
perspect ive on , 287, 287f
– anesthesia for, 290
– anterior sliding advan cem en t ,
h istorical perspect ive on ,
287, 287f
– asym m et r y after, 294
– bleeding and, 293
– and bony m alun ion /n onu nion,
293
– bony m arking for, 290, 291f
– case st udies, 295, 296f–297f,
298, 299f
– cephalom et r y for, 287, 288t,
289, 290f, 295, 297f, 298
– chin ptosis after, 294
– closure, 292
– com plicat ion s of, 293–295
–– allograft-related, 294–295,
295f
– dressing for, 292
– xat ion in, 292, 292f
– historical perspect ive on, 287,
287f
– histor y-taking for, 287
– in cision for, 290, 291f
– in dicat ion s for, 286
– in fect ion after, 293
– in t raoral approach for, 290, 291f
– key tech n ical poin t s in , 293
– labial m ucosal in cision for,
290, 291f
– lip drooping after, 294
– m an dibular bony irregu larit y
after, 294, 294f
– m arginal gingival in cision for,
290, 291f
– m en t al n er ve injur y in , 293
– narrow ing, 255, 255f, 256f
–– com bin ed w ith m an dible
reduct ion (con touring), 260,
260f
– pain after, 293
– pat ien t evaluat ion for, 287–288
– pearls, 286
– preoperat ive assessm en t for,
288–290
– sagit tal augm en tat ion (an terior
advan cem ent) tech nique,
290, 291f
– sagit tal reduct ion (posterior
reduction) technique, 290, 291f
– skin dim pling after, 294
– tech n iques for, 290–292, 291f
– t ran sverse correct ion tech n ique,
290, 291f
– ult rason ic bone cu t ter for, 292,
292f, 293
– vert ical augm en tat ion
techn ique, 290, 291f

– vert ical reduct ion tech n ique,
290, 291f
glabella
– an atom y of, 324–326,
325f–327f, 331–332, 332f
– augm en tat ion , 39
– preoperat ive evaluat ion , 15
glabellar frow n lin es, bot ulin um
toxin for, 379–380, 380f, 381f
glabellar rhyt idosis, 328
– evaluat ion , 329
glycopyrrolate, 16
gon ial angle, ideal, 256
Gore-Tex, 13, 113
– advant ages of, 14
– chin im plan t , com plicat ion s of,
294, 295f
– disadvan tages of, 14
– dorsal n asal graft , 43, 43f
– preform ed n asal dorsal im plan t ,
114, 114f, 115f
– rem oval rate for, 135
– in rh in oplast y, 8, 135
–– com plicat ion s of, 135
– sh eet , n asal dorsal im plant , 116
gran ulom a
– after en doscopic foreh ead an d
brow lift , 337
– after ller inject ion , 413
gran ulom atous disease(s), an d
saddle n ose, 89
gum m y sm ile, bot ulin um toxin
for, 384, 384f
H – n um bn ess after, 358–359
h air, Asian , 6, 9, 350
h air densit y, in Asian s, 350
h airline
– Asian , 349–350, 350f
– correct ion , laser h air rem oval
for, 365
– design
– – in h a ir t ra n sp la n t at ion ,
3 5 2 – 3 5 3 , 3 5 3 f, 3 6 0 – 3 6 1 ,
361f
–– laser h air rem oval an d, 369,
369f
– elevat ion , after en doscopic
foreh ead an d brow lift , 337
– evaluat ion of, 329
– unn at ural, after hair
t ran splant at ion, 359
h air loss, 305–307, 305f, 306f. See
also alopecia
– m ale pat tern , 349
– preven t ion , m edicat ion s for,
351
– tem porar y, after h air
t ran splant at ion, 359
h air rem oval/reduct ion, 9
– facial, using laser, 364–374. See
also laser h air rem oval
h air restorat ion , 9, 305–307,
305f, 306f. See also hair
t ran splant at ion
– follicu lar un it ext ract ion for,
306, 354–355, 355f
– follicu lar un it t ransplan t for,
306, 354, 355
h air t ran splan t at ion , 349–363. See
also h air restorat ion
– an d arterioven ous st ula, 360
– in Asian s, 349
– case st udies, 360–361, 361f
– com plicat ion s of, 358–360
– and deh iscen ce, 358
– den sit y gradien t an d layering
e ect in , 357, 357f, 358
– depth -con t rolled tech n ique for,
355–356, 356f, 358
– don or h ar vest ing for, 353–355.
See also follicular un it
ext ract ion
–– st rip su rger y m eth od,
353–354, 354f
– facial sw elling after, 359
– folliculit is w ith , 355, 356f,
359–360
– graft dissect ion , 355–356, 355f,
356f
– graft preser vat ion, 356
– gray hair follicles an d, 355,
355f, 358
– h airline design in, 352–353,
353f
– and h iccups, 360
– hyperesthesia after, 359
– hypoesth esia after, 358–359
– im planters for, 356, 356f
– key tech n ical point s in , 358
– and loss of t ransplan t , 360
– and n ecrosis, 358
– n eu ralgia after, 359
– opt im al densit y for, 358
– pain after, 358
– pat ien t evaluat ion for, 351–352
– pearls, 349
– pit t ing after, 360
– poor graft su r vival after, 360
– postoperat ive care, 358
– preparat ion for, on day of
surger y, 352
– recipien t site, 356–358, 357f
– scalp prurit us after, 359
– and scars, 351, 352, 358, 359
– and syn cope, 360
– tech n iques for, 352–358
– tem porar y hair loss after, 359
– un n at ural h airlin e due to, 359
– and W-plast y for scar revision,
358, 359, 359f
Han Ryu , 5
h em atom a
– after en doscopic forehead an d
brow lift , 337
– facial fat graft ing an d, 319
– after ller inject ion , 403
– w ith m an dible reduct ion
(contouring), 261
– preseptal, low er bleph aroplast y
an d, 206
– ret robulbar, low er
blepharoplast y an d, 206
h em orrhage. See also orbit al
h em orrhage
– gen ioplast y an d, 293
– in Le Fort I osteotom y, 280
– w ith m an dible reduct ion
(con touring), 261
– in m andibular sagit t al split
ram us osteotom y, 280
Hering’s law, 214–215
h iccu ps, h air t ran splan t at ion
and, 360
HIFU. See ult rasoun d, h igh -
in tensit y focused
high-frequency focused ultrasound
(HIFU), in face lift, 10
h igh sagit t al supraforam in al
osteotom y, m an dibu lar, 274,
276, 276f, 281
Hinderer an alysis, of m axim al
m alar project ion , 245, 245f
horizontal line, in lower eyelid, 198
HSSO. See h igh sagit t al
supraforam in al osteotom y
h um pectom y. See n asal h um p
surger y
h um p n ose(s). See also nasal
h um p
– Asian , 60–71
–– ch aracterist ics of, 60–61,
87, 88f
– p reoperat ive exam inat ion of,
60–61
hyaluron ic acid, 10, 393–394, 405
– biph asic, 393–394
– d erm al hydrat ion using, 402
