Non-Surgical Rejuvenation of Asian Faces-Springer (2022)

Non-Surgical
Rejuvenation
of Asian Faces
Souphiyeh Samizadeh
Editor
123
Non-Surgical Rejuvenation of Asian Faces
Souphiyeh Samizadeh
Editor
Non-Surgical Rejuvenation
of Asian Faces
Editor
Souphiyeh Samizadeh
Craniofacial Sciences, Centre for Craniofacial
and Regenerative Biology
King’s College London
London, UK
ISBN 978-3-030-84098-3 ISBN 978-3-030-84099-0 (eBook)

https://doi.org/10.1007/978-3-030-84099-0
© Springer Nature Switzerland AG 2022

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Foreword
The human face is infinitely complex and variable. Our faces connect us with our
evolutionary past. Much of the architecture of the face is linked to its physiological
functions, yet the face is so much more than just a functioning part of the human
body. The stages of human life can often be viewed just by the changes in facial
appearance, from embryonic life, through growth, maturation and the ageing pro-
cess. The static and dynamic appearance of the face is often the first line of interper-
sonal communication and can convey or attempt to hide our emotions. This is why
the face has such psychosocial, sociocultural and artistic importance. Therefore, the
ability of any clinician to alter the facial appearance of a patient carries enormous
responsibilities.
The field of treatments that sit under the umbrella term of non-surgical facial
rejuvenation has been burgeoning over the last decade. It also stands to reason that
medical information should always be obtained from credible sources. As such,
there has been a need for a comprehensive textbook on non-surgical facial rejuvena-
tion specifically for patients of East Asian ethnicity, and Dr. Souphiyeh Samizadeh
is the ideal clinician to have taken on the task.
I first met Dr. Samizadeh just over a decade ago at a conference in London and
was impressed by her passion for facial aesthetics and non-surgical treatment
modalities for facial rejuvenation. She excels as a clinician, educator and researcher.
However, her most impressive characteristic is placing ethics at the centre of her
clinical practice (more on this later).
It is important to mention that, unfortunately, we are living in an era of selfies,
social media and an extreme obsession with appearance, particularly facial appear-
ance. Market forces are perpetually pushing often vulnerable people towards
appearance-altering treatments that they do not need. A responsible clinician will
never follow such a bandwagon. Practising non-surgical facial rejuvenation may
appear easy to the uninitiated, but correct diagnosis, logical treatment planning,
excellent communication skills, the ability to provide truly informed consent, skill-
ful technique and the ability to deal with complications are far from easy. Added to
these factors is the psychological understanding of the needs, desires and expecta-
tions of patients, together with the limitations of what clinicians can provide.
v
vi Foreword
The purpose of a good clinician and clinical educator is to promote the highest
standards for clinical practice. Clinicians should be aware of the high levels of psy-
chological vulnerability in patients seeking appearance-altering treatments and be
adept at the recognition and management of such vulnerability. Where necessary,
the requirement for psychological support should be recognized by the treating cli-
nician, with appropriate referral pathways available to the patient. Unethical and
misleading marketing must be avoided. It is incumbent on each clinician to attain,
maintain, reflect upon and continually improve upon their professional competen-
cies in the areas of their practice.
There is a common misconception, presumably due to the terminology used, that
non-surgical facial rejuvenation is just about making people look younger. This is
far removed from reality. An important purpose of such procedures and familiarity
with them should be for the treatment of patients requiring aesthetic improvement
or reconstruction, often as part of complex multidisciplinary care, such as soft tissue
augmentation in patients with hemifacial microsomia or hemifacial atrophy.
The importance of an ethical approach to patient care cannot be underestimated.
The most basic and important tenet of medicine is for the clinician to always do
what is in the best interests of the patient. Sometimes the ethical judgement of a
clinician is to say “no” to a patient requesting treatment that is not clinically justi-
fied or justifiable. Another area that must be mentioned when discussing ethics is
the use of non-human animals. Most animal experimentation has been, and contin-
ues to be, a wasteful perversion of science, with claims of usefulness or human
application unable to stand up to scrutiny. One can only hope that the increased
availability and understanding of alternatives will mean that the exploitation of non-
human animals by humans will someday cease—in short, that ethics will prevail.
Clinical work can only excel when the clinician is well-trained, understands the
limitations of their work and is safe, professional and kind. Clinicians should never
view those who seek their care as ‘clients’, which would diminish our work to the
level of a business transaction, but as patients to whom we owe a duty of care.
The continuing growth of non-surgical facial rejuvenation and the surrounding
industry, over the past decade in particular, indicates that there is a need for a text-
book which is relevant to current clinical practice. This text provides a ready source
of information for the beginner and advanced practitioner who requires an up-to-
date overview of the clinical management of the patient desiring non-surgical facial
rejuvenation. The book will guide the clinician through the key core topics and
background principles, which will be encountered within a comprehensive and
robust training programme. The format of the text and layout of information is
excellent. The authors have placed considerable effort into providing good quality
figures and illustrations.
Individual variability is normal and attempts at categorisation of human facial
types are fraught with difficulties. Nevertheless, it is difficult to provide guidelines
for facial aesthetic analysis and treatment without attempting to understand the
broad differences between facial types, albeit at an arbitrary level. The focus of this
book is on the East Asian facial type, whilst acknowledging that the region
Foreword vii
comprises multiple ethnicities. The information will be relevant to clinicians prac-

ticing anywhere in the world.
There is no doubt that this book is a major contribution to the field. The chapters
include comprehensive background material presented together with scholarly
reviews of the pertinent literature and step-by-step descriptions of clinical tech-
niques. This text has achieved the high standards set by Dr. Samizadeh and the
content and presentation will satisfy the needs of tomorrow’s facial aesthetic
clinicians.
Much has been written on the subject of non-surgical facial rejuvenation. The
challenge in writing about such a subject is to bring new insights and information to
the readers. Dr. Samizadeh has met this challenge in Non-Surgical Facial
Rejuvenation of Asian Faces. The book is comprehensive, case-supported, well-
referenced, easy to follow and scholarly. This book should be required reading for
all clinicians interested in non-surgical facial rejuvenation.
London, UK Farhad B. Naini

February, 2021
Preface
With international trend towards improved life and wellbeing, surgical and non-
surgical aesthetic treatments are ever increasingly popular. These treatments used to
be taboo internationally. However, this is changing. What used to be labelled “vein”
or “bourgeois way of life” is becoming an accepted part of life, self-care, and
wellbeing.
Globalisation, advances in healthcare, increased life expectancy, fast evolving
technologies, and treatments means more men and women are seeking an improved
appearance, prevention of ageing, and rejuvenation.
Additional factors in expediting growth of medical aesthetics include continued
globalisation, eradication of cultural, medical, and socioeconomic barriers, wide-
spread access and use of media and social media, and various beauty applications
and filters that are used via smart phones or other devices. Furthermore, improved
purchasing power of people internationally, and in countries such as China, has
further enhanced taste for luxuries and a different lifestyle.
Most, if not all published papers, books and protocols are in English focus on
Caucasians. These need modifications for Asians and East Asians. The focus of this
book is on East Asians. There are a few facts to keep in mind:
1. Skeletal structure and facial morphology of East Asians population are different
from Caucasians
2. Ideals of beauty are different
a. This may differ further among different ethnicities within the same geograph-
ical region, country, and age groups
3. There are cultural aspects—for example, belief in facial physiognomy
a. Facial physiognomy (face reading) is still widely believed and practised
in Asia.
i. Some hospitals have professional “face reading experts” who contribute
towards consultation
ii. These experts are sometimes invited as part of aesthetic conferences/scien-
tific events in the region to contribute towards the content and educate
aesthetic practitioners
ix
x Preface
4. Recent media and trends have an effect

a. These can be local trends such as K-pop or international trends.
East Asian patients seeking cosmetic procedures, face and body enhancement are
not like their Western counterparts. The decision to alter oneself has a complex
multi-layered reality internationally. However, in East Asia, these layers and factors
are somewhat unique to the region. To expand on this, East Asian countries are
highly dense and populated. Culturally and traditionally, beauty is highly prized
since childhood. Factors such as “white skin” is still praised and during summer
months, it is not unusual to see ladies in head-to-toe suits covering every inch of
body and face skin from the sun. Beauty is a differentiating factor being at the heart
of interpersonal relationships, at times educational growth, work opportunities, and
choice of spouse. This is summed up in the Chinese proverb, “your face is your rice
bowl”. It is not unusual for parents to give double eyelid surgery as a high school
graduation gift.
Perhaps most importantly, Asia and China’s population and fast-growing econ-
omy lends hand in an improved quality of life and hence people seeking ways of
enhancing their beauty and wellbeing, including aesthetic treatments. This is sig-
nificant both in Asia and internationally as there is a growing Asian diaspora. In the
last 40 years, China’s economic success resulted in changes including enhanced
averaged incomes and in main cities being on par with other international cities,
much reduced poverty, rise of middle-class Chinese, enriched life, and improved
wellbeing.
How Is This Relevant to International Aesthetic Doctors?
There are estimates that the Chinese diaspora alone is over fifty million. This does
not include statistic for East Asia. Furthermore, increased people travel for medical
and aesthetic reasons. This means, no matter where aesthetic physicians are based,
a portion of their patients will be East Asian.
This requires many more trained doctors in the field and able to treat different
ethnicities successfully. Non-surgical and minimally invasive procedures with none
to minimal downtime are now preferred globally.
I have been truly fortunate to live in China for a few years and get to know this
beautiful country and people better. I have travelled across China getting to know
different ethnicities and their different morphology, aesthetic desires, and ways
of life.
I have visited many hospitals in mainland China and Taiwan as a consultant,
teaching for various pharmaceutical companies and through the academy I founded
in the UK, the Great British Academy of Aesthetic Medicine. We held training ses-
sions, workshops, annual scientific congress, and many sessions to exchange ideas
with colleagues. This provided me with a once in a lifetime opportunity to train
thousands of junior and senior doctors and experience their vast aesthetic hospitals.
Preface xi
Exchanges with colleagues, interaction with patients and treating them highlighted
the complex and multi-layered anatomy of this industry in China to me. I noticed
the differences in facial structure, culture, desires, and changes that needed to be
made in treatment protocols. All this inspired me to research this topic further, pub-
lish in the field, and put this book together. I am grateful for all the opportunities I
had, and I believe my learnings and my colleague’s contribution in this book can
help ignite interest in understanding Asian aesthetics and varied treatment planning
and delivery and help improve standards of practice and training.
Contrasting the general belief, East Asians are keen to enhance their own ethnic
beauty rather than looking Caucasian, apart from a small group of individuals.
This book can also be beneficial to pharmaceutical companies understanding dif-
ferences and desires and help develop techniques and procedures that suit this popu-
lation and enhanced patient satisfaction.
London, UK Souphiyeh Samizadeh

Acknowledgement
I would like to thank everyone who has helped at various stages of my training,
practice, teaching, and book writing, to all those who have mentored and supported
me throughout my past endeavours.
My gratitude to every single person or institution who have given me the confi-
dence and their invaluable assistance which has helped bring this book and project
to fruition, including friends, colleagues, and my family. Thanks to my husband
who has put up with many days of me travelling for work, conferences, teaching
sessions, or just sitting at my computer for hours on end and working.
Thanks to my Chinese assistant and friends, who helped me understand many of
the Chinese proverbs and cultural meaning of various things.
Thanks to all journals that gave permission for use of pre-published images and
re-drawing them.
I would thank all my colleagues for contributing to this book and all patients who
helped us get to where we are now, especially those who contributed their photo-
graphs to this book.
xiii
Contents
Part I Trend of Asian Beauty Standards: Past Present, Future

1 Facial Beauty�� 3
Souphiyeh Samizadeh
2 Beauty Standards in Asia�� 21
Souphiyeh Samizadeh
3 Facial Physiognomy �� 33
Souphiyeh Samizadeh
4 Characteristics of Asian Faces�� 41
Souphiyeh Samizadeh
5 Clinical Anatomy for Minimally Invasive Cosmetic Treatments�� 59
Sheng-Kang Luo, Wei-Jin Hong, Chun-Lin Chen, Li-Yao Cong,
Wei-Rui Zhao, and Souphiyeh Samizadeh
Part II Anatomy and Ageing

6 Facial Ageing: The Foundational Changes�� 85
Luiz Eduardo Toledo Avelar, Luciene Menrique Corradi, and
Souphiyeh Samizadeh
7 Facial Ageing in East Asians �� 97
Souphiyeh Samizadeh
8 Aesthetic Assessment of the Face�� 107
Souphiyeh Samizadeh
Part III Technologies and Techniques

9 Skin Aging and Skincare �� 125
Zhanchao Zhou and Souphiyeh Samizadeh
xv
xvi Contents
10 Mesotherapy �� 147

11 Light and Laser Treatments�� 161
12 Botulinum Toxin A: Treatment Principles �� 183
Xuefeng Han and Souphiyeh Samizadeh
13 Botulinum Toxin A: Practical Tips for Use in the
Field of Aesthetic Medicine �� 193
Souphiyeh Samizadeh and Rajiv Grover
14 Botulinum Toxin A: Injection Techniques for East Asian Facial
Rejuvenation-Upper and Midface�� 213
15 Botulinum Toxin A: Injection Techniques for East Asian Facial
Rejuvenation-Lower Face and the Neck�� 239
16 Dermal Fillers: Understanding the Fundamentals �� 253
Souphiyeh Samizadeh and Sorousheh Samizadeh
17 Dermal Fillers: Injection Considerations for East Asian Facial
Rejuvenation�� 267
Souphiyeh Samizadeh
18 Non-Surgical Aesthetics-Injection Strategy of East Asian Faces�� 297
Pan Baohua and Souphiyeh Samizadeh
19 MTV Lift and Nonsurgical Facial Rejuvenation Techniques�� 321
Jui-Hui Peng and Hsien-Li Peter Peng
20 The Butterfly Technique: Puttipong Poomsuwan and Rataporn
Ungpakorn�� 335
Puttipong Poomsuwan and Rataporn Ungpakorn
21 Threadlift for Facial Contouring�� 349
Fei Han and Souphiyeh Samizadeh
22 Endotine Ribbon Lower Face Lift�� 383
Wei-Chung Liang
23 AI Technologies Being Developed for Esthetic Practices�� 393
Chih-Wei Li and Chao-Chin Wang
24 The Cosmetic Patient: Psychology �� 405
Souphiyeh Samizadeh
Index�� 413
Part I
Trend of Asian Beauty Standards: Past
Present, Future
Chapter 1
Facial Beauty
Souphiyeh Samizadeh
“The quality present in a thing or person that gives intense pleasure or deep satisfac-
tion to the mind, whether arising from sensory manifestations (as shape, color,
sound, etc.), a meaningful design or pattern, or something else (as a personality in
which high spiritual qualities are manifest).”
“The combination of all the qualities of a person or thing that delight the senses
and please the mind”. https://www.dictionary.com/browse/beauty
The definition of beauty is a long-debated topic amongst philosophers, literari-
ans, artists, scientists, social scientists, sociologists, psychologists, clinicians, as
well as ordinary people. Beauty is a topic that poets of all cultures and geographical
regions have written about. Studies about beauty and attractiveness are diverse and
date back centuries, with increased research and publications more recently.
Physical attractiveness and facial beauty play a key role in sexual attractiveness,
partner selection, self-perception, social interactions, and status [1, 2]. Perception of
beauty motivates various behaviours, including sexual behaviour. Furthermore,
beauty and physical attractiveness in both genders, children, and adults, are associ-
ated with positive personality attributes, virtuous behaviour, and favourable treat-
ment in various social settings [3, 4]. “Unattractive infant faces” reported evoking a
negative response from adults [5]. Both children’s parents and strangers seem to
show favourable treatment for attractive children in line with the maxim, “beauty is
good” [6, 7]. As a result, attractive people could have a more favourable upbringing,
and hence a more favourable outlook on life. They possibly have more fulfilling
careers, may get paid more, or in general, be more successful. Facial attractiveness
S. Samizadeh (*)
King’s College London, London, UK
University College London, London, UK
Great British Academy of Aesthetic Medicine, London, UK
e-mail: info@baamed.co.uk
© Springer Nature Switzerland AG 2022 3

S. Samizadeh (ed.), Non-Surgical Rejuvenation of Asian Faces,
https://doi.org/10.1007/978-3-030-84099-0_1
4 S. Samizadeh
can even be a predictor of longevity [8]. This is summed up in a powerful and true
statement by consultant orthodontist Dr. Farhad Naini, “facial beauty has perhaps
always been the most valued aspect of human beauty” [2].
There is evidence to show that although certain features, shapes, or characteristics are
considered beautiful in different parts of the world, the ideals of beauty and the goals of
beautification are universal. Across all cultures, averageness, symmetry, harmony, and
balance are key features of attractiveness and facial beauty [1, 9]. In addition, recent
studies have reported that perception of attractiveness is consistent despite race, nation-
ality, and age [10]. In a study by Cunningham and colleagues, men from different ethnic
backgrounds were asked to judge the attractiveness of females from the same
race and from different racial groups. They reported that all Asian, Hispanic, and White
judges were strikingly consistent in their judgments of attractiveness. All three groups
provided similar ratings of Hispanic, Asian, and White female faces. In this study, the
mean ratings did not appear to be influenced by exposure to Western media [11]. Rhodes
et al., examined whether symmetry and averageness are shared hallmarks of attractive-
ness across cultures. The preferences for symmetry and averageness were similar for
Chinese and Japanese participants in their study, and there were no preferences for own-
race over other-race pictures presented [12]. In a meta-analytic and theoretical review,
Langlois and colleagues reported that within and across cultures, there was an agree-
ment between the participants about who is attractive and who is not [4].
The theory that beauty standards are innate has also been a subject of debate.
Various studies have shown that infants as young as 2–3 months old show visual and
behavioural preferences for attractive female faces (as rated by adults) [4, 13–15]. In
a study carried out by Langlois and colleagues, infants (2–3 and 6–8 months old) were
shown faces that were pre-rated attractive and unattractive. Both groups of infants
looked significantly longer at the pre-rated attractive faces [14]. This study reported
that the preferences for attractive faces exist from early infancy. Moreover, the prefer-
ences remain consistent across age, gender, and ethnicity [14]. Inherent and natural
tendency for beauty, rather than explicit social cognitive processes in humans, have
been reported [16]. Therefore, preferences for beauty can be biologically innate.
Perception of attractiveness can have various basis, including biology, natural
selection, environment and culture [1, 17]. Men and women have shown consensus
on their ratings of attractiveness [4]. Features that can help determine facial attrac-
tiveness include: [1, 18–21]:
• Averageness
• Symmetry
• Sexual dimorphism
The above three factors are known as the “biologically based standards of
beauty” and have been linked to mate quality (genetic resistance to disease and
parasites/offspring viability) [22]. The following six main attributes are internation-
ally linked to attractiveness (Fig. 1.1) [8, 23–25].
• Youth
• Body type
• Perceived health
1 Facial Beauty 5
Fig. 1.1 Adapted from

Henderson JJ, Anglin
JM. Facial attractiveness
predicts longevity.
Evolution and human Youth
behaviour [3, 4]. Main Perceived
attributes of attractiveness health
include youth, averageness,
symmetry, sexual
dimorphism, body time,
and perceived health
Body type Averageness
Sexual
Symmetry
dimorphism
• Averageness
• Sexual dimorphism
• Symmetry
Facial cues have been linked to physiological health. A study by Stephen et al. in
2017 reported valid cues to aspects of physiological health in Caucasian, Asian, and
African populations [26]. Averageness, symmetry, and sexual dimorphism have
been linked to health, fitness, immunocompetence, and reproductive success [1].
Average faces vary in different populations. In recent social media, bloggers have
put together morphed images of various ethnicities to make “average faces” and
these images can be found online. It is interesting to note that deviations from aver-
ageness decrease attractiveness [1]. However, Alley and Cunningham rightly argue
that average faces are relatively attractive, but very attractive faces are not average
[18]. Perception of averageness, however, depends on one’s experience and can be
calibrated accordingly [27]. Average faces in Chinese and Japanese cultures are
found to be attractive, with reported increased attractiveness with increased aver-
ageness of own-race faces and vice-versa [28]. In Westerners and Asians, both aver-
ageness and symmetry contribute to attractiveness independently and could be
biologically-based [28, 29]. Normal asymmetry is still found to be attractive and, in
some studies, found to be more attractive than when the same faces are turned into
perfectly symmetrical faces [30–32].
Sexual dimorphism and sexually dimorphic traits affect the perception of beauty
and attractiveness in both men and women. In men, hormonal changes during
puberty result in the growth of the mandible (jaw), midface (cheekbones),
6 S. Samizadeh
supraorbital brow ridges and facial hair indicating sexual maturity, individual’s
reproductive potential, and can signal mate quality (immunocompetence, health),
dominance, and status [22]. More recent male attractiveness studies report feminine
male faces are rated as more attractive. Less masculine male faces could be linked
to more favourable personality traits, in particular when it comes to parental invest-
ment and for long-term relationships. Characteristics associated with these faces for
parental investment and long-term relationships include good parenting, honesty
and cooperation, less dominance and warmer personality [22, 33]. Increased mascu-
line facial features are linked to negative attributes and perceptions, including
aggressiveness, dominance, cold character, and dishonesty [33]. Male faces indicat-
ing high testosterone exhibit dominance, but do not increase the rating of attractive-
ness by the opposite sex [34]. Increased dominance negatively affects reproductive
success, and moderate masculinity is usually preferred [35, 36]. Although more
recently challenged, hormonal changes and the menstrual cycle have been reported
to affect attractiveness rating by women with a preference for relatively more mas-
culine faces during the fertile phase [37–41].
Feminine faces and increased sexually dimorphic feminine features (high cheek-
bones and smaller lower face and chin, full lips) on female faces are reported to be
attractive [42]. These could be due to cues to youthfulness and fertility [43–46].
Parental characteristics (mainly opposite-sex parental characteristics), experience,
and “self-similar characteristics” can influence the attractiveness rating. Preference
for male and female faces could be influenced by parental age and characteristics (e.g.
colour characteristics—hair and eyes) by both men and women [47, 48].
Attractive faces activate the reward centres of the brain and an enhanced response
with positive attributes, e.g., smiling (Fig. 1.2). This is true even with passive view-
ing of beautiful female faces [49, 50]. Emotional expression is a key influencer of
the perception of facial attractiveness [51–54]. There is a link between how attrac-
tive a face appears and the processing of the emotional expression of the face [55].
Brain imaging studies have shown common and shared underlying neural mecha-
nisms (enhanced activity in brain’s reward system (medial orbitofrontal cortex))
between the processing of happy facial expressions and attractiveness [49]. This can
be further explained, positive expressions could affect the observer’s emotional
state and hence affect their perception of attractiveness [36, 55]. Furthermore, posi-
tive attributes consciously or unconsciously signal good health (cardiovascular
function, reduced stroke incidence) and wellbeing, which in turn results in an
increased perception of attractiveness [55–57].
Fig. 1.2 Smiling influences perception of attractiveness

1 Facial Beauty 7
Preferences for Neoteny in Humans
Studies have shown neoteny plays a role in facial attractiveness. In females, features
such as full/thick lips, large eyes but thin eyebrows, high forehead, prominent but
small cheekbones, and relatively small chin and nose are found to be attractive.
These all are “baby-like” features. Edler reported attractive female faces would be
child-like resulting in protective instincts. Furthermore, sexually dimorphic features
including high cheekbones and full lips signal maturity [30, 58–62]. The preference
for neoteny is most noticeable among both men and women in Asia (Japan, Korea,
and China) where popstars and cartoon characters have baby-like features. “Beauty
camera” applications are very popular. These applications use filters to improve
photo/selfie quality, neotenize facial features, improve complexion, remove lines
and wrinkles, enlarge eyes, and reduce the size of the lower face and chin area.
Mathematical Models of Beauty
Faces and bodies have been studied by the artists in the fourth century BC, who tried
to formulate proportional and mathematical rules, with the Greeks being the fore-
front artists. Romans described various rules, for example, the rule of facial thirds,
which is still practised today (Fig. 1.3) [61, 63]. Renowned artists, including da
Vinci, proposed rules for “ideal proportions” that result in optimal aesthetics and
optimal harmony [61]. In the sixteenth century, artist Albrecht Dürer established
that proportion in human faces is attractive and disproportion is unattractive [63].
The facial horizontal fifths rule may have come from ancient China [64]. The con-
cept that the perceived beauty is due to particular measures, proportions, orders, and
harmony between elements that also exist in the world [65].
Canons of Beauty
Canons of human beauty and facial beauty originated from Egypt, Greece, and the
Renaissance era. Scholars, artists, and philosophers, including Da Vinci, Vitruvius,
Bergmüller, Albrecht Dürer (division of the face into three equal lengths) revisited
and used canons [66]. Leonardo Da Vinci has comprehensive works on the propor-
tions and applied these canons to his work. According to these proportions, faces
and bodies should ideally be shaped. Leonardo da Vinci’s famous Vitruvian man
shows the proportions recorded by the Roman author Vitruvius (Fig. 1.4). Da Vinci
describes various ideal body and face proportions, for example, the size of the
mouth equals the distance between the parting of the lips and the edge of the chin in
a well-proportioned face [67].
8 S. Samizadeh
Fig. 1.3 Rule of facial

thirds—first described by
Roman artists and rule of
facial fifths. The facial
thirds divide the face
vertically into three equal
thirds. The transverse
facial fifths divide the face
into five eye widths
The neoclassical canons have been used as guides for drawing or sculpting beau-
tiful faces and bodies. These canons are based on the idea that portions of an attrac-
tive face or body should follow defined ratios [68]. For example, Forehead
height = nose length = lower face height.
These canons and guidelines were originally described in art and have been used by
clinicians for treatment planning [63]. Canons or anthropometric proportions are attrac-
tive to clinicians as such numerical values or guidelines for proportions may allow
reproduction of aesthetically attractive proportions. However, studies have shown that
these canons and proportions are not applicable in the general population [68, 69].
Hogarth’s Serpentine Line
William Hogarth, an eighteenth-century English artist and author, published The

Analysis of Beauty, in which he discussed the “serpentine line”, also referred to as
“line of beauty” and “the line of grace”. The line being curvilinear and described the
line being present as “line of beauty in faces” and that it “abounds”. A physician and
orthodontist, Calvin S Case (1847–1923) also described the importance of the facial
1 Facial Beauty 9
Fig. 1.4 Left: Leonardo da Vinci’s Vitruvian man, ca 1490. This famous figure shows that propor-
tionate human form fits perfectly in perfect geometric shapes—circle and square, with the navel
at the centre. Vertical facial trisection is shown. Vertical face height (hairline to inferior aspect of
chin) is one tenth of standing height. Interestingly, this is equal to length of hand (courtesy of
Gallerie dell’Accademia, Venice). Right: Leonardo da Vinci’s Male head in profile with propor-
tions, ca 1490. Vitruvian anterior vertical facial thirds are evident: hairline to eyebrows, eyebrows
to base of nose, base of nose to below chin. Lower facial third is again divided into upper third
(upper lip) and lower two-thirds. Ear is one third of facial height. What later came to be described
as Frankfort plane and its perpendicular, facial vertical from soft-tissue nasion, are also shown
(courtesy of Gallerie dell’Accademia, Venice). Used with permission—Naini, F. B., Moss, J. P., &
Gill, D. S. (2006). The enigma of facial beauty: esthetics, proportions, deformity, and controversy.
American Journal of Orthodontics and Dentofacial Orthopedics, 130(3), 277–282
profile curves. The interplay and relationship between undulating facial convexity
and concavities is known as “facial curvilinear relationships” [2, 70]. The Ogee
curve is possibly one of the serpentine lines described by Hogarth (Fig. 1.5).
Golden Proportions/“Divine Proportion”
The idea of Golden proportions is attributed to Plato and Pythagoras (a philosopher,

mathematician, and numerologist). The first written description and illustration
came from Euclid (“Father of Geometry”) of Alexandria [70]. The mathematician
Luca Pacioli renaming it to “divine proportions” in 1509 (Fig. 1.5) [63]. The
Egyptians had applied the golden proportion in their architecture [67]. It is known
as Golden Section, Golden Mean, Divine Proportion, or the Greek letter Phi (φ).
10 S. Samizadeh
Fig. 1.5 Illustration of the

Ogee curve
a b
a+b
Golden ratio = a+b/a = a/b
Fig. 1.6 Golden ratio: what is it? A line divided into two segments with the total length of the line
being 1. The larger segment would have a length of 0.618 known as Phi. Ratios are described as
(The shorter segment: The longer segment) = (the longer segment: the whole line). It is frequently
found in nature, from biological systems and inanimate objects. Examples include flower petals,
head of flowers, spiral patterns, pine cones, shells (snail, sea), spiral galaxies, hurricanes, faces,
fingers, and animal bodies
The Golden Ratio comes from the Fibonacci sequence which has fascinated math-
ematicians, artists, designers, and scientists for centuries. The Fibonacci sequence
is a naturally occurring sequence of numbers. It can be found everywhere, for exam-
ple, the number of petals in a flower, pine cones, the pattern of flower petals, number
of leaves on a tree, the shape of a seashell, spiral galaxies, hurricanes, animal body,
segments of fingers, facial features, etc. (Fig. 1.6). It is used in ancient architectures,
for example, in Egypt and Parthenon in Athens.
Golden Ratio is a geometric proportion, it exists when a line is divided into two
parts, and the longer part divided by the smaller part is equal to the sum of both
parts, divided by the longer part. It is equal to approximately 1.618 (Fig. 1.7). It is
found in mathematics, geometry, art, nature, architecture, logos, sculptures, animal
bodies, human anatomy, heart, blood cells, gait mechanics, etc. Many artists since
1 Facial Beauty 11
Fig. 1.7 Golden Ratio exists when a line is divided into two parts, and the longer part (a) divided
by the smaller part (b) is equal to the sum of both parts (a) + (b), divided by (a). It is equal to
approximately 1.618. φ = (1 + 51/2)/2 = 1.618
the Renaissance have used the principle of golden ratio. This ratio is thought to be
the key to aesthetically pleasing art.
The brain finds golden ration pleasing and responds with a positive response to
specifically proportioned shapes [71]. A professor of mechanical engineering has
shown that when images are withing the golden ration rectangle, the eyes scan the
image the fastest and therefore can take in information more efficiently. “It is the
oneness of vision, cognition, and locomotion as the design of the movement of all
animals on earth. The phenomenon of the golden ratio contributes to this under-
standing the idea that pattern and diversity coexist as integral and necessary features
of the evolutionary design of nature” [72].
12 S. Samizadeh
The orthodontic speciality has been the forefront in analysing facial parameters
and profiles (use of cephalometric radiographs) [63, 73–75]. It was discussed by
Ricketts in Clinics in Plastic Surgery in 1982 and used by Moss et al. in 1995,
reported in Semin Orthod [76]. In 1982, Ricketts published “The normal face and
the occlusion of the teeth have a majestic beauty. The study strongly suggests that
esthetics can indeed be made scientific rather than the need to resort to subjective
perceptions as in the past” [76]. In this paper, Ricket demonstrated use of a “golden
divider” for examining facial features and proportions (Fig. 1.8). He also demon-
strated golden divider for the hand [76].
Practical application of ideal proportions when treating the dentition and the
lower third of the face for improving facial aesthetics was published by Mack in
1991 [77, 78]. The correlation of the golden ration to facial beauty and attractive-
ness has become a popular concept recently. Jefferson explains that beautiful faces
have ideal proportions directly related to divine proportions and that treating to the
divine proportions would maximise facial aesthetics among other things including
quality of life [79–84].
More recently, the golden ratio in other areas of medicine has attracted much
attention. Examples include presence of golden ratio principle in the architecture
and evolution of the human skull (Fig. 1.9), heart anatomy with deviations showing
functional abnormality and pathological conditions, diastolic to systolic time inter-
val ratio, the branching structure of the coronary arterial tree, gait harmonics (lower
extremity dimensions based on Φ), optimal toroidal shape, and CO2-carrying capac-
ity of erythrocyte [70, 85].
Stephen Marquardt, an American oral and maxillofacial surgeon developed “The
Golden Decagon mask”, using the Phi ratios/golden ration to represent “ideal face”.
a b c
A B
Fig. 1.8 Ricket demonstrated use of a “golden divider” and golden proportions for examining
facial features and proportions of. According to research findings the mandible grows on an arc and
the occlusal plane rises posteriorly. This arc conforms to the logarithmic spiral which has at its
base the golden section in the divine proportion. Used with permission from Ricketts, R.M., 1982.
The biologic significance of the divine proportion and Fibonacci series. American journal of ortho-
dontics, 81(5), pp. 351–370
1 Facial Beauty 13
Fig. 1.9 Golden Ratio (Φ) in the partition of a line and also of the nasioiniac arc on the human
skull. Division of a line into 2 segments such that the ratio of the line (a) to the longer segment (c)
is identical to the ratio of the longer to the shorter segment (b). This ratio is 1.618…, known as the
Golden Ratio or Φ. In an analogous situation in human skulls, division of the nasioiniac arc (from
nasion to inion, NI) by bregma into a shorter frontal arc (from nasion to bregma, NB) and longer
parieto-occipital arc (from bregma to inion BI), creates a geometrical relationship in which the
ratio of the nasioiniac arc over the bregma-inion arc (NI/BI) coincides with the ratio of the bregma-
inion arc over the nasion-bregma arc (BI/NB), both 1.6. The subdivision of the nasioiniac arc by
bregma into 2 unequal arcs emulates the geometrical division of a line into the Golden Ratio. Used
with Permission—Mammalian Skull Dimensions and the Golden Ratio (Φ)—Tamargo, Rafael J.;
Pindrik, Jonathan A. Journal of Craniofacial Surgery 30(6):1750–1755, September 2019
He initially studied faces of professional models and movie stars and found that
golden radio occurred in their faces more often than less attractive faces [86]. The
geometrically complex mask is made up of triangles, rectangles, and decagons and
has front, lateral, and smiling versions. He explains that all faces are variations of
this mask. Application of the mask and variations are available on Stephen
Marquardt’s website.
Holland reported that the mask is not consistent with optimal preferences, of
femininity as it best describes “masculinized white women as seen in fashion mod-
els” [87]. Gopi et al. demonstrated that the mask does not conform with South
Indian facial traits and highlighted the need for consideration and incorporation of
ethnic differences [88].
14 S. Samizadeh
The concept of BeautiPHIcation was developed by plastic surgeons Arthur Swift

and B. Kent Remingto based on the use of the mathematical golden ratio Phi to
achieve proportion and harmony using fillers with a “comprehensive facial
approach” [89–91]. They explain the perception of beauty through golden ratio
means populations of different origin have similar perception of facial attractiveness
(termed “Phi-proportioned beauty”) and why individuals who have “near Phi pro-
portions” are found to be attractive despite lack of seemingly striking features [91].
Baker and Woods explained that divine proportions can be used to aid treatment
planning as an adjunct to other methods [92]. Stein et al. have demonstrated suc-
cessfully employing Phi (after the architect Phidias) principles for lower lid and
cheek rejuvenation using liposculpture [93].
The collective summary of some of the literature and studies demonstrates that
neoclassical rules and golden ratios are not always indicative of beauty or perception
of beauty by a population. Moss and colleagues analysed the faces of professional
models (3D study). They reported that the faces did not fit the golden proportion. A
fascinating finding was that face of models studies had various malocclusions and a
wide range of cephalometric values [94]. In another study, patients undergone orthog-
natic surgery had increased attractiveness after the treatment, though were as likely to
move towards or away from the golden proportion [92]. Ideal facial proportions in
Miss Universe Thailand and Miss Universe were studied by Burusapat and Lekdaeng.
They reported “facial golden ratios were statistically significantly invalid in modern
facial proportions of beauty” [95]. This was supported by a study that used 3D facial
analysis of Miss Korea pageant contestants and a selected group of women from the
general population [96]. Findings of other studies have supported this [96–100]. More
research is required to further examine and substantiate the significance of golden
proportion in the clinical assessment and treatment planning of facial aesthetics.
Wang et al. examined four neoclassical canons of facial proportion in Caucasian
(103 North American) and Chinese (106 Hans Chinese-main ethnic group in China).
The racial differences were highlighted and rejected the facial canons established by
Renaissance scholars for artists as the norm [101]. Although the most attractive face
in their study conformed to the Marquardt’s Golden Ratio facial mask, they dis-
puted most beautiful faces were those that complied with the golden ratio [102].
Kiekens et al.’s research also supported the above idea [97]. In a different study, the
anthropometric neoclassical canons did not conform with Southern Chinese [103].
Other studies support that neoclassicals canons are invalid for various populations,
including Asian, African American, North American, Arabian Peninsula, Persian,
and Turkish [68, 101, 104–108]. Neoclassical canons were found to be more valid
in whites than in Asians [60, 109, 110].
Cultural Variations of the Standards of Beauty
Environmental factors and culture on the perception of beauty have been studied.
An interesting finding is that individuals rated as attractive in one culture are usually
found to be attractive by other cultures too [36, 111, 112]. The study by Bernstein
1 Facial Beauty 15
et al. in 1982 reported that although attractiveness rating and “aesthetic criteria”
were similar in various races, the attractiveness rating was more similar among
“Black and White” than “Chinese and White” in their study [111]. In a study by
Martin, preference for faces varied between white and black American and black
African men with the former preferring black female faces that had white features
and the latter group having a preference for faces that had Negroid features [113].
Cross-cultural differences in face preferences were reported by Zhang et al. who
examined facial attractiveness judgment of Chinese (born in China and resident in
China, born in China but live in the UK) and Caucasians (UK born and UK resident).
However, few studies have shown consensus regarding attractiveness and beauty
across cultures [4, 22, 42]. Facial shape aesthetic judgment is found to be similar
across different cultural backgrounds [42]. Both Japanese and white of both genders
found the same female faces attractive (high cheekbones, narrow lower face, large
eyes) [42].
On the consensus paper, Changing Trends, Attitudes, and Concepts of Asian
Beauty by Liew et al., the panel agreed and reported that whilst retaining distinct
ethnic features, beautiful people of all races show similarity in facial characteristics
[9]. The general principles of beauty and aesthetic enhancement appear to be the
same for all individuals of all cultures, with similar aesthetic goals that are modestly
influenced by culture, environment, and media.
Media and social media, local and international fashions can also influence ide-
als of beauty [61, 114–116]. The ideals of beauty represented by the media affect
people’s perception of beauty [63]. Also, ideals of beauty may change over time and
by “developments in society”. Berneburg et al. study changes in aesthetic standards
since 1940 by looking at photographs of attractive men and women between 1940
and 2008. They reported that highly attractive male and female faces have become
similar in terms of chin size and position, with attractive male faces becoming less
masculine, more convex (shorter chins) and generalised preference for female faces
with more protrusive and fuller lips [115, 117].
Conclusion
It is not a single attribute that makes a face beautiful or attractive. A combination of

multiple factors plays a role. Not surprisingly, pleasant and positive expressions
(e.g. happiness, smiling), youthfulness and grooming also contribute to attractive-
ness rating [22, 55, 118]. Furthermore, when it comes to people in our private life or
social interactions, liking the person, respect, familiarity, and shared goals affect the
perception of beauty [44, 118–120]. Globalisation, multi-ethnic communities, and
social development all influence international standards of beauty independent of
one’s ethnic origin [115, 116]. Furthermore, our visual perception may influence
perceived attractiveness, as in the example of reduced ability to detect asymmetry
when intoxicated with alcohol [121].
16 S. Samizadeh
References
1. Thornhill R, Gangestad SW. Human facial beauty. Hum Nat. 1993;4(3):237–69.

2. Naini FB. Facial aesthetics: concepts and clinical diagnosis. Boca Raton, FL: Wiley; 2011.
3. Hosoda M, Stone-Romero EF, Coats G. The effects of physical attractiveness on job-related
outcomes: a meta-analysis of experimental studies. Pers Psychol. 2003;56(2):431–62.
4. Langlois JH, Kalakanis L, Rubenstein AJ, Larson A, Hallam M, Smoot M. Maxims or myths
of beauty? A meta-analytic and theoretical review. Psychol Bull. 2000;126(3):390–423.
5. Schein SS, Langlois JH. Unattractive infant faces elicit negative affect from adults. Infant
Behav Dev. 2015;38:130–4.
6. Stephan CW, Langlois JH. Baby beautiful: adult attributions of infant competence as a func-
tion of infant attractiveness. Child Dev. 1984;55(2):576–85.
7. Langlois JH, Ritter JM, Casey RJ, Sawin DB. Infant attractiveness predicts maternal behav-
iors and attitudes. Dev Psychol. 1995;31(3):464–72.
8. Henderson JJ, Anglin JM. Facial attractiveness predicts longevity. Evol Hum Behav.
2003;24(5):351–6.
9. Liew S, Wu WT, Chan HH, Ho WW, Kim H-J, Goodman GJ, et al. Consensus on changing
trends, attitudes, and concepts of Asian beauty. Aesthet Plast Surg. 2016;40(2):193–201.
10. Fink B, Neave N. The biology of facial beauty. Int J Cosmet Sci. 2005;27(6):317–25.
11. Cunningham MR, Roberts AR, Barbee AP, Druen PB, Wu C-H. “Their ideas of beauty are,
on the whole, the same as ours”: consistency and variability in the cross-cultural perception
of female physical attractiveness. J Pers Soc Psychol. 1995;68(2):261.
12. Rhodes G, Proffitt F, Grady JM, Sumich A. Facial symmetry and the perception of beauty.
Psychon Bull Rev. 1998;5(4):659–69.
13. Langlois JH, Roggman LA, Rieser-Danner LA. Infants’ differential social responses to
attractive and unattractive faces. Dev Psychol. 1990;26(1):153–9.
14. Langlois JH, Roggman LA, Casey RJ, Ritter JM, Rieser-Danner LA, Jenkins VY. Infant pref-
erences for attractive faces: rudiments of a stereotype? Dev Psychol. 1987;23(3):363–9.
15. Slater A, Bremner G, Johnson SP, Sherwood P, Hayes R, Brown E. Newborn infants’
preference for attractive faces: the role of internal and external facial features. Infancy.
2000;1(2):265–74.
16. Mo C, Xia T, Qin K, Mo L. Natural tendency towards beauty in humans: evidence from bin-
ocular rivalry. PLoS One. 2016;11(3):e0150147.
17. Naini FB, Moss JP. Three-dimensional assessment of the relative contribution of genetics
and environment to various facial parameters with the twin method. Am J Orthod Dentofac
Orthop. 2004;126(6):655–65.
18. Alley TR, Cunningham MR. Article commentary: averaged faces are attractive, but very
attractive faces are not average. Psychol Sci. 1991;2(2):123–5.
19. Thornhill R, Gangestad SW. Facial attractiveness. Trends Cogn Sci. 1999;3(12):452–60.
20. Grammer K, Thornhill R. Human facial attractiveness and sexual selection: the roles of aver-
ageness and symmetry. J Comp Psychol. 1994;108(3):233–42.
21. Langlois JH, Roggman LA. Attractive faces are only average. Psychol Sci. 1990;1(2):115–21.
22. Rhodes G. The evolutionary psychology of facial beauty. Annu Rev Psychol. 2006;57:199–226.
23. Berry DS. Attractiveness, attraction, and sexual selection: evolutionary perspectives on the
form and function of physical attractiveness. Adv Exp Soc Psychol. 2000;32:273–342.
24. Kalick SM, Zebrowitz LA, Langlois JH, Johnson RM. Does human facial attractiveness
honestly advertise health? Longitudinal data on an evolutionary question. Psychol Sci.
1998;9(1):8–13.
25. Bashour M. History and current concepts in the analysis of facial attractiveness. Plast
Reconstr Surg. 2006;118(3):741–56.
26. Stephen ID, Hiew V, Coetzee V, Tiddeman BP, Perrett DI. Facial shape analysis identifies
valid cues to aspects of physiological health in Caucasian, Asian, and African populations.
Front Psychol. 2017;8:1883.
1 Facial Beauty 17
27. Rhodes G, Jeffery L, Watson TL, Clifford CW, Nakayama K. Fitting the mind to the world:
face adaptation and attractiveness aftereffects. Psychol Sci. 2003;14(6):558–66.
28. Rhodes G, Yoshikawa S, Clark A, Lee K, McKay R, Akamatsu S. Attractiveness of facial
averageness and symmetry in non-Western cultures: in search of biologically based standards
of beauty. Perception. 2001;30(5):611–25.
29. Rhodes G, Sumich A, Byatt G. Are average facial configurations attractive only because of
their symmetry? Psychol Sci. 1999;10(1):52–8.
30. Faure JC, Rieffe C, Maltha JC. The influence of different facial components on facial aesthet-
ics. Eur J Orthod. 2002;24(1):1–7.
31. Swaddle JP, Cuthill IC. Asymmetry and human facial attractiveness: symmetry may not
always be beautiful. Proc R Soc Lond Ser B Biol Sci. 1995;261(1360):111–6.
32. Zaidel DW, Cohen JA. The face, beauty, and symmetry: perceiving asymmetry in beautiful
faces. Int J Neurosci. 2005;115(8):1165–73.
33. Perrett DI, Lee KJ, Penton-Voak I, Rowland D, Yoshikawa S, Burt DM, et al. Effects of
sexual dimorphism on facial attractiveness. Nature. 1998;394:884.
34. Swaddle JP, Reierson GW. Testosterone increases perceived dominance but not attractiveness
in human males. Proc R Soc Lond Ser B Biol Sci. 2002;269(1507):2285–9.
35. Mueller U, Mazur A. Reproductive constraints on dominance competition in male Homo
sapiens. Evol Hum Behav. 1998;19(6):387–96.
36. Cunningham MR, Barbee AP, Pike CL. What do women want? Facialmetric assessment of
multiple motives in the perception of male facial physical attractiveness. J Pers Soc Psychol.
1990;59(1):61–72.
37. Johnston VS, Hagel R, Franklin M, Fink B, Grammer K. Male facial attractiveness: evidence
for hormone-mediated adaptive design. Evol Hum Behav. 2001;22(4):251–67.
38. Penton-Voak IS, Perrett DI. Female preference for male faces changes cyclically: further
evidence. Evol Hum Behav. 2000;21(1):39–48.
39. Penton-Voak IS, Perrett DI, Castles DL, Kobayashi T, Burt DM, Murray LK, et al. Menstrual
cycle alters face preference. Nature. 1999;399(6738):741.
40. Puts DA, Bailey DH, Cárdenas RA, Burriss RP, Welling LL, Wheatley JR, et al. Women’s
attractiveness changes with estradiol and progesterone across the ovulatory cycle. Horm
Behav. 2013;63(1):13–9.
41. Jones BC, Hahn AC, Fisher CI, Wang H, Kandrik M, Han C, et al. No compelling evidence
that preferences for facial masculinity track changes in women’s hormonal status. Psychol
Sci. 2018;29(6):996–1005.
42. Perrett DI, May KA, Yoshikawa S. Facial shape and judgements of female attractiveness.
Nature. 1994;368(6468):239–42.
43. Jones D, Brace CL, Jankowiak W, Laland KN, Musselman LE, Langlois JH, et al. Sexual
selection, physical attractiveness, and facial neoteny: cross-cultural evidence and implica-
tions [and comments and reply]. Curr Anthropol. 1995;36(5):723–48.
44. Johnston VS, Franklin M. Is beauty in the eye of the beholder? Ethol Sociobiol.
1993;14(3):183–99.
45. Buss DM. Sex differences in human mate preferences: evolutionary hypotheses tested in 37
cultures. Behav Brain Sci. 2010;12(1):1–14.
46. Cunningham MR. Measuring the physical in physical attractiveness: quasi-experiments on
the sociobiology of female facial beauty. J Pers Soc Psychol. 1986;50(5):925–35.
47. Perrett D, Penton-Voak IS, Little AC, Tiddeman BP, Burt DM, Schmidt N, et al. Facial attrac-
tiveness judgements reflect learning of parental age characteristics. Proc R Soc Lond Ser B
Biol Sci. 2002;269(1494):873–80.
48. Little AC, Penton-Voak IS, Burt DM, Perrett DI. Investigating an imprinting-like phenom-
enon in humans: partners and opposite-sex parents have similar hair and eye colour. Evol
Hum Behav. 2003;24(1):43–51.
49. O’Doherty J, Winston J, Critchley H, Perrett D, Burt DM, Dolan RJ. Beauty in a smile: the role
of medial orbitofrontal cortex in facial attractiveness. Neuropsychologia. 2003;41(2):147–55.
18 S. Samizadeh
50. Aharon I, Etcoff N, Ariely D, Chabris CF, O’Connor E, Breiter HC. Beautiful faces have
variable reward value: fMRI and behavioral evidence. Neuron. 2001;32(3):537–51.
51. Tracy JL, Beall AT. Happy guys finish last: the impact of emotion expressions on sexual
attraction. Emotion. 2011;11(6):1379.
52. Harker L, Keltner D. Expressions of positive emotion in women’s college yearbook pictures
and their relationship to personality and life outcomes across adulthood. J Pers Soc Psychol.
2001;80(1):112.
53. Mehu M, Little AC, Dunbar RI. Duchenne smiles and the perception of generosity and socia-
bility in faces. J Evol Psychol. 2007;5(1):183–96.
54. Otta E, Abrosio FFE, Hoshino RL. Reading a smiling face: messages conveyed by various
forms of smiling. Perceptual Motor Skills. 1996;82(3 suppl):1111–21.
55. Golle J, Mast FW, Lobmaier JS. Something to smile about: the interrelationship between
attractiveness and emotional expression. Cognit Emot. 2014;28(2):298–310.
56. Ostir GV, Markides KS, Peek MK, Goodwin JS. The association between emotional well-
being and the incidence of stroke in older adults. Psychosom Med. 2001;63(2):210–5.
57. Dockray S, Steptoe A. Positive affect and psychobiological processes. Neurosci Biobehav
Rev. 2010;35(1):69–75.
58. Baudouin J-Y, Tiberghien G. Symmetry, averageness, and feature size in the facial attractive-
ness of women. Acta Psychol. 2004;117(3):313–32.
59. Cellerino A. Psychobiology of facial attractiveness. J Endocrinol Investig. 2003;26(3
Suppl):45–8.
60. Edler R. Background considerations to facial aesthetics. J Orthod. 2001;28(2):159–68.
61. Hönn M, Göz G. The ideal of facial beauty: a review. J Orofac Orthop. 2007;68(1):6–16.
62. Sforza C, Laino A, D'Alessio R, Grandi G, Binelli M, Ferrario VF. Soft-tissue facial char-
acteristics of attractive Italian women as compared to normal women. Angle Orthod.
2009;79(1):17–23.
63. Naini FB, Moss JP, Gill DS. The enigma of facial beauty: esthetics, proportions, deformity,
and controversy. Am J Orthod Dentofac Orthop. 2006;130(3):277–82.
64. Zhang D, Chen F, Xu Y. Computer models for facial beauty analysis. New York: Springer; 2016.
65. Gaut BN, Lopes D. The Routledge companion to aesthetics. New York: Routledge; 2005.
66. Schmid K, Marx D, Samal A. Computation of a face attractiveness index based on neoclassi-
cal canons, symmetry, and golden ratios. Pattern Recogn. 2008;41(8):2710–7.
67. Vegter F, Hage JJ. Clinical anthropometry and canons of the face in historical perspective.
Plast Reconstr Surg. 2000;106(5):1090–6.
68. Farkas LG, Hreczko TA, Kolar JC, Munro IR. Vertical and horizontal proportions of the face
in young adult north American Caucasians: revision of neoclassical canons. Plast Reconstr
Surg. 1985;75(3):328–38.
69. Pavlic A, Trinajstic Zrinski M, Katic V, Spalj S. Neoclassical canons of facial beauty: do we
see the deviations? J Cranio-Maxillofac Surg. 2017;45(5):741–7.
70. Tamargo RJ, Pindrik JA. Mammalian Skull Dimensions and the Golden Ratio (Φ). J Craniofac
Surg. 2019;30(6):1750–5.
71. Di Dio C, Macaluso E, Rizzolatti G. The golden beauty: brain response to classical and
renaissance sculptures. PLoS One. 2007;2(11):e1201.
72. Bejan A. The golden ratio predicted: vision, cognition and locomotion as a single design in
nature. Int J Des Nat Ecodyn. 2009;4(2):97–104.
73. Downs WB. Analysis of the dentofacial profile. Angle Orthod. 1956;26(4):191–212.
74. Steiner CC. Cephalometrics for you and me. Am J Orthod Dentofac Orthop.
1953;39(10):729–55.
75. Ricketts RM. A foundation for cephalometric communication. Am J Orthod.
1960;46(5):330–57.
76. Ricketts RM. Divine proportion in facial esthetics. Clin Plast Surg. 1982;9(4):401–22.
77. Mack MR. “Vertical dimension: a dynamic concept based on facial form and oropharyngeal
function”, The Journal of Prosthetic Dentistry. 1991;66(4):478–85.
1 Facial Beauty 19
78. Milutinovic J, Zelic K, Nedeljkovic N. Evaluation of facial beauty using anthropometric

proportions. The Scientific World Journal, 2014.
79. Jefferson Y. Facial beauty—establishing a universal standard. Int J Orthod (Milwaukee, Wis).
2004;15(1):9–22.
80. Henein MY, Zhao Y, Nicoll R, Sun L, Khir AW, Franklin K, et al. The human heart: applica-
tion of the golden ratio and angle. Int J Cardiol. 2011;150(3):239–42.
81. Iosa M, Morone G, Bini F, Fusco A, Paolucci S, Marinozzi F. The connection between
anthropometry and gait harmony unveiled through the lens of the golden ratio. Neurosci Lett.
2016;612:138–44.
82. Aparci M, Celik T, Yalcin M, Isilak Z. Golden ratio between left ventricular and aortic dimen-
sions. Int J Cardiol. 2016;205:60–1.
83. Ashrafian H, Athanasiou T. Fibonacci series and coronary anatomy. Heart Lung Circ.
2011;20(7):483–4.
84. Papaioannou TG, Vavuranakis M, Gialafos EJ, Karamanou M, Tsoucalas G, Vrachatis DA,
et al. Blood pressure deviation from the golden ratio φ and all-cause mortality: a pythagorean
view of the arterial pulse. Int J Appl Basic Med Res. 2019;9(1):55.
85. Purnell MC, Butawan MBA, Ramsey RD. Bio-field array: a dielectrophoretic electromag-
netic toroidal excitation to restore and maintain the golden ratio in human erythrocytes.
Physiol Rep. 2018;6(11):e13722.
86. Marquardt SR, Beauty HF. JCO Interviews.
87. Holland E. Marquardt’s Phi mask: pitfalls of relying on fashion models and the golden ratio
to describe a beautiful face. Aesthet Plast Surg. 2008;32(2):200–8.
88. Veerala G, Gandikota CS, Yadagiri PK, Manne R, Juvvadi SR, Farah T, et al. Marquardt’s
facial Golden decagon mask and its fitness with south Indian facial traits. J Clin Diagn Res.
2016;10(4):ZC49–52.
89. Swift A, Remington K. BeautiPHIcation™: a global approach to facial beauty. Clin Plast
Surg. 2011;38(3):347–77.
90. Swift A. The mathematics of facial beauty: a cheek enhancement guide for the aesthetic
injector. Injectable fillers: principles and practice. 2010;2010:140–57.
91. Swift A, Remington BK. The mathematics of facial beauty. In: Injectable fillers: facial shap-
ing and contouring. Boca Raton, FL: Wiley; 2019. p. 29.
92. Baker BW, Woods MG. The role of the divine proportion in the esthetic improvement of
patients undergoing combined orthodontic/orthognathic surgical treatment. Int J Adult
Orthodon Orthognath Surg. 2001;16(2):108–20.
93. Stein R, Holds JB, Wulc AE, Swift A, Hartstein ME. Phi, fat, and the mathematics of a beauti-
ful midface. Ophthalmic Plast Reconstr Surg. 2018;34(5):491–6.
94. Moss J, Linney A, Lowey M, editors. The use of three-dimensional techniquesin facial esthet-
ics. Seminars in orthodontics. New York: Elsevier; 1995.
95. Burusapat C, Lekdaeng P. What is the most beautiful facial proportion in the 21st century?
Comparative study among Miss Universe, Miss Universe Thailand, Neoclassical Canons, and
Facial Golden Ratios. Plast Reconstr Surg Glob Open. 2019;7(2):e2044.
96. Jang KS, Bayome M, Park JH, Park KH, Moon HB, Kook YA. A three-dimensional photo-
grammetric analysis of the facial esthetics of the Miss Korea pageant contestants. Korean J
Orthod. 2017;47(2):87–99.
97. Kiekens RM, Kuijpers-Jagtman AM, Van 't Hof MA, Van 't Hof BE, Maltha JC. Putative
golden proportions as predictors of facial esthetics in adolescents. Am J Orthod Dentofacial
Orthop. 2008;134(4):480–3.
98. Alam MK, Mohd Noor NF, Basri R, Yew TF, Wen TH. Multiracial facial golden ratio and
evaluation of facial appearance. PLoS One. 2015;10(11):e0142914.
99. Packiriswamy V, Kumar P, Rao M. Identification of facial shape by applying golden ratio
to the facial measurements: an interracial study in Malaysian population. N Am J Med Sci.
2012;4(12):624–9.
20 S. Samizadeh
100. Anand S, Tripathi S, Chopra A, Khaneja K, Agarwal S. Vertical and horizontal proportions
of the face and their correlation to phi among Indians in Moradabad population: a survey. J
Indian Prosthodontic Soc. 2015;15(2):125–30.
101. Dawei W, Guozheng Q, Mingli Z, Farkas LG. Differences in horizontal, neoclassical facial
canons in Chinese (Han) and north American Caucasian populations. Aesthet Plast Surg.
1997;21(4):265–9.
102. Fan J, Chau KP, Wan X, Zhai L, Lau E. Prediction of facial attractiveness from facial propor-
tions. Pattern Recogn. 2012;45(6):2326–34.
103. Jayaratne YSN, Deutsch CK, McGrath CPJ, Zwahlen RA. Are neoclassical canons valid for
southern Chinese faces? PLoS One. 2012;7(12):e52593.
104. Farkas L, Forrest C, Litsas L. Revision of neoclassical facial canons in young adult Afro-
Americans. Aesthet Plast Surg. 2000;24(3):179–84.
105. Borman H, Ozgür F, Gürsu G. Evaluation of soft-tissue morphology of the face in 1,050
young adults. Ann Plast Surg. 1999;42(3):280–8.
106. Le TT, Farkas LG, Ngim RC, Levin LS, Forrest CR. Proportionality in Asian and north
American Caucasian faces using neoclassical facial canons as criteria. Aesthet Plast Surg.
2002;26(1):64–9.
107. Al-Sebaei MO. The validity of three neo-classical facial canons in young adults originating
from the Arabian peninsula. Head Face Med 2015;11(1):1–7.
108. Sepehr A, Mathew PJ, Pepper J-P, Karimi K, Devcic Z, Karam AM. The Persian Woman’s
face: a photogrammetric analysis. Aesthet Plast Surg. 2012;36(3):687–91.
109. Choe KS, Sclafani AP, Litner JA, Yu G-P, Romo T III. The Korean American Woman’s face:
anthropometric measurements and quantitative analysis of facial aesthetics. Arch Facial Plast
Surg. 2004;6(4):244–52.
110. Torsello F, Mirigliani L, D'Alessio R, Deli R. Do the neoclassical canons still describe
the beauty of faces? An anthropometric study on 50 Caucasian models. Prog Orthod.
2010;11(1):13–9.
111. Bernstein IH, Lin T-D, McClellan P. Cross- vs. within-racial judgments of attractiveness.
Percept Psychophys. 1982;32(6):495–503.
112. Maret SM, Harling CA. Cross-cultural perceptions of physical attractiveness: ratings of pho-
tographs of whites by Cruzans and Americans. Percept Mot Skills. 1985;60(1):163–6.
113. Martin JG. Racial ethnocentrism and judgment of beauty. J Soc Psychol. 1964;63(1):59–63.
114. Auger TA, Turley PK. The female soft tissue profile as presented in fashion magazines during
the 1900s: a photographic analysis. Int J Adult Orthodon Orthognath Surg. 1999;14(1):7–18.
115. Berneburg M, Dietz K, Niederle C, Göz G. Changes in esthetic standards since 1940. Am J
Orthod Dentofacial Orthop. 2010;137(4):450.e1–9.
116. Iglesias-Linares A, Yáñez-Vico R-M, Moreno-Manteca B, Moreno-Fernández AM, Mendoza-
Mendoza A, Solano-Reina E. Common standards in facial esthetics: craniofacial analysis of
most attractive black and white subjects according to people magazine during previous 10
years. J Oral Maxillofac Surg. 2011;69(6):e216–e24.
117. Sundaram H, Huang P-H, Hsu N-J, Huh CH, Wu WTL, Wu Y, et al. Aesthetic applications of
Botulinum Toxin A in Asians: an International, multidisciplinary, Pan-Asian consensus. Plast
Reconstr Surg Global Open. 2016;4(12):e872.
118. Kniffin KM, Wilson DS. The effect of nonphysical traits on the perception of physical attrac-
tiveness: three naturalistic studies. Evol Hum Behav. 2004;25(2):88–101.
119. Rhodes G, Hickford C, Jeffery L. Sex-typicality and attractiveness: are supermale and super-
female faces super-attractive? Br J Psychol. 2000;91(1):125–40.
120. Russell R. Sex, beauty, and the relative luminance of facial features. Perception.
2003;32(9):1093–107.
121. Souto A, Bezerra BM, Halsey LG. Alcohol intoxication reduces detection of asymmetry:
an explanation for increased perceptions of facial attractiveness after alcohol consumption?
Perception. 2008;37(6):955–8.
Chapter 2
Beauty Standards in Asia
Souphiyeh Samizadeh
Asian cultures place particular importance on beauty and facial beauty. Philosophies
such as Taoist and Confucian emphasise the relationship between inner and outer
beauty, with the latter representing one’s character, talent, and fate [1, 2]. Asia is
Earth’s largest and most populous continent. Therefore, a review of all of Asia is
beyond the scope of any single book. For the purposes of this book, we shall focus
on East Asia, including China, Hong Kong, Macao, Mongolia, North Korea, South
Korea, Japan, and Taiwan (Fig. 2.1).
It is noteworthy that all oriental Asians are not the same genetically, nor have
identical facial morphologies and generalisation cannot be made. China alone has
56 ethnic minority groups (which make up 8.49% of the population of Mainland
China). The Hans ethnic population is the majority, however there are various
other Chinese ethnicities, including Achang, Bai, Bonan, Bouyei, Blang, Dai, Daur,
Deang, Dong, Dongxiang, Dulong, Ewenki, Gaoshan, Gelao, Hani, Hezhe, Hui,
Jing, Jingpo, Jinuo, Kazak, Kirgiz, Korean, Lahu, Li, Lisu, Luoba, Manchu,
Maonan, Menba, Miao, Mongolian, Mulao, Naxi, Nu, Oroqen, Ozbek, Pumi, Qiang,
Russian, Salar, She, Shui, Tajik, Tatar, Tibetan, Tu, Tujia, Uigur, Wa, Xibe, Yao, Yi,
Yugur, and Zhuang (Fig. 2.2).
In the past centuries, Chinese would pay attention to diet and nutrition, in addi-
tion to other aids to help maintain health and beauty. Varied makeup styles and
compositions have been used throughout time to enhance or alter beauty. During the
Han Dynasty (206 B.C.–220 A.D.), a fair complexion was found to be attractive and
thought to represent wealth, nobility, and aristocracy. Consumption of various foods
S. Samizadeh (*)

https://doi.org/10.1007/978-3-030-84099-0_2
22 S. Samizadeh
Fig. 2.1 Map of Asia
and aids (e.g. pearl powder) was recommended to assist with skin whitening. This
is also true in Japan, where a fair complexion was analagous to nobility. Skin whit-
ening powders (Oshiroi-originally made with lead or rice powder) were and are used
by kabuki actors, nihonbuyo, jiutamai dancers, performing artists and geishas. The
representation is still alive in Japan, with geishas, and in China, with actors in
Chinese Beijing opera (heavy face painting known as Hualian, not for the purpose
of making one more attractive, but to represent own’s characteristics, personality,
moral character, etc). In ancient times, Chinese girls used ceruse (white lead) to
make their skin appear white. There are old proverbs in the region regarding white
and fair skin; Japanese: “white skin covers the seven flaws” and Chinese: “white
skin can help conceal 100 flaws in your appearance”. A more recent popular saying
in China: “white, rich and beautiful” (白富美).
Similarly, in Korea, during the Gojoseon Era, a blemish-free, and fair complex-
ion was found desirable. The continued desire for “porcelain skin” has resulted in
cosmeceutical and pharmaceutical companies, and plastic surgery hospitals to
develop and offer various techniques and technologies for skin whitening, with
some reports of catastrophic health effects. This is true for other Asia Pacific coun-
tries, including India, Thailand, etc.
During Tang Dynasty (618–907), a Chinese medical scientist called Sun Simiuao
came up with methods of treating various dermatological issues such as sores and
freckles, and with treatments for moisturising the skin. One well-acclaimed skin
2 Beauty Standards in Asia 23
Fig. 2.2 China has a total of 56 ethnic groups, although the majority, Hans, make up about
91.5% of the population. The remaining ethnic groups are the minority and make up 8.49% of
the total population of Mainland China. These groups include Achang, Bai, Bonan, Bouyei, Blang,
Dai, Daur, Deang, Dong, Dongxiang, Dulong, Ewenki, Gaoshan, Gelao, Hani, Hezhe, Hui, Jing,
Jingpo, Jinuo, Kazak, Kirgiz, Korean, Lahu, Li, Lisu, Luoba, Manchu, Maonan, Menba, Miao,
Mongolian, Mulao, Naxi, Nu, Oroqen, Ozbek, Pumi, Qiang, Russian, Salar, She, Shui, Tajik, Tatar,
Tibetan, Tu, Tujia, Uigur, Wa, Xibe, Yao, Yi, Yugur, Zhuang
treatment is pearl or pearl powder. In Ben Cao Gang or Materia Medica, an ancient
Chinese medical text, pearl was documented for its skin healing attributes, such as
stimulation of skin growth, protection of skin from sun damage and elimina-
tion of age spots. China’s sole female emperor, or empress, Wu Ze Tian (625–705),
was an avid user of pearl powder for the maintenance of her beauty. She regulary
applied pearl powder to her skin and consumed it as medicine. Another female
leader, Empress Dowager Cixi (1636–1912), the first woman in power during the
Qing Dynasty, also appreciated the benefits of pearl powder. Moreover, she had
used it in conjunction with other methods for a brighter and more youthful complex-
ion. The Empress Dowager had her face cleaned with egg white, used human breast
milk for bathing, drank human milk obtained from “young, beautiful, and healthy”
women every few days, and sprayed celery juice on her skin. The benefits of pearl
powder are recently being recalled and their is renewed interest in using pearl in
modern skincare and cosmetic products.
24 S. Samizadeh
Nowadays, beauty ideals and desired facial features can be examined by looking
at various social media channels, live streaming applications, and photos published
by multiple individuals. These are readily available online with various public dis-
cussions on topics of beauty and ideal facial features. Also, many plastic surgery
and beauty institutes display before and after photos that presumably are according
to beauty standards of the time and these are used as part of adverts to help attract
more customers/patients. The role of facial physiognomy should also be understood
when looking into standards of beauty in Asia [3]. This is covered in another chapter.
Technology that allows users to change their appearance and retouch their photos
have become increasingly popular in Asia. For example, the popular and widely-
used photo-taking applications include, MeituPic in China, Line Camera in Japan
and Snow in South Korea. These technologies incorporate features and filters that
allow users to modify their pictures according to their preferences. All of these
applications allow users to improve skin complexion, remove lines and wrinkles,
enlarge eyes, contour the face (reduce the width of the face, alter and augment the
nose), reduce width of the chin and make it more pointed, to achieve V-shape facial
appearance, reduce/change lip size and shape, and add virtual makeup to the photos.
It is notable that many of these applications neotenize the faces, making them
look more babylike, feminine, and gentle. In the last chapter, we discussed
the role facial neoteny plays in attractiveness and, hence, mate selection.
Language and literature can also be used to help understand the ideals of beauty
in various periods. To this day, words such as “aegyo” (South Korea), “ke ai”
(China) and “kawaii” (Japan) are used to complement female attractiveness and
beauty. All these words embed ideas of a gentle, soft, and “cute” manner.
In Asia, a fair complexion is found to be desirable. Although historically, this
was due to fair skin being linked with status, the preference is still valid today. In
the past, wealthier individuals did not need to work outdoors or in the fields and,
hence, had a fairer complexion void of blemishes. This desire and link to status were
emphasised during Western colonisation. This desire has led to significant business
for skin-whitening topicals, injectables, and consumables. It is not unusual to see
Asian women, and more recently men, holding UV-protecting umbrellas or wearing
UV-protecting hats or face and body suits (“facekini/脸基尼;”). The following say-
ing from the Ming Dynasty is still used today:
“一白遮三丑 yībáizhēsānchǒu a white complexion is powerful enough to hide
three faults/ugliness.”
The pursuit for a fair complexion and “porcelain/glass skin” is not an attempt
at Westernisation as it dates to ancient times; however, it is possibly a subconscious
quest due to the historical correlation with status and wealth.
Another important feature in Asian beauty standards are the eyes. It is no doubt
that the eyes are one of the key defining features of the face. In ancient paintings in
the region, women were drawn with single-folded eyelids and almond-shaped
eyes. In ancient China, “bright eyes-明眸” were considered attractive. However,
“bright eyes” does not have the same meaning as “enlarged or large eyes”. Although,
more recently, large eyes (大眼睛 dà yǎnjīng) with double-fold eyelid (双眼皮
shuāng yǎnpí) are sought as they are found to be attractive. Plastic surgeon,
Dr Mikamo (Japan’s father of cosmetic surgery-late 19th century) designed and car-
ried out the very first double eyelid procedure. He is the pioneer of this procedure
and employed a suture technique. This was performed on a patient who had never
travelled to the West. There was a 250-year period of isolation in Japan under
Tokugawa sovereign rule. During this time any exchange of people or ideas between
Japan and the outside world was prohibited. Dr. Mikamo, in 1986, created the first
known “supratarsal crease” in the upper eyelid [4, 5]. The procedures to alter the
eyes (shape, size, and eyelids) are exceedingly prevalent in Asia [6]. Popularity of
aesthetic eye surgery is not limited to Asian blepheroplasty. Other procedures
include epicanthoplasty, canthoplasty and, more recently, enhancement of the pret-
arsal roll also known as “charming roll” or “lying silkworm-卧蚕” in Chinese are
also popular. Blepharoplasty, the “double eyelid surgery” is often given as a gift to
many young adults as their reward for entering university, graduating high school or
university, preparing for marriage or are carried out in the hopes of helping an indi-
vidual find a good job. This recalls the question of the influence of the Western
media, or simply the desire to bypass genetics or merely a survival advantage in the
world’s most populous country with nearly 1.4 billion residents. Especially in a
culture where “The face is the rice bowl” (脸蛋就是饭碗) and “A pretty face is a
star’s bread and butter” (漂亮脸蛋是明星的铁饭碗).
The nose is another key component of the facial aesthetics. There are numerous
Oriental nose morphologies. Furthermore, the Oriental nose varies in both anatomy
and morphology from other races and ethnicities [7]. However, there is a common
set of characteristics including low projection of the nasal dorsum with possibly
some convexity, round nasal tip and infratip fullness with low projection, poorly
defined or absent supratip break, and wide nasal base, commonly referred to as
“short and flat nose” [8]. Preference for high and straight nasal dorsum with well-
defined and well-projected nasal tip has made rhinoplasty one of the most popular
cosmetic procedures in the region. In contracts to Caucasians, surgical and non-
surgical augmentation rhinoplasty are performed.
Blepharoplasty and rhinoplasty are the most popular cosmetic surgeries per-
formed in the region.
Facial Features
An oval facial shape has been reported to be a desired facial shape in many cul-
tures [9–11]. Facial shape is a key feature of an attractive face in Asia. An oval face
with the harmony of elements from the hairline to the chin is found to be most
beautiful and described as “feminine and gentle.” [10–13] In China, the terms used
for preferred facial shapes are melon seed (瓜子脸 guāzǐliǎn) or goose egg (鹅蛋脸
é’dànliǎn) face (Fig. 2.3). This is in line with the studies that have reported a prefer-
ence for an oval facial shape, but also a preference for an oval facial shape with a
round pointy chin [14]. In contrast, a square facial shape is considered masculine
and not desirable. As such surgical and non-surgical cosmetic treatments targeting
mid-and lower face width reduction are exceedingly popular, and more so with the
younger generation. This is dissimilar to the West, where prominent and well-
defined jawlines are found to be attractive in both genders.
26 S. Samizadeh
Fig. 2.3 Goose egg-Facial shape preferred in China. An oval shape
Fig. 2.4 The actress Fan Bingbing from China is known as the symbol of female beauty. She has
a combination of neotanised (baby-like) facial features (thin, gently arched eyebrows, large eyes
with a lower eyelid roll, oval facial shape and a round and narrow chin) and sexually dimorphic
features (e.g. plump prominent lips)
The actress Fan Bingbing from China is known as the symbol of female
beauty. She possesses neotanized facial features, a round facial shape, thin, gently
arched eyebrows, relatively large eyes with a lower eyelid roll known as, oval facial
shape with a round and a narrow chin and sexually dimorphic features including
plump prominent lips. In comparison, Angelina Jolie, who has been praised as the
ideal of female beauty in the West, has prominent cheeks and jawline, submalar hol-
lowing and very plump lips (Fig. 2.4).
Fig. 2.5 Attractive composite faces of different races created by Rhee et al. [15]. Composite faces
were created by computerised morphing of the pictures of attractive famous female enter-
tainers [15]
Ree and Lee from Korea examined attractive composite faces of different races.
He used computerised morphing systems to generate composite faces, and faces of
20 actresses were used for creating the Chinese composite face. He reported the
attractive Chinese face was a slim and thin face with relatively narrow cheek (nar-
row bizygomatic width), slim and thin face (narrow bigonial width), and “lantern
jaw” (long, thin jaw and prominent chin). The Japanese composite face, in turn, had
a “relatively long face and slanted eyes,” “sharp chin,” and “ chubby cheeks”
(Fig. 2.5) [15].
In 2012, Meng Zhang published a qualitative research on examining Chinese
young women’s attitudes and behaviours towards beauty. Four main distinctive
themes were reported [16]:
The participants were young Chinese women
1. The participants believed beautiful Chinese woman should have:
a. A tall and thin body.
b. Big eyes.
c. A watermelon seed-shaped face.
d. Fair skin.
e. Qi Zhi (inner beauty).
2. Body image issues play a central and key role in their everyday experiences.
a. They felt under substantial cultural, societal, familial, and peer pressure to
pursue physical beauty.
3. The influence of culture and media on their perceptions of beauty was described
as complex and multi-layered.
4. They hope for potential positive social change and the liberation of
Chinese women.
a. Also, concern about the superficiality and extreme beauty standards advo-
cated in the media was raised.
28 S. Samizadeh
The author’s current studies regarding ideals of beauty among laypersons and
aesthetic practitioners in China are summarised as follows (Fig. 2.6) [12, 14]:
• Facial shape: Oval, heart/inverted triangle (Fig. 2.7)
• Jawline: Obtuse jawline for both men and women, aesthetic practitioners pre-
ferred a more angular jaw angle for men
• Nose: High bridge, 90-degree tip
• Chin: Round and pointy chin for both women and men, less pointy for men
• Lips: Full medially and taper off laterally with well-defined borders and
Cupid’s bow
Item Layperson [8] Aesthetic Practitioners

Facial Shape
Facial profile
Lip shape 2
4
Female jaw angle
2 2
Male jaw angle
Nose shape
7 7
Chin (female)
6 2
Chin (male)
6 6
Fig. 2.6 Differences between preferences for various facial features between laypersons and aes-
thetic practitioners. Sketches are as presented in the questionnaire. Photographs correlating to each
sketch have been added for reference
Fig. 2.7 Asian beauty

according to the ideals of
beauty by laypersons and
aesthetic practitioners
a b c d
e f g h
Fig. 2.8 Computer-generated face shapes by Zhao et al. [17]. (a) Round face. (b) Oval face. (c) Square
face. (d) Rectangular face. (e) Diamond face. (f) Triangular face. (g) Inverted triangle face. (h)
Trapezoidal face. Faces b (oval) and g (inverted triangle) were found to be most attractive, with face h
(Trapezoidal) least beautiful. This study reported that the following features were rated more attractive
in attractive Han women; larger temporal width and pogonion–gonion distance, shorter bizygomatic
and bigonial widths, increase the ratio of the temporal width to the bizygomatic width, increased ratio
of the distance between the pogonion and gonion to the bizygomatic width, and a more projecting
pogonion in profile view conforming to a more beautiful chin [17]. Used with permission
Zhao et al. examined the attractiveness of female Hans Chinese faces and con-
cluded the neoclassical ideal of attractiveness does not apply (Fig. 2.8) [17]. They
reported the preferences of Chinese Han women were as follows [17]:
• Oval and inverted triangular facial shape
• Small bizygomatic width
30 S. Samizadeh
• Small bigonial width

