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Aesthetic Surgery
Techniques
A Case-Based Approach
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 Aesthetic Surgery
Techniques
A Case-Based Approach

James D. Frame FRCS, FRCS (Plast)

Consultant Plastic Surgeon,
Professor of Aesthetic Plastic Surgery,
School of Medicine,
Anglia Ruskin University, Chelmsford, Essex, UK

Shahrokh C. Bagheri BS, DMD, MD, FACS, FICD

Chief of Oral and Maxillofacial Surgery,
Northside Hospital, Atlanta and Forsyth, GA, USA

David J. Smith Jr. MD

Professor of Surgery, Division of Plastic and Reconstructive Surgery,
University of South Florida; Richard G. Connar Professor and Chairman, Department of Surgery,
University of South Florida; Chief Medical Officer, Center for Advanced Medical Learning and
Simulation, Tampa, FL, USA

Husain Ali Khan MD, DMD, FACS

Attending Surgeon, Oral and Maxillofacial Surgery,
Northside Hospital, Atlanta and Forsyth, GA, USA

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Edinburgh London New York Oxford Philadelphia St Louis Sydney 2019

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 Contents

Video Contents vii Section 4: Rhinoplasty

Preface ix David J. Smith
Acknowledgments xi
List of Contributors xiii
15 Prominent Nose 111
Igor Niechajev
16 Aesthetic Nasal Tip Surgery 121
Part 1: Introduction Kirill Pshenisnov
David J. Smith 17 Crooked Nose 133
Charles East
1 Informed Consent: Protecting the Patient
18 The Middle Eastern–Mediterranean Nose 137
and the Surgeon 3 Nazim Çerkeş
Neal R. Reisman, Hugh Henderson
19 The Asian Rhinoplasty 147
2 Aesthetic Medicine: Surgical Pearls 7 Naoyuki Ohtake, Kazunari Karahashi, Nobuyuki Shioya
Jaffer Khan, Zara Yousufzai, Natasha Jaffer Khan
20 Male Rhinoplasty 153
3 Aesthetic Applications for Fillers 25 Clifford Clark, Jared Troy
Phillipe Bellity
21 Medical Rhinoplasty 161
Christopher M.E. Rowland Payne
Part 2: Head and Neck
Section 1: Forehead and Brow
James D. Frame Part 3: Perioral Aesthetics and Dentistry
4 Brow Lift 33 Shahrokh C. Bagheri and Husain Ali Khan
Peter Scott, Philip Peirce
22 Aesthetic Orthognathic Surgery 169
5 Endoscopic Endotine Brow Lift Made Easy 39 Michael Miloro, Michael R. Markiewicz
Peter Arnstein
23 Implantology 185
Section 2: Eyes Edward R. Schlissel
James D. Frame and David J. Smith 24 Aesthetic Dentistry of the Smile Line 189
6 Upper Blepharoplasty 45 Arun Nayyar
Janek S. Januszkiewicz
7 Asian Blepharoplasty 53
Takanori Yamawaki, Naoyuki Ohtake, Nobuyuki Shioya
Part 4: Breast
8 Midface Descent and Malar Support 61
James D. Frame
Ernesto J. Ruas
9 Anatomic Relationship of SOOF and ROOF 25 The Small Breast 195
in Eyelid Rejuvenation 67 Henrique P.L. Cintra
Hazem M. Aly, James D. Frame 26 Breast Reduction: Superomedial Pedicle
10 Nonsurgical Rejuvenation of the Periorbital Area 73 Wise-Pattern Approach 205
Patrick J. Treacy Alexandre S.F. Fonseca, Guilherme Flosi Stocchero,
Gustavo Flosi Stocchero
Section 3: Face Lift
27 Mastopexy with Mesh for Breast Ptosis 213
James D. Frame
Petrus V. van Deventer
11 High SMAS Face Lift 81 28 Simultaneous Augmentation and Periareolar
Bud S. Alpert Mastopexy: Indications and Limitations 219
12 Management of the Neck 91 Alberto Rancati, Claudio Angrigiani
Gregory P. Mueller, Nicholas R. Nikolov 29 Asymmetric Breast 225
13 The Turkey Neck: Surgical Management 99 Garrick Georgeu
Darryl J. Hodgkinson 30 Transaxillary Excision of Gynecomastia
14 Platysma Bands 105 (Andromastia) 231
Miles G. Berry, Jan J. Stanek Paul Levick
vi Contents

Part 5: Trunk and Abdominal Wall Part 6: Upper and Lower Extremity
James D. Frame James D. Frame
31 Improving the Waistline with the Modified 36 Upper Arms: Rejuvenation of the Arm 277
Brazilian Abdominoplasty 239 Graeme Southwick, Alenka Paddle
Bassem M. Mossaad 37 Aesthetic Management of the Aging Hand 283
32 Postbariatric Abdominoplasty 247 Kaushik Chakrabarty
Anne Dancey 38 Inner Thigh Lift 287
33 Nonexcisional Management of the Anterior Pedro S. Coltro, Fernanda B. Correa, Jayme A. Farina Jr.
Abdominal Wall 255 39 Inner Thigh Reduction: Reshaping Using a
Riccardo Frati, Grant Hamlet Two-Way Vector Technique 291
34 Body Contouring Following Massive Marcelo A. Cuadrado
Weight Loss 261 Index297
Shailesh Vadodaria, Dharmadev Trivedi
35 Gluteal Augmentation 269
Marcelo Olivan