– em bolizat ion , treat m en t of,
409–410, 411f
– for facial rejuven at ion, 393
– m on ophasic, 394
– p ropert ies of, 393t
hyaluron idase, t reat m en t of ller
em bolizat ion, 409–410, 411f
hyperbaric oxygen t reat m en t , for
ller em bolizat ion, 410f, 411
hyperesth esia, after h air
t ran splant at ion , 359
hyperpigm en t at ion
– facial, reduct ion , laser hair
rem oval an d, 368, 368f
– facial fat graft ing and, 319
– after laser facial hair rem oval,
370
– p ost-in am m ator y, 100, 196
hypoch lorous acid, 16–17
hypoesthesia, after hair
t ran splant at ion , 358–359
I 359
in clusion cyst , after eyelid
surger y, 226, 227f
in fect ion
– alloplast ic im plant s and, 23, 24,
25f, 141
– augm en tat ion rhin oplast y
and, 13
– en doscopic forehead an d brow
lift an d, 337
– ller inject ion an d, 413
– gen ioplast y an d, 293
– m an dible reduct ion
(con touring) an d, 261
– n asal alloplast ic im plan ts an d,
141
Index 421
– orth ogn ath ic surger y and, 280
– rh inoplast y an d, 143
– an d saddle n ose, 89
– septoplast y and, 143
– septorh inoplast y an d, 141, 143
in ferior alveolar ner ve inju r y,
in m an dible redu ct ion
(con touring), 261
in am m at ion
– facial fat graft ing and, 320
– ller inject ion an d, 412
– w ith m an dible reduct ion
(con touring), 261
– w ith n asal alloplast ic im plan ts,
140
infraorbital eye opening, botulinum
toxin for, 382–383, 383f
in fraorbital n er ve, injur y
– in orth ognath ic surger y, 281
– in zygom a reduct ion , 249
in fraorbital w rinkles, bot ulin um
toxin for, 382, 382f
in tense pulsed ligh t
– in facial rejuvenat ion , 340,
341–342, 341f, 342f
–– com plicat ion s of, 342, 342f
– for n on ablat ive rejuven at ion ,
339–340
in tercanth al dist ance, 185f
in terepican th al dist an ce, 184,
185, 185f, 189
in tern al n asal valve
– an atom y of, 87
– collapse of, 87–88
in terpalpebral ssure, 212, 213f
in t racran ial injur y, in endoscopic
foreh ead and brow lift , 337
intraoral vertical ram us osteotom y,
m andibular, 276, 277f
IPL. See inten se pulsed light
IVRO. See in t raoral vert ical ram us
osteotom y
J
jaw line, resh aping, ller inject ion
for, 401, 402f
jow l con touring, ller inject ion
for, 401, 402f
Juvederm . See hyaluronic acid
K
keloids, 9, 100
– h air t ran splant at ion an d, 351,
keratitis, after ptosis correction, 221
Korea, plast ic surger y in, 5
L
lacrim al carun cle
– bilateral size discrepan cy, 185
– exposu re
–– epican thal fold an d, 184, 185
–– excessive, 189
– h ook-sh aped, 184, 185f
– rou nd, 184, 185f
– sh ape of, 184, 185f
– t riangular, 184, 185f
– visible size of, after
epican thoplast y, 184
422 Index
lacrim al glan d
– injur y, in bleph aroplast y, 181
– posit ion , preoperat ive
evaluat ion, 177
lagoph th alm os
– w ith congen it al ptosis, 214
– evalu at ion , 177, 329
– iat rogenic postoperat ive, 176,
181
– after ptosis correct ion , 214, 221
laser(s)
– for ablat ive rejuven at ion, 340,
343, 344f
– Accusculpt , 344
– Aram is, in facial rejuven at ion,
342–343, 343f
– carbon dioxide (CO<sub>2</
sub>), in facial rejuven at ion ,
340, 343
– ch rom oph ores for, 339–340,
342, 342f
– CoolTou ch , in facial
rejuvenat ion , 342–343
– dye, in facial rejuven at ion,
339, 340
– Edge, in facial rejuven at ion, 344f
– in face lift , 10
– for facial hair rem oval, 364–374
–– pearls, 364
– in facial rejuven at ion, 340–344
– fract ion al, in facial rejuven at ion,
340, 343–344, 344f
–– ablat ive, 343, 344f
–– n on ablat ive, 343
– Fraxel, in facial rejuven at ion,
343
– interst it ial, in facial
rejuvenat ion , 344, 344f, 345f
– m idin frared, in facial
rejuvenat ion , 339, 342–343,
342f, 343f
– Nd:YAG, in facial rejuvenat ion ,
339, 340, 342
– for n onablat ive rejuvenat ion ,
339–340
– Q-sw itch ed, in facial
rejuvenat ion , 340
– Sm ar tlipo, 344
– Sm ooth beam , in facial
rejuvenat ion , 342–343
– thu liu m , in facial rejuven at ion ,
343–344
laser hair rem oval, 9, 364–374
– case st udies, 370–372, 371f,
372f
– com plicat ion s of, 370, 370f
– e cacy of, factors a ect ing,
365–366
– for fem ale East Asian s, 366–367,
367f
– h airlin e design for, 369, 369f
– h istorical perspect ive on , 364
– key techn ical point s in , 370
– lasers used for, 364
– for m ale East Asian s, 367–369
–– aesth et ic e ect s of, 368, 368f
–– goals of, 367
–– m ot ivat ions for, 364–365
–– techn ique for, 368
– m ech anism s of, 365, 365f
– pat ien t evaluat ion for, 366
– pearls, 364
– targets for, 365, 365f
– tech n iques for, 366–369
lateral canth al rhyt ids. See
crow ’s-feet
lateral canth oplast y, 6
– aesthet ic, 189–192
–– Blaskovics’ m ethod for,
190–191, 191f
–– can didates for, 190
–– case st udies, 194, 194f
–– Fox’s m ethod for, 191, 191f
–– patient evaluation for, 189–190
–– pearls, 184
–– principles of, 189
–– Sh in’s m eth od for, 191, 192f
–– surgical tech niques for,
190–192
–– Von Am m on’s m ethod for,
190, 190f
– clin ical applicat ion s of, 189
– com bin ed w ith Mongolian
slan t low ering, 191–192, 193f,
194, 194f
– cont rain dicat ion s to, 190
– m in im ally invasive, 204
– m odi cat ion an d re n em ent for
Asian s, 8
– postoperat ive care, 192
lateral crural graft
– in correct ive rh in oplast y
for sh or t con t racted n ose,
123–125, 124f
– for nasal t ip contouring, 53–54,
53f, 54f
– onlay, 53–54, 53f
– st rut , 53–54, 54f
lateral n asal arter y
– an atom y of, 404f
– ller inject ion in , preven t ion of,
404, 406
lateral t arsal st rip procedure, 204
Le Fort I osteotom y. See also
double jaw surger y
– m axillar y, 274t, 276–277, 278f
–– bleeding in, 280
leprosy, an d saddle n ose, 89
levator palpebralis, 210
– age-related changes in, 174
– apon eurosis
–– advan cem ent , 169, 169f, 177
–– deh iscen ce, 175, 212–213, 328