• Increased temporal width
• Small facial heights
• Small rations for:
–– Upper-face height and lower face height to the total face height
• Mildly increased ratio for:
–– Middle-face height to total face height
Lee et al. examined the faces of 800 normal young Korean females (19–26 years
old) and 21 beauty contestants in Korea (20–27 years old). They reported that attrac-
tive faces in comparison to normal faces had longer midface, narrower bigonial
width, and shorter lower face, particularly from stomion to menton. Also, Korean
female faces reported having shorter and narrower lower faces than neoclassical
canons [18].
Given the typical morphological appearance of Asian faces and the desired facial
morphology, surgical, and non-surgical facial changes are widespread in Asia.
Popular treatments include width reduction of the mala, zygoma, and mandibular
regions, temple enhancement, masseter reduction (surgical or botulinum toxin
injections) and similar procedures to achieve and maintain an oval or inverted tri-
angle facial shape, similar to famous and popular actresses, Fan Bingbing and
actress Zhang Ziyi [12, 14, 17]. Blepharoplasty, rhinoplasty, angleplasty (mandibu-
lar angle reduction), and malarplasty (zygoma reduction) are some of the most com-
mon facial cosmetic surgeries requested [19–21]. Also, chin augmentation (surgical
or non-surgical) aids in enhancing the total face length (fig) [17, 20]. The sexual
dimorphic features are markedly distinct in the lower face, the jaw and chin [22].
The trends for facial beauty and attractiveness may vary over time. For the past
few years, a very tapered lower face and pointy chin were found to be attractive in
Asia and China. However, this trend is moving towards a more natural-looking
facial shape and a less pointy chin. Beauty trends can be influenced by media and
famous characters at a time period. Ideals of beauty evolve due to the influence of
media, fashion, and popular culture and as communities become more diverse.
Furthermore, geographic, ethnic, and demographic dynamics (age, gender, educat-
ing background) and media exposure to ideal faces dynamics and influence the per-
ception of beauty [23–26].
The topic of Asian plastic surgery and the desire for Westernised facial charac-
ters to look more Caucasian is much debated. There was a time when beauty was
defined as the ideals of beauty of Caucasians [27]. In 2018, Jung examined cultural
standards of the ideal female beauty as perceived by young women in China and
reported that many Western standards for the female beauty ideal were endorsed by
the participants [28]. This study had 23 university students only, and generalisation
for Chinese women cannot be made. Although this may have been true in the past, it
is noteworthy that Asian oriental aesthetic values are not like the ideals of beauty in
the West, with Western women having preferences for high cheekbones, the hollow-
ness of prezygomatic area, and an angular jaw angle. There is a wealth of evidence
available supporting the idea that Asians “embrace their ethnic features,” seek
harmonisation, enhancement of their facial features, self-improvement, and preser-

vation of cultural traits rather than westernisation [1, 11, 20, 27, 29–34].
With globalisation and the availability of surgical and non-surgical procedures,
change of physical features is no longer perceived as disrespect to the individual’s
ancestors [32]. Korea is the Mecca of plastic surgery in Asia, and one in five women
is reported to have undergone plastic surgery, with reports that 90% of Korean females
would have plastic surgery and by the age of 50, 58% would have plastic surgery,
with growing numbers in male counterparts [27, 35]. With increased influence of
both Western and Eastern media, and increased wealth in the region, many undergo
procedures to improve their appearance in hopes of improving their quality of life
(job and marriage chance), but also to reciprocate the glamorous appearance and
lifestyle of celebrities [12, 14, 36]. China’s medical aesthetic industry is one of the
largest in the world and fast-growing with increased emphasis on good looks for
socio-economic growth, job, and marriage prospects. Chinese people also chose to
go to neighbouring countries and other countries for such treatments. In addition,
the immigration of Chinese people results in more Chinese patients attending cos-
metic clinics and hospitals outside China. Key concepts when treating other ethnici-
ties, Asians and in particular Chinese patients include different skull and facial
structures of the Asians from Caucasians, different ageing patterns and characteris-
tics, higher demand among the younger generation, the influence of local and dis-
tance media on their expectations, and the belief in facial physiognomy.
References
1. Luo W. Selling cosmetic surgery and beauty ideals: the female body in the web sites of Chinese
hospitals. Women’s Stud Commun. 2012;35(1):68–95.
2. Samizadeh S. Chinese facial physiognomy and modern day aesthetic practice. J Cosmet
Dermatol. 2019;19:161–6.
Dermatol. 2020;19(1):161–6.
4. Mathews G, White B, editors. Japan’s changing generations: are young people creating a new
society? London: Routledge; 2012.
5. Fakhro A, Yim HW, Kim YK, Nguyen AH. The evolution of looks and expectations of Asian
eyelid and eye appearance. Semin Plast Surg. 2015;29(03):135–44. Thieme Medical Publishers
6. Li FC, Ma LH. Double eyelid blepharoplasty incorporating epicanthoplasty using Y-V
advancement procedure. JPRAS. 2008;61(8):901–5.
7. Aung SC, Foo CL, Lee ST. Three dimensional laser scan assessment of the Oriental nose with
a new classification of Oriental nasal types. Br J Plast Surg. 2000;53(2):109–16. https://doi.
org/10.1054/bjps.1999.3229. PMID: 10878832
8. Bergeron L, Chen PK. Asian rhinoplasty techniques. Semin Plast Surg. 2009;23(1):16–21.
https://doi.org/10.1055/s-0028-1110097.
9. Goodman GJ. The oval female facial shape—a study in beauty. Dermatol Surg.
2015;41(12):1375–83.
11. Wu WT, Liew S, Chan HH, Ho WW, Supapannachart N, Lee H-K, et al. Consensus on current
injectable treatment strategies in the Asian face. Aesthet Plast Surg. 2016;40(2):202–14.
32 S. Samizadeh
12. Samizadeh S, Wu W. Ideals of facial beauty amongst the Chinese population: results from a
large national survey. Aesthet Plast Surg. 2018;2018:1–11.
13. Ahn J, Horn C, Blitzer A. Botulinum toxin for masseter reduction in Asian patients. Arch
Facial Plast Surg. 2004;6(3):188–91.
14. Samizadeh S. The ideals of facial beauty among Chinese aesthetic practitioners: results from a
large National survey. Aesthet Plast Surg. 2018;2018:1–13.
15. Rhee SC, Lee SH. Attractive composite faces of different races. Aesthet Plast Surg.
2010;34(6):800–1.
16. Zhang M. A Chinese beauty story: how college women in China negotiate beauty, body image,
and mass media. Chin J Commun. 2012;5(4):437–54.
17. Zhao Q, Zhou R, Zhang X, Sun H, Lu X, Xia D, et al. Morphological quantitative criteria and
aesthetic evaluation of eight female Han face types. Aesthet Plast Surg. 2013;37(2):445–53.
18. Lee JS, Kim HK, Kim YW. Anthropometric analysis of the attractive and normal faces in
Korean female. J Korean Soc Plast Reconstr Surg. 2004;31(4):526.
19. Macer D. Ethical consequences of the positive views of enhancement in Asia. Health Care
Anal. 2012;20(4):385–97.
20. Wong JK. Aesthetic surgery in Asians. Curr Opin Otolaryngol Head Neck Surg.
2009;17(4):279–86.
21. Kim Y-H, Cho B-C, Lo L-J. Facial contouring surgery for Asians. Semin Plast Surg.
2009;23(01):022–31.
22. Valenzano DR, Mennucci A, Tartarelli G, Cellerino A. Shape analysis of female facial attrac-
tiveness. Vis Res. 2006;46(8):1282–91.
23. Broer PN, Juran S, Liu Y-J, Weichman K, Tanna N, Walker ME, et al. The impact of geo-
graphic, ethnic, and demographic dynamics on the perception of beauty. J Craniofac Surg.
2014;25(2):e157–e61.
24. Chen C, Chen Y, Li Q, Kau CH. The esthetic difference of Chinese beauty evaluated by two
different human races based on three-dimensional average face analysis. J Craniofac Surg.
2019;30(5):1435–40.
25. Nomura M, Motegi E, Hatch JP, Gakunga PT, Rugh JD, Yamaguchi H. Esthetic preferences of
European American, Hispanic American, Japanese, and African judges for soft-tissue profiles.
Am J Orthod Dentofac Orthop. 2009;135(4):S87–95.
26. Hönn M, Dietz K, Eiselt M-L, Göz G. Attractiveness of facial profiles as rated by individuals
with different levels of education. J Orofac Orthop. 2008;69(1):20–30.
27. Jin HR. Aesthetic plastic surgery of the east Asian face, Chapter; 2016.
28. Jung J. Young Women’s perceptions of traditional and contemporary female beauty ideals in
China. Fam Consum Sci Res J. 2018;47(1):56–72.
29. Lam SM. Mikamo’s double-eyelid blepharoplasty and the westernization of Japan. Arch Facial
Plast Surg. 2002;4(3):201–2.
30. Ouellette A. Eyes wide open: surgery to westernize the eyes of an Asian child. Hast Cent Rep.
2009;39(1):15–8.
31. Dobke M, Chung C, Takabe K. Facial aesthetic preferences among Asian women: are all ori-
ental Asians the same? Aesthet Plast Surg. 2006;30(3):342–7.
32. Holliday R, Elfving-Hwang J. Gender, globalization and aesthetic surgery in South Korea.
Body Soc. 2012;18(2):58–81.
33. Kim T. Neo-Confucian body techniques: women’s bodies in Korea’s consumer society. Body
Soc. 2003;9(2):97–113.
34. Lindridge AM, Wang C. Saving “face” in China: modernization, parental pressure, and plastic
surgery. J Consum Behav Int Res Rev. 2008;7(6):496–508.
35. Holliday R, Cairnie A. Man made plastic: investigating men’s consumption of aesthetic sur-
gery. J Consum Cult. 2007;7(1):57–78.
36. Pu LL, Chen Y-R, Li Q-F, Wu W, Park D-H, Takayanagi S, et al. Aesthetic plastic surgery in
Asians: principles and techniques. Boca Raton, FL: CRC Press; 2015.
Chapter 3
Facial Physiognomy
Souphiyeh Samizadeh
“Your face, my thane, is as a book where Men may read strange matters.”—Macbeth,
William Shakespeare
Physiognomy: (merriam-webster.com):
1. “The art of discovering temperament and character from outward appearance.
2. The facial features held to show qualities of mind or character by their configu-
ration or expression.
3. External aspect; also: inner character or quality revealed outwardly.”
Physiognomy, or face reading, is the practice of assessing an individual’s character-
istics and fate according to their facial features. It is an ancient practice dating back
to the ancient Greeks, India (dating back to Vedic literature), ancient Egypt, and
China (approximately 3000 years old, based on Ying-Yang, Five Elements and Pa
Kua, Chinese medicine and religious ideologies including Taoism and Buddhism)
[1–5]. It has been reported that physiognomy played an important role in many
Chinese societies, including cultural development [6]. In the modern day, physiog-
nomy is still practiced in China, Korea (Gwansang (관상)), Japan, India, and some
Middle Eastern and African countries (e.g. Al Ferasa practiced by the
Bedouins). (Figs. 3.1 and 3.2) [7]. Japanese woodblock print books on physiog-
nomy dating back as far as 1684 are available.
S. Samizadeh (*)

https://doi.org/10.1007/978-3-030-84099-0_3
34 S. Samizadeh
87 88 89 90
1. Life House 7. Travelling House
86
15
91
85 92
18 23
2. Wealth House 8. Assistant House
24
21 18 17 20
19
9 84 93
3. Sibling House 7 11
12 12
11 7
9. Career House 30
22
29
3 3 8 34 32 25 31 33 1
1 83 9 27
43 28 42 26 94
4. Marriage House 10 10 10. Property House 10
2
4 4 40 30 40 35 33 3
6
5. Children House 5 5 11. Fortune House 82 11 41
44
45
46 4 95
12 5
2
6. Health House 12. Parents House 81 13 59
50 48 49
58 6
57 56
14 7 96
53 51 52
80 55 54 97
69 68
67 66
8 8 79 75 65 60 64 74
98
63 61 62
73 70 72
78 99
71
77 76
Fig. 3.1 Chinese facial physiognomy. (a) The face is divided into 12 houses/sections/parts knowns
as the 12 basic parts (life, wealth, siblings, marriage, children, travelling, assistant, career, prop-
erty, fortune, emotion, and parents) in face reading. The position, form/outline, texture, and rela-
tionship to other parts of each section can be interpreted and be indicative of one’s fortune and fate.
For example a life house (glabella) with no moles, lines, and wrinkles is indicative of success and
wealth. (b) Every facial section can be indicative of one’s luck at a certain age. (c) Nevi position,
shape, size, and colour on the face has different meanings for men and women
Fig. 3.2 Korean facial

physiognomy (known as
“gwansang-관상,” in
Korean) is the prediction
of fortunes using facial Social status, Reputation
features, personality, past,
The key place, Overall fate
present and future.
Different aspects of the Interpersonal relationships
face (the 12 gung) cover Married life, Love
different areas of the
personality and life. The Money fortune
harmony of features is Authority, Energy
important for “good Latter years
fortune”. The
nose is associated with
one’s luck with
money. Stubbornness and
selfishness are
characteristics linked with
a “short nose” in
Korea [8]
3 Facial Physiognomy 35
Face readers, some who enjoy increasing fame and fortune, offer to reveal the
personality, fate, and fortune of an individual, their past and future, relationships,
successes and failures, and help with life and business decisions based on one’s
facial characteristics. Vedic face reading is based on Vedic literature; Chinese face
reading is based on a combination of philosophies and practices, including Ying-
Yang, Five Elements, Pa Kua, Chinese medicine, and religious ideologies (Taoism
and Buddhism). Physiognomy also has a long history in Western culture and was
once used in the field of criminology.
The credibility of face reading has varied from time to time and in various parts
of the world. It was popular among the ancient Greek philosophers. However, it fell
into disrepute in the Middle Ages when practised by vagabonds (nomad, gypsies,
beggars) and ‘mountebanks’ (charlatans) [9]. While there is a lack of scientific evi-
dence to support facial physiognomy, from a different perspective there are studies
that suggest facial appearances may relate to a person’s personality [9]. It will not
be a surprise to readers to know that we make a judgement about the characteristics
of a person (e.g. trustworthy, aggressive, competent, caring, and so on) within a
tenth of a second of seeing their face or picture [10].
Scottish mathematician, philosopher, and scholar Michael Scot wrote Liber
(The Book of Physiognomy) in the early thirteenth century for Frederick II, the
Holy Roman Emperor, and this text was taught in English Universities. The book
became very popular, and the author refers to physiognomy as a “doctrine of salva-
tion,” as it was believed to distinguish if a person is virtuous or evil. Sir Thomas
Browne (1605–1682), an English polymath and author, discussed judgement of
inner qualities from the outer appearance of the face in Religio Medici (1643). In
addition, in Christian Morals (circa 1675), he further discussed physiognomy and
mentioned, “Brow speaks often true, since Eyes and Noses have Tongues” and
“Provincial Faces, National Lips and Noses.” Physiognomy was also used in the
field of criminology. During the mid-nineteenth century, Lombroso claimed that
criminals could be identified by physical defects, for example murderers had big
hawk-like noses, and rapists had “jug ears”, and that criminality was inherited
[11, 12].
Vaught’s Practical Character Reader 1902 and revised in 1907 by Emily
H. Vaught is an example of the application of physiognomy, “a person’s character
or personality from their outer appearance.” The book describes elements of human
nature (e.g. acquisitiveness, benevolence, and weight) and further describes how
these manifests in people’s facial features (e.g. head, nose, ears, and chin). In this
book, facial characteristics for being a good wife and mother are detailed.
Characteristics are described as “cruel eyes,” “selfish ears,” and “gross, sensual
chins,” and illustrations are provided. This book goes as far as having a chapter
entitled “How to Pick Out a Good Child.” This book aimed to teach the public how
to apply the principles of phrenology (form of physiognomy-linking personality
traits with scalp morphology) in judging people’s character and worth.
Phrenology is also considered a form of physiognomy, and has been described as
a pseudoscientific field, in which the shape of a person’s skull was thought to
36 S. Samizadeh
determine their mental faculties, intellect, personality, and character (Fig. 3.3).
Phrenology was developed and practiced by Dr. Franz-Joseph Gall (1758–1828), a
Viennese doctor. The practice became very popular in the nineteenth century.
However, the practice was later discredited by scientific research [13]. The ratio of
head width to head depth was supposed to be indicative of intelligence and a nar-
rower head was taken to signify a larger frontal lobe. This interpretation was respon-
sible for providing a “scientific” and “biological” truth to racism, sexism, and other
forms of discrimination.
In the modern day, the subject of how individuals are perceived based upon their
appearance, facial characteristics and visual cues is being researched extensively
throughout the world. Oommen and Oommen used pictures of leading scientists
from the Medical Photography Department of the Wellcome Library in the UK
and reviewed their facial features along with their biography. They reported discrep-
ancies between the physiognomy-based expected behaviours and the biography of
the scientists [14]. Studies are also emerging regarding the correlation between
facial appearance and trait inferences. People evaluate faces, form impressions of
Fig. 3.3 Phrenology

was developed in 1796 by
Dr. Franz-Joseph Gall—a
German physician. The
shape of an individual’s
skull was thought to
indicate their mental
faculties, intellect,
personality, and character
others, and make judgments about characteristics such as attractiveness, likeability,

trustworthiness, competence, and aggressiveness, in as little as 100 milliseconds
[10]. These judgements or facial evaluations are important as there is a plethora of
evidence that they can predict many significant social outcomes, ranging from elec-
toral success to sentencing decisions [15–19]. Dion et al. concluded that physically
attractive individuals are perceived as having more favourable qualities by others
including personality traits, overall happiness and career success [20].
Furthermore, Ballew and Todorov reported that the facial appearance of elec-
toral candidates affected voting decisions and predicted the outcomes of elections.
Their participants made rapid judgments of competence based on candidates’ facial
appearance [19]. This evidence suggests that people tend to evaluate and judge oth-
ers on their appearance within seconds of meeting them. It has been scientifically
shown that our facial appearance has a direct impact on various aspects of our lives
and all social interactions.
Writers and authors in literary fiction use facial types, forms and characteris-
tics to help build personalities and characteristics of their characters. This is also
done in traditional Chinese art, such as theatre artists (e.g. famous Peking Opera
facial makeup) who paint their faces to depict certain characteristics. To some
extent, facial appearance and characteristics are related by audiences to the sub-
ject’s personality. This is true in art, culture, and media. Since the silent film era,
filmmakers have used dermatologic disease on the face and scalp to indicate
immoral character. Filmmakers characterise villains with abnormalities such as
multiple facial scars, cosmetically significant alopecia, deep rhytids, periorbital
hyperpigmentation, nasal skin disease, facial verruca vulgaris, and abnormal skin
colour [21]. Character design is often used in the literature and media in order to
communicate aspects of a character’s personality through appearance, for example,
Disney villains and villainesses have certain facial characteristics that make them
look “evil.”
In China and Asia, facial physiognomy and facial features are important fac-
tors in one’s daily life, self-confidence, marriage, work, and future. Individuals’
mental or moral character, fortune, and future are often judged based on their facial
features [22]. Certain features of the face are believed to bring about luck or good
fortune and vice versa [23]. For example the mandibular angle is very important in
female facial shapes in Asia as “a woman who has a wide and square face is thought
to bring unhappiness to her husband” [24]. Furthermore, facial physiognomy is
still widely accepted and practiced in China, Japan, Korea and India [7]. An exam-
ple of this practice is mole removal. It has traditionally been accepted in the
region that mole size, shape, place, and colour on the face bear fortune-telling
powers [25]. Removal of facial moles is still very popular in the region. In
2019 many of the author’s Chinese staff in China had facial moles removed as their
meaning changed in the new Chinese year. Other examples include surgical and
non-surgical facial modifications (Fig. 3.4).
38 S. Samizadeh
Fig. 3.4 A retruded forehead and temples make the face look less three dimensional, less youthful,
unhealthy and disturb the oval shape of the face. Asians generally prefer slightly convex temples
and forehead with a smooth transition to the forehead, temporal hairline and the periorbital area.
In Chinese physiognomy, the forehead is said to signify a person’s luck in youth as well as
their parents and spouse luck, career prospects, analytic ability and so on. The temples are
also important predictors of marriage (relationships) in both males and females. Top images repro-
duced from the open access paper Samizadeh, S., Chinese facial physiognomy and modern-day
aesthetic practice. Journal of cosmetic dermatology, 2019
References
1. Hassin R, Trope Y. Facing faces: studies on the cognitive aspects of physiognomy. J Pers Soc
Psychol. 2000;78(5):837.
2. Dubey H. Mysteries of vedic face reading. Mumbai: Jaico Publishing House; 2013.
3. Haner J. The wisdom of your face. Reading: Hay House; 2008.
4. Bond MH. Beyond the Chinese face: insights from psychology. Oxford: Oxford University
Press; 1991.
5. Bridges L. Face reading in Chinese medicine. New York: Elsevier Health Sciences; 2012.
6. Gauld RD. A survey of the Hong Kong health sector: past, present and future. Soc Sci Med.
1998;47(7):927–39.
Dermatol. 2019;
8. Kim SH, et al. Analysis of the midface, focusing on the nose: an anthropometric study in
young Koreans. J Craniof Surg. 2010;21(6):1941–4.
9. Wiseman R, Highfield R, Jenkins R. How your looks betray your personality. New Scientist.
2009; 2695.
10. Willis J, Todorov A. First impressions: making up your mind after a 100-Ms exposure to a face.
Psychol Sci. 2006;17(7):592–8.
11. Lombroso C. Criminal man. Durham: Duke University Press; 2006.
12. Gibson, M. Born to crime: Cesare Lombroso and the origins of biological criminology.
2002; JSTOR.
13. The Editors of Encyclopaedia Britannica. Phrenology. Pseudoscientific practice.
14. Oommen A, Oommen T. Physiognomy: a critical review. J Anat Soc India. 2003;52(2):189–91.
15. Todorov A, Mandisodza AN, Goren A. Hall CC. Inferences of competence from faces predict
election outcomes. Science. 2005:308(5728):1623–26.
16. Little AC, Burriss RP, Jones BC, Roberts SC. Facial appearance affects voting decisions.
Evolution and Human Behavior. 2007;28(1):18–27.
17. Blair IV, Judd CM, Chapleau KM. The influence of Afrocentric facial features in criminal
sentencing. Psychological science. 2004;15(10):674–79.
18. Eberhardt JI. Davies PG, Purdie-Vaughns VJ, Johnson SL. Looking deathworthy: Perceived
stereotypicality out Black defendants predicts capital-sentencing outcomes (Cornell Law
School Research Paper No, 06–012). 2006.
19. Ballew CC, Todorov A. Predicting political elections from rapid and unreflective face judg-
ments. Proc Natl Acad Sci. 2007;104(46):17948–53.
20. Dion K, Berscheid E, Walster E. What is beautiful is good. J Pers Soc Psychol. 1972;24(3):285.
21. Croley J, et al. Dermatologic features of classic movie villains: the face of evil. JAMA
Dermatol. 2017;153(6):559–64.
22. McGrath C, Liu K, Lam C. Physiognomy and teeth: an ethnographic study among young and
middle-aged Hong Kong adults. Br Dent J. 2002;192(9):522–5.
23. Kim N-H, et al. The use of botulinum toxin type A in aesthetic mandibular contouring. Plast
Reconstr Surg. 2005;115(3):919–30.
24. Kim SK, Han JJ, Kim JT. Classification and treatment of prominent mandibular angle. Aesthet
Plast Surg. 2001;25(5):382–7.
25. Tempark T, Shwayder T. Chinese fortune-telling based on face and body mole positions: a
hidden agenda regarding mole removal. Arch Dermatol. 2012;148(6):772–3.
Chapter 4
Characteristics of Asian Faces
Souphiyeh Samizadeh
Facial morphology depends on many factors including genetics, gender, race, eth-
nicity, climate, nutrition, and socio-economic status. Facial characteristics and fea-
tures vary across Asia and this population is ever increasing and changing, with
expanded globalisation, immigration, and interracial marriages. Considerable
increased variation in human facial morphology is also influenced by gene
polymorphisms.
Asia is a vast geographical region, with a population characterised by abundant
and varied facial features, cultures, and languages. Consequently, Asians cannot be
grouped into one category based on facial or cultural characteristics by any means.
This chapter will focus on East Asians (China, Japan, and Korea). This group has
Mongol features and accounts for approximately 25% of the world population.
Various people indigenous to East Asia, Central Asia, Southeast Asia, North Asia,
Polynesia, and the Americas have Mongoloid ancestry. Facial dimensions between
ethnic groups are diverse, especially between Caucasians and Asians. Differences
include face width and length, lip and nose shape, and nasal root breadth [1]. Certain
phenotypic traits are also common among people with Mongoloid ancestry includ-
ing straight black hair, epicanthic folds, dark brown eyes and relatively flatter faces
in comparison to Caucasians (Fig. 4.1).
Although Asian populations have many similarities in facial morphology, great
diversity also exists within each region of Asia due to large ethnic variations. In
China alone, there are fifty-six ethnic groups, all with distinct facial features
S. Samizadeh (*)

https://doi.org/10.1007/978-3-030-84099-0_4
42 S. Samizadeh
Fig. 4.1 Certain phenotypic traits are common among people with Mongoloid ancestry including
straight, black hair, epicanthic folds, dark brown eyes and relatively flatter faces in comparison to
those of Caucasians
(Fig. 4.2). For example, the Uyghur population (the largest ethnic minority in north-
west China) present very different facial features from Han Chinese (the largest
ethnic group in China). The Uyghur ancestry goes back to a mix of Mongolian and
Caucasian due to their geographical location and the silk road. International travel-
lers, traders, and merchants passed through the silk road, and some settled there.
The Uyghur facial morphology is, therefore, a combination of Asian and
Caucasian [2].
The facial morphology of Caucasians is well studied and published. However,
there are limited English-language studies available describing Asian facial mor-
phology. Interestingly, the majority of English-language publications related to
facial morphology come from the fields of computer sciences, automatic face rec-
ognition, and artificial intelligence (AI), with fewer studies from medicine and
healthcare [3]. An example is the development of 3D morphable face models repre-
senting the complex shape, appearance, and structure of faces. These models are
used in various fields including facial recognition, facial expression synthesis, facial
animation, and in the perceptual and cognitive sciences. In the development of AI
based systems, ethnic representation and classification are becoming increasingly
studied, as ethnic facial traits have an impact on the performance of computational
algorithms. An example of these studies is “Do they all look the same? Deciphering
Chinese, Japanese and Koreans by fine-grained deep learning” which was carried
out by a group of computer scientists. Distinctive characteristics and attributes were
reported among Chinese, Japanese, and Koreans and the trained neural networks
developed achieved an accuracy of 75.0% in a classification task versus human
accuracy of 49.0% (Fig. 4.3) [4].
It is noteworthy that orthodontists and orthodontics journals also have greatly
contributed to our understanding of facial morphology in various races and
4 Characteristics of Asian Faces 43
Fig. 4.2 The faces of women and men from various ethnic groups in China can be seen on Chinese
banknotes
44 S. Samizadeh
Fig. 4.3 Chinese, Japanese, and Koreans are difficult to distinguish when randomly combined.
When grouped together, several patterns seem to emerge. Top role: Chinese, middle: Japanese,
bottom: Korean [4]
ethnicities through a myriad of publications on facial appearance, hard and soft tis-
sue measurements, and cephalometric studies.
The common characteristic differences between Asians and Caucasians faces
have also been noted in the medical literature. These generalised differences include
a wider and shorter face which appears flat or concave in profile, lacking anterior
projection in Asians. In comparison to Caucasians, Asian facial features are charac-
terised by differences in the periorbital region (increased intercanthal width, pres-
ence of epicanthal folds, reduced eye fissure length, hooding of the upper eyelid/
lateral brow), nose (flat nasal dorsum with a wide base, and less nose tip projection),
medial maxillary retrusion, perioral region (reduced oral width, fuller lips with
more prominent upper lip, bimaxillary dentoalveolar protrusion), and lower face
(increased mandibular width, square lower face, and chin retrusion) [5–9]. Recent
studies have also established that classical and neoclassical canons and standards of
beauty do not apply to Asians [10, 11].
In general, East Asians have brachycephalic head shapes where the head width is
relatively larger than its length [12]. The Han Chinese have the highest cephalic
index values (maximum head width/maximum head length × 100) and smallest
head circumference in both sexes [13]. This results in a broad and short face.
Examination of the faces of young adult Chinese, Vietnamese, and Thai has shown
that the dominant characteristics of the Asian face include [5, 8, 14]:
• Wide intercanthal distance
• Relatively shorter palpebral fissure
• Wide soft nose
• Wide facial contours
• Small mouth width
• Lower face smaller than the forehead height.
a b Asian features Clinical Features

compared to Caucasian
Increased width: Result in wider:

• Bitemporal • Forehead
• Bizygomatic • Midface
• Bigonal • Lower face
Retrusion of the following:
• Forehead Flat forehead
Heavy eyelids
• Orbital rim
Concave central midface,
• Medial maxilla perialar recession and nasolabial
• Pyriform margin fold, perioral retrusion,
shadowing on the base of nose,
c d wide nasal width
Low nasal bridge Nose: flat, short, retruded

deficient anterior nasal columella, broad nasal width
spine
Bimaxillart protrusion The upper and lower jaws are

projected forward
Hypoplastic mandible Retruded chin
Fig. 4.4 “Comparison of Asian (a, c) and Caucasian (b, d) skulls. (a, b) Anterior view. The Asian
skull (a) is wider overall, with greater bitemporal, bizygomatic, and bigonial width of the temple,
zygoma, and mandible, respectively, compared with those of the Caucasian skull (b). (c, d) Lateral
view. The Asian skull (c) has less anterior projection, with a more retruded frontal bone and supra-
orbital ridge, recessed nasion, infraorbital rim, medial maxilla, maxillary process of the zygoma,
anterior nasal spine, and pogonion of the mandible compared with the Caucasian skull (d).
(Illustrations courtesy of Prof Kim)” Image and table adopted from Consensus on Changing
Trends, Attitudes, and Concepts of Asian Beauty by Liew et al. [5]
A comparison of Asian and Caucasian skulls in anterior and lateral view (origi-
nally published by Liew et al) can be seen in Fig. 4.4. In summary, in comparison to
Caucasians, the Asian skull is wider overall (with increased bitemporal, bizygo-
matic, and bigonal width), and less anterior projection of the face (retrusion of the
following: “frontal bone and supraorbital ridge, nasion, infraorbital rim, medial
maxilla, maxillary process of the zygoma, anterior nasal spine, and pogonion of the
mandible”) [5].
China
The Han Chinese population is the most prevalent ethnicity in China and the largest
ethnic group in the world (Fig. 4.5). Several studies have examined the regional
distribution of physical characteristics of Chinese people, dividing Chinese into
three main subgroups of North, South, and central according to geographical
regions, with the Southern Han being the main portion of Han nationality [15–20].
46 S. Samizadeh
Fig. 4.5 The Han Chinese population is the most prevalent ethnicity in China
Differences in the head and facial characteristics of Northern and Southern Han
nationalities have been reported.
Yan and colleagues studied full-face photos of people of Han nationality from
South China including 1176 healthy persons (425 adult males ≥18 years, 421 adult
females and 157 boys and 173 girls under age of 18 years). They reported that Han
Chinese have great variability in facial anthropometric proportions in comparison
with Japanese, Indian, North American, and Persian populations. Significant facial
differences were also noted between genders [21]. In general, the Han Chinese pop-
ulation has wider bizygomatic and bigonal widths in comparison to other Asian
ethnic groups including Singaporean Chinese, Indians, Vietnamese, and Thai
(Fig. 4.6) [8, 22]. There are also significant differences between the craniofacial
morphology of Chinese and Caucasians in addition to gender differences in both
[7]. The cranial base of the Chinese is shorter than the average Caucasian anterior
cranial base and Chinese populations have a greater dental proclination than
Caucasian norms (bimaxillary protrusion) [23].
Qi Xue-feng and colleagues from the Department of Forensic Medicine, College
of Basic Medicine, Chongqing Medical University, examined facial features in six
ethnic minorities from Southwest China (Tujia, Tibetan, Buyi, Dong, Yao, and
Hani). They reported similar facial features among these minorities, with a distinc-
tive national identity [24]. Interestingly, a large number of studies in the field of
facial recognition have focussed on examining the facial characteristics of different
ethnicities within China. For example, Zhi Jie Li and colleagues developed and used
a national face database to examine the facial features of the six main Chinese
nationalities (Han, Korean, Mongolian, Tibetan, Uygur, and Zhuang). They reported
Mongolian, Korean, and Han nationalities have similar facial features, whereas
Tibetans and Uyghurs have larger differences [25]. Much research has been carried
out in the field of AI and facial recognition in China to develop methods of distin-
guishing various ethnic groups, with some facing criticism.
Fig. 4.6 Bizygomatic and

baronial widths
Bizygomatic
Bigonial
Zy Zy
G G
O O
For ease of understanding of the terms used below, please refer to the figures
provided explaining the orthodontic terminology.
In comparison with Caucasians, Chinese women have a smaller midface with
retrusive position of point A relative to nasion perpendicular, significantly retrusive
chin, longer lower anterior face height, steeper mandibular plane, anteriorly posi-
tioned lower incisors to the APo line, significantly more protrusive upper and lower
lips to the E-line, shorter cranial base and a larger ANB (the relative anterioposterior
position of the maxilla to the mandible, used to determine skeletal class), bimaxillary-
alveolar protrusion with a decreased interincisal angle, and more acute nasolabial
angle (Figs. 4.7, 4.8, 4.9, and 4.10 orthodontic terminology explained). Chinese
men have smaller midfaces and shorter mandibles, lower incisors positioned more
anteriorly relative to the APg line, a more protrusive facial profile, significantly
more protrusive upper and lower lips relative to the E-line, a more acute nasolabial
angle, greater vertical dimension of the face, and a steeper mandibular plane. In
both Chinese men and women, significant labial inclination of the lower incisors
results in protrusion of the lower lip in profile (Fig. 4.9). Chinese people generally
have a convex facial profile [7, 27, 28]. The soft tissue chin thickness is also less
than Caucasians [29]. In another study, young Chinese adults were compared with
Caucasian young adults (65 untreated Chinese adults—25 males, mean age
19.3 ± 3.0 years and 40 females, mean age 20.3 ± 3.4 years were compared with a
sample of 90 untreated Caucasian adults—30 males, mean age 24.1 ± 5.7 years and
60 females, mean age 22.9 ± 5.2 years). The Chinese female participants had smaller
midfacial and mandibular length and a longer lower anterior face height (average
value) than the Caucasian female participants. Analysis of the facial axis angle
showed a greater vertical dimension in Chinese males when compared with
Caucasian males. The upper and lower lips were more protrusive, and a more con-
vex facial profile was observed in the Chinese males compared with the Caucasian
males [7, 30].
48 S. Samizadeh
a b c
S N
Po
Pt 4
Or
5
R3 Or
Ba Ar ANS 3 PO
PNS UIA 1
Frankfor
t plane
ANS
6
Ma
R1 Point A ndib
ula y
pla
ne r Maxillar PNS
7
Plane
Is
Point B
2
Pog
Me
Fig. 4.7 (a) Orthodontic terminology—Cephalometric radiograph tracing is used to examine cra-
niofacial morphology, in particular prior to orthodontic treatment. A-point (Point A, Subspinale,
ss), Anterior nasal spine (ANS), Articulare (Ar), B-point (Point B, Supramentale, sm), Basion
(Ba), Bolton (Bo), Condylion (Co), Crista galli, Dacryon, Glabella (G), Gnathion (Gn), Gonion
(Go), Incision inferius (Ii), Incision superius (Is), Infradentale (Id, Inferior prosthion), L-point,
Menton (Me), Nasion (N, Na), Opisthion (Op), Orbitale (Or), Pogonion (Pog, P, Pg), Porion (Po),
Posterior nasal spine (PNS), Prosthion (Pr, Superior prosthion, Supradentale), Pterygomaxillary
fissure (PTM, Pterygomaxillare), R-point (Registration point), Sella (S), Cervical point (C),
Inferior labial sulcus (Ils), Labrale inferior (Li), Labrale superior (Ls), Pronasale (Pn), Soft tissue
glabella (G’), Soft tissue menton (Me’), Soft tissue nasion (N’, Na’), Soft tissue pogonion (Pg’,
Pog’), Stomion (St), Stomion inferius (Sti), Stomion superius (Sts), Subnasale (Sn), Superior
labial sulcus (Sls), Trichion (Tr), Soft tissue gnathion (Gn’). (b) Skeletal hard tissue cephalometric
reference points: 1 (nasion perpendicular to point A), the distance between nasion perpendicular
line and point A measured perpendicular to the nasion perpendicular line; 2 (Pog to nasion perpen-
dicular), the distance between pogonion and the nasion perpendicular line measured perpendicular
to the nasion perpendicular line; 3 (Frankfort to mandibular plane angle), the angle between the
Frankfort plane and the mandibular plane; 4 (facial axis angle), the angle formed by the basion-
nasion plane and the plane from foramen rotundum to gnathion; 5 (effective midfacial length), the
distance between condylion to point A; 6 (effective mandibular length), the distance between con-
dylion to gnathion; 7 (lower face height), the distance between ANS and menton measured perpen-
dicular to the Frankfort plane. Used with permission: Ioi H, Nakata S, Nakasima A, Counts
AL. Comparison of cephalometric norms between Japanese and Caucasian adults in antero-
posterior and vertical dimension. Eur J Orthod. 2007 Oct;29(5):493–9. [26]. (c) Frankfort, man-
dibular, maxillary planes
Japan
In comparison to Caucasians, on average, the Japanese are retrognathic, with a

greater vertical direction of facial growth, acute nasolabial angle, smaller facial axis
angle, retruded chin, and a more protrusive dentition and protrusive upper and lower
lips (Fig. 4.11). The facial axis angle is more vertical, indicating a more downward
direction of facial development, and steeper mandibular plane [26, 31–34]. Japanese
women are reported to have increased dental height and a significantly larger lower
face height in comparison to their Caucasian counterparts. Japanese with normal
occlusions are reported to be more dolichofacial than brachyfacial [26]. Using ceph-
alometric radiograms, Utsuno and colleagues reported thicker facial soft tissues in
Japanese children compared with Black African American, Hispanic, and White
European children [35].
Fig. 4.8 Dental hard tissue cephalometric reference points and analysis: 1 (upper incisor to point
A vertical), the distance between the facial surface of the upper incisor and point A measured per-
pendicular to the nasion perpendicular line; 2 (lower incisor to A-Po line), the distance between the
edge of the lower incisor and a line from point A to pogonion; 3 (lower incisor to mandibular plane
angle), the angle formed by the long axis of the lower incisor and the mandibular plane; 4 (upper
incisor to palatal plane), the distance from the edge of the upper incisor to the palatal plane; 5
(upper molar to palatal plane), the distance from the mesial cusp of the upper first molar to the
palatal plane; 6 (lower incisor to mandibular plane), the distance from the edge of the lower incisor
to the mandibular plane; 7 (lower molar to mandibular plane), the distance from the mesial cusp of
the lower first molar to the mandibular plane. Used with permission—Ioi H, Nakata S, Nakasima
A, Counts AL. Comparison of cephalometric norms between Japanese and Caucasian adults in
antero-posterior and vertical dimension. Eur J Orthod. 2007 Oct;29(5):493–9. [26]
A comparison of cephalometric norms between Japanese and Caucasian adults

in the antero-posterior and vertical dimension revealed (in the antero-posterior
dimension) a significantly more retruded chin position, protruding mandibular inci-
sors, and protruded lip positions (in both men and women) in comparison with aver-
ages in Caucasian populations [26]. In the vertical dimension, the Japanese were
reported to have a significantly steeper mandibular plane, significantly larger lower
face height, and increased dental height. Japanese male participants had a signifi-
cantly larger labiomental sulcus, a significantly smaller nasolabial angle and signifi-
cantly smaller Z angle than Caucasians. Female participants had significantly
thicker soft tissue of the chin than that of Caucasians [26]. Other facial characteris-
tics of the Japanese population include retruded position of the maxilla and the chin
in relation to the nasion or glabella, a less prominent nose, obtuse nasolabial angle,
and bilabial protrusion [36]. There is also evidence from a study conducted in 1993
50 S. Samizadeh
Fig. 4.9 Soft tissue cephalometric reference points and analysis: 1 (nasolabial angle), the angle
formed by a line tangent to the base of the nose and a line tangent to the upper lip; 2 (upper lip
protrusion), the distance between labrale superius and a line from subnasale to soft tissue pogo-
nion; 3 (lower lip protrusion), the distance between labrale inferius and a line from subnasale to
soft tissue pogonion; 4 (labiomental sulcus), the maximum depth from a line connecting soft tissue
pogonion and the lower lip; 5 (point A to subnasale), the distance from point A to subnasale mea-
sured parallel to the Frankfort plane; 6 (incision superioris to upper lip), the distance from incision
superioris to the upper lip measured parallel to the Frankfort plane; 7 (incision inferioris to lower
lip), the distance from incision inferioris to the lower lip measured parallel to the Frankfort plane;
8 (pogonion to pogonion ′), the distance from hard tissue pogonion to soft tissue pogonion mea-
sured parallel to the Frankfort plane; 9 (Z angle), the angle formed by the intersection of Frankfort
plane and a line connecting soft tissue pogonion and the most protrusive lip point. Used with per-
mission—Ioi H, Nakata S, Nakasima A, Counts AL. Comparison of cephalometric norms between
Japanese and Caucasian adults in antero-posterior and vertical dimension. Eur J Orthod. 2007
Oct;29(5):493–9. [26]
that the pogonion is in a more forward position in modern Japanese people, result-
ing in a straighter profile in comparison to previous generations [37].
A study of the three-dimensional anthropometry of the lips of young Japanese
adults reported thinner upper vermilion than the lower vermilion in the frontal view,
but nonetheless approximately the same thickness in linear distance [38]. In com-
parison with Caucasian American standards, the vermilion height and the width of
a b
c d
Fig. 4.10 (a) Rickett’s E-line as described first by the orthodontist Robert rickets in the 1950s for
examination of the relationship between nose, lips, and chin. It is a line from the tip of the nose to
the tip of the chin and relationship between the upper and lower lips to this line. In the average
Caucasian face, the ideal distance for the lower lip from this line would be 2 mm behind the line,
and the upper lip 4 mm behind the line. (b) Variations exits according to ethnicity. (c) For example,
in Chinese men and women, significant labial inclination of the lower incisors results in protrusion
of the lower lip in profile [7]. (d) Nasolabial angle
the philtrum were measured to be greater, with a shorter cutaneous lip height in
Japanese people [38]. These findings are supported by other studies. A further study
of the craniofacial structure of Japanese and European-American adults with nor-
mal occlusions and well-balanced faces demonstrated fundamental variation in the
craniofacial structure between Japanese and European-Americans. Although only
“well-balanced faces” in each group were analysed, this study also reported the
Japanese sample had smaller facial dimensions anteroposteriorly, proportionately
larger in vertical facial dimensions, a more vertical facial axis angle (more down-
ward direction of facial development), more protrusive dentally, more acute nasola-
bial angle, and a greater tendency toward bilabial protrusion [32].
Korea
In comparison to Caucasians, Koreans generally have a significantly wider face

width and nose breadth, relatively narrower lip width, and significantly narrower
nasal root breadth (Fig. 4.12 and Table 4.1) [1]. Hwang and colleagues examined
the facial soft tissue thickness of Korean adults using cone-beam computed tomog-
raphy images [39]. The means and standard deviations of 31 facial landmarks were
52 S. Samizadeh
Fig. 4.11 A group of Japanese women in Kimonos. Photo by T Watanabe, Deyson Ortiz and
Nicole Ene
Fig. 4.12 A traditional Korean wedding. Photos by M Ameen
computed in their study. These measurements were compared with those reported
by De Greef and colleagues (a large-scale in vivo Caucasian facial soft tissue thick-
ness database for craniofacial reconstruction). The majority of landmarks for
Koreans showed higher values, hence indicating thicker soft tissues in Koreans than
in White Europeans, with notable difference between genders in some of the land-
marks used. An art anatomical study of the facial profile of Koreans examined 1400
Korean profiles (630 males and 770 females). Nine indexes were developed using
measurements of distances between ten anthropometrical landmarks. The authors,
an artist in collaboration with the departments of anatomy at two Korean universi-
ties, reported that the total head height−length index and middle face−lower face
index were significantly different from Caucasians. The characteristic features
described above should be considered when visualising Koreans. Furthermore, all
nine indexes used showed variations between Caucasians and Koreans [40]. In two
different Korean-language books, Cho has described the characteristic facial fea-
tures of the Northern and Southern Koreans (The Beauty. Cho YJ., 1st rev. Seoul:
Hainaim Publishing. 2007:1–431 and Face, Features of Koreans. Cho YJ., 1st rev.
Seoul: Sakyejul Publishing. 1999:1–291). Migration has an impact on the facial
features of people internationally and this has been illustrated in these books. The
differences in facial features between the Northern and Southern Koreans go back
to their lineage. The Southern lineage migrated from Indonesia, Malaysia, and other
islands and the Northern lineage includes migration from Siberian people, all of
whom have distinctive differences. Koreans with Southern lineage typically have a
squared face, depressions of facial features, dark eyebrows and relatively bigger
54
Table 4.1 Comparison of selected facial dimensions among ethnic groups

(mm, mean ±
SD)
Korean American Australian
Gross and Oestenstad and Hughes and
Male This study Han [1] Korea [12]a Horstman [10] Perkins [8] USAF [18] Brazile et al. Liau et al. Lomaev [20]
dimensions (n = 70) (n = 408) (n = 272) (n = 61) (n = 38) (n = 2420) [9]b (n = 32) [4] (n = 190) (n = 389)
Face width 147.6 ± 5.0 145.1 ± – 140.6 ± 6.4* 139.0 ± 8.0* 142.3 ± 5.2* 134.0 ± 8.0* 136.6 ± 7.5* 140.4 ± 5.8*
5.9*
Face length 120.6 ± 5.9 120.2 ± 6.2 120.1 ± 6.1 122.1 ± 7.1 126.0 ± 7.0* 120.3 ± 6.1 118.0 ± 6.0 113.7 ± 7.3* 115.5 ± 7.1*
Lip width 49.3 ± 3.8 50.4 ± 4.2 51.1 ± 6.2 53.3 ± 4.5* 51.0 ± 4.0 52.3 ± 4.5* 51.0 ± 5.6 56.2 ± 5.5* 48.8 ± 3.7
Nose width 36.7 ± 2.7 – 38.3 ± 2.9* 35.3 ± 3.5 36.0 ± 3.0 35.4 ± 2.9* 29.0 ± 4.0* – –
Nasal root 11.4 ± 1.0 – – 12.3 ± 1.6* 16.0 ± 2.0* – 15.0 ± 2.0* 16.4 ± 2.0* –
breadth
Korean American
Female This study Han [1] Korea [12]a Gross and Horstman Oestenstad and Perkins USAF [19] Brazile et al. [9]b
dimensions (n = 40) (n = 101) (n = 250) [10] (n = 60) [8] (n = 30) (n = 1905) (n = 34)
Face width 136.6 ± 4.9 134.1 ± 5.9 – 130.1 ± 5.7* 129.0 ± 6.0* 129.0 ± 5.8* 129.016.0*
Face length 109.6 ± 4.2 109.5 ± 5.2 110.9 ± 5.3 110.9 ± 6.5 118.0 ± 5.0* 106.3 ± 6.1* 109.0 ± 7.0
Lip width 44.1 ± 3.2 44.5 ± 3.7 48.8 ± 4.6* 51.6 ± 3.9* 48.0 ± 3.0* 43.814.2 49.0 ± 3.0*
Nose width 33.2 ± 1.9 – 34.6 ± 2.8* 31.3 ± 2.9* 33.0 ± 4.0 31.9 ± 3.3 27.0 ± 3.0*
Nasal root 11.4 ± 0.8 – – 10.8 ± 1.4 16.0 ± 0.2* – 16.0 ± 0.2*
breadth
a
National Anthropometric Survey of Korea, Korea Research Institute of Standards and Science, 1999
b
Brazile et al.: white subjects only. *p < 0.01: Compared to this study by ANOVA and Dunnett’s multiple comparison
S. Samizadeh
Asian Facical Type Asian Facical Type

Facial Subtype Asian Facical Type I–“Northern” II–“Intermediate” III–“Southern”
Regions where Mongolia, some parts of Southern China, Hong Kong, Taiwan Malaysia, Indonesia, Vietnam, and other
these facial types Korea, Northern China Southeast Asian countries
are typical
Image
Palpebral fissure Narrow Wider than Type I Wider of the 3 facial types
Supratarsal crease No Either present or absent Present
Medial epieanthal May be present Usually absent Absent
fold
Nasal dorsum Highest and longest of the 3 facial May be slightly lower and wider Flat and short
types
Nasal ala Narrow with narrow ellipsoid nostrils Intermediate in width Widest of the 3 facial types with wide,
round nostrils
Mid face Madical malar area tends to be flatter Less flattening of the medial malar area Medial and lateral malar areas tend to
than the lateral malar area than have some convexity
Type I
Zygoma Prominent Varies in prminence Not prominent
Mandible Prominent mandibular angle, giving a Some degree of taper from the maxilla to the Tapering from maxilla to mandible gives a
square face or square jaw mandible can give a narrower appearance narrow appearance to the lower face,
to the lower face in comparison to Type I due to a less prominent bony
(a round face with small chin and chubby mandibular angle (oval facial shape)
cheeks)
Skin type Usually fair Fair or with intermediate pigmentation Usually more pigmented than the other 2
facial types
Fitzpatrick skin phototype II-III Fitzpatrick skin phototype II-IV Fitzpatrick skin phototype III-IV
Fig. 4.13 New classification of three Asian facial morphotypes and recommendations for appro-
priate treatment strategies with botulinum toxin type A from “Aesthetic Applications of Botulinum
Toxin A in Asians: An International, Multidisciplinary, Pan-Asian Consensus” written by Sundaram
et al. [42]
eyes, short noses with prominent nose tips, and a protruding forehead. Individuals
from the Northern lineage have flat faces with relatively smaller eyes, nose, and
earlobes with fuzzy eyelashes and eyebrows, a forehead that slopes backwards, and
a relatively high forehead and cranial cap [41].
Table 4.1 from “Facial Anthropometric Dimensions of Koreans and Their
Associations with Fit of Quarter-Mask Respirators” by Kim et al. [1]. This table
shows a comparison of some of the facial dimensions measured in this study with
previously published data from Korea and other countries. Most facial dimensions
(e.g. face width, lip width, nose width, and nasal root breadth) measured in this
study are significantly different from corresponding dimensions in other Caucasian
ethnic groups.
Differences in hard tissue structure also exist between Chinese, Japanese, and
Koreans. Chinese male and female adults have a larger average ANB angle than
Japanese or Korean adults. In women, the SNA angle (the relative anterioposterior
position of the maxilla to the cranial base) is reported to be larger in Chinese females
than in Korean and Japanese females, with a more prominent sagittal position of the
mandible. Also, in Chinese males, Point B was reported to be slightly more anterior
than in the other two groups [7]. Thus, heterogeneity of soft tissue profiles exists
among Chinese, Korean, and Japanese adults. For example, in men, Japanese have
the most retrusive upper lip relative to E-line. In comparison, Chinese men and
56 S. Samizadeh
Korean women have the most protrusive lower lip. Chinese have a more obtuse
nasolabial angle (approximately 104 degrees) in comparison to both Korean and
Japanese (approximately 90 degrees), with Chinese having less prominent nasal tips
and a sharper nasal bridge [7].
Sundaram et al. published a classification of three Asian facial morphotypes to
help treatment planning for injectable treatments (Fig. 4.13) [42]. These in combi-
nation with the information provided in this chapter can be used as a guide for
assessment and treatment planning in aesthetic settings.
Understanding the differences between facial hard and soft tissue morphology
among various ethnicities will enable improved treatment planning, outcomes, and
patient care. Although only limited English-language data and information are
available, some fundamental differences in facial structures can be appreciated and
these are helpful for aesthetic practitioners. More research in this field is required.
References
1. Kim H, Han D-H, Roh Y-M, Kim K, Park Y-G. Facial anthropometric dimensions of Koreans
and their associations with fit of quarter-mask respirators. Ind Health. 2003;41(1):8–18.
2. He H, Mi X, Zhang J, Zhang Q, Yao Y, Zhang X, et al. Correlation between facial morphology
and gene polymorphisms in the Uygur youth population. Oncotarget. 2017;8(17):28750–7.
3. Shin A, Lee S-W, Bülthoff H, Wallraven C, editors. A morphable 3D-model of Korean faces. In:
2012 IEEE International Conference on Systems, Man, and Cybernetics (SMC). IEEE; 2012.
4. Wang Y, Feng Y, Liao H, Luo J, Xu X, editors. Do they all look the same? Deciphering chinese,
japanese and koreans by fine-grained deep learning. In: 2018 IEEE Conference on Multimedia
Information Processing and Retrieval (MIPR). IEEE; 2018.
6. Farkas LG, Katic MJ, Forrest CR. International anthropometric study of facial morphology in
various ethnic groups/races. J Craniofac Surg. 2005;16(4):615–46.
7. Gu Y, McNamara JA Jr, Sigler LM, Baccetti T. Comparison of craniofacial characteristics of
typical Chinese and Caucasian young adults. Eur J Orthod. 2011;33(2):205–11.
8. Le TT, Farkas LG, Ngim RC, Levin LS, Forrest CR. Proportionality in Asian and North
American Caucasian faces using neoclassical facial canons as criteria. Aesthet Plast Surg.
2002;26(1):64–9.
9. Teck Sim RS, Smith JD, Chan AS. Comparison of the aesthetic facial proportions of southern
Chinese and white women. Arch Facial Plast Surg. 2000;2(2):113–20.
10. Jayaratne YS, Deutsch CK, McGrath CP, Zwahlen RA. Are neoclassical canons valid for
southern Chinese faces? PLoS One. 2012;7(12):e52593.
11. Dawei W, Guozheng Q, Mingli Z, Farkas LG. Differences in horizontal, neoclassical facial
canons in Chinese (Han) and north American Caucasian populations. Aesthet Plast Surg.
1997;21(4):265–9.
12. Kim H-J, Seo KK, Lee H-K, Kim J. Clinical anatomy of the face for filler and Botulinum toxin
injection. New York: Springer; 2016. p. 55–92.
13. Naini FB. Clinical diagnostic records, natural head position and cranifacial anthropometry. In:
Facial aesthetics: concepts & clinical diagnosis. Mary Ann Liebert. New York; 2011. p. 71–85.
14. Choe KS, Sclafani AP, Litner JA, Yu G-P, Romo T III. The Korean American Woman’s face:
anthropometric measurements and quantitative analysis of facial aesthetics. Arch Facial Plast
Surg. 2004;6(4):244–52.
15. Li Y, Zheng L, Yu K, Lu S, Zhang X, Li Y, et al. Variation of head and facial morphological

characteristics with increased age of Han in southern China. Chin Sci Bull. 2013;58(4):517–24.
16. Zhao T, Zhang G, Zhu Y, Zheng S, Liu D, Chen Q, et al. The distribution of immunoglobulin
Gm allotypes in forty Chinese populations. Acta Anthropol Sin. 1986;6:1–8.
17. Zhenbiao Z. An analysis of the physical characteristics of modern Chinese. Acta Anthropol
Sin. 1988;7:314–23.
18. Wu L, Yecheng YMW. Study of metric traits and geographical variations of modern Chinese
skulls. Acta Anthropol Sin. 1991;2:1.
19. Wen B, Li H, Lu D, Song X, Zhang F, He Y, et al. Genetic evidence supports demic diffusion
of Han culture. Nature. 2004;431(7006):302–5.
20. Hui L, Wu Yun P, Bo W, Ning Ning Y, Jian Zhong J, Li J, et al. Origin of Hakka and Hakkanese:
a genetics analysis. 遗传学报. 2003;30(9):873–80.
21. Yang Y-h, Wang B, Ding Y, Shi Y-W, Wang X-G. Facial anthropometric proportion of Chinese
Han nationality. J Craniofac Surg. 2019;30(5):1601–4.
22. Zhao Q, Zhou R, Zhang X, Sun H, Lu X, Xia D, et al. Morphological quantitative criteria and
aesthetic evaluation of eight female Han face types. Aesthet Plast Surg. 2013;37(2):445–53.
23. Maganzini AL, Tseng JY, Epstein JZ. Perception of facial esthetics by native Chinese partici-
pants by using manipulated digital imagery techniques. Angle Orthod. 2000;70(5):393–9.
24. Xue-Feng QI. Analysis of morphous characteristics of facial features in Chinese southwest 6
ethnic minorities. J Chongqing Med Univ. 2011:04.
25. Li ZJ, Duan XD, Wang CR, editors. Research on facial features of major chinese nationalities.
Applied mechanics and materials: Trans Tech Publications; 2014.
26. Ioi H, Nakata S, Nakasima A, Counts AL. Comparison of cephalometric norms between
Japanese and Caucasian adults in antero-posterior and vertical dimension. Eur J Orthod.
2007;29(5):493–9.
27. Liu Y, Kau CH, Pan F, Zhou H, Zhang Q, Zacharopoulos GV. A 3-dimensional anthropomet-
ric evaluation of facial morphology among Chinese and Greek population. J Craniofac Surg.
2013;24(4):e353–e8.
28. Moate SJ, Darendeliler MA. Cephalometric norms for the Chinese: a compilation of existing
data. Aust Orthod J. 2002;18(1):19–26.
29. Lew KKK, Ho KK, Keng SB, Ho KH. Soft-tissue cephalometric norms in Chinese adults with
esthetic facial profiles. J Oral Maxillofac Surg. 1992;50(11):1184–9.
30. Darkwah WK, Kadri A, Adormaa BB, Aidoo G. Cephalometric study of the relationship
between facial morphology and ethnicity. Transl Res Anat. 2018;12:20–4.
31. Nezu H, Nagata K, Yoshida Y, Kikuchi M. Bioprogressive shindan gaku. Japan, Rocky
Mountain Morita: Tokyo; 1989.
32. Miyajima K, McNamara JA Jr, Kimura T, Murata S, Iizuka T. Craniofacial structure of
Japanese and European-American adults with normal occlusions and well-balanced faces. Am
J Orthod Dentofacial Orthop. 1996;110(4):431–8.
33. Engel G, Spolter BM. Cephalometric and visual norms for a Japanese population. Am J Orthod
Dentofac Orthop. 1981;80(1):48–60.
34. Mantzikos T. Esthetic soft tissue profile preferences among the Japanese population. Am J
Orthod Dentofac Orthop. 1998;114(1):1–7.
35. Utsuno H, Kageyama T, Deguchi T, Umemura Y, Yoshino M, Nakamura H, et al. Facial soft
tissue thickness in skeletal type I Japanese children. Forensic Sci Int. 2007;172(2–3):137–43.
36. Alcalde RE, Jinno T, Orsini MG, Sasaki A, Sugiyama RM, Matsumura T. Soft tissue cephalo-
metric norms in Japanese adults. Am J Orthod Dentofac Orthop. 2000;118(1):84–9.
37. Nagaoka K. Normal standards for various Roengen cephalometric and cast model analyses in
present day Japanese adults: part I. J Jpn Orthod Soc. 1993;52:467–80.
38. Yamada T, Mishima K, Mori Y, Fujiwara K, Sugahara T. Three-dimensional anthropometry of
the lips in young Japanese adults. Asian J Oral Maxillofac Surg. 2004;16(1):15–20.
39. Hwang HS, Park MK, Lee WJ, Cho JH, Kim BK, Wilkinson CM. Facial soft tissue thickness
database for craniofacial reconstruction in Korean adults. J Forensic Sci. 2012;57(6):1442–7.
58 S. Samizadeh
40. Yun KH, Kim YC, Hu KS, Song WC, Kim HJ, Koh KS. An art anatomical study of the facial
profile of Korean. Korean J Phys Anthropol. 2002;15(4):251–62.
41. Kim E-H, Cho Y-J, Jung Y-H, Seo Y-K, Kim S-H, Lee S-K, et al. Anthropometric facial charac-
teristics of adult Tae-eumin of northern and southern lineage in the Korean peninsula. J Korean
Med. 2009;30(6):86–95.
42. Sundaram H, Huang P-H, Hsu N-J, Huh CH, Wu WTL, Wu Y, et al. Aesthetic applications of
Botulinum Toxin A in Asians: an international, multidisciplinary, Pan-Asian consensus. Plast
Reconstr Surg Global Open. 2016;4(12):e872.
Chapter 5
Clinical Anatomy for Minimally Invasive
Cosmetic Treatments
Sheng-Kang Luo, Wei-Jin Hong, Chun-Lin Chen, Li-Yao Cong,

Wei-Rui Zhao, and Souphiyeh Samizadeh
A thorough understanding of the intricate facial anatomy and facial layers is necessary
for all aesthetic practitioners. Although this knowledge is being constantly updated by
new findings, up to date published scientific studies, and keeping in mind that varia-
tions in the general population exist, this knowledge will enable practitioners to:
• Appreciate the three-dimensional nature of facial anatomy
• Recognize and appreciate risk factors, and high-risk zones
• Recognize and appreciate changes to skeletal and soft tissues that occur
with ageing
• Enable the planning of accurate, reproducible, and aesthetic results.
Knowledge of the face and neck anatomy, topography, proportions, and volume dis-
tribution is critical for successful treatment planning and optimal treatment outcomes.
Facial Units and Subunits
The face can be divided into specific areas, units, and subunits including the fore-
head, temporal area, periorbital area, nose, cheek, perioral area, chin, and jawline,
demarked by clear anatomical landmarks. Some authors describe these units
S.-K. Luo · W.-J. Hong · C.-L. Chen · L.-Y. Cong · W.-R. Zhao
Department of Plastic and Reconstructive Surgery, Guangdong Second Provincial General
Hospital, Guangzhou City, China
S. Samizadeh (*)

https://doi.org/10.1007/978-3-030-84099-0_5
60 S.-K. Luo et al.
according to areas where the skin has similar characteristics (thickness and colour,
subcutaneous fat layer thickness, texture, and presence/absence of hair) [1, 2].
An understanding of these anatomical units and subunits enables an appreciation
for the balance and harmony of the units relative to each other and influences treat-
ment planning and the precision of placement of various products including dermal
fillers. In this chapter, we will describe the clinical anatomy of the key facial regions.
Upper Face and Temporal Region
The upper face consists of the frontal and temporal parts. The frontal and temporal
areas have complex anatomy with many layers, extensive nerve distribution, and rich
vasculature. The vasculature of these areas is characterised by numerous lateral and
terminal branches that can be found in various layers, and branches that are con-
nected with ocular vessels and frontal vessels (internal and external carotid vascular
system anastomoses). As a results, this represents a high-risk area when considering
cosmetic injections, including fillers.
In Asians, the frontotemporal region tends to lose volume with age, mainly due
to fat volume decreases, followed by temporal muscle atrophy. Enhancement of this
area is therefore a commonly requested area of treatment and enhancement by Asian
patients by various means including fat transfer or dermal fillers. Recent studies
have shown that augmentation of the posterior-superior temple area results in soft
tissue repositioning, hence reduction of the volume of the midface and accentuation
of the jawline contour [3]. Both of these effects are often desired by Asian women.
The Forehead
Five distinct layers, including skin, connective tissue, aponeurosis, loose areolar
connective tissue, and pericranium, are evident in the forehead (Fig. 5.1) [4]. The
forehead skin is relatively thick in comparison to other facial areas, consisting of
sebaceous and sweat glands and closely adherent to the subcutaneous tissue.
Fig. 5.1 Cadaveric dissection demonstrating layers of the forehead. Five distinct layers can be
observed: skin, connective tissue, aponeurosis, loose areolar connective tissue, and pericranium
5 Clinical Anatomy for Minimally Invasive Cosmetic Treatments 61
The frontalis muscle exhibits four anatomical shapes, resulting in the formation
of various patterns of forehead lines. The corrugator supercilii exhibits three shapes
of muscles, resulting in six patterns of vertical glabellar lines. In contrast, the orbi-
cularis oculi and procerus usually have single patterns [5]. The subcutaneous fat
(above the frontalis muscle) is comprised of central and lateral fat pad compart-
ments. Supraorbital and supratrochlear vessels and nerves exit bony foramen at the
orbital rim, within the subfrontal fat, and travel superiorly [6, 7]. Deep fat pad com-
partments of the face can be found between the frontalis muscle and the periosteum
[7]. There are fibrous septa in the areolar tissue layer. Supraorbital and supratroch-
lear neurovascular structures are at risk of injury during enhancement of this area,
and extreme care should be taken. In addition, branches of the facial artery and
nerve enter the forehead lateral to the orbital rim.
Temporal Fossa
The temporal fossa (Latin: fossa temporalis), a concavity on the temporal region, is
an area surrounded anteriorly and superiorly by the superior temporal line (an arch-
ing ridge, the origin of the deep temporal fascia), anteroinferiorly by zygomatic
bone (frontal process), inferiorly by the zygomatic bone with the transition to the
forehead superiorly and the midface inferiorly and its posterior extension to approx-
imately the end of the parietal bone (Fig. 5.2) [4].
As evident from Fig. 5.3, superficially to the deep temporal region is divided into
nine layers (skin, subcutaneous fat, superficial temporal fascia, loose layer fascia,
deep temporal fascia of superficial and deep temporal fascia, temporal muscle, peri-
osteum, bone), frontal from shallow to deep is divided into five levels (skin, subcu-
taneous fat, muscle, periosteum, bone).
Fig. 5.2 Temporal Fossa

hollowing is observed with
advanced ageing. The
boundaries of the temporal
fossa can be appreciated
62 S.-K. Luo et al.
Fig. 5.3 Cadaveric

dissection of the temporal
area, superficial to the deep
temporal region. Nine
layers can be
observed: skin,
subcutaneous fat,
superficial temporal fascia,
loose layer fascia, deep
temporal fascia of
superficial and deep
temporal fascia, temporal
muscle, periosteum, bone
Fig. 5.4 Cadaveric

dissection after reflection
of the skin and exposure of
the subcutaneous tissue
The skin and the subcutaneous fat layer are intricately connected, and many vas-
cular terminal branches are distributed in this layer (Fig. 5.4). With ageing, there is
a loss of fat in the subcutaneous facial layer. Advanced fat loss and the associated
concavity seen in this region are common in the elderly. This area is rarely filled
with large volumes and, in special cases, a small amount of filling can be done at
this level.
The superficial temporal fascia, also known as temporoparietal fascia, is a vascu-
lar layer found under the subcutaneous fat and is bound to the overlying skin. The
temporoparietal fascia is intertwined with orbicularis oris, frontalis, and occipitalis
muscles, anteriorly and posteriorly, respectively and is continuous with the superfi-
cial musculoaponeurotic system [8–10].
The superficial temporal artery, vein, and the temporal branch of the facial nerve
(Fig. 5.6) run in the superficial temporal fascia. The superficial temporal artery has
a relatively constant position; originating from the external carotid artery in the
parotid gland, passing over the zygomatic arch (covered by a parotid gland at this
point), and extending upwards along the anterior tragus of the ear. It gives off
parotid, parietal, frontal, and anterior auricular branches, as well as transverse facial
and zygomatic-orbital arteries supplying the face and the scalp (Fig. 5.5). The pulse
of the superficial temporal artery is usually palpable.
The superficial temporal artery is superficial, with mean diameter of 2.03–2.14 mm
at the zygomatic arch and is located approximately 16.68 ± 0.35 mm anterior to the
tragus [12–15]. This is a danger zone for injection of volumizing and filling agents
and should be treated with caution (Fig. 5.5b). There is an extremely high risk
of serious complications in the case of accidental injection of intravascular dermal
fillers. There is an eponymous vein with the auriculotemporal nerve behind it. Chen
et al. have reported that the superficial temporal artery in the Chinese adult differs
from that in Caucasians and one of the differences is reported to be the site of bifur-
cation according to the zygomatic arch [12].
The frontal branch of the superficial temporal artery (external carotid) anastomo-
ses with the supraorbital and supratrochlear arteries (terminal branch of the ophthal-
mic branch of the internal carotid system), and its anastomotic branch runs along
the supratemporal septum, forming the medial boundary of the temporal region,
which is also the boundary between the central frontal region and the tempo-
ral region.
Fig. 5.5 (a) Frontal branch of the superficial temporal artery. The frontal branch of the superficial
temporal artery (external carotid) anastomoses with the supraorbital and supratrochlear arteries.
(b) Cadaveric dissection demonstrating the danger zone, the superficial temporal artery. Accidental
intravascular injection will have serious and potentially catastrophic consequences
64 S.-K. Luo et al.
The loose areolar tissue is also known as subgaleal fascia. The zygomatic orbital
artery arises from the superficial temporal fascia and travels between the two fas-
ciae, and extends anteriorly along the upper margin of the zygomatic arch to supply
the orbicularis oculi muscle. Posterior to the lateral margin of the zygomaticofrontal
suture, this artery forms an anastomosis with the periorbital arterial arcades
(Fig. 5.9) [11]. This information is of crucial importance for planning treatment
with injectable fillers. The zygomatic orbital artery penetrates through the layer
2 cm outside the lateral orbital margin and enters the temporal muscle. After cross-
ing the zygomatic arch, the frontal branch of the facial nerve crosses the loose fascia
layer close to the superficial temporal fascia (Fig. 5.6). Anastomotic vessels between
the superficial and deep temporal vascular systems cross this plane. There are anas-
tomotic vessels between the superficial and deep temporal vascular systems,
which traverse the loose areolar fascial plane [16].
a b
c d
Fig. 5.6 (a) Branches of the facial nerve including the temporal nerve branch. (b) The superficial
branch of the zygomatic orbital artery, which penetrates the fat layer and provides blood supply to
the orbicularis oculi muscle. (c) The zygomatic orbital artery also runs between the two deep fas-
cias. (d) Relationship between the course and distribution of the facial nerve temporal branch (blue
area) and the zygomatico-orbital artery (blue circle); 21.5–35.4 mm: the range of distance from the
root of the helix; 2.8–25 mm: the range of distance from the bony supraorbital ridge to the tempo-
ral branch 10 mm lateral to the supraorbital notch (SON) [11]. A hazardous zone is formed within
the 1- to 3-cm range of the lateral canthal area due to presence of the temporal branch of the
facial nerve
Fig. 5.7 Cadaveric dissection showing the superficial and deep layers of the deep temporal fascia,
with the fat pad attached between the two layers of fascia
Fig. 5.8 Cadaveric

dissection showing the
deep layer of the deep
temporal fascia and the
middle temporal vein
in blue
The deep temporal fascia can be divided into the superficial temporal fascia and
the deep temporal fascia (Fig. 5.7). The superficial layer of the deep temporal fascia,
also known as the superficial temporal fascia, is relatively thin with good light trans-
mittance and no important vascular attachment. It passes down over the zygomatic
arch and is transferred to the posterior masseter fascia. The deep temporal fascia is
dense and attached to the surface of the temporalis muscle and inferiorly to the deep
zygomatic arch. Within this layer, the middle temporal vessels can be found
(Fig. 5.8).
The deep temporal fat pad is situated on the temporalis muscle (deep to the deep
temporal fascia) and continues to the buccal fat pad (Fig. 5.9) [7]. The temporal/
cranial extension of the buccal fat pad is also called the deep temporal fat pad and is
found under the zygomatic arch and the temporalis muscle [17].
The suprazygomatic fat of the temple is found between the two layers of the
fascia [4]. The zygomatic temporal nerve is inserted and accompanied by the facial
nerve. The deep temporal fascia is attached to the temporal muscle by the deep
temporal fat pad (Fig. 5.9).
The temporalis muscle is a broad, fan-shaped muscle involved in mastication that
is firmly attached to the bone. It originates from the temporal fossa to the inferior
66 S.-K. Luo et al.
Fig. 5.9 The temporalis

muscle and the posterior
branch of the deep
temporal artery, which
ascend close to the
temporalis muscle and are
the main source of blood
supply
temporal line of the lateral skull and temporal fascia and inserts on the coronoid
process of the mandible. The anterior, mid, and posterior fibres have vertical,
oblique and horizontal orientation, respectively. The anterior and mid fibres elevate
the mandible and close the jaw, and the posterior fibres retract the mandible.
The muscle is supplied by all three arteries: anterior deep, posterior deep and
middle temporal (Fig. 5.9). The second division of the internal maxillary artery can
have an intra-muscular course within the substance of the temporalis muscle
(Fig. 5.10) [16, 18]. The middle temporal vein is embedded between two layers of
the deep temporal fascia and has a relatively large calibre. Accidental injection of
filling agents into this vein can have catastrophic consequences [19]. The Temporalis
is innervated by the deep temporal nerve (anterior, middle, and posterior) from the
mandibular nerve.
The periosteum is a dense fibrous membrane that covers the bones in the temporal
fossa region. This is a common layer for placement of filling agents to help overcome
the ageing look of temple concavity. Communication between the temple and mid-
face and extensions of the buccal fat pad, including temporal extension, should be
kept in mind (Fig. 5.10). The temporal extension has superficial and deep extensions.
Relatively safe injection zones are shown in Fig. 5.11. On the sagittal plane, the
temporal vessels and the lateral margin of the orbital bone divides the temporal
into regions A, B, C and D. A and B are relative safe areas for injection of filler,
while C and D are relative danger areas.
Periorbital Area
The Asian and mongoloid eye is morphologically distinct from Caucasians, includ-
ing shape and position of the eyebrows, absence of double eyelid fold, and dimen-
sions of the eyelid [20, 21]. Anatomical variations result in the absence of a lower
crease in the Asian upper eyelid. These include fusion of the orbital septum to the
levator aponeurosis at different distances under the superior tarsal border,
Fig. 5.10 The deep cavity

of the temporal muscle is
connected to the cheek.
When a high filler volume
is injected, it will flow into
the cheek through this
cavity and cause
complications
protrusion of the preaponeurotic fat pad, presence of a thick subcutaneous fat layer
that prevents levator fibres from extension towards the skin in proximity of the supe-
rior tarsal border and insertion of the aponeurosis into the upper eyelid skin and
orbicularis oculi muscle closer to the eyelid margin. The existence of a pretarsal fat
pad and a moderate increase in fat in the double Asian eyelid are structural distinc-
tions associated with higher fat in the Asian upper eyelid [22]. With ageing, lateral
hooding is also a common occurrence in Asians [23].
The orbit and each wall of the orbit are formed by several bones, including the
frontal, ethmoid, sphenoid, lacrimal, zygomatic, maxilla, and palatine bones
(Fig. 5.12). The orbital rim plays an important role with regards to mechanical
strength and also upper and middle face contours [24].
The retro-orbicularis fat (ROOF) is located superficial to the periosteum of the
frontal bone and deep to the orbicularis oris muscle and is connected with the lower
temporal compartment. It is surrounded superiorly by the inferior frontal septum
and inferiorly by the orbicularis retaining ligament [7]. The sub-orbicularis oculi fat
(SOOF) has medial and lateral sections and is located deep to the orbital portion of
the orbicularis oculi muscle. Superficial lamina of the deep temporal fascia sepa-
rates this fat pad from the zygomatic space fat with the bilaminar orbicularis retain-
ing ligament and zygomatico-cutaneous ligament forming the superior and inferior
boundary, respectively. This fat pad is connected to the lower temporal compart-
ment [7, 25–28]. The volume of subcutaneous and suborbicularis fat and the pretar-
sal fat compartment is relatively higher in Asians compared with Caucasians [22].
68 S.-K. Luo et al.
b c
d e
Fig. 5.11 (a–c) Zones A and B are relatively safe areas for injection filling, and zones c and d are
relatively dangerous areas. The figure shows the danger zone, the superficial temporal, accidental
intravascular injection into this zone will cause serious catastrophic consequences. (c) Cadaveric
dissection. The figure shows the recommended injection filling level. (d) the loose areolar tissue;
(e) the periosteum
a b
Fig. 5.12 Borders of the orbital walls. Oblique frontal (a) and parasagittal (b) views. The lateral wall
is bordered anteriorly by the frontozygomatic [1] and zygomaticomaxillary [2] sutures and posteri-
orly by the inferior [3] and superior [4] orbital fissures. The medial wall is bordered superiorly by a
line running along the frontoethmoidal suture [5] and inferiorly by the ethmoidomaxillary suture [6].
The outer border of the upper wall is the superior orbital fissure [4]; the inner border is the line con-
tinuing the frontoethmoidal suture [5] anteriad and posteriad. The inferior wall of the orbit (orbital
floor) is bordered on its lateral side by the inferior orbital fissure [3] and, on its medial side, by the
ethmoidomaxillary suture [6] continued anteriad and posteriad. The figure also shows the foramina:
[7] zygomaticofacial foramen; [4] zygomaticotemporal foramen; [8] supraorbital foramen; [9] infra-
orbital foramen; [10, 12] anterior and posterior ethmoidal foramina; [13] optic foramen; [14] lacrimal
sac fossa connecting with the nasolacrimal duct (not shown); and [15] meningo-orbital foramen of
the greater wing of the sphenoid bone. The oblique parasagittal slice of the orbit illustrates its topo-
graphic relationships with the pterygopalatine fossa [11] and cavernous sinus [16, 24]
The tear trough ligament is a true osteocutaneous ligament found between palpe-
bral and orbital parts of the orbicularis oculi, superiorly, and inferiorly, respectively.
It originates medially immediately inferior to the anterior lacrimal crest and post-
mid-pupillary line and continues laterally as the bilayered orbicularis retaining liga-
ment [27].
The orbicularis oculi muscle is a broad, flat, sphincter muscle with bands sur-
rounding the upper and lower eyelids and mainly mediates eye closure [29]. It has
orbital and palpebral portions (further divided into preseptal and pretarsal sections).
The muscle has a complex adherence to the surrounding structure, and medially, it
is tightly adherent to the periosteum.
The orbicularis oculi is closely surrounded by other muscles with direct or indi-
rect links to them, mediating various facial expressions. The direct muscular con-
nection between the zygomatic minor muscle and orbicularis muscle is reported to
be present in 89% of Asians [29].
The skin on the eyelids is the thinnest in the body. In the upper eyelid, in Asians,
the fascial attachments of the levator muscle are absent or closer to the lid mar-
gin [30].
70 S.-K. Luo et al.
The Nose
The Asian nose has several characteristic features. The South East Asian nose is
described as “small with voluminous thick skin, low dorsum, wide and hanging ala,
bulbous tip, and retracted premaxilla” [31].
In Asians, the nasal skin is thicker with a thick subcutaneous fat layer which is
reported to be oilier and denser in the fibro-fatty layer [32, 33]. The skin is thinnest
at the rhinion and hence thickest at the radix with the occasional exception of the
skin over the supratip area. Four distinct layers are present between the skin and the
osteocartilaginous frame, including periosteum/perichondrium, deep fatty layer,
fibromuscular layer (containing the superficial musculoaponeurotic system, which
is continuous with facial SMAS, galea, and platysma muscle) followed by the super-
ficial fatty layer and the skin. Major blood vessels and innervation to the nose are
found above or within the nasal SMAS [32]. There are arterial variations; however,
the alar and columellar arteries and alar plexus are distinctively always present [34].
In Asians, the “bulbous” tip is due to an excess thick skin soft tissue envelope
[33]. The alar lobule of the Asian nose was examined in a cadaveric study. The study
reported that the appearance of the alar lobule is mainly affected by the musculature
(dilator naris anterior muscle, the insertion of the dilator naris posterior muscle) and
the thickness of the external skin [35].
The superficial fatty layer is tightly attached to the skin (Fig. 5.13).
Various distinct fat pads can be seen in the dissection pictures below. The radix
fat pad is located over the procerus muscle and extends laterally. The sidewall and
supratip fat pads are attached to the dermis. The interdomal fat is found between
medial and middle crus (Fig. 5.14) [36].
The fibromuscular layer (SMAS and the superficial fatty layer) of the nose con-
sist of mainly procerus, anomalous nasi and transverse nasalis muscles, and enable
movement of the nasal envelope and support blood supply, in addition to maintain-
ing the contractile force of the muscles (Figs. 5.15 and 5.16) [36, 38]. The superfi-
cial nasal muscles (elevator, depressor, compressor, and minor dilator muscles) are
connected and distribute their forces to each other. Used with permission from Kim
Fig. 5.13 The superficial

fatty layer is tightly
attached to the overlying
skin with vertically
oriented fibrous septae [36]
Fig. 5.14 Nasal fat pads. MCL medial canthal ligament; LLSAN levator labii superioris alaeque
nasi muscle; TN transverse nasalis muscle [36]
Fig. 5.15 The nasal

superficial
musculoaponeurotic
system. Kim TK, Jeong
JY. Surgical anatomy for
Asian rhinoplasty. Arch
Craniofac Surg.
2019;20(3):147–57 [36]
a b
Anomalous nasi m.
Procerus m. PR
Transverse nasalis m.
OO
TN AN LLSAN
Dilator naris anterior m.
Levator labii superioris
alaeque nasi m.
DNA
Compressor narium
Dilator naris posterior
minor m.
Orbicularis oris m. Depressor septi m.
¤by JY Jrong 2019
Fig. 5.16 (a) Nasal muscles. (b) PR procerus; TN transverse nasalis; AN anomalous nasi; LLSAN
levator labii superioris alaeque nasi; OO orbicularis oculi; DNA dilator naris anterior. Reprinted
from Jeong JY. Jeong J, Kim T. Rebuilding nose: rhinoplasty for Asians. Uijeongbu: Medic
Medicine. 2018. Used with permission from Kim TK, Jeong JY. Surgical anatomy for Asian rhino-
plasty. Arch Craniofac Surg. 2019;20(3):147–57 [36, 37]
72 S.-K. Luo et al.
a b
Fig. 5.17 (a, b) Periosteum of the nose. Used with permission from Kim TK, Jeong JY. Surgical
anatomy for Asian rhinoplasty. Arch Craniofac Surg. 2019;20(3):147–57 [36]
TK, Jeong JY. Surgical anatomy for Asian rhinoplasty. Arch Craniofac Surg.
2019;20(3):147–57 [36].
Under the deep fatty layer, fused perichondrium (perichondral component-
containing nutrient vessels) or periosteum (periosteal component) with fibrous is
found (Fig. 5.17). Used with permission from Kim TK, Jeong JY. Surgical anatomy
for Asian rhinoplasty. Arch Craniofac Surg. 2019;20(3):147–57 [36].
The superficial blood supply of the nose is originated from three different arter-
ies; the ophthalmic artery (branch of internal carotid artery) consisting of the dorsal
nasal artery and external nasal branch of the ethmoidal artery, the facial artery
(branch of external carotid artery) consisting of angular and columellar arteries, and
the internal maxillary artery (external nasal branch of the infraorbital artery)
(Fig. 5.18), [36].
The lower facial layers are divided into five layers: skin layer, subcutaneous tis-
sue layer, SMAS fascia layer, ligament and septum layer, deep fascia layer, and
periosteum layer. The subcutaneous tissue layer mainly includes subcutaneous
superficial fat pads, facial artery, facial nerve, trigeminal nerve and superficial facial
muscle. The SMAS fascia layer consists of the superficial fascia layer of the muscle,
the muscle and the deep fascia layer of the muscle, and the buccal fat pad.
The musculature of the mid and lower face is complex and intertwined (Fig. 5.19).
These muscles are important for both facial expressions and functions including
speech and eating (Fig. 5.19).
Ophthalmic a.
Supraorbital a.
Supratrochlear a.
Maxillary a.
Infraorbital a.
Dorsal nasal a.
Facial a.
External nasal branch of
Lateral nasal a. anterior ethmoidal a.
Columellar a.
Angular a.
Superior labial a.
Facial a.
Lateral nasal artery Arcade
Angular artery
Lateral nasal artery Arcade
Columellar branch
Angular artery
Superior labial artery
Facial artery Columellar branch Facial artery
Superior labial artery
Fig. 5.18 External vasculature. Reprinted from Jeong JY. Jeong J, Kim T. Rebuilding nose: rhino-
plasty for Asians. Uijeongbu: Medic Medicine. 2018. Used with permission from Kim TK, Jeong
JY. Surgical anatomy for Asian rhinoplasty. Arch Craniofac Surg. 2019;20(3):147–57 [36, 37]
Fig. 5.19 Facial musculature: (1) Levator labii superioris alaeque nasi; (2) Zygomatic major mus-
cle; (3) Orbicularis oris muscle; (4) Depressor angel oris; (5) Masseter; (6) Zygomatic Minor
Muscle; (7) Risourius; (8) Depressor Labii Inferioris; (9) Mentalis
• Orbicularis Oris Muscle [38–41]

–– Encircles the orifice of the mouth.
–– Complex, multi-layered muscle.
–– Attaches to the dermis of the upper lip and lower lip.
–– Attachment site for many other facial muscles in the perioral region.
–– Fibres of this muscle run in different directions.
74 S.-K. Luo et al.
–– Comprised of different parts.