Chapter 2: Aesthetic Medicine: Surgical Pearls
• Video 2.1 Botulinum toxin to corrugator, depressor
supercilli; botulinum toxin to frontalis muscle and
procerus muscle complex
• Video 2.2 Tear trough and lateral orbital rim
enhancement
• Video 2.3 Temple filler: volumization of temple area
• Video 2.4 Nonsurgical rhinoplasty
• Video 2.5 Periocular rejuvenation
• Video 2.6 Cheek filler
• Video 2.7 Upper lip augmentation
• Video 2.8 Lip augmentation
• Video 2.9 Hyaluronic acid to prejowl sulcus,
marionette, and lower nasolabial fold
• Video 2.10 Nefertiti lift with botulinum
• Video 2.11 Hand rejuvenation with hyaluronic acid
Chapter 12: Management of the Neck
• Video 12.1 oVio360 dynamic imaging link. 50-year-old
woman before and after trampoline platysmaplasty
and neck-defining suture. (Courtesy of G. Mueller,
M.D. and oVio Technologies, Newport Beach, CA,
USA.)
Chapter 13: The Turkey Neck: Surgical Management
• Video 13.1 Identification of elevation point and
window under platysma
• Video 13.2 Triple-cable suture fixation to Lore’s fascia
• Video 13.3 Horizontal and vertical tightening of
platysma to Lore’s fascia using the triple-cable suture
technique
• Video 13.4 Redundant platysma band resection by
submental incision
Chapter 35: Gluteal Augmentation
Chapter 16: Aesthetic Nasal Tip Surgery
• Video 16.1 Second interdomal stitch (SIDS)
Chapter 39: Inner Thigh Reduction: Reshaping Using a
Chapter 30: Transaxillary Excision of Gynecomastia
(Andromastia)
• Video 30.1 Surgical management of gynaecomastia
(andromastia): the Levick technique
Chapter 34: Body Contouring Following Massive
Weight Loss
• Video 34.1 Preoperative circumferential marking in
standing position
Video Contents
• Video 34.2 Prone position with marking
• Video 34.3 Right posterior skin excision following
liposuction for pseudoundermining
• Video 34.4 Left posterior skin excision following
liposuction
• Video 34.5 Completed bilateral posterior skin excision
• Video 34.6 Skin closure of posterior wound
• Video 34.7 Final dressing of posterior wound
following insertion of suction drain
• Video 34.8 Patient turned supine and ventral torso
prepared
• Video 34.9 Power-assisted liposuction with 4-mm
cannula
• Video 34.10 Incision for skin excision
• Video 34.11 Preserving Scarpa’s fascia
• Video 34.12 Midline dissection
• Video 34.13 Completed dissection for excision of skin
flap
• Video 34.14 Excised skin flap
• Video 34.15 Marking for plication of the anterior rectus
sheath
• Video 34.16 Completed plication
• Video 34.17 Progressive tension sutures (quilting
sutures)
• Video 34.18 Umbilical transposition
• Video 34.19 Skin approximation in lower abdomen
and exteriorization of umbilicus
• Video 34.20 Deep dermal sutures with the halving
method
• Video 34.21 Skin closure of lower abdomen
• Video 34.22 Appearance after closure of anterior
wound
• Video 34.23 Application of Steri-Strips
• Video 35.1 Gluteal augmentation: surgical technique
Two-Way Vector Technique
• Video 39.1 Skin markings for two-way vector
technique for inner thigh reduction
• Video 39.2 Operative technique for two-way vector
technique for inner thigh reduction
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This book is dedicated to all those who suffer from deformity
and disfigurement and seek an opportunity to improve their
appearance and restore function. The skills of the Aesthetic
Surgeon in helping Cosmetic Surgery patients, as illustrated
in this book, can be translated to helping those such individuals.
It is up to the Surgeons to learn these specialty skills and put
them into practice. This concept is known as Aesthetica and
our book, with elaborate illustrations and videos, provides
many tips and tricks on how to improve as a Surgeon and,
more importantly, improve patient outcomes. Congratulations
to Elsevier for their insight and support throughout.
There is no substitute for clinical experience in aesthetic
medicine and surgery. It is the Hippocratic responsibility of
those with experience to enhance the knowledge base of those
embarking on their new careers. We (the editors) represent the
current interdisciplinary approach to educating for the many
specialties associated with the beauty industry.
A clinician’s aesthetic practice should represent her or his
fundamental roots in medical training. There must be limitations
to the unqualified extension of practice, all in the patients’ best
interests.
There are many traps for the unwary clinician that can be
largely circumvented with an understanding of the needs
and realistic expectations of the patient. The dysmorphic and
psychologically vulnerable patient must be identified and
protected from harm at all times. Similarly, if a surgeon can
provide for an appropriately selected patient’s desires, then
modern aesthetic medicine and surgical practice can be
immensely satisfying and rewarding.
Preface
Like many surgical disciplines, the practice of aesthetic
surgery has evolved by developing improved surgical tech-
niques to meet increasing patient expectations. In most cosmetic
procedures, the vast majority of advances are from the teaching
of surgical skill sets to younger surgeons through operative
training, textbooks, lectures, and symposia. The difficulty of
developing randomized or prospective cohort studies and
multicenter analyses for aesthetic procedures contributes to
the progression via more traditional modes of teaching. Aesthetic
surgery is unique due to constantly changing trends, as well
as the racial and regional ethnic preferences that drive patient
desires to achieve what is considered an aesthetic result.
There are few books that deliver a case-based approach to
common aesthetic problems, particularly with a global perspec-
tive. The topics included in this book are based on the basic
competencies recognized for hands-on training of an aesthetic
surgeon and include the latest tips and tricks in the aesthetic
and beauty industry. The authors are selected from experienced
clinicians across the globe, and each presents cases that are
easily identified in a normal practice, describing their technique
and outcomes with minimal but relevant bibliography and
operative videos.
We the editors hope that the inquiring clinician will be
stimulated to improve his or her best practice.
JDF
SCB
DJS
HAK
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We would like to thank James D. Frame (Jnr), BSc, MSc, who
worked hard to help reorganize and, in some cases, rewrite
chapters to fit in with style and assisted with the electronic
submissions. Without his work, none of this would have started.
Also, we would like to thank our wives who have put up with
our 30 year “working friendship.”
JDF
DJS
Acknowledgments
This project would not be possible without the deduction and
hard work of our contributors, all of whom, without hesitation,
offered their time and expertise to realize this unique textbook
of Aesthetic Surgery. We thank you for your kind contribution
and time. We would like to also acknowledge the team at
Elsevier whose continuous support throughout this project
has once again resulted in an outstanding publication for the
readers of Aesthetic Surgery.
SCB
HAK
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 List of Contributors
Bernard S. Alpert MD Henrique P.L. Cintra MD Jayme A. Farina Jr. MD, PhD
Plastic Surgeon Assistant Professor of Plastic Surgery Professor
California Pacific Medical Center Davies Pontifical Catholic University of Rio de Janeiro Head of Division of Plastic Surgery
Campus (CPMC) Rio de Janeiro Ribeirão Preto Medical School
San Francisco, CA, USA Medical Director University of São Paulo
11. High SMAS Face Lift Craniofacial Surgery Center Brazil
State University of Rio de Janeiro 38. Inner Thigh Lift
Hazem M. Aly MBBCh, MSc, PhD
Rio de Janeiro, Brazil
Professor of Plastic Surgery
25. Small Breast
Ain Shams University Alexandre S.F. Fonseca MD, PhD
Cairo, Egypt Clifford Clark MD Plastic Surgeon
Assistant Professor of Plastic Surgery Medical Director Breast Reconstruction Division
Dalhousie University Orlando Aesthetic Institute ICESP Cancer Center
Saint John, New Brunswick, Canada Orlando, FL, USA University of São Paulo School of Medicine
9. Anatomic Relationship of SOOF and ROOF in Assistant Clinical Professor São Paulo, Brazil
Eyelid Rejuvenation University of South Florida Centro Médico Viver Melhor
Tampa, FL, USA São Paulo, Brazil
Claudio Angrigiani MD
20. Male Rhinoplasty 26. Breast Reduction: Superomedial Pedicle
Chief of Plastic Surgery
Wise-Pattern Approach
Hospital Santollani Pedro S. Coltro MD, PhD
Buenos Aires, Argentina Professor of Plastic Surgery James D. Frame FRCS, FRCS (Plast)
28. Simultaneous Augmentation and Periareolar Ribeirão Preto Medical School Consultant Plastic Surgeon
Mastopexy: Indications and Limitations University of São Paulo Professor of Aesthetic Plastic Surgery
São Paulo, Brazil School of Medicine
Peter Arnstein FRCS (Plast)
38. Inner Thigh Lift Anglia Ruskin University
Consultant Plastic Surgeon
Chelmsford, Essex, UK
McIndoe Hospital Fernanda B. Correa MD
9. Anatomic Relationship of SOOF and ROOF in
East Grinstead, Sussex, UK Plastic Surgeon
Eyelid Rejuvenation
5. Endoscopic Endotine Brow Lift Made Easy Ribeirão Preto Medical School
University of São Paulo Riccardo Frati MD, PhD
Phillipe Bellity MD
Brazil Consultant Plastic Surgeon
Plastic Surgeon
38. Inner Thigh Lift Highgate Private Hospital
Hartmann Clinic
London, UK
Paris, France Marcelo A. Cuadrado MD
33. Nonexcisional Management of the Anterior
3. Aesthetic Applications for Fillers Plastic Surgeon
Abdominal Wall
Hospital Britanico de Buenos Aires
Miles G. Berry MS, FRCS (Plast)
Buenos Aires, Argentina Garrick Georgeu MBChB, MSc, FRCS
Cosmetic Surgeon
39. Inner Thigh Reduction: Reshaping Using a (Plast)
Cosmetic Surgery Partners
Two-Way Vector Technique Consultant Aesthetic Plastic Surgeon
London Welbeck Hospital
Cadogan Clinic
London, UK Anne Dancey, FRCS (Plast), MBChB
London
14. Platysma Bands (Hons), MMedSci (Hons) MCh (PASP)
Consultant Aesthetic Surgeon
Plastic and Reconstructive Surgeon
Nazim Çerkeş MD Chelmsford, UK
Birmingham, UK
Aesthetic Plastic Surgeon 29. Asymmetric Breast
32. Postbariatric Abdominoplasty
Cosmed Aesthetic Plastic Surgery Center
Grant Hamlet MBChB
Istanbul, Turkey Petrus V. van Deventer MBChB, BSc,
Director
18. The Middle Eastern–Mediterranean Nose MMedSc (UOVS), MMed (US)
The Hamlet Clinic
Lecturer in Plastic & Reconstructive Surgery
Kaushik Chakrabarty MBChB, MD, FRCS, Harley Street
University of Stellenbosch
FRCS (Plast) London, UK
Bellville, Western Cape, South Africa
Consultant Plastic Surgeon 33. Nonexcisional Management of the Anterior
27. Mastopexy with Mesh for Breast Ptosis
University Hospital of South Manchester Abdominal Wall
Wythenshawe, Manchester, UK Charles East MBBS, FRSC
Hugh Henderson FRCS
37. Aesthetic Management of the Aging Hand Consultant Surgeon at the Royal National Throat
Consultant Plastic Surgeon
Nose and Ear Hospital and University College
Leicester
London Hospitals
Medico Legal Advisor and Claims Examiner
NHS Trust
Leicester, UK
London UK
1. Informed Consent: Protecting the Patient and
Director of Rhinoplasty
the Surgeon
ENT@150
Harley Street
London, UK
17. Crooked Nose
xiv List of Contributors

Darryl J. Hodgkinson MBB (Hons), FRCS Gregory P. Mueller MD, FACS Alberto Rancati MD, PhD
(C), FACS, FACCS Plastic Surgeon Chief Division Oncoplastic Surgery
Plastic and Reconstructive Surgeon Private Practice Instituto Oncologico Henry Moore
The Cosmetic and Restorative Surgery Clinic Beverly Hills, CA, USA Universidad de Buenos Aires
Sydney, Australia 12. Management of the Neck Buenos Aires, Argentina
13. The Turkey Neck: Surgical Management Assistant Professor Plastic Surgery
Arun Nayyar DMD, MS
Florida International University
Janek S. Januszkiewicz MBChB, FRACS Private practitioner in Prosthodontics
Miami, FL, USA
(Plast) Former Director of Fixed Prosthodontics
28. Simultaneous Augmentation and Periareolar
Plastic Surgeon Medical College of Georgia School of Dentistry
Mastopexy: Indications and Limitations
New Zealand Institute of Plastic and Cosmetic Augusta, GA
Surgery Former Principle Research Scientist, (Adjunct) Neal R. Reisman MD, JD, FACS
Auckland, New Zealand Georgia Tech Research Institute Past President
6. Upper Blepharoplasty Atlanta, GA, USA The Aesthetic Surgery Education and Research
24. Aesthetic Dentistry of the Smile Line Foundation
Kazunari Karahashi MD
Clinical Professor Plastic Surgery
Clinical Fellow of Plastic Surgery Igor Niechajev MD, PhD
Baylor College of Medicine
St Luke’s International Hospital Chief
Immediate Past Chief Plastic Surgery
Tokyo, Japan Plastic Surgery
CHI Baylor St. Luke’s Medical Center
19. The Asian Rhinoplasty Lidingö Clinic
Attorney at Law
Stockholm, Lidingö, Sweden
Jaffer Khan MBBS, FRCSI, FRCS (Plast), Houston, TX, USA
15. Prominent Nose
FACS 1. Informed Consent: Protecting the Patient and
Chief Executive Officer Nicholas R. Nikolov MD, FACS the Surgeon
Aesthetics International Plastic Surgeon
Christopher M.E. Rowland Payne MB, BS,
Consultant Plastic and Reconstructive Surgeon The Nikolov Center for Plastic Surgery
MRCP
Aesthetics International Beverly Hills, CA, USA
Consultant Dermatologist
United Arab Emirates 12. Management of the Neck
The London Clinic
Senior Lecturer in Aesthetic Surgery
Naoyuki Ohtake MD, PhD Harley Street
Anglia Ruskin University
Director of Plastic Surgery London, UK
Cambridge, UK
St Luke’s International Hospital 21. Medical Rhinoplasty
2. Aesthetic Medicine: Surgical Pearls
Tokyo, Japan
Ernesto J. Ruas MD, FACS
Natasha Jaffer Khan MBBCh, BAO, LRCP, 7. Asian Blepharoplasty
Associate Clinical Professor
LRCSI 19. The Asian Rhinoplasty
Plastic Surgery
Aesthetics International
Marcelo Olivan MD, PhD University of South Florida College of Medicine
United Arab Emirates
Consultant Plastic Surgeon Tampa, FL, USA
2. Aesthetic Medicine: Surgical Pearls
University of Sao Paulo 8. Midface Descent and Malar Support
Paul Levick MS, FRCS (Ed), FRCS (Eng) São Paulo, Brazil
Edward R. Schlissel DDS, MS
Consultant Plastic Surgeon 35. Gluteal Augmentation
Professor Emeritus
Birmingham, UK
Alenka Paddle MBBS (Hons), FRACS General Dentistry
30. Transaxillary Excision of Gynecomastia
(Plast), PGDipSurgAnat Stony Brook University School of Dental
(Andromastia)
Advanced Aesthetic Plastic Surgery Fellow Medicine
Michael R. Markiewicz MD, DDS, MPH Melbourne Institute of Plastic Surgery New York, NY, USA
Assistant Professor Melbourne, Australia 23. Implantology
Department of Oral and Maxillofacial Surgery 36. Upper Arms: Rejuvenation of the Arm
Peter Scott, MBBCh, BSc (Hons), FRCS
University of Illinois
Philip Peirce MBBCh, FCS (SA) (Ophth) (Edin)
Chicago
Ophthalmic and Oculoplastic Surgeon Consultant Plastic Surgeon
Attending Surgeon
Sandhurst Eye Centre Morningside Clinic
Northwestern Memorial Hospital and Ann &
Sandton, South Africa Johannesburg, South Africa
Robert H. Lurie Children’s Hospital of Chicago
4. Brow Lift 4. Brow Lift
Chicago, IL, USA
22. Orthognathic Surgery Kirill Pshenisnov MD, PhD Nobuyuki Shioya MD, FACS
Professor and Chief of Plastic Surgery Professor Emeritus of Plastic Surgery
Michael Miloro MD, DMD, FACS
European Medical Center Kitasato University School of Medicine
Professor and Head of Department of Oral and
Moscow Sagamihara, Kanagawa, Japan
Maxillofacial Surgery
Professor of Plastic Surgery 7. Asian Blepharoplasty
University of Illinois
Russian National Research Medical University 19. The Asian Rhinoplasty
Chicago, IL, USA
Moscow
22. Orthognathic Surgery
Professor of Traumatology and Plastic Surgery
Bassem M. Mossaad MRCS, MSc (Aesth Yaroslavl State Medical University
Plast), FEBOPRAS, MD Yaroslavl, Russia
Lecturer and Consultant Plastic Surgeon 16. Aesthetic Nasal Tip Surgery
Plastic Surgery Unit
Suez Canal University
Ismailia, Egypt
31. Improving the Waistline with the Modified
Brazilian Abdominoplasty