–– plicat ion , in double-eyelid
surger y, 169
–– ptosis surger y an d, 210, 211
–– st retch ing or disin sert ion , 177,
212–213, 213f
– an d congenital ptosis, 211, 212f
– fun ct ion, evaluat ion , 175, 176f,
212, 213f
– m alfun ct ion, in aponeurot ic
ptosis, 213, 213f
– ptosis surger y an d, 210, 211
– resection, in ptosis correction, 219
lid lag, after ptosis correct ion , 221
lid m argin
– closed, 154, 155f
– de n it ion of, 154
– dou ble-eyelid su rger y an d,
154, 155f
– in/out (neut ral) fold, 154, 155f,
156
– inside fold, 154, 155f, 156
– open, 154, 155f
– out side fold, 154, 155f, 156
– sh apes of, 154, 155f
– ten sion eversion, 160, 160f
lip(s)
– Asian , ch aracterist ics of, 270
– drooping, after gen ioplast y, 294
– ller inject ion in , 400
– posit ion of, evaluat ion , 272,
272f, 288, 289f
– project ion of, 270
liposuct ion , for fat graft h ar vest ,
312–313
– com plicat ion s of, 321
low er eyelid, sagging, 8
low er-posit ion ed t ran sverse
ligam ent (LPTL), in upper
eyelid, 167, 168f
M –– n er ve injur y in, 261
m alarplast y, an d gen ioplast y, 286
m alar prom in ence, 6
m alar reduct ion , 9
m ale pat tern h air loss, 349
m align ancy, an d saddle n ose, 89
m alocclusion , 9
– classi cat ion of, 269, 270f
– in ter-arch problem s an d, 269
– in t ra-arch problem s an d, 269
– after orth ognath ic surger y, 281
m an dible. See also or th ogn ath ic
su rger y
– asym m et r y, an d low er facial
contouring, 257
– bilateral ver t ical sagit tal ram us
osteotom y, 274t
– fract ure, int raoperat ive, 261
– h igh sagit tal supraforam in al
osteotom y, 274, 276, 276f, 281
– hypoplasia, psych osocial e ects
of, 286
– in st abilit y, after orth ogn ath ic
su rger y, 281
– in t raoral vert ical ram u s
osteotom y, 276, 277f
– an d m axilla, abn orm al skeletal
relat ionsh ip bet w een , 257
– orth ogn athic surger y of,
274–275, 274t
–– case st udies, 282–283,
282f–284f
–– com plicat ion s of, 281, 282f
–– fract ure in , 281
–– in com plete osteotom y in , 281
– ostectom y
–– cur ved, w ith oscillat ing saw,
258, 258f, 259, 259f
–– tangent ial, w ith reciprocat ing
saw (lateral cortex ostectom y),
258, 258f
–– t ypes of, 258, 258f
– prot rusion , orthogn ath ic
surger y for, 274t
– reduct ion (con tou ring),
254–267
–– asym m et r y and, 257
–– case st u dies, 261, 262f, 263,
263f–264f, 265, 265f–267f
–– ch in an d, 257
–– com plicat ion s of, 261
–– con dylar fract ure in, 261
–– eth n icit y an d, 257
–– fract ure in, 261
–– fron tal plan e an alysis for,
256, 256f
–– gen eral procedure for,
258–260, 259f
–– h em orrh age w ith , 261
–– infect ion w ith , 261
–– in am m at ion w ith , 261
–– int raoral versus extern al
approach for, 258
–– key techn ical poin ts in, 260
–– m an dible-m axilla relat ion ship
an d, 257
–– an d n arrow ing gen ioplast y,
com bin ed, 260, 260f
–– patien t evaluat ion for, 255–256
–– pearls, 254
–– postoperat ive care, 260
–– preoperat ive im aging for, 256,
256f
–– sagit t al plan e an alysis for, 256
–– soft t issue and, 257
–– surgical plan n ing, 256
–– surgical tech niqu es for,
258–260, 259f
–– t ran sverse plan e analysis for,
256, 256f
–– an d un favorable aesth et ic
outcom e, 261
–– an d zygom a reduct ion ,
com bin ed, 246, 252, 252f,
253f, 263–265, 263f–267f
– ret rusion, orth ogn ath ic surger y
for, 274t
– sagit tal split ram us osteotom y,
274–275, 274t
–– bleeding during, 280
–– case st u dies, 282–283,
282f–284f
–– an d gen ioplast y, 286
–– infect ion after, 280
– vert ical de cien cy, or th ogn ath ic
surger y for, 274t
– vert ical excess, orthogn ath ic
surger y for, 274t
m an dibular angle
– Asian, 6, 7f, 254
– prom in ent , 254
– reduct ion , 9
–– an d gen ioplast y, 286
– resect ion of, 255
– secon dar y (postoperat ive),
259, 260
m an dibular plan e–sellar nasion
(MP-SN) angle, 256

m andibular prognath ism , w ith
long face, case st udies,
282–283, 282f–284f
m andibular ram u s osteotom y,
tech n ique for, developm ent
of, 269f
m andibular redu ct ion /
advan cem en t , 9
m argin -re ex distan ce
– clin ical signi can ce of, 175,
176f, 212
– m easurem en t of, 175, 175f,
212, 213f
m argin -re ex distan ce 1, 164,
210, 212, 213f
m argin -re ex distan ce 2, 198,
212, 213f
m arion et te lin es
– bot ulinum toxin for, 385, 386f
– ller inject ion for, 401–402
m asseter m uscle, hypert rophy
– bot ulinum toxin for, 386–388,
387f, 388f
– an d low er facial contouring, 257
Mat riStem , in h air t ran splant
procedures, 306
m axilla. See also bim axillar y
prot rusion ; orthogn ath ic
surger y
– dow n -fract ure, in orthogn ath ic
surger y, 281
– in st abilit y, after orthognath ic
surger y, 281
– Le Fort I osteotom y, 274t,
276–277, 278f
–– bleeding in , 280
– an d m an dible, abn orm al
skelet al relat ion ship bet w een,
257
– or th ogn ath ic surger y for, 274t,
276–277
–– com plicat ion s of, 281, 282f
–– in com plete osteotom y in , 281
– preoperat ive evaluat ion, 15
– prot ru sion, orth ognath ic
surger y for, 274t
– vert ical excess, orth ognath ic
surger y for, 274t
m axillar y ret rusion , 9
m axim al m alar project ion , 245,
245f
m edial epican th oplast y, 8, 165,
194, 194f
– w ith ptosis su rger y, 212
m edical skin care, in facial
rejuven at ion, 340
Medpor, 13, 113
– advant ages of, 14
– rem oval rate for, 135
– in rh in oplast y, 135
–– com plicat ion s of, 135
m elan in index, 366, 367f
m ent al n er ve injur y, in
genioplast y, 293
m icrognath ia, psych osocial e ect s
of, 286
m icrojet inject ion , in skin
rejuven at ion, 340, 347, 347f
m idface
– age-related ch anges in , 174
– four crescen t aging lin es,
397–399, 398f
m idpupillar y h orizon tal lin e, 27f,
60, 61f
m inoxidil, 351
MMCR. See Mü ller m uscle
conju nct iva resect ion (MMCR)
Mongolian slant , low ering,