–– Various parts act either independently or together with other adjacent muscles
(deep fibres are responsible for the sphincteric action—constrictor), (superfi-
cial fibres are responsible for facial expression and the precise movements of
lips—retractor).
–– Blood supply: Facial artery (superior labial branch and inferior labial branch,
maxillary artery (mental and infraorbital branch), and superficial temporal
artery (transverse facial branch)).
–– Innervation: Buccal and mandibular branches of the facial nerve.
• Zygomaticus Major Muscle [42, 43]
–– Origin: The zygomatic bone (medial to the zygomaticotemporal suture).
–– Insertion: It can divide into superficial, middle, and deep fibres, inserts into
the Modiolus, blend, and interlaces with fibres of levator anguli oris, orbicu-
laris oris and more deeply placed muscular fibres.
–– Anatomical Variation: Bifid-prevalent in Asians.
–– Blood supply: Facial artery and superior labial branch.
–– Innervation: Zygomatic and buccal branches of the facial nerve.
–– Function: Elevates the angle of the mouth upwards and laterally.
• Zygomaticus Minor Muscle [2, 44]
–– Origin: Lateral surface of the zygomatic bone, behind the zygomaticomaxil-
lary suture, blends with the inferior margin of orbicularis oculi.
–– Insertion: Three different insertion types: only to the upper lip, both the upper
lip and the alar portion, none, or only undeveloped fibres.
–– Blood supply: Facial artery.
–– Innervation: Buccal branches of the facial nerve.
–– Function: Draws the upper lip backward, upward, and outward.
• Levator Labii Superioris Muscle [45]
–– Medial, central, and lateral portions.
–– Origin: Superomedial part of the frontal process of maxilla, the infraorbital
margin-immediately superior to the infraorbital foramen, malar surface of
the zygomatic bone.
–– Insertion: Muscular area of the upper lip.
–– Blood supply: Facial artery, infraorbital artery.
–– Innervation: Zygomatic and buccal branches of facial nerve.
• Levator Labii Superioris Alaeque Nasi Muscle [46]
–– Origin: Upper frontal process of the maxilla, some fibres intertwine with
the superficial layer of the procerus and the depressor supercilia.
–– Insertion: Nasal ala and upper lip, intertwine with the transverse part of the
nasalis.
–– Blood supply: Facial artery, infraorbital artery.
–– Innervation: Buccal branch of the facial nerve.

–– Function: Dilates the nostrils and elevates the upper lip.
• Depressor Labii Inferioris Muscle
–– Origin: Oblique line of the mandible, between the symphysis and the mental
foramen.
–– Insertion: Intertwines with the orbicularis oris and the skin of the lower lip.
–– Blood supply: Mandibular branch of the facial nerve.
–– Innervation: Facial artery (inferior labial branch), maxillary artery (mental
branch).
–– Function: Draws the lower lip downward and forward.
• Levator Anguli Oris Muscle [47]
–– Origin: Canine fossa of the maxilla (below infraorbital foramen).
–– Insertion: Modiolus (muscle fibres intertwine with fibres of the zygomaticus
major, orbicularis oris, risorius, buccinator, and depressor anguli oris).
–– Blood supply: Small branches of the labial, infraorbital, and facial arteries.
–– Innervation: Buccal branch of facial nerve.
–– Function: Lifts the angle of the mouth.
• Buccinator Muscle [48–52]
–– Consist of three muscular bundles, two with bony origins (alveolar process of
the maxilla and buccal portion of the alveolar process of the mandible) and
the other bundle from the pterygomandibular raphe.
–– Insertion and intertwining with orbicularis oris muscle.
–– Blood supply: Buccal artery (maxillary artery) and facial artery.
–– Pierced by the parotid duct.
–– Innervation: Sensory innervation is by the long buccal nerve, motor innerva-
tion is via the temporal and cervical divisions of the facial nerve.
–– Function: Active role during swallowing, mastication, blowing, and sucking.
• Depressor Anguli Oris Muscle [53]
–– Origin: Mental tubercle (the mandibular border).
–– Insertion: Modiolus at the oral commissure.
–– Blood supply: Inferior labial branch of the facial artery.
–– Innervation: Marginal mandibular branch of the facial nerve.
–– Function: Depresses and pulls the corner of the mouth laterally.
• Mentalis Muscle [54, 55]
–– Origin: Incisive fossa (the alveolar process of the mandible).
–– Insertion: Mentolabial sulcus cutaneous tissue.
–– Blood supply: Inferior labial branch of the facial artery and the mental branch
of the maxillary artery.
–– Innervation: Marginal mandibular branch of the facial nerve.
–– Function: The sole elevator of the lower lip and the chin, provides vertical
support for the lower lip.
76 S.-K. Luo et al.
• Risorius Muscle [56]

–– Narrow bundle of muscle fibres.
–– Origin: The fascia of the lateral cheek over the parotid gland, superficial mas-
seter and platysma muscles.
–– Insertion: The skin of the angle of the mouth.
–– Blood supply: Facial artery and the transverse facial artery.
–– Innervation: Facial nerve.
–– Function: Pulls the corner of the mouth laterally.
• Masseter Muscle [57]
–– Quadrangular muscle, deep and superficial layers.
–– Origin: Zygomatic arch.
–– Insertion: Angle and lateral surface of the mandibular ramus.
–– Blood supply: Masseteric artery (branch of the internal maxillary artery).
–– Innervation: Motor innervation—the mandibular division of the trigemi-
nal nerve.
–– Function: Muscle of mastication, elevates the mandible for mouth closing.
• Platysma Muscle [58–60]
–– Origin: Upper portion of thorax anterior to clavicle/the subcutaneous tissue of
the subclavicular and acromial regions/pectoralis.
–– Insertion: Parotid fascia or periosteum of the mandible/ skin of the cheek/ the
mandibulocutaneous ligament or zygoma/ the commissure of the mouth, the
orbicularis oris muscle, to the posterior border of the depressor anguli oris
muscle and orbicularis oculi muscle.
–– Blood supply: Branches of the external carotid artery-submental artery, supe-
rior thyroid artery, occipital artery, and posterior auricular artery.
–– Innervation: Cervical branch of the facial nerve.
–– Function: Facial expressions, pulling down the mandible and corners of the
mouth (down and out).
Parotid Gland
Parotid glands are the largest of the major salivary glands, located in the preauricu-
lar region and extending from the masseter muscle to the posterior edge of the jaw.
The parotid gland is divided into two lobes, deep and superficial.
The accessory parotid gland occurs in about 20% of the population, and is usu-
ally located around 6 mm in front of the main parotid gland and usually adjacent to
the parotid duct. Multiple accessory glands may be present. The accessory gland
tissue differs histologically from the parotid tissue in that it may contain mucinous
acinar cells in addition to the serous acinar cells commonly found in the
parotid gland.
The parotid fascia forms a dense inelastic capsule above the parotid gland and
covers the masseter muscle on the deep surface. The parotid fascia should not be
confused with the SMAS layer (SMAS layer extending upwards to the superficial
temporal fascia and downwards to the platysma muscle), with parotid fascia being
an upward continuation of the deep cervical fascia. When it reaches the parotid
gland, the parotid fascia is divided into two deep and superficial layers tightly
enclosing the parotid gland. The superficial layer is thicker and extends upwards
from the masseter and sternocleidomastoid muscles below the zygomatic arch. The
deep layer is thinner and passes down to the mandibular ligament.
The ductal tissue of the parotid gland can be divided into two parts: proximal and
distal. Proximally, the parotid duct converts to dendritic branches and eventually to
acinar tissue. At the distal end, the parotid duct is located at the anterior border of
the parotid gland, around 1 cm below the zygomatic arch, parallel to the anterior
lateral direction of the zygomatic arch and passing through the masseter muscle.
The parotid duct passes through the buccal muscle and opens to the parotid papilla
on the buccal mucosa opposite to the maxillary second molar.
Vasculature
The common carotid artery supplies all arteries supplying the face. The main arter-
ies of the face directly originate from the external carotid artery including the facial
artery and superficial temporal artery, or from its branches including the transverse
facial artery (from the superficial temporal artery), and the infraorbital artery (from
the maxillary artery). The ophthalmic artery arises from the internal carotid artery
and supplies the eyes, the upper two thirds of the nose, and the central forehead [61,
62]. The vessels form three plexuses, deep facial, subcutaneous and subdermal
plexus [62].
Labial arteries display great variability with respect to distribution, presence, and
location (Fig. 5.20) [63].
Venous Drainage
The veins of the face generally run parallel to the arteries, but show variations. The
major venous drainage of the superficial regions of the face is provided by the facial
vein, and receiving deep facial vein. The deep facial vein drains the following veins:
masseteric, parotic, from inferior eyelid and lips and pterygoid plexus (infratempo-
ral fossa). The supratrochlear and supraorbital veins form angular veins near the
medial canthus running inferiorly and join the superior labial vein prior to joining
the facial vein at the lower border of the nose and cross body of the mandible [62,
64–66]. Within the parotid gland, the retromandibular vein is formed by the union
of the superficial temporal vein and the maxillary veins. The anterior branch of the
retromandibular vein with the facial vein forms the common facial vein. This vein
terminates entering the internal jugular vein and may also open into the external
78 S.-K. Luo et al.
Fig. 5.20 1. Facial artery 2. Superior lip artery 3, inferior lip artery 4, horizontal labiomental
artery 5, vertical labiomental artery
jugular vein. The posterior branch of the retromandibular vein joins the posterior
auricular vein forming the external jugular vein [62, 64, 67]. The superficial veins
have connections with the cavernous sinus through the: [62, 65].
• Angular vein
• Supraorbital vein
• Supratrochlear vein
• Superior ophthalmic veins
• Deep facial vein
• Pterygoid plexus
• Inferior ophthalmic vein
Lymphatic Drainage of the Face
Lymph-collecting vessels are found in three regions of the superficial tissue, the
scalp (dense), face (sparse-extending medial to lateral), and cervical region (dense in
lateral neck, sparse in the anterior and posterior neck) [62, 68]. The vessels superior
to the eyebrows drain into preauricular and deep parotid lymph nodes, from lateral
eyelids mainly to the parotid lymph nodes, from the medial canthus into subman-
dibular and buccinator and parotid lymph nodes, and the external nose and cheeks
directly into submandibular lymph nodes. The perioral region drains mainly into the
submental lymph nodes. The lower lip-central part, anterior tip of the tongue, the
floor of the mouth, and chin drain into bilateral submental lymph nodes. The upper
lip and lateral parts of the lower lip drain to the ipsilateral submandibular lymph
nodes. Lymph may directly drain into the parotid and submental lymph nodes. The
submental lymph nodes drain into their respective ipsilateral submandibular lymph
nodes, which in turn, in addition to the parotid, drain into the jugulodigastric lymph
nodes. Some lymph my drain directly into the cervical nodes [62, 69–71].
Conclusion
Various techniques for facial rejuvenation and facial contouring require an in depth
understanding of the three dimensional anatomy of the face. The use of injectables
requires an understanding of the various facial layers, as well as the position of
muscles, fat pads, vasculature, and innervations to minimize the risk of complica-
tions. Furthermore, this knowledge enables physicians to recognize and treat com-
plications arising from cosmetic treatments.
References
1. Ilankovan V, Ethunandan M, Seah TE. Facial units and subunits. In: Local flaps in facial recon-
struction. Cham: Springer; 2015. p. 23–43.
2. Choi DY, Hur MS, Youn KH, Kim J, Kim HJ, Kim SS. Clinical anatomic considerations of
the zygomaticus minor muscle based on the morphology and insertion pattern. Dermatol Surg.
2014;40(8):858–63.
3. Hernandez CA, Freytag DL, Gold MH, Pavicic T, Ascher B, de Almeida AT, et al. Clinical
validation of the temporal lifting technique using soft tissue fillers. J Cosmet Dermatol.
2020;19(10):2529c35.
4. Sykes JM, Cotofana S, Trevidic P, Solish N, Carruthers J, Carruthers A, et al. Upper face: clini-
cal anatomy and regional approaches with injectable fillers. Plast Reconstr Surg. 2015;136(5
Suppl):204s–18s.
5. Abramo AC, Do Amaral TPA, Lessio BP, De Lima GA. Anatomy of forehead, glabellar, nasal
and orbital muscles, and their correlation with distinctive patterns of skin lines on the upper
third of the face: reviewing concepts. Aesthetic Plast Surg. 2016;40(6):962–71.
6. Rose AE, Day D. Esthetic rejuvenation of the temple. Clin Plast Surg. 2013;40(1):77–89.
7. Cotofana S, Lachman N. Anatomy of the facial fat compartments and their relevance in aes-
thetic surgery. JDDG. 2019;17(4):399–413.
8. Bohr C, Bajaj J, Soriano RM, Shermetaro C. Anatomy, head and neck, temporoparietal fas-
cia. 2019.
9. Ferrari M, Vural A, Schreiber A, Mattavelli D, Gualtieri T, Taboni S, et al. Side-door tempo-
roparietal fascia flap: a novel strategy for anterior skull base reconstruction. World Neurosurg.
2019;126:e360–e70.
80 S.-K. Luo et al.
10. Mavropoulos JC, Bordeaux JS. The temporoparietal fascia flap: a versatile tool for the derma-
tologic surgeon. Dermatol Surg. 2014;40:S113–S9.
11. Choi DH, Eom JR, Lee JW, Yang JD, Chung HY, Cho BC, et al. Zygomatico-orbital artery: the
largest artery in the temporal area. J Plast Reconstr Aesthet Surg. 2018;71(4):484–9.
12. Chen T-H, Chen C-H, Shyu J-F, Wu C-W, Lui W-Y, Liu J-C. Distribution of the superficial
temporal artery in the Chinese adult. Plast Reconstr Surg. 1999;104(5):1276–9.
13. Marano SR, Fischer DW, Gaines C, Sonntag VK. Anatomical study of the superficial temporal
artery. Neurosurgery. 1985;16(6):786–90.
14. Pinar YA, Govsa F. Anatomy of the superficial temporal artery and its branches: its importance
for surgery. Surg Radiol Anat. 2006;28(3):248–53.
15. Stock AL, Collins HP, Davidson TM. Anatomy of the superficial temporal artery. Head Neck
Surg. 1980;2(6):466–9.
16. Elazab EEB, Abdel-Hameed FAM. The arterial supply of the temporalis muscle. Surg Radiol
Anat. 2006;28(3):241–7.
17. Dubin B, Jackson IT, Halim A, Triplett W, Ferreira M. Anatomy of the buccal fat pad and its
clinical significance. Plast Reconstr Surg. 1989;83(2):257–64.
18. Patil J, Kumar N, Guru A, Rao MK, Nayak SB, Abhinitha P. Maxillary artery piercing the
temporalis muscle: a rare variation in the infratemporal fossa. OA Case Rep. 2013;2(17):164.
19. Jiang X, Liu D-L, Chen B. Middle temporal vein. JAMA Facial Plastic Surg. 2014;16(3):
227–9.
20. Kunjur J, Sabesan T, Ilankovan V. Anthropometric analysis of eyebrows and eyelids: an inter-
racial study. Br J Oral Maxillofac Surg. 2006;44(2):89–93.
21. Yuzuriha S, Matsuo K, Kushima H. An anatomical structure which results in puffiness
of the upper eyelid and a narrow palpebral fissure in the mongoloid eye. Br J Plast Surg.
2000;53(6):466–72.
22. Jeong S, Lemke BN, Dortzbach RK, Park YG, Kang HK. The Asian upper eyelid: an anatomi-
cal study with comparison to the Caucasian eyelid. Arch Ophthalmol. 1999;117(7):907–12.
23. Osaki MH, Osaki TH, Osaki T. Infrabrow skin excision associated with upper blepharoplasty to
address significant dermatochalasis with lateral hooding in select Asian patients. Ophthalmic
24. Nikolaenko VP, Astakhov YS, Gaivoronsky IV. Clinical anatomy of the orbit and periorbital
area. In: Orbital fractures. New York: Springer; 2015. p. 1–67.
25. Amodeo CA, Casasco A, Cornaglia AI, Kang R, Keller GS. The suborbicularis oculi fat
(SOOF) and the fascial planes: has everything already been explained? JAMA Facial Plastic
Surg. 2014;16(1):36–41.
26. Mendelson BC, Muzaffar AR, Adams JW. Surgical anatomy of the midcheek and malar
mounds. Plast Reconstr Surg. 2002;110(3):885–96. discussion 97-911
27. Wong C-H, Hsieh MK, Mendelson B. The tear trough ligament: anatomical basis for the tear
trough deformity. Plast Reconstr Surg. 2012;129(6):1392–402.
28. Moss CJ, Mendelson BC, Taylor GI. Surgical anatomy of the ligamentous attachments in the
temple and periorbital regions. Plast Reconstr Surg. 2000;105(4):1475–90.
29. Kim H-J, Seo KK, Lee H-K, Kim J. General anatomy of the face and neck. In: Clinical anat-
omy of the face for filler and botulinum toxin injection. Singapore: Springer Singapore; 2016.
p. 1–53.
30. Watanabe K, Shoja MM, Loukas M. Anatomy for plastic surgery of the face, head and neck.
New York: Thieme; 2016.
31. Yap EC. Rhinoplasty for south east Asian nose. Facial Plast Surg Clin North Am.
2018;26(3):389–402.
32. Suh MK. Atlas of Asian rhinoplasty. Singapore: Springer; 2018.
33. Kim D, Jeong J, Oh S. Bulbous tip correction focusing on skin soft tissue envelope in Asian
rhinoplasty. Arch Aesthetic Plast Surg. 2014;20:140–7.
34. Wu W. The oriental nose: an anatomical basis for surgery. Ann Acad Med Singap.
1992;21(2):176–89.
35. Chun KW, Kang HJ, Han SK, Lee ES, Chang H, Kim SB, et al. Anatomy of the alar lobule in
the Asian nose. J Plast Reconstr Aesthet Surg JPRAS. 2008;61(4):400–7.
36. Kim TK, Jeong JY. Surgical anatomy for Asian rhinoplasty. Arch Craniofac Surg.
2019;20(3):147–57.
37. Jeong J, Kim T. Rebuilding nose: rhinoplasty for Asians. Uijeongbu: Medic Medicine; 2018.
38. Ghassemi A, Prescher A, Riediger D, Axer H. Anatomy of the SMAS revisited. Aesthet Plast
Surg. 2003;27(4):258–64.
39. Jain P, Rathee M. Anatomy, head and neck, orbicularis oris muscle. StatPearls [Internet]. 2020.
40. Nicolau PJ. The orbicularis oris muscle: a functional approach to its repair in the cleft lip. Br
J Plast Surg. 1983;36(2):141–53.
41. Hwang K, Jin S, Hwang SH, Chung IH. Innervation of upper orbicularis oris muscle. J
Craniofac Surg. 2006;17(6):1116–7.
42. Phan K, Onggo J. Prevalence of bifid zygomaticus major muscle. J Craniofac Surg.
2019;30(3):758–60.
43. Hu KS, Jin GC, Youn KH, Kwak HH, Koh KS, Fontaine C, et al. An anatomic study of the bifid
zygomaticus major muscle. J Craniofac Surg. 2008;19(2):534–6.
44. Hur MS, Youn KH, Kim HJ. New insight regarding the zygomaticus minor as related to cos-
metic facial injections. Clin Anat. 2018;31(7):974–80.
45. Bloom J, Rayi A. Anatomy, head and neck, eye levator labii superioris muscle. 2019.
46. Hur M-S, Hu K-S, Park J, Youn K, Kim H. New anatomical insight of the levator labii superi-
oris alaeque nasi and the transverse part of the nasalis. Surg Radiol Anat. 2010;32(8):753–6.
47. Dao D-PD, Le PH. Anatomy, head and neck, eye levator anguli oris muscle. StatPearls
[Internet]: StatPearls Publishing; 2019.
48. Rathee M, Jain P. Anatomy, head and neck, buccinator muscle. 2019.
49. da Silva RH, Porciúncula HF, Jardini RS, Pita AP, Ribeiro AP. External location of the buc-
cinator muscle to facilitate electromyographic analysis. Braz Dent J. 2008;19(2):130–3.
50. Baghele ON. Buccinator muscle repositioning. J Indian Soc Periodontol. 2012;16(3):456–60.
51. Mioche L, Hiiemae KM, Palmer JB. A postero-anterior videofluorographic study of the intra-
oral management of food in man. Arch Oral Biol. 2002;47(4):267–80.
52. Vitti M, Basmajian JV, Ouellette PL, Mitchell DL, Eastmen WP, Seaborn RD. Electromyo-
graphic investigations of the tongue and circumoral muscular sling with fine-wire electrodes.
J Dent Res. 1975;54(4):844–9.
53. Hur M, Hu K, Cho J, Kwak H, Song W, Koh K, et al. Topography and location of the depressor
anguli oris muscle with a reference to the mental foramen. Surg Radiol Anat. 2008;30(5):403–7.
54. Hur MS, Kim HJ, Choi BY, Hu KS, Kim HJ, Lee KS. Morphology of the mentalis muscle and
its relationship with the orbicularis oris and incisivus labii inferioris muscles. J Craniofac Surg.
2013;24(2):602–4.
55. Zide BM, McCarthy J. The mentalis muscle: an essential component of chin and lower lip
position. Plast Reconstr Surg. 1989;83(3):413–20.
56. Germann AM, Al Khalili Y. Anatomy, head and neck, risorius muscle. StatPearls [Internet]:
StatPearls Publishing; 2019.
57. Corcoran NM, Goldman EM. Anatomy, head and neck, masseter muscle. StatPearls [Internet]:
StatPearls Publishing; 2019.
58. Hwang K, Kim JY, Lim JH. Anatomy of the platysma muscle. J Craniof Surg. 2017;28(2):
539–42.
59. Uehara M, Helman JI, Lillie JH, Brooks SL. Blood supply to the platysma muscle flap: an
anatomic study with clinical correlation. J Oral Maxillofac Surg. 2001;59(6):642–6.
60. Hoerter JE, Patel BC. Anatomy, head and neck, platysma. StatPearls [Internet]. 2020.
61. von Arx T, Tamura K, Yukiya O, Lozanoff S. The face: a vascular perspective. A literature
review. Swiss Dent J. 2018;128(5):382.
62. Marur T, Tuna Y, Demirci S. Facial anatomy. Clin Dermatol. 2014;32(1):14–23.
63. Samizadeh S, Pirayesh A, Bertossi D. Anatomical variations in the course of labial arteries: a
literature review. Aesthet Surg J. 2018;39(11):1225–35.
82 S.-K. Luo et al.
64. Wobig J, Dailey R. Facial anatomy. Oculofacial plastic surgery, vol. 5. New York: Thieme; 2004.
65. Greco JF, Skvarka CB. Surgical anatomy of the head and neck. In: Dermatologic surgery:
requisites in dermatology. Philadelphia: Saunders Elsevier; 2009. p. 1–40.
66. Zhang J, Stringer MD. Ophthalmic and facial veins are not valveless. Clin Exp Ophthalmol.
2010;38(5):502–10.
67. Bertha A, Rabi S. Anatomical variations in termination of common facial vein. J Clin Res.
2011;5(1):24–7.
68. Pan W-R, Le Roux CM, Briggs CA. Variations in the lymphatic drainage pattern of the
head and neck: further anatomic studies and clinical implications. Plast Reconstr Surg.
2011;127(2):611–20.
69. Larrabee WF, Makielski KH, Henderson JL. Surgical anatomy of the face. Philadelphia:
Lippincott Williams & Wilkins; 2004.
70. Bolotin D, White L, Alam M. Cutaneous anatomy in dermatologic surgery. In: Dermatologic
surgery: step by step. Boca Raton, FL: Wiley; 2012. p. 1–13.
71. Uren RF, Howman-Giles RB, Chung D, Thompson JF. Role of lymphoscintigraphy for selec-
tive sentinel lymphadenectomy. In: Selective sentinel lymphadenectomy for human solid can-
cer. New York: Springer; 2005. p. 15–38.
Part II
Anatomy and Ageing
Chapter 6
Facial Ageing: The Foundational Changes
Luiz Eduardo Toledo Avelar, Luciene Menrique Corradi,

and Souphiyeh Samizadeh
Introduction
Each phase of human life has its own organic characteristics that show how the
organism develops according to functional and physiological demands.
According to Arbenz, it can be said that the human life cycle recognizes three
stages: one of progressive development, another of stabilization, and the third of
regression. The duration of these stages, especially the second and third, suffers
from individual, and environmental influences, sometimes in a very pronounced
manner [1].
These characteristics can be attributed to the concept of chronological age. In
other words, as age progresses, the organism experiences morphological and some-
times degenerative changes that develop along with its own physiological function-
ing in each period.
This same reasoning is applied to the facial ageing process, which will be treated
here in a more comprehensive and multidisciplinary way. This approach is justified
L. E. T. Avelar (*)
Clinic Luciene Corradi, Belo Horizonte, Brazil
e-mail: contato@luizeduardoavelar.com.br
L. M. Corradi
Police Department of Minas Gerais State, Instituto Médico Legal, Belo Horizonte, Brazil
S. Samizadeh

https://doi.org/10.1007/978-3-030-84099-0_6
86 L. E. T. Avelar et al.
by the fact that the face is the most exposed region of the body, and therefore more
susceptible to influences from external factors that may accelerate the aspect of the
characteristic signs of each age group, and thus, modify the pattern of chronological
age [2].
It is interesting to note that chronological age often differs from biological age.
Or rather, some factors can greatly influence how the specific characteristics of each
age group can become present. These factors are listed as genetic, environmental,
habits, nutrition, and several others such as individual care and access to health
services.
The aesthetic treatment of the face does not translate into creating a special face
type, but rather to know how to harmonize the various parts of a face with each
other. The harmony of a face, in turn, is a perfect agreement between several differ-
ent parts, which form a whole or compete for the same purpose [3]. Thus, the pro-
fessionals who works with aesthetics must have knowledge and understanding of
how facial structures relate to each other, from birth to adulthood in its various
stages. As such, it is considered the fact that the “ageing” process begins from birth,
being more marked in adulthood following genetic and environmental factors such
as exposure to ultraviolet (UV) radiation, amongst others [2].
Relationship of Facial Structures
The knowledge to determine the relationships of the different parts of the face lies
in the principles established by anthropology through the study of human body
measurements by applying metric systems or arithmetic operations and anthropom-
etry [3].
With the growing awareness of the general population regarding facial aesthet-
ics, analysis based on the relations of the soft tissues of the face with the skeletal
framework [4] have become necessary, allowing not only to see the external charac-
teristics of the face, but also to understand how its bone structure develops through-
out life.
However, firstly one must make use of the understanding of how the growth and
then the ageing process of the face occurs holistically.
Functional Matrix Concept
All the structures that make up the face integrate and interact at all stages of the
development of the human body. Therefore, the important and intimate relationship
of the bone structures that support the corresponding adjacent tissues should not be
neglected, the latter exerting a great influence on the bone remodelling reaction [5].
In the process of bone remodelling, osteoclasts remove minerals and collagen fibres
6 Facial Ageing: The Foundational Changes 87
from the bone, promoting bone resorption, and osteoblasts perform the addition of
minerals and collagen fibres to the bone, promoting bone deposition [6]. This phe-
nomenon is called bone remodelling guided by the functional matrix.
The concept of functional matrix explains how the bone grows, responding to the
functional relationships established by all the soft tissues that act in association with
that bone. That is, the functional soft tissue matrix is an epigenetic factor regulating
the entire skeletal growth process [5].
In other words, the face is a set of independent functional areas delimited by the
bones that compose it, whose spaces are occupied by soft tissues related to different
functions such as respiration, vision, phonation, chewing, amongst others. Thus, it
is understood that the bone grows and develops following the growth potentialities
according to the pattern of intrinsic factors, such as genetic factors, and at the
expense of extrinsic factors, such as the adjacent soft tissues, also called functional
factors [7].
After growth has ceased as age progresses, the bone structures of the face con-
tinue to experience morphological changes that can also be explained, in part, by
functional demand.
Functional factors are thus the very agents that cause the bone to grow and con-
tinue to develop during all phases of human life.
orphological Changes in the Bone Structures of the Face

M
with Age
Bones are composed of dense connective tissue, bone tissue, cartilage, epithelium,
fat tissue and nerve tissue. They have multiple functions, including support, protec-
tion, mineral homeostasis, movement, blood cell production and triglyceride
storage [8].
It becomes relevant the understanding the behaviour of the bone in the facial age-
ing, since even if there is no more “growth,” the bone continues to experience
changes in its morphology, even if discrete, according to its dynamic quality, since
the bone performs a continuous replacement of old bone tissue for new [5, 8]. Thus,
with ageing, there is a loss of bone mass and fragility due to demineralization (loss
of calcium and other minerals from the bone) and a decrease in protein production
[9, 10].
These morphological changes in the facial bones follow the phenomenon of bone
remodelling that occurs in all phases of human life: from childhood to old age [5].
This remodelling process is regulated by the set of soft tissues that relate to each one
of the bones. It should be noted here that although the functions of bone remodelling
are more evident in childhood, during growth, they are still present in adulthood and
old age, but to a lesser extent [5]. This can be explained, in part, by the progressive
increase in bone mass that occurs in the first two decades of life [9, 10], rhythming
the bone remodelling. In the ageing process, there is an increase in the action of
osteoclasts and a decrease in the action of osteoblasts with loss of bone mass [9, 10],
thus decreasing the bone density and its remodelling rhythm.
Anthropology makes use of simple measurements, proportions, and indices of
cranial points in order to classify them in the anthropological group that corre-
sponds and compares them with similar anthropometric data [3]. Thus, anthropom-
etry provides complete information on the developmental status of the individual
under examination in a specific age group, leading the clinical professionals to a
better optimization of diagnosis and treatment planning, since bone modifications
reflect on the face musculature.
For better orientation of the facial analysis and its chronological, regional char-
acteristics, the face is divided into upper, middle, and lower thirds (Fig. 6.1).
Upper Third Face
The fact that the base of the skull is the model that determines the shape and perim-
eter of the field of facial growth and development cannot be neglected [5], i.e., the
base of the skull is the pillar of facial architecture.
Thus, it is understood that the development of the face does not occur in isola-
tion. It is conditioned on its counterpart, the base of the skull [5, 11], in addition to
structural patterns and genetic factors [5, 12]. Recent studies have confirmed that
there are constant age-related remodelling of the cranial cap, its exocranial and
endocranial faces, and its base, being gender-specific [13].
Fig. 6.1 Upper, middle, and lower thirds in front and right profile standards
a b
Fig. 6.2 (a), glabella is not very pronounced in the female gender; (b), glabella is more pro-
nounced in the male gender
In the upper third of the face, with age, bone deposition continues in the glabellar
region, exocranial face, being more evident in males (Fig. 6.2) [5, 13].
Middle Face
Jaw Changes, Orbit and Piriform Opening
During growth, the orbital surface undergoes bone remodelling in three direc-
tions: lateral, anterior, and superior. In the medial wall of each orbit, bone apposi-
tion occurs, increasing the distance between them, modifying the morphology of
the underlying pyriform opening (Fig. 6.3) [7].
Similarly, during facial ageing, through the phenomenon of bone remodelling,
the pyriform opening becomes wider with remodelling of the lower and lateral
walls when an expansion of the nasal cavity in lateral and anterior directions
occurs, increasing the measurement of the maximum nasal opening, with conse-
quent lower palate “replacement” [2, 5].
The lower-lateral margin of the orbit also expands with age, modifying the
contour observed in younger individuals [2].
a b
Fig. 6.3 Development of the orbital region during facial growth: (a), orbit aspect in child; (b),
orbit aspect in adult
a b
Fig. 6.4 Development of the orbital region during facial growth: (a), young individual; (b) older
individual
The maxillary body changes mainly in its periosteal face of the anterior protuber-
ance, just below the infraorbital foramen, with remodelling by bone resorption of
this region resulting in a deeper aspect (Fig. 6.4) [5].
Lower Face Third
The lower third of the face preserves a close relationship with the rest of the facial
physiognomy [3]. The geometrical shape of the face as a whole may change during
the development (ageing) of the individual, although it usually maintains its facial
pattern (dolicum, meso, and brachyfacial).
The facial structures that make up its lower third are all those located below the
anterior nasal spine (skeletal base) or subnasal point (soft tissue), including the
mandible. Thus, like the rest of the face, the mandible may assume different situa-
tions with the craniofacial mass, maintaining an intimate relationship with the cra-
nial base, but needing to adapt to constant osseofacial remodelling, and consequently
changing its morphology [5]. Thus, for each individual, what can change is the
proportion that exists in each regional part of the mandible, in accordance with their
facial pattern, age, and sexual dimorphism [5, 11, 12].
In general, the changes that occur in the lower third of the face are conditioned
mainly by what occurs with mandibular bone remodelling, whether natural, result-
ing from the ageing process, or resulting from therapeutic interventions. In other
words, the process of mandibular transformation and adaptation is in accordance
with its functional demand, always codified by genetic heritage, in response to the
mechanism of bone remodelling conferring the dynamic quality of this facial struc-
ture [5, 11].
With age, there is a decrease in the vertical dimension, which is the measurement
obtained from the subnasal point to the chin. The vertical dimension encompasses
the vertical height of both the maxilla and mandible [2, 14, 15]. This loss of vertical
dimension can be partly explained by the anterior projection of the mandibular body
and chin as a consequence of the functional wear that occurs in the teeth, with the
resulting anterior displacement of the entire mandibular complex as a vector, and
also remodelling of the mandibular angle, increasing its value (Fig. 6.5) [2, 15–17].
The total absence of the dentition induces even greater bone resorption. In these
cases, there is a structural loss of the alveolar processes [14] and subsequently even of
the mandibular bone itself due to the absence of the antagonist tooth. Thus, the height
of the alveolar processes of the maxilla and mandible decreases (Fig. 6.6) [1, 14].
a b
Fig. 6.5 Vertical dimension in young individual (a) and older individual (b)
Fig. 6.6 Decrease in the height of alveolar processes due to total tooth loss
Younger people, therefore, have a more structured jaw while, with time, its con-
tour becomes less delineated and with less bone volume. This ageing process is very
evident by verifying the location of the mentonian foramen [1, 14]. In young indi-
viduals it is located between the upper and lower limits of the mandible, but with the
ageing process, it becomes more focused on the upper edge of the mandibular body.
In edentulous individuals, its presence is often so remarkable that it makes the
placement of dental prostheses difficult, as they are more superficial and very close
to the upper margin (Fig. 6.7) [1, 14].
The size and morphology of the lower third of the face changes with age, both in
males and females, notably with a decrease in its vertical dimension and alteration
in the contour of the mandibular lower margin (Fig. 6.8) [18].
This whole process occurs simultaneously and discreetly but gives an “aged”
(unpleasant) aspect of the lower third of the face, leading all its structures, including
the muscles, to adapt to this “new” profile of the lower third of the face.
However, it is worth noting that, in some individuals, the value of the vertical
dimension of the lower facial third may not change much with age, as will be
described in the following topic.
a b
Fig. 6.7 Jaw appearance and location of the Mental foramen in young (a) and old (b) adult
individuals
a b c
Fig. 6.8 Size and morphology of the lower third of the face in the young (a), young adult (b) and
old (c) individuals
elationship of the Facial Bones to each Other and to the Base

R
of the Skull
It is relevant to consider the regional relationships that exist between the whole bone
structure of the face and the skull base, not only during growth but also during age-
ing [5, 11].
The process of bone remodelling, with age, occurs more intensely on the face
than at the cranial base [5, 18]. However, its dimensional combinations are main-
tained. Therefore, when evaluating a certain facial region, i.e., the size of a certain
Fig. 6.9 Height of lower third increased due to mandibular prognathism and increased vertical
maxillary height
bone, it is its effective dimension that is being considered. It is interesting to observe

that, whenever possible, the analysis of a “part” of the face should be accompanied
by the observation of its “counterpart” in order to understand the real expression of
its dimension [4, 5, 11].
As an example, the relationship between the effective length of the mandible and
the vertical maxillary dimension is cited. In individuals presenting mandibular
prognathism and increased vertical maxillary height, they may also present an
increased lower third height and not decreased as occurs when the vertical maxillary
height presents a lower value (Fig. 6.9) [5].
Thus, it is emphasized that the analysis of an individual’s face should always be
compared with his own pattern and not with normative values of some statistical
mean, because in this way, his own morphological and evolutionary characteristics
will be respected and adequate.
Conclusion
The face has the utmost importance in individual characterisation [19]. Facial fea-
tures, sensations, and emotions are exteriorized through faces [20]. In this context,
the face plays a fundamental role in appreciative behaviour and must be analysed
following principles that have their foundation in somatic characters and in anthro-
pological points of greater or lesser precision [3].
The understanding of all the dynamics involved in the ageing process of the
structural bone foundation of the face is of extreme relevance for the professional
who works in facial aesthetics, considering the fact that all the muscular structures
of the face, throughout the life of the individual, accompany their bone bases, pro-
vided they are functionally active [13]. This occurs due to the constant search for the
architectural balance of all facial structures. However, at times, this can result in a
not very pleasant appearance since the ageing process comprises all four layers of
the face (bone, muscles, ligaments, subcutaneous, and skin), which are affected fol-
lowing the mechanisms of organic adaptation to environmental variations which, in
turn, are “weakened” with advancing age [2, 21].
References
1. Arbenz GO. Medicina legal e antropologia forense. Rio de Janeiro: Livraria Atheneu; 1988.
2. Avelar LET, et al. Aging and sexual differences of the human skull. Plast Reconstr Surg Glob
Open. 2017;5(4):e1297.
3. Costa C. Ortodontia. 1st ed. Niterói, RJ: Editora Dias Vasconcelos; 1939. p. 249.
4. Janson M. Ortodontia em adultos e tratamento interdisciplinar. Maringá: Dental Press;
2008. p. 672.
5. Enlow DH, Hans MG, Oppido T. Noções básicas sobre crescimento facial. São Paulo:
Santos; 1998.
6. Tortora GJ, Derrickson B. Principios de anatomía y fisiología. Buenos Aires: Médica
Panamericana; 2013.
7. Castellino AJ, Santini R, Taboada N. Crecimiento y desarrollo cráneo facial. Buenos Aires:
Mundi; 1967.
8. Silva H, et al. Tratado de Motricidade Orofacial. São José dos Campos: Pulso Editorial; 2019.
9. Callegari N, et al. Processos fisiológicos e metabólicos envolvidos no envelhecimento. In: Silva
HJ, et al., editors. Tratado de Motricidade Orofacial. São José dos Campos: Pulso Editorial;
2019. p. 840.
10. Figueriredo C, Fuller R. Envelhecimento do sistema osteoarticular. In: Tratado de Motricidade
Orofacial. São Jose dos Campos: Pulso Editorial; 2019. p. 840.
11. Suzuki H. Análise cefalométrica Jarabak. In: Interlandi S. Ortodontia: Bases para a iniciação.
4th ed. São Paulo: Artes Médicas; 1999.
12. Interlandi S, et al. Ortodontia: Bases para a iniciação. 4th ed. São Paulo, Brasil: Artes Médicas
Ltda; 1999.
13. Urban JE, et al. Evaluation of morphological changes in the adult skull with age and sex. J
Anat. 2016;229(6):838–46.
14. Vanrell JP. Odontologia legal e Antropologia Forense. 1st ed. Rio de Janeiro: Editora Guanabara
Koogan Ltda; 2002.
15. Fitzgerald R, et al. Update on facial aging. Aesthet Surg J. 2010;30(1 Suppl):11S–24S.
16. Avelar LET, et al. Dynamic changes of facial supporting cornerstones (pillars): considerations
in aesthetic approach. J Drugs Dermatol. 2018;17(4):466–70.
17. Haddad A, et al. Managing the aesthetic patient. J Drugs Dermatol. 2019;18(1):92–102.
18. Pessa JE, et al. Aging and the shape of the mandible. Plast Reconstr Surg. 2008;121(1):196–200.
19. Kehi R, Costa C. Ortodontia. 1st ed. Niterói, RJ: Editora Dias Vasconcelos; 1939.
20. Whaynbaum K, Costa CA. Ortodontia. Niterói, RJ: Editora Dias Vasconcelos; 1939.
21. Pernambuco L. Atualidades em Motricidade Orofacial, vol. 9. Rio de Janeiro: Revinter; 2012.
p. 123–33.
Chapter 7
Facial Ageing in East Asians
Souphiyeh Samizadeh
Regardless of ethnicity and gender, facial ageing is a multidimensional and multi-

factorial process involving all facial layers, including the skull, musculature, fat
pads and cutaneous tissue. Ethnic differences in age-related facial changes are not
fully established. In this chapter, the term “Asian” will refer to East Asians. The key
studies examining age-related changes of the facial skeleton and soft tissue are done
on Caucasians. There are distinct differences in facial structure and characteristics
of Asians and Caucasians, and this is true for the ageing process too.
Internationally, the pathophysiology of facial ageing includes skin changes
(reduced collagen and elasticity), loss of skeletal support and bony recession
(including dental), soft tissue volume reduction and repositioning. Asians usually
appear much younger than their chronological age, as compared to Caucasians and
other major ethnic groups. This perception is due to a combination of facial neoteny
(baby-like facial features), genetic factors and lifestyle. Genetic factors include a
thicker dermis with higher collagen content and UV protection provided by denser
pigmentation [1–3].
Shirakabe and colleagues relate the “unconscious illusion of youth” in Asians to
their face resembling a baby’s face with “infant like expression” [1]. Cultural behav-
iours also contribute to the delayed ageing appearance of Asians. Some such behav-
iours include skin care, which has been taught to young girls through generations
and, more popular nowadays, imitating practices shown on media and social media:
avoidance of sun exposure to preserve and maintian a “white/pearl” skin complex-
ion with no pigmentation and dietary habits including consumption of fermented
S. Samizadeh (*)

https://doi.org/10.1007/978-3-030-84099-0_7
98 S. Samizadeh
vegetables, green tea, collagen-rich soups/stews, variety of mushrooms and low

sugar food. Furthermore, Europeans have larger facial movements and are more
expressive than Asians, in particular, eyebrow, nose, and perioral regions [4].
It is important to note that skin ageing is not the same across the world due to
multiple factors, including genetic factors such as variations in melanosome size,
distribution, and number. Skin ageing features among Asian populations are highly
varied due to different skin types with a wide variety of skin textures and thick-
nesses (thicker dermis with high collagen content) [1, 5].
In comparison to Asians, Caucasians have earlier onset and more prominent
rhytids, skin laxity (in particular the lower face) and facial ptosis [6]. Asians are
predisposed to hereditary or acquired skin pigmentation [7]. Study by Tsukahara
et al. reported Caucasians aged significantly more (rhytids and sagging in particular
lower face) in comparison to the same age group of Japanese participants [8]. Skin
ageing in European and Asian (Chinese) female populations exposed to similar envi-
ronmental conditions were studied by Nouveau-Richard et al. They reported that skin
ageing (rhytids) of various facial areas was delayed by approximately 10 years in
Chinese women in terms of prevalence and severity. Periorbital rhytids are more
severe among French women, with linear increase during ageing. Pigmented spot
intensity is more of an ageing sign for Chinese women, reported to be severe in 30%
of those over the age of 40 [9]. Thus, extrinsic ageing in Asians is seen as pigmentary
changes, coarseness of skin texture, laxity and presence of rhytids [10]. Skin pig-
mentation proceeds facial rhytids in Chinese women [9]. Photoageing in Asians
could be explained by melanocytic function and the density and size of melano-
somes that are highly variable in this group and hence varied acute and chronic
responses to UV irradiation [9, 11]. Sun exposure and smoking have both been
reported as key factors in pigmentation and formation of rhytids [11–14]. Acceleration
of skin ageing in the 50s has been associated with genetic characteristics of Asian
skin and, possibly, the hormonal changes due to menopause and lack of oestrogen
[15]. As such, in Asians, skin rhytids are not the early signs of ageing. Pigmentation
and facial soft tissue ptosis, and pseudo-ptosis are the primary markers of ageing.
Rhytids primarily appear at the lateral canthal area (Crow’s feet), followed
by glabella and, only at later stages, in the perioral area [9, 16, 17]. Asians present
with deep, bristlier, and thicker rhytids than Caucasians, particularly in the perior-
bital and perioral areas, in comparison to Caucasians. However, differences in the
formation and progression of facial rhytids have been noticed among Asians despite
being exposed to the same factors. Genetics and the presence/absence of certain
genes have been proposed as the cause [11, 18].
Changes in the facial fat compartments of the face play a key role in facial ageing
and been described as a primary process of ageing [19–21]. Fat accumulation and
sagging is only seen during later ageing. Dense fat is present superficial and deep to
SMAS in this population. This in combination with fibrous connections between
facial layers, results in reduced midface soft tissue ptosis [22].
Hence, restoration and rejuvenation has been focused on the addition of volume
using dermal fillers or fat grafting. It is imperative to keep under consideration that
with ageing, fat compartments undergo selective hypertrophy or atrophy or both.
7 Facial Ageing in East Asians 99
Studies examining live participants with various methods such as ultrasound,

MRI, and other imaging techniques are becoming more available. This is important
as although cadaveric studies are beneficial, limitations may include old age of the
sample group, small sample group, morphological changes at various stages, and
therefore the results may not be representative of the population.
In Asians, the midface usually has minimal rhytids and mid-mod ptosis is seen
with ageing. Increased superficial fat in combination with thickened dermis in
Asians reduces the prevalence of superficial rhytids. Furthermore, there are dense
fat and fibrous connections between the superficial musculoaponeurotic system and
parotideomasseteric fascia which reduce the amount of soft tissue ptosis in
Asians [22].
Facial fat compartments in Asian (Chinese) women in three different age groups
with controlled body mass index have been studied by Wen et al. (Fig. 7.1) [23].
They reported that with ageing the infraorbital area became thicker (both superficial
and deep layers) [23]. Jang et al. similarly examined male patients of three different
age groups with controlled body mass index. They reported thickening of midfacial
fat in the elderly, in particular the infraorbital area and nasojugal area (Fig. 7.2) [24].
By using 3D volumetric analysis of the facial magnetic resonance image, Gosain
and colleagues reported thickening and augmentation of the cheek fat pad in the
elderly [25].
The thickness of fat in the nasolabial area in Asians was measured by Wen and
colleagues, reporting increased thickness with age, in particular in the lower third
[23]. This is consistent with studies carried out by Gosain and colleagues using
high-resolution MRI in both static and smiling states in Caucasian women [25, 26].
Fig. 7.1 Three-dimensional (3D) reconstruction of the cranial skin and soft tissue was performed
and followed by grading evaluation of tear trough deformity and nasolabial fold on the cranial skin
and soft tissue reconstruction with three-dimensional image of the skull rotating 45°.Used with
permission [23].
100 S. Samizadeh
a b
c d
Fig. 7.2 Difference of infraorbital fat thickness between young and old subjects. Reconstructed
sagittal images of females in their 20s (a, b) and 60s (c, d). The blue area indicates fat tissue (−200
to −50 Hounsfield units). There are two different compartments of fat tissue on the IO-lat (a, c) and
the IO-med (b, d). The red line on the sagittal images indicates the measuring line for thickness. In
the 20s, there is small fat tissue on the line, but, in the 60s, thick fat tissue is visible. IO-lat, inferior
orbital-lateral; IO-med, inferior orbital-medial. Used with permission [24]
The facial skeleton undergoes bone resorption after completion of the growth
period. The skeletal changes result in lack of support for the soft tissues and liga-
ments of the face, including soft tissue cheek mass support. This further results in
the displacement of the soft tissues and inferior and posterior displacement of the
inferior orbital rim, distortion of the orbital rim curve, and the scleral show in the
midface.
Factors that contribute to a greater degree of facial ageing in this population
include lack of three-dimensional skeletal support for the soft tissues which are
heavy, with relatively thicker skin, increased malar fat and retrognathic chin (or
microgenia) and hence providing poor support against tissue descent. The men-
tioned factors increase the effective gravitational force resulting in considerable
facial sagging [1].
Kim et al. examined ageing changes of four bony regions, including the glabel-
lar, orbital, maxillary, and pyriform aperture regions, and changes in the orbital
aperture width (distance from the posterior lacrimal crest to the frontozygomatic
suture) and the pyriform width (between both upper margins of the pyriform
aperture) [27]. They reported more midfacial changes in young and middle age
group women, which could possibly be explained by bone remodelling that happens
during menopause. The female subjects exhibited more midfacial angular changes
with ageing than the male subjects. The orbital and pyriform widths had significant
changes with aging. This is different from findings of Caucasian studies and can
possibly be explained to be due to “nutritional status and physique between genera-
tions” as this is a cross sectional study [27, 28].
With ageing, the canine fossa becomes more concave (Fig. 7.3) [29]. Asians usu-
ally tend to possess a higher arched zygomatic bone in comparison to Caucasians
[27, 30]. As such, the maxillary angle reflect the degree of midface skeletal resorp-
tion and the degree of zygoma desorption [29]. Jeon et al. examined computer
tomography scans of facial skeleton of 114 Koreans. They reported a statistically
significant decrease in canine fossa angle with ageing in both sexes, 3.3° (male) and
4.1°(female) [29].
Various studies have reported evident changes in maxilla and piriform angels
with ageing [31–33]. Computer tomography scans of the facial skeleton of 114
Korean participants were examined by Jeon et al. They reported increased concavity
of the canine fossa with increasing age. The decrease in angle was more pronounced
than those in other studies with Caucasian subjects. This was explained by the
authors to be due to the difference in morphology, Asians having higher arched
zygomatic bone [29]. In addition, in comparison to Caucasian studies, the maxillary
angle decrease with ageing was less pronounced in their sample of Korean partici-
pants [29, 31–35]. Kim and colleagues reported a significant decrease of maxillary
angle in both sexes and piriform angel in females with ageing [36]. Findings from
various studies could have been influenced by different methods used.
Poor skeletal support in the lower face (anterior-posterior dimension) and
recessed chin are common. These features result in an uneven ageing appearance
Fig. 7.3 Canine fossa. With ageing, the canine fossa becomes more concave [29]. Asians usually
tend to possess a higher arched zygomatic bone in comparison to Caucasians [27, 30]. As such, the
maxillary angle reflects the degree of midface skeletal resorption and the degree of zygoma desorp-
tion [29]. Jeon et al. examined computer tomography scans of the facial skeleton of 114 Koreans.
They reported a statistically significant decrease in canine fossa angle with ageing in both sexes,
3.3° (male) and 4.1°(female) [29]. Source: Jeon, A., et al., Anatomical changes in the East Asian
midface skeleton with aging. Folia morphologica, 2017. 76(4): p. 730–735
102 S. Samizadeh
between the mid and lower face. Soft tissue ptosis in the cervical region can there-
fore be seen with exacerbated platysma and soft tissue descent [1]. Consequently,
the collection of submental adipose appears more extensive. Therefore, reduced
anteroposterior projection of the chin and age related soft tissue changes result in
an aged appearance of the cervical area. However, platysma dehiscence in Asians
is only half as common as in Caucasians. [22]. In, Asians, the facial muscles are
to some extent thicker than Caucasians, and the platysma muscle’s central dehis-
cence is less common with reduced platysma muscle banding [22]. Despite these
anatomical differences, with advanced ageing, similar soft tissue changes in the
lower face and cervical region can be seen in both Asians and Caucasians
(Fig. 7.4).
Fig. 7.4 Facial ageing in East Asians

A study of 13,940 (6735 male, 7250 female) adults from Han Chinese ethnic
groups in 10 southern provinces of China has revealed that with ageing, the follow-
ing declined significantly in a linear fashion [37]:
• Head breadth, minimum frontal breadth
–– It was reported hair thickness, and the thickness of subcutaneous fat on the
side of the head have some impact on these values. Decline in the value was
linked with the thinning of the soft tissue of the zygomatic arch
• Face breadth
• Interocular breadth
• External biocular breadth
• Lip height, thickness, and lip index values
• Head circumference
• Auricular height
• Length-breadth head index
• Length-height head index
In addition, the following increased in a linear fashion:
• Nose breadth
• Mouth breadth
• Morphological facial height
• Upper lip height
• Physiognomic ear length and breadth
• Skinfolds
• Vertical head-facial index values.
They further published data for changes in men and women separately with age-
ing. These male indices were negatively correlated with age: head breadth, mini-
mum frontal breadth, face breadth, interocular breadth, external biocular breadth,
lip height, the thickness of lips, head circumference, auricular height, length-breadth
index of head, length-height index of head, breadth-height index of head, and lip
index, all of which showed linear decreases with age. Instead, the following indices
were positively correlated with age: nose breadth, mouth breadth, physiognomic
facial height, morphological facial height, upper lip height, physiognomic ear
length, physiognomic ear breadth, facial skin, physiognomic facial index, morpho-
logical facial index, transverse cephalo-facial index, and vertical cephalo-facial
index, thus having linear increases with age. These female indices were negatively
correlated with age: head breadth, minimum frontal breadth, face breadth, interocu-
lar breadth, external biocular breadth, lip height, the thickness of lips, head circum-
ference, auricular height, length-breadth index of the head, length-height index of
the head, and lip index, showing linear decreases with age. Indices that were posi-
tively correlated with age include: head length, nose breadth, mouth breadth, mor-
phological facial height, upper lip height, physiognomic ear length, physiognomic
ear breadth, facial skin fold, vertical cephalo-facial index, and height-breadth index
of the nose, showing linear increases with age. This study reported no significant
104 S. Samizadeh
difference in the quantity of changes in head-face morphological characteristics

quantities between men and women with ageing [37]. However, it is important to
keep in mind that the thickness and morphology of the soft tissues of the head and
face are different between various Chinese and East Asian ethnicities.
Lip thickness reduces with ageing in both men and women. In Li et al.’s study
lower-lip thickness decreased from 9.1 (20 year olds) to 7.6 mm (60 year olds) in
men and from 9.4 (20-year-olds) to 7.3 mm (60 year olds) in women. Mouth breadth
was reported to increase between 20 to 60 years of age on average by 2.1 mm in men
and 2 mm in women. In both men and women, the upper lip height increases by
approximately 3.4 mm due to structural changes in the subcutaneous tissue. Perioral
skin laxity with ageing was reported [37, 38].
In a different study, 643 Han adults (334 males and 309 females) were investi-
gated in Qionghai city and Wanning city. With the ageing process, they reported a
decrease in [39]:
• Interocular breadth
• External biocular breadth
• Lip heights and thickness
And increases in:
• Upper lip skin height
• Physiognomic ear length and breadth. The above studies and findings show con-
sensus regarding morphological changes of the soft tissues of the face. Further
studies are required to examine skeletal changes in this population. Characteristic
facial changes with ageing in East Asians can be seen in Figure 7.4.
Conclusion
There are many soft tissue and skeletal changes with ageing. Facial ageing leads to
characteristic changes in the appearance of the face in both Cuacasians and Asians.
Soft tissue and hard tissue (skeletal and the dentition) changes including facial
rhytids appear later in life in Asians in comparison to their Western peers. Facial soft
tissues of Asians are quantitatively and qualitatively different from Caucasions.
Furthermore, the skeletal support for the soft tissues are not similar. Moreover, Asian
women have baby like facial features and expressions that result in delayed per-
ceived age and thus maintaining a younger appearance despite age-related skin
changes. Lifestyle differences such as diet also contribute to differences seen in
ageing patterns. More research is needed regarding facial ageing in Asians. There
are presently limited published papers on this topic in English. Papers published in
other languages such as Chinese, Japanese, and Korean are not easily accessible to
English readers and non-scholars.
References
1. Shirakabe Y, Suzuki Y, Lam SM. A new paradigm for the aging Asian face. Aesthet Plast Surg.
2003;27(5):397–402.
2. McCurdy JA Jr, Lam SM. Cosmetic surgery of the Asian face. New York: Thieme; 2005.
3. Berardesca E, et al. In vivo biophysical characterization of skin physiological differences in
races. Dermatology. 1991;182(2):89–93.
4. Tzou CH, et al. Are there ethnic differences of facial movements between Europeans and
Asians? Br J Plast Surg. 2005;58(2):183–95.
5. Tsukahara K, et al. Comparison of age-related changes in facial wrinkles and sagging in the
skin of Japanese, Chinese and Thai women. J Dermatol Sci. 2007;47(1):19–28.
6. Rawlings AV. Ethnic skin types: are there differences in skin structure and function? Int J
Cosmet Sci. 2006;28(2):79–93.
7. Yu SS, et al. Diagnosis and treatment of pigmentary disorders in Asian skin. Facial Plast Surg
Clin North Am. 2007;15(3):367–80.
8. Tsukahara K, et al. Comparison of age-related changes in wrinkling and sagging of the skin in
Caucasian females and in Japanese females. Int J Cosmet Sci. 2004;26(6):314.
9. Nouveau-Richard S, et al. Skin ageing: a comparison between Chinese and European popula-
tions: a pilot study. J Dermatol Sci. 2005;40(3):187–93.
10. Siegrid SY, Grekin RC. Aesthetic analysis of Asian skin. Facial Plast Surg Clin North Am.
2007;15(3):361–5.
11. Chung JH. Photoaging in asians. Photodermatol Photoimmunol Photomed. 2003;19(3):109–21.
12. Hillebrand GG, et al. Quantitative evaluation of skin condition in an epidemiological survey of
females living in northern versus southern Japan. J Dermatol Sci. 2001;27:42–52.
13. Akiba S, et al. Influence of chronic UV exposure and lifestyle on facial skin photo-aging –
results from a Pilot study. J Epidemiol. 1999;9(6 suppl):136–42.
14. Roh KY, et al. Pigmentation in Koreans: study of the differences from caucasians in age, gen-
der and seasonal variations. Br J Dermatol. 2001;144(1):94–9.
15. Youn CS, et al. Effect of pregnancy and menopause on facial wrinkling in women. Acta Derm
Venereol. 2003;83(6):419–24.
16. Yang Z. Facial wrinkles in Chinese skin: impact of climatic factors. A clinical study on 2000
Chinese women. Ann Dermatol Venereol. 2002;129:1S81–1S141.
17. Takema Y, et al. Age-related changes in the three-dimensional morphological structure of
human facial skin. Skin Res Technol. 1997;3(2):95–100.
18. Chung JH. The effects of sunlight on the skin of Asians. In: Comprehensive series in photosci-
ences. New York: Elsevier; 2001. p. 69–90.
19. Rohrich RJ, Pessa JE, Ristow B. The youthful cheek and the deep medial fat compartment.
20. Coleman S, Saboeiro A, Sengelmann R. A comparison of lipoatrophy and aging: volume defi-
cits in the face. Aesthet Plast Surg. 2009;33(1):14–21.
21. Donath AS, Glasgold RA, Glasgold MJ. Volume loss versus gravity: new concepts in facial
aging. Curr Opin Otolaryngol Head Neck Surg. 2007;15(4):238–43.
22. Sykes JM. Management of the aging face in the Asian patient. Facial Plast Surg Clin North
Am. 2007;15(3):353–60.
23. Wen L-H, et al. Analysis of age-related changes in midfacial fat compartments in Asian women
using computed tomography. J Plast Reconstr Aesthetic Surg. 2019;72(11):1839–46.
24. Jang M-S, et al. An analysis of Asian midfacial fat thickness according to age group using
computed tomography. J Plast Reconstr Aesthet Surg. 2015;68(3):344–50.
25. Gosain AK, et al. A volumetric analysis of soft-tissue changes in the aging midface using high-
resolution MRI: implications for facial rejuvenation. Plast Reconstr Surg. 2005;115(4):1143–52.
discussion 1153-5
106 S. Samizadeh
26. Gosain AK, et al. A dynamic analysis of changes in the nasolabial fold using magnetic
resonance imaging: implications for facial rejuvenation and facial animation surgery. Plast
Reconstr Surg. 1996;98(4):622–36.
27. Kim SJ, et al. Analysis of age-related changes in Asian facial skeletons using 3D vector math-
ematics on picture archiving and communication system computed tomography. Yonsei Med
J. 2015;56(5):1395–400.
28. Shaw RB Jr, et al. Aging of the mandible and its aesthetic implications. Plast Reconstr Surg.
2010;125(1):332–42.
29. Jeon A, et al. Anatomical changes in the east Asian midface skeleton with aging. Folia Morphol
(Warsz). 2017;76(4):730–5.
30. Neligan PC, Warren RJ. Plastic surgery-aesthetic, vol. 2. New York: Elsevier Health
Sciences; 2012.
31. Shaw RB Jr, et al. Aging of the facial skeleton: aesthetic implications and rejuvenation strate-
gies. Plast Reconstr Surg. 2011;127(1):374–83.
32. Pessa JE. An algorithm of facial aging: verification of Lambros’s theory by three-dimensional
stereolithography, with reference to the pathogenesis of midfacial aging, scleral show, and the
lateral suborbital trough deformity. Plast Reconstr Surg. 2000;106(2):479–88.
33. Mendelson B, Wong C-H. Changes in the facial skeleton with aging: implications and clinical
applications in facial rejuvenation. Aesthet Plast Surg. 2012;36(4):753–60.
34. Shaw RB Jr, Kahn DM. Aging of the midface bony elements: a three-dimensional computed
tomographic study. Plast Reconstr Surg. 2007;119(2):675–81.
35. Richard MJ, et al. Analysis of the anatomic changes of the aging facial skeleton using
computer-assisted tomography. Ophthalmic Plast Reconstr Surg. 2009;25(5):382–6.
36. Kim YK, Lee HB. MACS lift on Asian: consideration on third purse string suture and malar
region. J Korean Soc Aesthet Plast Surg. 2009;15(2):116–20.
37. Li Y, et al. Variation of head and facial morphological characteristics with increased age of
Han in southern China. Chin Sci Bull. 2013;58(4–5):517–24.
38. Wu R, Wu X, Zhang Z. Anthropological study nationalities of Hainan Island, China. Beijing:
Ocean Press; 1993.
39. Zheng L-B, et al. The anthropometric characters’ changing by age in the heads and faces of
Han People in Hainan province. J Yunnan Univ. 2012;4:019.
Chapter 8
Aesthetic Assessment of the Face
Souphiyeh Samizadeh
This chapter is dedicated to Dr. Farhad Naini, a consultant orthodontist at St

George’s University Hospitals NHS Foundation Trust. He has inspired me to strive
for perfection. His reference book, Facial Aesthetics: Concepts and Clinical
Diagnosis is one of the most comprehensive books [1] in the field and highly recom-
mended to all aesthetic physicians. His knowledge, ethics, and care for patients are
outstanding and have even led to changes in terminology, such as “lip incompe-
tence” to “incomplete lip seal” [2]. As Dr Naini summarises: “The term ‘incompe-
tent lips’ implies that the lips are unable to form an adequate seal under unstrained
conditions, i.e. excessive separation of the lips at rest.”
“Everything has beauty, but not everyone sees it!” Confucius
“The most important aspect of the clinical assessment is for the clinician to know
what to look for. Leonardo da Vinci called this ‘saper vedere’, or ‘Knowing how to see’”
Source: Naini, F.B. and Gill, D.S., 2008. Facial aesthetics: 2. Clinical assess-
ment. Dental update, 35(3), pp. 159–170.
Clinical Assessment
Aesthetic physicians and practitioners must gain knowledge of facial assessment

and develop an aesthetic and “educated eye” [3]. Clinical evaluation and photo-
graphs should be conducted when a patient is in a “natural head position”. This is
defined as a relaxed body and head posture, when the subject is looking at a dis-
tant point at eye level (horizontal visual axis). This posture represents a
S. Samizadeh (*)

https://doi.org/10.1007/978-3-030-84099-0_8
108 S. Samizadeh
standardized and reproducible orientation of the head. The anatomical reference

planes such as the Frankfort plane are not recommended for facial assessment and
record taking, as anatomical landmarks are subject to individual variations and
hence considerable error can occur. Minor adjustments may be required when
patients assume their natural head position as we develop compensatory tilts to
minimize the aesthetic impact of various facial appearances such as asymmetries
(Fig. 8.1). For example, those with a relatively small chin may have a compensa-
tory upward tilt [1, 4–6]. Background and lighting are also important during both
assessment and clinical record taking. Facial proportions and symmetry should be
examined in full face and profile view. Ethnic variations and craniofacial norma-
tive values should be taken into consideration. Some guidelines are described
below. It is important to treat these as “guidelines” as such canons of beauty have
not held to be 100% reproducible in the general population. When examining
head and face features, ethnic differences should be taken into consideration.
What Is Facial Analysis?
Facial analysis is a process that starts prior to planning for aesthetic procedures
and continues throughout the procedure and after. Clinical observation plays a
significant role in clinical evaluation. Although our patients attend with specific
a b
Fig. 8.1 Schematic illustrations. (a) Natural head position. In the natural head position with a
horizontal visual axis, a difference in height of the oral commissures is apparent. (b) Compensatory
head posture. Tilting the head camouflages the lower face asymmetry, but results in canting of the
orbital plane [7]. Modified from Correction of Eyes and Lip Canting after Bimaxillary Orthognathic
Surgery. Yonsei medical journal
8 Aesthetic Assessment of the Face 109
areas of concern, a complete facial assessment is to be carried out initially. By

doing so, the practitioner can understand the nature of the concern that a patient
has presented with, understand their facial features, their needs and motivations,
and relay these to the patient. For example, in the case of deep nasolabial folds,
what is the role of facial ageing versus genetics, patient’s own facial characteris-
tics and possibly pathology/disease? Mid-face volume loss? Maxillary deficiency?
Loss of the dentition? Shape of nostrils and para-nasal ageing? Patient’s overall
facial shape and ethnicity? Any muscular hyperactivity? What is the appearance
and role of the nasolabial and other adjacent fat pads? History of previous surgical
or non-surgical treatments (both cosmetic and theapeutic), intraoral and extra-
oral is also important.
Accurate assessment and analysis play a significant role in treatment planning,
evaluation of treatment outcomes, comparison of strategies employed, and develop-
ment of new treatment plans and techniques for successful delivery. Facial assess-
ment and analysis, and an understanding of the ageing process, are the initial stages
of any aesthetic treatment. Variations in facial contours, anatomy, angles, and pro-
portions exist with race, sex, and age. For example, the highest cephalic index val-
ues occur in the Chinese [1]. In addition, the dental and the maxillary-mandible
relationships vary among different races and have been documented using cephalo-
metric studies [8–10]. There are also gender differences between specific facial
areas, standards of beauty, and aesthetic expectations [8].
This is the first step of patient assessment for facial cosmetic and aesthetic
procedures, assessing both form and function. It is conducted prior to treatment
planning to define the shape, proportions, volume and contour appearance, sym-
metry, visible deformities, and relative position of the facial features. This pro-
cess is ongoing throughout and after the completion of procedure(s). Such
analysis is carried out by direct examination, 2D and 3D photographs under
good lighting and, in the case of pre-surgical preparations, radiographs, CT, or
MRI imaging.
Striving for consistency and reproducibility of facial analysis is recommended
and this can be achieved through developing templates, following steps of analysis,
and documenting the findings.
An accurate facial analysis will enable a practitioner to successfully select
patients for the correct indications, and therefore reduce postoperative complica-
tions due to poor patient selection.
General Assessment
• Client/patient concerns
• Client/patient motivations
• Client/patient emotions
• The dominant facial expression
110 S. Samizadeh
Medical, Dental, Social, and Cosmetic History
As with any patient who attends for medical procedures, including cosmetic proce-
dures, a full medical history should be taken prior to clinical examination. It is not
within the scope of this book to detail the medical conditions that will impact the
delivery of non-surgical aesthetic procedures. However, if the client/patient reports
any significant illnesses at initial assessment it is prudent to contact the General
Medical Practitioner or Consultant Specialist for clarification or further investiga-
tions prior to planning any procedures.
It is important to establish the client’s/patient’s motivation and the level of their
motivation for treatment. If there is a history of repeated and frequent cosmetic
treatments and/or complaints about past treatments and practitioners, constant dis-
satisfaction with the appearance and changes made, and constant occupation regard-
ing appearance or “minor/non-existant” aesthetic issues, body dysmorphic disorder
(BDD) should be considered and referral for psychological assessment and possibly
treatment is recommended.
A patient’s social history should at least include questioning about smoking,
alcohol consumption, and occupation. This will help with risk assessment, informed
consent and affects treatment modality choice. For example, treating the peri-oral
muscles with botulinum toxin injections for a singer, speaker, translator, or musi-
cian who plays a wind instrument will have a detrimental effect on the individual’s
work and daily life, albeit only in the short term and, therefore, the positive aes-
thetic outcome of the treatment may not matter. It is also important to know about
any history of mental health problems, but specialist questioning in this area is most
appropriately undertaken at the psychology interview.
History of Dentofacial Dysmorphology
Assessing the dentofacial structures and dysmorphology and history of previous

treatment/procedures should be a routine part of aesthetic assessment and consulta-
tion. This should include checking for the following:
• Congenital anomalies1 (e.g. growth abnormalities, macrocephaly, microcephaly,
eye anomalies, cleft lip and palate, micrognathia, condylar hypoplasia or agene-
sis, hemi-facial microsomia)
• Familial traits (i.e. other family members with facial dysmorphology: cleft lip
and palate)
• Acquired:
(a) Traumatic
(b) Pathology
(c) Idiopathic
1
Craniofacial anomalies: a diverse group of deformities in the growth of the head and facial bones.
Anomaly: “irregularity” or “different from normal”.
• Ethnic characteristics:
(a) Anterior bi-maxillary protrusion (Black African, Chinese)
(b) Zygomatico-maxillary hypoplasia (Asian)
(c) Chin retrognathia (Asian)
• Progressive facial dysmorphology
Natural Head Position
For accurate and correct assessment and diagnosis, patients should be examined in
the Natural Head Position (NHP). This position is defined as a standardised and repro-
ducible position of the head in an upright posture with the eyes focusing on a point in the
distance at eye level (horizontal visual axis) or looking in a mirror mounted straight
ahead of the patient [4, 6, 10]. This can be achieved by instructing the patient to sit
upright and look straight ahead to a point on the wall in front of them at eye level.
Inappropriate head positioning can compromise facial assessment and result in a false
observation and assessment of the antero-posterior facial angle and jaw relationship.
Habitual tilting of the head is not uncommon and should be avoided. A patient’s head
may need to be adjusted, as people often develop a compensatory head posture in order
to minimize the impact of their facial appearance. For example, people with a small
chin, and a convex facial form may tilt their head up to increase the prominence of their
chin and, in the same manner, people with a large chin will tilt their head down while
those with facial asymmetry may tilt their head in a way to reduce the visible asymmetry
[11]. The peri-oral soft tissues should be relaxed, some individuals, for example those
with incomplete lip seal, tend to habitually purse their lips together through mentalis
hyperactivity and this gives a wrong impression of the lower face height.
Craniofacial Soft Tissue Landmarks
Soft tissue and skeletal landmarks can help facial analysis.
Subunit Analysis
The face is divided into aesthetic units and subunits that are assessed individually
and in relation to each other.
For each subunit, the following should be assessed:
• Height
• Width
• Projection
112 S. Samizadeh
• Transition from one unit to the other

• Relationship to the other units
Analysis: Frontal View
1. Facial type (Fig. 8.2)

• Facial height to width radio
• This ratio will determine if a face is “long”, “short”, or “square”
Basic Facial Shape-Frontal View
The basic facial shape can be a combination of the following:
Basic facial shape (frontal view)

Overall facial shape Square
Round
Triangular
Vertical facial height Reduced
Average
Increased
Transverse facial width Broad (wide)
Normal/Average
Narrow
Basic Facial Shape-Profile View
Facial divergence:
• Inclination/slope of the face in natural head position
• Not the same as facial concavity or convexity
Fig. 8.2 Basic facial types

• For assessing facial divergence, the head should be in a natural head position and
the upper and lower facial planes examined
Facial profile: convex, straight, concave (Fig. 8.3)
• Head in natural head position
• Overall contour is examined
• Relationship between the upper facial plane and lower facial plane
The skeletal pattern of the face describes the relative size of the mandible and
maxilla to each other. Patients are three-dimensional, and therefore the skeletal pat-
tern must be assessed in the following relationships:
• Anterior-posterior
• Vertical
• Transverse
The patient should be examined in the natural head position, as variations to this
position and different head postures can mask the true skeletal relationship [1, 12].
People usually unconsciously adopt different head postures to mask asymmetries
and deficient or excessive features of their face. The method of assessment below
describes clinical analysis of skeletal relationships without the use of radiographs.
Once in the natural head position, ask your patient to gently close their posterior
(back) teeth, examine them in profile, and identify the most concave points on the
upper and lower lip. The most concave point on the upper lip is called point A and
on the lower lip is called point B. The relationship between these two points will
determine the skeletal pattern and relationship. Although the soft tissues outline is
examined, this gives an indication of the underlying skeletal pattern. Variations in
soft tissue thickness may mask the true skeletal pattern or its severity.
Convexity: Sagittal skeletal class II relationship
Due to:
Fig. 8.3 From left to right: Relative position of maxilla to mandible can be examined by palpating
the midline through the base of the lips (points A and B). Class II—mandible is retrusive relative
to the maxilla. Convex profile (mild, moderate, or severe). Class I—mandible lies 2–3 mm poste-
rior to the maxilla. Straight facial profile. Class III—when the maxilla is retrusive relative to the
mandible. Concave profile (mild, moderate, or severe)
114 S. Samizadeh
• Sagittal maxillary excess

• Mandibular deficiency
• Sagittal chin deficiency
• Or a combination of the above
• Increased anterior cranial base length
Concavity: Sagittal skeletal class III relationship
Due to:
• Sagittal maxillary deficiency
• Sagittal mandibular excess
• Sagittal chin excess
• Or a combination of the above
Basic Facial Shape-Parasagittal Profile
Evaluation of the sagittal relationships of the soft tissues extending from the infra-
orbital area to the para-nasal area to the parasymphyseal area.
Basic Facial Shape-Vertical
• Directional pattern of facial growth

• Hyperdivergent growth pattern-long face
• Hypodivergent growth pattern-short face
Facial Curves and Curvilinear Relationships (Fig. 8.4)
The three curvilinear relationships of the face were described by Calvin S Case
(1847–1923). These include:
• Frontonasal curve
• Nasolabial curve
• Labio-mental (mentolabial) curve
Vertical Facial Proportions (Fig. 8.5)
• Facial dimension and proportions

• Asymmetries
The vertical dimension of the face can be measured using a ruler or index finger
and thumb. The face can be divided vertically into thirds and the dimensions of the
upper, middle, and lower, as such facial heights can be compared. The upper facial
height is the distance between the base of the nose to a point in between the
Fig. 8.4 Curvilinear relationships of the face
Fig. 8.5 Facial thirds.