Graeme Southwick OAM, MBBS (Hons),
FRACS, FACS
Consultant Plastic Surgeon
Chairman
Melbourne Institute of Plastic Surgery
Adjunct Senior Lecturer
Anatomy and Cell Biology
Hudson Institute of Medical Research
Monash University
Melbourne, Victoria, Australia
36. Upper Arms: Rejuvenation of the Arm
Jan J. Stanek MA, FRCS
Cosmetic Plastic Surgeon
Surgical Aesthetics
London, UK
14. Platysma Bands
Guilherme Flosi Stocchero MD
Plastic Surgeon
Centro Médico Viver Melhor
São Paulo, Brazil
26. Breast Reduction: Superomedial Pedicle
Wise-Pattern Approach
Gustavo Flosi Stocchero MD
Plastic Surgeon
University of São Paulo Hospital
São Paulo, Brazil
Centro Médico Viver Melhor
São Paulo, Brazil
26. Breast Reduction: Superomedial Pedicle
Wise-Pattern Approach
List of Contributors xv
Patrick J. Treacy MBBCh, LRCSI, MICGP, Shailesh Vadodaria MBBS, MS, MCh, FRCS
MBCAM, HDip Derm, BSc (Hons) (Plast)
Dermatologist, Founder and President of the Consultant Plastic and Reconstructive Surgeon
Ailesbury Clinic London Welbeck Hospital
Dublin, Ireland London
10. Nonsurgical Rejuvenation of the Periorbital Consultant Plastic and Reconstructive Surgeon
Area Clementine Churchill Hospital
Harrow
Dharmadev Trivedi MBBS, MS, MRCS,
Middlesex
FHEA (UK)
Director
Registrar in Upper Gastrointestinal /
Medical Arts for Cosmetic Surgery
Hepatopancreatobiliary Surgery
Watford, UK
Bristol Royal Infirmary
Consultant Plastic and Reconstructive Surgeon
Bristol
Kokilaben Dhirubhai Ambani Hospital and
Research Registrar in Cosmetic Surgery
Medical Research Institute
Medical Arts for Cosmetic Surgery
Mumbai, India
Watford, UK
34. Body Contouring Following Massive Weight
34. Body Contouring Following Massive Weight
Loss
Loss
Takanori Yamawaki MD
Jared Troy MD
Plastic Surgeon
Plastic Surgeon
St Luke’s International Hospital Tokyo
Winter Park, FL, USA
Japan
20. Male Rhinoplasty
7. Asian Blepharoplasty
Zara Yousufzai MBBS, MS (Plast)
Aesthetics International
United Arab Emirates
2. Aesthetic Medicine: Surgical Pearls
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PA R T 1
Introduction
David J. Smith
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Informed Consent: Protecting the Patient and
the Surgeon
The Process of Informed Consent
Neal R. Reisman MD, JD, FACS
The process of informed consent is very important to the practice
of plastic surgery. Not only is it a requirement from a legal
standpoint, but it should assist in clarifying goals and expecta-
tions. Understanding informed consent is a process and not
specifically the document that becomes signed; the process
should include not only the surgeon, but the team interacting
with the patient. There are legal standards that every jurisdiction
adheres to defining requirements in accomplishing informed
consent. The majority of states in the United States follow a
“reasonable patient” standard which defines informed consent
information necessary for a reasonable patient to make an
informed decision. The minority standard is what a “reasonable
physician” deems appropriate to accomplish informed consent.
Such standards do not mean that all information pertinent to
a procedure must be discussed but only such information as
a reasonable prospective patient would need to understand
to make an informed decision. Practices spend much time
creating and discussing informed consent. The reality is that
there are very few litigation cases specifically lost on a lack of
informed consent. It is important to have the consent discussion
and documents in the patient’s language. In addition to language
issues, the bigger task is having the patient “understand” what
the risks, hazards, inherent risks, and concerns are. The
understanding of this information becomes the main issue in
creating and achieving informed consent. A mere signature at
the bottom of the document only demonstrates that the patient
signed it and not that it is understood.
Informed consent documents present and discuss death and
significant morbidity. It may be difficult for a jury to believe
the plaintiff is objecting to a scar or a less than desirable result
when they have understood and signed to say that they
acknowledge that death is an acceptable risk. The scar seems
much less significant. Herein lies the challenge to achieve
informed consent, and I suggest to accomplish the legal
The Process of Informed Consent 3
1
Neal R. Reisman MD, JD, FACS
Hugh Henderson FRCS
requirement by going beyond the document itself and using
the discussion to better interpret and decide whether goals
can be reached.
The reasonable patient would inquire about the different
procedures suggested, their complications and inherent risks,
anesthesia concerns, drug interactions, cost and expenses, and
the risk of doing nothing. It behooves the practice to see the
prospective patient more than once and to utilize multiple
learning style techniques in providing necessary information.
There are many learning styles, but the most common three
are visual, auditory, and kinesthetic. Understanding is enhanced
when all three styles are incorporated in the informed consent
process. Many patients are visual learners and achieve under-
standing by looking at photographs, schematics, and other
tools the patient can see. One must be cautious in not having
photographs interpreted as a warranty of results but rather
representative of different aspects of the procedure. Demonstra-
tive tools should clearly not be presented as the prospective
patient’s result but rather a general representation. Patients
may bring in their own photographs of goals and expectations
that are helpful in defining their desires, but these should not
be made part of or included in the medical record. Auditory
learners are the next most common group. The auditory learner
listens in great detail to describing information pertaining to
the procedure, follow-up, and care. Your words paint a picture
for them, achieving a better understanding of the procedure
and inherent risks. Often the more detail you can provide in
advance, the more comfortable the patient is with the entire
event. The third learning style is the kinesthetic learner. This
can be more of a challenge in discussing how the procedure
specifically relates to the patient and past experiences the patient
can recognize. An example might be, when attempting to
determine size goals in a breast augmentation, to have the
patient reflect on a past pregnancy where breast size dramati-
cally increased. The patient may disclose that they liked their
shape as they reached a full C in size, but the full D size they
reached was too large. Such a personalized experience and
understanding significantly helps the patient in understanding
options and achieving their goal.
3
4   CHAPTER 1 • Informed Consent: Protecting the Patient and the Surgeon
Achieving informed consent can be a team event. The
surgeon has the responsibility to discuss aspects of the treat-
ment; however, some portions can be delegated to the office
team nurse or coordinator. In my opinion it is difficult to allow
or delegate others beside the surgeon to discuss and obtain
informed consent when these non-surgeon team members have
not received the training or credentials, or had the privilege
to ever perform such surgeries. It is wise to develop a team
approach in presenting such information, with the patient
coordinator and the nurse confirming and corroborating the
surgeon’s discussions.
The details of the informed consent document should reflect
the discussions had on the multiple visits prior to the actual
procedure. I have chosen to divide the document into general
risks and specific procedure risks to help the patient understand
what is involved.
General risks of surgery include healing issues, delayed
or undesirable results, bleeding, infection, scarring, pain,
complications related to anesthesia, cardiac pulmonary, deep
venous thrombosis (DVT) and sequelae, allergic reactions,
drug reactions, and unsatisfactory results, to name some of
the included discussions. Additional general advisories relate
to smoking and its negative effect on healing, off-label US
Food and Drug Administration issues, the negative effects
of sun exposure, and general concerns in the postoperative
period relating to travel and family interaction. Additional
discussions should include the possible need for additional
surgery, the importance of patient compliance, a revision policy
covering how long and what, and a separate financial disclosure
document covering patient responsibility, cosmetic surgery
component, present and future expenses, and cancellation policy.
The revision policy should include the period of time after
surgery in which a revision will not incur a fee. Ten months after
surgery might not be unreasonable for the surgeon to consider
a scar revision without additional fees while five years later
might be unreasonable. In addition, the limitations of a revision
would only cover the performed surgeries and not additional
areas or procedures. Revision of an abdominal scar might be
appropriate but additional liposuction or a body lift would not
be considered a ‘revision’. Lastly it is wise to state the revision
policy will only be effective when the patient attends their
postoperative appointments and adheres to recommended care.
Non-compliance waives the revision policy. A communications
consent is important to document and acknowledge how the
practice may communicate with the patient. This should include
permission for telephone numbers, email choices, texting and
cell phone permissions, and social media and other methods.
A general consent should also include the use of photographs
to be kept by the practice and commercial photograph consent
should any patient medical information or likeness be used for
marketing, advertising, or educational purposes. The general
Health Insurance Portability and Accountability Act (HIPAA)
consent would not be adequate for any use beyond practice
storage. The commercial consent is specific regarding where the
likeness would be used, for how long, and for what purpose.
Specific procedural consent should include technical and
specific information relevant to the selected treatment question.
This is the area where specific options related to the procedure
and patient choices are covered. Inherent risks and complications
specific to the procedure should be outlined carefully and in an
educational fashion. Choices offered to a patient or demanded
by a patient should fall within a peer-approved appropriate
selection choice. I have issues with the propriety of less than
desirable options being selected by the patient. One might say
that a patient cannot consent to a negligent procedure. The
surgeon has a duty to protect the patient, sometimes from
themselves. Remember that the informed consent standard is a
reasonableness standard. That is, what a reasonable physician
or a reasonable patient would want to discuss or know for the
patient to make an informed decision. Many have utilized a
checklist to cover the large amount of information that may be
necessary in a complex case. The concern with a large checklist is
that one item may be unintentionally omitted. If that is the one
complication the patient suffers, the perception may be that it
was omitted intentionally. Educational aids to assist with visual,
auditory, and kinesthetic learning are valuable. The concern is
not to create a warranty, either express or implied. An express
warranty includes a specific demonstrative in the medical record
that establishes an agreed-upon result. Patients bring pictures
from magazines and the Internet as a goal for their expectation.
While these are valuable, I would suggest they not be made
part of the medical record. Similarly your preoperative and
postoperative photographs should clearly represent a range of
results and not imply specific results for this patient. An implied
warranty can be more confusing, as it relates to expressed
concerns and desires the patient has that are not negated or
addressed. An example might be an important meeting 2
weeks following surgery that must be attended. Failing to offer
rescheduling or a disclaimer that meeting attendance may not be
possible may establish an implied warranty that the patient will
be able to attend. I like the additional paragraph “no warranties
express or implied are included and the patient understands
what can and cannot be done and, understanding this, elects to
proceed.”
Additional information as part of this informed consent
process includes a financial disclosure statement and a surgi-
cal revision policy statement. Finances are always significant
to the patient, and misunderstandings are quite common. It
is important to have a separate document that incorporates
expectations of named procedure, estimated time, and fees
including surgeon, anesthesia, facility, and any additional costs
that may be incurred, such as devices and instrumentation.
The patient should understand and acknowledge such a docu-
ment in advance of the procedure. The revision policy is also
important to avoid misunderstandings. Despite best intentions
patients may heal quite differently and unexpectedly. I like the
revision policy to include an understanding that the patient is
required to be compliant and not miss follow-up appointments
or postoperative suggestions of care. The surgeon can certainly
for some period not charge for agreed revisions, but there may
be additional charges for anesthesia, facility, or devices. I do not
believe that not billing is an admission of negligence and have
advised adding a clause in the policy manual stating “from
time to time, as an executive decision, fees may be waived,
discounted, or not created.”
There are so many aspects of the informed consent document;
I do not want to minimize its importance. I would, however,
seize the opportunity to have a robust and complete discussion
with the prospective patient about their goals and desires and
use this interactive informed consent process to determine
if such goals are realistic and achievable. Avoid letting the
patient dictate care and procedure selections unless such choices
are well within an appropriate peer-accepted range. Failed
expectations still remain a leading cause of unhappy patients