191–192, 193f, 194, 194f
Mongoloids, 3
– phen ot ypic feat ures of, 6
m outh corn er elevat ion ,
bot ulin um toxin for, 385, 386f
MP-SN angle. See m an dibu lar
plan e–sellar n asion (MP-SN)
angle
MRD. See m argin -re ex dist ance
m ucocele, w ith n asal alloplast ic
im plan t , 138, 139f, 140, 141f
Mü ller m uscle, 210
– ptosis su rger y an d, 210, 211,
214
Mü ller m uscle conjunct iva
resect ion (MMCR), 211, 214,
215, 219
m yasth en ia gravis, 164
N – com plicat ions of, 67, 138, 139f,
NAR. See n on ablat ive rejuven at ion
n asal ala (pl., alae). See ala (pl.,
alae)
n asal base, reduct ion, 39
n asal bon es, 6
n asal bridge, low, 6, 7f, 8f
n asal dorsal augm en tat ion, 8–9,
21, 135, 136f
– w ith alloplast ic im plant , and
sh ort n ose deform it y, 122
– alloplast ic im plan ts for, 135. See
also alloplast ic im plant s
–– pearls, 135
– an d base reduct ion , 39
– case st udies, 40–43, 40f–45f
– closure for, 39
– in correct ive rh in oplast y for
sh ort con t racted nose, 129,
129f
– costal cart ilage for, 8, 26–46,
30f, 41f, 43, 44f
–– pearls, 26
– dorsal graft placem en t an d
xat ion in , 35–37, 35f, 36f, 37f
– ller inject ion for, 395, 395f,
399–400, 399f
–– com plicat ion s of, 408–409,
410f
– and glabellar augm en tat ion , 39
– graft , w ithout osteotom y,
31–32, 32f
– w ith h um p resect ion , 65–67,
66f
– key tech n ical point s, 40
– m anagem en t of bony vault in,
31–32, 32f
– m anagem en t of m iddle th ird in,
32–33, 33f
– m an agem en t of n asal base in ,
34, 34f
– osteotom y in, 32
– p at ient evaluat ion for, 26–28,
27f
– p ostoperat ive care, 39–40
– p reoperat ive cou nseling for,
27–28
– silicone im plan ts for, 13–25
– spreader graft placem en t in,
32–33, 33f, 40, 41f
– surgical tech n iques for, 28–37
n asal dorsu m
– an d appearan ce of n asal base,
100, 105
– Asian , 26, 27f
– bony an d cart ilaginous,
relat ion sh ip of, 61–62, 62f
– p reoperat ive evaluat ion, 15
n asal h um p
– ch aracterist ics of, 60–61, 87, 88f
– gen eralized, 61
– localized, 61
– versus pseudo hu m p, 61, 61f
n asal h um p surger y, 60–71
– an atom ical con siderat ion s in ,
61–62, 62f
– case st udies, 68, 68f–69f, 70,
70f–71f
140, 141f
– com pon en t h um p reduct ion ,
63, 64f
– con ser vat ive h um pectom y,
65, 66f
– d issect ion an d septal cart ilage
h ar vest in , 62
– d orsal augm en t at ion an d t ip
re nem ent w ith, 65–67, 66f
– funct ion al problem s after, 67
– an d in ternal valve collapse, 67
– inverted-V deform it y after, 67
– key tech nical poin ts in , 67
– in large-h um p n ose, 63, 64f
– n asal dorsal irregularit y after,
67
– open versus closed approach
for, 62
– pearls, 60
– an d residu al convexit y, 67
– sequ en ce of surger y and t ip -
plast y in, 62–63, 63f
– in sm all-h um p n ose, 65, 66f
– spreader grafts in , 65, 65f
– tech niqu es for, 61–67
n asal obst ruct ion
– after alar base surger y, 105
– assessm en t for, 73–74
– after correct ive rhin oplast y for
short con t racted n ose, 131
– after n asal t ip surger y, 55
n asal pro le, 6, 7f
n asal pyram id, 6
n asal root , preoperat ive
evaluat ion , 15
n asal sept um , 6
– d eviated, st raigh ten ing, 77–78,
78f
Index 423
– dissect ion , in aesth et ic
rhin oplast y for South east
Asians, 111, 112f
– ischem ia, an d saddle n ose,
89–90
– L-st rut , fabricat ion of, 92–93,
93f
– perforat ion
–– Medpor im plant an d, 137, 138f
–– and saddle n ose, 89–90
– subtot al recon st ruct ion , for
class 3 saddling, 92–93, 93f
n asal skin , 6, 15, 26, 27f, 61, 62f,
100
– exam inat ion of, 74
n asal t ip, 6, 7f, 8f, 26, 27f
– an d appearan ce of n asal base,
100, 105
– asym m et r y, 55
– augm en tat ion , 13
–– case st udies, 56–57, 56f–58f
–– w ith en don asal on lay graft , 56,
56f–57f
– boxy, ceph alic resect ion of
low er lateral cart ilage lateral
cru s for, 52–53, 53f
– bulbous, ceph alic resect ion of
low er lateral cart ilage lateral
cru s for, 52–53, 53f
– cap graft via en don asal
approach , 48–49, 49f
– colum ellar st rut , in terdom al
sut ure, an d on lay graft via
endonasal approach , 49, 50f
– con touring, 37–39, 38f
–– case st udies, 40–43, 40f–45f,
56–57, 56f–58f
–– graft sh ow ing after, 55
–– key tech n ical poin t s, 40, 55
–– lateral crural st rut grafts for,
37–38, 38f
–– and n asal obst ru ct ion , 55
–– pain /discom for t after, 55
–– pat ien t evaluat ion for, 48, 48f
–– shield graft versus h orizon tal
onlay graft for, 38, 38f, 40, 41f,
43, 44f
– cost al cart ilage graft for, 26–46,
30f, 41f
–– pearls, 26
– deviat ion , 55
– evaluat ion of, 48, 48f
– lateral crural graft for, 53–54,
53f, 54f
– lift ing, bot ulin um toxin for,
383, 383f
– m odi cat ion
–– in correct ive rh in oplast y
for short con t racted n ose,
123–125, 124f, 127–128,
128f, 131
–– using open approach , 57,
57f–58f
– over-rot at ion, 55
– pain in , after correct ive
rhin oplast y for short
con t racted nose, 131
– preoperat ive evaluat ion, 15
424 Index
n asal t ip (cont inued)
– projection and counter-rotation,
in aesthetic rhinoplast y for
Southeast Asians, 112–113, 113f
– project ion of, 47–48, 48f, 60
–– augm en tat ion via en don asal
approach, 48–49, 49f, 50f
–– loss of, 55
–– sept al exten sion graft for,
49–51, 51f
– re n em en t
–– w ith h um p resect ion , 65–67,
66f
–– preoperat ive cou nseling for,
27–28
–– surgical tech n iques for, 37–39
– revision surger y, 136, 138, 138f
– rigid, w ith AlloDerm im plan t ,
secon dar y rh inoplast y for, 140
– rot at ion , 9, 60
–– septal exten sion graft for,
49–51, 51f
– rot at ion of, 47–48, 48f
– septal exten sion graft for,
49–51, 51f
–– en d-to-en d, 50, 52f
–– overlapping, 50, 51f
–– tech n ique for, 50–51, 51f, 52f
–– t ypes of, 50, 51f
– sh ape, evaluat ion of, 48, 48f
– sh ield graft for, 51, 53f
