FACIAL AESTHETIC

SURGERY

Dr Akshpreet Kaur
Dr S P S Sodhi
Dr Ramandeep Singh Brar
Dr Gursimrat Kaur Brar

DENT
UBLICATION
Facial Aesthetic Surgery
Authors

Dr Akshpreet Kaur Dr S P S Sodhi

Principal, Professor & H.O.D
PG Student
Department of Oral and Maxillofacial Surgery,
Department of Oral and Maxillofacial Surgery,
Dasmesh Institute of Research and Dental Sciences,
Dasmesh Institute of Research and Dental Sciences,
Faridkot, Punjab.
Faridkot, Punjab.

Dr Ramandeep Singh Brar Dr Gursimrat Kaur Brar

Professor Associate Professor
Department of Oral and Maxillofacial Surgery, Department of Oral and Maxillofacial Surgery,
Dasmesh Institute of Research and Dental Sciences, Dasmesh Institute of Research and Dental Sciences,
Faridkot, Punjab. Faridkot, Punjab.

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Facial Aesthetic Surgery

First Edition: 2023
ISBN 978-81-962936-1-1
 Chapter Page No.

1. Introduction 09

2. Anatomy 11

3. Ageing 24

4. Facelift Procedures 30

4A. Standard (SMAS) Facelift 34

4B. Extended Deep Plane Facelift 38

5. Rhinoplasty 45

6. Endoscopic Forehead & Browlift 54

7. Minimally Invasive Procedures 59

7A. Botox Injection For Facial Rejuvenation 61

7B. Dermal Fillers 67

8. Complications 76

9. Bibliography 89

07 Facial Aesthetic Surgery

 Chapter 1
Introduction

''The face is the most innate, most individual characteristic of your body. It is who you are''

O
ur face is a self portrait that we show to the world. Every person's face is unique. Even
identical twins possess certain distinguishing facial characteristics from each other. Our
face defines who we are as an individual. In fact, through the face it is possible to
recognize the expressions of happiness, suffering, wondering, and sadness among several other
reactions of the inner well-being of a person. Face being the mirror of what we are from inside, reflects
the signs and symptoms of aging, illness, deficiencies and personality traits.
Since time immemorial aesthetics is an individual's perception. People are treated differently
based on how physically attractive they are perceived to be. Even the minute defect on face engraves
an exaggerated long-lasting impression on person's mind.
Human beings undergo inexorable aging process which takes away youthfulness. No one is spared
from the rages of ageing. This natural alteration is noticeable more on the face although the entire body
presents significant metabolic disturbances during the life. This usual, unkind, complex process takes
place over 40 years of age. Fat compartments change their volume, thickness of subcutaneous fat
decreases, muscles exhibit mass reduction and bone undergo negative mineral balance and loose
volume & projection. The effects of aging, as well as other circumstances of life such as sun, pollution,
and general stress, are shown on individual's face and neckline. All these circumstances lead to laxity
of overlying skin, wrinkle formation, fold accentuation, drooping of upper eyelid, hollowness in the
under-eye area, deepening of nasolabial fold, sagginess of skin at the border of mandible etc.
Society's attitude toward ageing seems to have changed significantly over the past several
generations and although we have reluctantly accepted that but we do not necessarily need to show full
effects of ageing.
Aesthetic surgery is the pursuit of what is described by the Greek word 'aisthetikos' meaning
passion for that which is beautiful. Aesthetic surgery or cosmetic surgery represents a universal human
desire to maintain or restore normal appearance or to enhance it toward an aesthetic ideal. The goal
may be to return an abnormal or unsightly feature to normal or to produce a younger, more beautiful
appearance.

09 Facial Aesthetic Surgery

 The surgical enhancement of appearance was roundly dismissed until the late 1800s. Before this
time, it was socially unacceptable and the procedures themselves were considerably dangerous. As
the constraints of the Victorian era receded, women became empowered to alter their appearance as
they chose. Makeup and hair styling became commonplace and the shroud surrounding the world of
cosmetic surgery began to slowly unravel. Surgery, however, was a risky endeavour at the beginning
of the 20th century. Anaesthesia methods were crude and antibiotics were not in existence yet. The
knowledge of facial anatomy and function was marginal. Little was known about the complex
interplay of skin, muscle, fat, cartilage, and bone. (Azizzadeh et al., 2018)
Jacques Joseph is considered the founding father of modern facial plastic surgery, and he
pioneered many of the earliest surgical aesthetic techniques that were later adopted and modified by
fellow surgeons.
The 21st century has revealed an explosion in public's craving for aesthetic surgery. Everyone
seems to be searching for 'fountain of youth'. The increase in acceptability and procurement of
cosmetic surgery in the mainstream society may be attributed to numerous factors including
willingness to express body dissatisfaction, physical appearance, and positive media influence. In
addition to this, growing awareness regarding beauty is also responsible for increased number of
people altering their appearance through cosmetic procedures. Time and technology have also
evolved. With the advent of less invasive methods and glamorization of plastic surgery in the media,
the final barriers to aesthetic surgery were removed.(Hupp, Tucker and Ellis,2013)
Extensive research has been made involving minimally invasive procedures such as fillers,
suspension threads, stem cell facelifts, growth factors and topical injection of medication with the
goal of avoiding the biochemical phenomena related to the ageing tissue modifications. Despite the
great effort to postpone a more aggressive approach, some of these treatments are of unproven benefit,
which guides surgeons to address senescence alterations through surgical procedures.
Five major components that contribute to Facial complex includingforehead, nose, eyes,lips and
chin are altered by facial aesthetic surgery that includes facelifts, rhinoplasty, browlifts and certain
minimally invasive procedures such as injectable fillers, neural modulators, lasers and other devices
aimed at rejuvenating skin.(Chaung, Barnes and Wong, 2016)
This dissertation aims to collectively explore the various facial aesthetic surgical procedures.

10 Facial Aesthetic Surgery

 Chapter 2
Anatomy

T o create a more youthful, natural-looking form, the surgeon endeavours to reverse some of
the changes that occur due to ageing. A sound knowledge of facial anatomy will increase
the likelihood of success and reduce the incidence of undesirable results and
complications.(Shiffman and Giuseppe, 2013)

Basic facial soft tissues are composed with five layers:

Figure 2.1 - Layers of face

Skin
The skin is subdivided into the thinner, more superficial epidermis and the more fibrous dermis.
The epidermis is stratified squamous epithelium that varies greatly in depth, ranging from thickness
of the scalp to the delicate skin of the eyelid, which, at 0.04mm, is thinnest on the body (Jonathan et
al.,2020). The dermis, composed primarily of connective tissue, also contains nerves, blood vessels,
muscles, lymphatics, sweat glands and pilosebaceous glands. The more superficial and thinner dermis
is termed papillary dermis. The deeper and thicker dermis is reticular dermis. The dermis is composed
primarily of collagen. The collagen fibres in the papillary dermis are thin and randomly arranged
compared with the coarser bundles of the reticular dermis, which are arranged parallel to the surface.

11 Facial Aesthetic Surgery

 The dermal plexus of blood
vessels nourishes the skin
(and facelift flap) and must
at all times be respected. The
handling of lipocutaneous
flaps in cosmetic facial
surgery should be as gentle
as other procedures in which
the vascularity of the flap is
Figure 2.2 – Reflection of layers essential to its survival.
Figure 2.3 - Subdermal vascular plexus
of face I-Skin, II-Subcutaneous When dissecting a facelift
tissue/superficial areolar tissue, flap, several millimetres of
III- Superficial fascia, IV- Loose fat is left adherent to the
areolar tissue, V- Deep fascia and
VI- Temporalis muscle deep to dermal under surface to
deep fascia protect this area and
enhance flap viability. A good general rule is that there should be fat on both sides of the facelift flap.

Subcutaneous Layer
The subcutaneous layer has 2 components, subcutaneous fat which provides volume and the
fibrous retinacular cutis that connects the dermis with the underlying SMAS.
Superficial fat – It has varying degrees of thickness and adherence. The pretarsal part of the
eyelids and lips are compacted, and the subcutaneous fat is not present. The mid cheek can be divided
into 3 areas: lid cheek, malar, and nasolabial, and respectively, each area has thicker subcutaneous fat

Figure 2.4 - Subcutaneous fat Figure 2.5 - Retinacular cutis fibres

The retinacular cutis fibres vary in their orientation throughout the face; they can have a more
horizontal configuration in less adherent areas, and are vertically arranged in more adherent areas of
the face.
Overlying the retaining ligaments, the fibres are more densely arranged and vertically oriented. As
a result, to surgically develop a subcutaneous flap here usually requires sharp release.
In contrast, in the subcutaneous compartments overlying the sub-SMAS spaces the retinacular
fibres are less dense and more horizontally oriented so that a relatively easy blunt dissection is usually
sufficient to elevate the subcutaneous facelift flap here.

12 Facial Aesthetic Surgery

 The subcutaneous layer is basically a safe layer in the face and can be undermined in the
subcutaneous plane without damage to significant anatomic structures.

Deep fat of face - The deep fat of the midface is

interposed between the facial mimetic musculature and lies
deep to all compartments of superficial fat. In the upper
portion of the midface, the deep fat compartments overlie the
maxilla and the zygoma, giving shape and volume to the
face. The central deep fat compartments lie in a triangle
bounded laterally by the zygomatic ligament and medially
by the facial vein. The 3 central deep fat compartments are
the medial and lateral suborbicularis oculi fat (SOOF)
superiorly and the deep central fat compartment inferiorly Figure 2.6 – Deep fat of face The red and
blue areas correspond to the medial SOOF
(MS) and lateral SOOF (LS). BB, bare bone
SMAS – Superficial Musculo-Aponeurotic System area after sharp removal of the OOM from
its attachment on the orbital rim

The superficial fascia of the midface is the SMAS, which is

the key layer that is repositioned and suspended in most face-
lift techniques. The SMAS is attached to the skin above and to
the deep fascia (parotidomasseteric fascia) below by fibrous
connections. In some areas, the connections are dense and are
referred to as ligaments, which serve as points of strong
fixation and suspension (zygomatic ligament, orbicularis
retaining ligament) or pathways for arterial supply (McGregor
patch) Figure 2.7 – Lateral view of cadaver
showing SMAS (III)
In the temporal region, superior to the zygomatic arch, the superficial fascia (layer III) is termed the
superficial temporal fascia or temporoparietal fascia (TPF). The TPF is the superior extension of the
SMAS of the midface overlying the temporal fossa, extending from the zygomatic arch to the
temporal line. At the temporal line, the TPF
becomes the galeaaponeurosis of the
forehead.
In the midface, the superficial fascial
layer (III) is termed the SMAS. In the neck,
the superficial fascia (III) is the connective
tissue layer that invests the platysma muscle.
With the exception of the
levatorangulioris and mentalis, the facial
Figure 2.9 - The “fixed” SMAS
nerve travels deep into the SMAS layer and Figure 2.8 - Inferior view overlying
with SMAS and superficial the lateral face & parotid
innervates the muscles of facial expression, fat reflected laterally with a transition zone to the “mobile”
making dissection above the SMAS during SMAS medial to the parotid where
the jowl and lower face descends
facelift safe. more readily

13 Facial Aesthetic Surgery

 When this layer is stretched or pulled, it pulls on the mimetic muscles and basically moves the
entire lateral face in the desired vector.As the SMAS extends medial to the parotid gland, it is not
firmly adherent. A transition zone can be seen topographically in the ageing face where the medial
mobile SMAS descends and the lateral fixed SMAS does not.(Jacono and Bryant, 2018)

Sub-SMAS Plane
This surgical plane contains the facial nerve motor branches
and the parotid duct and is best avoided by surgeons. The
parotidomasseteric fascia is the facial layer that overlies the
parotid gland and masseter muscle; when operating superior to
this layer, the facial nerve branches are generally protected. Just
as the SMAS is an extension of the superficial cervical fascia,
the parotidomasseteric fascia is an extension of the superficial
layer of the deep cervical fascia into the face and the deep
temporal fascia above the zygomatic arch. The facial nerve
branches are deeper in the parotid gland until they emerge at the
anterior border of the gland and cross the masseter muscle Figure 2.10 - Superficial fat and SMAS
have been removed, exposing the peripheral
branches of the facial nerve
Retaining Ligaments
The facial ligaments are
condensations of connective Osteocutaneous retaining ligaments Fasciocutaneous retaining ligaments
tissue that subdivide the face
into compartments and Zygomatic ligament (Mc Gregor Masseteric ligament
connect the facial layers from ligament
the skin superficially to the
bone deeply. The ligaments Mandibular ligament Parotid cutaneous ligament
can be termed true, which
extend from the skin to the
Table 2.1 Retaining ligaments of face
facial skeleton, or false,
which connect only the
muscles to the bone and do
not extend superficially to the
skin. Figure 2.11 - Left facial dissection
T h e y a r e s u rg i c a l l y Elevation of the superficial fascia
released during face-lifting showing the ligamentous connections
procedures to facilitate to the deep fascia, including the
temporal ligamentous adhesion,
mobilization and lateral orbital thickening, zygomatic
repositioning of soft tissue ligament, and mandibular ligament
layers.
Osteocutaneous ligament – They run from periosteum to the dermis.
Stout zygomatic retaining ligaments originate from the inferior border of the zygomatic arch
towards the junction between the arch and the body and insert into the dermis of the skin as fibrous
septa. It is posterior to the zygomaticus major muscle, approximately 3 mm in width, 0.5 mm in
thickness and 4.5 cm anterior to the tragus. Loss of support results in malar fat descent.(Furnas, 1989)

14 Facial Aesthetic Surgery

 The mandibular ligament originates from the periosteum 10 mm above the mandibular border,
extends along the anterior one third of the mandibular body and inserts into the dermis. It coincides
with the anterior margin of the jowl. (Alghoul and codner, 2013)

Fasciocutaneous retaining ligaments – They are formed from a coalescence of superficial and
deep facial fascia.
Masseteric ligaments originate from the parotidomasseteric cutaneous ligaments, and. loss of
support results in facial jowling. Parotid cutaneous ligaments are formed by the posterior border of the
platysma, which had receded into fascial condensation. It is fused with the parotid fascia, is attached
to the overlying skin and provides firm anchorage between the platysma and the dermis in the inferior
auricular region.(Bonanthaya et al.,2021)

Deep Fascia
The deep fascia, the deepest soft-tissue layer of the face, is
formed by the periosteum where it overlies bone. Over the lateral
face, where the muscle of mastication (temporalis and masseter)
overlies the bone, the deep fascia is instead the fascial covering of the
muscles- deep temporal fascia and masseteric fascia above and
below the zygomatic arch, respectively. The parotid fascia is also
part of the deep fascia.(Jonathan et al.,2020)
The deep fascia, although thin, is tough and unyielding and gives
attachment to the retaining ligaments of the face. In the mobile Figure 2.12 - Left temporal fossa
with TPF (layer III) reflected inferiorly
shutters over the bony cavities, the deep fascia is absent, being The DTF (lay er V) is held by
replaced by a mobile lining derived from the cavities, that of the the forceps. The frontal and parietal
conjunctiva or oral mucosa. branches of the superficial temporal
ar ter y ar e seen cour sing al ong
the surface of the DTF
Muscles of Facial Expressions
The muscles of facial expression are the 'cosmetic muscles' as they are responsible for
hyperdynamic facial lines associated with ageing. The muscles of facial expression are manipulated
by cosmetic facial surgeons to camouflage the
ageing process. Interventions to these muscles
have profound effects on the upper, middle, and
lower thirds of the face. Muscular facial activity
and its relationship to the formation of wrinkles
is one of the major forces responsible for facial
ageing. Dividing the face into muscular thirds
will define the muscular groups responsible for
the formation of the lines, creases, furrows, and
folds that are so indicative of the aging Figure 2.13 - Muscles of facial expression
process.(Vigiliante,2005)

15 Facial Aesthetic Surgery

 Figure 2.14 - Functional anatomy of the face Table 2.2 – Actions of muscles of facial expressions
Orange—depressor muscles Purple—levator muscles Gray—sphincteric muscles

Of clinical note, there is a loose connective tissue surgical plane between the galea and the
pericranium that permits ease of dissection during brow- lift surgery.
The frontalis muscle is the main antagonist of the eyebrow depressors. Horizontal forehead
creases are treated effectively with botulinum toxin Type A treatment and are minimized by result of
brow lift.
The procerus muscle is one of the common sites for Botox injections. This treatment can produce a
medial brow chemo lift and eliminate the glabellar lines associated with aging.
Corrugator supercilliis the muscle of 'frowning'(Clemente, 1985). It can be easily softened with
injection of Botox into the muscle.
Forceful contraction of the orbital component of orbicularis oculiinduces concentric folds
emanating from the lateral canthus resulting in lateral canthal lines or crow's feet. In childhood, crow's
feet occur only in dynamic situations (e.g., laughter and squinting in bright light). In adulthood, these
lines are frequently seen even in facial repose. Botox and laser skin resurfacing are techniques often
used to soften and erase the line.(Carruthers and carruthers, 2001)
The upper nasalis lines or 'bunny lines' can be softened successfully with application of Botox on
each side. Care should be taken to not inject too low in the nasofacial groove which can weaken the
levator labii superioris alaque nasi and levator labii superioris, producing aesthetically significant
ipsilateral lip ptosis and creating an unpleasant aesthetic effect.(Carruthers and carruthers, 2001)
Injection intolevatorlabiisuperiorisalaequenasimuscle can result in temporary lip ptosis and an
unpleasant outcome. However, very small amount of Botox has been injected into this muscle to drop
the upper lip in the treatment of maxillary gingival excess on smiling.
Vertical lines in the midface (also known as Melo labial lines) give an impression of hostility,
fatigue and age. Weakening of the levatorlabiisuperioris with 1 to 2 U of Botox can soften the upper
half of the fold but at the cost of ptosis. Therefore, this treatment has not been popular.
The dynamic wrinkle produced by the action oflevatorangulioris muscle has a profound effect on
facial aging. Various wrinkle fillers and autologous fat have been used to camouflage a pronounced
nasolabial fold.

16 Facial Aesthetic Surgery

 Some people have persistent vertical grooves at the lateral corners of the mouth (also known as
mandibulolabial folds or 'drool lines'), giving an impression of fixed disapproval or sadness. By
selective chemo denervation of the depressor angulioriswith Botox, the zygomaticus muscles become
relatively unopposed as elevators of the corners of the mouth so that mouth corners assume a more
relaxed neutral position,
The dynamic action of the orbicularis oris in combination with photoaged skin or smoking can lead
to formation of vertical lip rhytids. These unsightly wrinkles are especially troublesome after the
application of lipstick. Local microinjection of Botox causes segmental weakening of the lip
sphincter relaxing the folds and allowing the lip to appear 'pseudo everted' and smoother.
Botox can be used to treat a deep labiomental fold or the ''peaud'orange'' chin dimpling seen in
patients with an overactive mentalis muscle.
Correction of neck laxity has been considered to be an integral part of what is currently considered
traditional face-lift surgery. Various techniques have been developed to treat the aging neck with or
without a face-lift, and most of these involve direct dissection of the platysma muscle. Some form of
anterior platysmaplasty is frequently performed in conjunction with liposuction of the neck.