FIGURE 1.1 An infected abdominoplasty wound.
and litigation. The wise old statement “if I tell you in advance
of a complication and you get it, I look smart, where if I tell
you the same statements after your complication I’m making
excuses” becomes significant when complications occur. Use the
informed consent process as an educational tool, recognizing
learning styles as well as the dialogue assessing patient goals.
Such a process often results in an educated, content, and satisfied
patient and a successful postoperative course.
Informed Consent: Protecting the
Surgeon
Hugh Henderson FRCS
The Legal Situation
“Justice must not only be done, but must be seen to be done,”
and so it is with informed consent. Surgeons need written proof
about what they have advised a patient. You are as often as
not assumed guilty until you prove your innocence (Fig. 1.1).
Courtroom Scenario
“Well Mr. Jones, did you really spend 45 minutes explaining
this operation to Mrs. Smith or only the 10 minutes as she
alleges? Did you think to make note of the duration of your
consultation and did you give her any written information
about the common risks of what you were proposing? Did
you show her photographs and suggest a second consultation
to ensure that she really understood…?”
If you want to avoid this sort of courtroom confrontation
with an aggressive barrister, you must get a watertight informed
consent which will convince a judge that the patient was well
informed and able to make a considered decision about whether
to have the operation and that the patient understood the risks.
Different surgeons have different ways of achieving this and
there are no mandatory or statutory rules about how to do it.
You can make a close record of what your verbal discussion
covered, you can enclose it in a letter to the general practitioner,
or you can give it to the patient in the form of an information
sheet that you can prove was actually delivered to the patient.
You can get photographs in hard copy on which you and the
Informed Consent: Protecting the Surgeon 5
FIGURE 1.2 Breast augmentation: the available implant options to be discussed
with a patient.
FIGURE 1.3 High right breast implant and sliding ptosis of breast tissue. Patient
unaware that this could happen after augmentation mastopexy.
patient have drawn to show the areas to be treated and the
type of changes that you agree will be attempted.
A recent court of appeal ruling (The Montgomery Case)1
not only expects you to inform the patient of the details of the
operation which you have agreed, but also requires that you
have explained all the alternative options and their merits and
demerits (see Fig. 1.2).
Patients tend to remember only 50% or less of what they
are told verbally in an initial consultation. The longer the
consultation, the more likely that they will “switch off” after
a certain time and forget important points. A lot of surgeons
think that one consultation is sufficient, but if you test a patient’s
knowledge of what has been discussed in that first consultation,
you will be saddened to find that they haven’t really taken in
quite a lot of important matters (Fig. 1.3).
If you give them one consultation plus a detailed informa-
tion sheet and then test them, their knowledge is much better.
If you give them one consultation and an information sheet
and make sure they read it and then see them for a second
consultation, most patients will have absorbed everything you
want them to know and you will have obtained proper informed
consent. Just because it is logistically difficult to arrange a
second consultation, it is not an excuse for not arranging one.
I have dealt with over 1000 medical negligence cases, and I
know that at least 200 of these would have never occurred if
there had been a second consultation before the day of surgery.
6   CHAPTER 1 • Informed Consent: Protecting the Patient and the Surgeon
Most hospital consent forms nowadays include reference
to whether an information sheet has been given. This is rec-
ognition that information sheets are important in the consent
process. Although information sheets are not mandatory as
yet, I think they should be because they can contain a lot
more information than is mentioned or highlighted in an
oral consultation. My own policy has always been to write
information sheets as comprehensively as possible so that a
lawyer will have a hard time trying to prove lack of consent.
They can be equivalent to a second consultation and can be
included on your website or sent to a patient in advance of the
first consultation or given to the patient at the time of the first
consultation.
Are tick lists proof of adequate discussion? It is only too
easy for a surgeon in a hurried consultation to speak to a
patient and then at the end of the consultation when the patient
has left to tick all the boxes. A more trustworthy way of using
a tick list is to give the patient a copy of your tick list at the
time of the consultation and invite them to tick the subjects
off and to sign it and hand it back to you as evidence that
these points have been discussed. It is also wise to record the
length of time spent going through this tick list.
It is important to indicate a percentage risk of occurrence
of the various complications you describe. It is also vital to
discuss the potential consequences of the complications rather
than simply giving a list of the name of complications. Thus,
for example, in breast reduction it is sensible to tell a patient
that most infections are of minor consequence but about 1%
to 2% of breast infections after breast reduction can be absolutely
devastating and can ruin the result and cause months of pain
and morbidity.
It is important to establish the financial consequences of
complications. Who will pay for “re-dos”? Some hospitals cover
the costs of complication for 1 month postoperatively. This
must be discussed and explained. Emphasize that you won’t
insure the patient for life. Some patients think they deserve
free correction years after their initial surgery.
It is essential to write down exactly what the patient asked
for in their own words rather than your translation of what
you interpret that they are asking for. The very first record
that you make of the consultation should be what the patient
is actually asking for. It is remarkable how few surgeons actually
do this. I have been involved in lots of medico-legal cases in
which the surgeon has failed to record what the patient actually
requests. If you don’t record it, the patient can come back and
blame the surgeon for doing the wrong operation. They can
say that they never asked for what the surgeon has recom-
mended. Therefore, if their request is ambiguous, then you
must clarify it. “I want nicer fuller breasts” could mean lots
of different things, but it doesn’t necessarily mean breast
augmentation. The patient might subsequently say, “Doctor I
never asked you to make my breasts bigger, I simply asked
you to lift them to make them look fuller.” Having recorded
what the patient is asking for, you should then record the
topics of discussion in relation to this request. It is quite possible
that the patient will change their mind as a result of this discus-
sion and you should then record what their secondary request
is. You must also record what you have recommended and
why and then, separately, what has been agreed.
It is always sensible to show photographs of both good and
bad results so that you can never be accused of showing atypi-
cally perfect results.
If a patient decides to have an operation, but wishes to
delay it for more than a few weeks, it is essential to see them
again for a brief reminder consultation a few days before the
operation. This is to remind you, the surgeon, and also the
patient of what has been agreed and of the risks, and it gives
the patient the chance to ask further questions.
If a patient asks you for a little bit of extra surgery on the
day of the operation, you have the dilemma of causing offense
by refusing or putting yourself in jeopardy if you haven’t sorted
it out properly in advance.
Summary
1. Record the time of the start of the consultation and its
duration.
2. Write down what the patient first asked for, not what you
think might suit them.
3. Write down the options for treatment.
4. Write down what you recommend for them.
5. Write down what you agree to do.
6. Write down the risks and separately the percentage
occurrence of the complications and the consequences of
the complications.
7. Give a comprehensive information sheet.
8. Insist upon a second consultation to run over what has
been discussed already, emphasizing the risks.
9. Discuss the costs of surgery, the financial consequences of
dealing with complications, and who is going to pay for
this.
Reference
1. Montgomery (Appellant) vs. Lanarkshire Health Board (Respondent)
(Scotland) before Lord Neuberger, President, Lady Hale, Deputy
President, Lord Kerr, Lord Clarke, Lord Wilson, Lord Reed, Lord
Hodge. Judgement given on 11 March 2015. Heard on 22 and 23 July
2014.
 Multimodality Nonsurgical Rejuvenation With a Regional Approach 7

2
Aesthetic Medicine: Surgical Pearls

Jaffer Khan MBBS, FRCSI, FRCS (Plast), FACS

Zara Yousufzai MBBS, MS (Plast)
Natasha Jaffer Khan MBBCh, BAO, LRCP, LRCSI

Commercially available botulinum toxin A are:

Introduction ■ onabotulinum toxin A (Botox)
Aesthetic medicine comprises all medical procedures that are ■ abobotulinum toxin A (Dysport)
aimed at improving the physical appearance and satisfaction ■ incobotulinum toxin A (Xeomin)
of the patient, using noninvasive to minimally invasive cosmetic Dilution
procedures.
These aesthetic procedures consist of: ■ 1 B.U. = 2.5 s.U
1 vial of Dysport (500 s.U) + 2.5 mL saline = 20 U/0.1 mL
■ injections of neurotoxins (can be rediluted in the syringe with 1 : 1 ratio to create a
■ dermal fillers/fat grafting concentration of 10 s.U/0.1 mL)
■ chemical peels ■ 1 vial of Botox (100 U) + 2.5 mL of saline = 4 U/0.1 mL
■ radiofrequency 30- to 32-gauge needle (a smaller needle is preferred in
■ cryotherapy sensitive patients)
■ lasers and intense pulsed light (IPL) 4 U Botox = 10 U Dysport
■ ultrasound treatment
■ platelet-rich plasma (PRP)
The author used a combination of these procedures for PREPROCEDURE MANAGEMENT OF
nonsurgical rejuvenation. This chapter provides an overview NEUROMODULATORS
of each of these with their clinical implications, recommended
indications, management, advantages, and disadvantages. ■ Conduct an assessment of the patient.
■ Note the location and depth of rhytids.
■ Obtain a history of the patient’s concerns.
• Brow position is important.
Multimodality Nonsurgical • Check for the presence or absence of compensatory
brow elevation.
Rejuvenation With a Regional • Check for blepharochalasis and dermatochalasis.
Approach • Check for collagen depletion.
• Measure the width of the forehead (a wide forehead
would need more neuromodulator/Botox).
Botulinum Toxin (Botox) • Assess strength of frontalis muscle and length of
corrugator.
In aesthetic medicine botulinum toxin (see Table 2.1 and Fig. ■ Take a preoperative photograph.
2.1) is the most commonly used nonsurgical treatment world- ■ Apply a eutectic mixture of local anesthetics (EMLA) 30
wide. In 2014, 4.89 million Botox treatments were done minutes prior to procedure.
worldwide. Its popularity is due to its excellent safety record ■ Give counseling about potential complications.
and predictable outcomes. ■ Obtain consent.