– silicon e im plant an d, 13–25
– skin thin ning on, augm ent at ion
rh inoplast y w ith silicon e
im plan t an d, 23
– stacked on lay graft for, 13
– support , evaluat ion of, 48, 48f
– surger y
–– in Asian s, 47
–– com plicat ions of, 55
–– in h um p resect ion, 62–63, 63f
–– key tech nical poin ts, 55
–– m odi cat ion an d re n em en t
for Asian s, 8–9
–– pearls, 47
–– prin ciples of, 47
–– tech n iques for, 47, 48–55
– volum e of, 47
–– reduct ion , ceph alic resect ion
of low er lateral cart ilage
lateral crus for, 52–53, 53f
– w idth of, 47
– w ing graft for, 13
n asion , level of, in Asian s, 60, 61f
n asion (N)–an terior nasal sp in e
(ANS)/an terior n asal spin e
(ANS)–m en ton (Me) rat io, 272,
272f, 287, 288t, 289, 290f
n asofron t al angle, 60
n asofron t al t ran sit ion , 14f, 15
n asolabial angle, 60, 272, 272f
– acute, 15
– in Asian s, 15
– obt use, 122, 123f
n asolabial fold(s), ller inject ion
in , 400, 400f
n eck. See also plat ysm al ban ds
– adiposit y, m an agem ent of, 309
n euralgia, after hair
t ran splan tat ion, 359
n eurotoxin inject ion . See also
bot ulin um toxin
– for brow depressors, 332
– for plat ysm al bands, 309
n onablat ive rejuvenat ion
– physiologic e ect s of, 340
– prin ciples of, 339–340
n onsurgical in ter ven t ion , 10
n ose. See also nasal ent ries;
saddle n ose
– alar base, 99
–– m odi cat ion of, 99–107
– ar terial su pply to, an d ller
inject ion , 403, 404, 406,
408–409, 409f
– Asian, anatom y of, 6, 26, 27f,
61–62
– basal view of, 100, 100f
– bird’s-eye view of, 73, 73f,
82f, 84f
– bony asym m et r y, 14
– bony pyram id
–– late deviat ion after correct ive
rh in oplast y, 81
–– an d saddle nose, 87, 88f
– cleft , 103, 104f
– cont racted, postsurgical, 122
– crooked
–– physical exam in at ion of,
72–73, 73f, 74f
–– surgical correct ion of, 72–86.
See also correct ive rhin oplast y
– deform it y. See also saddle n ose
–– oblique ligh t ing of, 74f
–– surgical correct ion of, 72–86.
See also correct ive rhin oplast y
– deviat ion
–– low er th ird, 79–80, 80f
–– m iddle th ird, 78–79, 79f
–– m idvault , 77
–– physical exam in at ion of,
72–73, 73f, 74f
–– surgical correct ion of, 72–86.
See also correct ive rhin oplast y
–– t ip, 77
–– upper-th ird, 75–77
– extern al, physical exam in at ion
of, 72–73, 73f, 74f
– in tern al, exam in at ion of, 73–74
– inverted-V deform it y, 67, 87,
88f
– keyston e area, 87, 88f
– lateral cru ra, m alposit ion ed, 54
– low er lateral car t ilages, 88
–– dest ruct ion , w ith alloplast ic
im plant com plicat ion s, 136
– physical exam inat ion of, 72–74
– preoperat ive exam in at ion of,
14–15, 14f, 26–28, 27f, 60–61
– preoperat ive X-ray of, 15, 15f
– quadrangular cart ilage, and
saddle nose, 87, 88f
– short . See also correct ive
rh in oplast y, for sh ort
con t racted n ose
–– congen ital, 122
–– correct ion , 122–134
–– path ogen esis of, 122
–– postoperat ive, 122, 123f
– skin -soft t issue envelope,
exam in at ion of, 74
– South east Asian, characterist ics
of, 108
– start ing point of, in Asian s,
60, 61f
– t w isted
–– physical exam in at ion of,
72–73, 73f, 74f
–– surgical correct ion of, 72–86.
See also correct ive rh in oplast y
– upper lateral cart ilages, 87–88
–– dest ruct ion, w ith alloplast ic
im plan t com plicat ion s, 136
nost ril(s)
– asym m et r y of, 99
–– after alar base surgery, 105, 105f
–– after correct ive rhin oplast y for
sh ort con t racted nose, 131
– large, 99
– teardrop, after alar base
surger y, 105, 105f
num bness, after h air
t ran splan t at ion , 358
O 282f–284f
oblique lin e, in low er eyelid,
197f, 198
Obw egeser-Dal Pon t m ethod. See
sagit tal split ram us osteotom y
(SSRO)
occlusion
– ideal, 269
– n orm al, 268–269
– preoperat ive evaluat ion , in
gen ioplast y, 288
ocular m ot ilit y, preoperat ive
evaluat ion , 177
open bite, orth ogn ath ic surger y
for, 274t
orbicu laris oculi, 326–327
– prom inen ce of, 197f, 198
– suspension procedure, 198, 199,
204, 206, 207f
– t igh ten ing procedure, 199
orbicu lus oculi m uscle, 6
orbit , 6
– age-related ch anges in , 174
orbit al fat
– age-related ch anges in , 198
– cen t ral, 164, 177, 198
– h ern iat ion , 164
– lateral, 198
– m edial, 164, 177, 198
– prolapse, 177, 197f, 198
– prot rusion , an d low er eyelid
appearan ce, 196
– pseudoh erniat ion of, 197f
– rem oval
–– aesthet ic e ects of, 197
–– in aging-related (upper)
bleph aroplast y, 179, 179f
–– in dou ble-eyelid surger y, 167,
167f
–– in dicat ion s for, 198
orbital hem orrh age
– aging-related (upper)
bleph aroplast y an d, 181
– low er bleph aroplast y an d, 206
orbital ret ain ing ligam en t , 326,
327f, 331
orth ogn athic surger y, 9
– aesth et ic, 268–285
–– pat ien t evaluat ion for,
269–272
–– pearls, 268
–– psych ological con siderat ion s
in, 269–270
– case st udies, 282–283,
282f–284f
– classi cat ion of, by diagn osis,
274, 274t
– com plicat ion s of, 280–281
– con dylar resorpt ion after, 281
– de n it ion of, 268
– developm en t of, 268, 269f
– fun ct ional relapse after, 281
– and fun ct ion al restorat ion , 268
– in com plete osteotom ies in , 281
– in fect ion after, 280
– key tech n ical poin t s in , 280
– m an dibu lar, 274–275, 274t
–– case st u dies, 282–283,
–– com plicat ion s of, 281, 282f
– m axillar y, 274t, 276–277
–– com plicat ion s of, 281, 282f
– n er ve injur y in , 281
– pain after, 280
– part ial necrosis of bon e
segm en t an d m ucosa after,
281, 282f
– postoperat ive care, 279–280
– psych osocial ben e t s of, 268
– tech n iques for, 274–279
– tech n ological advan ces an d, 268
– un favorable osteotom ies in , 281
osteotom y
– in aesth et ic rh inoplast y for
South east Asians, 113
– anterior segm en tal, for
bim axillar y prot rusion , 274t,
277–279, 279f
–– an d gen ioplast y, 286, 295,