Vascular Anatomy
The anatomy of the arterial
supply to the face and venous
drainage in the area of dissection
is significant, not only to avoid
injury to the vessels, but also for
consideration of flap viability
postoperatively. The main
arteries of the face include facial
artery, superficial temporal
artery and transverse facial
artery from superficial temporal
artery, infraorbital artery from
maxillary artery.(Von Arxand Figure 2.15 - The arterial blood Figure 2.16 - Lateral view of the arterial
supply to the face The external facial blood supply The external carotid
Lozan off 2017) carotid artery (ECA, red area) artery provides all extracranial branches
According to Soikkonen et and the internal carotid artery
al. (1991), the blood supply to (ICA, pink area)
the face is mainly provided by the facial, transverse facial and infraorbital arteries that are in
hemodynamic balance. The blood supply to the skin follows the connective tissue framework. The
main arterial skin perforators pierce the deep fascia originating from their source arteries, then
radiating to the skin areas of the face. In general, the vessels are intimately related to the superficial
musculo-aponeurotic system (“facial musculature”). Midline anastomoses of arterial vessels are
especially rich in the forehead and lips. (Houseman, Taylor and Pan 2000)
Many veins in the face accompany the homonymous arteries, but there are some exceptions to the
rule (inferior ophthalmic vein, retromandibular vein). Furthermore, the facial vein and artery run a
different course in the face at a certain distance from each other. From a surgical standpoint, the most
frequently encountered vessels in face-lift surgery are the external jugular vein and the transverse
facial artery.

17 Facial Aesthetic Surgery

 The jugular vein is encountered during the
neck dissection that begins posterior to the
ear and descends superficially above the
sternocleidomastoid muscle.

McKinney's point
Prior to surgery, McKinney's point is
marked on the skin surface at 6.5 cm inferior
to the bony external auditory meatus at the
Figure 2.17 - Venous drainage of Figure 2.18 - McKinney's midpoint of the sternocleidomastoid
the cranial region Note the super- point
ficial position of the facial nerve muscle. McKinney's point marks the site of
and its relationship with the super- the greater auricular nerve as it crosses over
ficial temporal vein the belly of the sternocleidomastoid muscle.
A 1-cm radius from this point is demarcated in all directions. The anterior portion of the resultant
circle will identify the site of the jugular vein as it passes the anterior border of the
sternocleidomastoid muscle.(Fonseca,2017)

Transverse facial artery

The site of perforation of the transverse facial artery is marked preoperatively on the skin surface
2.5 cm lateral and 3 cm inferior to the lateral canthus of the eye. A circle with a 0.5 cm radius is marked
around this point, creating a site of caution for the surgeon at this area of dissection. Disruption of the
transverse facial artery may contribute to skin flap necrosis and hematoma formation.

Sentinel vein (Medial zygomatico-temporal vein)

This vein runs perpendicularly through the temporalis fascia at a
location approximately 2 cm lateral or posterior to the lateral canthus.
It is clinically significant during open and endoscopic procedures as
one elevates tissue inferior to zygomatico – frontal suture in sub
periosteal plane because of the problems that are created by injury to it,
such as bruising and impaired visualization.(Keller and Mashkevich,
2009)
Figure 2.19 – Sentinel Vein
Innervation

Figure 2.20 - Illustration of the sensory territories of the skin of the face:
green = territory of ophthalmic division of trigeminal nerve;
blue = territory of maxillary division of trigeminal nerve;
beige = territory of mandibular division of trigeminal nerve;
red = territory of anterior branches of cervical plexus

18 Facial Aesthetic Surgery

Supraorbital and supratrochlear nerve
The supraorbital foramen or notch typically is
found within 1 mm of a line drawn in a sagittal plane
tangential to the medial limbus. Inferior dissection
from the scalp above should be performed only to
within 2 cm of the orbital rims, and that should be
followed by endoscopic guidance below this point to
decrease the chances of nerve injury.
Figure 2.21 – Supraorbital and supratrochlear nerve
Facial Nerve
The facial nerve is the master of facial expression, and postoperative dysfunction is devastating to
face-lift surgery. Branches of the facial nerve innervate all of the muscles of facial expression, and
typically from their deep surfaces, only three of the muscles of facial expression are innervated from
the superficial surfaces: the buccinator, the mentalis, and the elevator angulioris.Anatomic study
published by Dingman and Grabb demonstrated that in
19% of cadaveric specimens, the marginal mandibular
branch travels up to 1 cm below the inferior border of
the mandible posterior to the facial artery, and anterior
to the facial artery the nerve was found at or above the
inferior border of the mandible in 100% of
dissections.The temporal branch lies in the loose areolar
connective tissue layer between the superficial and deep
temporal fascia as it crosses the zygomatic arch; it
enters the superficial temporal fascia from its under
surface in a consistent region 1.5 to 3.0 cm above the Figure 2.22 - Motor nerves and fascia of the upper
face -The frontal nerve lies on the deep side of the
zygomatic arch and 0.9 to 1.4 cm posterior to the lateral temporoparietal fascia
orbital rim.(Fonseca,2017)

Pitanguy line
The superior division of the facial nerve courses
superiorly within the substance of the parotid gland and
proceeds along the Pitanguy line toward the temporal
region.This line is marked by an inferior point at 0.5 cm
below the tragus and superior point 1.5 cm above the
lateral brow.(Niamtu, 2010)

Figure 2.23 – Pitanguy line

At the zygomatic arch
The branches emerge from the parotid and cross the zygomatic arch approximately 2.5 cm anterior
to the external auditory meatus.At this crossing the nerve is most vulnerable to injury, however, in a
sub-SMAS dissection plane, it is protected within the fat just deep to the temporoparietal fascia.

19 Facial Aesthetic Surgery

Nasal Anatomy
A deep understanding of nasal anatomy is the
cornerstone of a good rhinoplasty. A slight change in one
nasal structure can have an impact on the rest and
dramatically modify the facial configuration.
The external nose consists of a bony and
cartilaginous framework, covered by muscles, soft
tissue, and skin.
§ Nasal Bones and Cartilages: The upper third of the
nose is defined by the paired nasal bones and the
frontal process of the maxilla, which constitute the
bony pyramid. Nasal bones are in an intimate
relationship with the perpendicular plate of the Figure 2.24 – External Nose Anatomy
ethmoid bone.
§ The middle third is formed by the upper lateral cartilages, which attach to the nasal bones cranially.
Nasal bones overlap the upper lateral cartilages for 4 - 5 mm, constituting the “Keystone area.”
This anatomical landmark is important for the aesthetics of the dorsal contour and should be
treated carefully during surgery(Fonseca,2017). Upper
lateral cartilages also attach to the septum dorsally,
forming an angle of 10 - 15 degrees approximately. This
narrow zone of air resistance is called the internal nasal
valve and during surgical manoeuvres, it is important to
maintain this angle in order to guarantee a patent airflow.
§ The lower lateral cartilages define the lower third with its
medial, middle, and lateral crura. The anatomical
configuration of these cartilages will determine the
shape and size of the nasal tip area. They also set the Figure 2.25 - Configurations of scroll -Inter
framework for the external nasal valves.(Bonanthaya et locked (52%), end-to-end (17%), overlapping
al., 2021) (20%), or opposed (11%)
§ The lower lateral cartilages connect with upper lateral
cartilages in a union described as scroll. The scroll is
described as interlocked (52%), end-to-end (17%),
overlapping (20%), or opposed (11%). The scroll
provides significant support to the nasal tip. Removing
cephalic strips of cartilage from the lower lateral
cartilages or performing an endonasal rhinoplasty
violates this junction.
§ Nasal tripod - The lower lateral cartilages act as a tripod
supporting the nasal tip. The two medial crura act as one
pillar and the lateral crura act as the other pillars of the
tripod. Manoeuvres that increase or decrease the length
or strength of these cartilages will affect nasal tip
projection and rotation. Figure 2.26 - The tripod concept

20 Facial Aesthetic Surgery

§Muscles: The main mimetic muscles of the nose are
the nasalis, levatorlabiialaequenasi, and depressor
septii. These muscles are enclosed and interconnected
by a fibrous fascia called the nasal superficial
musculoaponeurotic system (SMAS). The nasal
muscles are generally not addressed in rhinoplasty
procedures with exception of the depressor nasal septi
muscles. The depressor septi muscle, if overactive,
can cause inferior displacement of the nasal tip during
smiling and may require resection as part of the
rhinoplasty procedure.(Fonseca,2017) Figure 2.27 - Nasal musculature
§Skin and Soft Tissue Envelope (SSTE): When
divided into upper, medial, and lower thirds of the nose, the tissue covering the Rhinion zone is the
thinnest (0.6mm) followed by the upper (radix -1.25mm) third which is the thickest. When dealing
with patients with very thin SSTE, small changes in nasal cartilage and bony structures will have a
significant impact on the shape, and small irregularities of grafts utilized can be very noticeable.
Contrarily, in patients with very thick SSTE, a more aggressive approach is often needed so that
the changes can be perceptible, and small irregularities won't have such an impact on the aesthetics
of the nose after surgery.
Beneath the skin and above the underlying
osseocartilaginous framework are the layers of
superficial musculoaponeurotic system (SMAS). The
SMAS of the nose is continuous with the SMAS of the
face. Violating the SMAS can result in increased
bleeding, scarring, and postoperative oedema;
therefore, the dissection should be between the
cartilage and bone and the SMAS.
The arterial blood supply of the nose comes from both
the external and internal branches of the carotid artery.
The primary blood supply to the nasal tip comes from
the lateral nasal arteries, which are branches of the
facial artery. The lateral nasal artery course is
superficial to the alar cartilages, approximately 2 to 3
mm above the alar groove Figure 2.28 - Arteries of the external nose

The internal nose is constituted of the septum and the turbinates, all of which are covered by
mucosa.
§ Septum: The nasal septum is a rigid, quadrangular-shaped structure covered by mucosa that
separates the two nostrils, and it constitutes the principal support for the nose. In the junction
between the dorsal and caudal septum lies the anterior septal angle, which helps to determine nasal
projection. Through the internal nasal valve, it has a very important role in maintaining a patent
airway.

21 Facial Aesthetic Surgery

 Figure 2.29 - (a) Anatomy of nasal septum, (b) line diagram with landmarks

§Turbinates: Turbinates are bony outgrowths covered

by mucosa. These structures form pathways where
the air flows and is warmed and humidified and
additionally assist in regulating the airflow by
contracting and expanding. They are divided into
superior, middle, and inferior turbinates. Most of the
airflow passes through the middle and inferior
turbinates. Some causes like rhinitis or septal
deviation can induce turbinate hypertrophy, which
can obstruct the air canal to variable extents. If an
obstruction is found, it must be addressed during
surgery in order to improve nasal function. Figure 2.30 – Lateral wall of nose
§Arterial supply: The anterior and posterior ethmoidal arteries (branches of the internal carotid)
supply the superior portion of the lateral nasal wall. Branches of the internal maxillary artery
supply the inferior portion of the lateral nasal wall.

Figure 2.31 - Arteries of the lateral nasal wall

§Arterial supply of the nasal septum - Kiessel bach's plexus, a common site of epistaxis, is located
in the antero inferior portion of the nasal septum. This region represents the anastomosis of the
sphenopalatine, greater palatine, superior labial artery, and anterior ethmoidal arteries.

22 Facial Aesthetic Surgery

 Figure 2.32 - Arteries of the nasal septum

§Sensory nerves of the

external nose: The
ophthalmologic divisions
of the trigeminal nerve
that supply the nose
include the supratrochl-
ear and infratrochlear
nerves. The remainder of
the nose is supplied by
branches of the maxillary
division of the trigeminal
nerve.
Figure 2.33 - Sensory nerves of the external nose

23 Facial Aesthetic Surgery

 Chapter 3
Ageing

I n life, the ageing process comes naturally. Research on

the ageing process increased as people's average life span
became longer, and people started to pay greater attention
to their quality of life. Over time, senescence of the skin,
elastosis, decreased collagen, and lipoatrophy lead to the
loss of the face's youthful turgor and tightness, resulting in the
appearance of radiating vertical lines around the lips and mouth,
deepening and furrowing of the nasolabial folds, and the
development of a longer and flatter upper lip leading to a thinner
lip vermilion border. (Bonanthaya et al., 2021)
Through knowledge of the physiology of the aging process, it
is possible to evaluate each patient in an individual way and Figure 3.1 - Signs of ageing
program the most appropriate treatment that can range from less
invasive procedures such as fillers to surgical methods.

Ageing process occurs at four distinct levels

§Skin
§Subcutaneous issue
§SMAS
§Skeletal framework

Ageing of Skin
The normal turnover rate for skin is 40-50 days. The natural process of desquamation sheds off the
dry, old, hardened skin cells and gives way to the new cells to come to the surface. This process also
eliminates damaged and contaminated cells that carry pollutants and microorganisms from the
environment.
The specialised fibroblasts in the dermal layer produce two key proteins-collagen and elastin.
Collagen constitutes 80% of the dermis and provides strength and firmness to the skin. While elastin,
as the name implies, provides elasticity to the skin and enables the skin to bounce back to its original
shape after it is stretched, thus preventing wrinkles. (Bonanthaya et al., 2021)

24 Facial Aesthetic Surgery

Skin ageing is a dynamic mechanism that transpires dueto two basic factors:

Intrinsic or Innate factors Extrinsic or Exogenous factors

Insidious deteriorating elements Ultraviolet rays inthe sunlight, cigarette smoking,

influenced by internal metabolic processes, environmental pollution,etc.
genetic programming, cellular metabolism
and hormones.

Table 3.1 – Intrinsic and extrinsic factors of ageing Intrinsic Ageing

Intrinsic Ageing
§ Reduced turnover of skin (decreased desquamation of old cells, hard, dry skin)
§ Reduced production of two principal proteins i.e., Collagen and Elastin
The cumulative effect which is seen in case of the inherent ageing includes fine wrinkling, parched,
thin and transparent skin and depleted elastic nature of the skin.

Extrinsic Ageing
Extrinsic ageing is because of the aggregated damage caused by environmental factors such as
sun's UV radiation, gravity, sleeping posture, pollution, smoking, exposure to chemicals, etc. These
exogenous factors along with the innate factors cause premature ageing of our facial skin.
Recurrent and continual UV exposure disintegrates collagen and impedes the synthesis ofnew
collagen. Alongside, there is a breakdown of elastin causing the facial skin to become slack, wrinkled
and leathery much earlier than a sun-protected skin.
Gravity constantly works on different parts of our facial skin. As the skin elasticity reduces with
age, the effects become evident. It precipitates jowls, nasolabial fold, drooping of eyelids, elongation
of ears, etc.
Sleeping posture - Sleep lines are wrinkles that are etched on the facial skin of the people who sleep
with the face pressed on the cushion or sleep on the sides.
Cigarette smoking over a period of time causes many biochemical alterations in our body. The
nicotine causes vasoconstriction thereby impairing the supply of oxygen and important nutrients,
such as vitamin A to the skin. Many of the over 7000 chemicals released from the burning cigarettes
cause increased production of matrix metalloproteinases (MMP) that causes degradation of collagen
and causes abnormal creation of elastosis materials. These cause premature facial skin wrinkling.

Ageing Epidermis
Having no blood supply, the epidermis gains its nutrition through contact with the dermis. A major
cutaneous change in intrinsic skin ageing is a reduction in the surface contact between the epidermis
and dermis. There is a loss of rete ridges, which negatively affects the capillary rich dermal papillae,
resulting in a reduced supply of nutrients, metabolites and oxygen to the epidermis (Tobin, 2017). The
reduced contact between dermis and epidermis also results in less resistance to shearing forces. In
addition, with age, the epidermis atrophies because cell production decreases up to 50% between 20s
and 70s (Cerimele Celleno and Serri, 1990)

25 Facial Aesthetic Surgery

 With advancing age, there is a reduction in the hormones and chemical signals that are important
for skin growth and repair, as well as a decline in the receptors that detect them; for example, the
number of vitamin D receptors in epidermal keratinocytes declines with age.

Ageing Dermis
With the increasing age, there is a loss of dermal volume and dermal thickness by about 20%
(Farage et al., 2013) The collagen content of the dermis decreases by 1% per year throughout adult
life. In addition, collagen itself changes from well-organized bundles of fibers in young skin to
fragmented and disorganized fibers in older skin; it also loses its interwoven extensions with elastin
fibers, which in youth enable the skin to regain its shape after deformation.
Fibroblast activity decreases with age; these cells shrivel and fewer epidermal growth factor
receptors. There is associated drop in collagen synthesis, atrophy of collagen bundles and increase in
the levels of MMPs .(Khavkin and Ellis, 2011)
As collagen fibers decrease in number, rupture,
cross-link and stiffen, their capacity to bind water
diminishes and skin loses elasticity and becomes
wrinkled. Wrinkles appear not due to degeneration
of elastin fibers, as previously thought, but to a
decreased water-holding power of collagen and
mucopolysaccharides .
Skin ageing is also associated with a decrease in
cutaneous perfusion and reduced vascularity,
mainly in the papillary dermis.
Figure 3.2 – Age related changes in Dermis & Epidermis

Ageing of Subcutaneous Tissue

The subcutaneous fat gives the volume and shape to the face. The subcutaneous fat is distributed
throughout the face in a multidimensional fashion and is highly compartmentalized.A youthful face is
characterized by a smooth transition between these subcutaneous compartments. The superficial
musculoaponeurotic system(SMAS) divides this fat into superficial and deep layers
§ Zygomatic ligaments (McGregor's patch)
§ Mandibular ligament
§ Platysma auricular ligament
§ Anterior platysma-cutaneous ligament

Figure 3.3 – Superficial Fat compartments Figure 3.4 - Deep fat compartments

26 Facial Aesthetic Surgery

 Two theories explain the characteristic soft tissue changes that are distinguished during the mid-
face ageing.

Gravitational theory Volumetric theory

With the attenuation of the osteocutaneous ligaments, Corresponding volume loss or gain in the adjoining
there is vertical descent of facial soft tissue which areas of the face is what creates the deep creases of
contributes to the deep creases of the ageing face. age (Donofrio, 2000)
The diminished strength of the ligaments is because Ageing process was due to the relative deflation of
of the age-related elastosis and also because of the certain fat pads, especially the deep fat pads
repeated animation of the muscles of facial expression. (Lambros, 2007)

Table 3.2 – Theories of ageing of midface subcutaneous tissue

Ageing of SMAS
The superficial musculo aponeurotic system is a multidimensionalscaffold of organized fibrous
tissue that connects the facial muscles with the dermis and also segregates the superficial and deep
facial fat pads. Anatomically, the SMAS lies in the midface, inferior to thezygomatic arch and
superior to the muscular belly of the platysma. It blends with the superficial temporal fascia
andfrontalis muscle superiorly, and with the platysma muscleinferiorly.Since it connects the facial
muscles to the dermis,its purpose is to transmit, distribute and amplify the activityof all facial
muscles.
As we age, and with the continuous use of the muscles of facial expression, the SMAS weakens
and the strength diminishes. So, the ability to hold up the muscles, fat and the skin gets impaired.
Combined with the effect of gravitational forces, the weakening causes the structures of the face
toslump.
The youthful appearance of the face changes as jowls are formed, the nasolabial fold deepens and
the mandibular line angle becomes ill defined.