7
8   CHAPTER 2 • Aesthetic Medicine: Surgical Pearls
Table 2.1 Uses of botulinum toxin in aesthetic medicine
Dynamic rhytids • Forehead horizontal lines
• Glabellar vertical lines
• Periocular rhytids (crow’s feet)
• Hyperdynamic orbicularis/pretarsal
orbicularis (under the eyes)
• “Bunny” lines
• Perioral (smoker’s lines)
Diminishing the • Lateral fibers of orbicularis (brow
depressor activity elevation)
of certain muscles • Depressor septi (nasal tip elevation)
• Platysma (Nefertiti lift)
• Mentalis (chin deformity)
• DAO (for marionette lines)
Hypertrophic muscles • Masseter
• Nasalis (alar flare muscle)
• LLSAN (“gummy” smile and alar flare)
• Masseter
• Deltoid
• Medial head of gastrocnemius
DAO, Depressor anguli oris; LLSAN, levator labii superioris alaeque nasi.
POSTOPERATIVE CARE FOR NEUROMODULATORS
■ The lumps on the area injected will go down in 15 to 30
minutes.
■ Do not rub or apply pressure on the area that was
injected with Botox.
■ For 6 hours, avoid bending or stooping down; instead lie
down flat on your back.
■ Do not go to the gym or do any sports until the next day.
■ Follow up after 10 days.
■ Take a postoperative photograph.
Hyaluronic Acid (Fillers)
Adding volume along with short-scar face lift has largely
overtaken surgical correction for midface. The choice of filler
is dependent on the anatomy of each individual and the specific
treatment goals. Injectable soft-tissue fillers are durable, well
tolerated, and potentially reversible in unfavorable clinical
outcomes. Small-particle hyaluronic acid (HA) with lidocaine
(Restylane Silk, Galderma, Uppsala, Sweden) is used for
submucosal implantation for lip augmentation and dermal
implantation for correction of perioral rhytids. Side effects are
generally mild and transient.
PREPROCEDURE MANAGEMENT
■ Conduct a general assessment of the patient.
■ The patient should avoid aspirin (any product containing
acetylsalicylic acid), vitamin E, and other dietary
supplements, including gingko, evening primrose oil,
garlic, feverfew, and ginseng, for 2 weeks.
■ The patient should also avoid blood thinners such as
aspirin, ibuprofen (Advil, Motrin), and naproxen (Aleve,
Naprosyn) 1 week before the treatment.
■ Enquire about history of cold sores (or fever blisters)
prior to treatment.
■ Optionally, the patient can start taking an Arnica tablet
for 1 week prior to treatment and 4 days posttreatment.
The standard dosage is three Arnica tablets (30 CH) three
times a day 30 minutes before or after a meal.
■ Enquire about allergy or sensitivity to lidocaine.
■ Mild bruising is common and can last 7 to 14 days.
■ Take a preoperative photograph.
■ Apply EMLA 30 minutes prior to the procedure.
■ Give counseling about potential complications and obtain
consent.
POSTOPERATIVE MANAGEMENT
■ Follow up after 2 weeks for touch-up.
■ Take a postoperative photograph.
■ Counsel the patient that the volume will go down by
approximately 20%.
■ Give Voltarol for pain relief.
■ Massage with Arnica.
■ Avoid hot beverages after the dental block (for lip
augmentation).
■ Avoid cold compression to prevent headache (in the
temporal area).
■ Minimize movement of the treated area.
■ Avoid applying heat to the treated area until bruising or
any swelling has resolved.
■ On the day of treatment, avoid activities that cause facial
flushing including consuming alcohol, hot tub or sauna
use, exercising, hot wax, and tanning. Avoid extreme-cold
activities, like skiing or hiking outdoors.
■ Gently apply a cool compress or wrapped ice pack to the
treated areas for 15 minutes every few hours as needed
to reduce discomfort, swelling, or bruising up to a few
days after treatment. When bruising occurs it typically
resolves within 7 to 14 days.
■ Results last approximately 6 to 12 months.
■ For more than 4 cc of filler used, prednisolone 40 mg
with Nexium 40 mg daily for 2 days after meals may be
considered.
Upper Face
Forehead and Brow Rejuvenation (Fig. 2.2)
ASSESSMENT (TABLE 2.2)
■ Check the brow position (this is important).
■ Check for the presence or absence of compensatory brow
elevation.
■ Check for blepharochalasis or dermatochalasis.
■ Check for collagen depletion.
■ Assess the strength of muscle.
■ Measure the width of the forehead.
TECHNIQUE
■ The brow elevator (frontalis) and depressors (corrugator,
procerus, depressor supercilli [DSC] for the medial brow
and the superolateral fibers of the orbicularis oculi for the
lateral brow) should be treated as a single unit to prevent
brow ptosis.
■ Preventing brow ptosis should be the priority.
 Upper Face 9

Before After

A B
Before After

C D

FIGURE 2.1 Combination treatment of hyaluronic acid to periocular midface and marionette areas with botulinum toxin to glabellar forehead and periocular area.

■ This can be achieved by full treatment to the corrugator, ■ For the technique, see Video 2.1.
procerus, and DSC, a conservative dose to the frontalis, ■ Injections placed above the midpupillary line for the
and a later touch-up to the frontalis if required in 10 days. corrugator should be at least 1 cm above the bony orbital
■ Treatment of the superolateral fibers of the orbicularis rim to help prevent lid ptosis caused by diffusion of
oculi will also help to maintain an elevated brow Botox to levator muscles.
position. ■ Some return for a touch-up in 10 days.
■ Assess the activity of DSC. If DSC overactivity is missed,
the patient may come back with descent of the medial COMPLICATIONS
brow (an angry look).
■ If there is previous history of heaviness of brow after ■ Lid ptosis
treatment, inject only in the central forehead. ■ Brow ptosis
10   CHAPTER 2 • Aesthetic Medicine: Surgical Pearls

Before After

A B
Before After

C D

FIGURE 2.2 (A,B) Botulinum toxin to corrugator, depressor supercilli, and procerus muscle complex. (C,D) Botulinum toxin to frontalis muscle.

Table 2.2 Management of forehead and brow rejuvenation

Indication/patient’s
perspective Muscle Plane Treatment
Glabellar frown lines Corrugator Subdermal 4–8 injections in females
Glabellar frown lines Procerus Deep subdermal 6-10 injections in males
10 s.U in each injection
Glabellar frown lines Depressor supercilli Deep subdermal
Dynamic lines on the forehead Frontalis Subdermal One injection centrally and two laterally on forehead.
(between 10 and 30 s.U in divided doses)
To maintain the brow position Orbicularis oculi (superior Subdermal As a prophylactic measure, 10 s.U on each side to
To prevent lateral brow ptosis lateral fibers) be given under the tail of the brow to inactivate
the depressor action
 Hints and Tips 11

Periocular Rejuvenation (see Table 2.3, 4. Avoid the supraorbital bundle and the infraorbital
bundle.
Fig. 2.3, Video 2.2 and Video 2.5) 5. Avoid injecting above the orbital rim.
6. Inject slowly and don’t inject a large bolus.

☛ Hints and Tips

Temporal Area: Temple Augmentation
1. Plunger should be withdrawn three times to avoid (Fig. 2.4)
intravascular placement.
2. If oozing, hold for 2 minutes. Management of hollowness of the temporal area is aimed at
3. Always keep hyaluronidase handy. volumization.

Before After

A B
Before After

C D

FIGURE 2.3 Tear trough and lateral orbital rim enhancement with hyaluronic acid.
12   CHAPTER 2 • Aesthetic Medicine: Surgical Pearls

Table 2.3 Management of periocular rejuvenation

Patient characteristics Management
Dark circles • Mesotherapy
• Carboxytherapy
• Platelet-rich plasma
• Volumization
• Patient in upright position or semirecumbent position
• Low–G prime HA, Teosyal Redensity is my choice of product
• I prefer using a 30-gauge needle or a 25-gauge cannula, which gives accuracy of placement and less
likelihood of irregularity
• Patient is instructed to gently close eyes or open in forward gaze to assess the depth
• Inject deep below the orbicularis. Delivery of small aliquots of low G prime HA subdermally is also possible
• Always withdraw plunger three times with slow delivery and do not overfill
• Inform the patients about upper eyelid heaviness because filler has some lidocaine and causes
infraorbital anesthesia
Prominent eye bags • In minimal extraocular fat, volumize between the periocular and cheek fat just under the orbital rim to
decrease the disparity
• Volumizing may improve the look but the amount of volume required in the cheek to match the periocular
area would result in swollen eyes
• If periocular fat is normal but looks excessive due to inadequate cheek volume and a disharmonious lid
cheek junction then volumization would give a good effect
Prominent eyes • Volumize the lateral orbital rim below the rim to create a harmonious lid cheek junction
• For patients who don’t have bulging eyes, volumization would make their eyes look smaller
• Volumization in the lateral orbital rim area gives the effect of higher cheek bones, but eyes become small;
hence for bulging eyes, filling this area gives good results
• Test to assess extraorbital fat
• With the eyes closed, applying digital pressure on the globe would result in bulging of the periocular fat
Sleep lines • Fractional laser (CO2 laser)
• Volumize with low–G prime HA
Upper lid hollowness • Small amount of local anesthetic is injected at two points:
and brow position • 1 cm below the tail of brow, avoiding any superficial veins
• at midbrow area just above the orbital rim
• I use 27-gauge cannula 1.5 inch needle
• Enter into the subgaleal slide plane
• You will hear a pop as you enter
• I use a retrograde threading technique with very small amounts of volume placed above the orbital rim into
and above the eyebrow. No more than 0.5 cc per eye
• Second access point tends to use a smaller 30-gauge cannula
• Product of choice is low–G prime HA
• Massage well
Periocular rhytids • HA
• CO2 laser
• Botox for dynamic lines (Table 2.4)
• Assessment of extent and depth of rhytids (into cheek or under the eyes)
• Laxity and excess of periocular skin particularly in the infraorbital area
• Avoid injecting too low over the zygoma to prevent diffusion to zygomaticus major, as it would inactivate
cheek elevation upon smiling (masklike smile)
• Patients with excess lower eyelid skin, injections in the lower lid area can lead to descent of skin,
causing a malar crescent at the level of the lateral orbital rim
• Treating the periocular area can result in exaggeration of bunny lines, which may be treated on
subsequent treatment
• While treating the bunny lines, injection placed deep and low on the nasal sidewall can diffuse to LLSAN
may lead to an asymmetric smile
• Complication
• Blurred vision
• Double vision
• Diffusion to the zygomaticus major leading to a asymmetric smile
• Bunny line exaggeration
• In redundant skin injection to the pretarsal area can lead to descent of the skin resulting an arc at the lid
cheek junction
HA, Hyaluronic acid; LLSAN, levator labii superioris alaeque nasi.
 Midface 13