The face is divided into
horizontal thirds. The
upper third extends from
the hairline to glabella, the
middle third from glabella
to subnasale, and the lower
third from subnasale to
menton
116 S. Samizadeh
eyebrows. The lower face height is the distance between the base of the chin to the
subnasale (base of the nose). These two heights are usually equal [12]. The lower
anterior face height and total anterior face height ratio determines the vertical bal-
ance of the face.
• Equal: average facial type
• Reduced ratio: short-faced
• Increased ratio: long-faced
The lower anterior facial third is further sub-divided to enable assessment of the
vertical proportions of the upper and lower lips.
• The upper lip length: subnasale to stomion superius
• The lower lip length: stomion inferius to soft tissue menton
The upper lip length is normally 50% of the length of the lower lip. Incomplete
lip seal is not uncommon and, in such cases, the heights of the upper and lower lips
should be measured individually along with the overall lower face height
proportions.
Transverse (Fig. 8.6):
(a) Rule of fifths: face is divided into equal fifths (width of an eye)
(b) Facial dimensions and proportions
(c) Asymmetries
Fig. 8.6 Transverse facial

widths. Red: bitemporal
distance, White:
bizygomatic distance,
Purple: bigonial distance
Ear Shape and Position
Eyes
(a) Scleral show
(b) Eye lid shape
Lip form and symmetry
The acronym LAMPP can be used (Developed by Dr Farhad Naini) [13].
L: Lip lines
A: Activity (function)
M: Morphology (form)
–– Lip height
–– Lower lip/chin height
–– U and L vermillion height
–– Lip thickness
–– Lip contour and posture
P: Posture
–– Normal muscular tone without excessive muscle contraction at rest
P: Prominence
–– In relation to the nose and the chin.
Assess the Relationship Between
• Bitemporal distance
• Bizygomatic distance
• Bigonial distance
• Mental width
The above widths compared with the facial height will determine the facial form.
Symmetry
Although mild asymmetry is normal and recognized, symmetry is regarded as one

of the constituents of facial beauty. Several studies have reported that perceived facial
attractiveness is greater when the face is symmetrical and closer to average [14–17].
Craniofacial surface morphology can be assessed by direct anthropometry, digital
photography, and three-dimensional surface imaging systems. To assess facial sym-
metry it is recommended to examine the patient in an upright position as facial
symmetry is best judged when a patient is upright [18].
118 S. Samizadeh
Vertical Asymmetries
Upper Face
To evaluate vertical asymmetries, the inter-pupillary line should be used as a refer-
ence. Without the presence of anomalies such as dystopia, this would be a reliable
reference point.
Vertical Mandibular Asymmetry

This would present in patients who suffer from condylar hyperplasia, hypoplasia or
agenesis, which affects the height of the rami.
Facial Midline
Subtle facial asymmetries are not uncommon; however, only significant asymme-
tries require further assessment. To assess this, the facial midline should be found.
The inter-pupillary line is marked, followed by a line running down the middle of
the forehead. This line bisects the inter-pupillary line. The line continues down
through the middle of the dorsum of the nose and philtrum of the upper lip.
Upper Face
The lateral projection of the zygomatico-orbital complex should be assessed for
symmetry.
Analysis: Oblique View
The following features of the face can be examined in the oblique view:
• Temporal
• Zygomatic
• Orbital
• Cheek
• Paranasal
• Preaucular
• Mandibular angle
• Jaw line
• Submental area
During examining the oblique view, the lateral regions of the face can be evalu-
ated followed by the profile of the face on the opposite side.
Analysis: Lateral
Both sides of the face should be examined separately. The characteristic differences
will be detected in asymmetric faces. The following can be assessed by examining
the face from a lateral point of view:
• Jaw relationship
• Facial profile: straight, convex, concave
• The projection of the forehead
• Infra-orbital rims
• Nose
• Para-nasal region
• Nasolabial angle: between the philtrum to upper lip
• Upper lip
• Lower lip
• Lower lip and chin
• Lower lip to submental plane angle
• Mandibular plane angle
Infra-Orbital Rims
The relative position of the antero-posterior position of the infra-orbital rim can be
assessed to:
• the globe of the eye
• the supra-orbital ridge.
An underdeveloped infra-orbital rim usually accompanies high-level deficiency
of the maxilla and a hypoplastic mid-face.
Para-Nasal Region
Para-nasal hollowing is the result of a lack of bony support for the soft tissues in this
region, this is indicative of low level antero-posterior maxillary deficiency.
Upper Lip
The form and angle of the upper lip can be assessed. The slope of the columella and
the curvature of the upper lip and the angle can be measured in a number of differ-
ent ways.
An increased nasolabial angle could be the result of maxillary deficiency.
120 S. Samizadeh
Lower Lip and Chin
The profile balance of the lips in relation to the nose and chin and the anterior-
posterior relationship of the chin in relation to the forehead and upper face should
be assessed. The depth of the labio-mental fold determines the curvature of the
lower lip. That, in turn, usually reflects:
• the inclination of the lower incisors
• the antero-posterior position of the chin point (soft tissue pogonion)
• the lower anterior face height.
An accentuated labio-mental fold is produced as a result of a reduced lower ante-
rior face height accompanied with progenia. Retrogenia and increased vertical
dimensions results in a flat lower lip.
Lower Lip to Submental Plane Angle
The angle of the lower lip to the submental plane (throat) should be close to a right
angle in an average face and to be aesthetically pleasing. The angle depends on:
• Inclination of the lower lip
• The slope of the submental plane (this varies with the degree of mandibular
prognathism)
• The chin position
• Vertical dimension of the face
• Presence of submental adipose tissue
Mandibular Plane Angle
To assess the angle of the mandibular plane, place your index finger or a ruler along
the lower border of the mandible and the Frankfort Plane. These two planes inter-
sect just behind the back of the head where the angle is average. The right and left
mandibular planes may differ due to asymmetry and must be assessed separately.
Conclusion
Facial assessment is a skill and an art. It requires practice, repetition, and the devel-
opment of an aesthetic eye.
References
1. Naini FB. Facial aesthetics: concepts & clinical diagnosis. Boca Raton, FL: Wiley; 2011.
2. Naini FB. Lip seals. Br Dent J. 2010;209(3):106.
3. Naini FB, Gill DS. Facial aesthetics: 2. Clinical assessment. Dent Update. 2008;35(3):159–70.
4. Naini FB. Clinical diagnostic records, natural head position and cranifacial anthropometry. In:
Facial aesthetics: concepts & clinical diagnosis. Boca Raton, FL: Wiley; 2011. p. 71–85.
5. Lundström A, et al. Natural head position and natural head orientation: basic considerations in
cephalometric analysis and research. Eur J Orthod. 1995;17(2):111–20.
6. Naini FB. The Frankfort plane and head positioning in facial aesthetic analysis—the perpetu-
ation of a myth. JAMA Facial Plastic Surg. 2013;15(5):333–4.
7. Yang CE, et al. Correction of eyes and lip canting after bimaxillary orthognathic surgery.
Yonsei Med J. 2018;59(6):793–7.
8. Larrabee W, Makielski K, Henderson J. Variations in facial anatomy with race, sex, and age.
In: Larrabee W, Makielski K, Henderson J, editors. Surgical anatomy of the face. Philadelphia:
Lippincott Williams & Wilkins; 2004. p. 22–8.
9. Zhuang Z, et al. Facial anthropometric differences among gender, ethnicity, and age groups.
Ann Occup Hyg. 2010;54(4):391–402.
10. de Freitas LMA, et al. A comparison of skeletal, dentoalveolar and soft tissue characteristics
in white and black Brazilian subjects. J Appl Oral Sci. 2010;18:135–42.
11. Naini FB, Naini FB. Clinical diagnostic records, natural head position and cranifacial anthro-
pometry. In: Facial aesthetics. Boca Raton, FL: Wiley; 2011. p. 71–85.
12. Roberts-Harry D, Sandy J. Orthodontics. Part 2: patient assessment and examination I. Br Dent
J. 2003;195(9):489–93.
13. Naini FB, Gill DS. Facial aesthetics: 1. Concepts and canons. Dent Update. 2008;35(2):102–7.
14. Baudouin J-Y, Tiberghien G. Symmetry, averageness, and feature size in the facial attractive-
ness of women. Acta Psychol. 2004;117(3):313–32.
15. Fink B, et al. Facial symmetry and judgements of attractiveness, health and personality.
Personal Individ Differ. 2006;41(3):491–9.
16. Jones BC, DeBruine LM, Little AC. The role of symmetry in attraction to average faces.
Percept Psychophys. 2007;69(8):1273–7.
17. Komori M, Kawamura S, Ishihara S. Averageness or symmetry: which is more important for
facial attractiveness? Acta Psychol. 2009;131(2):136–42.
18. Jackson TH, et al. Face symmetry assessment abilities: clinical implications for diagnosing
asymmetry. Am J Orthod Dentof Orthop. 2013;144(5):663–71.
Part III
Technologies and Techniques
Chapter 9
Skin Aging and Skincare
Asian, Skin Aging and Skincare
Aging is a complex process, with biology, environment, genetics and culture all
influencing the aging process. In addition, skin varies not only in structure and func-
tion, but also in appearance as it ages, depending on race [1]. Skin is subjected to
internal and external factors such as sun exposure and climate conditions. Due to the
great variation in genetic diversity, climate, and culture, the signs associated with
aging may also vary greatly between various ethnicities. In Asia, with its vast terri-
tory, large population, and diverse cultures, there are big differences in the signs of
aging including pigmentation, wrinkles, and photoaging [2].
Intrinsic and Extrinsic Aging
There are many factors (both internal and external) that can affect skin with aging.
The main characteristics of aging skin include rhytids, texture change, loss of firm-
ness and sagging, vascular abnormalities, and pigmentary problems. These changes
are consistent with changes in the structure and function of the skin. Intrinsic aging
Z. Zhou (*)
Dr. Zhou’s Cosmetic Dermatological Clinic,
Nanjing, Jiangsu Province, People’s Republic of China
S. Samizadeh

https://doi.org/10.1007/978-3-030-84099-0_9
126 Z. Zhou and S. Samizadeh
is related to the genetic background [1]. Extrinsic aging is related to the environ-
mental factors and lifestyle. Such factors include sun exposure, diet and nutrition,
smoking, alcohol intake, and exercise. The most important extrinsic factor is chronic
sun exposure. The most common clinical manifestation is dyspigmentation fol-
lowed by sunspots, lentigoes, wrinkles, telangiectasia, pigmentation problems, and
skin laxity [1, 3]. Pigmented skin has a strong protective function, so it is less dam-
aged by sunlight. Therefore, the clinical manifestations of aging are less severe, and
skin aging symptoms appear 10–20 years later than those of caucasian people [4].
Photoaging Features of Asian Skin
Ethnic differences in skin type results in varied presentation of skin aging (Fig. 9.1).
Pigmentation/dyspigmentation are the main signs of aging in Asians in comparison
to rhytids in Caucasians (Fig. 9.2). In a study comparing age-matched Chinese
women with French white women, with similar environmental factors, rhytids were
delayed by 10 years and pigmentation spots density was greater in Chinese women
than in white French women [6]. Another study reported similar results, studying
500 Japanese and French women of similar ages with similar lifestyle and sun expo-
sure. French women had earlier and more severe photoaging and wrinkles and
Japanese women had earlier and more severely of pigmentation spots [7].
In Asia, skin conditions vary widely from region to region with heterogeneous
characteristics of different Asian populations. An epidemiological survey of skin
conditions was conducted studying healthy women aged 14–75 years from eight
Asian cities: China (Harbin, Guangzhou, and Shanghai), India (Calicat, New Delhi),
South Korea (Seoul), Japan (Sendai), and the Philippines (Manila). The results
shown that the most significant correlations with aging were wrinkles and sagging,
followed by pigmentation. Skin elasticity decreased and fatigability increased with
age in all 8 cities, with Harbin and Guangzhou having the lowest fatigability. The
skin of Asian people gradually turns sallow (yellow tone) with age, the people of
New Delhi being the most obvious. The biggest changes in sallowness were
observed in Chinese and Koreans with aging. The amount of moisture and TEWL
on the skin decreased with age in all subjects. The Japanese have the highest skin
moisture content, and the average TEWL level is the highest in Guangzhou and
Harbin. This indicates poor skin barrier function. Skincare regime starting at an
early age was reported to be associated with less wrinkling with age. In Japanese
and Koreans, early skincare habits with regular daily use were associated with less
severe photodamage, skin roughness, wrinkles, mottled hyperpigmentation, laxity,
and sallowness. In general, Japanese subjects exhibited the best conditions and had
the least deterioration with age [2].
9 Skin Aging and Skincare 127
Caucasian
Aging
Small melanosomes
Thinner dermis Photodamage
Less melanin
Decreased elasticity Loss of collagen
Thinner stratum corneum
Decreased TEWL
Oriental
Thinner stratum corneum Dyspigmentation

Preserved dermal
Decreased TEWL Hyperpigmentation
elasticity
Dense eccrine glands
Asian
More melanin Thicker dermis

Dyspigmentation
Photoprotection Compacted collagen
Preserved elasticity
African
More melanin Thicker dermis

Photoprotection More fibroblasts Frequent xerosis
Thicker stratum corneum Compacted collagen Dyspigmentation
Increased TEWL Preserved elasticity
Fig. 9.1 Representative differences within the epidermis and dermis among four ethnic skin types
and the age-related changes typical for the traits sensitive to environmental damage. TEWL: tran-
sepidermal water loss [5]. With permission from Markiewicz, E. and O.C. Idowu, Personalized
skincare: from molecular basis to clinical and commercial applications. Clinical, cosmetic and
investigational dermatology, 2018. 11: p. 161–171
Fig. 9.2 Pigmentation/

dyspigmentation are the
main signs of aging in
Asians in comparison to
rhytids in Caucasians
Prevention of Photoaging
The Effect of Environment on Skin
The environment has an impact on skin aging, including the direct effects of ultra-
violet, visible, infrared, and heat (Fig. 9.3). Air pollution is also a growing concern
because it affects the process of photoaging by triggering a variety of pathophysio-
logical processes in the body, including oxidative stress, matrix metabolic enzymes,
and by regulating cytokines and genes.
Effects of Ultraviolet
Two types of ultraviolet light reach the surface: UVB (290–320 nm) and UVA
(320–400 nm) [8]. UVB was thought to be the main source of the sun’s effects, but
now it seems that UVA also plays a very important role. UVA, the main UV compo-
nent of sunlight, is 20 times more likely to reach the surface than UVB (which
accounts for 95% of surface UV), penetrates deeper into the skin than UVB, and
causes noticeable changes in the skin’s connective tissue (Fig. 9.4). UVB gets to
earth in relatively small amounts, but at higher energies than UVA. It should be
emphasized that UV exposure is related to many geographical factors, such as loca-
tion and environment: latitude, season, time of day, meteorological conditions, and
ozone layer thickness. The influence on UVA and UVB of these geographical fac-
tors is quite different (Table 9.1). UVA is less affected by these factors and its varia-
tion amplitude is smaller than that of UVB radiation. For example, UVA irradiance
is less affected by season and less weakened in winter. Time of day also plays an
important role. The amount of UVA and UVB gradually increases during the day,
peaks around noon, then gradually decreases, while UVB peaks between 10:00 to
16:00 but UVA is different, it exists consistently for most of the day. Another inter-
esting feature of UVA is that it penetrates glass, whereas UVB rays are almost
Increasing Frequency (Q)

1024 1022 1020 1018 1016 1014 1012 1010 108 106 104 102 100 Q(Hz)
J rays X rays UV IR Microwave FM AM Long radio waves

Radio waves
10-16 10-14 10-12 10-10 10-8 10-6 10-4 10-2 100 102 104 106 108 O(m)
Increasing Wavelength (O)
Visible spectrum
400 500 600 700

Increasing Wavelength (O) in nm*
Sunlight
Gamma rays X-rays UV Infrared Radio waves
0.1 nm 1 cm
UV-C UV-B UV-A
300 nm 400 nm 500 nm 600 nm 700 nm
Fig. 9.3 Spectrum of solar radiation. VIS visible light, IR infrared
completely absorbed by glass. So even in indoor conditions, when UVB is filtered

out, UVA remains [9].
About 70% UVB is absorbed by the Stratum corneum, with about 20% UVB
reaching the epidermis. By the time it reaches the superficial layer of the dermis, it
may be only about 10%. UVA is different in that very little of it is absorbed by the
epidermis, and eventually about 20–30% of it reaches the deep layer of dermis.
Therefore, UVB has a greater effect on the epidermis than UVA, which may be a
major factor in skin photoaging and is also involved in the development of skin
cancer. In addition, the role of full-band UV should not be underestimated. In fact,
some changes in skin may be related to the cumulative dose of full-band UV radia-
tion [10]. The effect of UVA on Asian skin is particularly important because of the
low latitude in Asia, where UVA appears to have a greater impact on major
cities [8].
No UVA +UVA
a
Imm. 6h 2 days
b
No UVA
Oxidative stress Fiberoblasts alterations Fiberoblasts death

c
After UVA
exposure
Fig. 9.4 Left-hand side: UVA exposure induces alterations of epidermal and dermal protein
expression. Immunofluorescence microscopy using antisera against ferritin (a), tenascin (b), and
lysosyme (c). Right: Biological changes observed in vitro in reconstructed model without or after
UVA exposure. Oxidative stress was revealed by DCFH-DA probe, fibroblast alterations corre-
spond to apoptotic process (TUNEL reaction), and disappearance of dermal fibroblasts was
revealed by histology (HES staining) [9]
Table 9.1 Effect of environment on UVA and UVB illumination

UVA UVB
Wavelength 320–400 nm 290–320 nm
Surface UV composition ratio 95% 5%
Glass blocking capacity Can penetrate Cannot penetrate
The skin penetration Deeper Superficial
Seasonal influence Weaker, stable through seasons Strong, less in winter
The day affect Consistent throughout Strongest between
10:00–16:00
The damage of UVA to the skin is cumulative, and photoaging and photocarcino-
genesis can only occur after chronic and accumulated exposure to UVA. UVA is
also a major cause of pigmentation in photoaging. In Asian skin, there is a mix of
individual melanosomes (about 60%) and aggregated melanosomes (about 40%),
while European skin 85% is aggregated melanosomes. The density and size of
melanosomes in Asian skin vary greatly, which may explain why irregular spot pig-
mentation occurs. It has been proved that UVA can induce pigment formation more
than UVB in dark-skinned individuals, and the oxidative stress response induced by
UVA is more sensitive in dermis fibroblasts than in keratinocytes, and UVA can
directly induce dermal fibroblasts to produce Matrix metalloproteinase-1

(MMP-1) [9].
Effects of Infrared Light on Skin (IRA)
IRA can completely penetrate the skin and produce many biological effects on der-
mis, and is involved in the photoaging process [11]. IRA can change the transcrip-
tome of human skin fibroblasts, thereby affecting the stability of the extracellular
matrix, cellular apoptosis and growth, and stress responses. IRA can induce the
expression of MMP-1 mRNA, but its inhibitor tissue inhibitor matrix metallopro-
teinase 1 (TIMP-1) is not affected by IRA. Thus, IRA may directly accelerate col-
lagen fiber decomposition, and eventually the formation of deep wrinkles. Another
possibility is that IRA, like UV, can induce reactive oxygen species (ROS) produc-
tion and thus participate in photoaging damage. IRA may act on different chromo-
phore due to the different wavelengths. For example, UVB acts on both nuclear
DNA and cytoplasmic tryptophan, UVA may affect intracellular signaling (the
structure on cell membrane), and IRA is strongly absorbed in mitochondria. IRA
“heat” may be a factor in skin photoaging, and that exposure to natural sunlight
through black cloth cover (which absorbs ultraviolet and infrared rays, but generates
heat) still increases MMP-1 expression (although to a lesser degree than direct
exposure without cloth cover) [11]. The concept of thermal aging has even been
proposed, may be related to the production of reactive oxygen species caused by
thermal stimulation [12].
Visible Light
There is little research on the relationship between visible light and skin. At present,
it is known that visible light can stimulate the skin to produce reactive oxygen spe-
cies, and that artificial visible light (wavelength 400–800 nm without UV) at a dos-
age of 80–480mw/cm2 can cause skin pigmentation reaction, which has been
confirmed by histopathological on the other studies [11].
However, visible-induced pigmentation appears to occur only in darker skin
types (i.e., Fitzpatrick IV and darker skin types) and can induce or exacerbate
melasma and other hyperpigmentation skin diseases. In addition, visible light also
up-regulates the mRNA of MMP-1 and TNF-α, together with reactive oxygen spe-
cies in the skin, they can promote collagen degradation and participate in photoag-
ing [11]. Studies have shown that half of the free radicals produced in the skin may
be caused by the visible light.
Low energy blue light is clinically used for the treatment of hyperplastic skin
diseases and acne vulgaris, but high dose and long-term exposure can induce free
radicals, and can cause damage to the skin. Even HEV light from electronic devices
such as computer screens and big screen smart phones can cause skin damage. This
damage is thought to be caused by free radicals in the skin causing oxidative stress,
which is involved in photoaging. In addition, most sunblocks offers no protection

against visible or near-infrared radiation [13].
Effects of Pollution on Skin
More and more researchers are paying attention to the relationship between air pol-
lution and skin. At present, air pollution is known to be related to the incidence of
skin diseases. It is also involved in the biological process of photoaging, affects of
collagen synthesis in the skin by inducing oxygen free radical, and can cooperate
with the harmful effect of light on the skin. Finally, some toxic particles of air pol-
lution may directly affect skin health [13].
Existing Skin Protection
The production of reactive oxygen species in the skin has several biologically dam-
aging functions: oxidative nucleic acids, lipids, and proteins, all of which are associ-
ated with photoaging and skin cancer. Up-regulated matrix metalloproteinases
(MMPs)-1 degrade and destroy skin collagen and elastin. Therefore, it is extremely
important to provide strong full-band sun protection for the skin, including sun-
shade, sunscreen, and antioxidants, to prevent photoaging [14].
Broad-Spectrum Ultraviolet Protection
It is recommended to wear protective clothing (such as long sleeves and wide-

brimmed hats), install anti-ultraviolet film on windows, and apply sunscreen.
Sunscreens can be roughly divided into absorbent (chemical sunscreen) and reflec-
tor (physical sunscreen), which are composed of organic compounds (benzophe-
nones, avobenzone, ecamsule, methyl anthranilate, salicylates, cinnamates, etc.)
and the inorganic metal particles, respectively. The sun protection factor (SPF) of
sunscreen reflects the ability of UVB protection. The greater the value, the greater
the protection. While PA+ (low) to PA+++ (high) describe the protection capabil-
ity of UVA.
The commonly used functional ingredients in chemical sunscreen products
include oxybenzone, avobenzone, octanoate, octenoic acid, trimethylcyclohexyl
salicylate (homosalate), and octinoxate (octinoxate), but the combination and ratio
of these ingredients in specific products vary. The basic principle of chemical sun-
screen is to absorb ultraviolet light and convert it into infrared light (and thus lower
energy). Disadvantages include allergic reactions and “heat” due to the conversion
of infrared light. Even some products have been reported to have neurotoxic and
hormone-like effects. There have been reports of chemical sunscreens entering the
environment as a result of swimming in seawater and posing a risk to small Marine
life. In 2018, the state of Hawaii signed a law banning the use of oxybenzone and
octinoxate because of their harmful effects on coral reefs, a law echoed by cities like
Miami and the Florida Keys [13].
The basic principle of sunscreen is to reflect, disperse, and absorb solar radiation.
It usually contains two effective ingredients: titanium dioxide and zinc oxide. Zinc
oxide has protective effects against UVA and UVB, and titanium dioxide mainly
attenuates UVB radiation. The greatest advantages of physical sunscreen are that it
is less irritating, more suitable for sensitive skin, and more environmentally friendly.
Zinc oxide and titanium dioxide are recognized as safe sunscreen ingredients [13],
but they also have their disadvantages: difficultly achieving a high SPF without feel-
ing greasy and heavy. Many physical sunscreens in the past used opaque ingredients
that gave them a white latex paint appearance. With the birth of new materials, at
present, physical sunscreen has been qualitatively improved. Nanoscale fine parti-
cles have been developed to reduce white pigmentation of skin and/or clothing; But
it also brings up another debate: whether the skin absorbs it.
Visible and Infrared Light Protection
A growing number of independent studies from Europe, Asia, and the United States
have shown that visible (400–770 nm) and infrared (IR) spectra (770 nm–1 mm),
especially near-infrared (IR or IRA) (770–1400 nm) are also involved in the photo-
aging process of skin. Sun protection should therefore probably not only be limited
to UV protection, but should include full-band protection of visible and IRA radia-
tion. Unfortunately, most of the conventional sunscreens mentioned so far only
block ultraviolet light, offering no protection against visible light and IRA, although
some sunscreens and daily care products claiming to have IRA and visible protec-
tion have been available since 2006 [11].
For now, the simple solution is topical antioxidants, which provide true IRA
protection. Unfotunately, not all antioxidants work. It is reported that topical vita-
min C, vitamin E, ubiquinone (coenzyme Q), and grape seed extracts antioxidant
mixture can effectively prevent the IRA radiation by inhibiting the expression of
MMP-1 mRNA in human skin in vivo [11]. If this functional ingredient is properly
combined and used properly, the protective effect and antioxidant effect of IRA may
be further improved [11].
Pollution Protection
The relationship between air pollution and skin health is a newly researched topic
which is far from adequate. Air pollution is known to cause ozone and the produc-
tion of reactive oxygen species in the skin, which may be linked to photoaging.
There is no ideal method for personal protection against environmental pollution.
Recommended methods include topical applications to improve skin barrier
function (reducing the penetration of pollutants) and topical application of antioxi-

dants (neutralizing reactive oxygen species). For example, topical use such as vita-
min C and E can prevent damage caused by environmental pollution. Other
protective ingredients for topical use include antioxidants, vitamins, moisturizing
molecules, quercetin, aloin, silymarin, green tea extract, color alkanes (chromane/
benzodihydropyran) keel plant extract, ginseng, and water [13].
Cosmeceuticals
Cosmeceuticals (a combination of cosmetics and pharmaceuticals) are skincare

products that have a theoretical therapeutic effect on the skin. They are like topical
drugs in terms of efficacy and like cosmetics in terms of the usage. The term was
used in 1984 by dermatologist Albert Kligman, who discovered the anti-aging
effects of topical retinoic acid and its derivatives on the skin. American dermatolo-
gist Dr. Eugene Van Scott and pharmacologist Dr. Ruey Yu discovered the molecu-
lar mechanism of α-hydroxy acid on the skin and marketed it as a cosmetic
compound 10 years later (1989). Subsequently, antioxidants based on vitamins C, E
and plant extract were developed (Table 9.2). A double-blind, randomized, con-
trolled trial in 2009 confirmed the efficacy of the skin care product.
Anti-photoaging
Retinoic Acid and Its Derivatives [14]
• Retinoic acid is a derivative of vitamin A

• Antioxidant effect
• Some bioactive forms can repair photodamage (facial fine lines, mottled pigmen-
tation, and rough skin)
Table 9.2 The milestone of cosmeceutical development

Time Milestones
1960s: Kligman: Sunlight alters skin physiology
1970s: Van Scott & Yu: The effect of α-hydroxy acid on skin pathophysiology
1980s: Kligman: The anti-aging effect of topical retinoic acid
1990s: Van Scott & Yu: The anti-skin aging/photoaging effect of α-hydroxy acid
2000s: Pinnell et al.: The antioxidant effect of topical vitamins C and E
2010s: Watson et al. confirmed the anti-wrinkle effect of topical retinoic acid and its
derivatives.
However, retinoic acid is highly irritating and is prescription only. Although not
as effective, retinol, retinol aldehyde, and retinol palmitate are some of the retinoids
found in over the counter products.
Retinol
Retinol can oxidize and convert to retinaldehyde, which is then further converted to
retinic acid, which is an active vitamin A derivative. Studies have found that 1%
retinol reduces the expression of MMP in the skin and stimulates collagen synthe-
sis. In addition, randomized controlled trials found significant improvements in fine
wrinkles after 12–24 weeks of topical treatment.
Retinaldehyde
Retinal (retinaldehyde) is the aldehyde form of vitamin A and an intermediate in the

transformation of retinol into retinoic acid. It is also an active ingredient often found
in products. It has an anti-aging effect on external use to improve fine lines and the
overall appearance of skin.
Retinyl Palmitate
Retinyl palmitate is formed by combining Retinyl with palmitate. It has been dem-
onstrated to have a protective effect against UVB by inhibiting the formation of
thymine dimer caused by UVB. In addition, clinical studies have shown that it may
promote the deposition of fibrillin-1 and thus maybe have certain anti-aging effects.
It is not clear whether retinol palmitate has anti-aging properties also.
All-Trans Retinoic acid [15]
There are two types of retinoic acid receptors: RAR and RXR, both of which are in
the nucleus of the cell. Upon entry into the cells, all-trans retinoic acid binds to them
and initiates a programmed transcription process that regulates epidermal keratini-
zation, collagen synthesis, and matrix metalloproteinase (MMP) synthesis. Topical
all-trans-retinoic acid is currently the most well-documented anti-aging treatment.
The possible mechanisms of all-trans tretionic include stimulating collagen synthe-
sis and inhibiting UV-induced MMP synthesis. It has been clinically confirmed that
the collagen content and epidermal thickness of the skin increased after topical all-
trans retinoic acid. In addition, it is possible to inhibit the expression of enzyme
tyrosinase, increase the turnover of the epidermis, and promote the metabolism of
melanin, so it has a certain whitening and depigmentation efficacy.
Therefore, topical use of Tretinoin (all-trans-retinoic acid) has anti-aging effects

but causes skin irritation. As a result, it is rarely allowed to be added into cosmetics.
With the emergence of many vitamin A acid derivatives, these intermediate metabo-
lites are added to cosmetics as a main alternative to all-trans vitamin A acid. Such
as retinol and retinyl ester have less anti-aging effect in comparison. All-trans-
retinoic acid and its metabolites are unstable in sunlight and atmosphere and easy to
oxidize. However, it is suitable for use at night and should be stored with extra care.
Topical Antioxidants
The pathological mechanism of skin aging is complex, among which redox reac-
tions of the skin is an important final part of skin aging, especially photoaging.
Current research shows that environmental pollution, ultraviolet radiation, and
internal aging are all involved in the process of oxidation. Oxygen radicals are
chemical reactions of molecular oxygen, and the theory is that intracellular reactive
oxygen species, produced in the mitochondria can oxidize cell structure and dam-
age cell function. Oxidative stress can also cause ECM collagen to break down and
fragment. Therefore, antioxidant treatment naturally becomes a very reasonable
anti-aging approach, especially for direct topical use of products with antioxidant
effects on the skin. The products are abundant and varied, mostly from plant
extracts [16].
Vitamin C [14]
Vitamin C, also known as Ascorbic Acid, is the most common topical antioxidant
that reduces the effects of oxidative stress on the skin. Human beings cannot
synthesize vitamin C and rely almost entirely on dietary supplements, with only
a small portion of the vitamin ending up in the skin. Only L-vitamin C can suc-
cessfully penetrate the skin, ordinary vitamin C is absorbed by the skin very
rarely and with great difficulty. Even L-Vitamin C requires a high concentration
(for example, 15%) to be effective. It has a half-life of about 4 days in the skin,
and it is consumed by neutralizing oxygen groups during oxidative stress. The
ideal pH value of vitamin C solution is 3.5, which is relatively stable in this
environment.
It has been proved that vitamin C has a good clinical effect of anti-oxidation.
Topical application of stable form of ascorbic acid promotes the synthesis of type I
and III collagen and provides photoprotection against UVA and UVB radiation.
Topical application of ascorbic acid also has anti-inflammatory functions, inhibiting
tumor necrosis factor α and the activation of κB (nuclear factor B). When stored, it
must be sealed to prevent oxidation and inactivation.
Vitamin E [14]
Vitamin E is one of the most used antioxidants, after vitamin C. Its bioactive form is
α-tocopherol, which has long been considered to have effective anti-aging properties,
even when taken orally. Topical application has been shown to reduce and prevent
sunburn, neutralize free radicals, and act as a moisturizer. Additionally, vitamin E
seems to effect the synthesis of matrix metalloproteinases to adjust the breakdown of
collagen and elastin. But there has been no clinical report on the improvement of
photoaging by topical vitamin E alone. Neither vitamin C nor vitamin E alone is
effective in preventing UV-induced skin damage. L-Vitamin C and Vitamin E in
combination are effective, 15% vitamin C (L-ascorbic acid) combined with 1% vita-
min E (alpha-tocopherol) shows a good protective effect against oxidative stress.
Another compound (containing vitamins C, E, and ferulic acid) showed a stronger
antioxidant effect, increasing its ability to resist UV-induced light damage by up to
four times and increase MED, so it can be used as an effective sunblock [15].
α-Lipoic Acid [14]
α-Lipoic acid (ALA) is an essential cofactor of the mitochondrial multi-enzyme

complex and therefore plays an important role in energy metabolism. Topically,
ALA has anti-inflammatory properties and acts as an exfoliant. 5% ALA applied
topically for 12 weeks was reported to reduce skin roughness and fine wrinkles.
Vitamin B3 [14]
Vitamin B3, also known as niacinamide, which is the amide form of niacin, is an
effective antioxidant. Like most other antioxidants, nicotinamide is unstable when
exposed to the atmosphere.
Topical niacinamide has many benefits:
• repair the function of Stratum corneum
• improve the function of skin barrier
• anti-saccharification effect
• reduce the saccharification phenomenon in the process of skin aging (improve
the sallowness appearance of skin)
• interfere with the transfer process of melanosome in the epidermis (inhibit
pigmentation)
• Anti-inflammatory effect
Its anti-inflammatory effect is not only used as an adjunctive treatment for many
bullous diseases in dermatology, but also as a topical treatment for acne vulgaris.
Recently, it has been clinically shown to have a good anti-aging effect on skin, sig-
nificantly reducing fine lines and wrinkles, and improving skin elasticity.
N-Acetyl-Glucosamine [14]
Glucosamine and N-acetyl-glucosamine (NAG) both belong to the amino-mono-

saccharide group. The latter is a derivative of the former but more stable. Both are a
precursor of the synthesis of glycosaminoglycan hyaluronic acid and proteoglycan
of matrix. Oral treatment can improve skin hydration, while topical treatment can
speed up wound healing. When topical application is combined with niacinamide,
they can reduce skin wrinkles. In addition, it can inhibit the activation of tyrosinase,
thus inhibiting the production of melanin, topical use can improve skin pigmenta-
tion, combined with topical nicotinamide and NAG can synergize with its anti-pig-
mentation effect.
Hydroxy Acids [17]
α-hydroxy acids (AHAs) have been widely recognized and used in dermatology,
especially cosmetic dermatology, since 1970. The application methods include
chemical peeling and cosmeceuticals. There are many kinds of α-AHA, such as
glycolic acid, malic acid, lactic acid, citric acid, α-hydroxyethanoic acid,
α-hydroxyoctanoic acid, hydroxycaprylic acid, α-hydroxycaprylic acid, and
hydroxyl fruit acids. Benefits include moisturizing, lightening, acne treatment, anti-
aging, and anti-glycosylation. The α-AHAs peeling (20–70%) accelerates the
regeneration of normal skin, improves acne, and has anti-aging effect. α-AHA, peel-
ing and topical using, can promote epidermal renewal, thickening, increase of acidic
mucopolysaccharide in dermis, increase of collagen density of dermis, and improve-
ment of elastic fiber quality [14]. However, OTC products must have concentrations
below 10%.
In addition to the AHA, the newer AHAs, such as polyhydroxy acids (PHA)/
Bionic acids have been developed to reduce the irritation of the AHA on the skin,
while maintaining their moisturizing and barrier repairing properties. In vitro cell
culture models demonstrated that different concentrations of gluconolactone (PHA)
inhibited solar elastic fibers by downregulating UV-induced elastin denaturation
genes. In the model of banana skin oxidation and discoloration, gluconolactone and
lactose acid were shown to have strong antioxidant capacity. Clinical trials showed
that cream containing 8% glycolic acid and 8% L-lactic acid could significantly
improve the severity of light damage to skin and increase skin thickness [17]. This
effect may be due to the increased synthesis of collagen I and mucopolysaccharide
(GAGs), which is the main structure of hyaluronic acid molecules and normalizes
epidermal hyperplasia. Polyhydroxy/bionic acids are called second- and third-
generation hydroxy acids, respectively. These acids have a large molecular struc-
ture, good moisture, and low irritation.
Fig. 9.5 Grape

compounds
Promising New Actives
Grape Compounds [14] (Fig. 9.5)
Resveratrol
Resveratrol is a stilbenoid, a natural phenol produced when plants are attacked by
pathogens. Resveratrol is most found in the skins of red grapes and some other
fruits. Resveratrol has:
• good antioxidant effect
• anti-inflammatory properties
• can neutralize super oxygen from mitochondria internal groups
• can inhibit carcinogenesis and light damage caused by UV radiation
• Anti-aging properties
Some studies found that resveratrol seems to prolong the life of flies, and called
it “longevity factor.” It has been recommended as an adjuvant treatment for acne. In
vitro and in vivo studies in animal models have shown that topical resveratrol pen-
etrates the skin in a gradient manner and is capable of retaining its antioxidant and
anti-inflammatory properties once inside the skin [18, 19]. Therefore, topical resve-
ratrol may also have therapeutic effects on photoaged skin.
Flavonoids
These are the effective ingredients of polyphenols in many plants. For example,
grapes contain a variety of flavonoids, all of which have antioxidant functions.
Studies have found that they all protect keratinocytes from oxidative damage caused
by ultraviolet light.
Grape Seed Extract

Grape seed extract has a good antioxidant effect. A 2011 study found that oral
administration of grape seed extract reduced the risk of squamous cell carcinoma.
However, clinical studies are needed to confirm whether it has anti-aging and can
improve the symptoms of photoaging. Currently, this antioxidant is known to speed
up the healing of wounds.
Soy Isoflavones
Soy isoflavones are natural organic compounds called phytoestrogens that are of
interest to market researchers. Some studies have suggested that oral soy isofla-
vones can improve skin appearance, especially in postmenopausal women, and topi-
cal soy isoflavones can protect skin from UVB damage, but whether topical soy
isoflavones can improve skin appearance is still uncertain.
Tea Polyphenols
Polyphenols contained in green tea can inhibit the carcinogenic activity of ultravio-
let radiation. Topical green tea polyphenols can improve photoaging skin. Although
the anti-photoaging effects of tea polyphenols in vitro are encouraging, some clini-
cal studies got conflicting results. There are some cosmeceuticals based on green tea
extract on the market, good clinical studies are needed in the future to elucidate their
skin benefits [14].
Dimethylaminoethanol
Dimethylaminoethanol (DMAE) is an analog of choline and a precursor of acetyl-

choline. It can be found not only in cosmeceuticals, and even in some formulations
of mesotherapy injections, however little is still known about this compound. One
study showed that after 16 weeks of daily topical use of 3% DMAE gel, the wrinkles
in the forehead and fine lines around the eyes decreased, as well as improvements in
the shape and fullness of the lips, which improved the global appearance of photo-
aging skin. Studies of hairless mice and humans’ skin have shown that dermal thick-
ness increases, and collagen fibers increase after DMAE is applied externally. It can
also be found that water content in stratum corneum increased after topical use on
the forearm skin, which constitutes the basis for the cosmeceutical efficacy based on
DMAE [14].
Black Currants (R. nigrum L, RN) [20]
Black currants have many skin health benefits, including anti-oxidation, and anti-
UV-induced photoaging. The pathologic mechanisms are very complex, which pos-
sibly involve the downregulation of MAPK-related signals, such as activated protein
1 (AP-1) and nuclear factor kappa B (NF-kB), and growth factor TGF-β was up-
regulated by the adjustment of phase II gene heme oxygenase-1 (HO-1)/Nrf2
nuclear factor erythroid 2-related factor 2 (Nrf2) signaling system. Further studies
have shown that RN can also improve the expression of type I procollagen and
inhibit UVB-induced secretion of MMP-1 and IL-6. Therefore, it is speculated that
RN may have applications in the skincare industry.
Peptides or Cytokines [15]
Messengers Peptide
A peptide is a long chain molecule composed of amino acids. The long chain part is
generally lipophilic which makes it possible to absorb water and has the moisturiz-
ing efficacy. Thereby peptides can increase the skin water contents. Some peptide
molecules can be used as cell messengers. The signal peptides secreted by some
cells can enter other cells and participate in the regulation of the cell’s physiological
function. Anti-aging peptides stimulate collagen synthesis. Significant wrinkles and
skin quality improvement have been reported after 8 weeks of topical application of
some peoptides.
Growth Factors and Cytokines [15, 21, 22]
Growth factors/cytokines are involved in many skin physiological and pathological

processes: for example, regulating inflammatory responses, promoting wound heal-
ing, and improving skin barrier. Therefore, topical drugs containing growth factors/
cytokines are constantly being developed. For example, growth factors are used after
invasive treatment to promote skin regeneration and wound healing.
Transforming growth factor β-1 (TGF-β1) is a very promising cytokine. High
concentrations of TGF-β1 in neonatal dermal fibroblasts may be the one reasons
why there is no scar-healing after skin trauma. There are products in the market
containing growth factors derived from various sources. Such topical creams applied
twice a day for 6 weeks are reported to result in improved skin quality and signifi-
cant reduction of wrinkles, epidermal thickening, solar elastin denaturation is
improved, and collagen synthesis is increased. In addition, TGF-β1 seems to have a
skin-brightening effect because melanin synthesis depends on an important enzyme:
copper-containing tyrosinase and tyrosinase-related protein-1. TGF-β1 (from adi-
pose tissue stem cells) can promote the degradation of these enzymes. Clinical stud-
ies are required to determine the exact combination of growth factors, the amount
required, and the most effective source for skin rejuvenation and repair.
Skin-Lightening Agents
For more than half a century, low concentration (2%) hydroquinone has been the
gold standard for depigmentation OTC, which inhibits tyrosinase activity and
reduces melanin production. Whether hydroquinone can be added to cosmeceuti-
cals is controversial, and the biggest concern is its association with malignant
tumors, which can be seen from the literature of the first decade of this century.
There are many ingredients (estimated over 1000) claiming to have skin-lightening
properties, many of them are extracted from plants. These ingredients are localized,
and many are well known, but evidence-based medical research is not sufficient,
and many are not included in pharmacopeias. Most of them are inhibitors of tyrosi-
nase, and some may act on the translocation of melanin (Table 9.3).
Among them, hydroquinone, arbutin, Licorice extract, Ascorbic acid, Kojic acid,
vitamin E, corticosteroid, vitamin A acid have good evidence to prove their effec-
tiveness. Tranexamic acid is recently found to have a strong lightening effect and
has been promoted by many manufacturers.
Extracellular Matrix Modulation
Extracellular matrix (ECM) is the largest component of the dermis and is related to
wound healing and dermal regeneration. The main structural components in ECM
are collagen type I and collagen type III, which account for more than 70% and 15%
of dry skin weight, respectively. In terms of function, there are two different proteins
Table 9.3 Potential lighting-ingredients

Before melanin synthesis During melanin synthesis After melanin synthesis
Inhibition of tyrosinase transcription Tyrosinase inhibition Tyrosinase degradation
• Vitamin A acid • hydroquinone • Linoleic acid
• MITF-siRNA • Arbutin Inhibition of melanin transport
• Tranexamic Acid • Aloe vera • Serine protease inhibitors
• Azelaic acid • Soy/milk extract
• Kojic acid • Nicotinamide/Vit B3
• Licorice extract Skin turnover acceleration
• Emblica • Glycolic acid
• Tyrostat • Lactic acid
• Tranexamic Acid • Linoleic acid
• Paper mulberry • Retinoic acid
• Melatonin • Licorice extract
Peroxidase inhibitors • Sulfonic acid (HEPES)
• Phenol
Remove ROS
• Ascorbic acid
MITF Microphthalmia-associated transcription factor [23]
in the skin, among which collagen fiber is related to the skin’s tenacity, and elastin
is related to the skin’s elasticity, enabling the skin to adapt to a variety of physical
tension and pressure. Moreover, ECM is also a microenvironment for crosstalk sig-
nal transduction and regulation, in which extracellular or intracellular proteins are
degraded and modified under pathophysiological conditions. It is known that there
are various ways to remove these denaturized ECM components during the regen-
eration process of damaged and denaturized ECM, but according to one study,
matrix metalloproteinases (MMPs) are the most important enzymes in this removal
process. During skin photoaging, elastin and collagen components in ECM are frag-
mented, elastin, fibrin, microfiber, and fibrin in dermal papillary layer are reduced,
collagen degradation and ECM are destroyed. More severe photoaging will develop
elastin denaturation: many lumpy denaturated elastin deposition in the dermis.
In order to promote ECM repair and regeneration, various processes need to be
addressed including promoting the removal of fragmented components, balancing
inflammatory mediators and proteases, stimulating the function of basal keratino-
cytes stem cells and fibroblasts to lay the foundation for ECM repair and regenera-
tion [16]. There is a substance called matrikines, which are peptides produced by
the fragmentation of matrix proteins and are said to regulate the biological activity
of the matrix. This matrix peptide has the function of regulating ECM microenvi-
ronment, and it can be used clinically after resurfacing. It has been shown that
MMP, TIMP, decorin, dermatopontin, elastin, and collagen II were all up-regulated
after use. After 3 weeks, elastin and collagen were increased in ECM and reduction
in the downtime of resurfacing [16].
There is a lot of controversy about cosmeceuticals. On the one hand, many func-
tional ingredients have been reported, but many of them are not medicinal and not
listed in the pharmacopeia. Evidence-based medical research evidence for most of
them are not sufficient, and even some are “legendary and anecdotal.” On the other
hand, formulations of cosmeceutical are relatively complex, often a mixture of mul-

tiple ingredients, lack rigorous efficacy verification. There are a multitude of studies
evaluating specific active ingredients, yet there are few studies of OTC formula-
tions, which are often a mixture of many ingredients. Some cosmeceuticals also
seem to have completed some clinical studies, but compared with comprehensive
medical clinical trials, they are not deemed rigorous enough. Many of the studies
are carried out by the companies and not independent reviewers. More rigorous
studies of OTC skincare products are required. This is especially imperative because
these products comprise such a significant percentage of the cosmeceutical indus-
try. With the current lack of comprehensive information on these products, it is
extremely difficult for both clinicians and consumers to ascertain their efficacy.
Future studies can ameliorate this problem by not only evaluating products for clini-
cal efficacy but also using histology and gene and protein expression to ascertain
their effectiveness.
References
1. Vashi NA, Maymone MBDC, Kundu RV. Aging differences in ethnic skin. J Clin Aesthet
Dermatol. 2016;9(1):31.
2. Galzote C, et al. Characterization of facial skin of various Asian populations through visual
and non-invasive instrumental evaluations: influence of age and skincare habits. Skin Res
Technol. 2013;19(4):454–65.
3. Chung JH. Photoaging in Asians. Photodermatol Photoimmunol Photomed. 2003;19(3):109–21.
4. Kaidbey KH, et al. Photoprotection by melanin--a comparison of black and Caucasian skin. J
Am Acad Dermatol. 1979;1(3):249–60.
5. Markiewicz E, Idowu OC. Personalized skincare: from molecular basis to clinical and com-
mercial applications. Clin Cosmet Investig Dermatol. 2018;11:161–71.
6. Nouveau-Richard S, et al. Skin ageing: a comparison between Chinese and European popula-
tions: a pilot study. J Dermatol Sci. 2005;40(3):187–93.
7. Morizot, F., et al. Do features of skin ageing differ between Asian and Caucasian women? J
Investig Dermatol. 2004
8. Sabziparvar AA, Shine KP, Forster PMF. A model-derived global climatology of UV irradia-
tion at the earth’s surface. Photochem Photobiol. 1999;69(2):193–202.
9. Battie C, et al. New insights in photoaging, UVA induced damage and skin types. Exp
Dermatol. 2014;23(Suppl 1):7–12.
10. Vernez D, et al. Anatomical exposure patterns of skin to sunlight: relative contributions of
direct, diffuse and reflected ultraviolet radiation. Br J Dermatol. 2012;167(2):383–90.
11. Grether-Beck S, et al. Photoprotection of human skin beyond ultraviolet radiation.
Photodermatol Photoimmunol Photomed. 2014;30(2–3):167–74.
12. Cho, S., et al. Effects of infrared radiation and heat on human skin aging in vivo. J Investig
Dermatol Symp Proc. 2009.
13. Bernstein EF, et al. Beyond sun protection factor: an approach to environmental protection
with novel mineral coatings in a vehicle containing a blend of skincare ingredients. J Cosmet
Dermatol. 2020;19(2):407–15.
14. Nolan KA, Marmur ES. Over-the-counter topical skincare products: a review of the literature.
J Drugs Dermatol. 2012;11(2):220–4.
15. Lee CM. Fifty years of research and development of cosmeceuticals: a contemporary review.
J Cosmet Dermatol. 2016;15(4):527–39.
16. Widgerow AD, et al. Extracellular matrix modulation: optimizing skin care and rejuvenation
procedures. J Drugs Dermatol. 2016;15(4 Suppl):s63–71.
17. Stiller MJ, et al. Topical 8% glycolic acid and 8% L-lactic acid creams for the treatment
of photodamaged skin. A double-blind vehicle-controlled clinical trial. Arch Dermatol.
1996;132(6):631–6.
18. Alonso C, et al. Skin permeation and antioxidant efficacy of topically applied resveratrol. Arch.
Dermatol. Res. 2017;309:423–31. https://doi.org/10.1007/s00403-017-1740-5. [PubMed]
[CrossRef] [Google Scholar].
19. Murakami I, et al. Metabolism of skin-absorbed resveratrol into its glucuronized form in
mouse skin. PLoS ONE. 2014;9:e115359. https://doi.org/10.1371/journal.pone.0115359.
20. Li L, et al. Ribes nigrum L. prevents UVB-mediated photoaging in human dermal fibroblasts:
potential antioxidant and antiinflammatory activity. Photochem Photobiol. 2018;94(5):1032–9.
21. Samizadeh S, Belhaouari L, Effectiveness of growth factor-induced therapy for skin rejuvena-
tion: a case series. J Cosmet Dermatol. 2020.
22. Fabi S, Sundaram H. The potential of topical and injectable growth factors and cytokines for
skin rejuvenation. Facial Plast Surg. 2014;30(02):157–71.
23. Yi X, et al. MITF-siRNA formulation is a safe and effective therapy for human melasma. Mol
Ther. 2011;19(2):362–71.
Chapter 10
Mesotherapy
Mesotherapy, also known as biorevitalization/biorejuvenation, was first proposed

firstly by a French physician, Michel Pistor [1]. In 1952, Dr. Michel Pistor employed
multiple, local, superficial (3–5 mm deep) injections of procaine around patients’
ears to improve hearing. Although hearing was not restored, temporal-mandibular
joint pain syndrome, eczema, and tinnitus did improve in some patients. This treat-
ment was later recognized as the original application of mesotherapy. Pistor used
the term “mesotherapy,” which can be strictly defined as treatment of the mesoderm,
one of three primary germ layers in the early embryo that develops into connective
tissue, muscle, and the circulatory system. Referring to the effects of localized pro-
caine injections on a wide number of tissues, Pistor claimed, “the action on tissue
originating from the mesoderm is so extensive that these treatments deserve the
global name of mesotherapy” [2]. The main researchers of mesotherapy can be
found in Table 10.1.
The term “Mesotherapy” is from the Greek mesos, “intermediate,” and therapeia,
“medical treatment.” It is essentially an transdermal injection technique where a
variety of enzymes, vitamins, hormones, hyaluronic acid, and natural plant extracts
are injected into the skin. This is done to: [4–6]
• stimulate the biosynthetic ability of fibroblasts
• facilitate interaction between cells
• increase collagen and elastin production.
Z. Zhou (*)
S. Samizadeh

https://doi.org/10.1007/978-3-030-84099-0_10
Table 10.1 Main researchers of mesotherapy [3]

Karl Baunscheidt The first drug dermal injection (2 mm) 1847
Alexander Wood First injection of dermic morphine 1853
Bartolomeo Guala Systematic hypodermic treatment in hospital 1860
Gaetano Primavera First experiment to assess the degree of drug absorption in 1867
the urine after hypodermic administration
The London Medical Definition of “hypodermic injections” 1867
Society
Physicians during the Doctors injected distilled water into the dermis for pain 1870
Franco-Prussian war
William Halsted Intradermal inoculation of sterile water induces local 1885
anesthesia
Pietro Orlandini Dermal punctures for pain 1894
George D Gammon and The analgesic effect of sterile water inoculation into the 1941
Isaac Starr skin for pain
Michel Pistor Proposed the term “mesotherapy” 1958
Sergio Maggiori Proposed the term “local intradermal therapy” (LIT) 2004
It is a local drug delivery method, which must be differentiated from tissue filler
injection [7]. Mesotherapy injection has a long history and has been used in areas
such as pain treatment, sports medicine, and rheumatology for decades, but has
recently become more popular recently [2]. Popular treatments include:
1. The “mesolift/mesoglow” technique: a mixture of the vitamins, minerals,
and hyaluronic acid is injected into skin for anti-aging, improvement of the
aging appearance of the hands and neck, reduction of acne scars and
stretch marks.
2. Topical fat-dissolving and sculpting: Local injections of phosphatidylcholine
and enzymes (collagenase and hyaluronidase) are carried out to treat cellu-
lite, topical fat loss, weight loss, and topical sagging (bags under the
eyes) [2, 8].
3. Hair: telogen effluvium, androgenetic alopecia [9].
Classification of Mesotherapy
Needleless Mesotherapy
No-needle mesotherapy is a noninvasive treatment used to facilitate transepidermal

penetration of medicinal, regenerating, or nourishing substances. Electroporation
methods are used to enable access to deep layers of the epidermis. The device,
which produces high-frequency electrical current, temporarily increases
10 Mesotherapy 149
permeability of the cell membrane and stimulates formation of nanopores (hydro-

philic channels) providing more efficient transport into cells. Frequency, type, and
length of electroporation are individually tailored to the problem and the treatment
site. Xu et al. observed the efficacy and safety of 23.8% L-ascorbic acid serum pen-
etrated by iontophoresis on 20 Chinese women. The roughness, pigment, and fine
lines of the skin were significantly improved without obvious side effects [10].
Taylor et al. used ascorbate glucosinolates penetrated by iontophoresis in the treat-
ment of melanoderma. After 26 months of treatment, 63% of the patients improved
by at least 50% [11]. But these techniques are less effective than other invasive
techniques, including microneedles [12].
Microneedle Mesotherapy
The microneedles create mechanical damage and form channel on the skin sur-
face, which not only increase the penetration of active substances, but also stimu-
lates the process of skin self-renewal. In this treatment process the formation of
micro-damage can stimulate platelet and growth factor secretion, thereby acceler-
ating cell proliferation and differentiation, and promote the epidermal self-renewal
[13]. El-Domayti and colleagues treated a small number of patients (10) with
microneedles (1 mm) every 2 weeks for a total of 6 treatments. The results showed
that the epidermis and dermis were significantly improved, stratum corneum
thickened, and skin integrity increased. Dermis collagen levels of type I, III, and
VII increased significantly, as did elastin. Therefore, in clinical practice, the
patients have significantly reduced wrinkles, increased skin tension and elasticity,
and improved facial fullness [4]. Zasada and colleagues showed similar therapeu-
tic effects; The study group comprised 17 women aged 45–70 [12]. Participants
were subjected to a series of four needle-free and four microneedles (0.5 mm roll-
ers) mesotherapy treatments every 10 days. They reported improved absorption of
vitamin C, skin firmness, elasticity, brightness, and hydration with use of
microneedles [12].
Mesotherapy Injection
This is a local intradermal/transdermal injection technique. Depending on the symp-

toms, severity, and responsiveness of the patient, one or more courses of treatment
may be given. For example, in the treatment of chronic pain, there are usually three
different stages: the onset stage (4 injections per week), the subsequent control
stage (4 treatments every 2 weeks), and the stage of maintaining efficacy and pre-
venting short-term recurrence stage (maintenance stage, 1 monthly or seasonal
treatment). Similarly, cosmetic injections can be performed based on this experi-

ence, perhaps every 2 weeks or monthly in the early stage, and maintenance injec-
tions can be performed at longer intervals later. However, clinical studies and
evidence are required in addition to a consensus for various treatments and ingredi-
ents [14].
Mesotherapy injection is characterized by its unique injection technique where
short needles (4 mm (27G)) or 13 mm (30G or 32G) are used to inject active
ingredients directly into the skin. Generally, 0.10–0.20 ml of the chosen active
ingredient(s) is injected, with injection point distance of 2–3 cm apart from each
other. Treatment schedules (drug selection, duration of treatment, patient man-
agement, and follow-up) may vary depending on the purpose of injection, the
diagnosis and characteristics of the lesion, and the pharmacologic characteristics
of the ingredients. In some cases, the pH of the injected ingredients can cause
severe pain and the pH may be adjusted with sodium bicarbonate to reduce this
effect [14].
After the injection, a “micro deposit” of the drug is formed in the dermis and
then slowly released into surrounding tissues. Compared with conventional oral/
intramuscular administration, the drug will reach the concentration required for the
treatment rapidly and directly. Clinicians are cautioned regarding mixing too many
active ingredients. Potential interactions, assessment of efficacy, and isolating the
offending ingredient in case of adverse reactions may not be possible [14]. Various
products and devices are available in the market. Various injection depths can be
used for various indications. However, more scientific studies are required to deter-
mine the exact effect of injection of a particular substance at various layers.
Injection Technology and Depth
There are four different mesotherapy injection techniques, corresponding to four

different injection depths. The key questions are: At the time of actual injection,
whether the depth of injection claimed by those injection techniques is the actual
anatomical depth required by the injection [8]. The epidermis displays thickness
variations depending on the anatomical area considered, varying from about 0.06 to
greater than 0.3 mm. Beneath the epidermis lies the dermis. Based on fiber orienta-
tion, two different layers can be distinguished: the papillary dermis and reticular
dermis. While the mean papillary dermis thickness approximates 0.2 mm, reticular
dermis exhibits a thickness comprised between 0.3 and 3.0–4.0 mm. The total der-
mis thickness may vary from 0.73 to 3.18 mm and may reach 10.0 mm for certain
areas and subjects. The reticular dermis can be arbitrarily divided into three equipo-
tent thirds: superficial-, mid-, and deep-reticular dermis [15]. In first author’s expe-
rience, Chinese women’s facial skin thickness (epidermis and dermis) is generally
not more than 2 mm (range 1.5–1.8 mm) (unpublished data, ultra-high frequency
ultrasound (50 MHz) skin measurement results).
10 Mesotherapy 151
Intra-Epidermal Injection
Superficial Intradermal Injection
A papule is formed when the drug is injected to a depth of 1–2 mm. The injection
layer is located at the epidermal–dermal junction.
Deep Intradermal Injection
Injection deep into dermis: 4 mm depth, which has reached deep-reticular dermis.
Each point usually injects 0.05–0.2 mL of liquids and is 1–2 cm apart.
Dermo-Hypodermal Injection
Injection placed at a depth ranging from 4 to 6 mm, possibly up to 10 mm, contain-

ing 0.03 mL of therapeutic agent. These drugs are often combined in cocktails and
may be given with or without anesthetics like procaine or lidocaine.
In order to estimate the actual injection depth in clinical practice, Micheels et al.
conducted a thought-provoking study [8]. Based on the injection depth reported in
previous literature, they used the following formula to predict the actual injection
depth: sinus (°) × length impl (cm) = injection depth (mm). It is then compared to
the thickness of the skin. When considering the thinnest (0.01 mm) and thickest
(0.18 mm) epidermis, on the one hand, and the papillary dermis (0.20 mm) on the
other, attaining the superficial dermis means that the injection is placed as follows:
• For the thinnest skin, for example, the lower eyelid, at a depth ranging from 0.26
to 0.50 mm.
• For the thickest skin, for example, the back, at a depth ranging from 0.27 to
1.33 mm.
• For the zygomatic and malar area, at a depth ranging from 0.35 to 0.60 mm.
Deep Intradermal Injection (IDP). When considering this technique, reference is
made to the deep-reticular dermis. With the same calculations as those previously
used for the superficial-reticular dermis, injections into the thinnest (lower eyelid)
and thickest skins (back) must be performed at depths of 0.74–0.79 mm for the
lower lid and 1.33–3.25 mm for the back. Micheels’ reports that the injection depths
reported by authors in their published papers prove to be incorrect. While almost all
authors report on injections performed at the dermo–epidermal junction, in the
superficial-, mid-, or even deep-dermis, Micheels’ using methodological calcula-
tions came to the following conclusions: the injection depth reported in the previous
literature was not the depth they claimed. Most of the injection depth was in the
deep dermis or hypodermis [8]. Therefore, it is warranted that our injection tech-
niques and definitions be thoroughly reviewed in order to enable us to properly
compare published scientific reports pertaining to this growing field.
Clinical Application
Local Lipolysis [16, 17]
Tear trough area and infraorbital fat herniation are challenging to treat.
In 2001 there was a clinical report of local injection of phosphatidylcholine (PC) to
improve the lower eyelid fat herniation. Locally injected PC and deoxycholic acid
(DC) have the function of locally dissolving fat. DC can damage the adipocytes mem-
brane, which is swollen and vacuolized, increasing the permeability of adipocytes
membrane, and then the subsequent leakage of lysosomal hydrolytic enzymes destroys
the membrane, causing adipocyte lysis. The role of DC is non-specific, affecting not
only adipocytes, but also skeletal muscle cells, keratinocytes, and fibroblasts. However,
the protein components in non-adipose tissue may neutralize the effect of DC on the
key structure of cells, so DC can show some “selectivity” in practical application. In
addition, PC has a buffering effect, which can reduce local inflammation and tissue
damage, which is beneficial for large areas of injection, such as the hip and thigh.
Various products have obtained FDA approval for various indications.
Skin Rejuvenation or Anti-aging
With aging, function and synthesis of fibroblasts decrease. Hyaluronic acid, colla-
gen, and other intracellular, intercellular and extracelluar components decrease sig-
nificantly, and collagen decomposition increases. This causes the dermis to lose
support. Fibroblasts collapse when this support is reduced, and their function declines
further. This creates a vicious cycle. Studies have shown that aging fibroblasts have
the potential to be reactivated, so it is theoretically possible to activate fibroblast
function with mesotherapy. Adequate amounts and viability of various compo-
nents such as amino acids and nucleotides for restoration of fibroblast synthesis func-
tion is especially important [18]. Fibroblast synthesis must have enough enzymes
and energy to support its biosynthesis. The energy produced by fibroblasts in the skin
gradually decreases with the process of aging, so it is theoretically necessary to pro-
vide sufficient energy for fibroblasts to meet their biosynthesis [19]. Biosynthesis of
fibroblasts is related to their microenvironment. For example, the function of fibro-
blasts is related to the surrounding matrix, their interactions (through the biosignal-
ing system) affect their biosynthetic function as does the mechanical tension of the
extracellular matrix. All of these affect the balance between collagen production and
degradation. Therefore, various companies have products that contain vitamins, min-
erals, amino acids, nucleosides, co-enzymes, antioxidants, and hyaluronic acid that
may aid this process and hence have an anti-aging effect. The active ingredients
provide fibroblasts with an ideal environment that is conducive to biosynthetic reac-
tion, energy generation, and increased anti-reactive oxygen species. Furthermore, by
increasing the volume of the dermis through the filling action of fillers, the
10 Mesotherapy 153
Table 10.2 Various constituents available for mesotherapy