Ageing of Facial Skeleton

Traditionally, soft tissue lifting and redraping have constituted the cornerstone of most facial
rejuvenation procedures. Changes in the facial skeleton that occur with aging and their impact on
facial appearance have not been well appreciated. Accordingly, failure to address changes in the
skeletal foundation of the face may limit the potential benefit of any rejuvenation procedure.
The bony skeleton serves as a framework for the soft tissues
of the face including the skin, muscles and subcutaneous fat. Figu re 3. 5 -
The facial skeleton suffers changes throughout life. In Arrows indicate
the areas of the
childhood occurs the facial skull growth, and at adult age, the facial skeleton
bone presents some resorption areas and other bone deposition susceptib le to
areas. Degenerative and catabolic changes occur after resorption with
adolescence. With ageing, the facial skeleton keeps resorbing ageing. The size
of arrows corre-
in a very predictable manner and that contributes to the lates with the
appearance of an aged face. Areas with strong tendency to amount of
resorb include the periorbital area, the midface, the perinasal resorption
area and the mandible. (Mendelson and Wong, 2020)

27 Facial Aesthetic Surgery

Periorbital Region
The orbital aperture increases with age, in both area and width. Resorption is, however, uneven and
site specific. The superomedial and inferolateral aspects of the orbital rim, in particular, recede more,
although the changes occur at different rates. The inferolateral orbital rim changes manifest earlier, by
middle age, whereas in the superomedial quadrant, recession may be noted only in old age. The
inferomedial quadrant of the orbit also has
a tendency to recede in old age, especially
in males. In contrast, the central part of the
superior and inferior orbital rims is more
stable, with little if any resorption is
occurring with age.
This contributes to the stigmata of
periorbital aging such as increased
prominence of the medial fat pad, elevation
of the medial brow, and lengthening of the
Figure 3.6 - Orbital ageing
lid cheek junction

Midface
The rate of bony resorption in the
midface, however, is not uniform. The
maxilla is more susceptible to age-related
loss than the zygoma.
The maxilla retrudes with aging and
quantitated the changes. The maxillary
angle is decreased by about 10 between
young (age \30 years) and old (age [60
years) individuals (Mendelson and Figure 3.7 - The pyriform (pyriform angle) and the maxilla
(maxillary angle) significantly recede with aging from youth
Wong, 2020) (left) to old age (right)

Perinasal changes
The nose lengthens and the tip droops, with the columella and the lateral cruraedisplacing
posteriorly. Changes in the bony foundation i.e. the
paired nasal bone, and the ascending processes of the
maxillae are responsible for many of the soft tissues
changes seen in the nose with aging. Piriform Figure 3.8 - The loss
apertureenlarges with aging as the edges of the “nasal” of bone in the pyriform
bones recede with age. Similarly, bone loss is not area weakens the support
uniform, with the greatest resorption occurring in the of lateral crura. Deepening
of the maxilla results in
ascending process of the maxilla. The posterior posterior positioning of
displacement of the bone rim is greatest at the lower the nasolabial crease and
pyriform aperture, which is the critical area for support adjacent upper lip
of the lateral crura and the external nasal valves.

28 Facial Aesthetic Surgery

 The dentate mandible is assumed to expand continuously with aging. It is well established that
mandibular angle increases, the ramus height and body height and length decreases with age.
The ageing of human face is a highly complex, irreversible and progressive biologic phenomenon
that occurs with the ticking of time. Cosmetic facial surgeon tends to reverse the changes that occur
due to ageing through various surgical procedures

29 Facial Aesthetic Surgery

 Chapter 4
Facelift Procedures

P reservation of one's youthful looks has been a goal of humans regardless of cultures and
ethnicities. The search for this elixir of youth was found unexpectedly in the hands of
cosmetic surgeons. Even with the recent advent of skin peels, botulinum toxin injections,
lasers and injectable filler injections, the century-old facelift still possesses the most dramatic
improvement to the moderate to severe ageing lower face when done well.(Bonanthaya et al., 2021)
Facelift or rhytidectomy as its name suggests is a procedure to partially eliminate folds, creases
and wrinkles (rhytids) caused by gravity and degeneration. In effect, the creation of two large cervico
facial faps, which, after suspension and trimming, produces an overall tightening of the skin and the
fascial envelope of the face and neck, resulting in restored anatomical structure.

Patient Evaluation
Evaluation of prospective patients for face-lift surgery considers three main areas:
(1) Medical history,
(2) Facial esthetic evaluation, and
(3) Psychosocial considerations

Medical history
Thorough medical history is required. Complications associated with previous surgical
procedures should be noted. Peri-operative excess bleeding, postoperative infection, wound healing
problems, and any complications that resulted in patient dissatisfaction with the procedure. If
possible, all anticoagulation medication should be suspended prior to surgery.

Smoking & Drugs

Rule out current smokers from elective cosmetic surgery. The rate of skin sloughing in smokers is
almost three times the rate of nonsmokers (7.5% compared to 2.7%). Use of illicit drugs such as
cocaine, MDMA (3,4Methylenedioxymethamphetamine)and other stimulants should also disqualify
prospective candidates from elective cosmetic surgery because these drugs can compromise
cardiovascular health and perhaps have secondary effects on flap microvasculature. Heavy alcohol
use should also be investigated, as this can compromise coagulation and nutritional status, leading to
hematoma formation or poor healing potential respectively.(Fonseca, 2017)

30 Facial Aesthetic Surgery

Facial Esthetic Evaluation
The examination of the face begins with excellent preoperative
photographs. These should be taken with a black or blue
background in unshaded light. Photos should include frontal face
in repose and smiling, bilateral three-quarter views, bilateral
lateral views, and posterior ear on each side. The face is typically
divided into horizontal thirds and vertical fifths.
The face-lift procedure is the only procedure that addresses
jowling. Many patients desiring face-lift procedure also complain
of neck laxity, the profile of the neck should be addressed and is
easily characterized by the Dedo classification system. A
desirable cervicomental angle is 90 degrees. Patients with an
inferiorly positioned hyoid bone that (below the 4th cervical
vertebrae) necessarily have an obtuse cervicomental angle that is
not corrected by cervicoplasty or plastysmaplasty.
Figure 4.1 - Dedo classification
of facial profile

Patient Profile Surgeon

Well-definedcervicomental angle
I Normal Good muscle tone
No submental fat

II Cervical Skin Laxity Obtuse cervicomental angle due to relaxed skin

III Submental Fat Accumulation Requires submentallipectomy

IV Platysma Muscle Bending Requires muscle clipping, plication or imbrication

V Retrognathia Or Micrognathia Requires genioplasty or orthognathic surgery

VI Low Hyoid Difficult to alter inform patient of limitations

Table 4.1 – Dedo classification of facial profiles

Indications & Contraindications

Ideally, the patient should be around the age of fifty or below. Above this age may not be ideal
anymore, because the work may be more extensive than for younger individuals. This means that
more surgeries may be needed.
Fine wrinkles which can be managed by nonsurgical or conservative treatment very well are
contraindications of facelift surgery.
Secondary facelifts should also be done with caution because the scar from the primary procedure
may disrupt the original tissue planes and increase the risk of facial nerve damage.

31 Facial Aesthetic Surgery

 Indications Contraindications

Malar fat pad descent Patients taking anticoagulants, antiplatelet agents,

Nasolabial folds and nonsteroidal anti-inflammatory drugs
Jowling: a result of pseudo-herniated buccal fat Poorly controlled hypertension, both pre-operatively
and descent of the mobile, medial SMAS and intra-operatively.
Festoons (malar mounds): hammocks of lax skin Active smokers
and orbicularis muscle that form large bags typically Body dysmorphic disorder (BDD)
resting below the orbital rim
Facial dimples: caused by fascial bands from the
zygomatic major muscle (minor dimple) or a bifid
zygomaticus major muscle (major dimple)

Table 4.2 - Indications and contraindications of facelift

Preoperative Marking
The rhytidectomy incision is marked as well as the path of the
temporal branch of the facial nerve, and the deep plane entry point.
The deep plane entry point is marked as a line extending from the
angle of the mandible to the lateral canthus. This places the area of
SMAS manipulation anterior to the fixed lateral SMAS. A horizontal
line is drawn across the neck at the level of the cricoid to mark the
minimal inferior extent of neck skin elevation.

Incision
The purpose of a facelift incision is two-fold. First, the incision
allows elevation of a skin flap that can be repositioned to remove excess Figure 4.2 - Important landmarks
drawn preoperatively include the
skin – the primary goal of a skin-only subcutaneous facelift. Second, the trajectory of the temporal branch
incision provides access for the surgical manipulation of the deep tissues of the facial nerve, the deep plane
of the face – the primary goal of most modern facelift techniques. entry point, incision lines, & inferior
extent of neck skin elevation
The incision lines are divided into four sections (Bonanthaya et al.,2021):
§ Temporal
§ Preauricular
§ Postauricular and
§ Scalp extension

Temporal Incision
The temporal component is either into the hairline or just at the hairline/ sideburn border. If the
estimated postoperative lateral orbital rim to anterior hairline distance is <5cm (i.e., minimal temporal
skin resection), then the temporal portion of the incision can be concealed behind the hairline. If the
anticipated distance is >5cm, then a pre hairline incision is chosen to prevent post surgical sideburn
distortion. The latter has the advantage of not moving the sideburn position; however, it would give a
tell-tale sign of a visible scar. In the former approach, the sideburn area may get lifted into the
temporal area and the scar will be hidden.

32 Facial Aesthetic Surgery

Preauricular Incision
The preauricular marking could be a pre-tragal, intratragal or
post-tragal. The latter can distort the tragal projection, and the
pre-tragal will give a visible scar. A small step is placed at
inferior tragus to preserve natural depression at
intertragicincisure.

Post Auricular Incision

The postauricular incision should be a 2mm into the
postauricular area from the sulcus so that postoperatively the
scar will settle down comfortably into the sulcus (Jacono and
Bryant,2018). It is hidden behind the superior helix for 1cm.
The height of the postauricular incision is at the level of the
widest portion of the ear.
Figure 4.3 - Rhytidectomy skin incision
The scalp extension is carried out by multiple W or Z plasty marking
type incisions in a trichophytic fashion to minimize hair loss and
to have an invisible scar.

Cervicoplasty Incision
A 2.5 cm curvilinear submental incision parallel to the mandibular contour to the neck lift section
in order to expose the anterior border of the platysma and the platysmal dissection.
This chapter will provide detailed knowledge of standard SMAS and extended deep plane face lift
procedures.

33 Facial Aesthetic Surgery

 Chapter 4A
Standard (SMAS) Facelift

T he results of skin flap only facelift was short term with

limited correction of the ageing face, forcing surgeons
to search for better alternatives. In 1974, TordSkoog, a
Swedish surgeon, revolutionized facelift concepts by
describing the dissection, elevation and tightening of
the superficial fascia of the face in addition to removing excess
skin. He expounded the importance of retro-positioning the
“buccal fascia” and the platysma for better results. The importance
of this technique was later cemented when the superficial fascia of
the face was clarified as the “superficial muscular aponeurotic
system” (SMAS) by Mitz and Peyronie in a landmark paper in
1976. Manipulation of the SMAS layer in a superior or Figure 4.1.1 - SMASectomy with
superolateral vector became an important part of modern facelift. vectors of advancement

Surgical Technique
The submental flap dissection is carried out at first to expose the platysma muscle as much as
possible.(Bonanthaya et al.,2021)
While applying counter traction on the cheek (assistant's hand on the cheek), a skin flap is elevated
leaving adequate amount of fat on its
underside (3–4 mm). This is initially
done with a blade and can be advanced
using face lift scissors.
Next, the scalp and postauricular
dissection is carried out. The anterior
border of the sternocleidomastoid
muscle and posterior border of the
platysma are exposed, and a cavity of Figure 4.1.2 - Dissection is in Figure 4.1.3 - The postauricular flap is
the neck is connected anteriorly and the supraplatysmal plane then connected to the cervical fap and
the submental region made previously
posteriorly.
In the temporal, the deep part of deep temporalfascia is exposed, which we use as an anchor point
to the SMAS suturing.

34 Facial Aesthetic Surgery

 The preauricular dissection will
expose the zygomatic ligaments, lateral
end of the orbicularis oculi and the
anterior border of the parotid–
masseteric fascia with careful attention
towards the buccal branch of the facial
nerve. The preauricular, neck and
postauricular dissection should now be
Figure 4.1.4 - Deep layer of the Figure 4.1.5 - After the deep
in one cavity. The anterior aspect of this deep temporal fascia exposed temporal fascia is exposed,
flap is only about 5–6 cm.This skin flap dissection is carried out in a is
easily elevated in supra-SMAS plane different plane subcutaneously
to raise a skin flap
SMAS Elevation & Execution
Exposure of the SMAS is achieved once the skin flaps are
completely elevated.(Starkman and Mangat,2020)
The 2 most common ways to execute the SMAS advancement
are with plication or imbrication.

SMAS Plication
Plication, or folding, is performed by simply excising a
crescent-shaped section of supra-SMAS adipose tissue from the
preauricular and infra-auricular areas followed by suture
suspension of the intact SMAS fascia. The plane of the SMAS is not
violated when the plication technique is used. Patients with slender
Figure 4.1.6 - Elevation of the face
or narrow faces often benefit from plication without removal of and neck skin flaps, exposing the
supra-SMAS adipose tissue. underlying SMAS layer

SMAS Imbrication
Alternatively, imbrication involves excising supra-SMAS adipose tissue and a segment of
redundant SMAS fascia, which
therefore violates the plane of the
SMAS.
Mobility of the SMAS is easily
determined by grasping the fascia with
blunt forceps and pulling the SMAS in
the vector of desired advancement,
posterosuperiorly.
The degree of sub-SMAS dissection
required is dictated by the amount of
Figure 4.1.7 - Sharp excision of a Figure 4.1.8 - A face and neck sub-
SMAS mobility. Over the parotid gland, vertical strip of preauricular SMAS SMAS layer is raised and elevated,
the facial nerve is relatively well- tissue is performed. Care is taken before lift
protected by the parenchyma of the not to violate the underlying parotid
gland tissue

35 Facial Aesthetic Surgery

gland. However, anterior to the parotid gland, the nerve
becomes vulnerable to iatrogenic injury. Therefore,
blunt dissection in the direction of the facial nerve
fibres is advised when dissecting in this plane. When Figure 4.1.9 - The SMAS
adequate elevation and mobilization of the SMAS is layer is elevated and suture
approximated in multiple
accomplished, the SMAS may be advanced and vectors. The face SMAS
suspended in the appropriate vector. The SMAS is flap is a primarily vertical
usually sutured in a simple interrupted and buried vector, while the neck
SMAS is pulled in a more
fashion using a large, braided, synthetic absorbable horizontal vector
suture.

Playtsma Elevation & Plication

The anterior border of the platysma is sutured in the midline (Sebason and Ilankovan,2006). In
some patients with short neck, the platysmal suturing needs to be
hitched to the body of the hyoid bone. In some patients, a release of
the inferior border of the platysma muscle at this area could also be
considered.
Then the lateral border of the platysma muscle is sutured to the
anterior border of the sternocleidomastoid muscle. The third step is
in platysmal plication is placing a cinch suture, which is placed
joining the two anterior borders of the muscles in the midline and
sternocleidomastoid muscle and the final anchor into the mastoid
periosteum. Depending on the neck anatomy, sometimes a second Figure 4.1.10 - The medial edges of
the platysma are sutured to each other
cinch suture is placed about 5–6 mm below the first to avoid at the midline in a corset manner
bulging of the sub mandibular gland.

Skin Flap Trimming & Closure

Once the SMAS has been elevated and suspended, the redundant skin and
subcutaneous tissue mustbe repositioned. Skin trimming is accomplished in
2 steps: the first is securing the skin flaps at the 2 points of maximal tension;
the second is tailoring the skin flaps.(Jacono and Bryant, 2018)
The 2 points of tension are at the junction of the temporal hairline and
preauricular incision and at the transition from the postauricular incision to
the occipital scalp.To secure the skin flap, it is advanced under traction while
overlapping the auricle. While the flap is under traction, a staple is placed at
the posterior point of tension at the junction of the postauricular and occipital
scalp incisions. The position of the skin flap is then maintained using gentle
traction, and a Pitanguy flap demarcator is used to mark the placement of the
second staple at the junction of the temporal incision and preauricular
incision. The flap is divided sharply, and a staple is placed in the appropriate Figure 4.1.11 - A Pitanguay flap
marker is used to precisely mark
position. the skin flap tissue, which is to be
excised before skin flap closure

36 Facial Aesthetic Surgery

 The temporal scalp flap is
tailored to match the temporal
hairline incision to achieve a
tension-free closure. The
preauricular skin is marked with a
demarcator and is trimmed to
leave the post-tragal skin flap sli
ghtly longer than the tragal
Figure 4.1.12 - Excess skin is draped Figure 4.1.13 - Cuts are made perpen-
cartilage. This manoeuvreen- in a superolateral vector over the margins dicular to the flap margin stopping
sures that the incision remains and excised short of the margins and then excised
post-tragal after healing and accordingly
fibrosis occur.
Cuts are made on the excess skin, perpendicular to the flap margin, stopping just short of it. This
allows the margins to be visualized when trimming the excess skin.Drains if used may be inserted
through separate incisions in postauricular scalp and tunnelled to the area of neck dissection where
they are positioned in dependent portion of wound. Layered repair is then carried out in the final
closure.

Postoperative Care
The first postoperative appointment is on the day after surgery. Any dressings and drains are
removed, and careful examination of the skin flap is performed to evaluate skin vascularity. All areas
are inspected for the presence of a hematoma or seroma. A cooling mask can be used continuously for
the next 72 hours, taking short breaks for showering and wound care. The patient is allowed to shower
48 hours postoperatively. The patient is seen for their second visit on the seventh postoperative day for
complete suture removal and removal of one-half of the hairline staples. On the ninth postoperative
day, the remaining hairline staples are removed. If all wounds are healing well, the patient returns 4
weeks after surgery for evaluation

37 Facial Aesthetic Surgery

 Chapter 4B
Extended Deep Plane Facelift

D eep plane facelifting targets the mobile medial superficial muscular aponeurotic system,
bypassing the lateral fixed superficial muscular aponeurotic system dissected in these
techniques. Releasing facial and cervical retaining ligaments allows greater redraping of
the superficial muscular aponeurotic system and platysma during rhytidectomy.
Extending the deep plane flap inferiorly into the neck and incorporating a platysmal
myotomy creates a platysma hammock to define the inferior mandibular contour and support the
submandibular gland. Deep plane composite flaps of skin, the superficial muscular aponeurotic
system, and malar fat can be repositioned to volumize the midface and gonial angle.