296f–297f, 298, 299f
– in augm en tat ion rhin oplast y, 19
– bilateral vert ical sagit t al ram u s,
m an dibular, 274t
– in correct ive rh in oplast y, 76–77
– h igh sagit t al supraforam in al,
m an dibular, 274, 276, 276f,
281
– in t raoral vert ical ram us,
m an dibular, 276, 277f
– Le Fort I. See also double jaw
surger y
–– m axillar y, 274t, 276–277, 278f
––– bleeding in , 280
– m an dibu lar ram us, tech nique
for, developm ent of, 269f
– in n asal dorsal augm ent at ion ,
32
– in rh in oplast y, 76–77

–– lateral, 76–77, 76f, 77f
–– m edial, 76f, 77
–– t ips for perform ing, 77
–– t ypes of, 76, 76f
– sagit tal split ram us, m andibular,
274–275, 274t
–– bleeding du ring, 280
–– case st udies, 282–283,
282f–284f
–– an d gen ioplast y, 286
–– infect ion after, 280
– in zygom a reduct ion
–– an terior, 247, 247f
–– I-sh aped, 248
–– L-sh aped, 246–247, 247f, 248
–– ostectom y versus, 248
–– posterior, 247, 247f
P surger y, 232–233, 233f
p ain
– after ller inject ion , 403, 407
– after gen ioplast y, 293
– after h air t ran splan t at ion , 358
– after n asal t ip surger y, 55
– after orthogn ath ic su rger y, 280
Pain ter, Neil, 5
p alpebral apert ure, w idening
of, 378
p alpebrom alar groove, 197f,
198, 199
p aranasal augm ent at ion , 15
p aranasal im plant , 9
p aresth esia, after zygom a
reduct ion , 249
p arot id glan d, reduct ion,
bot ulin um toxin for, 388, 389f
p eau d’orange, on ch in , after
genioplast y, 294–295
p eriorbital fat , 164
p henyleph rin e test , 214, 215
p hotodocu m en tat ion
– for facial fat graft ing, 312
– postoperat ive, w ith ptosis
correct ion , 212
– preoperat ive, 27, 74, 101
–– for bleph aroplast y, 164
–– for endoscopic foreh ead and
brow lift , 330
–– for h air t ransplan tat ion , 352
–– for low er blepharoplast y, 199
–– for m andibular redu ct ion, 256
–– for ptosis correct ion, 212
– during ptosis correct ion , 218,
219f
p iriform ligam ent s, release of, in
augm ent at ion rh in oplast y, 18
Pit anguy line, 325, 325f
p latelet-rich plasm a
– in fat graft ing, 318
– in hair transplant procedures, 306
p lat ysm al ban ds
– bot u linum toxin for, 386, 386f
– neurotoxin inject ion for, 309
PLLA. See poly-L-lact ic acid
p neum at ic com pression , in skin
rejuven at ion, 340, 347, 347f
p neum oth orax, cost al car t ilage
h ar vest and, 130
polyacr ylam ide gel, proper t ies
of, 393t
poly-caprolacton e, 394
poly-L-lact ic acid, 394, 405
– proper t ies of, 393t
polym ethyl m eth acr ylate,
propert ies of, 393t
pore size, int raderm al bot ulin um
toxin inject ion an d, 388–389,
389f
porous h igh -den sit y polyethylen e.
See Medpor
prem axilla, preoperat ive
evaluat ion, 14f, 15
prem axillar y augm en tat ion , 15
prem axillar y graft , 54
pretarsal area
– fulln ess, after double-eyelid
– h eigh t-volum e relat ionsh ip in ,
232–233, 233f
pretarsal bulge, 378, 383
pretarsal sh ow, 165, 166f
procerus m uscle, 326–327
pro loplast y, 60–71
– pearls, 60
PRP. See platelet-rich plasm a
pseudo h um p, 61, 61f
pseudolift , in t raderm al
bot u lin um toxin inject ion an d,
388–389, 389f
pseudoptosis, 162
– cau ses of, 210
ptosis, 162, 176, 307, 307f. See
also ch in, ptosis; eyelash ptosis
– aesth et ic e ects of, 174, 327
– aging-related, 212–213, 327,
328
– apon eurot ic, 211, 212–213,
212f, 213f
– asym m et ric, 214–215
– versus blepharoptosis, 174, 175f
– congenital, 211, 212f, 213–214,
222, 222f
– con tact lens–in duced,
214– 214f
– correct ion of, 169, 169f,
210–224
–– an esth esia for, 216, 216f
–– case st udies, 221–222, 222f
–– com plicat ions of, 220–221
–– conjunct ival prolapse after,
221
–– con tour deform it y after, 221
–– dissect ion in, 216–217, 217f,
218f
–– an d early postoperat ive
revision, 221, 221f
–– ect ropion after, 221
–– en t ropion after, 221
–– eyelid crease design for,
215–216, 216f
–– and eye protective function, 214
–– xat ion of levator-Mü ller
m uscle ap in , 217–218, 218f,
219f
–– fron talis sling for, 210, 211,
215, 219–220, 220f
–– h istorical perspect ive on,
210–211
–– in cision for, 216, 217f
–– in st ru m en ts for, 215, 216f
–– kerat it is after, 221
–– key tech n ical poin t s in , 220
–– lagoph th alm os after, 221
–– and levator resect ion , 219
–– levator su rger y for, 215
–– lid lag after, 221
–– m eth od, select ion of, 215
–– Mü ller m uscle conjun ct iva
resect ion (MMCR) for, 211,
214, 215, 219
–– pat ien t evaluat ion for,
211–214
–– pearls, 210
–– photographs in sit t ing posit ion
during, 218, 219f
–– postoperat ive care, 220
–– preoperat ive con siderat ion s,
214–215
–– preparat ion for, 215–216, 216f
–– tech n iques for, 215–220
–– un ilateral versu s bilateral, 215
–– visual eld test before, 214
– d iagnosis of, 212–214
– after double-eyelid surger y,
238, 238f
– evaluat ion of, 164, 210
– funct ion al e ect s of, 174
– Hering’s test and, 214–215
– h istor y-t aking for, 211–212
– latent , 214–215
– m asked, 211
– over-correct ion of, 220
– physical exam ination for, 211–212
– u nder-correct ion of, 220, 221f
– u nilateral, 174, 175f, 176, 210,
215
pug n ose, 87
pulm on ar y em bolism , fat graft
and, 321
R – osteotom y in, 76–77
Radiesse. See calcium
hydroxylapat ite
radiofrequency devices, in facial
rejuven at ion , 340, 344–346
– bipolar, 344, 345
–– w ith ligh t , 345
– in lt rat ive fract ional, 345–346,
346f
– m on opolar, 344, 345
reduct ion rh in oplast y, 60
– pearls, 60
relapsing polych on drit is, and
saddle n ose, 89
Rest ylan e. See hyaluron ic acid
ret rogn athia, 9
ret ro-orbicularis orbit al fat
(ROOF), 164
– rem oval, in double-eyelid
surger y, 167, 167f
revision rhin oplast y, 24, 25f
rhin oplast y, 7f
– adjun ct ive surgeries and
procedures w ith, 9
Index 425
– aesth et ic, for South east Asians,
108–121