Class Component
Vitamins and Vitamin A(retinol), Vitamin C (ascorbic acid), Vitamin E (tocopherol),
vitamin-like Inositol B vitamins: Vitamin BI (thiamine), B2 (riboflavin), B3
substances (nicotinamide), B5 (pantothenic acid), B6 (pyridoxine), B8 (biotin), B9
(folic acid),
B10 (P-aminobenzoic acid), BI2 (cyanocobalamin)
Minerals Calcium chloride, Potassium chloride, Magnesium sulfate, Sodium acetate,
Sodium chloride, Sodium dihydrogen phosphate
Amino acids Alanine, Arginine, Asparagine, Aspartic Acid, Cystine, Glutamine,
Glutamic Acid, Glycin, Histidine, Hydroxyproline, Isoleucine, Leucine,
Lysine, Methionine, Ornithine, Phenylalanine, Proline, Serine, Taurine,
Threonine, Tryptophan, Tyrosine, Valine
Nucleosides Deoxyadenosine, Deoxycytidine Deoxyguanosine, Deoxythymidine,
Methylcytosine
Co-enzymes TPP (Co-carboxylase), COA, FAD, NAD, NADP, UTP
Other antioxidants Glutathione
Hyaluronic acid Non-reticulated sodium hyaluronate
extracellular matrix environment of fibroblasts can be restored and reversed, for

example, the mechanical tension of the matrix can be restored, which can promote
the recovery of the biosynthetic function of fibroblasts and thus produce collagen
[20]. There are many mesotherapy formulas/products for anti-aging injection, which
are basically designed and formulated accordingly (Table 10.2).
Platelet-Rich Plasma (PRP) Dermal Injections
PRP has been used with mesotherapy techniques for skin improvement and
rejuvenation.
Studies have reported skin biostimulation and improvement in terms of texture,
firmness, and elasticity, barrier function, capacitance, hair diameter, and hair den-
sity [16, 21]. Treatment with PRP might show variable efficacy depending on the
source of the PRP and method used.
Oily Skin and Enlarged Pores
There is some relationship between oily skin and enlarged pores, an aesthetic prob-
lem which more and more patients are concerned with. Treatment options include
topical treatments, such as retinoids, olumacostat glasaretil, cosmeceuticals, and
systemic treatments, such as isotretinoin, spironolactone, and oral contraceptives. In
addition, photodynamic therapy and lasers have been used to treat oily skin and
enlarged pores with some efficacy.
Botulinum-mesotherapy injection is a new and effective treatment for oil control

and reduction of size of pores [22–24]. Various studies have shown beneficial effects
of botulinum toxins on hyperhidrosis, rosacea, excessive sebum productions, scars,
and a “lifting” effect when proper dosage and techniques are used [17, 23, 25–27].
Intramuscular injection is less effective in reducing sebum secretion than intrader-
mal injection reported in previous studies [28]. More interestingly, some authors
have found that regular injections of botulinum toxins over a long period of time not
only control the development of wrinkles, but also preserve the skin’s youthful tex-
ture, possibly due to fibroblast activation [29–31].
Pigmentation
In the Oriental cultures, youthful, white skin with no pigmentation is the aesthetic
ideal. Pigmentation is an early sign of aging and melasma is common among Asians.
Among the treatments available, mesotherapy with active ingredients such as
tranexamic acid, Vit C, and glutathione can be used.
Plasmin activates following UV irradiation exposure. Tranexamic acid (TA) is a
plasmin inhibitor that acts by preventing adhesion of plasminogen to keratinocyte.
This procedure is accompanied with less prostaglandin production and eventu-
ally the reduction of melanocyte tyrosine kinase activity. Depigmentation character-
istics of glutathione have been discussed widely. This substance can be found in the
body with various biological functions including acting as an antioxidant. It is used
in aesthetics for skin lightening, through direct melanocyte tyrosine kinase inactiva-
tion, acting in intermediation of altering eumelanin production to pheomelanin pro-
duction, elimination of free radicals playing role in melanocyte tyrosine kinase
production and regulation of melanotoxic depigmentation factors. Mesotherapy
with a glutathione-based compound formula, TA, and vitamin C alone may be effec-
tive for treating melasma [32].
Etiology of periorbital dark circles (symmetrical, round, uniform, light to dark
brown and black pigmentation around the eyelid) is multifactorial (genetics, sys-
temic disease, allergic reactions, nutritional deficiencies, overexposure to sunlight,
or sleep disorders). In addition, tear trough deformity, local pigmentation (genetic
individual differences, or post inflammatory pigmentation), or thin skin (local vein
color) will aggravate the appearance. Therefore, multimodality treatment including
mesotherapy (for example, with vitamin C) over a period of time may be required.
Hyaluronic Acid (HA)
HA is often chosen for mesotherapy due to its ability to increase hydration and
fibroblast activation. HA stimulates fibroblasts to express collagen type I, matrix
metalloproteinase-1 (MMP-1), and tissue inhibitor of MMP-1 (TIMP-1). HA
10 Mesotherapy 155
seemes to activate fibroblasts and increase the synthesis of type I collagen and
elastin [33]. Increased dermal thickness, improved complexion, and rejuvenation
(for photoaging) post injection of non-cross linked HA has been reported
[6, 34–36].
Compound Components
Studies on the efficacy of compound injections, also known as “cocktail mesother-

apy” are required. Not all the cocktail formulas have revival efficacy, and more
scientific studies are needed in the future to confirm the real practical effects of
cocktail formulas. Some studies have reported no improvements or transient short
lived improvements post treatment with various cocktail products [5, 37, 38].
Complications
Infection is the most common complication, usually with mechanical equipment

and caused by nontuberculous atypical mycobacterial infections. Therefore, pro-
vision in a clinical environment and skin disinfection are paramount in prevention
of infection. Deoxycholic acid injection can cause necrosis of the reticular dermis
and damage of adnexal glands, blood vessels, and nerves in the deep dermis or
subcutaneous. Other side effects include erythema, edema, and ecchymosis, most
of which are very mild and resolve spontaneously without treatment [39]. Pain is
typically minimal during and after the superficial injections. The injected sites
may bleed transiently and exhibit signs of inflammation, which resolves in several
days. Localized mesotherapy complications include allergic reactions, urticaria,
lichenoid drug eruptions, psoriasis, hematoma, ulceration, necrosis, and various
bacterial infections. Most of the adverse reactions associated with fat-dissolving
injections are said to be mild and transient. Proponents argue that it is safer than
liposuction, and that the acute, neutrophil accumulation of adiponecrosis (pan-
niculitis) is a rare adverse event that may be caused by injection pressure, local
trauma, or the injected ingredients itself. More recently, pigmentation, ecchymo-
sis, prolonged swelling, and tenderness (lasting for several months) have also been
reported after injection.
Confusion, Consensus, and the Future
Mesotherapy has become as controversial as it is popular. Information on meso-

therapy in the English language medical literature is scant. There is little informa-
tion on their safety, efficacy, mechanism, formulation, technique, function
ingredients, dose, and toxicology of mesotherapies. Most of the clinical studies

did not set up positive and negative controls. All of this has led to controversy. The
controversy has focused on questions about its effectiveness and concerns about
potential adverse effects. Unlike recognized cosmetic treatments such as botuli-
num toxin and soft tissue fillers, mesotherapy’s efficacy is distinctively ambigu-
ous, making it vulnerable to criticism by the generally more skeptical medical
community.
Mesotherapy injections are permitted in many countries around the world. There
exists much controversy, mainly due to the lack of studies, evidence-based prac-
tices, standards or administration of injections for cosmetic purposes by non-
medical personnel/healthcare professionals. There are many unanswered questions.
Rigorous research is needed in the field to determine efficacy of various ingredients
and products, protocol for use should be established and validated by experts and
professional training received by physicians providing this treatment. Furthermore,
injectables as such should be regulated. It is essential that doctors fully inform
patients of the risks and benefits of treatment in the light of published clinical expe-
rience, without unduly raising patient expectations. In addition, the practitioner pro-
viding mesotherapy is responsible for reporting to the FDA or relevant authorities
where they practice any adverse events that may be related to mesotherapy, includ-
ing detailed information on ingredients, treatment regimens, and combinations [16].
This is not implemented or practised, specially by providers who are not a health-
care professional.
Medical associations have played an important role in mesotherapy injection,
clarifying issues and reaching consensus to make this controversial treatment stan-
dard and scientific. In the future, good, large-sample trials will be needed to deter-
mine the benefits/risks of such therapies in order to ensure that patients receive the
most appropriate injection. Finally, misleading advertising on injectable products
should be monitored and discouraged and continuing medical education for doctors
should be mandatory by third parties to keep information up to date and avoid medi-
cal errors [14].
It is difficult to reach an international basic consensus on mesotherapy modali-
ties, protocols and efficacy. Some of the Italian experts came together and published
“Mesotherapy, definition, rationale, and clinical role: a consensus report from the
Italian Society of Mesotherapy” in 2011. This basic framework can be useful in
clinical practice (Table 10.3) [14].
10 Mesotherapy 157
Table 10.3 Mesotherapy, definition, rationale, and clinical role: a consensus report from the
Italian Society of Mesotherapy [14]
The consensus Technical agreement
1. It must be injected by a trained licensed 1. Clinical/psychological analysis of the
physician who must have a knowledge of the patient prior to injection is recommended.
pharmacology of the ingredients injected and The patient should have a clear understanding
receive regular continuing medical education to of the practical effects of the treatment. Do
keep up with clinical and pharmacological not inject patients under 18 years of age,
developments patients with allergies, patients with
2. It must be injected in a medical institution coagulation disorders (hemophilia, patients
(hospital or clinic), with a well-established receiving anticoagulant or antiplatelet drugs),
treatment regimen, and try to avoid injecting pregnant women, breast-feeding, cancer
compounds that have not been tested before patients receiving chemotherapy
3. A document of detailed information on the 2. Simultaneous injection of multiple
treatment regimen (ingredients, dose, frequency components raises an interaction risk.
of administration, treatment conditions) and Injection of a single ingredient is
combination therapy (both pharmacological and recommended unless pharmacological and
non-pharmacological) should be included clinical studies demonstrate the efficacy and
4. The occurrence of adverse events should be tolerability of the formulae
reported to the Pharmacovigilance Health 3. Use sterile disposable syringes and
Authorities. needles and administer injections in
accordance with accepted health regulations
to reduce the risk of iatrogenic infection
4. The used sharps and syringes should be
safely placed in the prescribed containers,
and avoid contaminating the sterile materials
5. Use the injection medicine once, do not
recommend reusing after storage.
References
1. Deglesne PA, et al. In vitro study of RRS HA injectable mesotherapy/biorevitalization prod-

uct on human skin fibroblasts and its clinical utilization. Clin Cosmet Investig Dermatol.
2016;9:41–53.
2. Atiyeh BS, Ibrahim AE, Dibo SA. Cosmetic mesotherapy: between scientific evidence, sci-
ence fiction, and lucrative business. Aesthet Plast Surg. 2008;32(6):842–9.
3. Mammucari M, et al. Mesotherapy: from historical notes to scientific evidence and future
prospects. TheScientificWorldJOURNAL. 2020;2020:3542848.
4. El-Domyati M, et al. Multiple microneedling sessions for minimally invasive facial rejuvena-
tion: an objective assessment. Int J Dermatol. 2015;54(12):1361–9.
5. Amin SP, Phelps RG, Goldberg DJ. Mesotherapy for facial skin rejuvenation: a clinical, histo-
logic, and electron microscopic evaluation. Dermatol Surg. 2006;32(12):1467–72.
6. Lacarrubba F, et al. Mesotherapy for skin rejuvenation: assessment of the subepidermal low-
echogenic band by ultrasound evaluation with cross-sectional B-mode scanning. Dermatol
Ther. 2008;21(Suppl 3):S1–5.
7. Rho N-K, et al. Consensus recommendations for optimal augmentation of the Asian face with
hyaluronic acid and calcium hydroxylapatite fillers. Plast Reconstr Surg. 2015;136(5):940–56.
8. Micheels P, Goodman L. Injection depth in intradermal therapy: update and correction of pub-
lished data. J Drugs Dermatol. 2018;17(1):88–96.
9. Konda D, Thappa DM. Mesotherapy: What is new? Indian J Dermatol Venereol Leprol.
2013;79(1):127.
10. Xu TH, et al. Split-face study of topical 23.8% L-ascorbic acid serum in treating photo-aged
skin. J Drugs Dermatol. 2012;11(1):51–6.
11. Taylor MB, et al. Successful short-term and long-term treatment of melasma and postinflam-
matory hyperpigmentation using vitamin C with a full-face iontophoresis mask and a man-
delic/malic acid skin care regimen. J Drugs Dermatol. 2013;12(1):45–50.
12. Zasada M, et al. Preliminary randomized controlled trial of antiaging effects of l-ascorbic acid
applied in combination with no-needle and microneedle mesotherapy. J Cosmet Dermatol.
2019;18(3):843–9.
13. Samizadeh S, Belhaouari L. Effectiveness of growth factor-induced therapy for skin rejuvena-
tion: a case series. J Cosmet Dermatol. 2020;
14. Mammucari M, et al. Mesotherapy, definition, rationale and clinical role: a consensus report
from the Italian Society of Mesotherapy. Eur Rev Med Pharmacol Sci. 2011;15(6):682–94.
15. Della Volpe C, et al. Skin diversity: histological study of 140 skin residues, adapted to plastic
surgery. Annales de chirurgie plastique et esthetique. 2012;57(5):423–49.
16. Greco J, Brandt R. The effects of autologus platelet rich plasma and various growth factors on
non-transplanted miniaturized hair. Hair Transplant Forum International. 2009.
17. Wu WT. Microbotox of the lower face and neck: evolution of a personal technique and its clini-
cal effects. Plast Reconstr Surg. 2015;136(5 Suppl):92s–100s.
18. Kilberg MS, Häussinger D. Mammalian amino acid transport. Springer Science & Business
Media. 1992.
19. Krutmann J, Schroeder P. Role of mitochondria in photoaging of human skin: the defective
powerhouse model. J Investig Dermatol Symp Proc. 2009;14(1):44–9.
20. Prikhnenko S. Polycomponent mesotherapy formulations for the treatment of skin aging and
improvement of skin quality. Clin Cosmet Investig Dermatol. 2015;8:151–7.
21. Hersant B, et al. Efficacy of autologous platelet-rich plasma combined with hyaluronic acid on
skin facial rejuvenation: a prospective study. J Am Acad Dermatol. 2017;77(3):584–6.
22. Shah AR. Use of intradermal botulinum toxin to reduce sebum production and facial pore size.
J Drugs Dermatol. 2008;7(9):847–50.
23. Li ZJ, et al. Regulation of lipid production by acetylcholine signalling in human sebaceous
glands. J Dermatol Sci. 2013;72(2):116–22.
24. Bulstrode NW, Grobbelaar A. Long-term prospective follow-up of botulinum toxin treatment
for facial rhytides. Aesthet Plast Surg. 2002;26:356–9.
25. Dayan SH, Pritzker RN, Arkins JP. A new treatment regimen for rosacea: onabotulinumtox-
inA. J Drugs Dermatol. 2012;11(12):e76–9.
26. Glogau RG. Botulinum A neurotoxin for axillary hyperhidrosis. No sweat Botox. Dermatol
Surg. 1998;24(8):817–9.
27. Liew S. Discussion: microbotox of the lower face and neck: evolution of a personal technique
and its clinical effects. Plast Reconstr Surg. 2015;136(5 Suppl):101s–3s.
28. Min P, et al. Sebum production alteration after botulinum toxin type A Injections for the treat-
ment of forehead rhytides: a prospective randomized double-blind dose-comparative clinical
investigation. Aesthet Surg J. 2015;35(5):600–10.
29. Binder WJ. Long-term effects of botulinum toxin type A (Botox) on facial lines: a comparison
in identical twins. Arch Facial Plast Surg. 2006;8(6):426–31.
30. Bonaparte JP, Ellis D. Alterations in the elasticity, pliability, and viscoelastic properties of facial
skin after injection of onabotulinum toxin A. JAMA Facial Plast Surg. 2015;17(4):256–63.
31. Permatasari F, et al. Anti-photoaging potential of Botulinum Toxin Type A in UVB-induced
premature senescence of human dermal fibroblasts in vitro through decreasing senescence-
related proteins. J Photochem Photobiol B. 2014;133:115–23.
32. Iraji F, et al. Efficacy of mesotherapy with tranexamic acid and ascorbic acid with and without
glutathione in treatment of melasma: a split face comparative trial. J Cosmet Dermatol. 2019.
33. Vashi NA, Maymone MBDC, Kundu RV. Aging differences in ethnic skin. J Clin Aesthet
Dermatol. 2016;9(1):31.
10 Mesotherapy 159
34. Baspeyras M, et al. Clinical and biometrological efficacy of a hyaluronic acid-based meso-
therapy product: a randomised controlled study. Arch Dermatol Res. 2013;305(8):673–82.
35. Williams S, et al. Changes in skin physiology and clinical appearance after microdroplet place-
ment of hyaluronic acid in aging hands. J Cosmet Dermatol. 2009;8(3):216–25.
36. Tedeschi A, Lacarrubba F, Micali G. Mesotherapy with an intradermal hyaluronic acid for-
mulation for skin rejuvenation: an intrapatient, placebo-controlled, long-term trial using high-
frequency ultrasound. Aesthet Plast Surg. 2015;39(1):129–33.
37. El-Domyati M, et al. Efficacy of mesotherapy in facial rejuvenation: a histological and immu-
nohistochemical evaluation. Int J Dermatol. 2012;51(8):913–9.
38. Quan T, et al. Enhancing structural support of the dermal microenvironment activates fibro-
blasts, endothelial cells, and keratinocytes in aged human skin in vivo. J Investig Dermatol.
2013;133(3):658–67.
39. Lee JC, Daniels MA, Roth MZ. Mesotherapy, microneedling, and chemical peels. Clin Plast
Surg. 2016;43(3):583–95.
Chapter 11
Light and Laser Treatments
Asian Skin
The terms Asian skin and Asian skin type, differ widely from each other but are
often used loosely. East Asian skin, for example, is markedly different from that of
south or west Asia. An Asian population in Singapore comprises people of Chinese,
Indian, and Malay ethnicity, all of whom come from Asia, but the latter two are
distinctly different from the Chinese in skin color. Even in China, people living in
the south (such as Guangzhou) tend to have darker skin, while those in the east
(such as Shanghai) tend to have lighter skin. Therefore, using terms like Asian skin
or Asian skin type can be inaccurate. Given these complexities and diversity,
descriptors such as Asian skin and Asian skin types should not be used as generic
descriptive terms.
The Fitzpatrick skin classification is based on the different response of the skin
to the sunlight, which may be more relevant with Asian skin characteristics than
geographically relevant descriptions and classifications. The Fitzpatrick skin types
IV-VI may be more representative of the south Asian skin type found in India, as
well as across the Indian subcontinent: Bangladesh, Pakistan, Sri Lanka, Maldives,
Afghanistan, Tibet, and Nepal. Chinese and Japanese, on the other hand, have skin
types ranging from type III (light brown) to type IV (medium brown).
Z. Zhou (*)
S. Samizadeh

https://doi.org/10.1007/978-3-030-84099-0_11
The ideal Oriental skin is smooth, delicate (no large pores), and white (no spots
or pigmentation). Skin pigmentation is a common concern among Asian patients
attending dermatology or cosmetic clinic.
Asians have thicker dermis and more collagen than Caucasians. Based on char-
acteristics of Asian skin, two factors should be kept in mind at all times when
using lasers:
• Post-inflammatory hyperpigmentation (PIH).
• Scarring and possible keloid.
Pigmentation Change and Treatment
Skin color types essentially depend on the amount of pigmentation in the skin.
Melanin is a major determinant of skin color, including pheomelanins (yellow-red)
and eumelanin (brown-black). The amount and distribution of these two pigments
are different, depending on race and the degree of illumination, which determines
the skin color. Dark skin has higher levels of pheomelanins and eumelanin than light
skin. Moreover, a distinct relationship exist between skin pigmentation/color and
the amount, composition, and distribution of melanin in the epidermis.
Skin pigmentation disorders include hyperpigmentation and hypopigmentation.
The pigment changes may be in the dermis or the epidermis, partly due to hyperactiv-
ity of melanocytes, while others may be due to an increase in the number of melano-
cytes. However, this chapter only discusses skin pigmentation related to photoaging.
Freckles, Lentigines,
and Post-Inflammatory Hyperpigmentation
Lentigines are benign pigmentation lesions common in Asians; however, it is a com-

mon reason for patients attending cosmetic clinics. Freckles form during adoles-
cence and have a generally symmetrical distribution, same size, and color. Thus, the
epidermal melanin increased histopathologically, but the number of melanocytes
remains the same. Unlike freckles, Lentigines occur and increase with age, and the
size and color of lesions tend to vary widely and are not evenly distributed.
Histologically, there is increased melanocytes and epidermal melanin, and the epi-
dermal rete ridges are significantly prolonged [1].
Q switch laser is effective in treating Asian skin pigmentation (Fig. 11.1a, b, c).
However, lasers of different wavelengths (532 nm, 694 nm, 755 nm, and 1064 nm)
can all result in significant postinflammatory hyperpigmentation (PIH), which is
estimated to be present in about 25% of Asian skin after treatment (Fig. 11.2a, b, c).
Pulse width may influence the incidence of PIH. For example, although QS Nd:YAG
and long pulse width Nd:YAG have similar efficacy, in the treatment of Chinese
facial lentigines with 532 nm laser, the risk of pigmentation after QS laser treatment
11 Light and Laser Treatments 163
a b
Fig. 11.1 (a) Before: Freckles patient (Female, 36 years old), (b) Immediately treated with Pico-
Laser 532 nm (Picoway, Candela, Boston, USA): 0.3 mJ (2 passes), the endpoint was only moder-
ate erythema edema without gray change and peeling (to reduce the risk of PIH) C: 2 years after
treatment, without PIH
a b
Fig. 11.2 (a) Lentigo (40 years old, female), Left: Before treatment, Right: the marked regions by
P and Q were treated with picosecond laser (Picoway, Candela, Boston, USA) and Q Switch nano-
second laser (Fotona, Slovenia, EU), respectively. (b) Left: 3 months after treatment, Right:
6 months after treatment. There was circular pigmentation. (c) Left: 9 months after treatment, the
PIH almost disappear; Right: 16 months after treatment. The circular pigmentation faded
completely
is higher. Some authors believe that, unlike the long pulse width laser which is
caused by photothermal only, QS Nd:YAG laser not only has photothermal action,
but also has photomechanical effect, thus causing tissue damage and finally induc-
ing PIH. It is possible that a long pulse width laser is more suitable for Asian skin
treatment and can reduce the risk of PIH [1].
In order to reduce the occurrence of PIH after laser treatment of Asian skin, glass
slides can be used to compress the skin lesions during laser treatment, flattening the
blood vessels in the skin lesions (to empty the blood), so as to reduce the risk of
dermal vascular injury and hemosiderin deposition. The efficacy and complications
of the QS ruby laser and the 595 nm long pulsed width dye laser (PDL) for lentigi-
nes treatment have been compared. Although the efficacy was similar between the
two groups, the risk of PIH was much lower in patients with slide compression [1].
IPL is filtered incoherent broadband visible light, which only produces photo-
thermal effect. Several studies have confirmed the role of IPL in the treatment of
epidermal pigmentation in Asians (Fig. 11.3). Negishi (Japan) evaluated the pho-
torejuvenation effect of IPL [2, 3]. In the first study, 90% of the 97 Asian patients
(filter 550 nm, 28–32 J/cm2, dual-pulse mode, 2.5–4.0/4.0–5.0 ms, and delay time
20.0/40.0 ms) showed a significant reduction in lesions after 3–6 treatments
(2–3 weeks between treatments). In the second study, IPL devices with a contact
cooling system were used (filter 550 nm, 23–27 J/cm2, dual-pulse mode
2.8–3.2/6.0 ms, delay time 20.0/40.0 microseconds). After 3–5 treatments
(3–4 weeks of interval), 80% of the 73 patients showed significant reduction in
lesions. Kawada et al. evaluated 60 cases of lentigines and freckles. After 3–5 ses-
sions of IPL treatment (2–3 weeks interval, filter 560, 20–24 J/cm2, double/triple
pulse, 2.6–5.0 ms pulse width, and delay time 20 ms), 68% of patients achieved at
least 50% improvement, with freckles proving more effective than Lentigines.
Interestingly, none of these treatments detected the occurrence of PIH, which high-
lights the advantages of IPL as a photorejuvenation for Asian patients.
Post-inflammatory pigmentation (PIH) is a common pigmentation problem
among Asians. Since Asian skin is rich in melanin, PIH can be considered an
Fig. 11.3 Photoaging skin with freckles (Female, 37 years old): Left: Before treatment; Right:
30 months after treatment with IPL (M22, Lumenis, Israel) 560 nm: Pulsewidth 4 ms, Energy:
13–14 J/cm2. After 2 treatments, the spots faded. 30 months later, the effect was satisfactory with
improved skin texture
inevitable pathophysiological response. It is associated with a number of factors,

including increased melanocyte activity, an increase in the number of melanocytes,
and hemosiderin deposition after hemorrhage. The severity of PIH is related to the
degree of inflammation and damage in the epidermal–dermal junction. It can be
caused by an endogenous inflammatory skin disease, or can be iatrogenic, such as
laser treatment. With the use of laser and light energy, prevention and treatment of
PIH become more important [1]. The advantage of IPL treatment is the low inci-
dence of PIH, making it a good choice for Asian skin care. However, for patients
with a PIH trend, a course of treatment is recommended, and attention should be
paid to the use of the epidermal contact cooling system, a necessary technique to
prevent PIH [4].
Kim and Cho reported that treating PIH caused by acne with QS Nd:YAG laser
at a low fluency was effective in 20 Korean patients with phototypes IV and V. They
carried out 5 weekly full-face sessions (5–10 with a spot of 6 mm, 10 Hz, and flu-
ency of 3.3 J/cm2 in the first session and 5.8 J/cm2 in the last session). At 3 months
after the treatments, the authors observed an improvement of PIH with the laser
compared to the control group with no adverse effects (erythema, edema, purpura,
or scars) [5].
Given that the long pulse KTP 532 nm laser (LP 532 nm) and the long pulse Nd:
YAG 1064 nm laser (LP 1064 nm) can be used for rejuvenation in other races, LP
532-nm can safely and effectively remove Asian skin freckles, solar lentigines, and
port wine stains, LP 1064-nm with pulse width of millisecond can be used for depil-
ation of dark skin, while LP 1064-nm with pulse width of microsecond can be used
to stimulate skin remodeling. Therefore, Negishi et al. reported efficacy of LP
532 nm and LP 1064 nm laser on pigment-related skin rejuvenation [6].
Melasma
Melasma is a symmetrical pigment-increasing disease common in middle-aged

Asian women. Genetics, ultraviolet light, pregnancy, hormones, and other photo-
toxic drugs are all thought to be responsible for Melasma, which remains a difficult
disease to treat. In the past, Melasma was previously classified as epidermal, der-
mal, and mixed according to the depth of pigmentation. However, current histo-
pathological studies consistently report that increased epidermal pigment is the
main feature of Melasma and the target for Melasma treatment. Melasma lesions are
characterized by an increase in melanin throughout the epidermis, with an 83%
increase in epidermal melanin compared to the surrounding normal skin. Recent
studies have found that many melanin biosynthesis-related genes, such as tyrosi-
nase, TYRP1, TYRP2, and MITF are up-regulated in Melasma lesions. Increased
melanin synthesis in melanocytes leads to epidermal pigmentation and results in
melanin on the face [7]. Increased numbers of melanocytes and widely dispersed
melanosomes in keratinocytes are also found in melasma lesions. These investiga-
tors proposed that increased melanogenic enzymes activity results in hyperactive
melanocytes with increased synthesis and transfer of melanosomes, and decreased

degradation in keratinocytes. Sublethal laser damage to these labile melanocytes
can increase the production of melanin, leading to PIH. This could explain why
previous studies using a 510-nm pigmented lesion dye laser and a Q-switched (QS)
ruby laser for the management of melasma led to little improvement and worsening
pigmentation in some cases. Recent studies have also indicated that intense pulsed
light (IPL) can lead to manifestation of previously subclinical melasma; for this
reason, Wood’s light examination or UV photography prior to IPL treatment of
Asian skin is recommended [1].
In addition to the epidermis melanin increased, dermis melanin was also found
in some patients (36% in South Korea, 45% of Indian patients). However, whether
the melanin in the dermis has any practical significance in melasma is doubtful
because the dermal melanin content in Melasma lesions is not increased compared
to the surrounding normal skin, and the distribution of melasma lesions is often
uneven. In Caucasian melasma lesions, the amount of dermal pigment is very small
and almost undetectable. The dermal melanin in melasma seems to be more com-
mon in Fitzpatrick III–V skin, and can be seen in virtually all IV to V melasma
lesions except for a significant increase in epidermal melanin, as well as in normal
Korean and Japanese facial skin. Therefore, further studies are needed to determine
whether this small fraction of skin melanin actually affects treatment outcomes, or
whether there is indeed the existence of dermal melasma [7].
A histopathological study of 56 Korean Melasma patients showed no real dermal
type, suggesting that the dermal melanocytes seen in “dermal melasma” might be
mild, undiagnosed, and acquired bilateral nevus of Ota-like macules or Hori’s mac-
ules of the zygomatic region [1]. Also, a histological study revealed pathological
changes in the basement membrane of Melasma lesions: the structure of the basal
membrane in lesions skin is incomplete and shows a destructive appearance.
Compared with surrounding normal skin, the overall expression of type IV collagen
in skin lesions was significantly reduced. This feature is more pronounced at the
edges of some melanocytes, which are known as Pendulous melanocytes because
they protrude so prominently into the dermis. The expressions of MMP-2 and
mRNA in lesions were also significantly higher than those in surrounding normal
skin, suggesting that chronic UV exposure may lead to basement membrane dam-
age by upregulation of MMP-2 expression in Melasma [7]. The lysis of the base-
ment membrane may cause melanocytes to protrude into the dermis. In the event of
damage, including laser treatment, Pendulous melanocytes that protrude into the
dermis may easily fall into the dermis or be directly destroyed, resulting in severe
pigmentation in the dermis, as well as pigmentation during treatment. Therefore,
excessively intense laser therapy (especially for melasma removal) will not only
activate the function of melanocytes, but may also target the basal layer below mela-
nocytes, leading to more severe pigmentation.
Another hypothesis is that these changes may promote interactions between der-
mal and epidermal melanocytes. In fact, in addition to pigmentation, there are also
changes in dermal structure, suggesting that the dermis is involved in the formation
of Melasma, including prolonged exposure to the sun, netlike interactions among
fibroblasts, blood vessels, and melanocytes, etc. These complex interactions stimu-
late melanocytes and lead to epidermal pigmentation. According to the current lim-
ited clinical observation (personal experience, unpublished), PIH caused by
picosecond laser is not lower than that caused by nanosecond laser. Combined with
previous PIH reports, the incidence of PIH after treatment with IPL (millisecond
pulse width) and long pulse width 532 nm laser is lower than that of nanosecond
laser. Therefore, it can be further speculated that picosecond laser (shorter pulse
width, higher photoacoustic effect) may be more likely to cause PIH response when
treated in high-energy mode.
The dermal structure in the lesions of melasma is different from that of the sur-
rounding normal skin, which is characterized by obvious photodamage: obvious
denaturation of solar elastin and pathological changes of capillaries. The erythema
index is significantly higher than that of surrounding normal skin, indicating telan-
giectatic erythema confined to the skin lesion of melasma. Immunohistochemical
studies have shown an increase in the number of blood vessels in the upper dermis
and a positive correlation between the number of blood vessels and skin pigmenta-
tion in melasma, all of which suggest the significance of UV in the pathogenesis of
melasma [7]. It can be further speculated that melasma itself is an accompanying
symptom in the process of photoaging or one of skin manifestations of photoaging.
According to whether melasma is complicated with telangiectasia, some Chinese
scholars have classified melasma into pigment type, partial pigment type, partial
vascular type, and vascular type.
Although the specific role of damaged vascular in the pathogenesis of melasma
is not clear yet, some authors have reported that targeting damaged vessels at the
same time as melasma appears to have a synergistic effect in the treatment of
melasma. A prospective, controlled, and comparative split-face was conducted on
the efficacy of pulsed dye laser (PDL) combined with triple cream (corticosteroids,
vitamin A acid, and hydroquinone) in the treatment of melasma. It was found
that the combination of the cream and PDL was more effective than the cream
alone. Interestingly, this combination resulted in significant improvement even after
a summer, while the cream only group relapsed. Thus, this suggests that treating
melasma with vascular therapy can reduce the activity of melanocytes. Another
study showed that tranexamic acid was effective in treating melasma because not
only did the pigmentation of the epidermis decrease, but also the dermal lesions
associated with melasma improved, such as a decrease in the number of blood ves-
sels. Therefore, the relationship between diseased blood vessels and skin pigmenta-
tion needs further study [7].
The consensus is that the first-line treatment choice for melasma is still drug
therapy rather than laser and light, and comprehensive treatment regimens are rec-
ommended first (Fig. 11.4). Limitations of topical treatment include the longer time
required for effectiveness to become apparent and patient compliance. Glycolic
Fig. 11.4 Melasma (Female, 48 years old): Left: Before treatment; Right: (2 years later): The
patient’s melasma was effectively controlled and faded using a combination of Sunscreen/
Antioxidant, Citric acid/Glycolic acid peeling and laser treatment (Q switch 1064 low-energy
scanning treatment)
acid, salicylic acid, and trichloroacetic acid peels are also useful adjuncts to topical
treatments in the management of melasma in Asians [1].
Based on the previous reports and the experiences of Asian dermatologists,
Asian melasma can be effectively treated with Lasers and light, including Q switch
Nd:YAG laser, Q switch Ruby fractional lase, and IPL [8–10]. The treatment often
reported (such as fractional laser, especially ablative fractional laser) was often frus-
trating due to no anticipated effect or resulting in PIH. Fractional laser at least
become a controversial topic for Asian melasma.
Fractional Laser
There have been reports of treatment of melasma with CO2 laser. However, the long
recovery time and adverse effects of these lasers have made its use unpopular.
Despite being considered the best therapeutic option for wrinkles and acne scars,
they are less attractive for Asian skin due to the risks. There are reports of the use of
several types of equipment, such as carbon dioxide lasers, Er:AG lasers, or a com-
bination of CO2 and Er:YAG, in Asians and Hispanics. Some patients developed
PIH, which lasted 3–4 months in some cases. Post-inflammatory hypochromia have
been described in rare cases.
Non-ablative fractional skin resurfacing is another technique in the management
of melasma. This involves the use of a 1540-nm laser that creates microscopic zones
of thermal injury that are surrounded by normal skin. As the areas of thermal injury
are very small, lateral migration of keratinocytes to them occurs rapidly, leading to
re-epithelialization of the epidermis within 24 h.
IPL
The pulse duration of IPL (intense pulsed light) is usually milliseconds, which is
much longer than thermal relaxation time of melanosomes. Therefore, IPL cannot
selectively target activated melanocytes but can influence all of the structure-
containing melanosomes and melanin pigments in the epidermis through photother-
mal reaction, clearing out pigmentation through transepidermal elimination.
Unwanted thermal stimulation through IPL with millisecond pulse duration and
high fluence might aggravate melasma. Wang et al., in Taipei, showed that patients
with melasma in the IPL-treated group achieved a significant improvement after
four sessions of IPL and topical treatment [11]. Thus, IPL seems to be an effective
treatment; however, partial repigmentation has been reported.
PIP-IPL emits the same wavelength as other conventional IPL devices. Instead of
lowering applied fluence, it fractionates a pulse duration of 10 ms into 100 sub-
pulses in which the pulse width of one subpulse is 40 μs. Through these fractionated
pulses, PIP-IPL can achieve gentle removal of unwanted pigmentation without fol-
lowing aggravation or flare ups of melasma. Two to three passes of PIP-IPL are
usually required to achieve subtle, transient erythema around the melasma lesion,
the optimal response to treat melasma. Chung et al. conducted a small sample split-
face control clinical study: One half of the face received one treatment session of
conventional IPL and six successive treatments using a low-fluence QS Nd:YAG
laser (IPL/T combination treatment). The other half of the face was treated using
PIP-IPL, emitting a 550- to 800-nm wavelength, an applied fluence of 12–15 J/cm2,
in two to three passes to obtain mild perilesional erythema response. Treatments
were administered to each side of the face at 2-week intervals for a total of seven
sessions. This study demonstrates that PIP-IPL treatment every 2 weeks can be as
effective as IPL/T combination treatment [10].
QS Laser and Pico-Laser
In Asia, many practitioners have tried to treat melasma with low-fluence QS1064 nm
(laser toning) with rapid response. Because high-fluence laser- and light-based
treatment for targeting pigment, can aggravate melasma, these treatments are inef-
fective for treating melasma. From this point of view, low-fluence QS Nd:YAG laser
treatment (laser toning) has been extensively used, especially in Asian countries,
and have recorded successes. It applies very low fluence and does not destroy active
melanocytes with melanosomes. Repetitive sessions of laser toning exhaust mela-
nocytes and inactivate them so that they no longer produce or transfer melanin
pigments. When Kim and colleagues biopsied skin treated with multiple sessions of
laser toning, the remaining melanocytes were found to be inactive; however, the
treatment does not stimulate activity of these dormant melanocytes, hence, it can
achieve clinical improvement in melasma [12].
Nanosecond-domain QS laser exposure can provoke explosive mechanical waves
even though it is set at a low fluence [13]. These characteristics, together with
repeated treatments, over a short period, may be responsible for punctate leuko-
derma, which is cosmetically unacceptable and may persist if left untreated. In addi-
tion, with higher energy, this technique could also induce pigmentation; however,
stopping treatment can lead to a relapse. This approach has been improved by QS
fractional lasers with wavelengths of 694 nm and 1064 nm, and overall satisfaction
with the treatment effect has been reported [9]. Another promising treatment is the
pico-laser, which has a shorter wavelength. Pico-laser pulse width and little photo-
thermal effect laser treatments can theoretically provide better efficacy with a lower
risk of PIH after treatment.
Use of bleaching agents and sunscreens for at least 6 weeks, and preferably for
3 months, prior to any laser or light therapy can help suppress the function of these
hyperactive melanocytes and reduce the risk of PIH. Even with such precautions, a
recent study in Taipei comparing topical bleaching treatment only with bleaching
plus IPL treatment for melasma reported two cases of PIH in the IPL-treated group
despite prolonged use of bleaching agents and sunscreens prior to treatment [1].
Skin Texture Change and Rejuvenation Treatment
Skin resurfacing modalities can be divided into two categories: ablative and non-
ablative. Ablative skin resurfacing entails a treatment modality that removes the
epidermis and partial thickness of the dermis to achieve skin rejuvenation. The gold
standard in skin rejuvenation is ablative resurfacing with a carbon dioxide (CO2) or
Er:YAG laser. However, ablative therapies are painful and may require anesthesia.
They are associated with risks for erythema, infection, scarring and delayed
hypopigmentation, and often require a prolonged period of convalescence. So, abla-
tive resurfacing is not very popular in Asia.
Non-ablative modalities include laser, broadband light devices, and radiofre-
quency treatments. These therapies inflict thermal damage to the lower layers of
the dermis and stimulate collagen production but do not injure the epidermis.
Non-ablative skin rejuvenation with a laser/light source has gained much popular-
ity in Asia due to the lower risk of complications and limited downtime. It can
improve the signs of photoaging, which include lentigines, telangiectasia,
increased pore size, uneven texture, wrinkles, and skin laxity. Cooling is particu-
larly important in skin of color as it protects the epidermis and reduces the risk of
erythema and edema, which may lead to subsequent PIH. However, non-ablative
therapies have limited efficacy and require multiple treatments compared to abla-
tive modalities.
IPL Treatment
IPL is noncoherent broad-spectrum light used to stimulate the formation of collagen

within the papillary dermis and to treat pigmented skin lesions and telangiectasias.
Specific spectra of wavelengths are delivered and can be modified through the use
of light-filtering mechanisms. Typically, IPL devices are set such that their light is
absorbed by both melanin (absorbs from 250–1200 nm) and oxyhemoglobin
(absorbs at 418, 542, and 577 nm) simultaneously. This modality, much like that of
superficial chemical peels, usually requires a series of treatments for maximal ben-
efit. IPL has been reported to be an effective, safe, and well-tolerated procedure in
Asians with little to no post-inflammatory hyperpigmentation or prolonged ery-
thema [2, 3, 14]. Because pigmented lesions and telangiectasias are common age-
related skin changes in Asians, this modality may be ideally suited for this population
(Fig. 11.3).
However, in clinical practice, it was found that some patients, who had an appear-
ance of normal skin before treatment, developed melasma after IPL treatment.
Careful examination revealed that these patients had very mild melasma, which was
difficult to find with the naked eye. However, ultraviolet lamps could help to iden-
tify these patients and prevent the aggravation of melasma. In order to avoid post-
treatment complications, IPL users should be well aware of patients with subclinical
mild chloasma and very mild melasma [15].
Asians are concerned about three major problems: pigment problems (lentigi-
nes and hyperpigmentation), rough skin/large pores, and rhytids and wrinkles,
which usually show a good response to IPL treatment. When used on a yearly
basis, IPL therapy can truly reverse photodamage and skin aging; therefore, it
should be considered a major impact player for long-term skin health (Figs. 11.5
and 11.6) [16].
Many studies have proved the efficacy of IPL in treating irregular pigmentations
of photoaging skin [17–22]. Li et al. reported that IPL treatment can decrease the
density and intensity of epidermal melanin content, increase the content of dermal
collagen, and improve organization of elastic fibers [14]. It is possible that IPL
improves the irregular pigmentation of photoaged skin through promoting a rapid
differentiation of keratinocytes, accompanied by an upward transfer of melano-
somes along with necrotic keratinocytes, resulting in the elimination of melanin
from the skin.
In summary, IPL treatment can effectively improve skin texture and alleviate
signs of photoaging. Histologically, IPL treatment can decrease epidermal mela-
nin, promote the neocollagenesis as well as remodeling of collagen/elastic fibers,
which may explain the clinical improvement on photoaging. IPL is a safe modal-
ity in treating Asians. Moreover, adverse effects were minimal and acceptable,
including mild- to-
moderate pain, transient erythema, slight edema(usually
resolved in 0.5–12 h), temporary desquamating microcrusts(shed off within
7–10 days) usually without scarring, macroscopically hyperpigmentation and
hypopigmentation [14].
Fig. 11.5 Before and after photographs of a patient treated with 14 IPL treatments over a 12-year
period. Left: Before treatment (Male, 51 years old), Right: 12 years later (63 years old). Courtesy
of Dr. Chen, Ping. The Department of Plastic Surgery, the First People’s Hospital of Foshan,
Guangdong 528000, P.R. China
Non-ablative Laser Treatment
Non-ablative skin rejuvenation involves the use of lasers or other light sources with
a cooling device. These devices generate heat in the superficial layer of the skin up
to a depth of 1 mm. Due to the reduced risk of complications and shorter recovery
time, these procedures are becoming popular for the treatment of ethnic skins. The
objective of non-ablative skin rejuvenation is to improve the signs of photoaging,
such as dilated pores, a nonhomogeneous texture, telangiectasia, lentigines, wrin-
kles, and skin flaccidity. Cooling is important because it protects the epidermis,
reducing the chance of erythema and edema, which lead to PIH. Authors found
that lentigines, ephelides, wrinkles, and skin flaccidity of the face and neck in
Asians have improved using non-ablative lasers: 595-nm dye laser with a long
pulse, Ruby Q-switched laser, Nd-YAG 1320 nm, QS-Alexandrite laser, non-
ablative infrared, and light-emitting diode (830 nm, 633 nm, and combined), as well
as a full spectrum of infrared light (700–2000 nm) and bipolar radiofrequency
(electro-optical synergy) combined and IPL. However, only a few patients had
PIH [4].
Lasers and other light sources using yellow and green lights (Nd:YAG 532 nm,
pulsed dye laser 585 and 595 nm) target the skin pigment and the vessels in the
papillary dermis. A lesion in the vessels of the dermis and the microvasculature of
Fig. 11.6 The same patients: before the third IPL treatment in 2003, before the fifth IPL treatment
in 2004, before the sixth IPL treatment in 2005, before the seventh IPL treatment in 2008, before
the ninth IPL treatment in 2009, before the tenth IPL treatment in 2010, before the 15th IPL treat-
ment in 2014. Courtesy of Dr. Chen, Ping. The Department of Plastic Surgery, the First People’s
Hospital of Foshan, Guangdong 528000, P.R. China
sebaceous glands leads to a consequent reduction of telangiectasias and of the pro-

duction of sebum, in addition to promoting neocollagenesis during the healing
process.
In east Asia, Q switch 1064 nm is not only used for pigmented diseases, but also
popularly used in skin rejuvenation to improve skin texture and fine wrinkles.
However, there is no consensus about the combined exogenous topical carbon solu-
tion application before Laser therapy. Fractional picoway lasers are reported to be
effective in treating photoaging and enlarged pores. According to our clinical expe-
rience, the treatment of enlarged pores is relatively difficult and requires a compre-
hensive approach (Figs. 11.7 and 11.8).
Improvement in wrinkles and skin laxity as well as skin texture and fine lines,
increase in the density of collagen fibers in the papillary dermis were observed
histopathologically with use of long pulse Nd:YAG [23]. Together with a cooling
device, NIR lasers or light sources that use infrared light or a similar light
(1064 nm, 1320 nm, 1450 nm, 1540 nm, 1565 nm) to target the water in the der-
mis. They increased the dermal temperature through photothermolysis, resulting
in increased neocollagenesis and collagen tightening. Several monthly sessions
are necessary to achieve a good result. However, laser diode 1450 nm is
Fig. 11.7 A patient with enlarged pore after acne (Female, 29 years old), Before (left), and After
treatment (Right) with Picoway (Candela, Boston, USA): 1064 nm, Resolve handpiece: 0.7–1.3 mJ
(2000 pulse/face), 8 treatments combining with Citric acid/Glycolic acid peeling. Both the enlarged
pore and texture were greatly improved
associated with a significant risk of PIH (7–39%) due to excessive cooling [4].
Alexiades-Armenakas demonstrated statistically significant efficacy of the infra-
red device in treating skin laxity after 1–3 treatments and a mean of 2 months
follow-up [24]. Another study showed that immediate skin contraction after NIR
light radiation persisted through the immediate, intermediate, and long-term fol-
low-up in the vast majority of patients [25]. Tanaka et al. demonstrated that NIR
provides safe and effective long-term stimulation of collagen I and III and elastin
in vivo using an irradiation dose of 36 J/cm2 [26].
Fractional Laser Treatment
This is a therapeutic principle that lies between ablative and non-ablative treatment.
FP laser resurfacing differs from the traditional laser resurfacing in that it uses
micro-point beam on the surface of the skin to form localized small Thermal stimu-
lus/gasification zone (Microscopic Thermal Zones, MTZs), and keep MTZs sur-
rounding tissue uninvolved. After treatment, the uninvolved cells around quickly
crawl into MTZs and then repair skin quickly, so as to reduce the risk of infection
and scarring. However, on the epidermis and the dermis has formed a strong enough
Fig. 11.8 A patient with sensitive skin (flushing), enlarge pores, rough skin (female, 29 years old).
Due to skin sensitivity, the patient could not accept any intensive treatment. The damaged skin
barrier was repaired to reduce sensitivity of the skin using LED treatment (biostimulation) and
appropriate skincare (the redness subsided). And then the enlarge pores were treated using a com-
bining of laser and acid treatment. Left: before treatment, Right: after treatment by Picoway
(Candela, Boston, USA): 1064 nm, Resolve handpiece: 0.9–1.1 mJ (2000pulse/face), 8 treatments
combine with Citric acid/Glycolic acid peeling. Both the pore and rough skin improved
heat stimulation, accelerating skin turnover, dermal collagen remodeling, and

reconstruction.
The classical ablative FP techniques include fractional laser of Er:YAG, yttrium
scandium gallium garnet (YSGG) and CO2, and so on. Their target chromophore is
assumed to be water in tissues, so various water-containing structures such as col-
lagen, blood vessels, and epidermal keratinocytes can be used as target tissues for
treatment. Multiple studies have shown that fractional laser is a safe and effective
technique for wrinkles and skin texture improvement with a short recovery period.
A split-face study of treatment for Asian photoaging with fractional CO2 and
Er:YAG laser showed that Er:YAG laser was more suitable for superficial and mod-
erate photoaging skin, and the recovery period was shorter [4].
However, ablative fractional Lasers are not popular in Asia for skin-texture
improvement. Most practitioners prefer non-ablative fractional Lasers due to colla-
gen remodeling because skin tightening continues after 2–3 months of treatment
with less downtime and side effects. Non-ablative fractional laser resurfacing indi-
cations include periorbial rhytides, photorejuvenation (fine lines and wrinkles,
repair of sun-damaged skin) of face, neck, shoulders, and hands; other indications
include Acne scars, Traumatic scars, Stretch marks, Age-related brown spots, i.e.,
lentigines, Melasma, Syringomas, Striae distensae; Miscellaneous conditions

include granuloma annulare, poikiloderma, colloid milium, and disseminated super-
ficial actinic porokeratosis, etc. [27].
According to a review, evidence strongly suggests that NAFLA are a good treat-
ment choice for Fitzpatrick IV-VI skin. Grade I evidence suggests that NAFLA can
be used in the treatment of acne, striae, and skin rejuvenation. Grade II evidence
suggests that such lasers can be used for treatment of acne scarring, melasma, and
surgical/traumatic scarring. Therefore, they believe that NAFLA is a safe and effec-
tive treatment technique for all kinds of dark skin. However, the authors found little
literature on the treatment on Fitzpatrick V and VI skin types [28].
Generally, in patients with more severe degrees of photoaging, fractional resur-
facing can be useful for wrinkle and pigment reduction as well as acne scarring. By
using a high fluence and low density, dermal collagen remodeling is induced with
minimal epidermal injury. In skin of color, the principle of minimizing post-
treatment erythema in order to reduce the risk of PIH is a useful one. Hence, a
reduction in energy and density as well as lengthening of treatment intervals
(2–4 weeks for epidermal lesions, 4–6 weeks for dermal lesions) can also be helpful
in reducing the risk of PIH. The most significant side effect of fractional non-
ablative lasers is pain. Treatment of a small area with multiple passes without allow-
ing sufficient time for cooling can produce bulk heating and, consequently, scarring.
The mild erythema usually subsides on its own and the patient can go back to work
after applying a sunscreen. Several hours afterward, the skin usually feels tight and
has a “sunburned” look. The skin continues to look sunburned or bronzed/pink with/
without swelling, depending on the depth of treatment for the next 2–7 days.
Generally, as the skin heals, moderate skin flaking can last for up to 2 weeks. The
number of treatment sessions required depends on the individual and the condition
for which the patient is undergoing treatment [4, 29, 30].
Radiofrequency Treatment
Monopolar Radiofrequency
Since its approval by the U.S. Food and Drug Administration in 2002 for rhytides,
a number of articles have been published on Monopolar radiofrequency (MRF) with
data supporting its clinical efficacy. Monopolar radiofrequency therapy delivers
uniform heat at controlled depth to dermal layers, causing direct collagen contrac-
tion and immediate skin tightening. Subsequent remodeling and restoration of col-
lagen bundles and the formation of new collagen are achieved over months after
treatment. Although it is known that tightening continues for 3 months or more after
the end of radiofrequency treatment, little is known of the optimal treatment interval
and the long-term outcomes after successive MRF treatment.
Microneedle Radiofrequency
Microneedle Radiofrequency or microneedle fractional radiofrequency (MFRS) is

a novelty bipolar RF energy in esthetics. The needle diameter of the microneedle RF
is about 0.1–0.2 mm. During the treatment, not only can the energy and pulse time
can be adjusted arbitrarily, but the needle length can also be adjusted between 1 and
2 mm. However, there are two types of therapeutic microneedle available clinically:
insulated needles and non-insulated needles. The insulated needle conducts electric-
ity only at the distal end of the needle; however, the needle body does not conduct
electricity (Fig. 11.9). Non-insulated are different, both the body and tip of needle
conduct electricity. So theoretically, the insulated needle may cause bleeding during
treatment; heating the skin to different levels requires multiple treatments; skin
tightening is less effective. On the other hand, non-insulated microneedles, can lead
to a wide range of heating and coagulation in the dermal papillary layer and reticu-
lar layer, which will reduce bleeding during treatment. However, due to the greater
impedance of the epidermis, the epidermis will survive, improving the effect of
tightening treatment.
Because there is no damage to epidermal melanin, any skin type can be treated
with MFRS. These benefits persuade patients to utilize MFRS for non-ablative skin
rejuvenation, atrophic scar revision, vascular lesions, inflammatory acne, and acne
scars. Since the FDA approved the use of microneedles RF for skin rejuvenation in
2008, it has demonstrated to be effective in aging skin. After microneedle RF treat-
ment, skin thickening, collagen content increased, skin moisturizing improvement,
and epidermis thickening have been reported [31–34].
Hyaluronan (HA) is the well-known, predominant component of extracellular
matrix (ECM). It is abundant in many tissues, including skin, where it acts as a
hydrating agent and an organizer that forms structural scaffolding. Recent research
regarding the role of HA have demonstrated that it could act as an active regulator
of dynamic cellular processes, such as cell proliferation and migration during
embryonic tissue development, wound repair, and skin aging. As HA, CD44, and its
metabolizing enzymes are expected to be involved in the skin aging process, and
considering the fact that fractional RF have been used to treat aging skin effectively,
it can be speculated that microneedles RF may affect the expression of HA, CD44,
and HAS in the skin [35].
0.3mm
0.25mm
Fig. 11.9 The handpiece of Microneedle fractional radiofrequency device (Bodytite, Peninsula,
China), Insulation treatment microneedle: only the needle tip (0.3 mm) is conductive; the rest of
the body is not
Microneedle RF is a safe, effective method [36–39]. Clinicians can choose deep

insertion protocol to achieve better and more durable results, especially when treat-
ing nasolabial folds and infraorbital wrinkles. The best outcomes can be expected
2–3 months after treatment. Patients who have a tendency to bruise easily and are in
need of only minor corrections can benefit more from superficial treatment proto-
col. It is necessary to consider the skin thickness of different facial regions when
choosing treatment depths. Adverse reactions include crusting, edema, erythema,
petechia, pain/mild burn sensation, mild erythema, and other reactions generally
disappear spontaneously a few hours after treatment (Fig. 11.10).
Combination of Procedures
There are reports of combined approaches using several types of lasers and light
sources in the same session at monthly intervals. This approach targets several skin
chromophores, with good results. However, a lower fluency must be used with each
device to reduce the adverse effects associated with cumulative heat generation.
Kim et al. described a single session combined treatment of IPL, IR light, and laser
diode, all of which are associated with RF (four sessions in total with 3-week inter-
vals). The authors indicated that all patients showed reductions in the global index
Fig. 11.10 Overall improvement of periorbital wrinkles, nasolabial folds, and skin laxity when
assessed 1 year after treatment. Courtesy of Dr. Zhen Zhang. Shanghai Ninth People’s Hospital
of photoaging, improvements in melanin rates and elasticity, and increases in pro-

collagen types I and III and elastin levels. The combination of three different energy
sources with bipolar RF in the same session was effective for improving several
parameters, such as texture, tone, and laxity observed in photoaged Asian skin, with
a short recovery time [40].
To investigate the safety and efficacy of a combination therapy consisting of
intense pulsed light (IPL), near infrared (NIR) light, and fractional erbium YAG
(Er:YAG) laser for skin rejuvenation in Asian people, 113 subjects from six sites in
China were randomly assigned to a full-face group, who received combination ther-
apy, and split-face groups, in which one half of the face received combination ther-
apy and the other half received IPL monotherapy. Combination therapy showed
significantly greater improvements compared to monotherapy at two follow-up vis-
its. Also, combination therapy proved to be a safe and more effective strategy than
IPL monotherapy for skin rejuvenation in Asian people [41]. Considering the limi-
tations of monotherapy in improving skin quality, comprehensive treatment is rec-
ommended (Fig. 11.11), with treatment plans tailored to specific indications and
patient expectations.
Fig. 11.11 Female, 35 years old with rough skin, large pores after acne vulgaris. Left: before,
Right: after combining treatment with microneedle RF and picosecond fractional laser treatment,
the skin texture improved, skin fineness increased, and pore appearance improved. Microneedle
RF (Bodytite, Chongqing, China) non-insulation: 4-6w/1.4–1.6 mm/300 ms (Power/depth/pulse
time), 3Tx, combine with Picoway (Candela, Boston, USA): 1064 nm, Resolve handpiece:
0.7–1.3 mJ (2000pulse/face), 7 treatments
References
1. Ho SG, Chan HH. The Asian dermatologic patient: review of common pigmentary disorders
and cutaneous diseases. Am J Clin Dermatol. 2009;10(3):153–68.
2. Negishi K, et al. Photorejuvenation for Asian skin by intense pulsed light. Dermatol Surg.
2001;27(7):627–31. discussion 632
3. Negishi K, et al. Full-face photorejuvenation of photodamaged skin by intense pulsed light
with integrated contact cooling: initial experiences in Asian patients. Lasers Surg Med.
2002;30(4):298–305.
4. Chan IL, et al. Characteristics and management of Asian skin. Int J Dermatol. 2019;58(2):
131–43.
5. Kim S, Cho KH. Treatment of facial postinflammatory hyperpigmentation with facial acne
in Asian patients using a Q-switched neodymium-doped yttrium aluminum garnet laser.
Dermatol Surg. 2010;36(9):1374–80.
6. Negishi K, Tanaka S, Tobita S. Prospective, randomized, evaluator-blinded study of the long
pulse 532-nm KTP laser alone or in combination with the long pulse 1064-nm Nd: YAG laser
on facial rejuvenation in Asian skin. Lasers Surg Med. 2016;48(9):844–51.
7. Kang HY. Melasma and aspects of pigmentary disorders in Asians. Ann Dermatol Venereol.
2012;139(Suppl 4):S144–7.
8. Cho SB, Kim JS, Kim MJ. Melasma treatment in Korean women using a 1064-nm Q-switched
Nd:YAG laser with low pulse energy. Clin Exp Dermatol. 2009;34(8):e847–50.
9. Jang WS, et al. Efficacy of 694-nm Q-switched ruby fractional laser treatment of melasma in
female Korean patients. Dermatol Surg. 2011;37(8):1133–40.
10. Chung JY, et al. Pulse in pulse intense pulsed light for melasma treatment: a pilot study.
Dermatol Surg. 2014;40(2):162–8.
11. Wang CC, et al. Intense pulsed light for the treatment of refractory melasma in Asian persons.
Dermatol Surg. 2004;30(9):1196–200.
12. Kim JE, et al. Histopathological study of the treatment of melasma lesions using a low-fluence
Q-switched 1064-nm neodymium:yttrium-aluminium-garnet laser. Clin Exp Dermatol.
2013;38(2):167–71.
13. Chan NP, et al. A case series of facial depigmentation associated with low fluence
Q-switched 1,064 nm Nd:YAG laser for skin rejuvenation and melasma. Lasers Surg Med.
2010;42(8):712–9.
14. Li YH, et al. A split-face study of intense pulsed light on photoaging skin in Chinese popula-
tion. Lasers Surg Med. 2010;42(2):185–91.
15. Negishi K, et al. Study of the incidence and nature of “very subtle epidermal melasma” in rela-
tion to intense pulsed light treatment. Dermatol Surg. 2004;30(6):881–6. discussion 886
16. Ping C, et al. A retrospective study on the clinical efficacy of the intense pulsed light source for
photodamage and skin rejuvenation. J Cosmet Laser Ther. 2016;18(4):217–24.
17. Tierney EP, Hanke CW. Recent advances in combination treatments for photoaging: review of
the literature. Dermatol Surg. 2010;36(6):829–40.
18. Goldman MP, Weiss RA, Weiss MA. Intense pulsed light as a nonablative approach to photo-
aging. Dermatol Surg. 2005;31:1179–87.
19. Li YH, et al. A split‐face study of intense pulsed light on photoaging skin in Chinese popula-
tion. Lasers in Surgery and Medicine: The Official Journal of the American Society for Laser
Med Surg. 2010;42(2):185–91.
20. Li, et al. Application of a new intense pulsed light device in the treatment of photoaging skin
in Asian patients. Dermatol Surg. 2008;34(11):1459–64.
21. Bitter Jr, PH, Noninvasive rejuvenation of photodamaged skin using serial, full‐face intense
pulsed light treatments. Dermatol Surg. 2000;26(9):835–43.
22. Negishi, et al. Photorejuvenation for Asian skin by intense pulsed light. Dermatol Surg.
2001;27(7):627–32.
23. Chiba C, et al. Clinical experience in skin rejuvenation treatment in Asians using a long-pulse
Nd:YAG laser. J Cosmet Laser Ther. 2009;11(3):134–8.
24. Alexiades-Armenakas M. Assessment of the mobile delivery of infrared light (1100-1800 nm)
for the treatment of facial and neck skin laxity. J Drugs Dermatol. 2009;8(3):221–6.
25. Ruiz-Esparza J. Near [corrected] painless, nonablative, immediate skin contraction induced
by low-fluence irradiation with new infrared device: a report of 25 patients. Dermatol Surg.
2006;32(5):601–10.
26. Tanaka Y, Matsuo K, Yuzuriha S. Long-term evaluation of collagen and elastin following infra-
red (1100 to 1800 nm) irradiation. J Drugs Dermatol. 2009;8(8):708–12.
27. Sachdeva S. Nonablative fractional laser resurfacing in Asian skin--a review. J Cosmet
Dermatol. 2010;9(4):307–12.
28. Kaushik SB, Alexis AF. Nonablative fractional laser resurfacing in skin of color: evidence-
based review. J Clin Aesthet Dermatol. 2017;10(6):51–67.
29. Kono T, et al. Prospective direct comparison study of fractional resurfacing using different
fluences and densities for skin rejuvenation in Asians. Lasers Surg Med. 2007;39(4):311–4.
30. Chan HH, et al. The prevalence and risk factors of post-inflammatory hyperpigmentation after
fractional resurfacing in Asians. Lasers Surg Med. 2007;39(5):381–5.
31. Hantash BM, et al. Bipolar fractional radiofrequency treatment induces neoelastogenesis and
neocollagenesis. Lasers Surg Med. 2009;41(1):1–9.
32. Lee HS, et al. Fractional rejuvenation using a novel bipolar radiofrequency system in Asian
skin. Dermatol Surg. 2011;37(11):1611–9.
33. Seo KY, et al. Skin rejuvenation by microneedle fractional radiofrequency and a human stem
cell conditioned medium in Asian skin: a randomized controlled investigator blinded split-face
study. J Cosmet Laser Ther. 2013;15(1):25–33.
34. Seo KY, et al. Skin rejuvenation by microneedle fractional radiofrequency treatment in Asian
skin; clinical and histological analysis. Lasers Surg Med. 2012;44(8):631–6.
35. Lee HJ, et al. Microneedle fractional radiofrequency increases epidermal hyaluronan and
reverses age-related epidermal dysfunction. Lasers Surg Med. 2016;48(2):140–9.
36. Tanaka Y. Long-term three-dimensional volumetric assessment of skin tightening using a
sharply tapered non-insulated microneedle radiofrequency applicator with novel fractionated
pulse mode in asians. Lasers Surg Med. 2015;47(8):626–33.
37. Lu W, et al. Curative effects of microneedle fractional radiofrequency system on skin laxity in
Asian patients: a prospective, double-blind, randomized, controlled face-split study. J Cosmet
Laser Ther. 2017;19(2):83–8.
38. Lee SJ, et al. Treatment of periorbital wrinkles with a novel fractional radiofrequency
microneedle system in dark-skinned patients. Dermatol Surg. 2015;41(5):615–22.
39. Jeon IK, et al. Comparison of microneedle fractional radiofrequency therapy with intradermal
botulinum toxin a injection for periorbital rejuvenation. Dermatology. 2013;227(4):367–72.
40. Kim JE, et al. Combination treatment using bipolar radiofrequency-based intense pulsed light,
infrared light and diode laser enhanced clinical effectiveness and histological dermal remodel-
ing in Asian photoaged skin. Dermatol Surg. 2012;38(1):68–76.
41. Tao L, et al. Intense pulsed light, near infrared pulsed light, and fractional laser combination
therapy for skin rejuvenation in Asian subjects: a prospective multi-center study in China.
Lasers Med Sci. 2015;30(7):1977–83.
Chapter 12
Botulinum Toxin A: Treatment Principles
Botulinum Toxin A (BoNT-A)
General Goals and Principles for Facial Rejuvenation
The success of BoNT-A for facial rejuvenation lies in its safety, efficacy, longevity,
and patient satisfaction [1–7]. However, post-procedural patient comfort and satis-
faction play a key role in what is considered an optimal outcome for the patients.
In the primary author’s opinion, there is a lack of accurate evaluation of post-
procedural patient “comfort/satisfaction” in the current standard evaluation criteria.
Post-injection comfort/satisfaction refers to the absence of complaints from the
patient regarding lack of expression and stiffness, self-consciousness, unnatural
expressions, and discomfort. These are particularly important for patients seeking
cosmetic treatments and directly affect their satisfaction and feelings toward the
treatment. A more refined classification of postoperative comfort as an important
evaluation index can be used (Table 12.1).
The patient-reported satisfaction rating relates to presence/lack of expression (as
requested by the patient), rigidity or stiffness, and self-awareness. In our experi-
ence, levels 0, 1, and 2 are acceptable, and patients above level 3 usually complain.
How does one prevent “stiffness/rigidity” post-injection?
X. Han (*)
Fat Grafting Department, Plastic Surgery Hospital, Chinese Academy of Medical Sciences
and Peking Union Medical College, Beijing, China
S. Samizadeh

https://doi.org/10.1007/978-3-030-84099-0_12
184 X. Han and S. Samizadeh
Table 12.1 Postoperative satisfaction rating

Level 0: No expression of rigidity, discomfort, or self-consciousness
Level 1: Stiffness/rigidity in the area treated and lack of expression, discomfort, self-awareness,
and other unusual sensations lasting only 3–5 days after the injection has taken effect
Level 2: Stiffness/rigidity in the area and lack of expression, discomfort, self-awareness, and
other unusual sensations lasting up to 1 week after the injection has taken effect
and other unusual sensations lasting up to 3 weeks after the injection has taken effect
and other unusual sensations lasting up to 3 months after the injection has taken effect
and other unusual sensations lasting more than 3 months after the injection has taken effect
1. The most common cause is the use of an excessive dose, resulting in dispropor-
tionate paralysis of the targeted muscles of expression.
2. Anatomical variations in patients (e.g., deep injection layers) can result in BoNT
diffusing into non-target muscles, such as zygomatic muscles when treating lat-
eral canthal lines.
3. Muscular imbalance between different synergist muscles and antagonistic mus-
cles, or even within the same muscle, can also prove a catalyst.
The overall goal of facial rejuvenation with BoNT is to use optimal (i.e., safe)
doses to achieve a balanced and natural result. A few general principles can be fol-
lowed to achieve this. For example, one must take into consideration various factors
influencing the treatment and adjust the dose and injection point/layer/muscle group
accordingly.
The Main Influencing Factors and Considerations
Dose, injection site, concentration, injection depth, muscle strength, synergist/

antagonistic muscles are the main influencing factors.
Dose
The vast majority of publications have shown that dose is the decisive factor for
obtaining the optimal final effect and longevity [8–10]. While it’s true that higher
doses produce better, longer-lasting effects, the most adequate dose will take into
consideration each patient’s requirements and unique anatomy. It is easy to ignore
that the excessive paralysis of facial muscles will lead to long-lasting “stiffness/
rigidity,” discomfort, and compensation of other muscles, which is different from
the overall goal of a balanced and natural facial rejuvenation.
12 Botulinum Toxin A: Treatment Principles 185
Due to differences in anatomy and the desired outcome, the dose used in East
Asian patients is different from that of Caucasians. In East Asians, facial expres-
sions are significantly less than those of the Westerners, which may also be the
reason why the strength of the facial muscles is less in this population is less signifi-
cant, requiring a lower dosage. Most aesthetic physicians practicing in East Asia
believe that the dosage of BTN injection in these populations is approximately half
to a third of the dose size recommended and used for Caucasians. This was con-
firmed by a Korean study published in 2014 [11].
Injection Site
The injection site determination is a dynamic rather than static process depending
on the individual anatomy of each patient, treatment aims and objectives, and con-
sideration of three-dimensional dispersion of BoNT.
Depending on the individual anatomy, the position and depth of injection can be
changed for each patient. Moreover, the individual differences of facial wrinkles are
so varied that even the most detailed classification of wrinkles cannot include all
individual variations. Therefore, we should not mechanically determine the injec-
tion site according to a certain classification but assess patients and instruct patients
to make relevant expressions to determine the injection site. Fortunately, examina-
tion of static and dynamic wrinkles aids aesthetic physicians in treatment planning
and delivery. This principle is applicable to the expression produced by most super-
ficial muscles, but the deeper muscles such as the oblique head of the corrugator
supercilii muscle require different assessment. How to determine the exact injection
point will be described.
Various formulations may have spread differently within the injected tissues.
This is dependent on dose, volume, and dilution [12]. It is noteworthy that injection
of a single bolus into the targeted muscle may result in spread beyond the boundar-
ies of the target muscle. Therefore, multiple injections with the total intended dose
along the target muscle are recommended to ensure “even” distribution of the prod-
uct throughout the muscle [12].
Concentration
The concentration of BoTN is also an important factor affecting the therapeutic

effect, spread, and diffusion. This has been studied by many authors. Hsu et al.
examined the “diffusion” area of Botox with different volumes but the same dosage.
Higher volumes are reported to result in larger diffusion and a larger “affected area”
[13]. The above results suggest that the same dose of BoNT can have an increased
range of action after dilution, and vice versa. The idea of “Microbotox” was intro-
duced by plastic surgeon Woffles Wu in 2015. Hyper-diluted Onabotulinum toxin A
with 20–28 units/ml of solution and a single injection volume as small as 0.025 u
and 0.05 ml ensures the operator can achieve a smaller dose and more accurate
injection [14].
Onabotulinum toxin A is reconstituted to one of three concentrations in our
department to obtain a more uniform effect and a higher injection efficiency balance:
1. 100 u/1 ml. It is used when the muscle is bulky and strong (such as the men’s
glabellar complex) and a high dose is required for effective treatment. This
enables the injection of sufficient ds and prevents dispersion beyond the
intended site.
2. 100 u/2–2.5 ml. This is the conventionally recommended reconstitution, which
is suitable for most facial wrinkles.
3. 5–10 u/1 ml. When it is necessary to uniformly reduce the tension of large area
muscles (such as frontalis muscle and platysma muscle) or precise small dose
injections (such as blepharospasm and buccal striae), this configuration concen-
tration is used.
Injection Depth
To understand the injection depth, the following facts are important:

1. The dispersion of BoNT is three-dimensional, which can be imagined as a drop
of water on a sheaf of paper.
2. The dispersion of BoNT is affected by the degree of tissue porosity (e.g., the
densest is the skin, which varies from the middle of subcutaneous fat and the
space between muscle bundles).
3. The muscles of facial expression are superficial, and in most cases, the subcuta-
neous fat is very thin; its thickness is far less than the average dispersion distance
of BoNT (1 cm).
Previously, it was thought that the injection layer for facial rejuvenation could
only involve the muscles. However, studies have confirmed that the same dose of
BoNT injected into different layers (intradermal, subcutaneous, and intramuscular)
can achieve the same therapeutic effect [15, 16]. The following could explain
obtaining the same effect (as shown in Fig. 12.1):
1. When injected into the deep dermis, due to the tension of the skin, the diffuse
shape is round [15, 16]. Most of BoNT can only diffuse to deep tissues (subcu-
taneous fat and muscle) due to the limited diffusion space of the epidermis, and
the thickness of facial subcutaneous fat is far less than 1 cm, so even if BoNT is
injected into the dermis, most will enter into muscle and have an effect.
2. Accordingly, when BoNT is injected into the tissue with loose subcutaneous fat,
its diffusion range is elliptical [15, 16]; at the same time, BTN will diffuse to the
Der Der Der
Sub F Sub F Sub F
FM FM FM
Spa Spa Spa
B or DF B or DF B or DF
12 Botulinum Toxin A: Treatment Principles
diffusion fo botulinum toxin Inject in deep derma diffusion fo botulinum toxin Inject in facial muscles
diffusion fo botulinum toxin Inject in subcutaneous fat
Derma, Der
Subcutaneous Fat, Sub F Diffusion of Botulinum Toxin, DBT
Facial Muscels, FM
Space, Spa site of injection
Bone or Deep Fascia, B or DF
Fig. 12.1 The dispersion of BoNT injected into different layers (intradermal, subcutaneous, and intramuscular)
187
superficial skin and deep muscles. It is worth mentioning that the skin and sub-
cutaneous fat are not the target sites for wrinkle removal.
3. During intramuscular injection, the diffusion of BoNT can be clearly observed
through real-time dynamic MRI images [17], and the diffusion range of BoNT
in spasmodic biceps is significantly reduced, suggesting that the diffusion of
BoNT is closely related to the loose space between muscle bundles; meanwhile,
BoNT will move to the superficial subcutaneous fat layer, skin layer, and deep
interstitial layer, which are not the target of the injection. On the other hand, the
deep interstitial layer of muscle is very loose, muscles of expression are mostly
thin, and therefore it is easy to inject at the wrong depth, resulting in unpredict-
able dispersion, involving non-target muscles.
In summary, on the basis of the general principles explained (i.e., evenly and
moderately paralyzing one or several groups of target muscles as expected), the fol-
lowing factors should be fully considered:
• The degree of tissue space and tension at different layers and correlation with the
dispersion range;
• The different dispersion shapes at different layers (note: circular dispersion is the
best way to control the uniformity);
• The depth of muscles of facial expression that result in visible wrinkles and their
proximity to other muscles.
In general, intradermal injections are more conducive to the uniform control of
the dispersion range and shape, more in line with the general principle of wrinkle
removal using BoNT, and suitable for most indications (not all). BoNT injection
layers for various parts of the face are shown in Tables 12.2 and 12.3.
Table 12.2 Injection depth

Difficulty in
Injection Dispersion Dispersion controlling dispersion
depth Tissue structure shape range range
Intradermal Compact Near circular Skin, Simple
subcutaneous,
muscle
Subcutaneous Moderately loose Near oval Skin, Slightly difficult (need
tissue depending on subcutaneous, to understand the
the type of adipose muscle superficial fat division
tissue, the course of and that the superficial
blood vessels, and ligament and blood
location of vessel vary greatly)
ligaments
Intramuscular Moderately/ According to Skin, Difficult (unable to
extremely loose the shape of subcutaneous, know the exact
intermuscular space the space muscle, direction of the
between interstitial layer intramuscular tract)
muscle
bundles
Table 12.3 Injection depth for rhytid effacement