Objectives of Deep Plane Facelift

Figure 4.2.1 - Planes of dissection of the deep plane Figure 4.2.2 - Ligamentous attachments released in the
facelift extended deep plane face lift

Surgical Technique
Incision & Skin Flap Elevation
Skin incision is initiated with a No. 10 scalpel cutting perpendicular to the skin hairline of the
temporal hair tuft. The temporal and occipital hairline portions of the incision can be extended during
the operation if further skin redraping is need. Coursing inferiorly from the temporal region, the

38 Facial Aesthetic Surgery

incision should not be placed at the anterior edge of the helical crus
cartilage because it can make the root of the helix seem to be
unnaturally wide.(Jacono and Bryant, 2018) It should then traverse
along the posterior edge of the tragus, but not on its inner surface as
this can create an unnatural folding of the cheek skin that blunts the
tragus and can be a tell-tale sign of a facelift incision. A small step in
the incision is placed at the inferior tragus to preserve the natural
depression at the intertragic incisure. Around the earlobe, the incision
should continue 2 mm inferior to the lobule cheek junction to preserve
the natural sulcus between the lobe and the cheek. Posteriorly, the
incision should continue a few millimetres onto the posterior conchal
cartilage rather than directly in the postauricular crease. Figure 4.2.3 - Skin incision

After the initial skin incision is made, with no.10

scalpel subcutaneous flap is elevated. While applying
counter traction on the cheek (assistant's hand on the
cheek), a skin flap is elevated leaving adequate amount
of fat on its underside (3–4 mm). This is initially done
with a blade and can be advanced using face lift
scissors. If the dissected flap is too thin, the dermal
plexus of blood vessels of the fragile skin flap can be
compromised. If the flap is too thick, the operator may
invade the parotid gland or facial nerves. Figure 4.2.4 - Elevation of the subcutaneous flap
to the deep plane entry point

Subcutaneous elevation in the cheek ends approximately 2 to 4mm beyond the marked line of the
deep plane entry point. The deep plane facelift approach poses no risk to the frontal branch because
the dissection is superficial in the subcutaneous plane where the frontal branch exists, and the sub-
SMAS dissection is begun at the deep plane entry point, which is 2 cm anterior and parallel to the
course of the frontal branch of the facial nerve.

The postauricular skin is then

dissected in a similar fashion and
connected to the facial dissection. Once
dissection has reached the anterior
border of the SCM, the inferior and
medial subcutaneous/supraplatysmal
dissection in the neck is accomplished
Figure 4.2.5 - The preauricular Figure 4.2.6 - Neck flap subcutaneous
with afacelift scissors. subcutaneous flap ends at the dissection is continued to the midline
marked line of the deep plane using a longer lighted retractor and
entry point long facelift scissors

39 Facial Aesthetic Surgery

 The mandibular cutaneous ligaments are released using the
same backlit skin under tension method as the rest of the skin
flap, releasing the ligaments in a subcutaneous plane. In cases
with more fibrous and dense ligaments, dissection can be aided
through the submental incision.

Figure 4.2.7 - Release of the

mandibular ligaments
Deep Plane Dissection: Release of The Zygomatic–cutaneous Ligament,
Zygomaticus Major Muscle Fibrous Attachments, And Masseteric Cutaneous
Ligament
The incision extends from the mandible to the to the orbital rim near the lateral canthus.

Figure 4.2.8 - (A) An Anderson 5-prong retractor is placed at the anterior extent of the skin
dissection parallel to the deep plane entry point line. (B) With vertical tension on the retractor,
a No. 10 scalpel is used to make the incision into the deep plane
Composite flap of skin and SMAS is elevatedoff the parotid–masseteric fascia.
The masseteric cutaneous ligaments are released, allowing for
more complete repositioning of the jowl. Elevation of this flap
continues superiorly until resistance is reached at the zygomatic
osteocutaneous ligament. Blunt dissection through the inferior
part of the deep plane flap is continued under the platysma below
the mandibular border and onto the neck to facilitate later release
of the platysma from the sternocleidomastoid muscle.
Once the lateral border of the orbicularis is identified, the
prezygomatic space can be easily dissected with blunt finger Figure 4.2.9 - The sub- SMAS dissection
continues anteriorly with vertical spreading
dissection. This dissection is carried medially into the motion with a facelift scissor until the
premaxillary space, ending at the nasal facial crease. This masseteric cutaneous ligaments are released
technique was originally described as the FAME or finger- to the anterior border of the masseter
assisted malar elevation by Aston. (Aston,1998)

40 Facial Aesthetic Surgery

 Figure 4.2.10 - Elevation of the superior aspect of the deep plane pocket (A) Blunt dissection at the superior extent
of the deep plane entry point, creating a plane superficial to the orbicularis oculi muscle (B). (C) Blunt finger dissection
medially to free it to the deep plane to the nasal facial crease
At this point, the zygomatic osteocutaneous ligaments have been isolated between the upper and
lower composite deep plane flaps. These ligaments tether the SMAS/platysma complex to the malar
bone and must be released to accomplish vertical elevation of the composite flap.
Staying superficial to the zygomaticus protects the facial nerve branches, which innervate the
zygomaticus muscle from its deep surface. After sharp release of the dense ligaments, blunt dissection
continues along the plane of the zygomaticus major and minor until the premaxillary space and
nasolabial fold is reached.

Figure 4.2.11 - Release of the deep Figure 4.2.12 - (A) Deep plane flap is released through the zygomatic ligaments
plane flap with sharp dissection of and (B) elevated to the nasolabial fold
the zygomatic ligaments superior to
inferior and staying superficial to the
zygomaticus musculature
Release of the Cervical Retaining Ligaments
The deep plane flap in the neck is marked from the gonial angle to the anterior border of the
sternoclei-domastoid
muscle extending 5 cm
inferiorly into the neck.
The dissection plane
immediately below the
platysma ensures that the Figure 4.2.13 - Release of the cervical retaining ligaments (A) Surgical marking of the
marginal mandibular and lateral platysmal border at its connection to the sternocleidomastoid muscle extending
5 cm below the angle of the mandible. (B) A No. 15 scalpel is used to make a broad and
cervical branches of the gentle incision until a lip of tissue is obtained, the edge grasped and sharp dissection
facial nerve down remain within the sternocleidomastoid muscle fascia is continued for approximately 1 cm,
deep, on the superficial (C) Subplatysmal flap freed after bluntly dissecting through the ligaments 3 cm anterior
to the sharply elevated flap
cervical fascia.

41 Facial Aesthetic Surgery

Deep Plane Flap Suspension
The angle of flap suspension transitions from
vertically dominant at the mandibular angle to
horizontally dominant near the orbit.
The vector of lift for the composite flap in deep
plane rhytidectomy is vertical oblique. Suture
suspension begins with a half-mattress suture
connecting the SMAS cuff at the deep plane entry
point to the parotid masseteric fascia in the
preauricular region for suspension of the inferior
portion of the flap. The superior portions of the flap in
the upper cheek are suspended to the deep temporal
Figure 4.2.14 - The deep plane flap is typically sutured
fascia. Importantly, the point of flap suspension for at 5 to 7 nearly equidistant points along the cuff formed
the upper flap is to the deep temporal fascia 2 cm at the deep plane entry point to the preauricular & deep
above the zygomatic arch, similar to the high and temporal fascia
lateral SMAS facelift. Repositioning the ptotic midface revolumizes the upper cheek over the
zygoma.

Figure 4.2.15 - (A) The flap is suspended vertically at an angle that maximizes elevation of the cheek fat pads and
revolumizes the midface. (B) Suture suspension along vertically oblique vector of 60 degree

Lateral Platymsa Suspension in the Neck& Skin Closure

After resuspension of the composite flap in the face is finished, attention is directed to redraping of
the cervical platysma. A horizontal myotomy of the platysma is performed parallel to the inferior
margin of the mandible for approximately 4 cm, ending at the area over the submandibular gland. The
inferior platysmal tab is anchored to the mastoid fascia with a 3-0 nylon suture and positioned just
below the margin of the mandible. The vector of pull runs along the submandibular region and away
from the cervicomental angle.

42 Facial Aesthetic Surgery

 Figure 4.2.16 –Lateral playtsmal suspension in neck (A) Horizontal myotomy of the platysma performed parallel
to the inferior margin of the mandible for approximately 4 cm ending at the area over the submandibular gland.
(B) Intraoperative view of horizontal myotomy of the playtsma

Figure 4.2.17 - Lateral Playtsmal suspension in neck (C) The inferior platysmal tab is anchored to the mastoid fascia
with a 3-0 nylon suture and positioned just below the margin of the mandible creating a platysma hammock that elevates
the ptotic submandibular gland. Mandibular contour. (D) Note contour improvement of jawline and upper neck with
tension placed on platysmal hammock

After resuspension of the face and neck, attention is turned to redraping of the skin. The facial skin
is suspended in the same plane as the composite flap. The majority of the skin is removed vertically in
the temporal region. Deep, everting 4-0 Vicryl sutures are placed along the temporal incision prevent
depression and spreading of the scar over time. Skin closure is completed with everting 5-0 nylon
vertical mattress sutures. The remainder of the incision is closed with 5-0 nylon sutures anteriorly, 5- 0
nylon sutures behind the ear, and 4-0 nylon sutures in the occipital hairline.
Adjunctive submental procedures and platysmaplasty is indicated only if submental platysmal and
skin laxity is not corrected when surgeon places 3 fingers at deep entry point, a line from angle of
mandible to lateral canthus, on both sides of face and moves skin vertically.(Jacono and Bryant,
2018)

43 Facial Aesthetic Surgery

Figure 4.2.18 - The majority of the skin Figure 4.2.19 - (A) Preauricular and (B) postauricular skin closure
redundancy is removed vertically in the
temporal region
Post Operative Care
The patient is seen in 24 hours. The pressure dressing is removed to determine skin flap viability
and the presence of any hematomas. The pressure dressing is reapplied for another 24–48 hours. The
patient is instructed to avoid strenuous physical activities and to apply ice packs to the face to help
with post-operative oedema. The patient's head must stay elevated compared to his/her body to reduce
swelling. Any permanent suture is removed in 5 days.(Fonseca, 2017)

44 Facial Aesthetic Surgery

 Chapter 5
Rhinoplasty

R hinoplasty remains presently one of the most complex surgical procedures in aesthetic
Surgery. As a central landmark of the face, nasal proportions and symmetry are directly
linked to facial beauty. Technical difficulties, the wide range of different techniques
described, and the struggle to achieve consistent results can be challenging even for very
experienced surgeons.

Surface Landmarks

Radix : The deepest depression of the nasal dorsum, located at the junction between
the frontal bone and the nasal bones.
Glabella : The most forward projecting portion of the forehead, located at the midline
between the supraorbital ridges.
Rhinion : The osseocartilaginous junction formed by the nasal bones and upper lateral
cartilages.
Dorsum : The anterior surface of the nose formed by the nasal bones and upper lateral
cartilages.
Supratip break : The slight depression seen in profile at the point where the nasal dorsum joins
the lobule of the nasal tip.
Infratip lobule : The portion of the tip lobule located between the columella and the most
projected portion of the nasal tip.
Tip defining points : For proper nasal tip definition four points should be visualized. These four
points are composed of the supratip break, the infratip lobule, and the most
projected portion or domes of the lower lateral cartilages.
Alar sidewall : The rounded eminence forming the lateral nostril wall.
Alar-facial junction : The depressed groove formed at the junction where the ala joins the face.
Columella : The skin that separates the nostrils at the base of the nose.
Nasofrontal angle : The angle formed between the forehead and nasal dorsum as seen in profile
view.
Nasolabial angle : The angle formed by the columella and the upper lip as seen in profile view.
Pronasale : The most projected portion of the nasal tip.

Table 5.1 – Surface Landmarks

45 Facial Aesthetic Surgery

 Figure 5.1 - Surface landmarks
Clinical Examination For Rhinoplasty

Local
General/ systemic
Facial Nose

Airway/ breathing Intercanthal distance Skin quality

Mouth breathing Nasal bone – width, length & symmetry
Inter – eyebrow distance ULC – width and symmetry
LLC
Bleeding disorder · Cephalic malposition
Frontal bossing/ · Interdomal distance
Hypertension glabellar projection · Asymmetry of light reflecting points
· Lobule position
Diabetes/ Immunosuppression Upper lip position · Nostril – columellar relation
Alar base
Psychological assessment Chin position · Vertical and horizontal position
(in repose and smile)
· Inter alar distance (should be 2mm
wider than intercanthal distance)
· Insertion of alar base
Table 5.2 – Clinical examination for rhinoplasty

The radix is located vertically between the superior

palpebral margin and the upper eyelid margin and
is typically 4 to 9 mm anterior to the corneal plane.
The ideal nasofrontal angle is between 115 and 130
degrees and tends to be more acute in men and
obtuse in women. The nasal dorsum typically lies 2
mm behind a line drawn from radix to nasal tip in
women and on this line in men. (Fonseca, 2017)
The ideal tip projection is 0.55 to 0.60 RT, where
RT is the distance between radix and pronasale
Figure 5.2 - Dorsal profile & Figure 5.3 - Goode's method
provided that the nasofrontal angle is between 36 position of radix of nasal projection
and 40 degrees.

46 Facial Aesthetic Surgery

Surgical Approaches For Rhinoplasty

Open approach / open structure rhinoplasty

Closed / endonasal approach

Open Approach / Open Structure Rhinoplasty

The open structure approach is employed when extensive reconstruction is required. There is more
emphasis on the preservation and realignment of structures of the lower third of the nose and also
achieving balance of the nasal “tripod”.(Bonanthaya et al., 2021)

Indications
§ Marked asymmetry
§ Secondary rhinoplasty
§ Need for structural grafting
§ Post traumatic nasal deformity
§ Nasal valve correction

Incisions
§ Marginal
§ Columellar

Marginal
Figure 5.4 - Marginal and rim
(infracartilaginous) incisions
The incision is
The marginal incision (dotted placed along the
line) parallels the caudal edge caudal margins of the
of the lower lateral cartilages LLC, starting at the
and is commonly used in rhin- caudal margin of the
oplasty. The rim incision (red
line) follows the contour of medial crus, running
the nostril along the mucosa along the entire
just inside the nostril dome and extended
laterally along the
caudal margin of the
lateral crus.
Figure 5.5 - The transcolu-
mellar incision Various con- Columellar incision
figurations of the transcolu-
mellar incision are used to This is a transverse
prevent linear scar contrac- mid-columellar
ture and aid in re-approxima- incision extending
ting the skin at closure. across to connect the
The common configurations
include a V, inverted V, or
marginal incisions
stairstep configuration on either side.

47 Facial Aesthetic Surgery

 A mid-columellar inverted-V incision, placement of which should be where the underlying
cartilage is closest to the skin to avoid scar visibility and contracture is made. With the help of skin
hooks and sharp dissection (e.g., Converse scissors), the mid-columellar incision is transitioned to the
marginal incisions. The soft tissue envelope is further reflected superiorly in a relatively avascular
supra-perichondrial plane to expose the upper lateral cartilages (ULC). At this point, dissection over
the ULC is shifted to a sub-perichondrial plane using sharp dissection. A periosteal elevator (e.g.,
Joseph elevator) is then used elevate the periosteum over the nasal bones up to the nasofrontal angle.
The lower lateral cartilages are then separated in the midline to expose the anterior septal angle (ASA)
in preparation for septoplasty and/or septal cartilage harvesting.(Raggio and Asaria, 2019)

After dissecting the soft tissues of the lower and upper lateral cartilages, the soft tissues of the
columella and the domes are elevated and joined with the previously made pockets. Converse scissors
are used to begin dissection along the vestibular mucosa and a tunnel is created just caudal to the
medial crura. Next, a single skin hook is placed at the apex of the inverted V incision and the Converse
scissors are used to elevate the columellar skin.

Then tissues of the nasal dorsum are elevated. An Aufricht retractor is placed and the soft tissues
should be freed to the junction of the upper lateral cartilages with the nasal bones. The periosteum of
the nasal bones should be elevated sharply with a periosteal elevator.

Closed / Endonasal Approach

Nondelivery approaches are employed when minimal reduction of the lateral crus or mild cephalic
rotation of the tip complex is indicated. The technique in turn may involve either the cartilage splitting
approach or the retrograde eversion approach. (Bonanthaya et al., 2021)

Indications
§ Minimal tip correction
§ Access to dorsum and middle vault
§ Volume reduction of LLC
§ Septal surgery
§ Bony and cartilaginous hump removal

Incisions
§ Trans cartilaginous (Cartilage splitting)
§ Intercartilaginous (Retrograde eversion)

In Delivery approaches the first inter-cartilaginous incision and the subsequent marginal incision
to mark the chondrocutaneous unit of the LLC. The nonvestibular side is then dissected off the
overlying SSTE permitting the delivery of the LLC chondrocutaneous unit as a bipedicled flap.

48 Facial Aesthetic Surgery

Indication
Allows more delicate tip work than the nondelivery approach

Figure 5.6 - The intercartilaginous and transcartilaginous incisions

The intercartilaginous incision (blue dotted line) follows the junction
of the upper and lower lateral cartilages in the region of the scroll
The transcartilaginous incision (solid line) is made through mucosa
and the cephalic portion of the lower lateral cartilages

A retractor is placed holding the alar rim superiorly, and slight pressure is applied in order to evert
the mucosa and visualize the intercartilaginous groove. Depending on the surgical planning, an
approach to the tip area could be done via delivery or non-delivery of the lower lateral cartilages
The trans-cartilaginous incision is usually performed in the context of a patient with a bulbous or boxy
tip, and the cephalic trim of the lower lateral cartilages is planned. After the incision, with the use of a
hook, eversion of the nasal mucosa is performed, and excess cartilage is detached using scissors. At
least a 5 mm rim strip should be maintained in order to avoid a pinched tip or an external valve
collapse.(Fichman, 2020)
The delivery technique is used when more complex tip modifications are planned. It allows for
better visualization as an open approach would provide. It is performed by making a marginal incision
from lateral crus to medial crus and an intercartilaginous incision bilaterally, which connect in the
midline and can continue to a hemi transfixion incision. The soft tissue between the marginal and the
intercartilaginous incision is dissected so that the lower lateral cartilages can be “delivered out” of the
incisions in order to modify them. These modifications can include trimming of the cephalic portion
of upper lateral cartilages, inter or intradomal sutures, tip grafts, and controlled weakening of the
cartilages. After this step, using a periosteal elevator, soft tissues are separated from the cartilaginous
and bony dorsum in a subperichondrial and subperiosteal plane.

Septoplasty
Deformities of the nasal septum may either be congenital or acquired.

Killian incision

Figure 5.7 – Killian Incision

The Killian incision (red line)
is a common incision used for
septoplasty but is not routinely
used for rhinoplasty. The incision
is made several millimetrescephalad
to the caudal edge of the septum

49 Facial Aesthetic Surgery

 The ASA (Anterior Septal Angle) is sharply exposed, and a sub-mucoperichondrial pocket is
created caudally to the nasal spine and posteriorly beyond the septal bony-cartilaginous junction
bilaterally.