TECHNIQUE ■ I prefer Restylane as it is soft and flows easily, hence we

can use a smaller, finer 30-gauge needle.
■ The temporal fossa is occupied by the temporalis muscle. ■ Keep your nondominant thumb near the hairline to
There are three planes for injecting the filler: prevent wastage of material into the hairline.
• the subcutaneous plane (which can lead to ■ 0.5 mL to 1 mL is required for each fossa.
irregularities and less longevity) ■ For the technique see Video 2.3.
• between the leaves of the superficial and deep
temporal fascia (difficult to localize)
• under the muscle above the periosteum (which is safer
and easily located).
☛ Hints & Tips
■ The injection point is 1 cm behind the temporal crest and 1. Filler in this region has an immediate and long-lasting
1 cm above the lateral orbital rim, just above the effect (2–3 years).
periosteum. Avoid branches of subtemporal artery. 2. Inject slowly after withdrawing the plunger.
■ Give local anaesthetic intradermally raising a weal on the 3. Visualize the veins and avoid anastomoses of external
skin (0.1 mL Xylocaine + adrenaline). and internal carotid to prevent blindness.
4. Massage.
5. Do not place ice on the area postoperatively, as this can
lead to a headache, but keep compression on the injection
point to prevent oozing.
Table 2.4 Neuromodulators for occular area 6. Do not overfill; there should be a slight concavity.
Muscle Plane Treatment
Orbicularis oculi Subdermal 1 cm lateral to the lateral
orbital rim Midface
4–6 injections each side
10 s.U in each injection
Nose/Rhinoplasty (Table 2.5, Fig. 2.5)
Pretarsal orbicularis Subdermal Infraorbital injection
(bulge under the 5–10 s.U under the TECHNIQUE
eyes during eyes into the pretarsal
smile) fibers on each side in ■ I prefer to use Restylane with a 30-gauge needle, as it
divided doses flows easily, is easy to withdraw, has longevity, and is
dissolvable.
Bunny lines Subcutaneous One injection (5–10 s.U) ■ Give an intraoral block (infraorbital nerve block)
high on each side of
when injecting near the tip, columella, or nasal
the nasal sidewall
spine.
(form a bleb) ■ For the technique refer to Video 2.4.

Before After

A B

FIGURE 2.4 Hyaluronic acid to the temporal area.

14   CHAPTER 2 • Aesthetic Medicine: Surgical Pearls

Table 2.5 Nonsurgical rhinoplasty

Patient characteristics
Small nasal hump
Saddle deformity
Tip elevation
Small postrhinoplasty imperfections
Crooked nose or high external deviation
Alar flare (alar part of nasalis)
Plunging of tip (depressor septi muscle)
Management
Add volume to the dorsum proximal and distal to it to create a straight dorsal nasal profile
Volumize at the level of deformity to give a straight profile
Volumize on top of the alar dome or above the lateral crus of lower lateral cartilages and
also level of nasal spine
May be softened in appearance by placing product around or within it
Nasal asymmetry caused by high septal deviations can be masked by placing volume
within the concavity on opposing sides to create an illusion of straightness
Neuromodulators
Neuromodulators

Before After

A B
Before After

C D

FIGURE 2.5 Nonsurgical rhinoplasty.

 Hints & Tips 15

TECHNIQUE
☛ Hints & Tips
■ Lift the cheek to assess the depth of the fold.
1. Caution is advised at the columella or nasion if any signs ■ The depth of the nasolabial fold is caused by anatomical
of blanching are observed. This indicates for immediate structure as well as the descent of the midface; it is
use of hyaluronidase in small quantities of 0.5 mL or important not to overfill.
1 mL in total. ■ Correction must involve volumization of the midface in
conjunction with filling of the nasolabial fold in older
patients.
Nasolabial Area (Fig. 2.6) ■ For fine lines use a low–G prime HA (Restylane) to place
intradermally. To avoid a “chipmunk” effect, be careful
Management of fine lines or deep furrows of the nasolabial not to overfill the natural dimple area lateral to the
area is aimed at volumization. commissure of the mouth.

Before After

A B
Before After

C D

FIGURE 2.6 (A,B) Hyaluronic acid (HA) to periocular, nasolabial, and prejowl sulcus areas. (C,D) HA enhancement to nasolabial and marionette areas.
16   CHAPTER 2 • Aesthetic Medicine: Surgical Pearls
■ For deep furrows use high–G prime HA (Restalyne/
Juvederm Volift) and starting at the lower end of
nasolabial fold, work your way up to the alar base.
■ In the lower part of the nasolabial fold it is safe to inject
in the superficial plane, but as we reach the piriform
fossa the facial artery becomes superficial and therefore
care should be taken to inject deep against the bone or
very superficial subdermally.
■ Use a 26-gauge needle for Radiesse and a 30-gauge
needle for Restylane.
■ Give a regional block (infraorbital nerve block).
■ For the technique refer to Video 2.9.
☛ Hints & Tips
1. Do not overfill, as this can accentuate the thickness of
cheek because of lateral migration.
2. In the lower part of the nasolabial fold also fill just lateral
to the fold.
3. Be careful while filling to avoid nodules. Fill slowly and
massage bimanually.
4. Nasolabial volumization at the alar base may
cause extrinsic compression and vascular
compromise.
Malar/Cheek Augmentation (Fig. 2.7)
Patient characteristics that indicate this technique include:
■ an extended tear trough into the midface
■ heaviness of the nasolabial fold
■ descent of the midface
■ a hypoplastic malar area
■ negative vector
■ severe weight loss
Malar/cheek augmentation is done in two planes:
1. deep, to correct skeletal hypoplasia
2. subcutaneous, to correct deflation of fat compartments
TECHNIQUE FOR CHEEK AUGMENTATION
■ Draw lines to mark the highest point.
■ Up to 2 mL volume can be added per side.
■ Infiltrate local anesthesia with a long 30-gauge
needle.
■ Inject the local anaesthetic as you withdraw, raising a
weal on the skin.
■ Wait for the area to be anesthetized.
■ Midface and malar area should be harmonious in the
elevation created by the malar arch.
■ Volume should added from the highest point and it
should extend superomedially towards the junction of
the side wall of the nose with the cheek.
■ Product of choice is a high–G prime HA (Restylane
Sub-Q or Teosyal Deep Lines).
■ I use the fanning technique with a long cannula
(2 inch or 25 gauge) and inject through a single
entry point.
■ It is better to use low–G prime HA in patients
with very little subcutaneous tissue, as it is easily
malleable.
■ Use the cannula for the fanning technique just above the
periosteum.
■ For the technique refer to Video 2.6.
TECHNIQUE FOR MIDFACE AUGMENTATION
■ I use the bolus technique with a 30-gauge needle,
building a pillar from deep to superficial.
■ Inject a bolus dose and wait for skin surface to lift/rise
and using conservative amounts (0.1–0.2 mL per
injection).
■ Products of choice are Restylane or Redensity Teosyal in
the subcutaneous to replace volume loss in the deeper fat
compartments of the midface (superior medial cheek fat
compartment).
■ The idea is to inflate the midface extending
superomedially into the tear trough, thereby lifting the
nasolabial fat pad and diminishing the depth of the
nasolabial fold. It can be completed by adding additional
volume just below and lateral to the rim to complete the
arc.
■ It is important to blend with the tear trough area to
create a harmonious arc from the low part of the midface
to the lid cheek junction.
☛ Hints & Tips
1. The patient should be counseled about upper eyelid
heaviness when augmenting the midface with a product
containing lidocaine.
2. It is not advisable to use more than 2 mL per side.
Additional volume should be done in stages.
3. In patients with less subcutaneous tissue, very small
volume should be used over the bony prominences.
4. While augmenting the malar area, place volume medially
and above it so as not to create a skeletonizing
prominence.
5. Be careful with patients who have a sunken periocular
area (in these patients it is not advised to augment
the malar area alone as it would increase the
discrepancy).
6. In patients with hollowness around the orbit, malar
augmentation must be combined with volumization
below the orbital rim, so as not to increase the
discrepancy between the lid cheek junctions.
Masseter
TREATMENT OF MASSETERIC HYPERTROPHY
■ The masseter muscle is in three layers: superficial,
middle, and deep.
■ The point where the layers of the muscle overlap each
other is the thickest part and is palpable when the patient
clenches their teeth.
■ The outline and the border of the muscle are marked.
 Lower Face 17

Before After

A B
Before After

C D

FIGURE 2.7 Cheek augmentation with hyaluronic acid.

■ Three to five injections are given on the masseter bulk in

the lower half of the muscle below the line drawn from Lower Face
the tragus to the angle of the mouth, 1 cm away from the
border of the muscle.
■ Depending on the extent of hypertrophy, 15–25 s.U is Perioral (see Table 2.6, Fig. 2.8)
injected per side.
TECHNIQUE FOR VOLUMIZATION
COMPLICATIONS ■ I use a 30-gauge needle and prefer not to use a
cannula.
Superficial placement of the injection will only inactivate the ■ Inject 0.5 mL xylocaine + adrenaline (1 : 1000) in the
superficial head of the muscle leading to the chipmunk effect
canine fossa with the needle pointing towards the pupil
on chewing.
for the upper lip.
18   CHAPTER 2 • Aesthetic Medicine: Surgical Pearls

Table 2.6 Perioral augmentation

Patient characteristics Management
Perioral rhytids • Neuromodulators to prevent dynamic movement of the muscles
• Laser (fractional CO2 or Er:YAG) for the upper lip. It stimulates the dermis and produces collagen,
improving the perioral rhytids
• Rehydration Volumization with hyaluronic acid
• Correction of asymmetry
• Lip contour
• Vermilion enhancement
• Upper lip eversion
Er:YAG, Erbium-doped yttrium aluminium garnet.

Before After

A B
Before After

C D

FIGURE 2.8 Lip augmentation with hyaluronic acid.