Rhytids Corresponding muscles Injection depth
Forehead Frontalis muscle Intradermal
Subcutaneous
Intramuscular
Eyebrow Corrugator Intramuscular
pattern Oblique head of corrugator (end at middle Intradermal
part of eyebrow)
Depressor supercilii Subcutaneous
Procerus muscle Intramuscular
Crow’s feet Orbicularis oculi Intradermal
Lower eyelid Orbicularis oculi Intradermal
Medial canthus Orbicularis oculi Intradermal
Eyebrow lift Brow junction of orbicularis oculi and Intradermal
frontal muscles
Nasal dorsal Orbicularis oculi Intradermal
striae Subcutaneous
Superioris alaeque nasi Subcutaneous
Nasalis Intradermal
Subcutaneous
Procerus Intramuscular
Depressor supercilii Subcutaneous
Nasolabial fold Superioris alaeque nasi Subcutaneous
Smoking lines Orbicularis oris muscle Intradermal
Chin dimpling Mentalis Intradermal
Subcutaneous
Marionette Depressor anguli oris Intradermal
lines Platysma Subcutaneous
Depressor labii inferioris
Lower face Platysma Intradermal
Subcutaneous
Muscle Strength
The strength of muscles used to form facial expressions is difficult to quantify. The
dose of injection can be determined according to the strength difference of patients’
respective expressions. The stronger the intensity and muscle volume, the higher the
dose is required. It is worth noting that the severity of static wrinkles is not posi-
tively related to muscle strength. The patients with genitalized and deep static wrin-
kles are mostly the elderly patients who had no BoNT injections done. The tension
of mimetic muscles does not significantly increase or decrease after aging [18].
Therefore, static wrinkles should not be used as a basis for increasing BoNT dose.
In addition, the strength of muscles of facial expression in men is usually stronger
than in women, so the amount of BoNT for wrinkle removal in men will also
be higher.
Synergist and Antagonist Muscles
Facial expressions and animation result from the contraction and relaxation of
groups of muscles and no single muscular movement. For example, frowning
involves the procerus, corrugator supercilii, depressor supercilii, and the medial part
of the orbital orbicularis oculi.
Moreover, we usually cannot only produce one expression in a given moment in
the natural state. For example, when we smile, in addition to crow’s feet, we often
produce the nasal dorsal wrinkles. This also varies on an individual basis and should
be examined as such. The synergistic and antagonist muscles treat the related mus-
cle to prevent compensatory enhancement of the non-treated muscles.
Attention should also be paid to the antagonistic muscles, such as the orbicularis
oculi and frontalis, and one ought to evaluate these relationships for each muscle in
detail before injection. Even in the same muscle, different parts can be antagonistic
to each other. For example, injecting the frontalis muscle into the hairline extends
the forehead height [19]. The principle is: the frontal muscle is a bi-directional con-
traction muscle, the upper frontal muscle can pull down the hairline, while the lower
frontal muscle can lift the eyebrow. When the upper frontal muscle is paralyzed, it
can pull down the hairline. The function of the eyebrow-lifting component of the
lower frontal muscle is then relatively enhanced, resulting in the elevation of the
upper portion. Another interesting example of the same principle is the improve-
ment of mild eyelid ptosis by BoNT injection into the pre-tarsal orbicularis oculi
muscle [20]. There are also individual differences in antagonistic muscles, so it is
still necessary to evaluate them in detail before a rhytidectomy.
The balance of synergic and antagonistic muscles in the face constitutes our
natural expression. Any treatment that destroys this balance may cause the expres-
sion to be unnatural or stiff. For example, the “mephisto sign” on the lateral part of
the eyebrow is the effect of the relative enhancement of the activity of the frontalis
muscle on the lateral part of the eyebrow. One variety of migraine is due to the
increased sensitivity of hemifacial muscles. BoNT injection for this type of migraine
will achieve a good clinical effect [21, 22]. Interestingly, when BoNT is injected
into the orbicularis Oris muscle to reduce crow’s feet rhytids or the frown line, some
patients will report experiencing a headache [23]. The author speculates that this
kind of headache could be related to the unbalanced muscle strength of the syner-
getic or antagonistic muscles and the spasm caused by the excessive local muscles.
In this regard, the author has carried out microinjection of frontalis to remove wrin-
kles in three patients who had more than three headaches following the injection of
frontalis. According to the current morphology of frontalis, all frontalis areas were
paralyzed evenly and none of the three patients had headache symptoms, which
further confirmed the author’s speculation. In addition, the author speculates that
the occurrence of stiffness after injection is also related to the imbalance of the
muscle strength of the synergistic and antagonistic muscles. Therefore, it is very
important to evaluate the shape of individual wrinkles and the specific situation of
the synergistic/antagonistic muscles in detail before the procedure, so as to “evenly”
paralyze the synergistic and the antagonistic muscles, which effectively reduces the
occurrence of postoperative discomfort.
In summary, we should follow the general principle of “evenly and moderately
paralyzing one or several groups of target muscles” and adjust the six variables of
dose, injection site, concentration, injection depth, muscle strength, and synergetic/
antagonistic muscle factors, to achieve the goal of BoNT wrinkle removal with a
balanced outcome achieved safely.
References
1. Lowe NJ, et al. Double-blind, randomized, placebo-controlled, dose-response study of the

safety and efficacy of botulinum toxin type A in subjects with crow’s feet. Dermatol Surg.
2005;31(3):257–62.
2. Rivers JK, et al. Subject satisfaction with onabotulinumtoxin A treatment of glabellar
and lateral canthal lines using a new patient-reported outcome measure. Dermatol Surg.
2015;41(8):950–9.
3. Carruthers J, Carruthers A. Botulinum toxin type A treatment of multiple upper facial sites:
patient-reported outcomes. Dermatol Surg. 2007;33:S10–7.
4. Beer KR. Comparative evaluation of the safety and efficacy of botulinum toxin type
A and topical creams for treating moderate-to-severe glabellar rhytids. Dermatol Surg.
2006;32(2):184–92.
5. Chang BL, et al. Patient perceived benefit in facial aesthetic procedures: FACE-Q as a tool to
study botulinum toxin injection outcomes. Aesthet Surg J. 2016;36(7):810–20.
6. Kowalski J, et al. Initial development of a patient-completed questionnaire to assess outcomes
of aesthetic treatment for hyperfunctional facial lines of the upper face. In Poster presented at
the American Academy of Dermatology Academy’s ’05 Annual Meeting, Chicago, IL. 2005.
7. Cox SE, et al. Development of the facial lines treatment satisfaction questionnaire and initial
results for botulinum toxin type A–treated patients. Dermatol Surg. 2003;29(5):444–9.
8. Hexsel D, et al. Fields of effects of 2 commercial preparations of botulinum toxin type A at equal
labeled unit doses: a double-blind randomized trial. JAMA Dermatol. 2013;149(12):1386–91.
9. Hexsel D, et al. Field effect of two commercial preparations of botulinum toxin type A: a pro-
spective, double-blind, randomized clinical trial. J Am Acad Dermatol. 2012;67(2):226–32.
10. Alimohammadi M, Andersson M, Punga AR. Correlation of botulinum toxin dose with neu-
rophysiological parameters of efficacy and safety in the glabellar muscles: a double-blind,
placebo-controlled, randomized study. Acta Derm Venereol. 2014;94(1):32–7.
11. Kim H, et al. A study on glabellar wrinkle patterns in Koreans. J Eur Acad Dermatol Venereol.
2014;28(10):1332–9.
12. Ramirez-Castaneda J, et al. Diffusion, spread, and migration of botulinum toxin. Mov Disord.
2013;28(13):1775–83.
13. Hsu TS, Dover JS, Arndt KA. Effect of volume and concentration on the diffusion of botuli-
num exotoxin A. Arch Dermatol. 2004;140(11):1351–4.
cal effects. Plast Reconstr Surg. 2015;136(5):92S–100S.
15. Cao Y, et al. A comparative in vivo study on three treatment approaches to applying topical
botulinum toxin A for crow’s feet. Biomed Res Int. 2018;2018:6235742.
16. Jiang HY, et al. Diffusion of two botulinum toxins type A on the forehead: double-blinded,
randomized, controlled study. Dermatol Surg. 2014;40(2):184–92.
17. Elwischger K, et al. Intramuscular distribution of botulinum toxin--visualized by MRI. J
Neurol Sci. 2014;344(1–2):76–9.
18. Gosain AK, et al. A volumetric analysis of soft-tissue changes in the aging midface
using high-resolution MRI: implications for facial rejuvenation. Plast Reconstr Surg.
2005;115(4):1143–52; discussion 1153–5.
19. Cohen S, Artzi O, Heller L. Forehead lift using botulinum toxin. Aesthet Surg
J. 2018;38(3):312–20.
20. Mustak H, et al. Use of botulinum toxin for the correction of mild ptosis. J Clin Aesthet
Dermatol. 2018;11(4):49–51.
21. Jay GW, Barkin RL. Primary Headache disorders-part 2: tension-type headache and medica-
tion overuse headache. Dis Mon. 2017;63(12):342–67.
22. Belvís R, Mas N. Treatment of chronic migraine with intramuscular pericranial injections of
onabotulinumtoxin A. Recent Pat CNS Drug Discov. 2014;9(3):181–92.
23. Rzany B, et al. Repeated botulinum toxin A injections for the treatment of lines in the upper
face: a retrospective study of 4,103 treatments in 945 patients. Dermatol Surg. 2007;33:S18–25.
Chapter 13
Botulinum Toxin A: Practical Tips for Use
in the Field of Aesthetic Medicine
Souphiyeh Samizadeh and Rajiv Grover
Botulinum toxin injections for cosmetic purposes are one of the most requested
non-surgical cosmetic treatments worldwide. In this chapter, the current literature is
explored, and practical tips are provided to help aesthetic practitioners optimize
their treatment preparation and procedures. Pre-procedural factors including prepa-
ration and reconstitution, diluents, storage after reconstitution, needles and syringes
and pain management are discussed. Furthermore, topics including skin preparation
and disinfection, the nerve endplates, speed and direction of injection, and volume
and dose, are examined. This chapter aims to provide background knowledge to
help optimize clinical practice and patient safety.
The Basic Structure
Botulinum neurotoxin (BoNT) is produced by anaerobic spore-forming bacteria of

the genus Clostridium. There are eight immunologically distinct serotypes (A–H)
produced by different strains of C. botulinum [1]. Serotypes A and B are the only
two serotypes that are widely used for clinical applications, including therapeutic
and cosmetic purposes [2]. The efficacy and safety of BoNT for cosmetic purposes
are well established [3–7].
S. Samizadeh (*)
R. Grover

https://doi.org/10.1007/978-3-030-84099-0_13
194 S. Samizadeh and R. Grover
BoNTs are di-chain proteins containing a 100 kDa heavy chain (HC) and a
50 kDa light chain (LC) linked via a disulfide bond (Fig. 13.1). These chains have
various functions; the HC is mainly involved in the three processes of internaliza-
tion (cell binding, internalization, and translocation) of the BoNT into the nerve, its
site of action. The LC is responsible for the neurotoxin activity and controls the
duration of action of BoNT (Fig. 13.2) [11, 12]. BoNT has various target sites but its
interaction with the following targets make it a unique therapeutic agent: [13–17]
• The neuromuscular junction
• Autonomic ganglia
• Postganglionic parasympathetic nerve endings
• Postganglionic sympathetic nerve endings
Various factors (pre-, intra-, and post-procedural) can affect the efficacy of BoNT
products, some of which are discussed below.
a b
Fig. 13.1 Structure of BoNT/A1 and BoNT/B1 molecules. Crystal structures of BoNT/A1 (PDB
ID: 3BTA) [8] (a) and BoNT/B1 (PDB ID: 1EPW) [9] (b) are represented as space-filling models
of the two opposite surfaces of each toxin molecule, showing the organization of the three toxin
domains: the neurospecific binding HC-C subdomain (green), the lectin-like HC-N subdomain
(purple), the translocation HN domain (yellow), and the metalloprotease L domain (red). The pink
cavity in the HC-C subdomains shown in the lower panels is the polysialoganglioside binding site.
A peptide belt (shown in blue) surrounding the L domain and the interchain disulfide bond (white
in the upper panels) and linking the L and HN domains, which stabilizes the structure, is also
shown [10]
13 Botulinum Toxin A: Practical Tips for Use in the Field of Aesthetic Medicine 195
Fig. 13.2 The nerve terminal intoxication by botulinum neurotoxins is a multi-step process. The
first step (1) is the binding of the HC domain (green) to a polysialoganglioside (PSG) receptor of
the presynaptic membrane (gray and black), followed by binding to a protein receptor. The cur-
rently known protein receptors are (i) synaptotagmin (Syt, gray) for BoNT/B1, /DC, and /G; (ii)
glycosylated SV2 (black with its attached N-glycan in pink) for BoNT/A1 and /E1. Syt may be
located either within the exocytosed synaptic vesicle or on the presynaptic membrane. The BoNT
is then internalized inside SVs, which are directly recycled (2a), or inside SVs that fuse with the
synaptic endosome and re-enter the SV cycle by budding from this intermediate compartment (2b).
The acidification (orange) of the vesicle, operated by the v-ATPase (orange), drives the accumula-
tion of neurotransmitter (blue dots) via the vesicular neurotransmitter transporter (light blue). The
protonation of BoNT leads to the membrane translocation of the L chain into the cytosol (3), which
is assisted by the HN domain (yellow). The L chain (red) is released from the HN domain by the
action of the thioredoxin reductase-thioredoxin system (TrxR-Trx, blue and dark blue) and Hsp90
(brown color), which reduce the interchain disulfide bond (orange) and avoid the aggregation of
the protease (4). In the cytosol, the L chain displays its metalloprotease activity: BoNT/B, /D, /F,
/G cleave VAMP (blue); BoNT/A and BoNT/E cleave SNAP-25 (green); and BoNT/C cleaves both
SNAP-25 and syntaxin (Stx, dark red) (5). Each of these proteolytic events is sufficient to cause a
prolonged inhibition of neurotransmitter release with consequent neuroparalysis [10]
Pre-Procedure
Product Factors
Vial Preparation and Reconstitution
Several studies have focused on various factors that may affect the efficacy of the
product during preparation. The recommendation is to clean the rubber stopper of
the vials (both the neurotoxin and diluent) with 60–70% alcohol (isopropyl alcohol
or ethanol) [18, 19]. There is a theoretical risk of inactivation of BoNT by the alco-
hol used to clean the rubber stopper [20–23]. A literature search of Pubmed Central
Fig. 13.3 It is recommended to clean the rubber stopper of the vials (both the neurotoxin and dilu-
ent) with 60–70% alcohol (isopropyl alcohol or ethanol) [18, 19]
(1980–2018) with keywords “botulinum toxin A” and alcohol resulted in 509 items.
Also, PROSPERO was checked. None of the search results were relevant and no
studies demonstrating the interaction of residual alcohol from the rubber stopper
with BoNT within the vial were identified. Therefore, there is no evidence to sug-
gest that cleaning vials of BoNT with alcohol has an adverse effect on its effi-
cacy in subsequent procedures (Fig. 13.3).
Other parameters that may affect product efficacy include shaking or bubbling dur-
ing reconstitution. Almeida et al. examined the efficacy of a gently reconstituted vial
of onabotulinum toxin A and one that was reconstituted aggressively, with foam for-
mation. Their study concluded that foaming does not affect the potency, or the short-
or long-term effects of the product [24]. Kazim and Black’s study using a vortex post
reconstitution was supportive of these findings [25]. In an animal study, Shome et al.
examined the efficacy of onabotulinum toxin A “when it is agitated vigorously for up
to 6 weeks.” They reported that the efficacy of the product did not change [26]. A 2004
consensus panel “Consensus recommendations on the use of botulinum toxin type A
in facial aesthetics” and currently available studies all support the fact that BoNT may
be more resistant to degradation than thought previously [27, 28].
However, poor reconstitution techniques can reduce the efficacy of the product,
completely render them inactive or result in inaccurate units and hence inaccurate
delivery of the treatment [29, 30]. Carey reported that there would loss of units if
INCO is reconstituted without inversion of the vial [29]. Niamtu examined the
waste of reconstituted BoNT when drawing the product through a vial stopper. He
reported that, on average, 5 units were lost if the conventional method of drawing
the product was used. This results in incorrect units being delivered and loss of
product [30]. Furthermore, the vacuum should be checked by inserting a needle.
Lack of vacuum could potentially mean contamination during distribution [31].
Diluents for Reconstitution
The manufacturers of BoNT products suggest to dilute the product with normal,
non-preserved saline (preservative-free 0.9% sodium chloride) [32–34]. However, in
practice, preserved saline is commonly used for the dilution of BoNT. In Liu et al.’s
study. 77.9% of 322 physician members of the American Society for Dermatologic
Surgery who replied to their questionnaire reported using bacteriostatic saline [35].
Some authors believe preservatives in the saline could result in partial deactivation
of the toxin [21, 36]. However, there is evidence for the equivalent clinical effective-
ness of the toxin diluted with preserved saline containing benzyl alcohol [37]. A few
studies have reported less pain and greater tolerability with the use of bacteriostatic
(preservative-containing) saline, with no difference in treatment efficacy [21, 37–
39]. Reduced pain with preserved saline is due to the presence of benzyl alcohol
which is a preservative and an anaesthetic [35, 40]. The consensus panel on the
consensus paper by Carruthers et al. agreed that preserved saline could be used [41].
Dressler used various diluents including isotonic sodium chloride solution 0.9%,
Ringer-Acetat, bacteriostatic saline 0.9%, Ringer lactate, and electrolyte solution to
examine pH normalization and reduction of injection site pain. They reported
an acidic pH for all reconstituted BoNT-A products in their study and reduction of
injection site pain with pH normalization. Amongst the examined diluents, bacterio-
static saline had the lowest pH, and the pH value for Ringer-Acetat was the most
neutral. They reported that, in comparison to bacteriostatic saline, Ringer-Acetat
was superior with regards to injection site pain and can be used as a substitute with-
out loss of BoNT-A efficacy [42].
Kim et al. reported that use of 1% lidocaine with epinephrine 1:1000 did not
result in reduced pharmacologic potency or patient satisfaction. It was added that it
could help produce immediate feedback that can be beneficial to the clinician [43].
De Almeida et al. collected information from various studies in their review paper,
“Handling Botulinum Toxins: An Updated Literature Review.” Preserved and un-
preserved saline, saline with hyaluronidase, lidocaine, and epinephrine, bupivacaine,
sterile water and albumin were the diluents mentioned [27]. Goodman reported
improved diffusion of onabotulinum toxin A with maintained efficacy with diluation
using saline with hyaluronidase [44]. Five studies reported maintained efficacy when
lignocaine and epinephrine and one study when bupivacaine was used [45–50].
Sterile water was also reported to not affect the potency of botulinum toxin A [51].
Storage After Reconstitution
The manufacturers make recommendations regarding storage before and after

reconstitution for their products. Several studies (1998–2012) assessed BoNT’s effi-
cacy post reconstitution and storage for various periods of time. These studies
reported maintained activity and potency from 24 h to 6 weeks post reconstitution
[21, 35, 52–56]. No reduced efficacy has been reported by storage of reconstituted
BoNT for 1 week (2007-study on external canthus dynamic lines) [57], 2 weeks
(1997-study on extensor digitorum brevis (frozen and refrigerated post reconstitu-
tion) [58], 2007-study on lateral periorbital rhytids [54], 2009-study on the glabellar
region [59], 2008-study on the frontalis muscle [53]), 6 weeks (2007-in the ophthal-
mology outpatient) [60], and 6 months (2007–118 sites) [61].
However, in the above studies, the question of sterility and bacteria/fungal con-
tamination was not addressed sufficiently. Alam et al. (2006) reconstituted BoNT
with saline with preservative (benzyl alcohol) and stored it in a plastic kidney basin.
It was then placed in an unlocked, multiuse medication refrigerator. The vials that
were used multiple times (without using the metal cover) were examined for steril-
ity at a microbiology laboratory using a thioglycolate broth. They reported that in
their study, the content was not contaminated despite the following conditions:
extended storage, handling of the reconstituted vial by multiple personnel, “storage
in a communal-use medication refrigerator,” and “clustering of vials in open kidney
basins.” [52] Menon and Murray (2007) employed aseptic precautions, including
cleaning the rubber stopper of each vial using an alcohol wipe (sterets) and using a
new sterile needle for each withdrawal. They kept the reconstituted vial of abobotu-
linum toxin A in the clinic for the duration of each clinic (4 h) and then refrigerated
it at 3–5°C for 5–7 days. The contents were then studied by a microbiologist using
various mediums. They reported that no bacterial growth was observed from the
used bottles of BoNT after 7 days of incubation [60]. This study supports the previ-
ous one in that multiple extractions of the product from the same vial did not result
in contamination when aseptic precautions were respected. In addition, the expo-
sure to room temperature did not change the outcome [60]. Osaki et al. studied the
bacterial and/or fungal proliferation of reconstituted BoNT vials that were refriger-
ated for 4 weeks. They reconstituted onabotulinum toxin A with normal saline with-
out preservatives under aseptic conditions and stored the vial in “sealed plastic
containers in a refrigerator at 5°C” for 4 weeks. They removed the metal, and rubber
caps for each subsequent treatment and the fridge was used multiple times during
the storage period. They also reported no detectable bacterial or fungal contamina-
tion [62]. In a blind multicentre study, Hexsel et al. reported no evidence of micro-
organisms in vials that were reconstituted (with 0.9% sterile saline solution without
preservatives) and stored for 30 days and in vials that were reconstituted 10 months
prior to being examined for the presence of microorganisms or bacterial growth
[59]. Barrow et al. treated 743 subjects with 6216 BoNT intralaryngeal injections,
with single-use vials of onabotulinum toxin A used for multiple patients. They
reported a high success rate, low occurrence of side effects and no evidence of
infection [63]. It is advised not to freeze the reconstituted product [64].
Syringes and Needles
Factors that should be considered when choosing a syringe and needle include: [65]
• Device accuracy
• Loss of volume and unit of products in the syringe or needle
• Silicone particles that may be introduced intradermally via the method of delivery
• Needle sharpness and blunting
• Practitioner’s skill level and comfort when handling the syringe
Traditionally, insulin syringes have been used for injection of BoNT. For
improved delivery, the following devices or methods can also be considered
(Fig. 13.4):
• Use of new devices/syringes (e.g. 3Dose Vlow Medical/3Dose™). These can
help reduce/eliminate loss of solution, and enhance ease of use as number of
units for various dilutions are visible. If used properly, these devices can help
improve the accuracy of delivery. Studies that examined the accuracy and preci-
sion of insulin administration using traditional syringes and injector pens
reported greater accuracy with pens and pump injectors [66–68]. Keith et al.
reported that “Syringes were dangerously inaccurate.” [66].
• Small gauge needles can reduce pain [69–71]. For example, the invisible needle
by TSK is 33% thinner than a 30G needle and has a low dead space hub, resulting
in reduced loss of product [72]. Sezgin et al. also reported less bruising using a
33G needle [69].
Fig. 13.4 From left to right: Becton Dickinson (BD) Ultra-Fine Insulin Syringe 31G × 6 mm,
0.5 cc Insulin Syringe, 29G × 1/2, “dead space and no dead space” needles, 33G × 9 mm invisible
needle by TSK, Ultra-Fine Insulin Syringe 31G × 6 mm in comparison to TSK invisible needle
33G, 3Dose system
Pre-Procedure Pain Management
Various analgesic methods have been studied and employed to reduce the pain asso-
ciated with BoNT injections. It is important to understand the difference between
anaesthesia (elimination of pain and other sensation) and analgesia (reduction of
pain) [73]. Low intensity mechanical (mechanoreceptive) and thermal skin stimuli
(cold-sensitive units) can suppress the sensation of pain [74].
Topical Agents
Topical analgesic creams are common modalities used. Examples of topical creams
include EMLA and Elamax. The use of these topical creams is time-consuming
(30–60 min to take effect), and contact dermatitis is a common complication
[75–77].
Cooling
Another popular method of pain reduction is cooling agents, including ice packs
and vapocoolant sprays. Weiss and Lavin reported a significant decrease in pain at
BoNT injection sites (glabellar area) when vapocoolant spray was used [78].
A paper by Hogan and colleagues, “A systematic review of measures for reducing
injection pain during adult immunisation” reported that skin cooling or tactile stim-
ulation results in pain reduction [79]. Irkoren and colleagues also reported a signifi-
cant reduction in pain during injection of BoNT (forehead) after the use of ethyl
chloride spray [80].
However, it should be kept in mind that changes in temperature may affect the
uptake of BoNT as it is temperature dependant. Cooling to the extent that muscle
temperature is reduced results in decreased uptake of BoNT and hence reduced its
efficacy [81–83].
Vibration—Vibration-Assisted Analgesia
Sharma et al. studied the safety and efficacy of this method for reducing BoNT
injection pain. They reported reduced discomfort when vibration-assisted anaesthe-
sia was used [84]. Nanitsos et al. studied the effect of using vibration on pain during
the delivery of local anaesthesia in dentistry. They reported a significant pain differ-
ence when vibration was used [85]. Smith et al. reported the analgesic effect of
vibration for dermatological procedures and injectables [73]. The effect of vibration
on the spread of neurotoxins and dermal fillers has not been studied. Also, the
impact of the distance of the vibration device from the injection site on effectiveness
and prevention of complications needs to be studied.
Other measures for reducing pain include gentle injection, sharp, small gauge
needles, and small volume [69–71, 84, 86, 87]. Furthermore, injection site pain,
bruising, and oedema are due to injection technique and can be reduced by improv-
ing the technique of administration [88].
Skin Preparation and Disinfection
In the paper “Global Aesthetics Consensus: Botulinum Toxin Type A—Evidence-

Based Review, Emerging Concepts, and Consensus Recommendations for Aesthetic
Use, Including Updates on Complications” by Sundurum et al., it is emphasized that
from a pre-treatment preparation aspect, and to minimize preventable contamina-
tion, the injection of neurotoxins or dermal fillers is a minor surgical procedure.
Hence, it is mandatory to cleanse well prior to injections by removing all makeup,
skin cleansing (before, during, and after treatment), and employ a sterile injection
technique [89]. Injection of dermal fillers requires a sterile environment and skin
pre-treatment. A real danger exists with dermal fillers due to the high chance of
infection and biofilm formation [90–93]. However, this risk of infection is not
as significant for BoNT injections. Coté et al. examined the side effects of BoNT-A
injections reported to the US FDA in therapeutic and cosmetic cases. Out of the
1437 adverse events reports, 1031 were due to cosmetic injection, with no report of
serious infections and 0.6% non-serious infections [94]. As such, although there is
a low chance of infection, we recommend cleaning the skin with a disinfectant prior
to botulinum toxin injections. Agents used for antiseptic skin preparation can reduce
the presence of pathogens in the skin surface. It is essential to keep in mind that dif-
ferent antiseptic solutions vary in terms of their efficacy, the ability to penetrate the
subcutaneous layer and rate of re-colonization [95].
Procedure
Injection Sites
Nerve Endplates
The uptake of BoNT only occurs at the endplate into the nerve terminals. Therefore,
a greater uptake would result due to injection close to the endplates (locations with
the highest concentration of neuromuscular junctions), which are normally in the
middle of muscle fibres. Furthermore, the direction of muscle fibres in target injec-
tion muscles should be studied and known prior to the injections [81]. Delnooz
et al. studied BoNT injections targeted at the motor endplate zone in cervical dys-
tonia. They reported that when BoNT injections were targeted to the motor endplate
zone, half-dosed treatment resulted in a similar effect to the standard treatment [96].
Gracies and colleagues, in a double-blind randomized controlled trial (spastic

biceps brachii) reported that endplate-targeted high volume BoNT injections
resulted in greater results than non-targeted low volume injections [97]. Lapatki
et al.’s study also reported the same findings, that targeted injection towards end-
plates enhances the effect of injection and may lead to a reduction of the dose
required and hence treatment costs. This, in turn, is beneficial, as a method of reduc-
ing adverse effects is administration of the lowest dose that is effective [98]. Childers
also reported that the key for dose reduction without compromising clinical efficacy
would be targeted injection of BoNT [99]. Therefore, an ideal situation would be
the use of the lowest dose required without compromising the efficacy of
BoNT. Motor endplate zone localisation is usually carried out using surface electro-
myography [100–102]. Identifying and developing methods of identifying motor
endplate zones for facial muscles in clinical practice would be beneficial for cos-
metic use of BoNT.
Delivery: Speed, Direction, Pressure
Movement of the fluid within the injected target muscle is mainly determined by the
injected volume and the force used. Therefore, the accuracy of the placement of the
needle, its direction, and volumes injected can help prevent affecting the adjacent
muscles. BoNT-A is distributed along the long axis of muscle post-injection [81].
Hexsel et al. recommend the injection of the periorbital area for cosmetic purposes
with “needle oriented in the opposite direction of the ocular globe” to prevent com-
plications [103]. Injection technique manuals and books also emphasize accurate
placement and correct “injection direction and depth” to avoid complications and
affecting the adjacent muscles [104–108]. The distribution of BoNT-A within spas-
tic muscles may be lower than normal muscles [81]. Therefore, injection into
relaxed muscles would be more efficient [87].
The accuracy of placement is decreased with increased volume, speed, and inac-
curate depth of the injection, thus increasing the chance of complications [109].
Electromyographic or ultrasound-guided injections can improve the accuracy of
delivery, optimize outcomes and prevent complications [108, 110–113].
Delivery: Volume, Dose
There is a debate within the scientific community regarding the effect of dilution on
various factors, including spread or diffusion of the product, clinical efficacy, side
effects and duration. Some authors have reported higher dilution (lower concentra-
tion) being associated with enhanced risk of spread of the product, reduced duration
of effect, unwanted side effects or suboptimal results [21, 98, 114, 115]. However,
there are also multiple studies and authors that dispute these findings. Gracies et al.
have reported enhanced efficacy of large volumes (same units) when used for the
treatment of large muscles. In this study, larger volumes were used to increase the
spread of the product to endplates distant from the injection site [116]. However, for
cosmetic purposes, in particular for the facial areas, the muscles are relatively small
and in close proximity to each other.
Carruthers et al. reported that the degree of dilution of onabotulinum toxin A
within a fivefold margin has a minor effect on the results in the lateral orbital area
[117]. In another study, Carruthers et al. used four different dilutions (100, 33.3, 20,
or 10 U/mL) for the glabellar region. They reported no significant differences [118].
In a prospective, randomised, controlled study, Hsu et al. injected the forehead with
two dilutions (five-fold difference in volume). They reported enhanced affected
areas with larger volume and change in the shape of rhytid elimination [119]. These
findings were supported by Abbasi et al.’s study using various concentrations/vol-
ume of abobotulinum toxin A to treat the forehead [120]. Punga et al. used two
different volumes (abobotulinumtoxin A-twofold) for the treatment of glabellar
lines and reported no difference in efficacy or adverse events [121]. Hence these
studies and their results must be critically evaluated. The issue of volume should be
examined according to target site characteristic (muscle size, activity, location),
treatment aims and objectives, and product characteristics.
BoNT A causes dose-dependent muscle weakness and paralysis [122, 123].
Lower than optimal and recommended doses produce suboptimal clinical results
and reduced longevity [124, 125]. Optimal and safe doses for various treatment
areas and aims and objectives can be found from company recommendations and
open-label trials. This information can be used for treatment optimisation. Dressler
et al. reported that when higher doses are used, the longevity is believed to saturate
in about 3 months [126]. Recently, a trial conducted by Allergan plc reported
enhanced longevity of clinical results with increased doses of BOTOX® Cosmetic
[127]. This is in line with previous studies, including the study by Poewe et al., who
reported enhanced longevity and efficacy with higher doses of abobotulinum toxin
A in patients with rotational torticollis [128]. It is important to keep in mind the
dose equivalences of different preparations and products.
Immunogenicity
Any protein-based treatment or therapeutic, such as neurotoxins, can cause an immune

response resulting in the production of neutralizing antibodies. Immunogenicity refers
to antibody formation due to exposure to a protein. Primary non-response (Fig. 13.5)
is when a patient does not respond to the first treatment and treatment provided after
that [129–131]. This can be due to insufficient dose, vaccination against BoNT, target
muscle missed, presence of contractures or degradation of BoNT during storage [129,
132]. Discord between patient and physician perceptions of benefit should be
(–) Response: Repeat injection

with altered injection plan
(–) Respone: Assess for

(+) Response:
history of botulinum infection or
Continue injection plan
BoNT vaccine exposure
(+) History: Test for

(–) History: Adjust
clinical resistance
injection plan
with UBI
(+) Response: (–) Response: Test

Continue for clinical resistance
injection plan with UBI
(+) Response (i.e. asymmetric (–) Response (i.e. symmetric

frowning): Not consistent with PNR frowning): consistent with PNR
Adjust injection plan Switch BoNT serotype and

monitor for recurrent SNR
(+) Response: Continue (–) Response: Screen for NAbs by a

injection plan structural assay (i.e., ELISA, IPA)
+NAb: Consider confirmatory –NAb: Adjust injection plan

Legend:
bioassay (i.e., MPA)
UBI = unilateral brow injection
PNR = Primary non-
responsiveness
NAb = neutralizing antibody +MPA: Switch BoNT serotype
MPA = mouse protection assay
Fig. 13.5 Proposed primary non-responsive (PNR) detection and management pathway [129]
Source: Bellows, S. and J. Jankovic, Immunogenicity Associated with Botulinum Toxin Treatment.
Toxins, 2019. 11(9): p. 491
considered [129, 132]. Secondary non-response happens when a patient responds to

the first treatment but not the subsequent treatments or loses responsiveness over time
[130]. Secondary non-responsiveness (Fig. 13.6) has been reported in the literature
[133–136]. This is more common when the treatment dose is large per injection and
with large cumulative doses, for example for therapeutic purposes, when there
are short intervals between treatments (e.g. booster injections), and due to product-
related factors (e.g. certain formulations, inactive neurotoxins or the antigenic protein
load). Preventive measures include using the smallest effective dose with no booster
injections and a treatment interval of at least 3 months [65, 130, 137–140].
(–) Response: Repeat injection with

altered injection plan
(+) Response: Continue injection (–) Response: Test for clinical

plan resistance with UBI
(+) Response (i.e., asymmetric (–) Response (i.e., symmetric

frowning): Not consistent with SNR frowning): Consistent with SNR
Switch BoNT serotype and monitor

Adjust injection plan
for recurrent SNR
(+) Response: Continue injection (–) Response: Screen for NABs by a

plan structural assay (i.e. ELISA, IPA)
+ NAb: Consider confirmatory

– NAb: Adjust Injection plan
bioassay (i.e., MAP)
+MPA: Switch BoNT serotype
Legend:
UBI = unilateral brow injection
SNR = Secondary non-responsiveness
NAb = neutralizing antibody
Fig. 13.6 Proposed secondary non-responsive (SNR) detection and management pathway [129].
Source: Bellows, S. and J. Jankovic, Immunogenicity Associated with Botulinum Toxin Treatment.
Toxins, 2019. 11(9): p. 491
Conclusion
BoNT-A is a safe and effective treatment for various indications in the field of aes-
thetic medicine, including facial rejuvenation and contouring. The use of various
BoNT products is becoming better supported by clinical and scientific studies. An
understanding of published studies and regular updates of this knowledge as new
studies become available would facilitate a move towards an evidence-based prac-
tice. This will enable a better understanding of the products, procedures, and poten-
tial complications, as well as their prevention and treatment. Successful treatment
planning entails an understanding of pre-, intra-, and post-procedural related factors
in addition to patient-related factors.
References
1. Rossetto O, Pirazzini M, Montecucco C. Botulinum neurotoxins: genetic, structural and

mechanistic insights. Nat Rev Microbiol. 2014;12(8):535–49.
2. Boone B. Botulinum toxin in aesthetic medicine. In European handbook of dermatological
treatments. Springer, p. 1089–1106. 2015.
3. Gadhia K, Walmsley AD. Facial aesthetics: is botulinum toxin treatment effective and safe?
A systematic review of randomised controlled trials. Br Dent J. 2009;207(5):E9. discus-
sion 216–7
4. Brin MF, et al. Safety and tolerability of onabotulinumtoxinA in the treatment of facial lines:
a meta-analysis of individual patient data from global clinical registration studies in 1678
participants. J Am Acad Dermatol. 2009;61(6):961-70.e1-11.
5. Kaltreider SA, et al. Cosmetic oculofacial applications of botulinum toxin: a report by the
American Academy of Ophthalmology. Ophthalmology. 2005;112(6):1159–67.
6. Naumann M, Jankovic J. Safety of botulinum toxin type A: a systematic review and meta-
analysis. Curr Med Res Opin. 2004;20(7):981–90.
7. Cavallini M, Cirillo P, Fundaro S. Safety of botulinum toxin A in aesthetic treatments. A
systematic review of clinical studies, p. 40. 2014.
8. Lacy DB, et al. Crystal structure of botulinum neurotoxin type A and implications for toxic-
ity. Nat Struct Biol. 1998;5(10):898–902.
9. Swaminathan S, Eswaramoorthy S. Structural analysis of the catalytic and binding sites of
Clostridium botulinum neurotoxin B. Nat Struct Biol. 2000;7(8):693–9.
10. Pirazzini M, et al. Botulinum neurotoxins: biology, pharmacology, and toxicology. Pharmacol
Rev. 2017;69(2):200–35.
11. Pirazzini M, et al. On the translocation of botulinum and tetanus neurotoxins across
the membrane of acidic intracellular compartments. Biochim Biophys Acta Biomembr.
2016;1858(3):467–74.
12. Brunger AT, et al. Botulinum neurotoxin heavy chain belt as an intramolecular chaperone for
the light chain. PLoS Pathog. 2007;3(9):e113.
13. Nigam PK, Nigam A. Botulinum toxin. Indian J Dermatol. 2010;55(1):8–14.
14. Simpson LL. Kinetic studies on the interaction between botulinum toxin type A and the cho-
linergic neuromuscular junction. J Pharmacol Exp Ther. 1980;212(1):16–21.
15. Naumann M. Clinical comparison of botulinum neurotoxin effects at the neuromuscular
junction and autonomic nerves: similarities and differences. Toxicon. 2015;93:S46.
16. Rowe JA, et al. Introduction to the autonomic nervous system and autonomic pharmacology.
Veterinary Pharmacology and Therapeutics. 2017.
17. Ozcan C, Ismi O. Botulinum toxin for rhinitis. Curr Allergy Asthma Rep. 2016;16(8):58.
18. Mauad BA, et al. Changes in lower dental arch dimensions and tooth alignment in young
adults without orthodontic treatment. Dental Press J Orthod. 2015;20(3):64–8.
19. In WHO best practices for injections and related procedures toolkit. Geneva. 2010.
20. Cohen JL, Beer K, Toxins B. In: Goldberg DJ, editor. Facial rejuvenation: a total approach.
Berlin: Springer; 2007. p. 79–103.
21. Klein AW. Dilution and storage of botulinum toxin. Dermatol Surg. 1998;24(11):1179–80.
22. Jaspers G, Pijpe J, Jansma J. The use of botulinum toxin type A in cosmetic facial procedures.
Int J Oral Maxillofac Surg. 2011;40(2):127–33.
23. Klein AW. Cosmetic therapy with botulinum toxin anecdotal memoirs. Dermatol Surg.
1996;22(9):757–9.
24. Trindade de Almeida AR, et al. Foam during reconstitution does not affect the potency of
botulinum toxin type A. Dermatol Surg. 2003;29(5):530–2.
25. Kazim NA, Black EH. Botox: shaken, not stirred. Ophthalmic Plast Reconstr Surg.
2008;24(1):10–2.
26. Shome D, et al. Botulinum toxin A: is it really that fragile a molecule? Dermatol Surg.
2010;36(Suppl 4):2106–10.
27. Trindade de Almeida AR, Secco LC, Carruthers A. Handling botulinum toxins: an updated
literature review. Dermatol Surg. 2011;37(11):1553–65.
28. Carruthers J, Fagien S, Matarasso S. Consensus recommendations on the use of botulinum
toxin type A in facial aesthetics. Ophthalmic Plast Reconstr Surg. 2005;21(2):165.
29. Carey WD. Incorrect reconstitution of incobotulinumtoxinA leads to loss of neurotoxin. J
Drugs Dermatol. 2014;13(6):735–8.
30. Niamtu J III. Neurotoxin waste from drawing product through the vial stopper. J Clin Aesthet
Dermatol. 2014;7(6):33.
31. Seo KK Botoxology. In Botulinum toxin for Asians. Springer. p. 1–28. 2017
32. Khanna R, Tikku T, Sharma V. Position and orientation of hyoid bone in class II division I
subjects: a cephalometric study. J Indian Orthod Soc. 2011;45:212–8.
33. Using XEOMIN® (incobotulinumtoxinA) – Step by Step Reconstitution and dilution
instructions. 2017 [cited 2018 June]; Available from: http://www.xeomin.com/physicians/
about-xeomin/reconstitution-storage/
34. Hoffman JA, Hoffman RL. Tongue-thrust and deglutition: some anatomical, physiological,
and neurological considerations. J Speech Hear Disord. 1965;30:105–20.
35. Liu A, et al. Recommendations and current practices for the reconstitution and storage of
botulinum toxin type A. J Am Acad Dermatol. 2012;67(3):373–8.
36. Carruthers JD, Carruthers JA. Treatment of glabellar frown lines with C. botulinum-A exo-
toxin. J Dermatol Surg Oncol. 1992;18(1):17–21.
37. Alam M, Dover JS, Arndt KA. Pain associated with injection of botulinum A exotoxin recon-
stituted using isotonic sodium chloride with and without preservative: a double-blind, ran-
domized controlled trial. Arch Dermatol. 2002;138(4):510–4.
38. Kwiat DM, Bersani TA, Bersani A. Increased patient comfort utilizing botulinum toxin type
a reconstituted with preserved versus nonpreserved saline. Ophthalmic Plast Reconstr Surg.
2004;20(3):186–9.
39. Sarifakioglu N, Sarifakioglu E. Evaluating effects of preservative-containing saline solution
on pain perception during botulinum toxin type-a injections at different locations: a prospec-
tive, single-blinded, randomized controlled trial. Aesthet Plast Surg. 2005;29(2):113–5.
40. Wilson L, Martin S. Benzyl alcohol as an alternative local anesthetic. Ann Emerg Med.
1999;33(5):495–9.
41. Carruthers J, Fagien S, Matarasso SL. Consensus recommendations on the use of botulinum
toxin type A in facial aesthetics. Plast Reconstr Surg. 2004;114(6):1S–22S.
42. Dressler D, Saberi FA, Bigalke H. Botulinum toxin therapy: reduction of injection site pain
by pH normalisation. J Neural Transm. 2016;123(5):527–31.
43. Kim A, Jung J, Pak A. Botulinum toxin type A reconstituted in lidocaine with epinephrine for
facial rejuvenation: results of a participant satisfaction survey. Cutis. 2013;Suppl:13–8.
44. Goodman G. Diffusion and short-term efficacy of botulinum toxin A after the addition
of hyaluronidase and its possible application for the treatment of axillary hyperhidrosis.
Dermatol Surg. 2003;29(5):533–8.
45. Gassner HG, Sherris DA. Addition of an anesthetic agent to enhance the predictability of the
effects of botulinum toxin type A injections: a randomized controlled study. In Mayo Clinic
Proceedings. Elsevier. 2000
46. Haubner F. Simultaneous injection of lidocaine improves predictability of effect of botulinum
toxin. Laryngo-Rhino-Otologie. 2009;88(12):764.
47. Kenner JR. Hyaluronic acid filler and botulinum Neurotoxin delivered simultaneously in
the same syringe for effective and convenient combination aesthetic rejuvenation therapy. J
Drugs Dermatol. 2010;9(9):1135–8.
48. Vadoud-Seyedi J, Simonart T. Treatment of axillary hyperhidrosis with botulinum toxin type
A reconstituted in lidocaine or in normal saline: a randomized, side-by-side, double-blind
study. Br J Dermatol. 2007;156(5):986–9.
49. Hantash BM, Gladstone HB. A pilot study on the effect of epinephrine on botulinum toxin
treatment for periorbital rhytides. Dermatol Surg. 2007;33(4):461–8.
50. Yen MT, Wall VK. Bupivacaine-induced myotoxicity and its effect on botulinum toxin pare-
sis. Ann Plast Surg. 2008;60(1):6–9.
51. Moore P, Naumann M. Handbook of botulinum toxin treatment. Wiley-Blackwell; 2003.
52. Alam M, et al. Sterility assessment of multiple use botulinum A exotoxin vials: a prospective
simulation. J Am Acad Dermatol. 2006;55(2):272–5.
53. Yang GC, Chiu RJ, Gillman GS. Questioning the need to use Botox within 4 hours of recon-
stitution: a study of fresh vs 2-week-old Botox. Arch Facial Plast Surg. 2008;10(4):273–9.
54. Hui JI, Lee WW. Efficacy of fresh versus refrigerated botulinum toxin in the treatment of
lateral periorbital rhytids. Ophthalmic Plast Reconstr Surg. 2007;23(6):433–8.
55. Hexsel DM, et al. Multicenter, double-blind study of the efficacy of injections with botulinum
toxin type A reconstituted up to six consecutive weeks before application. Dermatol Surg.
2003;29(5):523–9.
56. Kane M, et al. Expanding the use of neurotoxins in facial aesthetics: a consensus panel's
assessment and recommendations. J Drugs Dermatol. 2010;9(1 Suppl):s7–22. quiz s23–5
57. Lizarralde M, Gutierrez SH, Venegas A. Clinical efficacy of botulinum toxin type A recon-
stituted and refrigerated 1 week before its application in external canthus dynamic lines.
Dermatol Surg. 2007;33(11):1328–33.
58. Sloop RR, Cole BA, Escutin RO. Reconstituted botulinum toxin type A does not lose
potency in humans if it is refrozen or refrigerated for 2 weeks before use. Neurology.
1997;48(1):249–53.
59. Hexsel D, et al. Blind multicenter study of the efficacy and safety of injections of a com-
mercial preparation of botulinum toxin type A reconstituted up to 15 days before injection.
Dermatol Surg. 2009;35(6):933–40.
60. Menon J, Murray A. Microbial growth in vials of Botulinum toxin following use in clinic.
Eye (Lond). 2007;21(7):995–7.
61. Parsa AA, Lye KD, Parsa FD. Reconstituted botulinum type A neurotoxin: clinical efficacy
after long-term freezing before use. Aesthet Plast Surg. 2007;31(2):188–91. discussion 192-3
62. Osaki T, et al. Absence of bacterial or fungal growth in vials of reconstituted botulinum toxin
type A after storage. Aesthet Surg J. 2015;35(2):189–93.
63. Barrow EM, et al. Safety and efficacy of multiuse botulinum toxin vials for intralaryngeal
injection. Laryngoscope. 2015;125(5):1149–54.
64. Haney B. Reconstitution and dosing of neurotoxins. In: Haney B, editor. Aesthetic proce-
dures: nurse practitioner's guide to cosmetic dermatology. Cham: Springer International
Publishing; 2020. p. 91–7.
65. Samizadeh S, De Boulle K. Botulinum neurotoxin formulations: overcoming the confusion.
Clin Cosmet Investig Dermatol. 2018;11:273–87.
66. Keith K, Nicholson D, Rogers D. Accuracy and precision of low-dose insulin administration
using syringes, pen injectors, and a pump. Clin Pediatr. 2004;43(1):69–74.
67. Gnanalingham MG, Newland P, Smith CP. Accuracy and reproducibility of low dose insulin
administration using pen-injectors and syringes. Arch Dis Child. 1998;79(1):59–62.
68. Lteif AN, Schwenk WF. Accuracy of pen injectors versus insulin syringes in children with
type 1 diabetes. Diabetes Care. 1999;22(1):137–40.
69. Sezgin B, et al. The Effect of microneedle thickness on pain during minimally invasive facial
procedures: a clinical study. Aesthet Surg J. 2014;34(5):757–65.
70. Zelickson BR, et al. Finer needles reduce pain associated with injection of local anesthetic
using a minimal insertion injection technique. Dermatol Surg. 2018;44(2):204–8.
71. Alam M, et al. Effect of needle size on pain perception in patients treated with botulinum
toxin type A injections: a randomized clinical trial. JAMA Dermatol. 2015;151(11):1194–9.
72. TSK The Invisible Needle™. 2017 [cited 2018 June]; Available from: https://tsklab.nl/wp-
content/uploads/TSK-Aesthetic-Brochure.pdf.
73. Smith KC, et al. Vibration anesthesia: a noninvasive method of reducing discomfort prior to
dermatologic procedures. Dermatol Online J. 2004;10(2).
74. Bini G, et al. Analgesic effect of vibration and cooling on pain induced by intraneural electri-
cal stimulation. Pain. 1984;18(3):239–48.
75. Friedman PM, et al. Comparative study of the efficacy of four topical anesthetics. Dermatol
Surg. 1999;25(12):950–4.
76. Dong H, Kerl H, Cerroni L. EMLA cream-induced irritant contact dermatitis. J Cutan Pathol.
2002;29(3):190–2.
77. Timmermans MW, Bruynzeel DP, Rustemeyer T. Allergic contact dermatitis from EMLA
cream: concomitant sensitization to both local anesthetics lidocaine and prilocaine. J Dtsch
Dermatol Ges. 2009;7(3):237–8.
78. Weiss RA, Lavin PT. Reduction of pain and anxiety prior to botulinum toxin injections with
a new topical anesthetic method. Ophthalmic Plast Reconstr Surg. 2009;25(3):173–7.
79. Hogan M-E, Kikuta A, Taddio A. A systematic review of measures for reducing injection
pain during adult immunization. Vaccine. 2010;28(6):1514–21.
80. Irkoren S, Ozkan HS, Karaca H. A clinical comparison of EMLA cream and ethyl chlo-
ride spray application for pain relief of forehead botulinum toxin injection. Ann Plast Surg.
2015;75(3):272–4.
81. Hallett M. Explanation of timing of botulinum neurotoxin effects, onset and duration, and
clinical ways of influencing them. Toxicon. 2015;107:64–7.
82. Poulain B, et al. Differences in the temperature dependencies of uptake of botulinum and
tetanus toxins in Aplysia neurons. Neurosci Lett. 1992;139(2):289–92.
83. Pirazzini M, et al. Time course and temperature dependence of the membrane translocation
of tetanus and botulinum neurotoxins C and D in neurons. Biochem Biophys Res Commun.
2013;430(1):38–42.
84. Sharma P, Czyz CN, Wulc AE. Investigating the efficacy of vibration anesthesia to reduce
pain from cosmetic botulinum toxin injections. Aesthet Surg J. 2011;31(8):966–71.
85. Nanitsos E, et al. The effect of vibration on pain during local anaesthesia injections. Aust
Dent J. 2009;54(2):94–100.
86. Cheng CM. Cosmetic use of botulinum toxin type A in the elderly. Clin Interv Aging.
2007;2(1):81.
87. Stephan S, Wang TD. Botulinum toxin: clinical techniques, applications, and complications.
88. Carruthers J, Glogau RG, Blitzer A, Facial Aesthetics Consensus Group Faculty. Advances in
facial rejuvenation: botulinum toxin type A, hyaluronic acid dermal fillers, and combination
therapies—consensus recommendations. Plast Reconstr Surg. 2008;121(5 Suppl):5S–30S.
89. Sundaram H, et al. Global aesthetics consensus: botulinum toxin type A—evidence-based
review, emerging concepts, and consensus recommendations for aesthetic use, including
updates on complications. Plast Reconstr Surg. 2016;137(3):518.
90. Funt D, Pavicic T. Dermal fillers in aesthetics: an overview of adverse events and treatment
approaches. Clin Cosmet Investig Dermatol. 2013;6:295.
91. Sadashivaiah AB, Mysore V. Biofilms: their role in dermal fillers. J Cutan Aesthet Surg.
2010;3(1):20.
92. Beer K, Avelar R. Relationship between delayed reactions to dermal fillers and biofilms: facts
and considerations. Dermatol Surg. 2014;40(11):1175–9.
93. Rohrich RJ, et al. Soft-tissue filler complications: the important role of biofilms. Plast
Reconstr Surg. 2010;125(4):1250–6.
94. Coté TR, et al. Botulinum toxin type A injections: adverse events reported to the US
Food and Drug Administration in therapeutic and cosmetic cases. J Am Acad Dermatol.
2005;53(3):407–15.
95. Hebl JR, Horlocker TT. You’re not as clean as you think! The role of asepsis in reducing infec-
tious complications related to regional anesthesia. Reg Anesth Pain Med. 2003;28(5):376–9.
96. Delnooz CC, et al. The clinical utility of botulinum toxin injections targeted at the motor
endplate zone in cervical dystonia. Eur J Neurol. 2014;21(12):1486–e98.
97. Gracies JM, et al. Botulinum toxin dilution and endplate targeting in spasticity: a double-
blind controlled study. Arch Phys Med Rehabil. 2009;90(1):9–16.e2.
98. Bakheit AMO. The possible adverse effects of intramuscular botulinum toxin injections and
their management. Curr Drug Saf. 2006;1(3):271–9.
99. Childers MK. The importance of electromyographic guidance and electrical stimulation for
injection of botulinum toxin. Phys Med Rehab Clin. 2003;14(4):781–92.
100. Guzmán-Venegas RA, Araneda OF, Silvestre RA. Differences between motor point and
innervation zone locations in the biceps brachii. An exploratory consideration for the treat-
ment of spasticity with botulinum toxin. J Electromyogr Kinesiol. 2014;24(6):923–7.
101. Lapatki B, et al. Botulinum toxin has an increased effect when targeted toward the mus-
cle’s endplate zone: a high-density surface EMG guided study. Clin Neurophysiol.
2011;122(8):1611–6.
102. Lim EC, Quek AM, Seet RC. Accurate targeting of botulinum toxin injections: how to and
why. Parkinsonism Relat Disord. 2011;17:S34–9.
103. Hexsel D, et al. Botulinum toxin for facial wrinkles: history and future. Expert Rev Dermatol.
2007;2(4):417–26.
104. Jost WH, Valerius K-P. Pictorial atlas of botulinum toxin injection: dosage, localization,
application. Quintessence Books. 2008.
105. Truong D, et al. Manual of botulinum toxin therapy. Cambridge University Press. 2014.
106. Chin TY, et al. Accuracy of intramuscular injection of botulinum toxin A in juvenile cerebral
palsy: a comparison between manual needle placement and placement guided by electrical
stimulation. J Pediatr Orthop. 2005;25(3):286–91.
107. Picelli A, et al. Accuracy of botulinum toxin type A injection into the gastrocnemius muscle
of adults with spastic equinus: manual needle placement and electrical stimulation guidance
compared using ultrasonography. J Rehabil Med. 2012;44(5):450–2.
108. Schnitzler A, et al. Manual needle placement: accuracy of botulinum toxin A injections.
Muscle Nerve. 2012;46(4):531–4.
109. Klein AW. Complications, adverse reactions, and insights with the use of botulinum toxin.
Dermatol Surg. 2003;29(5):549–56.
110. Klein AW, Mantell A. Electromyographic guidance in injecting botulinum toxin. Dermatol
Surg. 1998;24(11):1184–6.
111. O’Brien CF. Injection techniques for botulinum toxin using electromyography and electrical
stimulation. Muscle Nerve. 1997;20(S6):176–80.
112. Dogu O, et al. Ultrasound-guided versus ‘blind’intraparotid injections of botulinum toxin-A
for the treatment of sialorrhoea in patients with Parkinson’s disease. Clin Neurol Neurosurg.
2004;106(2):93–6.
113. Westhoff B, et al. Ultrasound-guided botulinum toxin injection technique for the iliopsoas
muscle. Dev Med Child Neurol. 2003;45(12):829–32.
114. Mantell AM. Dilution, storage, and electromyographic guidance in the use of botulinum tox-
ins. Dermatol Clin. 2004;22(2):135–6. v
115. Wollina U, Konrad H. Managing adverse events associated with botulinum toxin type A: a
focus on cosmetic procedures. Am J Clin Dermatol. 2005;6(3):141–50.
116. Gracies J-M, et al. Botulinum toxin dilution and endplate targeting in spasticity: a double-
blind controlled study. Arch Phys Med Rehab. 2009;90(1):9–16.e2.
117. Carruthers A, et al. A randomized, evaluator-blinded, two-center study of the safety and effect
of volume on the diffusion and efficacy of botulinum toxin type A in the treatment of lateral
orbital rhytides. Dermatol Surg. 2007;33(5):567–71.
118. Carruthers A, Carruthers J, Cohen J. Dilution volume of botulinum toxin type A for the treat-
ment of glabellar rhytides: does it matter? Dermatol Surg. 2007;33(1 Spec No.):S97–104.
119. Hsu TS, Dover JS, Arndt KA. Effect of volume and concentration on the diffusion of botuli-
num exotoxin A. Arch Dermatol. 2004;140(11):1351–4.
120. Abbasi NR, et al. A small study of the relationship between abobotulinum toxin a concentra-
tion and forehead wrinkle reduction. Arch Dermatol. 2012;148(1):119–21.
121. Punga AR, et al. A randomized, comparative study to evaluate efficacy and safety of two
injection volumes of AbobotulinumtoxinA in treatment of glabellar lines. Dermatol Surg.
2016;42(8):967–76.
122. Carruthers JA, et al. 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
Acad Dermatol. 2002;46(6):840–9.
123. Dressler D, Rothwell JC. Electromyographic quantification of the paralysing effect of botuli-
num toxin in the sternocleidomastoid muscle. Eur Neurol. 2000;43(1):13–6.
124. Feng Z, et al. Optimal dosage of botulinum toxin type A for treatment of glabellar frown
lines: efficacy and safety in a clinical trial. Dermatol Surg. 2015;41:S56–63.
125. Carruthers A, Carruthers J, Said S. Dose-ranging study of botulinum toxin type A in the treat-
ment of glabellar rhytids in females. Dermatol Surg. 2005;31(4):414–22.
126. Dressler D, Adib Saberi F. Botulinum toxin: mechanisms of action. Eur Neurol.
2005;53(1):3–9.
127. Allergan Announces Results of Higher Dose BOTOX® Cosmetic (onabotulinumtoxinA) for
the Treatment of Moderate to Severe Glabellar Lines. 2018.
128. Poewe W, et al. What is the optimal dose of botulinum toxin A in the treatment of cervical
dystonia? Results of a double blind, placebo controlled, dose ranging study using Dysport®.
J Neurol Neurosurg Psychiatry. 1998;64(1):13–7.
129. Bellows S, Jankovic J. Immunogenicity associated with botulinum toxin treatment. Toxins.
2019;11(9):491.
130. Naumann M, et al. Immunogenicity of botulinum toxins. J Neural Transm (Vienna, Austria:
1996). 2013;120(2):275–90.
131. Dressler D. Clinical presentation and management of antibody-induced failure of botulinum
toxin therapy. Mov Disord. 2004;19(Suppl 8):S92–s100.
132. Jinnah HA, et al. Botulinum toxin treatment failures in cervical dystonia: causes, manage-
ment, and outcomes. J Neurol. 2016;263(6):1188–94.
133. Borodic G. Immunologic resistance after repeated botulinum toxin type a injections for facial
rhytides. Ophthalmic Plast Reconstr Surg. 2006;22(3):239–40.
134. Dressler D, et al. Antibody-induced failure of botulinum toxin a therapy in cosmetic indica-
tions. Dermatol Surg. 2010;36(Suppl 4):2182–7.
135. Stengel G, Bee EK. Antibody-induced secondary treatment failure in a patient treated with
botulinum toxin type A for glabellar frown lines. Clin Interv Aging. 2011;6:281–4.
136. Torres S, et al. Neutralizing antibodies to botulinum neurotoxin type A in aesthetic medicine:
five case reports. Clin Cosmet Investig Dermatol. 2014;7:11–7.
137. Frevert J. Pharmaceutical, biological, and clinical properties of botulinum neurotoxin type A
products. Drugs R&D. 2015;15(1):1–9.
138. Jankovic J, Schwartz K. Response and immunoresistance to botulinum toxin injections.
Neurology. 1995;45(9):1743–6.
139. Atassi MZ, et al. Molecular recognition of botulinum neurotoxin B heavy chain by human
antibodies from cervical dystonia patients that develop immunoresistance to toxin treatment.
Mol Immunol. 2008;45(15):3878–88.
140. Dressler D, Saberi FA. Safety of botulinum toxin short interval therapy using incobotulinum-
toxin A. J Neural Transm (Vienna). 2017;124(4):437–40.
Chapter 14
Botulinum Toxin A: Injection Techniques
for East Asian Facial Rejuvenation-Upper
and Midface
Botulinum toxin A can be effectively used to reduce rhytids and signs of ageing.
East Asians show periorbital rhytids later than Caucasians. In this population, botu-
linum toxin injections are mainly used for facial contouring in youngeradults and
for rhytid reduction and elimination at a later stage. East Asians have different facial
characteristics and ideals of beauty from Caucasians [1–5]. The dosage, injection
pattern and landmarks are therefore varied in East Asians.
In this chapter, treatment of the upper face and midface, including the glabellar
complex, forehead, lateral canthal lines, and nasal bridge line (bunny lines) are dis-
cussed. Furthermore, anatomy, classification based on the muscle groups, muscle
function and location, and injection techniques and recommendations are explained.
Typical cases and considerations, including tips and tricks are presented.
The unit of dosage of botulinum toxin A (BNT-A) in this chapter is based on the
Onabotulinum toxin A unit. Various formulations are available in the market, and
their units are not interchangeable [6–8].
X. Han (*)
Fat Grafting Department, Department of Plastic Surgery Hospital, Chinese Academy of
Medical Sciences and Peking Union Medical College, Beijing, China
S. Samizadeh

https://doi.org/10.1007/978-3-030-84099-0_14
The Upper Face
The main areas of treatment with BoNT-A for cosmetic purpose are the following:
• Glabellar complex.
• The forehead.
• Lateral canthal lines.
Two-dimensional anatomy of the facial muscles is found in most anatomy books
(Fig. 14.1). This gives a basic understanding of the muscles, their positions and
names. However, it is pertinent to keep in mind that facial muscles have a 3D anat-
omy with varied length, diameter, and tonicity. They have synergist and antagonist
muscles and interact with other facial structures.
Forehead Lines
Horizontal forehead rhytids are mainly due to contraction of the frontalis muscle
(Fig. 14.2). Other contributing factors include loss of collagen, skin elasticity, fat,
and sleep lines. Dynamic lines appear with expression (Table 14.1).
1 Frontalis
2 Corrugator supercilli 1
3 Depressor supercilli
4 Procerus
5 Orbicularis oculi
6 Nasalis 2
4
7 Levator labii superioris alaeque nasi 5 3
8 Levator labii superioris
9 Zygomaticus minor 6
10 Zygomaticus major 7
11 Orbicularis oris 8
12 Buccinator 9
10
13 Masseter 13 12
14 Risorius 11
15 Plastysma 14
15
16 Depressor anguli oris
17 Depressor labii inferioris 16 17
18 Mentalis 18
Fig. 14.1 Facial muscles. The muscles of facial expression are those involved in various expres-
sions, originate from bone or fascia, and insert onto the skin
14 Botulinum Toxin A: Injection Techniques for East Asian Facial… 215
Fig. 14.2 Unilateral

frontalis muscle
Table 14.1 Related muscle anatomy

Muscle Origin and Insertion Function Synergist Antagonist
Frontalis Origin: galea aponeurotica Bidirectional None Procerus
Insertion: fibres of procerus contraction Corrugator Supercilii
muscle, orbicularis oculi The upper Depressor Supercilii
and corrugator muscles portion-pulls down Orbicularis Oculi
the hairline
The lower
portion-elevates the
eyebrows.
Classification (Fig. 14.3)
There are four main types of rhytid formation in East Asians. These include:
Type I: Forehead lines limited to the area 2cm above the eyebrows.
Type II: Forehead lines within 2 cm above the eyebrows only.
Type III: Mild forehead lines- the entire forehead.
Type IV: Generalise medium and deep/strong forehead lines.
The boundary line: 2 cm above the eyebrows. This classification is shown in
Fig. 14.3.
Classification of frontalis muscle according to the extend and coverage of mus-
cle fibers across the forehead has previously been published. Abramo and colleagues
published four anatomical shapes which correlated to four different patterns of
Fig. 14.3 The

classification of forehead
lines
Fig. 14.4 Injection technique guidance for each type
horizontal parallel lines on the forehead skin. Type I or full form, type II or V-shaped
form, type III or central form, type IV or lateral form [9].
Injection Technique and Consideration
See Fig. 14.4 and Table 14.2 for injection guidance.

Table 14.2 Frontalis injection technique and considerations
Synergist and
Type Muscle strength and total recommended dose Injection points Reconstitution Injection Layer antagonistic muscles
I Mild(u) Medium(u) Strong(u) Upper 2/3 of the forehead 100u/2–2.5 ml Subcutaneous, Caution: the
F 3–4 4–6 6–9 8–16 points, each point is Intramuscular antagonistic muscles:
M 5–6 6–8 8–12 1 cm apart frontalis vs. orbicularis
oculi, Corrugator,
II Mild(u) Medium(u) Strong(u) It is located within 2 cm 5–10u/ml Intradermal
Depressor Supercilii
F 2 of the eyebrow,16–32
and Procerus. Injecting
M 2–4 points, each point is 1 cm
the frontalis muscle
apart
close to the hairline can
III Mild(u) Medium(u) Strong(u) All areas of the forehead, 5–10u/ml Intradermal increase the forehead
F 5–7 / / 40–70 points, each point height.
M 8–10 / / is 1 cm apart
IV Upper Mild(u) Medium(u) Strong(u) The upper 2/3 of the 100u/2–2.5 ml Subcutaneous,
2/3 F 4–6 6–9 forehead, 8–16 points, Intramuscular
M 6–8 8–12 each point is 1 cm apart
14 Botulinum Toxin A: Injection Techniques for East Asian Facial…
Lower Mild(u) Medium(u) Strong(u) The lower 1/3 of the 5–10u/ml Intradermal
1/3 F 2 forehead, 16–32 points,
M 2–4 each point is 1 cm apart
217
Typical Cases
See Figs. 14.5, 14.6, 14.7, and 14.8.
Other Considerations and Key Points
1. Before injection, check whether the patient has an existing eyebrow or eyelid
ptosis, especially young male patients with deep forehead lines. If there is ptosis,
it is recommended not to treat the forehead lines or reduce the dose to 1/3rd of
the conventional dose, or half for patients with mild ptosis.
2. The most important complications of forehead treatment with BoNT are lateral
eyebrow elevation and eyebrow and consequently eyelid ptosis and hence diffi-
culty opening the eye. To avoid eyelid ptosis, previous publications and text-
books recommend avoiding injections immediately above the eyebrows.
However, when the area within 2 cm of the eyebrow is not treated, a strange
expression and increased muscle compensation in that area will appear.
The authors believe that there is no “forbidden zone” for cosmetic facial botu-
linum toxin injections, as long as the treatment is provided with a great under-
Fig. 14.5 Typical case: type I. Female, 32y
Fig. 14.6 Typical case: type II. Female, 40y
Fig. 14.7 Typical case: type III. Female, 39y

Fig. 14.8 Typical case: type IV. Female, 43y
standing of individual patient muscle anatomy, product used and patient

expectations. Therefore, the dose within 2 cm of the eyebrows is within 2–4u
range and intradermal, and there are no reported complications of eyebrow pto-
sis in thousands of patients treated. Furthermore, the total injected dose in the
area should be controlled to avoid complications (male <12u, female <9u).
3. Mephisto sign can appear if the superior lateral forehead lines are not treated or
treated insufficiently relative to the treatment of the medial forehead lines. The
area will show a moderate/severe compensatory effect, and lateral eyebrows
will rise.
4. Another rare but bothersome complication is a headache. The frontalis muscle is
a large muscle, when the injection is not done uniformly, active frontalis muscle
fibres compensate; the imbalance of muscle strength may be an important factor
that causes the frontal discomfort or headache.
Periocular Rhytids
The periocular rhytids are mainly related to the contraction of the orbicularis oculi
muscle. The muscle is composed of three parts: the orbital portion, the palpebral
portion, and the lacrimal portion, each of which produces different rhytids. The
nasalis muscle is often involved in the generation of periocular rhytids as a synergist
muscle, and sometimes the zygomaticus major muscle and zygomaticus minor mus-
cle are also synergists and are involved (Fig. 14.9 and Table 14.3).
Classification
I: lateral canthus rhytids, the periocular rhytids located outside the 5 mm vertical
line inside the apex of lateral canthus angle (see picture)- mainly produced by
the orbicularis oculi muscle, zygomaticus major muscle and zygomaticus minor
muscle are also involved in the formation of dynamic lines inferior to the lateral
canthus. According to involvement of different parts of the orbicularis oculi muscle,
the lines are further divided into three subtypes (see Fig. 14.10)
Fig. 14.9 Orbicularis

oculi muscle

Origin and
Muscle Insertion Function Synergist Antagonist
Orbicularis Origin: Orbital portion: closes Corrugator, Frontalis and
Oculi Medial orbital the eyelids firmly Depressor Supercilii, Levator
margin and (voluntary). Procerus, Dorsum Palpebrae
lacrimal sac Palpebral portion (the Nasalis, Superioris
(orbital, pretarsal portion, the Zygomaticus Major,
palpebral and pre-septal portion, and Zygomaticus Minor
lacrimal parts) the ciliary portion.): close
Insertion: the eyelids (involuntary
Lateral or reflex blinking).
palpebral raphe Lacrimal portion
compresses the lacrimal
sac, which receives tears
from the lacrimal ducts
and conveys them into
the nasolacrimal duct.
• Type I.I, the rhytids superior to the lateral canthal angle.

• Type I.II, the rhytids between a line drawn from eyebrow tail to the lateral can-
thus angle and the line from the starting point of the zygomaticus major muscle
to the lateral canthus.
• Type I.III, the rhytids between the 5 mm vertical line inside the vertex of the
lateral canthus and the line between the starting point of the zygomaticus major
muscle and the vertex of the lateral canthus angle.
Fig. 14.10 The

classification of periocular
rhytids. ZM (the Origin of
zygomaticus major),
ORL-TTL (orbicularis
oculi retaining ligment-tear
through ligment)
Type II: the lower eyelid rhytids, located between the 5 mm vertical line of the
inner side of the vertex of the outer canthal angle and the vertical line of the lower
lacrimal punctum. These lines are found within the lower eyelid, the area where
tarsal plate, orbital septum and medial parts of the orbicularis oculi muscle are found.
Type III: inner canthus rhytids, found in the area covered by the orbicularis oculi
muscle and the lacrimal pump, between the vertical line of the inferior lacrimal
punctum and 5 mm within the apex of the inner canthus angle.
The classification is shown in Fig. 14.11.
Injection Technique and Considerations
See Fig. 14.11 and Table 14.4 for schematic diagram of each classification and
injection guide.
Typical Cases (Figs. 14.12, 14.13, and 14.14)

Fig. 14.11 Periocular rhytids: Injection recommendations
Other Considerations and Key Points
1. In East Asians and from a cultural perspective, eyebrow lift makes people look
very serious, ferocious, angry, and unapproachable. Most East Asians do not like
the shape of arched or raised eyebrows, especially for older women. Therefore,
special attention should be paid to this matter, in particular in type I lateral can-
thal lines (crow’s feet). It is recommended to take the horizontal line of the eye-
brow as the central axis, giving botulinum toxin treatment symmetrically (at the
same level, at the same dose, at the same distance) to maintain the eyebrows in
the existing position. Asymmetry of the frontal muscle should be noted and
treated accordingly.
2. The injection of lateral canthal lines close to zygomatic muscles in type I.II and
type I.III requires special attention to prevent the involvement of zygomatic
muscles and hence smile asymmetry. In particular, in people with poor skin
thickness and texture, loose subcutaneous tissue and in older individuals.
Recommendations to prevent and reduce the complication are as follows:
Table 14.4 Periocular Rhytids—injection technique and considerations
Type Total dose and muscle strength Injection point Reconstitution Layer Synergist and antagonist muscles
I I.I Mild(u) Medium(u) Strong(u) It is located between the 5 mm 100u/2–2.5 ml, Intradermal Pay attention to the antagonistic effect of
F 0.2–0.5 0.5–1 1–2 vertical line inside the vertex of 5–10u/ml the frontalis muscle and orbicularis oculi
M 0.5–1 1–2 2–3 the outer canthus angle and the (when single muscle. When there is no need for
line from eyebrow tail to the vertex point <0.25u) eyebrow re-positioning/lifting/lowering,
of outer canthus angle, 1–3 points, the eyebrow should be taken as the central
with an interval of 1 cm axis, and the same dose should be given at
the same level at the same distance from
the forehead of the eyebrow region; when
it is necessary to lift the eyebrow laterally,
it is not necessary to inject the eyebrow
region.
I.II Mild(u) Medium(u) Strong(u) It is located between the top line of 100u/2–2.5 ml Intradermal Pay attention that there may be a
F 2–3 3–7 7–12 eyebrow tail outer canthus angle synergistic effect of zygomaticus major in
M 2–4 4–10 10–15 and the top line of zygomaticus producing crow’s feet. When the injection
muscle and outer canthus angle. is near the insertion point of zygomaticus
2U/point near the outer canthus major, it is necessary to be very careful
gradually decreases to 1U/point and intradermal injections only,
and 0.5u/point laterally. 2–16 the zygomaticus muscle should not be
points/side in total, each point is affected. Otherwise, it is likely to cause
1 cm apart asymmetry when smile.
I.III Mild(u) Medium(u) Strong(u) It is located between the 5 mm 5–10u/ml Intradermal Pay attention to the antagonist and
F 0.2–1 vertical line inside the vertex of synergist fibers of the orbicularis oculi
M 0.2–1.2 the outer canthus angle and the muscle in the meibomian, orbital septum
line between the starting point of and orbital regions, and the weakening of
zygomaticus major and the vertex some parts will lead to the compensatory
of outer canthus angle, 1–5 points, action of the other parts.
with an interval of 1 cm between
each point
(continued)
223
Table 14.4 (continued)
224
Type Total dose and muscle strengthInjection point Reconstitution Layer Synergist and antagonist muscles
II Mild(u) Medium(u) Strong(u)
The covering area of the 5–10u/ml Intradermal Pay attention to the antagonist and
F 0.2–0.5 0.5–1 orbicularis oculi muscle of the synergist fibers of the orbicularis oculi
M 0.2– 0.75–1.25 lower eyelid, the orbital septum muscle in the meibomian, orbital septum
0.75 and the orbital part, which is and orbital regions, and the weakening of
located between the 5 mm vertical some parts will lead to the enhancement of
line inside the apex of the lateral the other parts.
canthus angle and the vertical line
of the lower lacrimal dots, is 1–4
points, each dot is 1 cm apart
III Mild(u) Medium(u) Strong(u) The coverage area of orbicularis 5–10u/ml Intradermal As a synergist muscle, the nasalis muscle
F 0.2–0.5 0.5–1.5 oculi muscle in the lacrimal pump often participates in the generation of
M 0.5–1 1–2 between the vertical line of the periocular rhytids and must be treated,
inferior lacrimal punctum and the otherwise, it will only compensate and
vertex of the inner canthus angle. result in a strange expression when
1 point: the intersection point of laughing.
the median horizontal line of the
inner canthus and the inner 5 mm
of the inner canthus; 2 points: 1
point for each of the above points
X. Han and S. Samizadeh
Fig. 14.12 Typical case: type I.I + I.II + I.III + III. Red point: treatment of nasal dorsal striae.
Female, 35y
Fig. 14.13 Typical case: type I.I + I.II + I.III + II+III. Red point: treatment of nasal dorsal striae.
Female, 43y
Fig. 14.14 Typical case: type I.II + I.III + II. Female, 50y
(a) The injection points should not be set within 5 mm of the starting point
radius of zygomaticus major muscle.
(b) If there are deep rhytids at the insertion point of the zygomaticus major
muscle, injections should be avoided and dermal fillers considered. If treat-
ment is needed with BoNT in this area, injection should be limited to the
dermis layer, the single point dose should not exceed 0.5u, and attention
should be paid to the symmetrical injection on both sides.
(c) If there are rhytids at the origin of zygomaticus muscle, with fragile thin
skin and loose subcutaneous tissue, the injection at this point is not
recommended.
3. When carrying out Type I.III and Type II lower eyelid injections, the balance
between the orbicularis muscle palpebral and the orbital parts should be taken
into consideration.
(a) The injection should be close to the orbicularis oculi supporting ligament
and lacrimal groove ligament complex, immediately inferior to the projec-
tion site, in order to reduce the impact on the orbicularis oculi muscle lower
eyelid roll. Otherwise, it will make the lower eyelid too flat. This roll is
called “silkworm” in Chinese and is desirable in East Asia. Dermal fillers
are also used to enhance this lower eyelid roll, also known as the “charm roll”.
(b) Tear production and/or drainage can be affected if injections are done incor-
rectly, resulting in dry or watery eyes or both. Therefore, the injection dose
of the entire lower eyelid should not exceed 3u, and always within 2u.
(c) When treating the lower eyelid rhytids, it is easy to cause periorbital edema,
“eye bags” appearance or ectropion. So, the following principles should be
considered to avoid the complications.
(i) Before injection, the elasticity of the orbicularis oculi and the skin
should be examined. If it is too loose, this will exacerbate the appear-
ance of eye bags, the patient should be informed and not treated.
(ii) Do not inject too much. Maximum 3 u. Always less than 2 u.
(iii) Dilute the botulinum toxin and make sure the injection is precise.
(iv) Multiple injection sites to ensure the uniformity of dispersion.
(v) The injection should be close to the orbicularis oculi supporting liga-
ment and lacrimal groove ligament complex and just below the projec-
tion site, not to worsen the “eye bags.”
(vi) Before injection, patients should be asked if they have dry or watery
eyes or tear duct problems. If they do, the treatment should be avoided
or reduce the does to 1/2 or 1/3 of the regular injection.
4. For type III, the main function of the orbicularis oculi muscle in the lacrimal pump
is to draw off tear fluid into the lacrimal duct, and it contributes to 70% of this func-
tion. Therefore, before treatment, patients must be asked if they get dry or watery
eyes or other similar problems. These would be contraindications to the treatment
in this region. The nasal dorsum muscle collaboratively involves the forming inner
canthus rhytid, so treatment of this muscle should be considered as well.
Glabellar Complex
Muscles of the glabellar complex are responsible for the formation of frown lines,
also known as 11-line, and include the procerus, corrugator supercilii, depressor
supercilii, frontalis, and orbicularis oculi (Fig. 14.15 and Table 14.5).
Fig. 14.15 Muscles of the

glabellar complex
responsible for the
formation of frown lines
include the corrugator 1
supercilii, depressor
1 Frontalis 2
supercilii, procerus, 2 Corrugator supercilli 5 3 4
frontalis and orbicularis 3 Depressor supercilli
4 Procerus
oculi 5 Orbicularis oculi

Corrugator Originates from the medial Move the eyebrow Depressor Frontalis
Supercilii end of the superciliary arch of down and inward supercilia
frontal bone, cranially to the toward the nose Procerus
root of the nose. and inner eye. Nasalis
Its fibres extend diagonally,
laterally, and slightly
superiorly to insert into the
skin of the eyebrow above the
middle part of the supraorbital
margin
Procerus Extending from the lower part Depresses the Depressor Frontalis
of the nasal bone to the medial eyebrow supercilii
middle area in the forehead Corrugator
between the eyebrows Nasalis
It is attached to the frontalis
muscle.
Depressor Originates from the medial Depresses the Procerus Frontalis
Supercilii orbital rim medial eyebrow Corrugator
inserts into the skin below the Nasalis
eyebrow and in the
intercanthal region, on the
medial side of the bony orbit.
Classification
The muscles involved in the formation of frown lines include the procerus, corrugator
supercilii, depressor supercilii, orbicularis oris and the frontalis muscle. Different mus-
cles are involved in the formation of glabellar lines, and hence different frown line for-
mation and shapes are seen depending on muscles participating, their size, tonicity, and
portion involved. Therefore, one treatment protocol cannot be applied to all different
variations. Injection methods and dosage should be personalized accordingly.
De Almeida et al. classify frown lines into “U” shape, inward contraction shape,
“Ω” shape, “V” shape and inverted “Ω” shape; [10] Kim et al. from South Korea
divide the glabellar pattern into “U,” “X,” “a,” “π,” and “I.” [11]. However, even a
detailed classification cannot cover all patterns, so personalized treatment is necessary.
Because of the “superficial” layer of the involved muscles, we can accurately deter-
mine which muscles are involved through preoperative evaluation and personalize
treatment plans and injection points. Therefore, the practitioner can carry out a compre-
hensive assessment and develop a treatment plan that is optimal for each person. Hence,
in the general classification of facial lines and rhytids can be done according to the
participating muscles or parts of a single muscle (e.g. forehead). The morphological
classification can only be used as an auxiliary and has no major clinical significance.
Therefore, classification here is done according to the participating muscles and
the dominant muscle in formation of the frown. The name for each type is according
to the dominant muscle involved.
Type I: corrugator type. divided into two subtypes:
• I.I type, oblique head is dominant (brow).
• I.II type, horizontal head is dominant (middle brow).
Type II: Procerus type.
Type III: Depressor supercilia type.
Type IV: Frontalis muscle type.
Type V: Orbicularis oculi muscle type.
The classification is shown in Fig. 14.16.
Fig. 14.16 The

classification of frown
lines according to
involvement of various
muscles and the dominant
muscle in the formation of
frown pattern
Fig. 14.17 Injection technique and recommendation for each type of frown lines
Injection Techniques and Considerations
See Fig. 14.17 and Table 14.6.
Typical Cases (Figs. 14.18, 14.19, 14.20, and 14.21)
Considerations and Tips
In type I, when the oblique head of the corrugator muscle is strong, or the length is
more than 1.5 cm, in order to reduce the possibility of involving the adjacent frontal
is muscle, reconstitution of 100u/1 ml should be used, and the injection point should
be increased to 2 or more points.
Type I.II, needle entry point is at the most elevated point of the skin during
muscle contraction, about 1–2 mm above the eyebrow, and 1–3 injection points
which are determined according to the length of the muscle. Because of the indi-
vidual differences, the traditional “5 points” or “7 points” injection method is not
comprehensive, and the injection points should be determined according to the
shape of the muscle to achieve personalized treatment. In addition, intradermal
injection is advisable, and the direction of the injection needle is inclined superiorly,
which can effectively reduce the probability of ptosis.
In type II, it is necessary to evaluate whether procerus is involved in this type.
Otherwise, it is not necessary to inject the muscle.
In type III, when the depressor supercilii muscle is strong and not paralysed fully
upon injection, eyebrows can depress medially, and eyebrow tails will elevate. This
is not common as some botulinum toxin will diffuse into the descending eyebrow
muscle when injected into the oblique head of the corrugator muscle. Only when the
Table 14.6 Glabellar complex-injection technique and considerations
230
I I.I Mild(u) Medium(u) Strong(u) When the length of the oblique 100u/2–2.5 ml, Intramuscular Be careful not to inject deep in this
F 4–6 6–8 8–10 head of the corrugator muscle is 100u/1 ml region. The levator palpebrae
M 5–7 7–9 9–14 more than 1.5 cm, an injection (when single superioris is the muscle in the orbit
point is added and the interval point >5u) that elevates the upper
between the two points is 1 cm. eyelid. Weakening or paralysis of this
muscle causes upper eyelid ptosis.
I.II Mild(u) Medium(u) Strong(u) Projection position of horizontal 100u/2–2.5 ml, Intradermal This part is the intersection of the
F 0.25– 0.5–1 1–2 head of corrugator, 0.25-1u/point, 10u/ml (when horizontal head of the corrugator,
0.5 1–4 points/side (adjust points single point orbicularis oculi and frontal is
according to the length of <0.25u) muscles. Injection of botulinum toxin
M 0.5–1 1–2 2–4
horizontal head of corrugator), with into the skin can paralyze these three
an interval of 1 cm muscles evenly, without breaking the
dynamic balance between the local
muscles. Be sure to inject intradermal
to reduce the possibility of involving
levator palpebrae superioris.
II Mild(u) Medium(u) Strong(u) It is located at the intersection of 100u/2–2.5 ml, Intramuscular The muscles between the lower
F 1–2 2–4 4–7 the line between bilateral eyebrows 100u/1 ml eyebrows are antagonistic to the
M and inner canthus, and injected at 1 (when single frontalis, in synergy with the lower
point point >5u) eyebrows, and sometimes with the
levator muscles of the upper lip and
the alar of the nose and the dorsum of
the nose. Pay attention to the balance
between the muscles.
III Mild(u) Medium(u) Strong(u) About 5 mm below the eyebrow, it 100u/2–2.5 ml Subcutaneous The depressor Supercilii and procerus
F 0.5–1.5 1.5–4 can be seen when trying to lower are synergists. When BTN-A is only
M the eyebrow, it can be absent in used to inactive the procerus but not
some. 1 point/side injection to the depressor supercili. In presence
of a strong depressor supercili
muscle, the inner eyebrow will fall,
and the lateral eyebrow will rise
relatively, resulting in an unnatural
expression.
IV Mild(u) Medium(u) Strong(u) Some frontalis muscle fibers can be 100u/2–2.5 ml, Intradermal, Injection can only be carried out
F 0.5–1 1–2 involved in frowning, 0.25-1u/ 5–10u/ml Subcutaneous, when it is clear that the frontal
M 1–3 point, 1–10 points, with an interval (when ingle Intramuscular muscle is involved in frowning.
of 1 cm point <0.25u) Otherwise, the ferocious expression
of inner brow descending will appear
after the frontal muscle around the
vertical line of the forehead is
numbed due to the antagonistic effect
of the brow descending muscle and
the brow descending muscle.
V Mild(u) Medium(u) Strong(u) The lolasised area where fibers of 100u/2–2.5 ml, Intradermal The orbicularis oculi muscle on the
F 0.25–2 the orbicularis oculi muscle are 5–10u/ml medial side of the upper eyelid has
involved in frowning, 0.25–1u/ (when single the effect of lowering the eyebrow.
M
point, 1–2 points, and the interval point <0.25u) Extreme care should be taken when
between each point was 1 cm injecting this area, very superficial
injection and the dose should be
controlled less than 1U/side.
231
Fig. 14.18 Typical case: type I.I + I.II + III + V. Female, 29y
Fig. 14.19 Typical case: type I.I + I.II + II + III + V. Female, 40y
Fig. 14.20 Typical case: type I.I + I.II + II + III + V. Female, 41y
Fig. 14.21 Typical case: type I.I + I.II + IV. Female, 45y
depressor supercilii is particularly strong, this appearance will be seen due to the
insufficient injection.
Type V is not so common. Pay attention to the insertion point, 5 mm away from
the midline of the pupil (to the nose) to prevent the levator palpebrae muscle from
being involved. If there are rhytids in the midline of the pupil line, do not inject. If
the orbicularis oculi muscle is clearly involved in frowning without treatment, post-
treatment, when frowning, compensatory action of the muscle results in a strange
appearance, as shown in Fig. 14.22.
***Some people will display multiple frowning patterns, which will bring diffi-
culties to treatment planning. However, there is usually a dominant frown pattern.
Only treating the dominant frown pattern can improve the brow pattern and obtain
a good result without dealing with other non-dominant frown patterns. As shown in
Fig. 14.23.
If different types exist, they can be treated at the same time. Targeting the domi-
nant muscles involved will result in an overall improvement.
Fig. 14.22 Compensatory

activation of orbicularis
oculi muscle
fibers upon frowning when
the orbicularis muscle is
involved but not treated
with BoNT. Female, 40y
Fig. 14.23 Different frown types can exist in the same person. Treating the dominant frown pat-
tern can result in a good aesthetic outcome. Male, 45y
Fig. 14.24 Nasal dorsal

striae and related muscle
3 Depressor supercilli
4 Procerus
6 Nasalis
7 Levator labii superioris
alaeque nasi
Table 14.7 Related muscle anatomy. The main muscles involved in the dorsum of the nose are the
nasalis, sometimes the levator muscles of the upper lip and alar are also involved (Fig. 14.24)
Nasalis Originates from the maxilla It compresses Depressor None
Inserts into the nasal bone. the nasal supercilii
cartilage. Procerus
Depresses the tip Levator labii
of the nose while Superioris
it elevates the alaeque nasi
nostril’s corners.
Levator labii It is divided into two fascicles Contraction Medial: Depressor
superioris from the inferior part of the dilates the nostril, dilator naris anguli oris
alaeque nasi frontal process of the maxilla. elevates the wing Lateral: Orbicularis
The medial fascicle is inserted of the nose and Levator labii oris muscle
into the nasal cartilage and the the upper lip superioris
skin of the nose. The lateral Zygomatic
fascicle is inserted into the major
upper lip and fused with the Zygomatic
levator labii muscle and minor
orbicularis oris muscle. Levator
anguli oris
Nasal Dorsal Rhytids (Table 14.7)
The classification is done according to the dominant muscle involved.