Figure 5.8 - Septoplasty intra-operative steps (a) The part of the septum anterior to the line dropped from the tip
of nasal bone (NB) to the anterior nasal spine (ANS) has tobe preserved (b) Dysjunction of the cartilaginous septum
from the bony septum (c) Septal repositioning with sutures to the midline crest of the maxilla
Nasal Osteotomies
Indication
§ Close an open roof after dorsal hump removal
§ Correction of a deviated bony nasal vault (crooked nose/ bent nose)
§ Correction of concave or convex nasal bones
§ Reduce or narrow bony base width
§ Mobilise malunited fractured nasal bones prior to reduction

Lateral Osteotomy Medial Osteotomies

Lateral osteotomy is performed with a 2mm/ 4mm A 7mm osteotome placed on the edge of the nasal
osteotome from inferior, swept laterally to the bony bone where it meets the dorsal septum angling 15
nasofacial groove and then superiorly at the level degrees laterally. Tapped with a mallet till the level
of medial canthus of the medial canthus.

Table 5.3 - Lateral and Medial Osteotomies

Once the osteo-

tomies performed,
bilaterally fracture is
completed with slight
digital pressure. Three
separate digital strokes
are made along the mid
dorsum and on either
side to assess the Figure 5.9 - Lateral nasal osteotomies The dotted black line in Figure 5.10 - The medial
smooth straight dorsum (A) demonstrates a low-to-low lateral nasal osteotomy. The red dotted osteotomy
without irregularity. line depicts a low-to-high lateral nasal osteotomy. The small triangle of
bone preserved in the piriform rim described as Webster's triangle.
(Fonseca,2017) (B) demonstrates the use of a 2-mm osteotome to perform a micro
puncture osteotomy along the nasalbones

50 Facial Aesthetic Surgery

Dorsal Hump Deformity
The dorsal hump is the most common problem for which a patient may seek rhinoplasty.
Based on the anatomical units
involved, three main types of dorsal
hump may be identified (Bonan-
thaya et al.,2021)
1. Osseous/bony hump that
exclusively involves the bony
vault,
2. C a r t i l a g i n o u s h u m p t h a t
involves the cartilaginous
Figure 5.11 - Dorsal hump reduction (A) A No. 11 blade can be used to incise
middle vault with septal and the upper lateral cartilages and remove excessive cartilaginous prominence
upper lateral cartilages and (B) Reduction of the bony dorsum is then performed using a Rubin osteotome
3. The osseocartilaginous hump (C) Rasping of the bony dorsum is an alternative technique for reducing
the bony prominence
that is a combination of the two.

Saddle Nose Deformity

A saddle nose deformity is defined as a wide and fat nose with a concavity on the nasal dorsum.
Classical clinical presenting features of this deformity are
§ Loss of height of the nasal dorsum (appearance of a shortened nose)
§ Increased width of the nasal dorsum (wide nose)
§ Under projected tip due to inadequate septal support to the tip complex

Implants:
§Autografts: Nasal septum, pinna & rib
cartilage, Iliac crest, Mastoid cortex or
tibia.
§ Homograft (allografts): Preserved,
irradiated or lyophilized cartilage and
bone.
§ Heterograft (xenograft): porcine or
bovine collagen.
§ Synthetic Alloplasts: Silastic, acrylic,
ivory, silicon, teflon, gore-tex, supramid Figure 5.12 – Augmentation of Post traumatic Saddle
mesh, proplast. nose deformity (a, b) with subtotal loss of the cartilaginous
septum using multi-layered quilted septal and conchal
cartilage graft (c)
Correction of the Deviated Nose
Deviated noses can be of two types
1. “Bent” nose where the nasal bones and the upper lateral cartilages point to the same side
2. “Crooked” nose where the nasal bones and the upper lateral cartilages face in opposite directions

51 Facial Aesthetic Surgery

 Figure 5.13 – Correction of deviated nose (a) Differential reduction Figure 5.14 – Correction of deviated nose
of hump prior to osteotomy, (b) Septal repositioning, (c) Digital (d) Line diagram of “low-to-low” osteotomy,
reduction/manipulation after osteotomy (e) Intraoperative picture with osteotome
positioning (low-to-low), (f) Line diagram
of “nasal bone osteotomy”, (g) Intra-operative
picture with osteotome positioning (nasal bone
osteotomy)

Tip Plasty
The nasal tip is the centre of focus for both nasal anatomy and aesthetics. It is a very important
anatomical subunit and can be most challenging to refine surgically. The nasal tip is the centre of focus
for both nasal anatomy and aesthetics. It is a very important anatomical subunit and can be most
challenging to refine surgically. (Tasman,2007)

Types of tip deformities

§ Wide
§ Bulbous
§ Over projected
§ Under projected
§ Over-rotated (piggy nose/toffee nose)
§ Under-rotated (ptotic tip)
§ Asymmetric

Figure 5.15 - Narrowing of boxy Figure 5.16 - Lateral crural steal A horizontal mattress suture
tip The dome can be (A) Dissected placed in the lateral crura which is advanced to the midline can
(B) Transected (C, D) and recons- increase nasal tip projection
tructed after resection of segment
intermediate crus
52 Facial Aesthetic Surgery
 Figure 5.17 - Rotation of tip (A)Transfixion (B)Excision of skin and cartilage wedge of caudal septum
(C) Columella anchored to caudal cartilaginous septum in desired position with anchoring suture

Wide Ala
The normal width of the ala falls within or just beyond an imaginary vertical line dropped from the
medial canthus to the upper lip.(Bonanathaya et al., 2021)

Figure 5.18 - Wide ala

surgery techniques
(a) Traditional Weir
excision (leaves a notch
deformity) and
(b) modified excision
incorporating a lateral
advancement which
prevents notch deformity
and restores continuity
of alar rim
Figure 5.19 - Nasal dressing
Dressings and Splinting
The thermoplastic splint should cover the region from radix to the supratip, should cover just the
nasal bones, and should not extend laterally onto the cheek. Intranasal packs or stents are generally not
required. If a turbinectomy is performed or if a large tear is created in the septal mucosa, a silicone
stent can be placed.(Fonseca,2017)

Follow Up And Care

The patient is seen at 24 hours and again in 1 week, at which time the splints and dressing are
removed. The patient is instructed not to blow the nose, so that bleeding is not stimulated. The patient
can gently clean inside the nostril with a cotton applicator and dilute peroxide at 1 week.
(Fonseca,2017)

53 Facial Aesthetic Surgery

 Chapter 6
Endoscopic Forehead & Browlift

T he ageing process typically leads to forehead and brow ptosis for almost every patient.

Of all the forehead and brow lift procedures, the endoscopic forehead and brow lift has proved to
be the most common and predictable of the facial cosmetic techniques.

Indications Contraindications

Brow ptosis Excessive hairline recession (endoscopic

brow lifting may raise the hairline slightly)
Deep rhytids and/or furrows traversing
the forehead, glabella, and/or nasal radix Excessively curved forehead and/or frontal
bossing (inhibits the passing of endoscopic
The appearance of a heavy or redundant instruments to the periorbita)
forehead or temporal skin

Pseudo-blepharoptosis and/or visual

field restriction

Table 6.1 – Indications and Contraindications of Endoscopic Brow and forehead lift
Several key assessments necessary for any patient undergoing an endoscopic brow lift include:
§Position of the eye brows
§Presence of dermatochalasis of the upper lids
§Forehead rhytids
§Position of the frontal hairline
§Slope and length of the forehead
§Status of the corrugator muscles

An endoscopic brow lift is intended to elevate the ptotic brows more normal position. Forehead
rhytids, especially deep rhytids, are improved with an endoscopic brow lift.Superficial and shallow
rhytids usually require a laser resurfacing.

54 Facial Aesthetic Surgery

Ideal Eyebrow
The ideal eyebrow in a male is a straight brow that is 0–2 mm above the supraorbital rims. (Evans,
1998)
The ideal female brow
should be arched with the
medial head 0–2 mm
above the supraorbital
rim, apex 10–12 mm
above the supraorbital
rim, and the tail sloping
slightly inferior.
Figure 6.1 - Ideal eyebrow position in Males Figure 6.2 - Ideal eyebrow position in females
Markings
The right and left temporal crescents, denoting the fusion of
periosteum, deep temporal fascia, and temporoparietal fascia at the
conjoined tendon, are palpated and marked. Marks are then made at
the right and left lateral orbital rims at the level of the lateral canthal
angle. These marks denote the area of the zygomaticotemporal
(sentinel) vein and should be the lateral limit of the dissection.
The supraorbital notch is then palpated on each side, and a “safety
zone” of approximately 2 cm is drawn around these notches to
protect the supraorbital and supratrochlear nerves during later
dissection. Figure 6.3 - Markings for an
endoscopic brow lift
Endoscopic Ports
Most clinicians use five ports for an endoscopic brow lift including two temporal ports, two lateral
(paramedian) ports and a central (median) port. (Langdon et al., 2017)
The median and paramedian ports are marked 1 cm inside the hair line. Each of these incisions is
1–1.5 cm in length in a cranio-caudal direction.
The central port is marked in the middle of the frontal hairline; the two paramedian ports are
parallel to the lateral limbus/canthus region.
The two temporal markings are made after drawing a line that intersects the ala of the nose and the
lateral canthus and extends on to the temple. The temporal port is tangent to this line, is 2 cm in length
and is obliquely directed.

Surgical Procedure
After administration of a local anesthetic with a vasoconstrictor, the central and paramedian
incisions are made with a No. 15 blade through all five layers of the scalp onto the bone.
The two temporal incisions are then made with a No. 15 blade through skin, subcutaneous layer
and temporoparietal fascia. The incision stops at the superficial layer of the deep temporal fascia. All
incisions should be beveled along the length of hair follicles to reduce alopecia.

55 Facial Aesthetic Surgery

Frontal Cavity Creation
Over the frontal bone cavity is created in subperiosteal
plane. Blunt subperiosteal undermining, without the
endoscope, is performed with an elevator curved down
almost 90 degrees at the tip to delineate markings. In the
glabellar region, this dissection is carried to the origin of
the corrugators in the midline. The dissector then ''pops
through'' the periosteum and enters the subgaleal plane
over the nose. This leaves the origin of the corrugators and
neighbouring ligaments intact. Near the temporal line, the
subperiosteal dissection is taken to the level of
Figure 6.4 - Elevator used to blindly undermine
arcusmarginalis. The arcus is not elevated at this point. in the subperiosteal plane over the frontal bone.
(Keller and Mashkevich, 2009) A semi-circular area above the supraorbital
nerve is not elevated
Temporal Cavity Creation
The temporal incision is carried through skin and
temporoparietal fascia to the superficial layer of the deep
temporal fascia, overlying the temporal muscle. Between
the temporoparietal fascia and the superficial layer of the
deep temporal fascia, there exists a loose areolar layer, the
innominate fascia. This layer consolidates, when pushed
upward to form a layer of fascia that forms the ''basement''
of the temporal fat pad containing the facial nerve. It is
emphatic that the surgeon elevates the entire innominate
fascia to protect the facial nerve.
The dissection is carried bluntly with the straight Figure 6.5 - Loose areolar tissue of the in-
elevator in a posterior direction along the superficial layer nominate fascia is swept upward
of the deep temporal fascia under direct visualization.
This creates a cavity, which can then be extended forward
under direct visualization to the hairline.
Beyond the hairline, the temporal cavity is under direct
endoscopic control using 30-degree endoscope. The
sentinel vein, one of the zygomatico-temporal veins, is
visualized at the level of the zygomatico-frontal suture.
Lateral to this, the zygomatico-facial nerve, often
accompanied by a second vein is seen at the lateral malar
eminence. Dissection into the midface is safe between
these two landmarks. If necessary, the sentinel vein can be Figure 6.6 - Sentinel vein and another vein lateral
safely cauterized with bipolar cautery to improve access to that. A nerve passing above this may represent
and ease of dissection. a frontal branch of the facial nerve
At the lateral orbit rim, the dissection meets resistance. This area of resistance represents the
thickened lateral orbicularis retaining ligament, also called the ''precanthal tendon'' or ''lateral orbital
thickening (LOT). To elevate the brow, especially in its lateral aspect, the orbicularis muscle must be
freed and elevated. The lateral orbital thickening (or precanthal tendon) is cut in a supraperiosteal
plane with a scissors or, for diminished bruising, the PEAK Plasma Blade.

56 Facial Aesthetic Surgery

Connecting The Frontal & Temporal Cavities
Connection of the two cavities is performed
from the temporal side. At the temporal line, there
is a consolidation of fascias termed the ''conjoint
fascia.'' As the orbital rim around the lateral brow is
approached, the conjoint fascia thickens and is
termed the ''conjoint tendon'' or the ''frontal
ligament.'' The conjoint tendon (or frontal
ligament) is excised sharply, lifting the periosteal
attachments with the curved-down elevator. Then
frontal and temporal cavities are connected. Often
there is a vessel in this area that can cause
troublesome bleeding. This vessel must be Figure 6.7 – Connecting frontal and temporal cavities
coagulated cautiously, as the facial nerve is in this (Top Left) Periosteal elevator is placed on the temporal line.
region. The facial nerve passes in the temporo- (Top Right) Incision of the frontal periosteum at the temporal
parietal fascia 0.5 cm lateral to the lateral brow at line. (Bottom Left) Elevation of the frontal periosteum.
(Bottom Right) Connection of the temporal and frontal
the superolateral orbit. dissections from lateral to medial

Release of the Frontal Ligaments, Arcus Marginalis & Depressor Musculature

The arcusmarginalis represents the insertion of the orbital septum to the periosteum. The surgeon
can perform further elevation of the periosteum to the level of the arcusmarginalis in one of two ways.
The endoscopic surgeon can use the
dissection sheath with one hand to
simultaneously elevate the periosteum
and visualize the dissection. Alternately,
the surgeon can triangulate, using the
endoscopic sheath to retract and
visualize, while using a curved-down
elevator to elevate the periosteum. By
elevating the periosteum to the Figure 6.8 - Supraorbital bundle a)Supraorbital bundle is seen to emerge
arcusmarginalis under direct vision with from a foramen 1.5 cm above the orbital rim. If the surgeon were to blindly
undermine to the orbital rim, he or she would avulse the nerve on this side
the endoscope, the surgeon can avoid b)A left lateral supraorbital nerve branch is seen exiting from a foramen
cutting the supraorbital nerve or a 1 cm above the orbital rim. The main supraorbital bundle is seen emerging
branch of the supraorbital nerve that from a notch below the supraorbital rim
emerges from a foramen.
Medial to the supraorbital nerve, and lateral to the Figure 6.9 -
The corrugator
corrugator insertions, the periosteum usually must muscle may
be incised. The periosteum is then elevated, be ident ified
by its oblique
exposing the corrugator and procerus muscles. course between
Either a scissors (used bluntly and sharply), a plasma the supraorbital
& supratroch-
knife (PEAK Surgical), an ultrasonic scalpel, or a lear neurovas-
laser are then used to incise the corrugator, cular bundles.
Endoscopic
depressor, and procerus muscles, preserving the scissors are
supraorbital and supratrochlear nerve branches. used to divide
this muscle

57 Facial Aesthetic Surgery

 Undermining of the orbicularis muscle is performed both medially and laterally to the level of the
tarsal plate along the orbital septum.
At the end of the dissection, attention is turned to the lateral precanthal area (or lateral orbital
thickening). Usually, further dissection and incision of this area is warranted. After further separation
of the precanthal ligament, the brow tail loosens and becomes movable in all directions, often
dramatically so. The lateral canthal ligament is not incised as we do not usually wish to elevate the
canthus.

Rotation & Fixation To Elevate The Brow

After the dissection is complete, the brow is
quite movable. The medial brow requires more
than several millimetres elevation while the lateral
brow is elevated more than 5 mm (0.5 cm). The
brow is fixed only from temporal incision. After
backward pull and suture fixation from the
temporo- parietal fascia to the superficial layer of
deep temporal fascia, with a figure-of-eight
interlocking suture, the lateral brow is placed into
desired position.(Fonseca, 2017)
After the periosteum has been released, the Figure 6.10 – Rotation and fixation of brow . Bone tunnel
forehead flap must be elevated and fixated. at right parasagittal incision and suture fixation with a single
Titanium miniplates or resorbable plates can be heavy suture (0 Nurolon or 0 Vicryl). A thick “bite” galea
at the level of the hairline is needed to secure the final
used to anchor the forehead flap and fixate the flap location of lateral brow elevation. A poor or thin amount
in an elevated fashion. Usually, two points of of tissue in this single suture could lead to unwanted release
fixation is sufficient unless severe medial brow & asymmetry a few hours or days later
ptosis is present at which time three points of
fixation (median, two paramedian) will be
necessary.
The two temporal incisions are closed while the assistant elevates the lateral brow region and the
inferior limb of the incision is elevated and anchored to the deep temporal fascia superior to the initial
incision using 2/0 PDS. This allows temporal elevation of the lateral brow. To obviate the need for a
surgical drain, fibrin sealant is sprayed into the surgical field.
Next, the three forehead incisions are closed in two layers. Staples are used on the scalp. A pressure
dressing is applied to the forehead.

Post Operative Care & Follow-up

The patient is seen in 24 hours to remove the pressure dressing and assess any hematoma
formation. Most patients will experience transitory headaches following an endoscopic brow lift. The
patient is instructed to refrain from strenuous exercise. The scalp stapes are removed in 10 days.
Perioperative antibiotics are discontinued in 24–48 hours as per the surgeon's discretion.(Fonseca,
2017)

58 Facial Aesthetic Surgery

 Chapter 7
Minimally Invasive Procedures

A s individuals enter their 30s and 40s, fine lines, creases, rhytids, and sagging skin become
apparent, and deep furrows and frown/scowl lines often develop. A wrinkle, or rhytid, is
categorized into dynamic and static conditions.

Dynamic Wrinkles Static Wrinkles

Dynamic wrinkles appear when expressing Static wrinkles, however, remain on the face
emotions, such as fear, worry, joy, sadness, even after our facial muscles relax and tend
or surprise. Dynamic wrinkles fade as to deepen with age. With aging, collagen
quickly as they appear. Once the emotion production declines and causes the skin to
passes and face goes blank, they will no lose elasticity. As a result, dynamic wrinkles,
longer be appreciated. Common dynamic such as smile lines around the nose & mouth
wrinkles include: will eventually become static wrinkles.
Frown Lines (between the eyebrows) Lines at the corners of the mouth, across
the cheeks, and along the neck.
Forehead wrinkles

Crow's Feet

Smile lines

Table 7.1 – Difference between Dynamic and Static Wrinkles

Figure 7.1 - Younger

patient demonstrating Figure 7.2 - Older patient
dynamic frown lines demonstrating dynamic
seen with glabellar frown lines seen with
complex muscle glabellar complex muscle
contraction & lack contraction and static
of static lines at rest lines at rest

59 Facial Aesthetic Surgery

 Although botulinum toxin is often believed to be the mainstay of wrinkle treatment by general
people, it cannot be applied to the treatment for all wrinkles. Main indications of botulinum toxin for
wrinkle treatment are dynamic wrinkles such as forehead lines, glabellar frown lines, periorbital
wrinkles, wrinkles on dorsum of the nose, fine lines around the lips, and the platysmal bands by
paralyzing the underlying facial mimetic muscles.
However, it is ineffective in static wrinkles. Therefore, filler injections should be recommended
for the treatment of furrows, including nasolabial folds, the marionette lines, and glabellar frown
lines.
This chapter will provide insight into the two most commonly used minimally invasive procedures
in the present time.