–– alar lift via sail excision in ,
109–110, 110f–111f
–– case st udies, 117, 118f, 119,
119f–121f
–– closure, 116
–– com plicat ion s of, 117
–– con ch al cart ilage h ar vest for,
109
–– dorsal im plan t for, 113–116
–– key tech n ical poin t s in , 116
–– m em bran ous sept um
dissect ion in , 111, 112f
–– osteotom y in , 113
–– pat ien t coun seling before, 109
–– pat ien t evaluat ion for,
108–109
–– pearls, 108
–– sept al extension graft in, 112,
112f, 113f
–– tech n iques for, 109–116
–– t ip project ion an d coun ter-
rot at ion in, 112–113, 113f
– alloplast ic im plant s in . See also
alloplast ic im plan ts
–– com plicat ion s of, 135–148
–– pearls, 135
– augm en tat ion . See
augm en t at ion rh in oplast y
– correct ive. See correct ive
rhin oplast y
– for deviated/t w isted n ose,
72–86. See also correct ive
rhin oplast y
–– pearls, 72
– edem a after
–– late (persisten t), 81
–– m an agem en t of, 81, 140
– in fect ion s in , 143
– inject ion, asym m et r y caused
by, 412
– m odi cat ion an d re n em en t for
Asians, 8
–– lateral, 76–77, 76f, 77f
–– m edial, 76f, 77
–– t ips for perform ing, 77
–– t ypes of, 76, 76f
– pat ient evaluat ion for, 14–15,
14f, 15f, 72–75
– plan n ing for, 27
– preoperat ive cou nseling for,
27–28
– preoperat ive evaluat ion for, 27,
60–61
– secon dar y
–– for alloplast-related
com plicat ion s, 135–148
–– case st udies, 143, 144f, 145,
145f–147f
–– and capsule aroun d silicone
im plan t , 136, 137f
–– for deviated im plant , 138–139
–– for dorsal skin redn ess, 139
–– and Gore-Tex im plan t
com plicat ion s, 137
–– for h ard n asal t ip, 140
426 Index
rh in oplast y (cont inued)
– secon dar y (cont inued)
–– for im plan t calci cat ion , 139,
140f
–– for im plan t prot ru sion, 139
–– for in fect ious con dit ion s,
140–141
–– key tech nical poin ts in,
142–143, 142f
–– an d Medpor im plan t
com plicat ion s, 137, 138f
–– for m obile im plan t , 139
–– for n on in fect ious con dit ion s,
138–140
–– pat ient evalu at ion for,
136–138
–– for sh ort nose deform it y,
141–142, 142f
–– tech niqu es for, 138–142
–– for visible im plan t , 139
rhyt idectom y, 309
rhyt ids
– foreh ead, 327
– glabellar, 327
– lateral can th al. See crow ’s-feet
– perioral, bot ulin um toxin for,
384–385, 385f
Ricket t s line. See esthet ic line
(E-line)
ROOF. See ret ro-orbicularis orbital
fat (ROOF)
rule of fth s, 270, 271f, 324
rule of th irds, 270, 271f, 288,
289f, 324
S – resurfacing, 10
saddle n ose (deform it y)
– aesth et ic e ects of, 87, 88f, 89f
– an atom ic con siderat ion s, 87–88,
88f, 89f
– case st udies, 94, 95f, 96, 96f–98f
– ch aracterist ics of, 87, 88f
– class 1, 90–91, 91f
– class 2, 90, 91–92, 91f, 92f
– class 3, 90, 91f, 92–93, 93f
– class 4, 90, 91f, 93, 94f
– classi cat ion of, 90, 91f
– correct ion of, 87–98
–– pearls, 87
– disease an d, 89
– et iology of, 88–90
– exten ded spreader graft for,
92, 92f
– fun ct ion al e ects of, 87
– iat rogenic cau ses, 89
– m alignan cy an d, 89
– pat ien t evaluat ion , 90
– versus pseudo saddle, 87, 88f
– septal exten sion graft for, 92,
92f
– spreader graft for, 92, 92f, 93
– surgical tech niqu es for, 90–93,
91f–94f
–– key tech nical poin ts, 93
– system ic disease an d, 89
– total dorsal recon st ruct ion for,
93, 94f
– t raum a-related, 89
SAFI. See sequen t ial autologous fat
inject ion (SAFI) tech n ique
sagit tal split ram us osteotom y
(SSRO), m an dibular, 274–275,
274t
– bleeding during, 280
– case st udies, 282–283,
282f–284f
– an d genioplast y, 286
– in fect ion after, 280
Sam urai eyebrow, 382
sarcoidosis, an d saddle n ose, 89
sausage eyelid, 232
scalp, prurit us, after h air
t ran splan tat ion, 359
SCALP m n em onic, 396, 396f
scar(s), 8. See also keloids
– after alar base surger y,
104–105, 105f
– w ith epican th oplast y, 187–189
– after eyelid surger y, 226, 226f,
227f
– facial fat graft ing an d, 319–320
– after ller inject ion , 411
– hair t ran splan tat ion and, 351,
352, 358, 359
– hypert roph ic, 100, 185, 196
–– w ith epican th oplast y, 189
–– after eyelid surger y, 226
–– h air t ran splan t at ion an d,
351, 359
–– t reat m en t of, 189
– w ith n onin cision al sut u re
techn ique for dou ble-eyelid
surger y, 159, 160f
Sculpt ra. See poly-L-lact ic acid
seborrh eic derm at it is, after laser
facial hair rem oval, 370, 370f
sent inel vein, in forehead, 325,
326f, 331–332
Sephyl. See blood, as ller
septal extension graft , 135, 136f
– in aesth et ic rh inoplast y for
Sou th east Asian s, 112, 112f,
113f
– in correct ive rh in oplast y
for sh or t con t racted n ose,
123–125, 124f
septoplast y, in fect ion s in , 143
septorh in oplast y, 135
– com plicated, 135, 143
–– alloplast ic im plan ts for, 135
–– pearls, 135
– in fect ion s in , 143
sequen t ial autologous fat
inject ion (SAFI) tech n ique,
313, 313f, 314t–315t, 316f,
317t
serom a, after en doscopic
foreh ead an d brow lift , 337
shield graft , in aesthet ic
rh in oplast y for South east
Asian s, 113
Sh in’s m eth od, for aesth et ic
lateral can th oplast y, 191, 192f
silicon e, liquid, propert ies of, 393t
silicon e im plan t s, 8, 113
– advan tages of, 13–14
– for augm en tat ion rh inoplast y,
13–25
–– capsu le aroun d, 136, 137f
–– pearls, 13
– ch in , com plicat ions of, 294
– com plicat ion s of, 22–23, 28,
28f, 135
– derm al fat graft w ith, 22, 23f
– popularit y of, 13–14
– rem oval rate for, 135
– in rhin oplast y, 135
–– com plicat ions of, 135, 136,
137f
–– an d m ucocele form at ion, 138,
139f, 140, 141f
–– pearls, 135
Silskin . See silicon e, liquid
single eyelid, 152, 152f, 162–163,
173
– an atom y of, 153
– opening ph ase, 153f
– rest ing ph ase, 153f
skeletal reduct ion surger y, 9
skin, Asian, 6
– age-related ch anges in , 174,
178, 310
–– sun exposu re an d, 303–304