I: Nasalis type
II: Procerus and Depressor supercilli type
III: Levator labii superioris alaeque nasi type
Fig. 14.25 The

classification of nasal
dorsal striae
Fig. 14.26 Injection techniques of each type of nasal dorsal striae
Injection Technique and Considerations
The injection technique schematics are shown in Fig. 14.26 and Table 14.8.
Typical Cases
Other Considerations and Tips
1. East Asians have a strong nasalis muscle; therefore, higher doses are needed to
significantly reduce these lines (Figs. 14.27 and 14.28); 10u is the starting dose,
about 2–4 times the recommend dose for Caucasians.
2. Before the procedure, the patients should be carefully evaluated. Type III patients
may require injection of the levator labii superioris alaeque nasi to achieve
improvement.
3. If different types exist at the same time, they can be treated at the same time.
Table 14.8 Nasal dorsum- injection technique and considerations
236
Synergist and antagonist

Type Total dose and muscle strength Injection point Reconstitution Layer muscles
I Mild(u) Medium(u) Strong(u) The nasal 100u/2–2.5 ml, Intradermal, Procerus,depressor
F 1–4 4–8 8–15 dorsum. 1–6 5-10u/ml (when Subcutaneous supercilii, levator labii
M 1–5 5–10 10–20 points, the single point superioris alaeque nasi
interval between <0.25u) and the appropriate
each point is muscles -all should be
about 1 cm, and treated according to
the interval individual assessment.
between each
point can be
0.5 cm when the
dosage of single
point injection is
small.
II Mild(u) Medium(u) Strong(u) It is located at the 100u/2–2.5 ml Intramuscular
Procerus F 1–2 2–4 4–7 intersection of the
M line between
bilateral eyebrows
and inner canthus,
and injected at 1
point.
Mild(u) Medium(u) Strong(u) About 5 mm 100u/2–2.5 ml Subcutaneous
Superciliary F 0.5–1.5 1.5–4 below the brow. 1
depressor point/side
M
muscle injection
III Mild(u) Medium(u) Strong(u) Starting point of 100u/2–2.5 ml Subcutaneous
F 0.5–1 1–4 4–8 levator muscle of
M upper lip and alar,
1 point/side
injection
Fig. 14.27 Typical case: type I + II + III. Female, 44y
Fig. 14.28 Typical case: type I + II + III. Male, 32y
Conclusion
This chapter has demonstrated cosmetic use of botulinum toxin A in the upper face
and midface in East Asians. The forehead, glabellar complex, periocular area and
the nasal areas are focused on, presenting a unique classification for each region
according to the musculature involved, injection technique recommendation, with
the discussion of considerations and tips. Common cases with the injection pattern
and dose used (Onabotulinum toxin A) are presented. It can be appreciated that the
appearance of lines and rhytids, treatment planning and injection sites, dosage, vol-
ume, and cultural expectations are different from Caucasians.
References
large national survey. Aesthet Plast Surg. 2018:1–13.
2. Samizadeh S, Wu W. Ideals of facial beauty amongst the chinese population: Results from a
Dermatol. 2019.
4. Liew S, et al. Consensus on changing trends, attitudes, and concepts of Asian beauty. Aesthet
Plast Surg. 2016;40(2):193–201.
5. Wu WT, et al. Consensus on current injectable treatment strategies in the Asian face. Aesthet
Plast Surg. 2016;40(2):202–14.
6. Samizadeh S, De Boulle K. Botulinum neurotoxin formulations: overcoming the confusion.
7. Bonaparte JP, et al. A comparative assessment of three formulations of botulinum toxin A for
facial rhytides: a systematic review and meta-analyses. Syst Rev. 2013;2:40.
8. Carruthers A, Carruthers J. Botulinum toxin products overview. Skin Therapy Lett.

2008;13(6):1–4.
9. Abramo AC, et al. Anatomy of forehead, glabellar, nasal and orbital muscles, and their correla-
tion with distinctive patterns of skin lines on the upper third of the face: reviewing concepts.
Aesthet Plast Surg. 2016;40(6):962–71.
10. de Almeida ART, et al. Glabellar contraction patterns: a tool to optimize botulinum toxin treat-
ment. Dermatol Surg. 2012;38(9):1506–15.
11. Kim H, et al. A study on glabellar Rhytid patterns in Koreans. J Eur Acad Dermatol Venereol.
2014;28(10):1332–9.
Chapter 15
Botulinum Toxin A: Injection Techniques
for East Asian Facial Rejuvenation-Lower
Face and the Neck
Orange Peel Chin
Related Muscle Anatomy
Retrusive mandible with bimaxillary protrusion is common in East Asians. Mentalis

hyperactivity and the “orange peel” appearance are therefore a consequence. The men-
talis muscle is an essential component of the lower face aesthetics, chin, lower lip
position and central lip motion [1]. BoNT injections can relax the mentalis muscle and
improve appearance of the lower face. Lip seal should be examined as relaxation of the
mentalis muscle may further compromise the lip seal. Patients should be asked to
contract the muscle to identify correct injection sites (Fig. 15.1 and Table 15.1). Common
cases with injection pattern and dosage used (Onabotulinum toxin A) are presented
I: “Orange peel appearance” limited to the lower part of the chin only
II: “Orange peel appearance” limited to the upper part of the chin.
II: Combination of I and II
X. Han (*)
Fat Grafting Department, Department of Plastic Surgery Hospital, Chinese Academy of
Medical Sciences and Peking Union Medical College, Beijing, China
S. Samizadeh

https://doi.org/10.1007/978-3-030-84099-0_15
Fig. 15.1 The mentalis

muscle, depressor labii
inferioris and depressor
anguli oris

Muscle Origin and insertion Function Synergist Antagonist
Mentalis Origin: Incisive fossa of Protrusion of Depressor anguli Levator anguli
mandible the lower lip oris oris
Insertion: Mentolabial Depressor labii Zygomaticus
sulcus inferioris major
Fig. 15.2 The

classification
Injection techniques and schematics see Fig. 15.3 and Table 15.2.
Fig. 15.3 Injection techniques and recommendation
Typical Cases (Figs. 15.4 and 15.5)
1. The depressor anguli oris and depressor labii inferioris muscles are usually syn-
ergic muscles to the mentalist muscle. The position of each of these muscles can
be located through expression. Mentalis and depressor anguli oris muscles can
be treated at the same time. The injection points for type I and type II should be
chosen according to the preoperative evaluation. The injection points should be
away from the depressor labii inferioris, and determined according to the width
of the mentalis muscle.
2. For type II, intradermal injection is advisable, which can effectively prevent dif-
fusion to the depressor labii inferioris muscle; the purpose of midline injection
is that even if botulinum toxin is inadvertently dispersed to the muscle, the cir-
cular uniform diffusion of intradermal injection will not easily lead to the asym-
metry of bilateral depressor labii inferioris muscles if correctly injected.
3. If type I and type II exist at the same time, they should be treated at the same time.
Oral Commissures-“Sad or Downturned Mouth”
The dynamic downturn of the lips is mainly caused by the depressor anguli oris
muscle (DAO) (Fig. 15.4). This muscle and the platysma work synergistically. DAO
is a triangular superficial muscle, and its contour can be determined on animation
and when contracted. Generally, the depression caused by this muscle can be seen
by skin tethering in the region under the vertical line of the angle of the mouth.
242
Table 15.2 Chin Injection techniques and considerations

Type Total dose and muscle strength Injection point Reconstitution Layer muscles
I Mild(u) Medium(u) Strong(u) 1–3 injection points in the area of 100u/2–2.5 ml Subcutaneous, It is necessary to pay
F 1–4 4–10 mentalis muscle, less than 1 cm Intramuscular attention to the balance
above the mandibular margin, and between the three muscles.
M 1–5 6–12
1 point in the middle at the In most cases, the
junction of the midline and the depressor anguli oris
mandibular margin. If it is muscle and the mentalis
necessary to increase the injection muscles need to be treated
points, keep the symmetry at the same time.
II Mild(u) Medium(u) Strong(u) In the area between 1 cm above 100u/2–2.5 ml Intradermal

F 0.5–1.5 1.5–5 the mandibular margin and the
vermilion border of the lower lip
M 0.5–2 2–6
1–4 points, 1 cm apart
Fig. 15.4 Typical Case: Type I + II. Female, 38y
Fig. 15.5 Typical Cases: Type I + II. Female, 45y
Table 15.3 Injection techniques and considerations

Muscle Origin and insertion Function Synergist Antagonist
Depressor Origin: Mental tubercle and Downward pull Platysma Levator
anguli oris oblique line of the mandible of corners of the Depressor anguli oris
(continuous with platysma mouth labii inferior Zygomatic
muscle) Major
Insertion: Modiolus
In 2014, Choi suggested a safe area for the injection of DAO [2]. Theoretically
the safe area for injection is within the area 30° inward and 45° outward of the cen-
tral point of the oral axis. Due to the large individual differences, the determination
of a safe boundary mainly refers to the muscle shape. We recommend individual
assessment and treatment planning due to the large individual differences
(Table 15.3). See Fig. 15.1 for the regional anatomy.
Classification
I: Only the upper section is involved. On depression of the corners of the mouth,
skin depression can be seen within 1.5 cm below the angle of the mouth.
II: Only the lower section is involved, on depression of the corners of the mouth,
skin depression can be seen 1 cm above the mandibular margin. Generally, the pla-
tysma and inferior labii muscles also participate in the production of lines.
II: Combination of I and II (Fig. 15.6).
Injection pattern Fig. 15.7 and Table 15.4.
Fig. 15.6 The

classification
Fig. 15.7 Injection techniques

Table 15.4 Sad or Downturned Mouth—injection techniques and considerations
I Mild(u) Medium(u) Strong(u) The concave area under the angle 100u/2– Intradermal In this area, the depressor anguli
F 0.25–0.5 0.5–1 of mouth when lowering the oral 2.5 ml, 5–10u/ oris muscle is adjacent to the
M 0.5–1.5 commisures, usually about ml (when depressor labii inferioris. The
1–1.5 cm below the vertical line single point approximate range can be
of the axis of mouth. Single point <0.25u) determined by mentioned
injection. reference lines [2]. Intradermal
injection to reduce the dispersion
to the depressor labii inferior
muscle.
II Mild(u) Medium(u) Strong(u) The injection point is located 100u/2–2.5 ml Subcutaneous Pay attention to the synergistic
F 2–4 4–8 8–12 between 1 cm above the mandible effect of the platysma. Usually,
M 2–5 5–10 10–14 margin and the lower mandible the platysma will participate in
margin line, and 5 mm outside the depression of the angles of the
medial line of reference [2]. 1–3 mouth.

points, with an interval of 1 cm. If
the platysma is involved, it should
be treated at the same time.
245
Fig. 15.8 Typical Case: Type I + II. Male, 32y
1. Type I must be injected subcutaneously to reduce the possibility of involving the

depressor labii inferioris muscle.
2. In type II, the medial border for the injections are shifted more laterally, and
subcutaneous injections are recommended to reduce the possibility of involving
the depressor labii inferioris muscle. The platysma muscle is usually involved,
and needs to be treated at the same time.
3. If type I and type II exist at the same time (the combination type), they should be
treated at the same time.
Platysma
The platysma is the most expressive muscle with a downward force on the face.
When it is hyperactive or becomes hyperactive due to ageing or other reasons, it will
depress the lower face soft tissues resulting in an unclear mandibular margin,
a downward turn of the oral commissures, and aggravation of cervical lines and
rhytids. Upon contraction, the longitudinal cords become visible. The platysma
muscle can be separated in the midline; presents cord-like shape when contracting,
and contributes to the formation of “turkey neck” appearance. In East Asians,
the platysma muscle is mostly fused in the midline, so midline fat herniation and
“turkey neck” is rare (Fig. 15.10 and Table 15.5).
Fig. 15.10 Platysma

muscle

Platysma Arises from (upper thoracic Contraction of the Depressor Levator
and shoulder regions) the muscle causes elevation anguli angularis,
fascia that covers the upper of the neck with oris zygomaticus
segments of the deltoid and accentuation of the major,
pectoralis muscles cross over platysmal bands and also zygomaticus
the clavicle and proceed lowers the midfacial minor
obliquely superiorly, tissues, including the
laterally, and medially over lower lids and midface,
the neck. The platysma with deepening of the
muscle fibres thin out malar and nasolabial
anteriorly and attach just folds.
behind the symphysis Menti.
On the lateral side, the
muscle fibres pass over the
mandible, and some fibres
insert into the bone, and
others fibres merge in the
subcutaneous tissues and
other muscles medially.
Fig. 15.11 The

classification
Fig. 15.12 Injection techniques and recommendation
The type of the platysma was classified after the evaluation of its range and morpho-
logical characteristics.
I: Diffuse tension of the platysma.
II: Localised muscular tension.
Injection techniques Fig. 15.12 and Table 15.6.
Microbotox technique has been previously published [3, 4].

Table 15.6 Platysma–injection techniques and considerations
Type Total dose and muscle strength Injection point Concentration Layer muscles
I Mild(u) Medium(u) Strong(u) A total of 100–250 points, 100u/2–2.5 ml, Intradermal, The platysma and labial
F 30–45 45–60 60–75 microinjection mode, single 10u/ml (when Subcutaneous depressor muscles are
point 0.1–0.4u, each point single point close to each other.
M 40–55 55–70 70–85 interval 1 cm. <0.25u) Intradermal injection
should be used to reduce
II Mild(u) Medium(u) Strong(u) Evaluation of the locations of 100u/2–2.5 ml Intradermal,
the diffusion to depressor
F 30–45 45–60 60–75 the broad neck lines. There are Subcutaneous
labii superioris. Pay
10–50 points in total, single
M 40–55 55–70 70–85 attention to the synergistic
point 0.5–2.5u, and the interval
effect of platysma and
between each point is 1 cm.
deltoid.
249
Fig. 15.14 Typical Case: Type II. Female, 42y
The vast majority of patients are mixed type but be careful not to exceed the total
recommended dose to ensure safe injection. Conservative treatment in this area is
recommended, especially for those who do sports such as yoga.
Conclusion
This chapter has demonstrated cosmetic use of botulinum toxin A in the lower face
and the neck in East Asians. Presenting a unique classification for each region
according to the musculature involved, injection technique recommendation, with
the discussion of considerations and tips. Common cases with injection pattern and
dosage used (Onabotulinum toxin A) are presented.
References
1. Zide BM, McCarthy J. The mentalis muscle: an essential component of chin and lower lip posi-
tion. Plast Reconstr Surg. 1989;83(3):413–20.
2. Choi Y-J, et al. Anatomical considerations regarding the location and boundary of the depres-
sor anguli oris muscle with reference to botulinum toxin injection. Plast Reconstr Surg.
2014;134(5):917–21.
cal effects. Plast Reconstr Surg. 2015;136(5):92S–100S.
4. Liew S. Discussion: microbotox of the lower face and neck: evolution of a personal technique
and its clinical effects. Plast Reconstr Surg. 2015;136(5 Suppl):101s–3s.
Chapter 16
Dermal Fillers: Understanding
the Fundamentals
Souphiyeh Samizadeh and Sorousheh Samizadeh
Facial augmentation, volumetric restoration, and facial contouring through the use
of injectable fillers are exceedingly popular in the era of minimally invasive and
non-surgical procedures. These agents can be used for total facial rejuvenation.
There are various filling agents available internationally with their own specific
characteristics and indications for use. Dermal fillers can be categorised in many
ways; according to their source (biologic or synthetic), longevity within the tissues
(temporary, semi-permanent, or permanent), the biomechanics of filling (volumet-
ric, structural, or fibroplastic), or according to their bio-stimulatory effects [1].
Injection of any filling agent into the facial tissues can prompt a local tissue injury
response [2]. It is therefore essential for an aesthetic physician to become familiar
with some of the unique characteristics of commonly available products, to facili-
tate an informed decision regarding their usage. Choice of correct product depends
on the patient, indication, knowledge, and expertise of the physician.
S. Samizadeh (*)
S. Samizadeh

https://doi.org/10.1007/978-3-030-84099-0_16
254 S. Samizadeh and S. Samizadeh
Silicone (Permanent)
Paraffin, silicone, and collagen have been historically used as filling agents.
Autologous fat was one of the first agents used for soft tissue augmentation over
100 years ago [3]. However, paraffin and silicone were eliminated as filling agents.
The US FDA never approved and banned (in 1991) the use of liquid silicone as a
filling agent for cosmetic purposes [3]. Paraffin and other oils resulted in foreign
body granulomas and migration, and their use was abandoned in the USA and
Europe prior to the 1920s [4].
Many complications following injections of liquid silicone have been reported,
including foreign body reactions, migration of product, nodules, chronic cellulitis,
and severe granulomatous reactions, mostly years after treatment and regardless of
“good technique, good material, and small amounts injected” [5–8]. In the 1940s
and 50s, the available liquid silicone was reported to be contaminated with heavy
metals in addition to the inclusion of inflammation-inducing chemicals in order to
promote fibroblast formation. Furthermore, quantities as high as 2L were often
injected during a single session. As such, this practice resulted in various complica-
tions and permanent devastating outcomes including permanent deformation,
and migration of silicone to distant organs that was associated with autoimmune
reactions, malignancy, and death [9–13]. Siliconoms have been reported to occur up
to 11 years post implantation, even with the use of medical grade silicone, and cor-
rect injection technique [6]. Purified polydimethylsiloxane “silicone oil” is used for
the treatment of retinal detachment and has been used off-label for aesthetic pur-
poses and indications in the USA. However, it is not recommended to use liquid
injectable silicone off-label [14].
Collagen
Since 1977, bovine collagen has been used as a soft tissue filling agent [15]. Other
sources of collagen used as filing agents include human collagen (processed from
surgically excised skin or cadaveric skin) and porcine collagen [16]. Bovine colla-
gen carries risks of allergic reaction, immunogenicity, and xenogeneic transmission
of bovine spongiform encephalopathy (transmission of bovine particles and prions).
Sensitivity can be seen in 3.0–3.5% of subjects, and skin testing is required at 2 and
6 weeks and does not eliminate the transmission risk of bovine spongiform enceph-
alopathy [17, 18]. It is also possible to develop hypersensitivity to bovine collagen
upon repeated treatment [19]. This form of collagen persists for 2–5 months post
injection and is eliminated by foreign body reaction.
Porcine collagen filling agents are popular in Asia. The structure of porcine-derived
collagen is histologically similar to human dermal collagen and eliminates the risk of
bovine spongiform encephalopathy transmission [15]. However, correct patient selec-
tion and indications are important. Saray reported successful treatment of clinically
visible soft tissue defects with aesthetic results using “a dermal replacement material
16 Dermal Fillers: Understanding the Fundamentals 255
derived from fibrous acellular porcine dermal collagen” [20]. An open-label, multi-
centre, retrospective data collection study examined the effect of a ribose cross-linked
collagen dermal filler for lip enhancement in 51 subjects. The authors established the
treatment as “safe and effective” for lip enhancement with a majority of the subjects
showing no swelling, bruising, or lumpiness [21]. Braun and Braun used porcine-
derived collagen filler for lip enhancement in 20 patients. Sixteen of the 20 patients
experienced multiple lip nodules [22]. However, Cassuto reported a “high degree of
clinician and subject satisfaction” with the use of a suspension of cross-linked, fibril-
lar type I collagen isolated from porcine tendons for non-surgical rhinoplasty in 12
cases. The most common reason for subjects in this study requesting rhinoplasty
augmentation procedures was trauma, followed by basal cell carcinoma excision, and
previous rhinoplasty [23].
Human bioengineered collagen products (from human dermal fibroblast cell
lines) are also available, with a duration effect of 3–7 months, and eliminate the need
for allergy testing [24]. Injectable collagen cultured from the patient’s own skin is
now also a possibility [25].
Polymethylmethacrylate (Permanent)
Polymethyl methacrylate (PMMA) is a synthetic resin produced from the polymeri-

sation of methyl methacrylate, a transparent and rigid plastic. It is commonly used
as a substitute for glass in products such as shatterproof windows, skylights, illumi-
nated signs, and aircraft canopies. It is used in dental dentures, and bone cements
(space-filler) for implant fixation in various orthopaedic and trauma surgeries
[26, 27].
The PMMA microspheres are suspended in bovine collagen, methylcellulose,
carboxyglutamate, carboxymethylcellulose, and hyaluronic acid (HA) and used as
micro-implants/filling agents. However, some of these filling agents have been
withdrawn from the market [1]. Collagen is a carrier substance. The methacrylate
particles are non-biodegradable, non-absorbable/permanent, and inert. Immediately
after implantation, the microspheres are encapsulated with the patient’s own colla-
gen fibres and within 2–4 months become surrounded by connective tissue/capsule
[28]. These implants have the potential to elicit a cellular immune response [1].
Lee et al. examined the safety and efficacy of polymethylmethacrylate (PMMA)
and cross-linked dextran in hydroxypropyl methylcellulose for the treatment of
nasolabial folds in Korea. They reported satisfactory results with no complications
[29]. Lemperle and colleagues discussed their 10-year experience with “a suspen-
sion of 20% PMMA microspheres of 30–40 μm diameter in 80% bovine collagen
solution produced from US calf hides”. They reported the agent to be a reliable and
predictable substance. However, there is a learning curve for the injector to avoid
technical mistakes as the product has “high viscosity and persistence” and injec-
tors need to have “knowledge about the effect of crystalline corticosteroid” [28, 30].
A Brazilian consensus recommendation on the use of polymethylmethacrylate filler

in facial and corporal aesthetics was published in 2018.
There have been recorded cases of granuloma formation, blindness, and facial
necrosis and complications reported to be “difficult or even impossible to treat” fol-
lowing use of PMMA-based fillers [31–37]. Injection of PMMA based products is
permanent and therefore it is crucial to keep in mind that the results, as well as tech-
nical errors and incorrect injections, will last forever. An excellent case selection and
injection technique is therefore required for these products [38]. In addition, physi-
cians should adhere to the regulations and recommendations regarding the use of
PMMA-based products, as injection of large volumes has been reported to lead to
the development of severe hypercalcaemia and chronic kidney damage [39–41].
alcium Hydroxylapatite Fillers (Bio-Stimulatory/

C
Semi-Permanent)
Calcium hydroxyapatite in some of the available fillers has the same chemical compo-
sition as the inorganic constituent of teeth and bone. It is synthetic, non-animal derived,
and works as a scaffold. It is a biocompatible, non-toxic, non-mutagenic, non-anti-
genic material with more than 20 years of use for various medical applications (e.g.
otolaryngology, dentistry, and radiology) [42]. Biocompatibility studies have reported
no to minimal inflammatory response and no foreign body reaction associated with
these agents. For cosmetic purposes, and soft tissue augmentation, there are calcium
hydroxylapatite microspheres suspended in an aqueous gel carrier [43].
Calcium hydroxyapatite provides an immediate volumisation for up to 12 months.
This is then bio stimulated, resulting in new collagen production and hence a longer-
term correction [44]. Injection of microspheres of calcium hydroxyapatite stimu-
lates new tissue formation comparable to its adjacent environment [45]. Within the
soft tissues it does not calcify; however, if placed on the bone, it promotes the activ-
ity of osteoblasts and osteoclasts for new bone formation. Similarly, following
implantation in the dermis, it promotes fibroblastic ingrowth and new collagen for-
mation [45–47]. Post injection results are reported to last for 12–24 months with no
inflammation or migration [48, 49]. Longevity of longer than 30 months post treat-
ment of the nasolabial fold has been reported, with no delayed-onset or long-term
adverse events for 3 years post injection [50]. In addition, improvement of sauce-
rised acne scars, volume restoration of mid face, lower face, and hands can be effec-
tively achieved with these agents [42, 44, 51]. Shumaker and colleagues reported
persistence of calcium hydroxyapatite microspheres and associated fibrosis at least
6 years post implantation in the facial dermis [52]. The carboxymethylcellulose car-
rier agent was resorbed and replaced by collagen 2–3 months post implantation.
Calcium hydroxyapatite gradually breaks down, going through the same metabolic
pathway as elimination of bone debris from bone fracture [42, 45].
Jansen and Graivier treated 609 subjects with a calcium hydroxylapatite-based
implant for various facial areas, with an average follow-up time of 17 months. They
reported safety, efficacy, and tolerance for facial soft tissue augmentation.
Development of lip nodules within 6 to 12 weeks was reported, with some requiring
excision. This was explained by aggressive volume injection in a highly mobile tis-
sue [45]. Similarly, Tzikas, in large-scale clinical review (1000 patients) conducted
over more than 4 years, reported a good safety profile, high patient satisfaction, and
good durability [53]. This was supported by another multicentre study of the safety
and efficacy of calcium hydroxylapatite for soft tissue augmentation of nasolabial
folds and other areas of the face [54]. It is recommended not to treat highly mobile
areas and anatomically unforgiving areas (e.g. lips and the periocular region, respec-
tively). This is due to increased incidence of nodule formation [44, 55]. Cases of
orbital complication, ocular ischaemia and ischaemic oculomotor nerve palsy, and
blindness post vascular embolisation of calcium hydroxylapatite filling agents have
been reported [56, 57]. These filling agents are a potential cause of a false-positive
imaging study, usually visible on CT scans, hypermetabolic on FDG-PET imaging,
and intermediate signal intensity on MRI [58, 59].
Polymers
Biodegradable synthetic polymers have been used for various clinical applications.
For example, in wound closure (sutures, staples), and orthopaedic fixation devices
(pins, rods, screws, tacks, ligaments), dentistry, cardiovascular surgery, intestinal sur-
gery, urology, nerve repair, drug delivery, and oncology [60, 61]. Examples of avail-
able biodegradable polymers used as medical devices include products made from
poly(lactides), poly(glycolides), poly(dioxanone), and poly(ε-caprolactone). In the
field of orthopaedics, tissue-engineered solutions are a significant area of research.
Development of new polymers that would meet a variety of demanding requirements
is a remarkably interesting area. Such polymers can act as scaffolds and provide
mechanical support during tissue growth and degrade gradually. They can also be
used for guided tissue and guided bone regeneration. Other characteristics that are
beneficial include incorporation of cells, drugs, or growth factors that would provide
a nourishing environment for the given purposes, e.g. osteoconductive and osteoin-
ductive environments in the case of orthopaedic injuries or disease [62].
Some synthetic biodegradable polymers such as Poly-L-Lactic acid and polycap-
rolactone have been recently incorporated in the area of aesthetics and are being
used as injectables.
Poly-L-Lactic Acid (Bio-Stimulatory/Semi-Permanent)
Poly-L-lactic acid (PLLA) is a synthetic polymer that has been used in a variety of
medical applications for over 40 years [63]. Some examples include orthopaedic
fixative devices, stents (urethral and tracheal), dentistry (periodontal surgery-tissue
guided surgery), various vaccines (sustained-release injectable medications), and
some sutures.
As an injectable polymer (dermal stimulatory agent, not a filler) [64], PLLA relies
on a foreign body response, stimulates fibroblastic ingrowth and production of
extracellular matrix and endogenous collagen and hence increases volume slowly
over time. Post injection, tissues are expanded until the carrier is reabsorbed.
Following this process, there will be long-term volumetric improvement due to
induced tissue reaction [65]. Initially, PLLA microspheres stimulate fibroblast pro-
liferation, followed by collagen type I synthesis [66–69]. Furthermore, they cause
a non-immunogenic foreign body granulomatous reaction. This reaction results in
the microspheres being walled off and biodegraded. This results in fibroplasia,
which in turn leads to increased dermal thickness [69, 70]. Increased dermal thick-
ness 4–6 mm post injection in the nasolabial and cheek areas has been reported [71].
The resorption typically happens 10–12 months post implantation [65].
However, some PLA deposits can be detected in late onset papules (2 years or
more). Clinical studies suggest that results achieved are maintained for up to
24 months [72–74]. PLLA can be effectively used in the face and body, usually
in small areas that require contouring [75–77].
Patients should be informed that they will experience swelling for 1–3 days post
injection and may only see noticeable or significant correction 2 months post proce-
dure, and that repeated treatments are required [78]. To obtain good efficacy and
safety, the product should be appropriately reconstituted and correct injection tech-
nique used at all times [75].
One of the most common side effects associated with PLLA is the occurrence of
subcutaneous papules of 5 mm or less and nodules [75, 79]. These are thought to be
due to injection technique (incorrect reconstitution, injection technique, overcorrec-
tion, imprecise and uneven distribution of the product) [78, 80]. Injection of the
hypermobile areas including the periorbital and perioral areas is not recommended
[78, 81]. Further recommendations for prevention of such complications include
use of higher dilution volumes and fewer vials per session, correct injection plane,
respecting an adequate interval between treatments and post treatment massage by
the patients [76, 77, 80]. Severe visual loss and orbital infarction following perior-
bital aesthetic PLLA injection has been reported [82].
Polycaprolactone (Bio-stimulatory)
Polycaprolactone (PCL) has been used in the biomedical field (e.g. sutures, 3D
printing (tissue and organs—promote repair and regeneration in bone, skin, or other
tissues), drug-delivery devices, airway devices) for more than 70 years [83–86].
PCL is biocompatible, biodegradable, and bioresorbable [83]. PCL microspheres
suspended in various carriers such as carboxymethyl cellulose are bio-stimulatory
dermal filling agents and act as a 3D scaffold.
Implantation results in an immediate temporary filling effect due to the carrier
agent (absorbed in 2–3 months) and long-term volume due to new collagen produc-
tion (neocollagenesis) [83, 87]. A study by Kim and Van Abel performed post treat-
ment biopsy (human temples) and demonstrated that PCL particles are maintained
in their original state 13 months after implantation. New collagen was formed
around the particles, with new fibroblasts in the vicinity. In addition, new elastin
fibres were formed, and neovascularization was observed [88]. Longevity is reported
to be 1–4 years [89]. Degradation of the PCL microspheres is a two-step process,
resulting in hydrolytic degradation, fragmentation, and degradation into water and
carbon dioxide which are eliminated from the body [84, 90, 91].
Various clinical studies have reported the efficacy of PCL based fillers for volu-
misation and rejuvenation of different areas (face and hands) in addition to skin
quality improvement [87–89, 92–97]. However, some of the quoted studies had a
very small cohort of subjects. Lin and Christen examined complication rates of a
PCL-based dermal filler retrospectively in 780 patients (1111 treatments, 5595
syringes) over 3 years. They reported a low complication rate with no cases of intra-
vascular injection, nodules, and/or granulomas during the 3-year observation.
Higher injection volumes resulted in longer lasting oedema and malar oedema was
due to lymphatic compression. The reported complications such as discoloration
and nodule/granuloma formation were reported to be due to injection technique
[89]. Granuloma formation, xanthelasma-like reaction, and foreign body reaction
(3 years post injection) with PCL have been reported [98–100].
Experts’ recommendations and consensus were published in 2017, describing
injection techniques, indications, and contraindications (eyelids and vermilion bor-
der of the lips) [95]. The expert group emphasised the importance of “appropriate
training in establishing the correct diagnoses and developing the necessary skills”
when treating patients with PCL-based fillers. This is due to a longer learning curve
compared to HA fillers and high technique sensitivity [95].
Hyaluronic Acid-Based Dermal Fillers
The physical and chemical characteristics of HA dermal fillers vary widely, contrib-
uting towards their overall performance and clinical outcomes [101]. In addition,
the methods of manufacture of different products are different, also affecting their
performance. Understanding these properties will enable physicians to choose
appropriate products for the correct indication.
HA is a glycosaminoglycan disaccharide that is naturally occurring and found in
many human tissues (skin, joints, eyes, and cartilages). Approximately 50% of the HA
is found in the skin, it binds to water significantly and goes through enzymatic degra-
dation or is destroyed through reaction with reactive oxygen species [102]. HA mol-
ecules are cross-linked to form a gel in HA-based dermal fillers. The molecular weight
is determined by the number of disaccharides in the HA molecule. HA is a water-
soluble polymer and therefore requires modification to act as a filling agent. The bio-
chemical properties of these highly soluble polymers can be modified by various
methods of cross-linking while preserving their biological activity and biocompatibil-
ity. Various cross linkers include divinyl sulfone, diglycidyl ethers, and bis-epoxides
[101, 103–105]. The higher the cross-linkage density, the stronger the network and
hence the harder/stiffer the gel. Cross-linked HA can withstand enzymatic and radical
degradation. Dermal fillers also contain soluble fluid and/or free HA which are
degraded soon after implantation [102]. HA is biocompatible and non-immunogenic.
Viscoelastic properties refer to the elastic component and viscous component of
the gel (solid and liquid, respectively). Elastic modulus, viscous modulus and com-
plex modulus are all dynamic. They change with frequency of force applied, tem-
perature, pressure, and other factors [106]. Rheological properties can be
described by: [102, 107–111].
Property
Elastic modulus (G’) The capacity of a material to regain its original shape following
shear deformation.
Hardness or softness of a gel/ability to resist deformation.
This is determined primarily by the fluid phase of the gel and its
interactions with the solid phase.
The degree of cross-linkage and gel concentration influence G’.
The resistance of a material to deformation during injection.
Viscous modulus (G”) Measure of the flow properties.
The viscoelastic gel's inability to revert to its original shape
following the removal of shear stress.
Injectability of the gel.
Complex modulus (G* ) The combined viscous and elastic behaviour—material's total
resistance to deformation.
Tan (δ) A ratio to the viscous and elastic modulus.
Complex viscosity (η*) The ability of the gel structure to resist shear forces.
This is determined primarily by the solid phase of the gel and its
interaction with the fluid phase.
This refers to the way a material flows from the needle.
Following injection, the filler's η* and G′ properties influence how
well it resists skin tension forces caused by facial movements.
Cohesivity Molecular attraction among cross-linked HA molecules/
measurement of resistance against vertical compression.
The concentration of HA and specific cross-linking steps influence
the gel's cohesivity.
The capacity of HA filler to swell depends on various factors including concen-

tration, the process used to hydrate the gel, and cross-linkage concentration. Gels
that are fully hydrated or ‘equilibrium gels’ will not swell post implantation/injec-
tion as they have already reached their hydration capacity [102].
The gel is absorbed by the adjacent tissues over time and disappears by the pro-
cess of isovolumetric degradation.
Conclusion
No filling agent can be considered as a universal agent that would be appropriate for
all indications and patients. Understanding the properties of each individual filler
and how they interact will allow understanding of the expected clinical outcome and
planning for the optimal outcome for each individual patient.
References
1. de Jesus LH, et al. Location of injected polymethylmethacrylate microspheres influences the

onset of late adverse effects: an experimental and histopathologic study. Clin Cosmet Investig
Dermatol. 2015;8:431–6.
2. Gilbert E, et al. The basic science of dermal fillers: past and present Part II: adverse effects. J
Drugs Dermatol. 2012;11(9):1069–77.
3. Fagien S, Klein AW. A brief overview and history of temporary fillers: evolution, advantages,
and limitations. Plast Reconstr Surg. 2007;120(6S):8S–16S.
4. Klein AW, Elson ML. The history of substances for soft tissue augmentation. Dermatol Surg.
2000;26(12):1096–105.
5. Rapaport MJ, Vinnik C, Zarem H. Injectable silicone: cause of facial nodules, cellulitis, ulcer-
ation, and migration. Aesthet Plast Surg. 1996;20(3):267–76.
6. Achauer BM. A serious complication following medical-grade silicone injection of the face.
7. Mastruserio DN, Pesqueira MJ, Cobb MW. Severe granulomatous reaction and facial ulceration
occurring after subcutaneous silicone injection. J Am Acad Dermatol. 1996;34(5):849–52.
8. Bon A, Eichmann A. Serious long-term complication following silicone injection of the face.
Dermatology. 1993;187(4):286–7.
9. Gilbert E, Hui A, Waldorf HA. The basic science of dermal fillers: past and present Part I:
background and mechanisms of action. J Drugs Dermatol. 2012;11(9):1059–68.
10. Henly DR, et al. Particulate silicone for use in periurethral injections: local tissue effects and
search for migration. J Urol. 1995;153(6):2039–43.
11. Dewan P, et al. Migration of particulate silicone after ureteric injection with silicone. BJU Int.
2000;85(4)
12. Dolwick MF, Aufdemorte TB. Silicone-induced foreign body reaction and lymphade-
nopathy after temporomandibular joint arthroplasty. Oral Surg Oral Med Oral Pathol.
1985;59(5):449–52.
13. Hatanaka S, et al. Induction of malignant fibrous histiocytoma in female Fisher rats by implan-
tation of cyanoacrylate, zirconia, polyvinyl chloride or silicone. In Vivo (Athens, Greece).
1993;7(2):111–5.
14. Coleman SR. Injectable silicone returns to the United States. Aesthet Surg J. 2001;21(6):576–8.
15. Moon SH, et al. Comparative study of the effectiveness and safety of porcine and bovine atelo-
collagen in Asian nasolabial fold correction. J Plast Surg Hand Surg. 2015;49(3):147–52.
16. Pollack SV. Some new injectable dermal filler materials: hylaform, restylane, and artecoll. J
Cutan Med Surg. 1999;3(4_suppl):S4-27–35.
17. Downie J, et al. A double-blind, clinical evaluation of facial augmentation treatments: a com-
parison of PRI 1, PRI 2, Zyplast and Perlane. J Plast Reconstr Aesthet Surg. 2009;62(12):
1636–43.
18. Lee JH, et al. Efficacy and safety of porcine collagen filler for nasolabial fold correc-
tion in Asians: a prospective multicenter, 12 months follow-up study. J Korean Med Sci.
2014;29(Suppl 3):S217–21.
19. Owens JM. Soft tissue implants and fillers. Otolaryngol Clin N Am. 2005;38(2):361–9.
20. Saray A. Porcine dermal collagen (permacol) for facial contour augmentation: preliminary
report. Aesthet Plast Surg. 2003;27(5):368–75.
21. De Boulle K, et al. Lip augmentation and contour correction with a ribose cross-linked col-
lagen dermal filler. J Drugs Dermatol. 2009;8(3 Suppl):1–8.
22. Braun M, Braun S. Nodule formation following lip augmentation using porcine collagen-
derived filler. J Drugs Dermatol. 2008;7(6):579–81.
23. Cassuto D. The use of dermicol-P35 dermal filler for nonsurgical rhinoplasty. Aesthetic Surg
J. 2009;29(3_Suppl):S22–4.
24. Sánchez-Carpintero I, Candelas D, Ruiz-Rodríguez R. Dermal fillers: types, indications, and
complications. Actas Dermo-Sifiliográficas (English Edition). 2010;101(5):381–93.
25. Johl SS, Burgett RA. Dermal filler agents: a practical review. Curr Opin Ophthalmol.
2006;17(5):471–9.
26. Vaishya R, Chauhan M, Vaish A. Bone cement. J Clin Orthop Trauma. 2013;4(4):157–63.
27. Zafar MS. prosthodontic applications of polymethyl methacrylate (PMMA): an update.
Polymers. 2020;12(10):2299.
28. Lemperle G, Gauthier-Hazan N, Lemperle M. PMMA-Microspheres (Artecoll) for long-
lasting correction of wrinkles: refinements and statistical results. Aesthet Plast Surg.
1998;22(5):356–65.
29. Lee YB, et al. Safety and efficacy of a novel injectable filler in the treatment of nasolabial
folds: polymethylmethacrylate and cross-linked dextran in hydroxypropyl methylcellulose. J
Cosmet Laser Ther. 2014;16(4):185–90.
30. Lemperle G, Romano JJ, Busso M. Soft tissue augmentation with artecoll: 10-year history,
indications, techniques, and complications. Dermatol Surg. 2003;29(6):573–87. discussion 587
31. Kim KJ, et al. Artecoll granuloma: a rare adverse reaction induced by microimplant in the
treatment of neck wrinkles. Dermatol Surg. 2004;30(4):545–7.
32. Requena C, et al. Adverse reactions to injectable aesthetic microimplants. Am J Dermatopathol.
2001;23(3):197–202.
33. Christensen L, et al. Adverse reactions to injectable soft tissue permanent fillers. Aesthet
Plast Surg. 2005;29(1):34–48.
34. Branco de Castro AC, et al. Extensive facial necrosis after infiltration of polymethylmethac-
rylate. Braz J Otorhinolaryngol. 2007;73(6):850.
35. Silva MTT, Curi AL. Blindness and total ophthalmoplegia after aesthetic polymethylmethac-
rylate injection: case report. Arq Neuropsiquiatr. 2004;62(3B):873–4.
36. Salles AG, et al. Complications after polymethylmethacrylate injections: report of 32 cases.
37. Friedmann DP, Kurian A, Fitzpatrick RE. Delayed granulomatous reactions to facial cos-
metic injections of polymethylmethacrylate microspheres and liquid injectable silicone: a
case series. J Cosmet Laser Ther. 2016;18(3):170–3.
38. Haneke E. Polymethyl methacrylate microspheres in collagen. Semin Cutan Med Surg.
2004;23(4):227–32.
39. Manfro AG, et al. Case reports of hypercalcemia and chronic renal disease due to cosmetic
injections of polymethylmethacrylate (PMMA). J Bras Nefrol. 2020.
40. Tachamo N, et al. Hypercalcemia associated with cosmetic injections: a systematic review.
Eur J Endocrinol. 2018;178(4):425–30.
41. Goldman A, Staub H, Wollina U. Hypercalcemia due to polymethylmethacrylate injections?
(Literature review and case reports). Georgian Med News. 2018;282:17–20.
42. Jacovella PF. Use of calcium hydroxylapatite (Radiesse) for facial augmentation. Clin Interv
Aging. 2008;3(1):161–74.
43. Flaharty P. Radiance. Facial Plast Surg. 2004;20(2):165–9.
44. Emer J, Sundaram H. Aesthetic applications of calcium hydroxylapatite volumizing filler: an
evidence-based review and discussion of current concepts: (part 1 of 2). J Drugs Dermatol.
2013;12(12):1345–54.
45. Jansen DA, Graivier MH. Evaluation of a calcium hydroxylapatite-based implant (Radiesse)
for facial soft-tissue augmentation. Plast Reconstr Surg. 2006;118(3S):22S–30S.
46. Marmur ES, Phelps R, Goldberg DJ. Clinical, histologic and electron microscopic findings
after injection of a calcium hydroxylapatite filler. J Cosmet Laser Ther. 2004;6(4):223–6.
47. Zerbinati N, et al. Microscopic and ultrastructural evidences in human skin following calcium
hydroxylapatite filler treatment. Arch Dermatol Res. 2017;309(5):389–96.
48. Mayer R, Lightfoot M, Jung I. Preliminary evaluation of calcium hydroxylapatite as a trans-
urethral bulking agent for stress urinary incontinence. Urology. 2001;57(3):434–8.
49. Stein J, et al. Histopathologic study of alternative substances for vocal fold medialization.
Ann Otol Rhinol Laryngol. 2000;109(2):221–6.
50. Bass LS, et al. Calcium hydroxylapatite (radiesse) for treatment of nasolabial folds: long-
term safety and efficacy results. Aesthet Surg J. 2010;30(2):235–8.
51. Goldberg DJ, Amin S, Hussain M. Acne scar correction using calcium hydroxylapatite in a
carrier-based gel. J Cosmet Laser Ther. 2006;8(3):134–6.
52. Shumaker PR, et al. Calcium hydroxylapatite tissue filler discovered 6 years after implanta-
tion into the nasolabial fold: case report and review. Dermatol Surg. 2009;35(s1):375–9.
53. Tzikas TL. A 52-month summary of results using calcium hydroxylapatite for facial soft tis-
sue augmentation. Dermatol Surg. 2008;34(Suppl 1):S9–15.
54. Sadick NS, Katz BE, Roy D. A multicenter, 47-month study of safety and efficacy of calcium
hydroxylapatite for soft tissue augmentation of nasolabial folds and other areas of the face.
Dermatol Surg. 2007;33(Suppl 2):S122–6. discussion S126–7
55. Kanchwala SK, Holloway L, Bucky LP. Reliable soft tissue augmentation: a clinical com-
parison of injectable soft-tissue fillers for facial-volume augmentation. Ann Plast Surg.
2005;55(1):30–5. discussion 35
56. Sung MS, et al. Ocular ischemia and ischemic oculomotor nerve palsy after vascular
embolization of injectable calcium hydroxylapatite filler. Ophthalmic Plast Reconstr Surg.
2010;26(4):289–91.
57. Glass LRD, Choi CJ, Lee NG. Orbital complication following calcium hydroxylapatite filler
injection. Ophthalmic Plast Reconstr Surg. 2017;33(3S):S16–7.
58. Carruthers A, et al. Radiographic and computed tomographic studies of calcium hydroxyl-
apatite for treatment of HIV–associated facial lipoatrophy and correction of nasolabial folds.
Dermatol Surg. 2008;34(s1):S78–84.
59. Feeney JN, Fox JJ, Akhurst T. Radiological impact of the use of calcium hydroxylapatite
dermal fillers. Clin Radiol. 2009;64(9):897–902.
60. Middleton JC, Tipton AJ. Synthetic biodegradable polymers as orthopedic devices.
Biomaterials. 2000;21(23):2335–46.
61. Barrows T. Degradable implant materials: a review of synthetic absorbable polymers and
their applications. Clin Mater. 1986;1(4):233–57.
62. Gunatillake PA, Adhikari R. Biodegradable synthetic polymers for tissue engineering. Eur
Cell Mater. 2003;5(1):1–16.
63. Rotunda AM, Narins RS. Poly-L-lactic acid: a new dimension in soft tissue augmentation.
Dermatol Ther. 2006;19(3):151–8.
64. Lowe N. Dispelling the myth: appropriate use of poly-l-lactic acid and clinical consider-
ations. J Eur Acad Dermatol Venereol. 2006;20:2–6.
65. Lombardi T, et al. Orofacial granulomas after injection of cosmetic fillers. Histopathologic
and clinical study of 11 cases. J Oral Pathol Med. 2004;33(2):115–20.
66. Burgess CM, Quiroga RM. Assessment of the safety and efficacy of poly-L-lactic acid
for the treatment of HIV-associated facial lipoatrophy. J Am Acad Dermatol. 2005;52(2):
233–9.
67. Vert M, Li S, Garreau H. Attempts to map the structure and degradation characteristics
of aliphatic polyesters derived from lactic and glycolic acids. J Biomater Sci Polym Ed.
1995;6(7):639–49.
68. Brady JM, et al. Resorption rate, route of elimination, and ultrastructure of the implant site of
polylactic acid in the abdominal wall of the rat. J Biomed Mater Res. 1973;7(2):155–66.
69. Pietrzak WS, Sarver DR, Verstynen ML. Bioabsorbable polymer science for the practicing
surgeon. J Craniofac Surg. 1997;8(2):87–91.
70. Cutright DE, Hunsuck EE. Tissue reaction to the biodegradable polylactic acid suture. Oral
Surg Oral Med Oral Pathol. 1971;31(1):134–9.
71. Moyle G, et al. A randomized open-label study of immediate versus delayed polylactic acid
injections for the cosmetic management of facial lipoatrophy in persons with HIV infection.
HIV Med. 2004;5(2):82–7.
72. Humble G, Mest D. Soft tissue augmentation using sculptra. Facial Plast Surg.
2004;20(2):157–63.
73. Mest D. Experience with injectable poly-L-lactic acid in clinical practice. Cosmet Dermatol.
2005;18(2):S2.
74. Valantin M-A, et al. Polylactic acid implants (New-Fill)® to correct facial lipoatrophy in
HIV-infected patients: results of the open-label study VEGA. AIDS. 2003;17(17):2471–7.
75. Vleggaar D. Soft-tissue augmentation and the role of poly-L-lactic acid. Plast Reconstr Surg.
2006;118(3 Suppl):46s–54s.
76. Sadick NS. Poly-l-lactic acid: a perspective from my practice. J Cosmet Dermatol.
2008;7(1):55–60.
77. Schierle CF, Casas LA. Nonsurgical rejuvenation of the aging face with injectable poly-L-
lactic acid for restoration of soft tissue volume. Aesthet Surg J. 2011;31(1):95–109.
78. Narins RS. Minimizing adverse events associated with poly-l-lactic acid injection. Dermatol
Surg. 2008;34(s1):S100–4.
79. Engelhard P, Humble G, Mest D. Safety of Sculptra: a review of clinical trial data. J Cosmet
Laser Ther. 2005;7(3–4):201–5.
80. Lam SM, Azizzadeh B, Graivier M. Injectable poly-L-lactic acid (Sculptra): technical con-
siderations in soft-tissue contouring. Plast Reconstr Surg. 2006;118(3 Suppl):55s–63s.
81. Beljaards RC, de Roos KP, Bruins FG. NewFill for skin augmentation: a new filler or failure?
Dermatol Surg. 2005;31(7):772–7.
82. Roberts SAI, Arthurs BP. Severe visual loss and orbital infarction following periorbital aes-
thetic poly-(L)-lactic acid (PLLA) injection. Ophthalmic Plast Reconstr Surg, 2012;28(3).
83. Christen M-O, Vercesi F. Polycaprolactone: How a well-known and futuristic polymer has
become an innovative collagen-stimulator in esthetics. Clin Cosmet Investig Dermatol.
2020;13:31.
84. Woodruff MA, Hutmacher DW. The return of a forgotten polymer—polycaprolactone in the
21st century. Prog Polym Sci. 2010;35(10):1217–56.
85. Abedalwafa M, et al. Biodegradable poly-epsilon-caprolactone (PCL) for tissue engineering
applications: a review. Rev Adv Mater Sci. 2013;34(2):123–40.
86. Zopf DA, et al. Treatment of severe porcine tracheomalacia with a 3-dimensionally printed, bio-
resorbable, external airway splint. JAMA Otolaryngol Head Neck Surg. 2014;140(1):66–71.
87. Kim JA, Van Abel D. Neocollagenesis in human tissue injected with a polycaprolactone-
based dermal filler. J Cosmet Laser Ther. 2015;17(2):99–101.
88. Kim JS. Changes in dermal thickness in biopsy study of histologic findings after
a single injection of polycaprolactone-based filler into the dermis. Aesthet Surg
J. 2019;39(12):Np484–np494.
89. Lin SL, Christen MO. Polycaprolactone-based dermal filler complications: a retrospective
study of 1111 treatments. J Cosmet Dermatol. 2020;19(8):1907–14.
90. Woodward SC, et al. The intracellular degradation of poly(epsilon-caprolactone). J Biomed
Mater Res. 1985;19(4):437–44.
91. Heimowska A, Morawska M, Bocho-Janiszewska A. Biodegradation of poly (ε-caprolactone)
in natural water environments. Pol J Chem Technol. 2017;19(1):120–6.
92. Figueiredo VM. A five-patient prospective pilot study of a polycaprolactone based dermal
filler for hand rejuvenation. J Cosmet Dermatol. 2013;12(1):73–7.
93. Moers-Carpi MM, Sherwood S. Polycaprolactone for the correction of nasolabial folds: a
24-month, prospective, randomized, controlled clinical trial. Dermatol Surg. 2013;39(3 Pt
1):457–63.
94. Bae B, et al. Safety and long-term efficacy of forehead contouring with a polycaprolactone-
based dermal filler. Dermatol Surg. 2016;42(11):1256–60.
95. de Melo F, et al. Recommendations for volume augmentation and rejuvenation of the face
and hands with the new generation polycaprolactone-based collagen stimulator (Ellansé(®)).
96. Lowe NJ, Ghanem AM. Volume restoration of hands with polycaprolactone by cannula deliv-
ery; a prospective single center consecutive case series evaluation. J Cosmet Laser Ther.
2020;22(2):55–9.
97. Galadari H, et al. A randomized, prospective, blinded, split-face, single-center study compar-
ing polycaprolactone to hyaluronic acid for treatment of nasolabial folds. J Cosmet Dermatol.
2015;14(1):27–32.
98. Skrzypek E, et al. Granuloma as a complication of polycaprolactone-based dermal filler
injection: ultrasound and histopathology studies. J Cosmet Laser Ther. 2019;21(2):65–8.
99. Or L, et al. Xanthelasma-like reaction to filler injection. Ophthalmic Plast Reconstr Surg,
2017;33(4).
100. Moon SY, et al. Foreign body reaction three years after injection with polycaprolactone
(Ellanse®). Eur J Dermatol. 2017;27(5):549–51.
101. Tezel A, Fredrickson GH. The science of hyaluronic acid dermal fillers. J Cosmet Laser Ther.
2008;10(1):35–42.
102. Kablik J, et al. Comparative physical properties of hyaluronic acid dermal fillers. Dermatol
Surg. 2009;35:302–12.
103. Gold MH. Use of hyaluronic acid fillers for the treatment of the aging face. Clin Interv Aging.
2007;2(3):369.
104. Almond A. Hyaluronan. Cell Mol Life Sci. 2007;64(13):1591–6.
105. Monheit GD, Prather CL. Juvéderm: a hyaluronic acid dermal filler. J Drugs Dermatol.
2007;6(11):1091.
106. Ave MN, de Almeida Issa MC, Issa M, Tamura B. Hyaluronic Acid Dermal Filler: Physical
Properties and Its Indications. Botulinum Toxins, Fillers and Related Substances. Clinical
Approaches and Procedures in Cosmetic Dermatology. 2018;4:187–97.
107. Sundaram H, Michaels J. Rheological evaluation of the physical properties of hyaluronic acid
dermal fillers. J Drugs Dermatol. 2011;10(9):974–80.
108. Sundaram H, Fagien S. Cohesive polydensified matrix hyaluronic acid for fine lines. Plast
Reconstr Surg. 2015;136:149S–63S.
109. Sundaram H, Rohrich RJ, Liew S, Sattler G, Talarico S, Trévidic P, Molliard SG. Cohesivity
of hyaluronic acid fillers: development and clinical implications of a novel assay, pilot valida-
tion with a five-point grading scale, and evaluation of six U.S. food and drug administration-
approved fillers. Plast Reconstr Surg. 2015;136:678–86.
110. Choi MS. Basic rheology of dermal filler. Arch Plast Surg. 2020;47(4):301–4. https://doi.
org/10.5999/aps.2020.00731.
111. Sundaram H, Voigts B, Beer K, Meland M. Comparison of the rheological properties of
viscosity and elasticity in two categories of soft tissue fillers: calcium hydroxylapatite and
hyaluronic acid. Dermatol Surg. 2010;36:1859–65.
Chapter 17
Dermal Fillers: Injection Considerations
for East Asian Facial Rejuvenation
Souphiyeh Samizadeh
Facial Structure
In general, East Asians have brachycephalic head shapes where the head width is
relatively larger than its length [1]. The Chinese have the highest cephalic index
values (maximum head width/maximum head length x100) and smallest head cir-
cumference, in both sexes [2]. This results in a broad and short face [3, 4].
Examination of the faces of young adult Chinese, Vietnamese, and Thai has shown
that the dominant characteristics of the East Asian face include: [3, 5, 6] (Fig. 17.1)
• Wide intercanthal distance relative to a shorter palpebral fissure
• Wide soft nose
• Wide facial contours
• Small mouth width
• Lower face smaller than the forehead height
Beauty Requests
• Enhance beauty while retaining ethnic features

• Focus is not on Westernisation
• Oval facial shape with no convexities and concavities in a line that connects the
forehead to the chin
S. Samizadeh (*)

https://doi.org/10.1007/978-3-030-84099-0_17
268 S. Samizadeh
a b Asian features compared Clinical Features

to Caucasian
Increased width: Result in wider:

• Bitemporal • Forehead
• Bizygomatic • Midface
• Bigonal • Lower face
Retrusion of the following:

• Forehead Flat forehead
Heavy eyelids
• Orbital rim
c d • Medial maxilla
Concave central midface, perialar
recession and nasolabial fold, perioral
• Pyriform margin retrusion, shadowing on the base of
nose, wide nasal width
Low nasal bridge Nose: flat, short, retruded columella,

deficient anterior nasal spine broad nasal width
Bimaxillart protrusion The upper and lower jaws are projected

forward
Hypoplastic mandible Retruded chin
Fig. 17.1 Comparison of Asian (a, c) and Caucasian (b, d) skulls. (a, b) Anterior view. The Asian
skull (a) is wider overall, with greater bitemporal, bizygomatic, and bigonial width of the temple,
zygoma, and mandible, respectively, compared with those of the Caucasian skull (b). (c, d) Lateral
view. The Asian skull (c) has less anterior projection, with a more retruded frontal bone and supra-
orbital ridge, recessed nasion, infraorbital rim, medial maxilla, maxillary process of the zygoma,
anterior nasal spine, and pogonion of the mandible compared with the Caucasian skull (d).
(Illustrations courtesy of Prof Kim) Image and table adopted from Consensus on Changing Trends,
Attitudes, and Concepts of Asian Beauty by Liew et al. [3]
Fig. 17.2 Ideals of beauty among the Chinese population and aesthetic practitioners. For more
in-depth information the referenced papers by the author can be read [7, 8].
• 3D facial structures with anteriorly projected forehead, nose, and chin

• Small delicate face with harmonious bitemporal, bizygomatic, and bigonial width
• Small delicate lips that are harmonious with other facial features (Fig. 17.2)
17 Dermal Fillers: Injection Considerations for East Asian Facial Rejuvenation 269
Cultural Aspects
The practitioner should keep in consideration:

• Motivating factors for requested treatment (e.g. forced by parents/spouse, peer
pressure, etc.)
• Facial physiognomy [9]
–– Belief in facial physiognomy is not uncommon
• Importance of skin and complexion
• Cultural pressure regarding the importance of being beautiful
• Marriage (M:F ratio) and job aspects
The above factors may force an individual to undergo cosmetic treatment against
their own wishes and must be examined during the consultation. Art and cultural
representations of beauty can help practitioners develop a sense for the ideals of
beauty of a nation from historical and modern perspectives (Fig. 17.3).
Anatomical Variations
It is important to appreciate that anatomical variations exist. However, it is beyond

the scope of this chapter to discuss all anatomical variations. Some will be men-
tioned in each section.
Common Themes
• Young patients: Facial contouring and anterior projection, acne treatment

• Middle age and older: Skin complexion improvement and anti-ageing
Facial Contouring Using Dermal Fillers
Aims and objectives: Aesthetic patients are usually within the younger age range in
Asia and request facial contouring and anterior facial projection. Therefore, the fol-
lowing should be taken into consideration sequentially. Starting the treatment supe-
riorly, laterally and moving to medially, inferiorly is recommended. Treatment of
various subunits has an impact on the rest of the face. For example, it has been
recently shown that enhancement of the posterior superior temple results in a reduc-
tion of volume of the middle face in addition to accentuation of the contouring of
the jawline. This is due to re-positioning of the soft tissues and the underlying facial
anatomy [10].
270 S. Samizadeh
Fig. 17.3 Chinese art and representation of beauty and beautiful faces
Part 1: Lateral Contouring

• Facial shape
• Temples
• Zygoma
• Pre-zygomatic area
• Buccal area
• Chin
Part 2: Central Anterior Projection
• Forehead and eyebrows
• Nose
• Medial cheek and tear trough
• Lips
• Chin
The emphasis is on delicate facial features, balance, and harmony. The author’s
experience and surveys among Chinese lay persons and aesthetic professionals have
shown that over-masculine facial features, for example a very angular jawline and
dominant chin are not desirable in men [7, 8]. This is supported by international
studies. Over-masculine facial features are related to aggressiveness by women, and
men with more gentle facial features are considered for long-term relationships and
parental investment [11, 12].
Part 1: Lateral Contouring
Temples
This is a common area of interest for enhancement in Asian patients. This is partly
due to high zygomatic arches that result in an appearance of hollow temples in
Asians (ageing sign), but also a desire for an oval facial shape that is disrupted by
the concavity of the forehead and convexity of high arched cheek bones. Furthermore,
belief in facial physiognomy means the concavity or convexity of the temples has
different connotation regarding one’s fate and fortune.
Asian Aesthetic Ideals [3, 7–9, 13]
• Convex temples are desirable, the curvature of the temples to be even and harmo-
nious with a line running from the forehead to the chin, creating an oval
facial shape.
• Facial physiognomy belief.
272 S. Samizadeh
a b c
III
V
I+III
VI
FP
d Parietal branch
of superficial
e
temporal a.
Frontal branch of
superficial temporal a.
Superficial temporal v.
Transverse
facial a. Facial n.
Maxillary v.
Maxillary a. Superficial
temporal a. Retromandibular v.
Facial v.
Internal jugular v.
Facial a.
Occipital a.
External jugular v.
Angular v.
Submental a. Posterior auricular a. Anterior jugular v.
Communicating v.
External carotid a. Internal carotid a.
Fig. 17.4 (a) Layers of the temple. I, skin; II, subcutaneous tissue; III, TPF (superficial temporal
fascia); FP, temporal fat pad; V, DTF; VI, temporalis muscle. (b) Cadaver dissection after reflection
of the skin and the subcutaneous tissue showing the TPF with the arrow pointing to the frontal
branch of the superior temporal artery. (c) Left-sided cadaver dissection depicting the continuity of
the TPF of the temporal region with the SMAS of the midface [14]. (d) Lateral view of the arterial
facial blood supply. The external carotid artery provides all extracranial branches (formalin-fixated
and coloured-latex injected cadaveric head). (e) Venous drainage of the cranial region. Note the
superficial position of the facial nerve and its relationship with the superficial temporal vein
(formalin-fixated and coloured-latex injected cadaveric head). All used with permission. Source of
D & E von Arx T, Tamura K, Yukiya O, Lozanoff S. The Face—A Vascular Perspective. A litera-
ture review. Swiss Dent J. 2018 May 14;128(5):382–392. PMID: 29734800
Anatomical Considerations [14–20] (Fig. 17.4)
• Arteries and veins to be mindful of: superficial temporal, middle temporal, deep
temporal, superficial muscular, sentinel, internal maxillary artery.
• Frontal branch of the facial nerve, auriculotemporal nerve, zygomaticotempo-
ral nerve.
• The middle temporal artery can be found superior and parallel to the zygomatic
arch (18.5–20.0 mm), with an average size of 5.1 mm, connected to cavernous sinus.
• There are multiple fat compartments in the temple; the subcutaneous fat consisting of
lateral temporal-cheek fat compartment and lateral orbital fat compartment, the
superficial and deep temporal extensions of the buccal fat pad (the larger superficial
portion passes between the temporal fascia and surface of the temporalis muscle and
the deep extension passes superiorly between the superficial and deep fibres of the
temporalis muscle and the superficial temporal fat pad found between two layers of
deep temporal fascia.
• There are a series of ligamentous structures perpendicular to the temporal fasciae.
Considerations: [14–16, 21–25]
• High-risk zones.
• Cases of vascular compromise, and blindness have been reported. Thrombotic
and non-thrombotic pulmonary embolism can occur as a result of an inadvertent
injection in the middle temporal vein.
• Risk for intracranial penetration with injection and direct pressure on the bone
has been reported.
• Various authors and experts have published different “safe injection zones”, cli-
nicians should critically analyse such papers and gain expertise in the techniques
prior to using the recommended methods.
• The temporalis is a muscle of mastication; temporal enhancement may result in
pain which is aggravated during mastication, or headaches.
• Sentinel vein injury can result in a large haematoma.
• Mechanical compression of the auricotemporal vein with a cannula can cause
post injection pain and migraine.
Recommendations [17, 24, 26–28]
• Frontal branch of the superficial temporal artery to be located prior to injection.

• Both needle and cannula can be used.
• Six injection techniques have been described in a recent publication [17].
–– Anterior temple—results in mainly volumisation.
1. Subdermal/superficial fatty layer (22G cannula recommended).
• Venous visibility post injection—spontaneous remission usually.
2. Between superficial and deep temporal fascia (22G cannula recommended).
• Continuous with the loose alveolar tissue of the forehead and scalp.
• Product with lidocaine can cause temporary brow ptosis.
3. Low supraperiosteal layer “one up, one over technique” (27G sharp needle).
• Results in intramuscular product deposition.
• Maintain constant bony contact during injection.
• Patient in seated position.
• Mouth open during injection relaxes the muscle.
4. High supraperiosteal (27G sharp needle).
• Maintain constant bony contact.
• ½ inch needle should reach the bone otherwise placed too inferiorly
–– Posterior temple-results in mainly a “lifting” effect of the middle and lower face.
5. Supraauricular (22G cannula).
• Subdermal plane of the posterior temple.
274 S. Samizadeh
6. Posterior temporal-supra-SMAS (22G cannula).

• Subdermal plane of the posterior temple (hair bearing area), exact injection
layer is crucial.
• Mouth open to relax the muscle.
• Local pressure or tension may be experienced after injection.
• Aspiration (both needle and cannula).
• Slow injection with low pressure.
• Use the non-dominant hand to help prevent displacement of the product.
• Digital control of the product when using a cannula.
• Pressure can be applied at specific high-risk areas prior to injection.
• Multi-layer treatment may be required.
Zygoma, Lateral Cheeks, Subzygomatic Area, Buccal Area
Asian Aesthetic Ideals [3, 7–9, 13, 29, 30]
• Even flow of an imaginary curve from the forehead to the temples, zygoma, sub-
zygoma, and the chin, to form an oval facial shape.
• High cheek bones are not desirable.
• Wide bizygomatic distance not desirable.
• Fullness of subzygomatic area is desirable, hollowness is linked with poverty.
• Belief in facial physiognomy.
–– “appear older and stubborn”, or associated with “bad luck”.
• Special care to be taken when placing fillers in the subzygomatic area—vital

structures are found in this area including the facial nerve, parotid gland and
duct, zygomatic and masseteric ligaments.
• Skin thickness varies across subunits.
• The buccal region forms the most mobile area of the face.
• In the buccal region, the facial artery runs under the superficial muscles within
the buccal space.
• The facial vein lies posterior to the facial artery, anterior to the parotid duct, deep
to the zygomaticus major muscle.
• The transverse facial artery runs in the superior premasseter space.
• The transverse facial artery gives off a branch that runs within the zygomatic
ligament.
• The depth of the artery in the buccal area is dependent on the amount of subcu-
taneous fat.
• The masseteric ligaments are reported to be important landmarks for branches of
the buccal nerve.
a b c
d Superficial Fat Compartments

e Relationship of Facial Nerve Branches to Retaining
Ligaments of Face
Middle forehead
compartment
Superior temporal
septum
Central forehead
compartment Lateral temporal-
cheek compartment Inferior temporal branch
Superior orbital Inferior temporal Main zygomatic ligament

Temporal branch
septum
compartment
Laterall orbital
Inferior orbital compartment
compartment
Orbicularis retaining Zygomatic branch
Nasolabial ligament Upper masseteric ligament
compartment
Superior cheek septum
Medial cheek (zygomatic cutaneous Buccal fat pad
compartment ligamentd)
Platysma auricular
Superior jowl ligament
Buccal branches
compartment
Inferior jowl Middle cheek compartment
compartment Parotid masseteric fascia
Jowl Masseteric cutaneous ligament Masseteric retaining ligaments
Mandibular septum Marginal mandibular branch
Pre-platusmal fat Mandibular cutaneous ligament Mandibular cutaneous ligament
Fig. 17.5 (a–c) The 3 types of middle midface perforators according to their main arterial origin.
(a) Buccal artery perforator. (b) Parotid artery perforator, and (c) facial artery perforator branches
from the facial artery (FA). With written permission from the nearest living relatives for publica-
tion of these photographs in this article. Open access paper, Rungsawang, C., et al., Determining
safe entry sites for filler injections on the lateral canthal vertical line: anatomical study of the
midface arterial perforators in soft embalmed cadavers. Asian Biomedicine, 2017. 10(6):
p. 619–625. (d–e) Superficial facial fat compartments and retaining ligaments. (e) Relationship of
the retaining ligaments of the face to facial nerve branches. Redrawn and modified from Alghoul,
M. and M.A. Codner, Retaining Ligaments of the Face: Review of Anatomy and Clinical
Applications. Aesthetic Surgery Journal, 2013. 33(6): p. 769–782. (f) A red-latex-injected speci-
men. The arterial supply to the face and the anterior of the external surface of the mandible. Take
note of the parotid gland, masseter muscle, facial artery, superficial temporal artery, emerging
nerves, and superior labial artery. Used with permission from Loukas, M., et al., Anatomical varia-
tion in arterial supply of the mandible with special regard to implant placement. International
Journal of Oral and Maxillofacial Surgery, 2008. 37(4): p. 367–371 [37].
276 S. Samizadeh
• Facial nerve branches penetrate ligaments.

• The parotid duct runs between the masseter and the parotideo-masseteric fascia.
Considerations: [3, 7, 8, 38–42]
• Volumisation of lateral zygoma will increase the bizygomatic width—not

desirable.
• Buccal fat removal is a popular procedure in Asia.
• Treatment of masseter muscles with botulinum toxins or mandibuloplasty to
reduce the bigonial width is very popular in Asia—this can result in subzygo-
matic hollowness and jawline ptosis-filling agents can be used to volumise and
for the “lifting” effect.
• Patients may have had reduction malarplasty and zygoma reduction.
• East Asians usually have a greater amount of malar and subcutaneous fat and
relatively thicker skin (fibrous and rich in collagen).
• Acute parotitis after injection has been reported.
Recommendations [32]
• Focus of treatment in East Asians: submalar and buccal regions.

• Needles and cannula can be used.
• Large treatment areas can be treated with cannula to reduce insertion points,
swelling, and bruising.
• Overfilling not recommended.
• Correct filling agents should be selected to avoid unevenness.
• Massage post treatment may be required to ensure even dispersion of the product.
• Aspiration.
• Use the non-dominant hand to help guide the cannula in the correct layer.
Part 2: Central Anterior Projection
Forehead
Aesthetic Ideals [3, 7–9, 13]
• Convex, even forehead.

Anatomical Considerations [3, 8, 13, 34] (Fig. 17.6)
• Comparatively flat forehead in Asians.

• Many arterial sources running in various layers including periosteal, supratroch-
lear, and supraorbital arteries (emerging from the orbit, passing through the fron-
a b
d e
Fig. 17.6 (a) Forehead of a young Asian lady. (b) The glabella and central forehead are supplied
by many arterial sources. These run in different facial layers and include the central and paracentral
arteries, and the superficial branch of the supratrochlear artery. (c) The periosteal artery divides
from the main artery and travels in the supraperiosteal layer. It crosses the superciliary arch of the
supraorbital rim for a short distance and penetrates the periosteum above the superciliary ridge,
adhering tightly to the bony surface. This provides a rich arterial network within the periosteum
[43]. (d and e) After placement of 1 ml hyaluronic acid dermal filler
278 S. Samizadeh
talis, and becoming superficial towards the hairline, connected to the ophthalmic
artery). Risk of blindness and cerebral infarction due to inadvertent intravascular
injection of filler.
• Supratrochlear and supraorbital vasculature arises from deep to superficial layers.
• The above vessels cross the inferior frontal septum and the middle fron-
tal septum.
• Forehead has compartmentalised fat pads above and below frontalis muscle.
• Temporal branch of the facial nerve travels below the frontalis muscle.
• Supratrochlear and supraorbital nerves provide sensory innervation of the central
forehead.
• The glabella is one of the most common filler injection sites leading to visual loss.
Considerations
• High-risk area: vascular compromise, vision loss, embolism.

• Product choice and placement technique are important to avoid irregularities and
an uneven appearance.
Recommendations [43–47]
• Supraperiosteal layer.
• Slow injection, less than 0.05 ml at each point/line.
• Both needles and cannula can be used.
• Prior to injection, manual compression on the radix and medial supraorbital rim.
• The periosteal artery adheres to the bone, fibrous tissues, the periosteum, and the
cutaneous retaining ligament of the brow—vulnerable to tearing.
• Colour Doppler ultrasonographic examination recommended.
• May require massage afterwards to even out the product.
• Aspiration.
The Nose
Non-surgical rhinoplasty of Asians requires complex treatment planning and highly

skilled practitioners. This is due to structural changes (nasal dorsum (lateral sec-
tions, midline, ensuring the dorsum enhancement is symmetrical), naso-orbital line,
frontonasal angle, columella, nasal tip, nasolabial angle) being made, multiple sub-
units need to be addressed, most likely in multiple layers, with relatively larger
volumes and number of cannula passes/needle insertion. In Caucasians, usually
central injection of small amounts of fillers is sufficient.
Asian Aesthetic Ideals [7–9, 48–50]
• Dorsal augmentation, degree of projection of radix varies in men and women.