60 Facial Aesthetic Surgery

 Chapter 7A
Dermal Fillers

M ethod of restoring facial aesthetics in a minimally invasive way is now well established.
Soft tissue augmentation may be accomplished by surgery or intradermal injection of
synthetic or biological fillers.

Ideal Properties of Filler

§Ideally, it should be of non-animal origin, biocompatible,
§Biodegradable, low risk of allergic reaction, easy to use and
§Have minimal side effects such as bruising, infection,migration and tissue reaction

Classification
The majority of injectable fillers are temporary, lasting from several weeks to several months,
although some reportedly last 9–12 months. (Langdon et al., 2017)

Temporary (3–12 mo.) Semi-permanent (1–5 yrs.) Permanent (>5 yrs.)

These are mainly used to Calcium hydroxy apatite is These are mostly synthetic
replace collagen in the skin, one of the commonest semi- implants, Which are made
which weakens with age permanent fillers. It creates of polymethylmethacrylate
and loses its elasticity. a stable scaffold for soft (PMMA) microspheres.
Collagen has three main tissues to grow. PMMA microspheres may
sources—bovine, porcine, be mixed with denatured
human. It can be injected into the Bovine collagen & lidocaine,
deep dermis, where the and suspended in a phosphate-
Bovine collagen is very similar microspheres are held in
to the human molecule and is buffered saline solution.
place until they are resorbed Since PMMA is inert, it is
widely used. and collagen deposition well tolerated by the body
Hyaluronic acid is the most occurs. and does not induce allergic
commonly used temporary reactions
filler.

Table 7.1 – Classification of fillers

Facial Aesthetic Surgery

Dermal Filler Injection Methods
Different techniques were described for filler injections (Bonanthaya et al., 2021)
Linear Threading: In this technique, fillers are
injected in a needle and thread fashion. The needle
is inserted and withdrawn repeatedly along a
straight line. It has two types.
1. Anterograde Injection: The filler is injected
while the needle is being advanced, and the
filler is therefore easily tracked in the front of
the needle
2. Retrograde Injection: The filler is not injected
simultaneously during needle advancement.
Once the needle is slowly withdrawn, the filler
Figure 7.1.1 – Linear Threading
is injected

Depot: In this technique, a small amount of the filler is deposited in the correct plane.
Serial Puncture: In a single wrinkle or fold, multiple closely spaced depot injections are placed.

Figure 7.1.2 – Depot and Serial Puncture

Fanning: It is done through one point of entry and the needle is rotated like a fan in multiple
directions, and the fillers are deposited in a retrograde way. It is important to stop injecting as the
needle comes close to the insertion site in order to avoid build-up of fillers at the point of entry.

Figure 7.1.3 – Fanning

62 Facial Aesthetic Surgery

 Cross Hatching: Inject-
ing as multiple linear
thread and filler is
deposited in an X-shaped
fashion.
Grid: It is injected as
linear threads intersecting
perpendicular to each
other point of entry.
Ferning: This is similar to
retrograde injection. The Figure 7.1.4 – Cross Hatching Figure 7.1.5 – Grid
needle is inserted on either
side of the central tract,
and the fillers are depo-
sited in a branch-like
fashion almost like the
branches of a fern. Figure 7.1.6 – Ferning

Temporal Fossa
Depression of the temporal area tends to become much more visible with aging. This is due in part
to fat atrophy and in part to temporal muscle atrophy.
Superficial temporal artery and frontal branch of facial nerve should be taken care of while
working in this area.

Figure 7.1.7 – Markings for temporal fossa injection

The injection is Figure 7.1.8 – Temporal

adminis-tered in a single fossa injection technique
point. Safe point of 0.5cc of anaesthetic
injection is located solution is injected 5 min
before the treatment.
2.5cm laterally from This injection is per-
lateral margin of the formed in the supra-
orbital cavity and 2.5cm periosteal and subcu-
superiorly from the taneous layers. On each
side 0.75cc of filler is
superior border of injected into supraperio-
zygomatic arch. (Goisis, steal layer as a bolus
2014)

63 Facial Aesthetic Surgery

Forehead Wrinkles
Before injecting, the patient should frown the
brow and the needle is inserted at the subdermal plane
and injected in a linear fashion and it is also deposited
deep and parallel to the wrinkle. Small depots or
serial puncture fashion of fillers are injected along the
line of the wrinkles throughout its entire length.
Gentle rub or massaging to be done to distribute the
filler uniformly.
Figure 7.1.9 – Injection technique for forehead wrinkles
Malararea
While inject-
ing this area it is
important to
avoid the damage
of the infraorbital
nerve with the
needle.
If a sudden
pain is felt in the
area of the skin
innerved by the
infraorbital nerve Figure 7.1.10 - Safe point for malar area. The point Figure 7.1.11 - The point of introduction of
during needle of injections is in the superolateral quadrant individ- the cannula and its pattern in the treatment
insertion or pro- uated with Hinderer's lines ( Green arrow)
duct injection,
treatment should
be immediately
stopped, no pro-
duct should be
further injected
in order to avoid
possible com- Figure 7.1.12 – Steps of injection for malar area. (a)The initial Figure 7.1.13 – Steps of injection
pression of the opening is made above the Hinderer's lines intersection point for malar area. (c) A fan of 3
infraorbital nerve with a small and thin needle of 26G (b) A 27-G cannula 40mm concentric lines can be disposed
length is introduced perpendicularly to the skin plane through beneath the skin of the malar area
the hole created with the needle with retrograde injection technique.
No resistance should be encountered
Tear Trough
Tear Trough is usually referred to as the crease at the medial segment of the inferior orbital region.
As ageing occurs, the infraorbital rim becomes more skeletonised and depressed.
The skin in this area is really thin, and for this reason, any irregularity of the filler injected becomes
very evident. Any over correction with HA products in the periorbital area may cause an edematous
and puffy appearance of the lower eyelids. To avoid these bad outcomes, the injections must be at a
supra-periosteal level of the orbital rim.

64 Facial Aesthetic Surgery

Figure 7.1.14 – Injection Technique for Tear Figure 7.1.15 – Injection Technique for Tear Trough. (c)P e r p e n d i c u l a r
Trough. (a)To see better tear trough deformity, insertion of a 27G blunt tip cannula. The cannula is plunged deep into
the patient should be kept in a semi- seated the skin through the orbicular muscle, advancing to the periosteum
position. The point of insertion of the needle
is about 1cm below the orbital rim in line with (d)The cannula is then directed diagonally up toward the medial
mid-pupillary line and pattern of the cannula canthus of the eye and made it slide forward to the top of tear trough.
follows the dip. (b)A little hole is created The tip of cannula should be positioned over the lacrimal crest, touching
around 1cm below the orbital rim with the the bone (e)HA should be injected with retrograde technique along the dip
midpupillary line using 26 G needle
Nasolabial Fold
The nasolabial fold is defined as the groove from corner of the alar base to the margin lateral to the
angle of the mouth. The nasolabial groove must never be eliminated completely as this can result in an
unesthetic appearance.
Injection should be done in the mid-deep dermis: not too superficially to avoid the creation of
lumps, not too deep as no fold correction would be noticed. A linear threading retrograde technique
along the nasolabial fold can be used, concentrating on the upper
triangular shaped area below the nostrils and lateral to the ala.
Attention should be paid in injecting the crease near the mouth
corner: here just minute volume of filler should be delivered
because of the dynamical feature of this area. This is known as
smile lines, and overcorrection will result in unattractive lumps at
both sides of the mouth.
Safe point of injection: There are no particular dangerous
anatomical structures in the nasolabial crease area. For this
reason, there are no particular safe points to pay attention to Figure 7.1.16 - Nasolabial fold injection
technique
Lip Augmentation
This is one of the most common cosmetic procedures done using Hyaluronic acid filler for
augmenting or everting the lips. The areas to be augmented are the outline of the lip, body of the lip or
both. There is a potential space in the body of the vermilion, which, if correctly entered, will allow the
filler to move within it along the entire lip margin. Dermal fillers
injected in the body of the lips can augment, rejuvenate and
improve the symmetry of the lips.
Injections in the red lip enhance volume. When injecting, it's
important to avoid an unnatural look (duckbill like look) or an
unbalancedlip.With respect to ''centre or outer,'' it is better
t o i n j e c t m o r e c e n t r a l l y t h a n l a t e r a l l y. T h i s i s
becauseoverzealous injections laterally can make lips look
veryunnatural, almost sausage like.Overfill or overcorrection of
the vermilion border isnot recommended. This creates an acute
angle at themucocutaneous junction that appears unnatural. Vestibular injection of 0.2cc per side
will provide anaesthesia for upper lip

65 Facial Aesthetic Surgery

Figure 7.1.17 – Anae s- Figure 7.1.18 – Injection technique for lip augmentation. (a) 0.4cc of filler is delivered
thesia for lip augmentation. slowly while the cannula is withdrawn – retrograde injection; the injection is done from
Anaesthesia is also performed the lateral end of the cupid's bow to the entrance point of cannula. (b)Linear threading
in the entrance point located with serial puncture technique. Redefinition of the vermillion border begins just laterally
in correspondence with labial to the cupid's bow (c)The volume of upper lip body is augmented by intramuscular
commissure at the corner of injection of HA
mouth
Marionette Lines
Marionette lines are the result of loss of support normallyprovided by the soft tissue of the cheek
Facial artery and marginal mandibular nerve should be taken care of while filler injection.

Figure 7.1.19 - Injection Technique for marionette lines. The cannula slides in a natural plane so no
hard resistance should be perceived by the practitioner. Multiple threads are disposed beneath of the
skin of the cheek area using a fanning technique in a retrograde manner from the same port of entry
Chin Augmentation
Chin augmentation can lead to substantial improvement in the appearance of the face, giving a
better look to the patient
The injection of local anaesthesia takes place in 3 different points. The first safe point of injection
is located at the centre of the
mandibular symphysis and
lateral point is located on the
left, 1 cm medially to the
mental foramen and around 1
cm laterally to the centre of
the symphysis. The mental
foramen is placed 1 cm
superiorly to the inferior
mandibular border between Figure 7.1.20 – Markings for chin Figure 7.1.21–Injection technique for
the first and second premolar augmentation. Three safe points where chin augmentation. Filler is injected in
and can be identified through to inject; there is 1 cm distance between every of the three points in the supra-
palpation. (Goisis, 2014) the central and the lateral point periosteal layer

66 Facial Aesthetic Surgery

 Chapter 7B
Botox Injection For Facial Rejuvenation

B otulinum Toxin type A was first used on the face by Carruthers and Carruthers in the late
1980s. Following studies in the 1990s about its cosmetic use, botulinum toxin was
approved by the USA Food and Drug Administration (FDA). This led to a revolution in
treating ageing skin in recent years.

Pharmacology & Mechanism of Action

Clostridium botulinum produces an exotoxin. It is an anaerobic gram-positive bacillus which
forms spore that has eight types of strains labelled alphabetically as: A, B, C, D, E, F, G, and H. Two
types of strains, A and B, are available currently. These result from the modification of the protein
structure that has been used for a variety of medical and cosmetic purpose. (Bonanthaya et al., 2021)
Three sources contain type A: (1) Botox Medical
and (2) Botox Cosmetic are available worldwide from
Allergan (Irvine, CA, USA); (3) Dysport, from Spey
wood Pharmaceuticals (Spotsylvania, VA, USA). The
fourth source, Myobloc, from Elan Pharmaceuticals
(San Francisco, CA, USA), contains botulinum
toxin type B.
Botulinum Neurotoxin causes denervation of the
motor neuron temporarily in the treated muscle and
selectively inactivates the nerve terminals by
blocking the release of acetylcholine and the target
protein SNAP25, leading to a temporary and
reversible blockade of cholinergic transmission. In
the neuromuscular junction, the blockade of the
Figure 7.2.1 - Botulinum toxin inhibits the release
release of acetylcholine promotes muscle relaxation. of acetylcholine at the neuromuscular junction

Reconstitution, Dilution & Dose

Botulinum Toxin Type-A is available as lyophilised powder that must be stored frozen - 4 °C or
lower. Reconstitution of the powder may be done using 0.9% Normal Saline solution, which is
isotonic. For reconstituting 100 U, 2.5 ml of 0.9% Normal Saline may be used, which gives a
concentration of 40 U/ml. Once reconstituted, the solution must be used within 4–8 h, after which the
potency of the drug may be lost, and contamination of the vials may occur. (Bonanthaya et al., 2021)
Basic & Advanced Procedures

67 Facial Aesthetic Surgery

 Indications Contraindications

Wrinkling of the face Pregnancy and breastfeeding.

Facial rejuvenation of ageing face Individuals with an infection in the proposed
Gingival smile area of the injection.
Masseteric hypertrophy Neuromuscular transmission disorders
Facial asymmetry (myasthenia gravis).
Platysmal wrinkling and bands Individuals under medications that may
Hyperhidrotic conditions (excessive sweating) influence neuromuscular transmission.
Blepharospasm Individuals under medications that interfere
Spasmodic torticollis with coagulation like Acetylsalicylic Acid,
Dystonia – cranial, lower facial, cervical, Anticoagulants and Vitamin E
oromandibular

Table 7.2.1 – Indications and Contraindications of Botox Treatment

Basic - Areas of hyperdynamic muscles in the upper third of the face (frown lines, crow's feet and
horizontal forehead lines) yield the most predictable results with the greatest efficacy, and fewest
reported side- effects when treated with botulinum toxin.

Common Name Medical Name Muscles

Frown lines Glabellarrhytids Glabellar complex: corrugator

and depressor supercilii,
procerus

Horizontal frown lines Frontalisrhytids Frontalis

Crow's feet Lateral canthalrhytids Lateral orbital orbicularis oculi

Table 7.2.2 – Basic procedures for facial rejuvenation

Advanced - Botulinum toxin treatments in the lower face are considered advanced procedures.
This is a highly functional region and, in addition to facial expression, lower face muscles serve
essential functions of mastication. Treated muscles in the lower face must retain partial functionality
which requires more practiced injection skill with precise placement of small doses of toxin.

68 Facial Aesthetic Surgery

 Common Name Medical Name Muscles

Lower eyelid wrinkle Infraocularrhytids Inferior preseptal orbicularis

oculi

Reduction of ptotic eyebrow Superior lateral orbital

Eyebrow lift
and dermatochalasis orbicularis oculi

Bunny lines Nasal rhytids Nasalis

Lip lines Perioral rhytids Orbicularis oris

Marionette lines Melomental folds Depressor angulioris

Nasolabial folds Melolabial folds Levator labii superioris

alaeque nasi

Gummy smile Gingival show Levator labii superioris

alaeque nasi

Neck bands Platysmal banding Platysma

Table 7.2.3 – Advanced procedures for facial rejuvenation

Patient Selection
Patients with dynamic wrinkles that have minimal to no static component demonstrate the most
dramatic improvements with botulinum toxin treatment. Patients with static wrinkles are slower and
cumulative, and may require two to three consecutive treatments for significant improvements. Deep
static lines may not fully respond to botulinum toxin treatment alone and may require combination
treatment with dermal fillers or resurfacing procedures to achieve optimal results. Severe static
wrinkles and laxity, commonly seen in patients aged 65 years or older, may require surgical
intervention. Discussion regarding realistic expectations and results during the evaluation and
consultation process is essential.

Syringe & Needle For Injection

A ½ ml insulin syringe with a marking at each 0.01ml is used that allows for measurement of units
of Botox. A 30G-13 mm needle is standard and is recommended for the injection. The length of the
needle is divided into three parts (the first, middle and last third) and the position of the needle is
hereafter used as an indication of injection depth. (Fonseca,2017)

69 Facial Aesthetic Surgery

Patient Preparation & Anaesthesia
The skin should be prepared with an alcohol swab. Application of topical anesthetic or ice maybe
desired by some patients. The patient is asked to flex the muscles planned for treatment.

Frown Lines
Muscles targeted -Botulinum toxin frown line treatment targets the glabellar complex depressor
muscles, which include the corrugator supercilii, procerus, and depressor supercilii.

Instruct the patient to perform any of the following expressions:

“Frown like you're mad”
“Concentrate”
Injection point, dose and technique - The safety zone is at least 1 cm above the supraorbital ridge
at the lateral limbus line, and extends inferiorly to a point approximately 1 cm below the glabellar
prominence. It is bounded by vertical lines extending from the lateral limbi to the hairline
(Small,2014).
For the treatment of glabellar lines, a five-point
injection is recommended, with one point in the
procerus and two points in each corrugator. All
points should be 0.5–1 cm from the upper orbital
rims and internal to the mid-pupillary lines.
Injection should be perpendicular, intramuscular
and deep, to the last third of a 30G needle. The total
dose for glabellar line ranges from 10 to 15 U and
can be increased to a maximum of 40 U based on
the severity of the wrinkle (Bonanthaya et al.
,2021). Figure 7.2.2 – Safe zone for frown lines

Figure 7.2.3 - Recom- Figure 7.2.4 - Lateral and medial corrugator muscle botulinum Figure 7.2.5 - Procerus
mended injection points, toxin injection technique muscle botulinum toxin
the mid-pupillary lines injection technique
and the upper orbital
rim line are illustrated
Horizontal Forehead Lines
The frontal region should always be treated in association with the glabellar area to avoid
increased compensatory use of glabellar muscle, which are mainly depressors.
Muscles targeted - Botulinum toxin horizontal forehead line treatment targets the broad frontalis
muscle, which spans the forehead attaching laterally at the temporal fusion lines.

70 Facial Aesthetic Surgery

Instruct the patient to perform any of the following expressions:
“Raise your eyebrows up like you're surprised”
“Lift up your forehead”
Injection point, dose and technique - For the treatment of horizontal forehead lines, a total of
four to six points are recommended in the forehead below the hairline. The points should form a
slightly curved V-shape in women, and straight in men if applicable.
The typical dose ranges from 2 to 3 U in each point of small dots represented on the upper and
lower aspects of the forehead or 5 U per point of the middle aspect of the muscle, represented in a big
dot. (Carruthers and carruthers,2001)
The dose of the injections must be kept
small enough to just weaken the muscle
instead of producing total paralysis. This
is because the frontalis is responsible for
facial expressiveness, and total paralysis
would cause brow ptosis. It is also
important to preserve at least some
frontalis muscle movement, responsible
for facial expression and lift of the eyelids
and brows. Figure 7.2.6 - Forehead lines injection Figure 7.2.7 - Frontalis
technique muscle botulinum toxin
injection technique
Crow's Feet
Muscles targeted - Botulinum toxin crow's feet treatment targets the lateral portion of the orbital
orbicularis oculi muscle.

Instruct the patient to perform any of the following expressions:

“Make a cheesy grin” or “make a big smile”
“Squint like the sun is in your eyes”
“Wink”
Injection point, dose and technique - The
injection must be placed 1 cm lateral to the orbital
rim and must be above the canthal angle, to avoid
upper lateral lag. To achieve this, one can place a
guiding finger of the other hand at the lateral
orbital rim. (Small,2014)
Owing to the superficial location of the muscle,
the needle need not be advanced deep into the
subcutaneous tissue. Three to four injections of
Botulinum toxin-A may be administered lateral to
the eye in the 'crow's feet' region that radiates out
from the lateral canthi. Around 8–20 U may be
administered on each side. (Kontis and Lacombe,
2013) Figure 7.2.8 - Crow's feet safety zone for botulinum
toxin treatments

71 Facial Aesthetic Surgery

 Figure 7.2.9 - Lateral orbicularis oculi muscle botulinum toxin injection

Lower Eyelid Wrinkles

Muscles targeted - Lower eyelid wrinkle treatments with botulinum toxin target the preseptal
orbicularis oculi muscle.