– of alar base, 101
– ch aracterist ics of, 196
– ch in
–– dim pling, after genioplast y,
294
–– peau d’orange appearance,
after gen ioplast y, 294–295
– in epican th al area, 185
– of eyelid, 164
– facial, laser h air rem oval and,
368, 368f
– lift ing, in low er facial
contouring, 257
– low er eyelid, loss of elast icit y,
198
– n asal, 15, 26, 27f, 61, 62f, 100
–– dam age in correct ive
rh inoplast y for sh ort
cont racted n ose, 130
–– dorsal redn ess, secondar y
rh inoplast y for, 139
–– exam in at ion of, 74
–– m obilit y, evalu at ion , 123,
123f
– n ecrosis
–– w ith fat graft em bolizat ion ,
320, 320f
–– after ller inject ion , 403, 403f,
406, 406f, 409, 410f, 411, 412f
–– after h air t ran splan t at ion , 358
– palpebral, 6
– rejuvenat ion , 310
– resist ance to aging, 303–304,
378
– resurfacing, 310
– topical therapy for, 310
skin color
– cu lt u ral beliefs about , 5,
303–304
– an d h air t ran splant at ion, 350
skin rejuvenat ion
– ablat ive, 339–340. See also
ablat ive rejuven at ion
– n on ablat ive, 339. See also
n on ablat ive rejuven at ion
– t ype I, 339, 340
–– w ith in ten se pulsed ligh t ,
341–342, 341f
– t ype II, 339, 340
–– w ith in ten se pulsed ligh t , 342
skull, Asian, ch aracterist ics of,
349–350, 350f
sn ap -back test , for eyelid laxit y,
198–199
sn ub n ose, postoperat ive, 122,
123f
soft t issue, lift ing, in low er facial
con tou ring, 257
SOOF. See suborbicularis orbit al
fat (SOOF)
South east Asians, 3, 8f
– aesth et ic rh in oplast y for,
108–121
–– pearls, 108
squ are jaw, bot ulin um toxin for,
386–388, 387f, 388f
SSRO. See sagit t al split ram u s
osteotom y (SSRO)
stereoph otogram m et r y,
preoperat ive, 27
steroid inject ion , after correct ive
rh in oplast y, 81
st im ulator(s) ( ller), propert ies
of, 393t
subn asale–labialis in ferior:labialis
inferior–soft t issue m en ton
(Sn –Li:Li–Me´) rat io, 272f,
288, 289f
subn asale–stom ion :stom ion –soft
t issue m en ton (Sn–St:St–Me´)
rat io, 272f, 288, 289f
suborbicularis orbital fat (SOOF)
– elevat ion (lift), 198, 199, 203,
207, 207f
– in fat reposit ion ing
bleph aroplast y, 203, 203f
sun exposure
– avoidan ce, after laser facial h air
rem oval, 370
– and skin aging, 303–304
superior palpebral fold, 6, 7f
superior su lcus
– deepen ing
–– age-related, 175, 175f
–– w ith ptosis, 211, 212f
– m an agem en t in aging-related
(u pper) blepharoplast y, 181
supraorbital ner ve, injur y, in ller
inject ion , 403
supraorbital neurovascular
bundle, 325, 326f
suprat roch lear n eurovascular
bundle, 325–326, 326f
supt rat rochlear arter y, ller
inject ion in , prevent ion of,
404, 406
surgical tech niqu es, m odi cat ion
an d re n em en t for Asians, 8–9

syn cope, hair t ran splan tat ion
an d, 360
syph ilis, and saddle n ose, 89
T t ransconjun ct ival Mü ller t ucking,
tear breakup t im e, 177, 181
tear secret ion , preoperat ive
evaluat ion , 177, 181
tear t rough , ller inject ion in , 399
tear t rough depression, 197–198,
197f, 199
– fat graft ing for, 322, 322f
teeth , exposure, an d facial
aesth et ics, 270
tem p le, ller inject ion in,
396–397, 397f
tem p oral fossa
– ller inject ion in , 396–397, 397f
– layers of, 396, 397f
tem p oral region , an atom y of,
324–326, 325f–327f
tem p orom an dibular join t (TMJ)
– dysfunct ion , preoperat ive
docum en tat ion of, 270
– in st abilit y, after orthognath ic
surger y, 281
– pain, after orth ogn athic surger y,
280
tem p oropariet al fascia, 325, 325f,
326f
Th erm age, 344
thread lift ing, 10
th um bprint sign , 32
TMJ. See tem porom an dibular
join t (TMJ)
Tran ilast , 188
158, 159f, 161, 161f
t raum a, an d saddle n ose
deform it y, 89
t riam cinolon e acetate, inject ion
– after correct ive rh in oplast y, 81
– for hyper t roph ic scar, 189
t riangular m alar m oun d, 198
t rism us, after zygom a reduct ion ,
249
t w o-jaw su rger y, 268. See also
double jaw surger y
U X
u lt rasoun d
– in facial rejuven at ion, 340
– h igh -in ten sit y focused, in facial
rejuvenat ion , 340, 346, 346t
u pper eyelid crease, 6, 7f, 162
– low, 163
V zero-m eridian, 288–289, 289f
visual eld(s)
– im provem ent, after aging-related
(upper) blepharoplast y, 180
– ptosis and, 174
– test ing, w ith ptosis correct ion ,
214
vit am in c ion toph oresis, in facial
rejuven at ion , 340
V-lin e surger y, 255, 255f
volum izer(s), propert ies of, 393t,
405
Von Am m on’s m eth od, for
aesthet ic lateral can thoplast y,
190, 190f
W 246–247, 247f, 248
Wegen er’s gran ulom atosis, an d
saddle n ose, 89
West Asians, 3
W h it nall’s ligam en t , 167
Wilkin son an alysis, of m axim al
m alar project ion , 245, 245f
X-ray, preoperat ive
– for gen ioplast y, 287, 289
– for m an dibular reduct ion , 256
– of n ose, 15, 15f
– for secon dar y rh inoplast y, 136
Z – an d u nder-correct ion , 250
zygom a reduct ion , 243–253
– an esth esia for, 247
– an terior osteotom y in , 247, 247f
– approach for, 246–247
– asym m et r y after, 249
– case st udy, 250, 250f, 251f
Index 427
– com plicat ions of, 249–250
– xat ion in , 247, 248f, 249
– goals of, 243–244
– in fraorbit al n er ve injur y an d
paresth esia after, 249
– in t raoral approach for, 246–247
– I-sh aped osteotom y in, 248
– key tech n ical poin ts in , 248–249
– L-sh aped osteotom y in ,
– an d m an dible reduct ion
(con touring), com bin ed, 246,
252, 252f, 253f, 263–265,
263f–267f
– n on un ion after, 249
– ostectom y versus osteotom y
in , 248
– pat ient evalu at ion for, 244–246
– pearls, 243
– posterior osteotom y in, 247,
247f
– soft t issue sagging after, 249
– surgical tech n iques for, 246–247
– t rism us after, 249
– vector of t ran sposition in , 248
zygom at ic arch, 6
zygom at ic body, 6
– posit ion of, 244–245
– volum e of, 244
zygom at ico-tem poral vein ,
m edial, 325, 326f