■ For lower lip anesthesia inject between the incisor and
first premolar at the mental foramen.
■ I use the threading technique, with the needle between
the thumb and the index finger feeling the
vermiliocutaneous junction for contouring.
■ Avoid placing too much volume near the lateral
lip line.
■ The volume should be placed deep into the vermilion,
just below the muscle or, with care, submucosally.
■ Lower lip line enhancement is usually only done for the
middle third to avoid placing too much volume near the
lateral lip line.
■ For vermilion enhancement, product should be
place in the submucosal plane either side of the
midline.
■ The products of choice are Restylane Lip Volume for lip
line or lip contour and Teosyal Kiss for vermilion
enhancement.
■ Massage gently, mainly for irregularities.
■ Do not use excessive pressure, as this can lead to
bruising.
■ For the technique refer to Videos 2.7 and 2.8.
MANAGEMENT OF THE PERIORAL AREA WITH
NEUROMODULATORS (Table 2.7)
■ Start with an ultraconservative dosage, as these muscles
have functional requirements like oral competency,
pursing of the lips, and mastication.
■ Patients should be warned that the efficacy would be of
shorter duration.
■ Dosage may be increased progressively, based on
tolerance.
■ Lower face treatment is less predictable than that of the
upper face.
■ Recommended treatment for perioral rhytids is a
combination of:
• prevention (using neuromodulators)
• fractional CO2 laser or erbium-doped yttrium
aluminium garnet (Er:YAG) resurfacing (for
improvement of fine lines)
• replacement of volume with hyaluronic acid
Table 2.7 Management of perioral area with neuromodulators
Muscle Plane
Upper lip rhytids Subdermal
• Orbicularis oris
Gummy smile Deep subcutaneous
• Excess activity of
LLSAN + LLS
Lower lip Subdermal
• Orbicularis oris
LLS, Levator labii superioris; LLSAN, levator labii superioris alaeque nasi.
Hints & Tips 19
COMPLICATIONS
■ Reduced oral competency.
■ Inability to suck from a straw or to whistle.
☛ Hints & Tips
1. Augment the upper lip first and then the lower lip in a
40 : 60 ratio.
2. Augmentation of the philtral column gives a more
youthful appearance.
3. Add more volume in the middle and less laterally.
4. If you are not trying to evert the lip, inject below the
vermiliocutaneous junction.
5. For the correction of vertical rhytids of the upper lip,
judicious use is necessary to prevent a “simian” look.
6. Patients with the long upper lip, lip eversion, and
augmentation/creation of philtral columns can decrease
upper lip length.
Melomental Augmentation (Table 2.8,
Fig. 2.9)
TECHNIQUE
■ I use a 30-gauge needle and give a fan block before
volumizing the melomental area (0.5 mL xylocaine with
adrenaline).
■ After the block, wait for the xylocaine to settle down and
not obscure the defect.
■ The blanching effect of adrenaline helps prevent
bruising.
■ At the commissure I prefer a low–G prime HA; moving
down to the lower marionette and prejowl area, I prefer a
high–G prime HA or calcium hydroxyapatite.
■ The product of choice for prejowl sulcus and lower
marionette is a high–G prime HA.
■ When augmenting the melomental fold extending in the
prejowl area start in the inferior part and progressively
volumize upwards until you see the mouth corner
improve.
Treatment
• 5 s.U just above the vermiliocutaneous junction
• Line is drawn from lateral alar border down to the lip on each side
• One injection of 5 s.U each side, and can extend to 4 injections
of 5 s.U along the alar border
• Give infraorbital regional block. The block inactivates the muscles
and gives the patient an idea of what Botox action will be like.
• Injections are given just adjacent to the alar margin
• Deep injection at the apical triangle of the upper lip
• One injection 10 s.U each side
• Try not to do upper and lower lip together
• Line is drawn from lateral alar border down to the lip
• Two injections each side of 5 s.U
20   CHAPTER 2 • Aesthetic Medicine: Surgical Pearls

■ The plane of injection should be as follows: to simulate what the volumization of the area may
• At the angle of the mouth, inject in the intradermal look like.
plane. ■ Mark the area and place 0.2 mL xylocaine with
• In the lower marionette area, inject in the subdermal adrenaline in the prejowl sulcus to avoid bruising.
plane. ■ The products of choice are Radiesse or Teosyal Deep
• At the prejowl sulcus, inject in the subcutaneous plane. Lines.
■ For the technique refer to Video 2.9. ■ I use a 26-gauge needle with Radiesse and a 28-gauge
needle with Teosyal Deep Lines (a cannula can also be
used).
☛ Hints & Tips ■ Volume should be placed in the subcutaneous plane
under the mandible.
1. Never put too much volume near the corner of the ■ For the technique refer to Video 2.9.
mouth to avoid lumpiness.
2. Underfill and touch-up after 2 weeks.
☛ Hints & Tips
Prejowl Sulcus (Table 2.9, Fig. 2.10)
1. Massage continuously for better results.
TECHNIQUE
■ Roll forward the soft tissue below the inferior border
Deep Anguli Oris
of the mandible in the direction of prejowl sulcus ■ Overactivity can lead to depletion of collagen in the
marionette area.
■ Patients often complain of a sad look in photographs.
■ Inhibition of depressor action with neuromodulators can
Table 2.8 Melomental augmentation management
create a lifting effect of the corner of the mouth and also
Patient characteristics Management prevent further collagen loss.
Extended marionette into Volumization
prejowl sulcus
Table 2.9 Prejowl sulcus augmentation
Downturned oral Neurotoxins to prevent the
commissure action of DAO Patient characteristics Management
Volumization to improve the Prominent prejowl sulcus Volumization (not in very heavy
fine lines Jowling jowl)
Drooling Volumization Ultherapy
Thread lifts
DAO, Depressor anguli oris.

Before After

A B

FIGURE 2.9 Hyaluronic acid to the marionette area.

 Hints & Tips 21

Before After

A B
Before After

C D

FIGURE 2.10 Hyaluronic acid to prejowl sulcus and marionette area.

■ In cases where HA fillers are being used concurrently in ■ Lateral injection is preferred to prevent diffusion to
the same area, this should be done before the the depressor labii inferioris causing an asymmetrical
neuromodulators. smile.
■ 5–10 s.U on each side to start with one injection (5 s.U on
each side).
TREATMENT
Treatment is in the immediate subdermal plane. COMPLICATIONS
■ A line is drawn from the alar margin to the angle of the ■ Difficulty with chewing
mouth; continuing 2 cm downwards is the point of ■ Asymmetric smile if there is diffusion to the depressor
injection. labii inferioris
22   CHAPTER 2 • Aesthetic Medicine: Surgical Pearls

■ Inability to push the bolus of food from the oral sulcus to band will benefit from neuromodulators applied to
the grinding surface of the molars the subdermal plane to improve the definition of the
• If this occurs, reassure that it will be gone in 10 to 12 days. jawline.
■ Any ancillary treatment to the deep anguli oris and the
Mentalis anterior platysmal bands should be avoided to prevent
abnormal mimic movements.
■ Causes chin elevation ■ There is no benefit to injecting below the top half of the
■ Witch’s chin deformity posterior platysmal band.
■ In conjunction with actions of the deep anguli oris may
cause a crescentic loss of collagen from the lower
marionette area to the supramental crease.
TECHNIQUE
■ Only those patients whose jawline becomes distorted
TREATMENT during grimace will benefit from the treatment.
■ Injections are given along the posterior band and under
Treatment is in the deep subcutaneous plane. the mandible.
■ Injection of 10 s.U into each head of the mentalis slightly ■ Inferior injection on the posterior band should be given
lateral to the midline of the chin. in contracted muscle and other injections under the
■ Avoid massage. mandible should be given in relaxed muscle.
■ The patient should be in a sitting position.
A line is drawn 1 cm posterior to the junction of the
COMPLICATIONS
■

nasolabial fold and the mandible. The patient is asked to

■ Diffusion of neuromodulators to the depressor anguli contract the muscle, and the posterior platysmal band
inferioris leads to an asymmetric smile. should be marked on the skin.
■ Asymmetric dimpling of the chin can be caused by ■ Three injections are given in the posterior platysmal
partial block of one side of the muscle. band, with 10 s.U in the most prominent point and 5 s.U
■ Correction can be done on follow up. in the remaining two points.
■ Under the mandible three injections of 5 s.U are given
with the needle directed towards the angle of the
Neck ■
mandible.
For the technique refer to Video 2.10.

Nefertiti Lift (Fig. 2.11) COMPLICATIONS

■ Selected patients who have demonstrable strong ■ Diffusion to the depressor labii inferioris may lead to an
depression action of the posterior part of the platysmal asymmetric smile. To prevent, always inject 1 cm

Before After

A B

FIGURE 2.11 Nefertiti lift with botulinum toxin showing improvement in the jawline.
 Hints & Tips 23

posterior to the junction of the nasolabial fold and the of Radiesse is mixed with 0.25 mL of xylocaine and
mandible. adrenaline).
■ Dysphagia may occur if too much neurotoxin is placed in ■ An average volume of 1.5 mL Radiesse with 0.5 mL
the interior platysmal band. xylocaine is used in each hand.
■ For hydration give approximately 1 mL HA intradermally
in each hand (Restylane Vital).
Hand ■ Use ice packs to prevent bruising.
■ For the technique refer to Video 2.11.

Hand Augmentation (see Table 2.10,

Fig. 2.12)
TECHNIQUE
☛ Hints & Tips
■ Identify and mark the hollows and the areas of concern 1. Pinch the skin to avoid the veins.
with the patient.
■ Inject local anesthesia subdermally with a 30-gauge
needle (0.1 mL at each injection point) to prevent pain Complications of Hyaluronic Acid Fillers and
and bruising. Their Management
■ Pinch the skin to avoid the veins and inject 0.2 mL
Radiesse subcutaneously from an ampule (where 0.75 mL See Table 2.11.

Table 2.10 Hand augmentation

Patient characteristics Management
• Visibility of veins and tendons • Peels, laser, and lights for improvement of sun damage (skin quality), texture, and tone
• Wrinkling of skin • Addition of HA subdermally for hydration (Restylane Vital)
• Volumization of the subcutaneous layer around the veins and tendons for diminishing
their prominence
HA, Hyaluronic acid.

Before After

A B

FIGURE 2.12 Hand rejuvenation with Radiesse and hyaluronic acid combination treatment.
24   CHAPTER 2 • Aesthetic Medicine: Surgical Pearls

Table 2.11 Complications of hyaluronic acid fillers and their management

Complication Management
Hematoma (bruising) While injecting put gentle pressure for 2–3 minutes
Good lighting to visualize the blood vessels while injecting
Use of knowledge of the anatomic structures
Cold compression
Vascular occlusion Withdraw needle three times prior to injecting
Blindness Avoid intraarterial injection.
Use of knowledge of the anatomic structures
Special care required while treating temporal/periocular/nasal areas
Daily monitoring
Aspirin
Vasodilators
Hylase
Steroids
Warm compress
Hyperbaric O2
Anti-viral in case of herpes infection
Frost bite Avoid prolonged use of ice postinjection, especially if anesthesia is used
Small nodules (lip) Avoid over or incorrect placement. If occurs can be expressed out by small incision or
dissolved with hyaluronidase.
Avoid injecting large particles of HA rapidly
Acute herpes infection (lip) Inquire about history of cold sore or chickenpox. If required, give antiviral 3 days prior to
procedure
Lumpiness or nodules Slow injection, meticulous placement, choice of filler, and bimanual massage if in nasolabial
area
Over volume Overfilling should always be avoided
Delayed hypersensitivity reaction Systemic steroids and Hyaluronidase
(swelling/granulomas)
Malar pouch water retention (after If occurs give steroid injection 1–2 mL of triamcinolone with 0.3 mL of xylocaine or dissolve with
periocular augmentation) hyaluronidase
Tyndall effect and bluish discoloration Dissolve it with hyaluronidase
(after subdermal augmentation)
HA, Hyaluronic acid.