Instruct the patient to perform any of the following expressions:

“Make a cheesy grin” or “make a big smile”
“Squint like the sun is in your eyes”
Injection point, dose and
technique- For the treatment
of lower eyelid wrinkles, 1–2
injections are recommended at
the mid-pupillary line, about 2
mm below the border of the
lower eyelids. (Small,2014) Figure 7.2.10 - The medial injection is Figure 7.2.11- The lateral injection is placed
A total dose of 5 U (2.5 U placed with the muscles at rest during orbicularis oculi muscle contraction
per side) is recommended,
divided among 2–4 injection
points (about 1–2.5 U per
point). Injection should be very
superficial, with the needle
held tangentially to the eye, to
create a white papula or a 'bleb'
upon injection. If applicable,
lower eyelid wrinkles should
be treated together with the
lateral periorbital wrinkles Figure7.2.12 - Medial and lateralbotulinum toxin injection of the inferior
('crow's feet') to obtain optimal orbicularis oculi muscle
results. (Ascher et al., 2010)

Eyebrow Lift
Muscles targeted - Lateral eyebrow lift with botulinum toxin targets the superior lateral orbital
portion of the orbicularis oculi muscle.

72 Facial Aesthetic Surgery

 Instruct the patient to perform the following
expression:
“Blink hard and hold it”
Injection point, dose and technique - The safety
zone is at least 1 cm outside the orbital rim, below
the supraorbital ridge and lateral to the lateral
limbus line.
Figure 7.2.13 - Eyebrow lift safety zone for botulinum toxin treatments
Injecting superiolateral to the safety zone
may involve the frontalis muscle, resulting in
eyebrow ptosis.
Injecting superior medial to the safety zone
at the lateral limbus line may involve eyelid
levator muscles, resulting in blepharoptosis
(droopy upper eyelid)
2.5 units are injected approximately 1.5cm
to lateral limbus line. Angle the needle towards
the forehead and insert sub dermally.
(Small,2014) Figure7.2.14 - Lateral eyebrow lift botulinum toxin
injection technique
Bunny Lines
Muscles targeted -Botulinum toxin bunny line treatment targets the nasalis muscle
Instruct the patient to perform the following expression:
“Think of a bad skunk smell”
Injection point, dose and technique - The
safety zone is a diamond-shaped region with the
superior point of the diamond located at the nasion
(the least protruding part of the nose between the
medial canthi) and the inferior point located
halfway between the nasion and nasal tip. The
lateral diamond points lie along the nasion-ala
line. The nasion-ala line is drawn from the edge of
the nasal ala inferiorly and intersects the
intercanthal line superiorly Figure7.2.15 - Bunny line safety zone for botulinum toxin treatments
For the treatment of bunny lines, two injection
points with one on each side of the nose are
recommended. The injection points should be
about 1 cm above the upper lateral part of the
nostril. About 5–10 units are injected per injection
point and a total of 10–20U. The injection should
be very superficial to create an obvious papule,
avoiding contact with blood vessels or periosteum.
The orientation of the injection should be
perpendicular, with an angle of about 45degree to Figure 7.2.16 - Nasalis muscle sidewall and Nasalis
the nasal bone. (Ascher et al.,2010) muscle dorsum botulinum toxin injection technique

73 Facial Aesthetic Surgery

Perioral Wrinkles
Muscles targeted - Botulinum toxin lip line treatment targets the orbicularis oris, a sphincteric
muscle that encircles the mouth.

Instruct the patient to perform any of the following expressions:

“Whistle”
“Sip on a straw”
“Pucker
Injection point, dose and technique: Upper lip safety zone is at least 1 cm from the lateral
corners of the mouth, 0.5 cm or less from the vermillion border, and extends to the lateral edge of the
philtral column.
Lower lip line safety zone is at
least 2 cm from the lateral corners
of the mouth and is 0.5 cm or less
from the vermillion border.
4-6 injection points are
recommended, with four
symmetrical points on the upper
lip, and if applicable, two points
on the lower lip. Injection points
should be at the vermilion border
and parallel to the lips. The lateral
points should be at least 1.5 cm Figure 7.2.17 - Lip line safety zones Figure 7.2.18 - Treatment of perioral
away from the mouth corners, at for the upper lip (A) and lower lip wrinkles (a) Recommended injection
the cross points of the lip (B), with botulinum toxin treatments points. (b) Photographs of a patient
puckering before and 21 days after
vermilion border and vertical the treatment
lines extended from the external
ala. The medial points should be 1 mm away from the philtrum. A total dose of 4–12 U is
recommended.

Marionette Lines
Muscles targeted - Botulinum toxin treatment of marionette lines targets the depressor angulioris
muscle.

Instruct the patient to perform any of the

following expressions:
“Clench your teeth and pull the corners of your
mouth downward”
“Show me your bottom teeth”
“Grimace”
Say “ew” or “eek”
The safety zone is at least 1 cm anterior to the
border of the masseter muscle, posterior to the
marionette line, and within 2 cm of the mandibular
margin. Figure 7.2.19 - Safety Zone for Marionette Lines

74 Facial Aesthetic Surgery

 While the depressor angulioris muscle
is contracted, insert the needle in the
depressor angulioris muscle, at least 1 cm
inferior to the corner of the lip. Angle the
needle towards the corner of the mouth
with the tip at the depressor anguli
muscle. Inject 2.5 units on either side.
(Kontis, 2013)
Figure 7.2.20 - Depressor angulioris muscle botulinum
toxin injection technique
Gummy Smile
Muscles targeted - A gummy smile
associated with a deep nasolabial fold
result from contraction of the levator
labii superioris alaeque nasi muscle.

Instruct the patient to perform the

following expression:
“Smile as hard as you can”
1-2 units of botulinum neurotoxin is
injected on each side of levator labii
superioris alaeque nasi muscle.
Figure 7.2.21 - Levator labii superioris alaeque nasi
Neck Bands muscle botulinum toxin injection technique
Muscle targeted - Botulinum toxin neck band treatment targets the anterior neck platysma
muscle.

Instruct the patient to perform any of the following expressions:

“Strain as if lifting heavy dumbbells with
your arms”
“Clench your teeth and pull the corners of
your mouth downward”
Say “ew” or “eek”
The safety zone is 1 cm lateral to the
trachea and extends to the oral commissure
lines, which are vertical lines extending
inferiorly from the oral commissures to the
clavicles. The safety zone is at least 2 cm
inferior to the mandible and at least 4 cm
superior to the clavicle margins.
The muscle ridge is palpable beneath the Figure 7.2.22 - Neck band safety Figure 7.2.23 - Platysma
zone for botulinum toxin treatments muscle botulinum toxin
skin. The needle is angled medially, at about injection technique
45-degrees that should just pass into the
muscle ridge, and botulinum toxin is injected at that site (Small,2014). There may be several creases
but each treatment session must not use more than 15-20 units. (Bonathayaet al., 2021)

75 Facial Aesthetic Surgery

 Chapter 8
Complications

A ny procedure necessitates a relative understanding between the possible risks and

expected benefits that may be achieved. The surgeon must have a detailed understanding
of all potential untoward outcomes and complications, including their management.

Complications Following Rhytidectomy

Post-operative complications of facelifts include postoperative
§ Haematoma
§ Skin necrosis
§ Sensory and motor disturbances
§ Obvious scarring
§ Alopecia
§ Auricular deformity
§ Dyspigmentation

Haematoma
Haematoma formation is by far the most
common complication (Bloom, Immerman and
Rosenberg, 2012). Hematomas may present as
small collections or may occur as large rapidly
expanding bleeds. The most dangerous hematomas
occur from arterial bleeding and should be
considered acute emergencies. These present with
sudden onset of unilateral or even bilateral facial
pain, swelling, firmness, and tightness of the
overlying skin, followed by ecchymosis and
trismus. Late signs of hematoma include swelling
and discoloration of the lips and buccal mucosa. If
large enough, an expanding hematoma can lead to
dyspnoea with ensuing loss of the airway and death.
Most major hematomas occur within 10 to 12 hours Figure 8.1 - Haematoma. A and B, Appearance
of hematoma prior to evacuation. Note boggy dark
after surgery and almost all within the first 24 hours appearance of the preauricular and infra-auricular
after of surgery. (Moyer and Baker,2005) regions in the immediate postoperative period.
C and D, Intraoperative photo of evacuation of
hematoma

76 Facial Aesthetic Surgery

 A thorough medical history is needed prior to surgery. Antiplatelet medications such as Aspirin,
Clopidogrel, Dipyridamole and powerful anticoagulation drugs such as warfarin will have to be
stopped after consultation with the patient's prescribing physicians. Patients on herbal or traditional
Chinese medications such as ginkgo biloba and Cordyceps will also need to be stopped before
surgery.
Expanding haematoma usually happens in the first 24 hours and must be evacuated. Smaller
haematoma can be aspirated, and pressure bandage is placed for pressure haemostasis. Meticulous
haemostasis with bipolar diathermy is mandatory for facelift procedures. The flap and the underlying
bed should be scrutinized for bleeding spots with a good head light or fibre optic light attached to a
retractor. Brisk bleeding from larger vessels should be ligated. Adjunctive measures including fibrin
glue (Griffin and Jo, 2006) and platelet gel and facelift bandages have been explored. Large
haematoma is a cause for concern and need to be evacuated. They can cause problems in healing
including skin ischaemia

Skin Ischaemia & Necrosis

Ischaemic changes and flap necrosis can occur due to
circulatory disturbances. This can happen when the flap is too
thin or had undergone extensive undermining and exuberant
cautery, closed under excessive tension or compromised by
excessively tight bandage compression. The incidence ranges
between 1.1 and 3% (Baker et al.,1983). Venous congestion or
arterial obstruction can result in skin ischaemia and necrosis.
Large unevacuated haematoma separates the flap off the
underlying bed during which perfusion is only by the vessels
supplying the flap. This causes the areas farthest away from the
perfusing vessels to be at risk of ischaemia. Necrosis of the skin is
more common in the postauricular than the preauricular region.
Figure 8.2 – Skin necrosis.Skin necrosis
Application of nitro-glycerine paste may help to encourage in the preauricular and supra-auricular
vasodilation when done in the early stages (Niamtu,2010). portions of the flap. This is also commonly
Conservative treatment to allow healing via secondary intention seen in the posterior auricular region just
over the mastoid process. In these areas,
followed by laser, excision of the scar with repair via rotation the skin flap may become excessively
flaps can be carried out at a later stage. thin and contribute to skin necrosis

Obvious Scarring
Scarring can occur when the wounds are Figure 8.3 – Post
closed under excessive tension or if the operative scarring
(A) View of a patient
incisions are placed at an inappropriate pre se nting fo r a
position due to poor design. Skin slough and re visio n fa ce-li ft
necrosis of the flap can lead to severe scarring. aft er a p rev io u s
short-scar face-lift.
Patients who are more prone to hypertrophic The patient's tragal
scarring or keloids should be warned. Wound incisions have mig-
tension can develop and cause scarring if there rated to a visible
preauricular position.
is excessive removal of skin or if undermining (B) Close-up of the
of the flap is inadequate. visible tragal incisions

77 Facial Aesthetic Surgery

 Treatment of scarring includes conservative treatment with antibiotic ointment such as
Tetracycline cream 3% or Bactroban cream. This is followed by steroid injections such as
triamcinolone acetate, application of silicone sheet or gel dressing. As the scar improves and
stabilizes, it can be lasered, excised and revised. (Bonanthaya et al., 2021)

Alopecia
The incidence of alopecia after rhytidectomy is as high as 8.4% with rates of permanent hair loss
requiring surgical revision ranging from 1 to 3% (Bloom,Immerman and Rosenberg, 2012).
Patients with thinning hair and those having a tendency for alopecia are prone to greater hair loss after
face-lift surgery. Usually hair loss is transient, and patients with healthy scalps can expect their hair to
grow back promptly. Most permanent hair loss occurs in the temporal areas adjacent to the skin
incisions rather than in the postauricular area. This can be secondary to several factors: direct trauma
to the hair follicles during dissection, either due to transection of follicles or electrocautery; necrosis
of hair-bearing skin, infection with destruction of hair follicles; or a hypertrophic scar in which hair
cannot grow. To avoid incisional alopecia, hairline incisions are bevelled at a 45-degree angle toward
the anterior or inferior edge, allowing hair to grow up through the incision site. (Kabaker,1979)

Sensory Disturbances
Sensory disturbances occur invariably due to the dissection and separation of the facial planes
during the facelift procedures but this usually occurs temporarily and resolves in 1 year. The most
common sensory disturbance occurs to the great auricular nerve. The greater auricular nerve crosses
the sternocleidomastoid muscle at approximately 6.5 cm inferior to the external auditory meatus and
travels superiorly to supply the postauricular region. Injury to this nerve can be temporary or
permanent due to dissection over the postauricular, mastoid region and to a lesser extent in the cervical
region. This results in numbness of the ear lobe and postauricular area. Other forms of numbness can
be found in preauricular region

Motor Nerve Disturbances

Keeping away from the planes that the facial nerve travels in is
the safest method to avoid motor nerve problems. The facial nerve
branches course through the parotid gland and exits the parotid
gland to travel deep to the SMAS layer before innervating the
muscles of facial expression. Care should be taken when
dissecting beyond the parotid or when dissecting deep into the
SMAS layer. Facial nerve injury ranges from 0.4 to 2.6%
(Bloom,Immerman and Rosenberg, 2012). The most common
motor nerve damage is the marginal mandibular nerve followed by
the temporal nerve and then the buccal branch. Neuropraxia from
exuberant retraction, cautery heat and compression can result in
temporary or permanent loss of the motor function. The marginal
mandibular branch courses in the superficial layer of the deep
cervical fascia, deep into the platysmal layer, and may be damaged
Figure 8.4 - Damage to marginal
when dissecting in this region. The temporal branch of the facial mandibular nerve branch. Note injury
nerve courses just deep to the superficial temporal fascia and to right marginal mandibular branch
travels 0.5 cm anterior to the tragus and then obliquely to 1.5 cm demonstrated by weakness of the
above the lateral edge of the eyebrows. depressor muscles of the right lip
and lower face

78 Facial Aesthetic Surgery

Earlobeir Regularities
“Pixie or elf-like” ear is a stigma of facelift.
The ear lobe should be repositioned in a
tensionless fashion, and the ear lobe should be
placed 15° posterior to the vertical axis of the
pinna (Fonseca, 2017). Over resection of the
flap at the base of the auricle as well as failure to
place subcutaneous stay sutures on the facial
flap at the ear base can result in the ear being
pulled inferiorly. Pixie ears can be revised by
releasing the base of the auricle and creating a
new ear lobe. Figure 8.5 - Pixie ear deformity. Note the loss of the free
lobule of the earlobe and subsequent elongation secondary
Complications Following Rhinoplasty to elongated attachment to the cheek tissue
Common sequelae following rhinoplasty can be divided into early and late (Bonanthaya et al.,
2021)

Early sequelae Late sequelae

Bleeding Infra orbital discoloration

Swelling Loss of tip lobule definition

Bruising Lateral shortening

Paraesthesia False “poly-beak'' deformity

Swelling of tip and supratip area

Table 8.1 – Early and Late sequelae following Rhinoplasty

The most common postoperative complication is nasal bleeding, and it is estimated that
troublesome bleeding will occur less than 2% to 4% of the time. If nasal bleeding does occur, it
usually occurs in a bimodal distribution either in 48 hours from raw mucosal edges or in 10 to 14 days
after escharsbegin to separate. The patient is instructed to use 0.05% oxymetazoline nasal spray and
apply ice compresses. If the patient cannot control the bleeding, the surgeon may need to cauterize the
bleeding points or perform nasal packing. Obviously, the patient should also be avoiding medications
that interfere with bleeding.
The key to minimise or preventing unfavourable outcomes depends on proper case selection after a
thorough evaluation of the patient both physically and psychologically. It is important to understand
our limitations and accept them while not refraining from seeking professional help/support when
needed.

79 Facial Aesthetic Surgery

 Complications in rhinoplasty may depend on the area of surgery and the procedure
performed as indicated below:
Complications associated with the nasal dorsum include loss of dorsal height, concavity or saddle
deformity (due to over-resection), residual hump, supratip prominence or a true “polly-beak”
deformity due to under-resection. There may be bony or cartilaginous irregularities (inadequate
removal). An open roof deformity may present if the nasal
1. Bones are not infractured after hump reduction. An incomplete lateral osteotomy may result in a
lateral wall step deformity, while medialisation of the upper lateral cartilages may result in an
inverted “v” deformity. Another complication is the appearance of a visible dorsal septal edge.
2. Complication of tip deformities may present as a “pinched tip” or a “knock-knee” alar deformity
(over-resection of the lateral crus). It may also show tip changes like “buttontip” deformity,
tip/domal asymmetry, supra-alar concavity or alar retraction. Loss of tip support produces ptosis of
the tip; loss of tip projection may produce infratip slip below the anterior septal angle and excess
resection of the caudal septum may lead to over-rotation of the tip complex.
3. Alar base reduction complications may include narrowing of the nostril circumference, which may
contribute to increased nasal airway pressure. The surgery by itself may cause a web scar at the
alar-facial junction. It may also result in distortion and secondary deformity of the nose, cheek and
lips.
4. Complications following septal surgery include failure to straighten, midline deviation, tip
deviation secondary to caudal septal displacement and septal collapse leading to a saddle nose
deformity. The columella may develop retraction or scarring and rarely necrosis.

The skin and soft tissue envelope may also show scarring, ischemia/discolouration.
Management of complications may be necessary when the deformity is visible to both the surgeon
and the patient. This necessitates revision or secondary surgery which may be indicated in about 5–8%
of the patients. Even when indicated, it is better to wait for a year prior to attempting revisions or
secondary interventions. This is to facilitate a careful assessment of long-term changes following the
procedure and the final outcome prior to intervention.

Complications Following Forehead & Browlift

Fortunately, major complications are rare with properly performed endoscopic forehead and brow
lifting techniques. These include:
§ Bleeding
§ Brow malposition
§ Nerve damage
§ Alopecia

Bleeding
Excessive bleeding can occur that could be arterial, venous or from skin edges. Preoperative
evaluation to note blood dyscrasias and patient education on avoidance of agents that cause bleeding
will prevent most issues. Injection with haemostatic agent, ensuring intraoperative haemostasis, and
avoidance of injury to superficial temporal or zygomaticotemporal arteries, supraorbital or
supratrochlear vascular bundles, and sentinel vein will decrease postoperative haematomas.

80 Facial Aesthetic Surgery

Brow Malposition
Too much resection of skin or
excessive suspension with any
procedure may result in lagophthalmos
and brow malposition. The risk is
increased when simultaneous
blepharoplasty is performed. To avoid
excessive skin resection during
blepharoplasty the forehead lift should
be completed before the eyelid surgery Figure 8.6 – Brow Malposition. Over-elevation of the medial & lateral brow.
(Terella, Wang and Kim, 2013). Lateral brow elevation looks attractive on most females but medial brow
elevation greater than the lateral brow third creates an odd look for male
or female brow lift patients
Nerve Damage
Direct injury to the nerves is an uncommon occurrence but traction injury (neuropraxia) can occur
due to suspension. When neuropraxia injury occurs, it may take up to 12 months to completely
resolve. In the temporal region the dissection plane is superficial to the superficial layer of the deep
temporal fascia and damage to the zygomaticotemporal and auricotemporal nerves (second division
of trigeminal nerve) should be minimal. In particular, the temporal (frontal) branch is at risk for injury
in the temporal lateral dissection.

Alopecia
Alopecia can also result from improper incision design and closure, including inappropriate
wound tension, rough handling of wound margins, and excessive use of electrocautery. Peri-
incisional alopecia can appear as a widened scar; when the scar is visible by the endoscopic approach,
the scar can be excised at a later date. Alopecia around endoscopic scars can make them more obvious
and scar revision can be performed to improve the scars by excision of the widened scars and close
reapproximation of the hair-bearing scalp.

Complicatons Following Botox Injections

Injection reactions Undesired botulinum toxin effects

Ecchymosis Allergic reaction

Erythema, oedema and tenderness Antibodies against botulinum toxin
Headache Blepharoptosis
Infection Distant spread from injection site
Pain Eyebrow ptosis
Paraesthesia or dysthesia Facial asymmetry
Anxiety or vasovagal syncope Undesired eyebrow shape or unsatisfactory result

Table 8.2 - Complications following Botox Injections

81 Facial Aesthetic Surgery

Injection Reactions
Mild erythema, oedema and tenderness at injection sites are expected and resolve within a day.
Headaches can occur with facial injections but most are mild and resolve spontaneously few days after
treatment (Naumann and Jankovic,2004). Infection is rare but can occur with any procedure that
breaches the skin barrier. Paraesthesia or dysesthesia in treatment area is rare and may be caused by
nerve trauma. Anxiety with injection is common. Vasovagal episodes associated with severe anxiety
can occur.

Recommendations
§Apply pressure at the site before and after treatment. Cold packs may also be used.
§The use of small syringes and fine-gauge (30 g) needles can reduce pain and bruising at the injected
site.
§Using topical anaesthesia (EMLA—Eutectic Mixture of Local Anaesthesia) reduces pain while
injecting.

Undesired Effects
The complications related to botulinum toxin occur less frequently than injection reactions. These
are primarily caused by temporary denervation of adjacent muscles outside of intended treatment
area. These complications are technique dependent; incidence declines as injector skill improves.
Temporary blepharoptosis is uncommon (1% to 5%) but is distressing for patient (Carruthers et
al.,2002). It is caused by deep migration of
botulinum toxin through orbital septum fascia to
levator palpebrae superioris. It can be avoided by
placing injection 1cm above the supraorbital ridge
at mid-pupillary line (Ascher et al.,
2010).Blepharoptosis may be treated using
ophthalmic solutions that have alpha-adrenergic
effects, such as over-the-counter naphazoline
0.025%/ pheniramine 0.3% or prescription
apraclonidine 0.5% (Iopidine). Both medications
cause contraction of Müller muscle, an adrenergic
levator muscle of the upper eyelid, resulting in Figure 8.7 - Right eye blepharoptosis three weeks after
botulinum toxin treatment of glabellar complex
elevation of the upper eyelid.

Facial asymmetry can result from uneven dosing of botulinum toxin. Consistent technique and
careful attention to injection volumes at the time of treatment can reduce the incidence of
asymmetries. Other rare complications associated with botulinum toxin injections include formation
of antibodies (less than 1%), which can render treatments ineffective (Naumann et al., 2010).
Although extremely rare, immediate hypersensitivity and allergic reactions may occur, with signs of
urticaria, oedema, and possibly anaphylaxis. Distant spread has not been reported with cosmetic use
of botulinum toxin for frown lines or other facial indications

82 Facial Aesthetic Surgery

Complications Following Dermal Filler Injections
Complications associated with fillers include immediate, early and late complications (Goisis,
2014)
§ Immediate complications (within 72 h after injection) include immediate hypersensitivity
reaction, transient erythema, oedema, induration, pruritus and ecchymosis.
§ Early complications (days to weeks after injection) include overcorrection, local infection, skin
necrosis, herpes reactivation, discoloration, and persistent local symptoms (erythema, oedema,
induration, pruritus, and hyperpigmentation).
§ Late complications include infection, filler migration, delayed hypersensitivity reaction, foreign-
body granuloma and scarring, rapid resorption etc.

Complication Diagnosis Management

Immediate hypersensitivity Oedema, severe and Systemic steroids

reaction disfiguring swelling

Oedema Moderate swelling Ice, arnica gel

Indurations Hardness 2 days massage

Extravasation of blood under

Ecchymosis and hematoma Ice, topical arnica
the skin, bruising

Heat, redness, swelling, Amoxicillin associated with

Bacterial infections clavulanic acid 1 mg x 2
and pain for 5 days

Herpes simplex Typical lip rash Topical Acyclovir, oral

Valacyclovir: 500 mg x 2
days or oral Acyclovir:
200 mg x 5 days
Overcorrection Excess of filler injected Wait for filler resorption

Chronic inflammatory reaction

Chronic inflammation Clarithromycin
with erythema and swelling

Foreign body granulomas Chronic inflammatory nodules Triamcinolone 1 mg local injection

Skin necrosis Interruption of the vascular Kept warm 2% nitro-glycerine

supply: pain, discoloration paste

Table 8.3 - Complications following dermal filler injections

A thorough knowledge of the anatomy and technical skills is necessary for the prevention of the
complications associated with facial aesthetic surgery.

83 Facial Aesthetic Surgery

 Chapter 9
Bibliography

1. Alghoul, M. and Codner, M.A., 2013. Retaining Ligaments of the FaceReview of Anatomy and
Clinical Applications. Aesthetic surgery journal, 33(6), pp.769-782.
2. Ascher, B., Talarico, S., Cassuto, D., Escobar, S., Hexsel, D., Jaén, P., Monheit, G.D., Rzany, B.
and Viel, M., 2010. International consensus recommendations on the aesthetic usage of
botulinum toxin type A (Speywood Unit)–part II: wrinkles on the middle and lower face, neck
and chest. Journal of the European Academy of Dermatology and Venereology, 24(11),
pp.1285-1295.
3. Ascher, B., Talarico, S., Cassuto, D., Escobar, S., Hexsel, D., Jaén, P., Monheit, G.D., Rzany, B.
and Viel, M., 2010. International consensus recommendations on the aesthetic usage of
botulinum toxin type A (Speywood Unit)–part I: upper facial wrinkles. Journal of the European
Academy of Dermatology and Venereology, 24(11), pp.1278-1284.
4. Avelar, J.M. ed., 2021. Aesthetic Facial Surgery. Springer Nature.
5. Baker, D.C., 1983. Complications of cervicofacial rhytidectomy. Clinics in plastic surgery,
10(3), pp.543-562.
6. Baker, T.J., Gordon, H.L. and Mosienko, P.E.T.E.R., 1977. Rhytidectomy: a statistical
analysis. Plastic and Reconstructive Surgery, 59(1), pp.24-30.
7. Baran, R. and Maibach, H., 2010. Textbook of cosmetic Dermatology. CRC Press.
8. Bloom, J.D., Immerman, S.B. and Rosenberg, D.B., 2012. Face-lift complications. Facial
Plastic Surgery, 28(03), pp.260-272.
9. Bonanthaya, K., Panneerselvam, E., Manuel, S., Kumar, V.V. and Rai, A. eds., 2021. Oral and
Maxillofacial Surgery for the Clinician. Springer Singapore.
10. Burgess, C.M. ed., 2005. Cosmetic dermatology (p. 170). Heidelberg, Germany: Springer.
11. Carruthers, A. and Carruthers, J., 2001, June. Botulinum toxin type A: history and current
cosmetic use in the upper face. In Seminars in cutaneous medicine and surgery (Vol. 20, No. 2,
pp. 71-84). WB Saunders.
12. Carruthers, J.A., Lowe, N.J., Menter, M.A., Gibson, J., Nordquist, M., Mordaunt, J., Walker, P.
and Eadie, N., 2002. BOTOX Glabellar Lines I Study Group. A multicenter, double-blind,
randomized, placebo-controlled study of the efficacy and safety of botulinum toxin type A in
the treatment of glabellar lines. J Am AcadDermatol, 46(6), pp.840-849.
13. Cerimele, D., Celleno, L. and Serri, F., 1990. Physiological changes in ageing skin. British
Journal of Dermatology, 122, pp.13-20.
14. Chuang, J., Barnes, C. and Wong, B.J., 2016. Overview of facial plastic surgery and current
developments. The Surgery Journal, 2(01), pp.e17-e28.

84 Facial Aesthetic Surgery

15. Clemente, C.D., 1985. Oseteology, and Muscles and fasciae of the upper limb. Gray's anatomy,
pp.233-234.
16. De Maio, M. and Rzany, B., 2007. Botulinum toxin in aesthetic medicine. Springer Science &
Business Media.
17. De Maio, M., DeBoulle, K., Braz, A. and Rohrich, R.J., 2017. Facial assessment and injection
guide for botulinum toxin and injectable hyaluronic acid fillers: focus on the midface. Plastic
and Reconstructive Surgery, 140(4), pp.540e-550e.
18. De Maio, M., Swift, A., Signorini, M. and Fagien, S., 2017. Facial assessment and injection
guide for botulinum toxin and injectable hyaluronic acid fillers: focus on the upper face. Plastic
and Reconstructive Surgery, 140(2), pp.265e-276e.
19. De Maio, M., Wu, W.T., Goodman, G.J. and Monheit, G., 2017. Facial assessment and injection
guide for botulinum toxin and injectable hyaluronic acid fillers: focus on the lower face. Plastic
and Reconstructive Surgery, 140(3), pp.393e-404e.
20. DINGMAN, R.O. and GRABB, W.C., 1962. Surgical anatomy of the mandibular ramus of the
facial nerve based on the dissection of 100 facial halves. Plastic and Reconstructive Surgery,
29(3), pp.266-272.
21. Donofrio, L.M., 2000. Fat distribution: a morphologic study of the aging face. Dermatologic
Surgery, 26(12), pp.1107-1112.
22. Evans, T.W., 1998. Browlift. Atlas of the Oral and Maxillofacial Surgery Clinics of North
America, 6(2), pp.111-134.
23. Farage, M.A., Miller, K.W., Elsner, P. and Maibach, H.I., 2013. Characteristics of the aging
skin. Advances in wound care, 2(1), pp.5-10.
24. Fonseca, R.J., 2017. Oral and Maxillofacial Surgery-Inkling Enhanced E-Book: 3-Volume Set.
Elsevier Health Sciences.
25. Furnas, D.W., 1989. The retaining ligaments of the cheek. Plastic and reconstructive surgery,
83(1), pp.11-16.
26. Furnham, A. and Levitas, J., 2012. Factors that motivate people to undergo cosmetic surgery.
Canadian Journal of Plastic Surgery, 20(4), pp.47-50.
27. Goisis, M. ed., 2013. Injections in aesthetic medicine: atlas of full-face and full-body
treatment. Springer Science & Business Media.
28. Griffin, J.E. and Jo, C., 2007. Complications after superficial plane cervicofacial rhytidectomy:
a retrospective analysis of 178 consecutive facelifts and review of the literature. Journal of oral
and maxillofacial surgery, 65(11), pp.2227-2234.
29. Hoeyberghs, J.L., 1999. Cosmetic surgery. BMJ, 318(7182), pp.512-516.
30. Houseman, N.D., Taylor, G.I. and Pan, W.R., 2000. The angiosomes of the head and neck:
anatomic study and clinical applications. Plastic and reconstructive surgery, 105(7), pp.2287-
2313.
31. Ilankovan, V., 2017. Recent advances in face lift to achieve facial balance. Journal of
maxillofacial and oral surgery, 16(1), pp.3-12.
32. Jacono, A. and Bryant, L.M., 2018. Extended deep plane facelift: incorporating facial retaining
ligament release and composite flap shifts to maximize midface, jawline and neck
rejuvenation. Clinics in Plastic Surgery, 45(4), pp.527-554.
33. Kabaker, S.S., 1979. Juri flap procedure for the treatment of baldness: two-year experience.
Archives of Otolaryngology, 105(9), pp.509-514.

85 Facial Aesthetic Surgery

34. Kane, M.A., 2005. Botox injections for lower facial rejuvenation. Oral and Maxillofacial
Surgery Clinics, 17(1), pp.41-49.
35. Keller, G.S. and Mashkevich, G., 2009. Endoscopic forehead and brow lift. Facial Plastic
Surgery, 25(04), pp.222-233.
36. Khan, H.A. and Bagheri, S., 2014. Surgical anatomy of the superficial musculo-aponeurotic
system (SMAS). Atlas of the Oral and Maxillofacial Surgery Clinics of North America, 22(1),
pp.9-15.
37. Khavkin, J. and Ellis, D.A., 2011. Aging skin: histology, physiology, and pathology. Facial
Plastic Surgery Clinics, 19(2), pp.229-234.
38. Kontis, T.C. and Lacombe, V.G., 2018. Cosmetic injection techniques. Thieme.
39. Lambros, V., 2007. Observations on periorbital and midface aging. Plastic and reconstructive
surgery, 120(5), pp.1367-1376.
40. Langdon, J.D., Patel, M.F., Ord, R. and Brennan, P.A. eds., 2017. Operative oral and
maxillofacial surgery. CRC Press.
41. Leist, F.D., Masson, J.K. and Erich, J.B., 1977. A review of 324 rhytidectomies, emphasizing
complications and patient dissatisfaction. Plastic and Reconstructive Surgery, 59(4), pp.525-
529.
42. Mendelson, B. and Wong, C.H., 2020. Changes in the facial skeleton with aging: implications
and clinical applications in facial rejuvenation. Aesthetic plastic surgery, 44(4), pp.1151-1158.
43. Moyer, J.S. and Baker, S.R., 2005. Complications of rhytidectomy. Facial Plastic Surgery
Clinics, 13(3), pp.469-478.
44. Murphy, M.R., Johnson Jr, C.M. and Azizzadeh, B., 2007. The aging face consultation. In
Master techniques in facial rejuvenation (pp. 1-16). WB Saunders.
45. Murphy, M.R., Johnson Jr, C.M. and Azizzadeh, B., 2007. The aging face consultation. In
Master techniques in facial rejuvenation (pp. 1-16). WB Saunders.
46. Naumann, M., Carruthers, A., Carruthers, J., Aurora, S.K., Zafonte, R., Abu- Shakra, S.,
Boodhoo, T., Miller- Messana, M.A., Demos, G., James, L. and Beddingfield, F., 2010.
Meta- analysis of neutralizing antibody conversion with onabotulinumtoxinA (BOTOX®)
across multiple indications. Movement disorders, 25(13), pp.2211-2218.
47. Naumann, M., Carruthers, A., Carruthers, J., Aurora, S.K., Zafonte, R., Abu- Shakra, S.,
Boodhoo, T., Miller- Messana, M.A., Demos, G., James, L. and Beddingfield, F., 2010.
Meta- analysis of neutralizing antibody conversion with onabotulinumtoxinA (BOTOX®)
across multiple indications. Movement disorders, 25(13), pp.2211-2218.
48. Niamtu III, J., 2006. Endoscopic brow and forehead lift: a case for new technology. Journal of
oral and maxillofacial surgery, 64(7), pp.1129-1132.
49. Niamtu, J., 2005. New lip and wrinkle fillers. Oral and Maxillofacial Surgery Clinics, 17(1),
pp.17-28.
50. Niamtu, J., 2010. Cosmetic Facial Surgery-E-Book. Elsevier Health Sciences.
51. Quatela, V., Montague, A., Manning, J.P. and Antunes, M., 2020. Extended superficial
musculoaponeurotic system flap rhytidectomy. Facial Plastic Surgery Clinics, 28(3), pp.303-
310.
52. Raggio, B.S. and Asaria, J., 2019. Open Rhinoplasty.
53. Robert, L., Labat-Robert, J. and Robert, A.M., 2012. Physiology of skin aging. Clinics in
plastic surgery, 39(1), pp.1-8.

86 Facial Aesthetic Surgery

54. Rubin, J.P. and Neligan, P.C., 2017. Plastic Surgery: Volume 2: Aesthetic Surgery. Elsevier
Health Sciences.
55. Shiffman, M.A. and Di Giuseppe, A. eds., 2013. Advanced aesthetic rhinoplasty: art, science,
and new clinical techniques. Springer Science & Business Media.
56. Small, R. and Hoang, D., 2012. A practical guide to botulinum toxin procedures. Lippincott
Williams & Wilkins.
57. Small, R., 2014. Botulinum toxin injection for facial wrinkles. American family physician,
90(3), pp.168-175.
58. Soikkonen, K., Wolf, J., Mattila, K. and Hietanen, J., 1991. Three main arteries of the face and
their tortuosity. British Journal of Oral and Maxillofacial Surgery, 29(6), pp.395-398.
59. Starkman, S.J. and Mangat, D.S., 2020. Less Invasive Superficial Musculoaponeurotic System
Approaches in Rhytidectomy: How, When, and Why. Facial Plastic Surgery Clinics, 28(3),
pp.273-283.
60. Sykes, J.M., Riedler, K.L., Cotofana, S. and Palhazi, P., 2020. Superficial and deep facial
anatomy and its implications for rhytidectomy. Facial Plastic Surgery Clinics, 28(3), pp.243-
251.
61. Tasman, A.J., 2007. Rhinoplasty–indications and techniques. GMS current topics in
otorhinolaryngology, head and neck surgery, 6.
62. Terella AM, Wang TD, Kim MM: Complications in periorbital surgery, Facial PlastSurg
29(1):64–70, 2013.
63. Tobin, D.J., 2017. Introduction to skin aging. Journal of tissue viability, 26(1), pp.37-46.
64. Vigliante, C.E., 2005. Anatomy and Functions of the muscles of facial expression. Oral and
Maxillofacial Surgery Clinics, 17(1), pp.1-15.
65. von Arx, T., Tamura, K., Yukiya, O. and Lozanoff, S., 2018. The face–a vascular perspective. A
literature review. Swiss dental journal, 128(5), pp.382-392.
66. Warren, R.J., Aston, S.J. and Mendelson, B.C., 2011. Face lift. Plastic and Reconstructive
Surgery, 128(6), pp.747e-764e.
67. Webster, R.C., Smith, R.C., Papsidero, M.J., Karolow, W.W. and Smith, K.F., 1982.
Comparison of SMAS plication with SMAS imbrication in face lifting. The Laryngoscope,
92(8), pp.901-912.
68. Wulc, A.E., Sharma, P. and Czyz, C.N., 2012. The anatomic basis of midfacial aging. Midfacial
rejuvenation, pp.15-28.

87 Facial Aesthetic Surgery

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