Further Reading Jones, D., Murphy, D.K., 2013. Volumizing hyaluronic acid filler for midface
volume deficit: 2-year results from a pivotal single-blind randomized
controlled study. Dermatol. Surg. 39 (11), 1602–1612.
Braz, A., Humphrey, S., Weinkle, S., et al., 2015. Lower face: clinical anatomy
Kim, H.-J., Seo, K.K., Lee, H.-K., Kim, J., 2016. Clinical Anatomy of the
and regional approaches with injectable fillers. Plast. Reconstr. Surg.
Face for Filler and Botulinum Toxin Injection. Springer, Singapore.
136, 235S–257S.
Kuhne, U., Imhof, M., 2012. Treatment of the ageing hand with dermal
Carruthers, J.D.A., Fagien, S., Rohrich, R.J., et al., 2014. Blindness caused
fillers. J. Cutan. Aesthet. Surg. 5 (3), 163–169.
by cosmetic filler injection: a review of cause and therapy. Plast.
Luebberding, S., Alexiades-Armenakas, M., 2012. Safety of dermal fillers.
Reconstr. Surg. 134, 1197–1201.
J. Drugs Dermatol. 11 (9), 1053–1058.
Cotofana, S., Schenck, T.L., Trevidic, P., et al., 2015. Midface: clinical anatomy
Ogden, S., Griffiths, T.W., 2008. A review of minimally invasive cosmetic
and regional approaches with injectable fillers. Plast. Reconstr. Surg.
procedures. Br. J. Dermatol. 159 (5), 1036–1050.
136, 219S–234S.
Park, T.H., Yeo, K.K., Seo, S.W., et al., 2012. Clinical experience with
Dayan, S.H., Bassichis, B.A., 2008. Facial dermal fillers: selection of appropri-
complications of hand rejuvenation. J. Plast. Reconstr. Aesthet. Surg.
ate products and techniques. Aesthet. Surg. J. 28, 335–347.
65 (12), 1627–1631.
Gart, M.S., Gutowski, K.A., 2015. Aesthetic uses of neuromodulators:
Skyes, J.M., Cotofana, S., Trevidic, P., et al., 2015. Upper face: clinical
current uses and future directions. Plast. Reconstr. Surg. 136, 62S–
anatomy and regional approaches with injectable fillers. Plast. Reconstr.
71S.
Surg. 136, 204S–218S.
Goldman, A., Wollina, U., 2010. Facial rejuvenation for middle-aged women:
Vedamurthy, M., Vedamurthy, A., 2008. Dermal fillers: tips to achieve
a combined approach with minimally invasive procedures. Clin. Interv.
successful outcomes. J. Cutan. Aesthet. Surg. 1 (2), 64–67.
Aging. 5, 293–299.

Aesthetic Applications for Fillers
The Clinical Problem—The Aging Face
(Fig. 3.1)
How Does the Face Age?
Each face ages in its own way according to genetics and external
factors, such as sun, tobacco, diet, life stress, and illness.
The main phenomena are the appearance of wrinkles,
■
loss and shifting of facial volumes, and contraction of the
muscles used in making facial expressions.
■ The solution for the shifting of facial volumes will be
surgical and, for muscle contractions, botulinum toxin
will be used.
■ Hyaluronic acid will treat wrinkles and the loss of facial
volume by supplying good hydration, thus enhancing the
condition of the tissue.
■ Analyzing the face will detect the weak areas to be
treated first. The next step is to determine the healing
and preventive treatment plan by focusing on the facial
■
areas that tend to age faster.
A distinction among wrinkles, skin folding, and
grooves should be made because their treatments are
different.
WRINKLES AND SKIN FOLDING
■ A wrinkle can be described as a fracture of the skin. It
can range from deep to shallow and may appear as being
inscribed or engraved into the skin. When superficial, it
may appear as just a thin line. Most importantly, it is
apparent even when the face is at rest, without
expression or contraction.
■ Wrinkles are due to a modification of the cellular
architecture of the skin. They should be differentiated
Clinical Examples 25
3
Phillipe Bellity MD
from grooves, which are permanent hollows, and from
skin folding, which is visible only when the muscles used
for facial expression contract and then disappear once the
muscles relax. For example, the muscle contraction near
the upper lip shows folds when the vowel “u” is
pronounced. Later in life, a skin fracture may replace
these temporary folds and, as wrinkles, will eventually
cease to disappear at rest. The treatment for wrinkles and
skin folding differs.
GROOVES
Grooves are hollows that do not all have the same origin.
The grooves of glabella are due to the corrugator contrac-
tion, the nasolabial folds are due to multiple factors, such as
zygomatic contraction, fall of the nasolabial fat, and maxillary
bony loss, and so-called bitterness folds, which are due to a
fall of the jowl fat. The medical treatment for these grooves
consists in filling them by raising tissues with a highly
reticulated filler.
Clinical Examples
Treating Wrinkles (Fig. 3.2)
Using a very fine needle, 32 or 33 gauge, hyaluronic acid is
injected to raise the wrinkle level and, in effect, make it disap-
pear or strongly fade. The depth of the injection will depend
on the wrinkle depth. All wrinkles, even the finest, can be
treated. An injection that is too superficial can leave visible
small beads, and too deep an injection can be ineffective. Thus,
the quality of the result will rest on the appropriate depth of
the injection, size of the needle used, and amount of injected
hyaluronic acid.
The effect on superficial wrinkles is remarkable. The skin
texture changes. The product seems to integrate the dermis
25
26   CHAPTER 3 • Aesthetic Applications for Fillers

Shape of face at different ages

Age 20 Age 40 Age 60

FIGURE 3.1 The aging face. Merely by changing the angularity of the face and the shifting depiction of light and shadow, an artist can render the age of the subject as a
younger person. (From Donofrio, L.M., 2005. Evaluation and management of the aging face. In: Siegel, D. (Ed.), Surgery of the Skin. Mosby, St. Louis, with permission.)

A B

FIGURE 3.2 Wrinkle treatment. Treating the deep wrinkles individually at early stages will allow a progressive disappearance of the wrinkles with an annual treatment.

and contributes to real tissue regeneration. A well-treated
wrinkle, even if it reappears afterward, will no longer have
the same texture; some will even disappear. It is difficult to
answer the question, “How long does the result last?” People
willing to take care of their skin and face should consult their
clinician annually to receive the necessary treatment and have
their wrinkles treated as and when they arise. Patients will
then notice that the annual appointment requires fewer pro-
cedures. People who have been consulting their clinician for
several years enjoy a real rejuvenation because the trophic and
moisturizing effects of the hyaluronic acid on the skin acts a
healing and preventive treatment on the aging process.
 Clinical Examples 27

A B

FIGURE 3.3 Cheek and treatment of multiple areas. These photos show correction of superficial wrinkles, dermis hydration by cannula nappage, and deep volume
replacement on the cheek nasolabial and bitterness grooves.

Topping, or Nappage (Fig. 3.3)

The use of the microcannula has opened a new therapeutic
field. Different sizes and diameters have diverse indications.
Topping is also referred to as a nappage technique.
The introduction of a fine microcannula (27 gauge) in the
eye of a needle allows an area to be topped; that is, the product
can be spread over a given surface (e.g., the chin). This is done
by making the deep dermis and hypodermis more dense to
restore an elastic padding and treat an entire wrinkled area,
such as the upper lip or the chin.
Topping with a microcannula (22 gauge) can be used for
the cheeks as well. The use of a long cannula with less reticulated
products can give a so-called healing glow and remarkable
moisturizing effect, but without modifying skin volume (skin
booster).
FIGURE 3.4 Folding mouth. Folding is the early stage of wrinkle creation. It can
be treated by deep dermis injection as a preventive measure.
Skin Folding (Fig. 3.4)
To reduce skin folding, the deep dermis should be made more
dense with hyaluronic acid without inducing bumps. This
applies to the upper lip and frown as well.
However, if the injection is to be done again 2 weeks
Nasolabial Grooves (Fig. 3.5) later, the product will have time to penetrate, for a perfect
result.
The paranasal hollows are treated by filling them with strongly
reticulated hyaluronic acid. Different depths will be treated to
raise the grooves, starting from the deepest ones. If the hollows Bitterness Groove and Chin
are deep, they should be treated with deep, medium, and
Treating these is more challenging. They can appear as mere
shallow reticulations, with each becoming less and less tight.
hollows at the corner of the mouth or as grooves. The treatment
Note that one should be careful not to allow the product to
of the hollows must be very precise and follow the different
rise beyond the nasolabial fat. Here are two suggestions:
depth levels; otherwise, the jowl fat will increase and will yield
1. The injection should be very slow. a reverse effect. A slow injection, and a two-session injection,
2. Once the area is full, the product should not continue will be more effective. The filling of the lateral parts of the
to enter the area or it will tend to rise, giving an chin with a cannula will restore the lateral pillar of the lower
adverse effect. lip and raise the chin level to meet the level of the cheek. This
28   CHAPTER 3 • Aesthetic Applications for Fillers
A B
FIGURE 3.5 Nasolabial groove treatment. Deep, intermediate, and superficial layers are injected to get a complete result.
procedure provides harmony to the face oval. Frequently, the
chin itself has to be augmented to reconstruct the oval line.
Cheek
Recent anatomic studies have revealed that the face is made
of compartments, which do not have the same result when
treated. The deep compartments of the cheek undergo a sort
of melting effect over time. To restore them is a significant and
efficient step in facial rejuvenation.
It is necessary to feel the cheek between the nasolabial fat
and body of the malar bone to appreciate the lack of volume
and to draw the shape of the hollow to be filled in precisely.
Then, the injection will be given in order of depth, start-
ing at bone level and progressively bringing up the needle
to raise the area between the nose and cheekbone without
excess. In contrast, injections facing the cheekbone should
be very moderate. To redefine or recreate the cheekbone
area, when necessary, I suggest the use of a cannula, starting
from the side whiskers and following the zygomatic arch
and staying in depth to reach the area between the nose and
cheekbone.
Some people will have a hollowed cheek. The volume filling
will have to be done with a cannula (22 gauge) after defining
the area to be filled, starting at the limit of this zone. The filling
of the chin was discussed earlier. This is often very beneficial
when the indication is well set and the volume is well controlled.
A central hole will allow it to be extended laterally, with more
symmetry.
Eyebrow
The eyebrow is an area that ages by loss of volume. Deep
injections in the lateral part of the eyebrow, in contact with
the bone, give excellent results. One has to be very cautious
about the amount used; the so-called boxer effect may appear
faster than expected.
Forehead
With the use of botulinum acid, it is possible to have a smooth
and relaxed forehead, which is quite important. The domed
and uniform side of the forehead is an essential aesthetic criteria,
although it is often neglected. The tracking of postorbital
hollows, their in-depth filling with a cannula in contact with
the periosteum, and massage give excellent results on the upper
third of the face. The procedure will harmonize the forehead
and raise the eyebrows.
Temples
Temples hollow with age. It is essential that the lost volume
be replaced. Apparent veins will be spotted and pricked deeply,
crossing the temporal fascia. The slow injection will penetrate
the central part while controlling the result. Finally, massage
will spread the product harmoniously.
Dark Circles (Fig. 3.6)
This is a very challenging treatment. A 32-gauge needle or
microcannula can be used. The product has to be injected very
deeply, contacting the orbital border with a certain degree of
undercorrection and avoiding injection of the fat pads.
It is also important to inject the external part if there is a
hollow. I use a very fluid product with the needle on the bone
level, holding the left thumb over it to spread out the product
perfectly.
Nose Reshaping (Fig. 3.7)
It is sometime useful to correct a defect on the dorsum or
correct a tip asymmetry with hyaluronic acid, using a moderate
amount of product. Filling the columella can give a good
opening and provide support to the nasolabial angle. The
treatment has to be redone once annually. Sometimes a long-term
effect can be seen.
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