• Lengthening and columella support.
• Tip augmentation and refinement, over-projected tip is not desirable.
• Reduction of alar width.
• Optimal transition of the line running from the medial eyebrow to the nose root
and frontonasal angle, with optimal forehead convexity.
• Most arteries in the midline are subcutaneous.

• Small side branches of the supratrochlear artery at the glabella.
• In some cases, a large dorsal nasal artery may be present across the midline in the
dense subcutaneous tissue of the nasal dorsum.
• The nasal tip is also high risk due to presence of sizeable lateral nasal artery.
• Substantial arterial anastomosis at the supratip region.
Considerations [50, 53–55]
• High-risk area; vascular compromise, nasal tip/alar necrosis, vision loss, embo-
lism. Glabella injections and nose enhancement are the first- and second-most
common cause of blindness following filler injections.
• Augmentation of retropositioned anterior nasal spine elongates the pseudocolu-
mella, increases alar length and nasal tip protrusion, reduces nasal width.
• The arch from the medial aspect of the eyebrows to the nasal dorsum and the
correction of the frontonasal angle should not be ignored—very high-risk injec-
tion area with regard to vascular complications.
• Combination treatment with botulinum toxins can be considered—alar lobule
possesses muscular components, and “bunny lines” are common among Asians.
Recommendations [49, 50, 52, 53, 56]
• Sharp needle (more precise placement, minimal shape distortion or deviation) or

blunt cannula (need to keep in mind that cases of blindness with cannula have
been reported, so cannula will not eliminate risk of vascular compromise) can be
used—both with great caution.
• Product placement on pre-periosteal layer of the nasal bone in the midline, multi-
layered placement of product has been published by Chinese experts.
• Avoid using dermal fillers that attract water/swell post injection.
• Needle insertions not to be closer than 5 mm to each other.
280 S. Samizadeh
• Aspiration.
Medial Cheek and Tear Trough [3, 7, 8, 13]
High and wide zygomatic arch with increased bizygomatic width, retruded, and
concave or flat medial maxilla is a typical anatomical feature in Central and East
Asians. The lack of support in medial maxilla results in the appearance of aged
midface including:
• Appearance of dark shadows under the eyes
• Lack of midface volume
• Broad nasal width
• Shadow present—base of the nose
Asian Aesthetic Ideals [3, 7, 8, 13, 57]
• “Apple cheek” is a common term used in China referring to desirable full, round
medial maxilla volume.
Fig. 17.7 (a) Typical appearance of an Asian nose, characterised by a broad nasal tip, short colu-
mella, wide nasal alar base, flat nasal bridge, and lack of dorsal projection. (b) High pressure
injection of dermal filler agents into the superficial temporal, supratrochlear, supraorbital, angular
or lateral nasal arteries could force filler droplets into the ophthalmic artery via the anastomoses at
the superior nasal corner of the orbit. Visual and neurological symptoms are likely to develop if
these injected filler droplets enter the origin of the ophthalmic artery or the internal carotid artery.
Redrawn from Tansatit, T., et al., Safe planes for injection rhinoplasty: a histological analysis of
midline longitudinal sections of the Asian nose. Aesthetic plastic surgery, 2016. 40(2): p. 236–244
[49]. (c) There is midline anastomosis between the lateral nasal arteries and the dorsal nasal artery.
The dorsal nasal, supraorbital, and supratrochlear arteries branch from the ophthalmic artery fol-
lowing the artery emerging from the right orbital septum. Redrawn from Tansatit, T., et al., Safe
planes for injection rhinoplasty: a histological analysis of midline longitudinal sections of the
Asian nose. Aesthetic plastic surgery, 2016. 40(2): p. 236–244 [49]. (d) Summary of the danger
areas during nasal injections. Redrawn from Tansatit, T., et al., Safe planes for injection rhino-
plasty: a histological analysis of midline longitudinal sections of the Asian nose. Aesthetic plastic
surgery, 2016. 40(2): p. 236–244 [49]. Three vascular danger points where filler can escape into the
arterial lumen include the rhinion (the dorsal nasal anastomosis is occasionally found here), the
supratip (there is significant lateral nasal anastomoses), and the infratip (cavernous tissue that
continues from the nasal submucosa containing an arteriovenous shunt, the columellar artery
enters from below and cavernous tissue infiltrates). The supratip poses the highest risk. (e, f) The
arch from the medial aspect of the eyebrows to the nasal dorsum should not be ignored. (f, g)
Before and after picture of nose enhancement and frontonasal angle using hyaluronic acid der-
mal fillers
a b
c d
Supraorbital and supratrochlear as
Ophthalmic a
Dorsal nasal anastom osis

0.2 mm
Angular a
Layerak nasal anastomosis

Buccal a 0.7 mm
f Subalar a
Facial a
Columellar a
Superior labial a
Inferior labial a
Labiomental a
g
282 S. Samizadeh
• Injection on the zygoma is usually not desirable as this would further increase
the bizygomatic width and give the appearance of a wider face.
Anatomical Considerations [31] (Fig. 17.8)
• Infraorbital foramen (6-8 mm inferior to the orbital margin—ageing may affect

this distance), accessory infraorbital foramen may also exist.
• Angular artery and vein.
• Zygomatic facial vessels and nerve.
Fig. 17.8 (a) The tear trough ligament—orbicularis retaining ligament complex has been marked
and divided. The orbicularis retaining ligament (ORL) is a bilayered structure, merging medially
as the tear trough ligament [58]. Redrawn from Wong, C.-H., M.K. Hsieh, and B. Mendelson, The
tear trough ligament: anatomical basis for the tear trough deformity. Plastic and reconstructive
surgery, 2012. 129(6): p. 1392–1402. (b) Schematic representation of the tear trough ligament. The
anatomical basis for the tear trough deformity is shown. TTL, tear trough ligament; ORL, orbicu-
laris retaining ligament; OO, orbicularis oculi; PZs, pre-zygomatic space; LLS, levator labii supe-
rioris; Zmj, zygomaticus major; Zmi, zygomaticus minor [58]. Redrawn from Wong, C.-H.,
M.K. Hsieh, and B. Mendelson, The tear trough ligament: anatomical basis for the tear trough
deformity. Plastic and reconstructive surgery, 2012. 129(6): p. 1392–1402. (c) Illustration of the
anatomical relationships of the facial fat compartments. The midfacial fat is arranged in two inde-
pendent anatomical layers and in three independent anatomical layers paranasally. The superficial
layer include the middle and medial cheek fat, lateral-temporal cheek compartment, forehead com-
partments, nasolabial fat, and orbital compartments [59]. (d) Illustration of the anatomical rela-
tionships of deep midfacial fat compartments. It includes the medial and lateral suborbicularis
oculi fat, and the deep medial cheek fat that consist of medial and lateral parts. Lateral to the pyri-
form aperture, there are three layers of distinct fat compartments. The deep compartment is found
posterior to the medial part of the deep medial cheek fat. The buccal extension of the buccal fat pad
extends from the paramaxillary space to the subcutaneous plane [59]. (e) Tear trough deformities
are located between the palpebral and orbital parts of the orbicularis oculi, and the location of the
nasojugal groove corresponds to the inferior border of the orbicularis oculi. Blue dashed line, tear
trough deformity; red dashed line, nasojugal groove; OF, orbital fat; OS, orbital septum; SOOF,
suborbicularis oculi fat; PO, palpebral part of the orbicularis oculi muscle; LLSAN, levator labii
superioris alaeque nasi muscle; MFP, malar fat pad; OOM, orbicularis oculi muscle. Source: Lee
JH, Hong G. Definitions of groove and hollowness of the infraorbital region and clinical treatment
using soft-tissue filler. Archives of Plastic Surgery. 2018 May;45(3):214–221 [60]. (f) Important
vessels of the face of which practitioners should be cautious when treating grooves or hollowness
in the infraorbital region. Aa, angular artery; Av, angular vein; OO, orbicularis oculi muscle; ZFa,
zygomaticofacial artery; IOa, infraorbital artery; ITFa, infraorbital trunk of facial artery; Fv, facial
vein; Fa, facial artery Source: Lee JH, Hong G. Definitions of groove and hollowness of the infra-
orbital region and clinical treatment using soft-tissue filler. Archives of Plastic Surgery. 2018
May;45(3):214–221 [60]. (g and h) Before and after picture for treatment of medial cheek and tear
trough area with hyaluronic acid dermal fillers
a b
Upper Lamella of the ORI
Palpebral Part of the OO

ORL
TTL
PZs
Orbital Part of the OO
LLS
Tear Trough Ligament
Lower Lamella of the ORI
Zmj Zmi
c d
Superior orbital fat
Inferior orbital fat
Lateral orbital fat Sub-orbicularis oculi fat(lateral part)
Sub-orbicularis oculi fat(medial part)
Medial cheek fat Deep medial cheek fat (medial part)
Middle cheek fat Deep medial cheek fat (lateral part)
Nasolabial fat Buccal extension of the buccal fat
Lateral temporal-cheek fat Ristow’s space
Buccal extension of the buccal fat
e f
PO
OF
Aa OO ZFa
LLSAN
OS Av
IOa
MFP
ITFa
OOM Fv
SOOF Fa
h
284 S. Samizadeh
Considerations [3, 7, 8, 13, 57, 61]
• To assess these areas at rest and during animation.

• Asymmetry and muscular asymmetry (during rest and animation) should be dis-
cussed with the patient—not unusual.
• Moderate premaxillary deficiency in this ethnic group.
• Too much volumisation of the medial cheek area will accentuate appearance of
the nasolabial fold.
• Injection of the lid–cheek junction requires expertise, as there is an increased risk
of haematoma, persistent oedema, lumps and unevenness, Tyndall effect, displace-
ment of the product to the orbit, asymmetry, embolization, and double vision.
• Overcorrection should be avoided, the in particular in the lid–cheek junction.
• Choice of product is important, to avoid products that cause water absorption and
hence swelling post placement.
• The orbicularis retaining ligament plays a key role in the formation of the tear
trough. With ageing, atrophy and descent of the malar fat pad occur making the
tear trough and palpebromalar groove more noticeable.
Recommendations [3, 7, 8, 13, 57]
• Focus of treatment: anterior projection, enhancement of anterior cheek, nasoju-

gal groove, and piriform fossa, this anterior projection results in a “narrowing
effect”.
• Sequence of treatment: 1. Malar, 2. Tear trough, 3. Nasolabial area.
• Localisation of infraorbital foramen prior to treatment.
• Needle and cannula can be used.
• Periosteal/supraperiosteal and subcutaneous injections may be needed.
• Knowledge of fat pads in the area can help optimise treatment provision.
• The area close to the infraorbital foramen is considered a high-risk area and
injection with a cannula and in the subcutaneous layer may be relatively safer.
• Aspiration.
• Use the non-dominant hand to help prevent displacement of the product, protect
the eye and infraorbital foramen.
Lips
Lips have functional importance as well as being one of the important aesthetic
units of the face. Bimaxillary dentoalveolar protrusion and retrognathic profile are
common. This results in appearance of prominent lips that are not in proportion with
the nose and chin. Lip reduction is more common than lip enhancement.
Asian Aesthetic Ideals [3, 7–9, 13]
• Narrow full lips.

• Usually, upper lip to lower lip ratio of 1:1.
• Fullness in the central portion of the upper lip is desirable tapering laterally.
• Facial physiognomy belief.
• The labial arteries display high variability with respect to path (distribution),
presence, and location.
• There is communication between the superior labial and columellar arteries in
the Cupid’s bow area.
• In the majority of cases, the superior labial artery and inferior labial artery run in
the submucosal layer between the orbicularis oris muscle and oral mucosa, and
are less likely to be found subcutaneously.
• The superior labial artery is more superficially in the midline.
• The external diameter of the superior labial artery varies from 0.3 to 3.0 mm.
• The origin of the superior labial artery is approximately 1.0–1.5 mm lateral to the
oral commissure.
• Lip augmentation could be a likely cause of blindness post filler injections.
• Deep injection in proximity of the oral commissure and submucosal injection of
the medial and middle segments of the vermilion zone are to be avoided.
• Anatomy may vary side to side.
• Unilateral presence of some of the vasculature has been reported.
• More dominant presence of the SLA and ILA on one side has been reported.
• Possibility of an aberrant inferior labial artery.
• Labiomental artery.
Considerations [3, 13, 66–69]
• Asians have different lip morphology, parameters, and lip-projection volumes

from that of Caucasians. The top lip may be thicker than the lower lip.
• The dentition to be examined (presence of overjet, overbite, or crowding)—
affects position and aesthetics of the lips.
• Bimaxillary dentoalveolar protrusion is common; therefore, the upper and lower
lip to E-line.
• The underlying upper and lower incisor to AP-line has negative influence on
profile.
• Due to a retrognathic profile, overactivity of the mentalis muscle may result in
incomplete lip seal.
• May require mild enhancement of the upper lip to help disguise maxillary
retrusion.
286 S. Samizadeh
• Lips need to be treated as a larger unit of the perioral area, including the chin, for
better balance and harmony.
• Optimal treatment requires multidisciplinary treatment (maxillofacial, orthodon-
tics, aesthetics).
Recommendations
• Anterior dental support and classification.

• Relationship of the maxilla and mandible.
• Degree of maxillary or mandibular retrusion to be taken into consideration.
• Degree of chin prognathism or retrognathism.
• Examine symmetry at rest and during animation.
• Examine muscles that affect speaking and animation, notice any asymmetry,
hypo- or hyperactivity.
• Lower facial height to be examined.
• Lip seal at rest: complete or incomplete lip seal?
• Check if patient is a public speaker, singer, or musician (wind instrument); alter-
ing the shape and tonicity of the lips can affect their function as well as
appearance.
• Aspiration.
Fig. 17.9 (a, b, c, d) The varied origin of the SLA and ILA, and their inconsistent presence, loca-
tion, and route. The SLA and ILS both follow a tortuous route and change layers throughout their
course. Black arrow: SLA giving off septal branches that run vertically to the nasal septum. Both
the SLA and ILA give off smaller branches throughout their course. ILA, inferior labial artery;
SLA, superior labial artery [62]. (e) Illustration diagram: Typical courses of the labial arteries are
in red. A significant variation is in purple. The fishbone pattern shows the arteries which usually
divide their perpendicular branches alternately along the submucosal plane. (f) Larger superior
labial artery terminating as columellar artery. A single right inferior labial artery enters the lower
vermilion near the midline [63]. Re-drawn from Tansatit, T., P. Apinuntrum, and T. Phetudom,
Cadaveric Assessment of Lip Injections: Locating the Serious Threats. Aesthetic Plastic Surgery,
2017. 41(2): p. 430–440. (g) Inferior labial arteries pass in proximity of the oral commissure as it
arises as a common trunk with the superior labial artery. Redrawn from Tansatit, T., P. Apinuntrum,
and T. Phetudom, Cadaveric Assessment of Lip Injections: Locating the Serious Threats. Aesthetic
Plastic Surgery, 2017. 41(2): p. 430–440. (h) Bimaxillary protrusion is characterised by protrusive
and proclined upper and lower incisors. Lips appear prominent with a convex facial profile, hyper-
activity and contraction of the mentalis muscle can be seen. (i) A red-latex-injected specimen. The
arterial supply to the face, as well as the anterior of the external surface of the mandible, is evident.
A cortical branch from the facial artery is clearly demonstrated. Take note of the superior labial
artery. Used with permission from Loukas, M., et al., Anatomical variation in arterial supply of the
mandible with special regard to implant placement. International Journal of Oral and Maxillofacial
Surgery, 2008. 37(4): p. 367–371 [37]. (j) Overjet is characterised by the protrusion of the upper
front teeth. A deep overbite is when the upper front teeth overlap the lower front teeth by more than
one-third. In open bite, the back teeth in contact and the front teeth do not meet. (k) Before and
after pictures of lip enhancement using hyaluronic acid dermal fillers
a b
c d
e f
g h
288 S. Samizadeh
i j
Fig. 17.9 (continued)

Chin
Chin hypoplasia or retrusion and convex facial profiles are not uncommon. This in
combination with bimaxillary protrusion results in hyperactivity of the mentalis
muscles. Chin enhancement is very popular in Asia. Non-surgical enhancement has
become more popular than surgical enhancements.
Asian Aesthetic Ideals [3, 7–9]
• A well projected chin.

• Straight facial profile is desirable.
• Apex of the chin: round and narrow for females, round and less narrow in males.
• The mental arteries exit mental foramina close to the apex of the second premo-
lars and are the primary blood supply to the chin.
• Further blood supply from: inferior labial artery and labiomental artery.
• Submental artery (largest of the cervical branches of the facial artery).
–– The superficial terminal branch:
passes between the cutaneous tissue and levator labii inferioris muscle,
anastomoses with the inferior labial artery.
–– The deep branch:
passes between the muscle and the bone,
supplies the lip and periosteum of the mandible,
anastomoses with the inferior labial and mental arteries.
• The inferior alveolar nerve exits the mental foramen and provides sensory inner-
vation to the chin and lower lip.
• Superficial and deep fat pads are present.
• Platysma mandibular ligament, mandibular osseocutaneous ligament.
• Muscles closely related and intertwined.
Considerations: [3, 13, 75]
• It is usually not sufficient to enhance the chin area alone, the area should be
treated as a unit with the labiomental area, labiomandibular grooves, prejowl
sulcus and the jawline.
• An angular jawline is not found to be desirable in men or women.
• Multi-layered and multimodality treatment may be required.
• The mentalis muscle can be relaxed with botulinum toxins.
290 S. Samizadeh
Recommendations
• Augmentation and elongation may be needed.

• To keep facial units proportional, not to elongate the face unproportionally.
• Avoid multiple syringes on the same visit, mentalis muscle contraction, lip clo-
sure, speaking and mastication can become painful.
• When treatment planning, imagine placement of a chin implant with prejowl
extension, with the apex at the apex of the chin and then evenly and proportion-
ally tapering laterally.
• Aspiration.
Fig. 17.10 (a) The layers from superficial to deep: Superficial subcutaneous fat and deep mental
fat and periosteum are exposed when the muscles are moved laterally. Two possible depths of
injection in the chin: the superficial fat compartment and the submuscular/supraperioteal plane.
Take note of the facial artery and inferior labial artery. Used with permission from Loukas, M.,
et al., Anatomical variation in arterial supply of the mandible with special regard to implant place-
ment. International Journal of Oral and Maxillofacial Surgery, 2008. 37(4): p. 367–371 [37]. The
mental nerve emerges from the mental foramen which is located in line with the vertical axis of the
second premolar tooth [35]. (b) Group-A, Dissection photograph of the head and neck. Illustration
shows the sources arteries of the perforators; B, Angiogram of the integument of the head and
neck. FA, facial artery; SA, submental artery; FAP, facial artery perforator; SAP, submental artery
perforator; DGM, digastric muscle; SMG, submandibular gland. With permission from Tang, M.,
et al., Three-dimensional angiography of the submental artery perforator flap. Journal of Plastic,
Reconstructive & Aesthetic Surgery, 2011. 64(5): p. 608–613 [74]. (c) Group 3D-reconstruction of
the mandible and surrounding arteries from a cadaver angiographic injection specimen. A, Anterior
view; B, Inferior view. FA, facial artery; SA, submental artery; C and D are from another cadaver
angiographic injection specimen. C, anterior view; D, inferior view. 1, sublingual artery, 2, sub-
mental artery; 3, mental artery; RP1, first right submental artery perforator; RP2, second right
submental artery perforator; LP1, first left submental artery perforator; LP2, second left submental
artery perforator; LP3, third left submental artery perforator; White circle shows the anastomosis
of sublingual artery and submental artery. With permission from Tang, M., et al., Three-dimensional
angiography of the submental artery perforator flap. Journal of Plastic, Reconstructive & Aesthetic
Surgery, 2011. 64(5): p. 608–613 [74]. (d) Lateral right view of face. Illustration re-drawing of
cadaver image from Pilsl, U. and F. Anderhuber, The chin and adjacent fat compartments.
Dermatologic surgery, 2010. 36(2): p. 214–218. Subcutaneous compartments: violet, lateral-
temporal cheek compartment; red, middle compartment and submental region; green, medial com-
partment; yellow, inferior to the middle compartment the jowl compartment and anterior to the
medial compartment the nasolabial fold compartment; black, labiomandibular compartment; blue,
chin compartment. (e) Before and after pictures of chin and lip enhancement using hyaluronic acid
dermal filler
a b
a b
c
a b
c d
d e
292 S. Samizadeh
Conclusion
Use of dermal fillers for facial rejuvenation and contouring is an art combined with
the knowledge of anatomy, physiology, pharmacology, aesthetics and psychology.
An in depth understanding of anatomy, physiology, pharmacology, and product
characteristics is required with understanding and appreciation that anatomy is vari-
able. Once the correct product is used for the correct indication, in the correctly
selected patient, optimal natural looking enhancement can be achieved with mini-
mal to no downtime. Results of such enhancement depend on many factors includ-
ing patient and product related factors. Furthermore, understanding of ethnic
variations in morphology, anatomy, and aesthetic ideals would aid in successful
treatment planning, provision, and patient satisfaction.
References
1. Kim H-J, et al. Clinical anatomy of the face for filler and botulinum toxin injection.
Springer; 2016.
2. Naini FB, Naini FB. Clinical diagnostic records, natural head position and cranifacial anthro-
pometry. In: Facial Aesthetics. New York: Wiley; 2011. p. 71–85.
3. Liew S, et al. Consensus on changing trends, attitudes, and concepts of Asian beauty. Aesthet
Plast Surg. 2016;40(2):193–201.
4. Liu Y, et al. A 3-dimensional anthropometric evaluation of facial morphology among Chinese
and Greek population. J Craniof Surg. 2013;24(4):e353–8.
5. Le TT, et al. Proportionality in Asian and North American Caucasian faces using neoclassical
facial canons as criteria. Aesthet Plast Surg. 2002;26(1):64–9.
6. Choe KS, et al. The Korean American Woman’s Face: anthropometric measurements and
quantitative analysis of facial aesthetics. Arch Facial Plast Surg. 2004;6(4):244–52.
7. Samizadeh S. The ideals of facial beauty among chinese aesthetic practitioners: results from a
large national survey. Aesthet Plast Surg, 2018: 1–13.
8. Samizadeh S, Wu W. Ideals of facial beauty amongst the chinese population: results from a
large national survey. Aesthet Plast Surg, 2018: 1–11.
Dermatol. 2019;
10. Hernandez CA, et al. Clinical validation of the temporal lifting technique using soft tissue fill-
ers. J Cosmet Dermatol. 2020;19(10):2529–35.
11. Perrett DI, et al. Effects of sexual dimorphism on facial attractiveness. Nature.
1998;394(6696):884–7.
12. Little AC, et al. Partnership status and the temporal context of relationships influence human
female preferences for sexual dimorphism in male face shape. Proc R Soc Lond B Biol Sci.
2002;269(1496):1095–100.
Plast Surg. 2016;40(2):202–14.
14. Sykes JM, et al. Upper face: clinical anatomy and regional approaches with injectable fillers.
Plast Reconstr Surg. 2015;136(5 Suppl): 204s–218s.
15. Jung W, et al. Clinical implications of the middle temporal vein with regard to temporal fossa
augmentation. Dermatol Surg, 2014:40(6).
16. Scheuer JF III, et al. Facial danger zones: techniques to maximize safety during soft-tissue
filler injections. Plast Reconstr Surg. 2017;139(5):1103–8.
17. Cotofana S, et al. The six different injection techniques for the temple relevant for soft tis-
sue filler augmentation procedures – Clinical anatomy and danger zones. J Cosmet Dermatol.
2020;19(7):1570–9.
18. Huang RL, et al. Anatomical Study of Temporal Fat Compartments and its Clinical Application
for Temporal Fat Grafting. Aesthet Surgery J. 2017;37(8):855–62. https://doi.org/10.1093/
asj/sjw257.
19. Rathod N, Khobaragade B, Ganesan K. Use of the temporal extension of the buccal fat pad for
closure of oroantral communications. Int J Oral Maxillofac Surg. 2021.
20. Stuzin JM, et al. The anatomy and clinical applications of the buccal fat pad. Plast. Reconstr.
Surg. 1999;85(1):29–37.
21. Kapoor KM, et al. A systematic literature review of the middle temporal vein anatomy: ‘venous
danger zone’ in temporal fossa for filler injections. Aesthet Plast Surg. 2020;44(5):1803–10.
22. Jiang X, Liu D-l, Chen B. Middle temporal vein. JAMA Facial Plastic Surgery.
2014;16(3):227–9.
23. Philipp-Dormston WG, et al. Intracranial penetration during temporal soft tissue filler injec-
tion—is it possible? Dermatol Surg. 2018;44(1):84–91.
24. Breithaupt AD, et al. Anatomical basis for safe and effective volumization of the temple.
Dermatol Surg. 2015. 41.
25. Janis JE, et al. Anatomy of the auriculotemporal nerve: variations in its relationship to the
superficial temporal artery and implications for the treatment of migraine headaches. Plast
Reconstr Surg. 2010;125(5).
26. Freytag DL, et al. Facial safe zones for soft tissue filler injections: a practical guide. J Drugs
Dermatol. 2019;18(9):896–902.
27. Oliveira B. Supra-Auricular Lifting With Fillers : New Technique Lifting supra-auricular com
uso de preenchedores: nova técnica. 2017.
28. Suwanchinda A, et al. The posterior temporal supraSMAS minimally invasive lifting technique
using soft-tissue fillers. J Cosmet Dermatol. 2018;17(4):617–24.
29. Lee HY, Yang HJ, Cho YN. Minimally invasive zygoma reduction. Plast Reconstr Surg.
2006;117(6):1972–9.
30. Lee JG, Park YW. Intraoral approach for reduction malarplasty: a simple method. Plast
Reconstr Surg. 2003;111(1):453–60.
31. Rai AR, et al. Anatomical and morphometric analysis of accessory infraorbital foramen. J
Craniof Surg. 2013;24(6).
32. Cotofana S, et al. Midface: clinical anatomy and regional approaches with injectable fillers.
Plast Reconstr Surg. 2015;136(5):219S–34S.
33. Cotofana S, et al. The anatomy of the facial vein: implications for plastic, reconstructive, and
aesthetic procedures. Plast Reconstr Surg. 2017;139(6):1346–53.
34. Cotofana S, Lachman N. Anatomy of the facial fat compartments and their relevance in aesthetic
surgery. JDDG: Journal der Deutschen Dermatologischen Gesellschaft. 2019;17(4):399–413.
35. Braz A and C.C.d.P. Eduardo. Reshaping the lower face using injectable fillers. Indian J Plast
Surg. 2020. 53(2):207–218.
36. Ryu M-H, Moon VA. High superficial musculoaponeurotic system facelift with finger-assisted
facial spaces dissection for Asian patients. Aesthet Surg J. 2015;35(1):1–8.
37. Loukas M, et al. Anatomical variation in arterial supply of the mandible with special regard to
implant placement. Int J Oral Maxillofac Surg. 2008;37(4):367–71.
38. Khadka A, et al. Clinical observations of correction of square jaw in East Asian individu-
als. Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontology.
2011;111(4):428–34.
Plast Surg. 2016;40(2):202–14.
40. Cui J, et al. The effect of different reduction mandibuloplasty types on lower face width and
morphology. Aesthet Plast Surg. 2008;32(4):593–8.
294 S. Samizadeh
41. Shirakabe Y, Suzuki Y, Lam SM. A new paradigm for the aging Asian face. Aesthet Plast Surg.
2003;27(5):397–402.
42. Yang DB, Park GH, Chung JY. Facial Rejuvenations in North East Asians. J Korean Soc Aesth
Plast Surg. 2003;9(1):6–12.
43. Phumyoo T, et al. Anatomical and ultrasonography-based investigation to localize the arter-
ies on the central forehead region during the Glabellar augmentation procedure. Clin Anat.
2020;33(3):370–82.
44. Carruthers JD, et al. Blindness caused by cosmetic filler injection: a review of cause and ther-
apy. Plast Reconstr Surg. 2014;134(6):1197–201.
45. Khan TT, et al. An anatomical analysis of the supratrochlear artery: considerations in facial
filler injections and preventing vision loss. Aesthet Surg J. 2017;37(2):203–8.
46. Tansatit T, Apinuntrum P, Phetudom T. A dark side of the cannula injections: how arterial wall
perforations and emboli occur. Aesthet Plast Surg. 2017;41(1):221–7.
47. Tansatit T, et al. Verification of embolic channel causing blindness following filler injection.
Aesthet Plast Surg. 2015;39(1):154–61.
48. Jin H-R, Won T-B. Recent advances in Asian rhinoplasty. Auris Nasus Larynx.
2011;38(2):157–64.
49. Tansatit T, et al. Safe planes for injection rhinoplasty: a histological analysis of midline longi-
tudinal sections of the Asian nose. Aesthet Plast Surg. 2016;40(2):236–44.
50. Han X, et al. Multiplane hyaluronic acid (EME) in female Chinese rhinoplasty using blunt and
sharp needle technique. J Plast Reconstr Aesthet Surg. 2015;68(11):1504–9.
51. Wu W. The oriental nose: an anatomical basis for surgery. Ann Acad Med Singap.
1992;21(2):176–89.
52. Wu W. Commentary on: microautologous fat transplantation for primary augmentation rhino-
plasty: long-term monitoring of 198 Asian Patients. Aesthet Surg J. 2016;36(6):657–9.
53. Beleznay K, et al. Avoiding and treating blindness from fillers: a review of the world literature.
Dermatol Surg. 2015;41(10):1097–117.
54. Li X, Le Du J-JL. A novel hypothesis of visual loss secondary to cosmetic facial filler injec-
tion. Ann Plast Surg. 2015;75(3):258.
55. Chun KW, et al. Anatomy of the alar lobule in the Asian nose. J Plast Reconstr Aesthet Surg.
2008;61(4):400–7.
56. Schuster B. Injection rhinoplasty with hyaluronic acid and calcium hydroxyapatite: a
retrospective survey investigating outcome and complication rates. Facial Plast Surg.
2015;31(03):301–7.
57. Rho N-K, et al. Consensus recommendations for optimal augmentation of the Asian face with
hyaluronic acid and calcium hydroxylapatite fillers. Plast Reconstr Surg. 2015;136(5):940–56.
58. Wong C-H, Hsieh MK, Mendelson B. The tear trough ligament: anatomical basis for the tear
59. Gierloff M, et al. Aging changes of the midfacial fat compartments: a computed tomographic
study. Plast Reconstr Surg. 2012;129(1):263–73.
60. Lee J-H, Hong G. Definitions of groove and hollowness of the infraorbital region and clinical
treatment using soft-tissue filler. Arch Plast Surg. 2018;45(3):214.
61. Yang C, Zhang P, Xing X. Tear trough and palpebromalar groove in young versus elderly
adults: a sectional anatomy study. Plast Reconstr Surg. 2013;132(4).
literature review. Aesth Surg J. 2018.
63. Tansatit T, Apinuntrum P, Phetudom T. Cadaveric assessment of lip injections: locating the
serious threats. Aesthet Plast Surg. 2017;41(2):430–40.
64. Tansatit T, Apinuntrum P, Phetudom T. A typical pattern of the labial arteries with implication
for lip augmentation with injectable fillers. Aesthet Plast Surg. 2014;38(6):1083–9.
65. Koh KS, et al. Branching patterns and symmetry of the course of the facial artery in Koreans.
Int J Oral Maxillofac Surg. 2003;32(4):414–8.
66. Ohmori K, Kamiji T. Segmental osteotomy of the upper and lower jaw. Clin Plast Surg.
1991;18(1):163.
67. Lee J-K, Chung K-R, Baek S-H. Treatment outcomes of orthodontic treatment, corticotomy-
assisted orthodontic treatment, and anterior segmental osteotomy for bimaxillary dentoalveo-
lar protrusion. Plast Reconstr Surg. 2007;120(4):1027–36.
68. Huang Y-P, Li W-r. Correlation between objective and subjective evaluation of profile in
bimaxillary protrusion patients after orthodontic treatment. Angle Orthod. 2014;85(4):690–8.
69. Wong WW, et al. Contribution of lip proportions to facial aesthetics in different ethnicities: a
three-dimensional analysis. J Plast Reconstr Aesthet Surg. 2010;63(12):2032–9.
70. Atamaz Pinar Y, Govsa F, Bilge O. The anatomical features and surgical usage of the submen-
tal artery. Surg Radiol Anat. 2005;27(3):201–5.
71. Fang M, Rahman E, Kapoor KM. Managing complications of submental artery involve-
ment after hyaluronic acid filler injection in chin region. Plast Reconstr Surg. Global Open.
2018;6(5):e1789–9.
72. Wilson MJV, et al. Role of nonsurgical chin augmentation in full face rejuvenation: a review
and our experience. Dermatol Surg. 2018;44(7):985–93.
73. Pilsl U, Anderhuber F. The chin and adjacent fat compartments. Dermatol Surg.
2010;36(2):214–8.
74. Tang M, et al. Three-dimensional angiography of the submental artery perforator flap. J Plast
Reconstr Aesthet Surg. 2011;64(5):608–13.
75. Ahn BK, et al. Consensus recommendations on the aesthetic usage of botulinum toxin type A
in Asians. Dermatol Surg. 2013;39(12):1843–60.
Chapter 18
Non-Surgical Aesthetics-Injection Strategy
of East Asian Faces
Pan Baohua and Souphiyeh Samizadeh
The skull is the foundation of the face and determines facial contours. Ideal skeletal
development (depending on the genetic and environmental factors) ensures bal-
anced and harmonious facial shape and features, and therefore forms the foundation
of facial beauty. Facial muscles determine facial expressions and their development,
balance, size, and movement have a direct impact on facial appearance. Fat pads
determine facial volume and hence are key contributors towards youthfulness and
beauty. Other factors contributing to facial beauty include skin (quality and texture)
and well-developed and functioning organs and nervous system.
In Asia, it has traditionally been believed that women’s beauty is expressed
by their inner beauty. The perception of facial beauty has changed with time. In the
West, people tend to prefer a face with very well-defined contours and features
which are perceived and are described as “rugged” beauty in the Chinese language.
In East, people have long preferred very delicate facial features. With globalization,
people’s concept of beauty is gradually becoming unified. A few years ago, in
China, the most attractive actresses had a sharp pointy chin, big eyes, and “incredi-
bly soft facial features”. Now, stars with well defined cheekbones and a three-
dimensional facial features are becoming more popular. Asians prefer a glowing
skin, full and firm complexion, refined features, and oval or heart-shaped facial
shape. Minimally invasive procedures including injectables are frequently used to
reduce wrinkles, correct depressions, improve contours, refine facial features, and
tighten and lift an aging face.
P. Baohua (*)
Chongqing Huamei Plastic Surgery Hospital, Second Military Medical University,
Chongqing, China
S. Samizadeh
Great british academy of aesthetic medicine, London, UK

https://doi.org/10.1007/978-3-030-84099-0_18
298 P. Baohua and S. Samizadeh
Fig. 18.1 Side view of

facial concavities and
convexities, and curvatures
that contribute towards
facial beauty including the
1 3
“ogee curve” Concave 1
Convex
There is subjectivity when discussing facial beauty, but there is also objectivity,
mathematics, and established facts. Some of these are described below:
The Curvilinear Lines
The facial contour is formed by various arcs. These curves and projections make a
face beautiful. For example, the Ogee curve is present in youthful and beautiful
faces. It is a double curve with the convexity at the apex of the cheeks and mildly
concavity towards the midface [1]. It is also known as the “double soft-S curves”.
Other lines and angles, concavities and convexities all contribute towards facial
form and perception of beauty (Fig. 18.1).
Proportionality
The proportional relationships of the facial features contribute towards facial beauty.
In Chinese language, “the features are correct” is a praise and a compliment, mean-
ing that the facial features and proportions are balanced and that the individual is
beautiful. Facial proportions were discussed and recorded in Han Dynasty paintings,
and the “three stops and five eyes” referring to facial vertical and horizontal propor-
tions were mentioned. Adolf Zeising, a German psychologist whose main interests
included mathematics and philosophy, put forward the concept of the “golden ratio,”
a proportionality relationship. This and other proportional relationships and can-
ons can be used to examine the beauty of the human body and face. For example, in
Ancient China, “Li Qi” and “Zuo Wu” were used, the head height was used as a
18 Non-Surgical Aesthetics-Injection Strategy of East Asian Faces 299
a b
Fig. 18.2 Facial fifths and thirds
yardstick for the lengths of the body, and the ratio of body parts to it provided a
consistent and credible method of measurement. This measurement indicated that
the height of a person standing upright is seven times (or 7.5 times) the length of the
head. Vertical thirds and horizontal fifths are thought to be based on this proportion-
ality. The eye’s width is used to measure transverse facial proportions (Fig. 18.2).
Symmetry and Harmony
Symmetry is one of the important features of facial beauty. However, perfect sym-
metry is not the norm. A study by Chinese maxillofacial surgery expert Zhang
Zhenkang and colleagues showed that the average asymmetry rate of beautiful faces
is within a 10% range. An asymmetry rate of less than 10% can be ignored. Greater
than 10% may be considered to have a certain degree of visible asymmetry. Harmony
between various facial units and features such as eyes, ears, nose, mouth, and facial
contours results in an overall facial beauty.
Color: Hair and Skin Color (From A Chinese Perspective)
Since ancient China, dark black hair has been considered most beautiful. Red lips
are considered beautiful especially when they have a certain luster and moisture,
with pale or dark purple lips being considered to “lack of vitality.” Younger genera-
tions prefer lighter and more fashionable hair colors.
Smooth, white, and delicate skin with the following features is considered
beautiful:
1. “Watery color:” refers to the skin’s luminosity. The young and people with oily
skin tend to have this characteristic.
2. “Reddish color:” Red hue of the skin represents vitality.
In traditional Chinese medicine, it is believed that a person’s complexion is rep-
resentative of their “feelings” and “spirit” as these are embodied in their facial
expression. It is believed that facial beauty cannot be perceived in the presence of
persistent, dominant facial expressions that are representative of negative expres-
sions such as anger or disgust, even if the person is perfectly proportional and
beautiful.
Facial Assessment
Through many clinical observations, the primary author has developed his own
practical evaluation method called “Facial three-curve theory:” (Fig. 18.5).
1. Front median line.
2. Front contour line.
3. Outer contour line.
Front Central Line (Mark Line “1” in Fig. 18.3)
Landmarks: Central line of the face, the middle point of the hairline, central line of
the nose, the midpoint of the upper lip, and chin apex.
Three curves of facial aesthetic Three curves of facial aesthetic Front contour line fixed point
evaluation (front view) evaluation (side view)
Fig. 18.3 Three curves of facial esthetic evaluation

Evaluation purpose:
1. Facial symmetry.
2. Forehead projection and eyebrows.
3. Nose shape, projection, and related angles.
4. Lips and philtrum: including the shape, vermillion border, height, width
and volume.
5. Chin height and width.
Front Contour Line (Mark Line “2” in Fig. 18.3)
Landmarks: Frontotemporal junction, lateral eyebrow arch, zygomatic eminence,

the intersection point of the extension line between the labial plane and nasolabial
sulcus point and the apex of the chin. The front contour line is mainly related
to assessment of aging and the contour of the face. In youth, this curve is smooth.
The curve is wide at the top and narrow at the bottom, indicating a desirable
face shape.
Evaluation Purpose:
1. The width of both sides of the forehead.
2. The position of eyebrows and eyebrow arch.
3. The position of malar eminence.
4. Prezygoma, depression of the middle cheek and cheekbones.
5. Nasolabial folds and marionette lines.
6. Chin apex.
Outer Contour Line (Mark Line “3” in Fig. 18.3)
Landmarks: The outer contour line of the frontal view of the face.
Evaluation Purpose:
1. Determine facial shape.
2. Temple concavity.
3. Zygoma convexity.
4. Masseter hypertrophy.
5. Ptosis.
6. The shape of the tip of the chin, including roundness and protrusion.
Evaluation and Grading of Facial Aging
The following classifications can be used to evaluate and grade the aging degree of
various facial areas, which is conducive to establishing a systematic treatment plan.
Facial Wrinkles
Alexiades-Armenakas assigns 0 to 4 points for facial wrinkles: (Fig. 18.4).

• 0 points: no wrinkles.
• 1 point: A few superficial wrinkles during facial activity.
• 1.5 points: Large and superficial wrinkles during facial activity.
• 2 points: Static face, no expressions-Localised, a few partial, superficial wrinkles.
0 point: no wrinkles 1 point: a small number 1.5 points: large and 2 points: When the face
of superficial wrinkles superficial wrinkles is stationary, small,
during facial activity during facial activity partial, superficial
wrinkles
2.5 points: numerous, 3 points: multiple areas 3.5 points: multiple 4 points: deep wrinkles
localized, superficial (forehead, periorbital, areas, numerous, that are multiple,
wrinkles when the face is perioral), numerous, superficial wrinkles and numerous and widely
stationary superficial wrinkles a few deep wrinkles distributed when the
when the face is when the face is face distributed when
stationary stationary the face is stationary
Fig. 18.4 Grading of Facial Wrinkles

• 2.5 points: Static face, no expressions-Localised, large area and superficial

wrinkles.
• 3 points: Static face, no expressions-Multiple areas (forehead, periorbital, peri-
oral), large, superficial wrinkles.
• 3.5 points: Static face, no expressions-Generalised-many superficial wrinkles,
and a few deep wrinkles and folds.
• 4 points: Static face, no expressions-Generalised, multiple deep wrinkles and
folds in multiple areas, and widely distributed.
Middle and Lower Face Aging
Yang and colleagues examined 1000 photographs of 500 Chinese men and 500
Chinese women to classify aging characteristics of the middle and lower face. They
reported the following aging characteristics (Fig. 18.5): [2].
1. Tear trough deformity (TTD).
2. Orbit malar fold (OMF)-orbital zygomatic grooves. The inner 1/3 of the orbital
malar fold is known as the tear trough, while the medial and lateral folds are the
orbit malar fold.
3. Mid cheek fold (MCF).
4. Nasolabial fold (NF).
5. Labiomandibular fold (LF).
6. Cheek groove (CG).
7. Submaxilla line (SL).
8. Cheek strip (CS) (Fig. 18.6).
According to the eight characteristics mentioned above, the aging degree of the
middle and lower parts of the face were evaluated comprehensively and quantita-
tively. Based on the results, the following scoring table was formulated, which
Fig. 18.5 Yang and

colleagues examined 1000
photographs of 500
Chinese men and 500
Chinese women to classify
aging characteristics of the
middle and lower face.
They reported on
characteristics of ageing
face among Chinese [2]
0 1 2 3
Fig. 18.6 Example of nasolabial fold grading
contains eight items in the table, including four subscales, and the total score of 15
points (Table 18.1—4.1).
Nasolabial Folds (Fig. 18.6)
Nasolabial fold morphology score can be divided into 4 grades:

• 0: When smiling slight nasolabial fold creases.
• 1 point: Mild nasolabial fold ridge was found in static state, but obvious crease
when smiling.
• 2 points: Obvious nasolabial fold crease in static state, but nasolabial fold ridge
does not exceed nasolabial fold range.
• 3 points: In static state, deep nasolabial folds are present, and nasolabial fold
crest exceeds inferiorly and merge with marionette lines.
Injectables
Botulinum Toxin A
Many factors need to be considered prior to choosing the correct dose, volume,
injection site and injection points for each indication and each individual patient.
This is discussed in detail in other chapters in this book.
The pre-operative evaluation and full facial assessment is necessary, including
assessing the movement of individual muscles of expression, their contraction and
shape, strength, skin quality and overall facial appearance and ageing features.
Furthermore, special attention needs to be paid to the injection layer, volume, speed,
and the choice of device to achieve the best results. When botulinum toxin is used
for facial remodeling, it is necessary to convey pleasant emotions without the need
to produce a stiff face/frozen look. The author uses a modified injection method to
help achieve optimal results and prevent complications. The number of injection
points increases with the use of lower dose at each injection point. Injections are
placed more superficially than traditionally advised to weaken the superficial
Table 18.1 Middle and lower face aging quantitative score table [2]
Scoring Items standard Score
Tear trough deformity (TTD) Formation of tear trough deformaty 1 point
Orbitomalar fold (OMF) The horizontal part of orbit malar fold 1 point
appears
The vertical part of orbit malar fold 1 point
appears
Mid cheek fold (MCF) Formation of mid cheek fold 1 point
Nasolabial fold (NF) (The nasolabial fold Appearance of folds or ridges of 1 point
was divided into upper, middle, and lower nasolabial fold (NF1)
segments, and continuous segments) The appearance of nasolabial fold folds 1 point
or ridges in the middle (NF2)
The appearance of folds or ridges of 1 point
nasolabial fold (NF3)
Nasolabial fold (NF4) 1 point
Cheek groove (CG) The emergence of cheek groove 1 point
Labiomandibular fold (LF) (The cheek The appearance of labiomandibular 1 point
groove is divided into three parts: upper, fold (LF1)
middle, and lower) The appearance of labiomandibular 1 point
fold (LF2)
The appearance of labiomandibular 1 point
fold (LF3)
Submaxilla line (SL) Submaxilla line curve is not smooth 1 point
(SL1)
SL2 appeared in submaxilla line 1 point
Cheek stripe (CS) The emergence of cheek stripe 1 point
The total score is 15 point
muscle fibers but preserve the function of the muscle. The smaller single-point dose
will avoid unnecessary diffusion to deep muscle and non-target muscle, thus main-
taining more muscle function and more natural appearance and avoiding the stiff-
ness that occurs when the whole muscle is paralyzed and the paralysis of un-targeted
muscles. Superficially placed injections can have the added benefit of reducing the
secretion of sebaceous and sweat glands and reducing pore size. However, the lon-
gevity of this method is shorter than that of the traditional methods or when higher
doses are used. Patients should be informed before injection, and the injection can
be repeated 3–4 months later.
Treatment of Common Wrinkles
The main cause of wrinkles is the repeated movement of muscles of facial expres-
sion. Anatomy and function of these muscles need to be comprehensively under-
stood prior to treatment provision. This is covered in other chapters in this book.
Each person should be examined individually, and the treatment plan derived
accordingly.
Forehead
The injection dose indicated in Chinese books and literature is 2 U/point with 8–10
injection points in two rows according to individual anatomy. A safety margin of
1.5–2.0 cm above the eyebrows is recommended to avoid eyebrow ptosis.
Glabellar Wrinkles
Kim analyzed the photos of 139 Korean patients who received botulinum toxin
treatment for the first time. Experienced dermatologists classified the wrinkles.
Based on the vertical and horizontal wrinkles between eyebrows, nasal lines and
forehead wrinkles, Kim classified the wrinkles into five categories: [3].
1. Vertical plus horizontal wrinkles “U”.
2. Only vertical wrinkles “11”.
3. Nose back lines, vertical and horizontal wrinkles “X”.
4. Forehead lines and vertical wrinkles “π”.
5. Forehead lines, vertical and horizontal wrinkles “I”.
A retrospective study of Chinese-specific glabellar contraction patterns was pub-
lished by Hsieh et al. to provide reference for BoNT A injections, to achieve effec-
tive and personalized results. They reported, in comparison to the Caucasians (using
de Almeida and colleague’s classification as a reference), Chinese exhibited a higher
frequency of “converging arrows” and a lower frequency of “V” pattern. The two
most frequently found patterns were the “converging arrows” and “U” patterns, fol-
lowed by “V,” “inverted omega,” and “omega” patterns (Figs. 18.7, 18.8, 18.9) [4].
a a
b b
a a
b b
Fig. 18.7 Various glabellar patterns published by Hsieh et al. [4]

Marked points for forehead lines and glabellar The direction of movement of the upper
wrinkles injection treatment facial expression muscles
Fig. 18.8 Association between frontal lines and glabellar wrinkles injection marks and corre-
sponding expression muscles
Before injection: when Before injection: when After injection: when the After injection: when
the eyebrows are raised frowning eyebrows are raised frowning
Fig. 18.9 Effect of botulinum toxin type A injection on glabellar wrinkles and forehead lines after
one month. Note muscle asymmetry prior to injections
Jiang and colleagues also examine different glabellar contraction patterns in Chinese
and the efficacy of botulinum toxin type A for treating glabellar lines. They reported
“Converging Arrows” pattern was the most common, followed by the “U” pattern in
Chinese. This was attributed to reduced significance of procerus in Chinese than
Caucasians in the formation of glabella lines. They reported that injection of pro-
cerus was not required in almost half of their subjects. In addition, they reported
success with 5 injection points in “V pattern” due to lower muscle volume and
muscle strength in the Chinese [5]. Furthermore, studies have shown shorter corru-
gators in Asians (Chinese cadavers) [6].
Mark the injection points according to the individual’s anatomy when the patient
is frowning and inject when the muscles are relaxed. An example can be seen in
Fig. 18.9.
Crow's feet pre-injection marking One month after botulinum toxin injection
Fig. 18.10 Results of botulinum toxin type A at one month of Crow’s feet injection
Before crow's feet injection alone One month after crow's feet injection alone
Fig. 18.11 The dynamic wrinkles on the medial side of the lower eyelid were aggravated by
crow’s feet injection alone
Crow’s Feet
In the Chinese population, the orbicularis oris muscle is relatively weak, so it is

recommended to use injection points according to specific muscle topography, each
with a dose of 2-4 U (Fig. 18.10).
Because the orbicularis oris muscle is circular, when the lateral orbital fibers are
relaxed or paralyzed, the medial and lower fibers compensate, and an aggravation of
the angular and lower lid lines occurs (Fig. 18.11). Hence, injections need to be
considered along with treatment of the lower lid and nasal crease with care and care-
ful patient selection. Lower doses (e.g., 1 U) should only be used to avoid ectropion.
The nasal dorsum can be treated with the same complex of muscles as compensa-
tion equally happens in this region (Figs. 18.12, 18.13).
Treatment of Masseter Hypertrophy
The masseter muscles are muscles of mastication and affect esthetics of the lower
face and hence overall facial contour. Masseter hypertrophy is common in East
Asians due to genetics. Another major contributing factor is prolonged or frequent
chewing of hard food/chewing gum. The regional cuisine and eating habits where
chewing of bones is common contributes to masseter hypertrophy. This can stimu-
late the masseter sufficiently to cause excessive growth which ultimately leads to
the development of masseter hypertrophy. Non-surgical treatment of masseter
hypertrophy is extremely popular in Asia. Botulinum toxin type A can cause differ-
ent degrees of paralysis of the muscles, resulting in the gradual atrophy of the mas-
seter. In terms of efficacy, the onset of effect is 1–4 weeks, and the time to notice the
effect is 9–15 weeks. The satisfaction rate is usually 100% (Fig. 18.14). After
Fig. 18.12 Botulinum

toxin injection point and
dose assessment and
treatment planning before
treatment
Static state before wrinkle Smile before wrinkle Frown before wrinkle
removal removal removal
Static after wrinkle removal Smile after wrinkle removal Frown after wrinkle removal
Fig. 18.13 Comparison of the effect of botulinum toxin type A after one month
Before botulinum toxin injection Before botulinum toxin injection
After botulinum toxin injection(6 months) After botulinum toxin injection(6 months)
Before botulinum toxin injection, right Before botulinum toxin injection, left
After botulinum toxin injection, right After botulinum toxin injection, left
Fig. 18.14 Before pictures and 6 months after botulinum toxin type A injection of masse-
ter muscles
botulinum toxin injection, the effect will be rapid, with visible results within
4 months and results lasting for 6 months or more. Over time, the patient’s masseter
strength and bulk return.
Evaluation of the Masseter Injection
The location and size of the masseter are determined by asking the patient to bite
and palpating the jaw angle. Guidelines for safe zone injection of masseter muscles
have been published by Kim et al. [7]
The safe injection zone is shown in Fig. 18.15, with blue lines determining the
borders. Caution is advised if the practitioner wishes to inject zone A. Usually, more
than one injection point is required. In Asians, subzygomatic hollowness is not an
esthetic feature and hence not desirable. Therefore, caution is needed for the upper
section of the masseter muscle.
In general, for Chinese patients, 15–30 U per masseter muscle can be used and it
is recommend not exceeding 50 U to avoid complications. If jowl ptosis is present,
even smaller doses are recommended so not to contribute further to jowling.
Masseter injections will result in a corresponding compensation and thickening of
the temporalis muscle (the masticatory muscle group).
Very rarely, temporal hollowing is observed. This could possibly be due to:
1. The interaction of the posterior temporal muscle, masseter muscle, zygomatic
arch, and the tempro-buccal fat pad.
2. Widespread mild single-fiber EMG abnormalities were also found in the distal
septal muscles after local injection of therapeutic doses of type A botulinum
toxin. This phenomenon suggests that botulinum toxin type A injections can
trigger a muscular response at the distal septum, and thus atrophy of the tempo-
ralis muscle after masseter injections.
3. Drug dispersion if large amounts are injected close to the temporalis muscle.
Fig. 18.15 Safe area for masseter injection. Kim et al. published safety zone for treatment of mas-
seter muscle with botulinum toxin A [7]. Area A should be injected cautiously
The treatment is required to be repeated to maintain the results and further reduce
the size of the masseter muscle if required. This is usually done at intervals of
4 months and for three or more sessions.
Dermal Fillers
At present, the main facial fillers used in China are a permanent methyl methacrylate-
based product, short-acting hyaluronic products, and collagen. The permanent
methyl methacrylate-based products and long-acting hyaluronic acids are generally
used for facial contouring and shaping, such as non-surgical rhinoplasty, chin aug-
mentation, and temporal augmentation. Collagen is used for the correction of tear
trough and skin texture improvement. Some hyaluronic acid filling agents can be
uniquely injected to achieve lift injections in addition to simple volumisation.
Injections into the Front Median Line: Forehead, Nose, Lips, and Chin
Forehead
Forehead augmentation with dermal fillers involves placement of dermal fillers deep
at the periostea level. Some superficial rhytids can be addressed intradermally with
extreme care. Use of homogeneous hyaluronic acid can reduce postoperative uneven-
ness due to muscle movement and contraction. During the same session or prior to
augmentation, botulinum toxin type A can be injected to reduce the frontalis muscles’
movement. This will enhance the post augmentation results, reduce unevenness and
improve longevity of dermal fillers (Fig. 18.16). Use of blunt cannula is relatively
safer. Extreme care should be taken when injecting the forehead. Attention should be
paid to anatomy, position of the supraorbital and supratrochlear vessels and nerve, and
their relevant layer according to each section of the forehead treated.
Nose
The choice of product for injection rhinoplasty is especially important. It is recom-

mended not to use small particle hyaluronic acid filling agents to avoid the phenom-
enon of gradual widening of the nasal root at a later stage. The height of the nasal
root must be coordinated with the forehead, and the angle between the forehead and
the bridge of the nose should be 115° ~ 135° (frontal nasal angle). This area is tech-
nique sensitive and gender should be taken into account to avoid masculinisation of
female patients unless desired and requested (Fig. 18.17).
Lips
There are three types of lip techniques that can be used among many other, depend-
ing on patient requirements. One technique utilizes a blunt needle for complete lip
volumisation. The other techniques require the use of sharp needles, employing a
Before frontal hyaluronic acid filler, front Before Frontal Hyaluronic Acid Filling, side
view view
After hyaluronic acid filler on the After hyaluronic acid filler on the forehead,
forehead, front view side view
Fig. 18.16 One month after hyaluronic acid forehead filler
Before augmentation Before augmentation rhinoplasty, Before augmentation rhinoplasty,

rhinoplasty, front view right side view left side view
After augmentation rhinoplasty, After augmentation rhinoplasty, After augmentation rhinoplasty,

front view right side view left side view
Fig. 18.17 Methyl methacrylate-based filler was injected into augmentation rhinoplasty- over two
years, with a total dose of 3 ml
three-point injection technique, one point is procheilon (the central prominence on

the upper margin of the upper lip), and two lower lip tubercles on either side of the
midline (the outcome of this injection technique is desirable and requested fre-
quently in China and East Asia) (Fig. 18.18). Another technique can be used to form
the perception of “smiling lips” as shown in Fig. 18.19. The anatomy of vasculature
in the perioral area is variable, and hence great caution is to be taken [8].
The Chin
The purpose of chin injections are to increase the length, refine the shape, projection
and sharpness of the chin. Dermal fillers can be placed deep (periosteal placement)
and subcutaneously. In order to achieve the natural results and an esthetic effect, it
is necessary to consider the natural esthetic characteristics of the chin, as well as
chin’s relation with the surrounding tissues and facial units. Injection for chin aug-
mentation, the tip of the chin is the focal point, and the periphery needs to be tran-
sitional (Figs. 18.20 and 18.21). The first author uses a sequence of 1–9 injections,
and has named them C1–C9 (C for chin-inspiration for the name from MD codes
developed by Dr Mauricio de Maio). C1 - the lowest point right in the middle of the
chin (apex), injection on the periosteum, C2, C3 - next to the apex of the chin, injec-
tion on the periosteum, all three are the basis for maintaining the shape of the tip of
the chin, C4 - a subcutaneous injection at the apex of the chin, either blunt can-
nula or sharp needle can be used to enhance the shape of the apex of the chin. C5 -
subcutaneous placement of dermal fillers to reduce the depression and for perception
Beep lips injection method (submucosal one shot injection)
Before hyaluronic acid injection Immediately after hyaluronic acid injection
Fig. 18.18 Results of hyaluronic acid “Beep lips” injection

Before hyaluronic acid injection Immediately after hyaluronic acid injection
Fig. 18.19 Smiling lip injection method: point 1, 2, 3, 4, 5 for submucosal injection, point 6, 7 for
subcutaneous injection. Results of hyaluronic acid “smiling lips” injection
Front view Side view
Fig. 18.20 Chin injection points and injection landmarks- yellow lines 1 median line; 2 front
contour line; 3 outer contour line. The red circle indicates the injection sites
Front view before injection Side view before injection Side view before injection
Front view after injection Side view after injection Side view after injection
Fig. 18.21 Three months after hyaluronic acid injection for chin augmentation
Fig. 18.22 Rendering of changes to front contour line
of a longer chin, and C6, C7, C8, and 9 are the finishing touches to the margins of
the chin. Finishing touches are usually done subcutaneously with a blunt cannula.
To enhance the effect, type A botulinum toxin may be used at the same time to relax
the mentalis muscle.
ront Contour Line Injections: The Main Purpose of This Line Is

F
To Correct Aging Signs and Change the Face’s Shape
By volumetric filling, the front contour line is widened at the top and narrower at the
bottom, resulting in the perception of a relatively “smaller face”. The uneven front
contour line is smoothed by “lifting effect” of the filling agents, thus giving a youth-
ful appearance to the face (Fig. 18.22). This technique was developed by the first
author, who took inspiration from MD codes developed by Dr Mauricio de Maio [9].
The sequence of injection to achieve this outline:
1. The temples, improving the convexity of the temples and hence changing the
proportion of the upper-mid-lower face. Volumising this area also supports the
tail of the eyebrow.
2. Midface-treatment to volumize areas that have lost fat, volume and youthful pro-
jection. This would in turn improve the nasolabial folds and changes the dynam-
ics of the infraorbital area.
3. Ligamental support.
Front contour line lift injection and a sample dose can be seen in Fig. 18.23 and
Table 18.2.
Fig. 18.23 Front contour

line lifting injection site
Table 18.2 Injection landmark and example volume

corresponding Needle/
Point Landmark ligament Layer and example volume Cannula
T1 Temples Orbital ligament Periosteal surface, approx. 0.5 ml Needle
P1 Zygomatic Zygomatic ligament Periosteal surface, three points, Needle
fissure approximately 0.1 ml each.
P2 Zygomatic Orbicularis oculi Periosteal surface, approx. 0.2 ml Needle
eminence supporting ligament
P3 Medium cheek Zygomatic Periosteal surface, 0.3 ml; Needle
groove cutaneous ligament Subcutaneous—0.3 to 0.5 ml Cannula
P4 Prezygomatic Latissimus dorsi Subcutaneous, 0.5 to 1 ml Cannula
area ligament
P5 Prejowl sulcus Mandibular ligament Periosteal surface or subcutaneous, Needle
about 0.3 to 0.5 ml Cannula
NL Nasolabial fold Maxillary ligament Within 0.5 ml on the surface of the Needle
periosteum, 0.3 to 0.5 ml Cannula
subcutaneously
Case Study
Case 1. female, 46 years old, requested non-surgical rejuvenation, undergone facial

ultrasound and freckle treatment. Pre-operative evaluation: In the outer contour
line-temporal depression; protruding zygomatic arch; hollowness subzygomatic
area, depression of cheeks, unclear jawline contour; and accumulation of submen-
tal fat (double chin). In the front contour line-brow ptosis; malar eminence lost,
deep nasolabial fold; obvious marionette lines. Treatment with Hyaluronic acid
dermal fillers (9 ml in total). Overall improvement of facial shape and contour can
be seen. Patient looks younger and rejuvenated without overfilling and unnatural
results.
A-Injection points B-Pre-treatment C-post treatment of the RHS
D-Pre-injection E-2days post injection F-Pre-injection G-2days post injection

H-Pre-injection E-2 days post injection
Conclusion
Non-surgical and minimally invasive esthetic medicine is the combination of art,

science and psychology. As such esthetic physicians and practitioners need to have
an eye for esthetics and beauty, an understanding of patient psychology, comprehen-
sive knowledge of anatomy, physiology, and pharmacology. Furthermore, differ-
ences in facial morphology in various races, cultural differences and ideals of
beauty should be understood and taken into consideration. Multimodality treatment
may be required to achieve the best result.
References
1. Hamra ST. Composite rhytidectomy. Plast Reconstr Surg. 1992;90(1):1–13.

2. Yang N, et al. Investigation of Asian adult aging features and the facial aging scoring system of
the middle and lower face. Plast Reconstr Surg. 2011;128(2):77e–9e.
3. Kim H, et al. A study on glabellar wrinkle patterns in Koreans. J Eur Acad Dermatol Venereol.
2014;28(10):1332–9.
4. Hsieh DM-Y, et al. A retrospective study of chinese-specific glabellar contraction patterns.
Dermatol Surg. 2019;45(11):1406.
5. Jiang H, Zhou J, Chen S. Different glabellar contraction patterns in Chinese and efficacy of bot-
ulinum toxin type A for treating glabellar lines: a pilot study. Dermatol Surg. 2017;43(5):692–7.
6. Wen J-H, Ji Z-I, Lu F. Clinical anatomical study of the corrugator and prcerus muscles. J Pract
Aesth Plast Surg. 2001;1:28.
7. Kim NH, Park RH, Park JB. Botulinum toxin type A for the treatment of hypertrophy of the
masseter muscle. Plast Reconstr Surg. 2010;125(6):1693–705.
literature review. Aesth Surg J. 2018.
9. de Maio M. MD Codes™: a methodological approach to facial aesthetic treatment with inject-
able hyaluronic acid fillers. Aesth Plast Surg. 2020.
Chapter 19
MTV Lift and Nonsurgical Facial
Rejuvenation Techniques
Jui-Hui Peng and Hsien-Li Peter Peng
Esthetic medicine is one of the fastest-growing medical fields today, and nonsurgi-
cal esthetic treatments are especially popular. According to the American Society
for Aesthetic Plastic Surgery (ASAPS) annual statistics, demand for surgical
esthetic procedures has grown 2.2 times in the last 20 years, but demand for nonsur-
gical esthetic procedures has grown 15.8 times in the same period [1]. Among the
variety of nonsurgical procedures available, botulinum toxin injection has remained
the most-performed procedure for over two decades, followed by filler injections, of
which hyaluronic acid (HA) fillers are among the most popular. Drawing from the
author’s extensive experience of injections and fillers, his chapter will focus on
these nonsurgical facial rejuvenation techniques.
Youth and beauty contribute to visual attractiveness. Signs of facial aging includ-
ing lines, wrinkles, folds, dryness, eye bags, sagging, and contours may enhance
and fixate negative facial expressions and hence reduce attractiveness. As such,
youthfulness is a quality sought by many patients and there is better understanding
that combination of youth and femininity, another attribute highly associated with
attractiveness [2].
J.-H. Peng
Kaohsiung Chang-Gung Memorial Hospital, Kaohsiung City, Taiwan
H.-L. P. Peng (*)
P-Skin Professional Clinic Kaohsiung, Taiwan, Kaohsiung, Taiwan
Department of Dermatology, Tri-Service General Hospital, National Defense Medical Center,
Taipei, Taiwan

https://doi.org/10.1007/978-3-030-84099-0_19
322 J.-H. Peng and H.-L. P. Peng
Fig. 19.1 MTV lift
MTV Lift
The MTV lift is a concept and series of techniques developed by the author for the
beautification and rejuvenation of the East Asian female face (Fig. 19.1). There are
three major components of the MTV lift:
• M, which stands for Midface augmentation and lifting;
• T, which stands for T-area reshaping and recontouring;
• V, which stands for V lifting of the lower face.
The MTV approach can effectively target areas of congenital volume deficiency
and bone loss from aging and restore the underlying support structures that allow
creation of a youthful face. The MTV lift utilizes a variety of injection techniques,
which are summarized in Table 19.1.
M: Midface Augmentation and Lifting
The youthfulness of the face comes from the overall shape and fullness of the cheek
with its ogee curve. In MTV lift, points M1 to M4 are injected according to the fol-
lowing protocol when performing the M procedure (Fig. 19.2).
19 MTV Lift and Nonsurgical Facial Rejuvenation Techniques 323
Table 19.1 Commonly used HA filler injection techniques (Modified from [3–8])
Technique Subtype Remark
Deposit Small bolus <=0.3 mL per injection
Aliquot 0.1–0.2 mL
Micro-aliquot 0.01–0.05 mL per point
Serial puncture
Tower technique
Blanching technique
Linear (threading) Antegrade
Retrograde
Fern pattern
Fanning
Cross-hatching
Grid
Layering
Subcision/tunneling
Fig. 19.2 M1–M4

injection points
M1: The Zygomatic arch area. Inject with needle on the bone level, with 2–4
points of injection depending on the clinical condition of the patient. Deposit 0.1 mL
in each point; physicians may use up to 0.2 mL per point in some conditions (e.g.,
severe volume loss over that area.)
M2: the Palpebromalar groove (PMG). This area frequently experiences pro-
nounced bone loss in the aging process, especially in the upper medial and lower
lateral periorbital areas [9]. Inject with needle on the bone level in microbolus
deposits of 0.03–0.05 mL at each point, for 2–3 injections.
M3: The Infraorbital area. Asian patients tend to exhibit weaker bony support
over this area compared to Caucasian patients [10]. This kind of bony structural
change may lead to early onset of eye bags in some young Asians, as demonstrated
in previous studies [4]. Inject with needle on the bone level, in small bolus injec-
tions of about 0.3–0.5 mL. Care must be taken to not exceeding the midpupillary
line, and injections should be over the lateral parts of the infraorbital area in order
to prevent serious complications such as blindness. The injection should be
extremely gradual and at the correct depth, and there should be an attempt to aspira-
tion for at least 5–8 s before each injection, to ensure that arterioles are not impacted
[11, 12]. For some patients, needle bolus injection may be insufficient; if concavity
is still seen after injection, especially in female patients, inject with cannula in a
“fanning” fashion over the whole area, with about 0.5–1 mL per side.
M4: The Canine fossa area. This area is also known as the pyriform margin or
pyriform aperture. As with M3, the M4 area is prone to bony or structural loss with
age in Asian patients [3, 9]. Inject with needle over the bone level in bolus deposits
of about 0.2–0.5 mL.
Other midface injection points are shown in Fig. 19.3.
Fig. 19.3 M5–M8

injection points
M5: The Subzygomatic area (lateral cheek) area. Asian patients will commonly
exhibit some volume deficiency in this area. Inject with cannula at least 25G in size,
in the subcutaneous level, in a “fanning” fashion over the whole area. This creates a
lateral vector over the cheek, which produces a “lifting” effect. The usual amount of
injection is 0.5–1 mL per side of face.
M6: The Anterioinferior cheek area. This area is just below the infraorbital area.
Injection over this area can create an anterior projection over the anterioinferior
cheek (fuller cheek). Inject with cannula in a “fanning” fashion, and deposit
0.5–1 mL per side.
M7: The Tear Trough area. This area is a frequently requested target for treat-
ment, but is one of the most difficult areas to treat well [3]. Complex regional ana-
tomic structures such as the suborbicularis oculi fat (SOOF), orbicularis oculi
muscle, or tear trough ligaments [13, 14] significantly complicate treatment proce-
dures. Inject with cannula just below the orbicularis oculi muscle in microbolus
deposits of about 0.1–0.3 mL per side, using a linear or “fanning” technique.
M8: The Nasolabial folds. Like M7, M8 is also a commonly requested target for
treatment, owing to its prominence and noticeability especially with age. Many HA
filler clinical studies are also performed over this area. Nasolabial folds may be
caused by saggy cheeks, loss of bony support, deep fat pad loss, or accumulation of
superficial fat pads. Indirect injections in other areas should be performed first (M1–
M5) to create a lifting or supporting effect, before injections over the M8 area can
be attempted. Care should be taken to avoid the facial artery passing through this
area. Inject with cannula in the subcutaneous layer, in a “linear” or “fanning” fash-
ion, with about 0.5–1 mL per side depending on folding severity (Tables 19.2
and 19.3).
Table 19.2 Summary of Midface augmentation and lifting

Injection Injection Injection Injection
Code Location layer tool technique amount Note
M1 Zygomatic arch Bone Needle Bolus 0.1–0.2 mL 2–4
points
M2 Palpebromalar Bone Needle Micro- 0.03– 2–3
groove (PMG) aliquot 0.05 mL points
M3 Infraorbital area Bone, deep Needle/ Bolus/ 0.3–1.5 mL
fat Cannula Fanning
M4 Canine fossa area Bone Needle Bolus 0.2–0.5 mL 1–2
points
M5 Subzygomatic area Subcutaneous Cannula Fanning 0.5–1 mL
M6 Anterioinferior Subcutaneous Cannula Fanning 0.5–1 mL
cheek area
M7 Tear trough area Deep fat/bone Cannula Micro- 0.1–0.3 mL
aliquot
M8 Nasolabial folds area Subcutaneous Cannula Fanning/ 0.5–1 mL
Linear
Table 19.3 Summary of T-area reshaping

Injection Injection Injection
Code Location Injection layer tool technique amount Note
T1 Temporal Bone Needle Bolus 0.5–2mL/side 2–4
points
T2 Eyebrow Bone Needle Micro-aliquot 0.1–0.2 1–2
tail mL/side points
T3 Nose radix Bone Needle Bolus 0.05–0.1 mL 1–3
points
T4 Chin apex Bone Needle Bolus 0.2–0.3 mL 1–3
points
Forehead Subgaleal Cannula Fanning 1–4 mL
Glabella Subcutaneous Needle/ Serial puncture/ 0.1–0.2 mL
Cannula linear
Nose On Bone or Needle/ Linear 0.5–1 mL
cartilage Cannula
Lips Submucosa Needle/ Fanning/Linear 0.5–1 mL
Cannula
T: T-area Reshaping
Midface reshaping is followed by the T-area (forehead and nose) reshaping proce-
dures, which involves injection points T1-4 (Fig. 19.4).
T1: The Temporal area. The temporal area is a complex area with more than ten
anatomical structural layers. Several important vessels run through this area, such as
the superficial temporal artery and its anastomoses with the supraorbital or supra-
trochlear arteries, making this area one of the “danger zones” for filler-induced
occlusion [15]. To avoid adverse events and sequelae, it is vital to inject at the cor-
rect location and depth [16]. For T1, inject with needle over the periosteum level
and deposit 0.5–1 mL per injection, and before each injection, aspirate and wait at
least 5 s [11, 12]. The temporal fossa can be severely depressed in some patients,
which may require up to 4 mL per side for full correction.
T2: The Eyebrow Tail. The eyebrow tail area may become sunken and drooped
with age, which creates an enervated, dispirited look. Inject with needle onto the
bone, in small bolus deposits of 0.1–0.2 mL per side. The clinical goal of T2 injec-
tion is the reshaping of the eyebrow tail and the vanishing of the transition zone
between the eyebrow and the temporal area.
T3: The Nose Radix. Asian patients frequently display severe volume loss in this
area, making it a frequently requested target for correction. Care should be taken to
not over-inject, which may otherwise create a widening effect through regional
facial overfilling. Injection with needle onto the bone, in small bolus deposits of
about 0.05–0.1 mL per injection.
T4: The Chin Apex. This point is also called the V1 point in the MTV anatomy
system and will be discussed accordingly in the V-lift section.
Fig. 19.4 T-area

reshaping—T1-T4 points
Other T Areas of the Face
The Forehead: The forehead area in Asians will commonly exhibit retrusion [10],
and the use of filler injections to reshape the forehead is an important treatment
option for Asian patients [4]. Inject with cannula into the subgaleal layer (layer 4),
or the deeper layer of the deep fat pad space, using a “fanning” technique [4, 17].
The injection amount varies depending on the severity of volume, but 1–4 mL over
the whole forehead is generally sufficient. Care should be taken to avoid possible
intravascular injection and occlusion.
The Glabella: This area is a hotspot for dynamic wrinkles, which usually require
botulinum toxin treatment. For some patients, where dynamic wrinkles are compli-
cated by volume deficiency and static wrinkles, HA fillers may be necessary to
achieve a satisfactory correction result. The glabella area is also one of the most
high-risk areas for vessel occlusion after filler injection, and the standard precau-
tions such as aspiration should be taken [15]. For static wrinkles, inject with needle
very superficially into the intradermal layer, in serial puncture fashion.
The Nose: The Asian nose is usually less distinct, with the anterior nasal spine
lying closer to the facial plane, creating less support in nasal structures [10]. Bony
remodeling in aging may also cause the nasal tip to droop [9]. The safe injection
level for the nose lies above the nasal bone or nasal cartilage. Inject gradually with
cannula 23G or larger at the safe injection level, in deposits of roughly 1 mL. In
select patients, use needle injections to enhance and fine-tune the nose shape.
The Lips: Asian lips are generally fuller than Caucasian lips, with longer cutane-
ous upper lip length, longer cutaneous lower lip length, and fuller vermillion lips
[18]. This creates some differences in the procedures for enhancing the lips, as well
as the demand and goal. For thinner-lipped Caucasian patients, lip augmentation is
a frequent request, but in Asian patients, reshaping and beautification is the objec-
tive. Inject with 25G cannula from an entry point about 0.5 cm lateral to the mouth
corner and deposit an average of 1 mL for the whole two lips.
V: V-lifting of the Lower Face
T-area injection is followed by V-lifting of the lower face, which involves injecting
points V1-7 (Figs. 19.5 and 19.6).
V1: The Chin. The Asian chin is usually shorter and more retruded in comparison
with the Caucasian chin [10]. If elongation of chin is a main objective, inject with
needle over the chin apex, in small bolus deposits of 0.2–0.3 mL per injection and
Fig. 19.5 V-lifting—

V1-V3 injection points
Fig. 19.6 V-lifting-V4-V7

injection points
up to 2–4 injection. A total volume of 1–1.5 mL should be sufficient, although in

some patients with severe retrusion, the progonium part of the chin will need
enhancements, which may require another 0.5–1 mL of HA filler.
V2: The Prejowl Sulcus. This structure is located at the lowermost part of mari-
onette line, near the mandibular ligament, and is one of the most important areas for
rejuvenation injection treatment. This area also can be the target for bony remodel-
ing as a part of the aging process. Inject with needle, on the bone level, in small
bolus deposits with 0.2–0.3 mL per side.
V3: The Mandibular Angle. Bony remodeling of the mandible includes blunting
of the mandibular angle, so the aim for this point is to project the mandibular angle,
enhance the jawline shape, and subsequently improve the facial shape on a whole.
Inject with needle on the bone level, in bolus deposits of 0.3–0.5 mL. Two injections
per side can be performed if necessary.
V4: The Lowermost part of the Mandible. Inject with cannula over the subcuta-
neous layer, in a linear injection fashion, depositing about 0.5–1 mL per side.
V5: The Lower Mandible. This area borders the lowermost part of cheek, and is
covered by the platysma muscle and mandible, which constitute the boundary
between the face and the neck. This area may exhibit sagginess with jowl formation,
irregularity of jawline due to mandibular bony remodeling [9], and a downward
movement of the platysma muscle. Both filler and botulinum toxin can be used for
jawline lifting. For fillers, inject with cannula on the subcutaneous layer, in a “linear
threading” fashion, depositing about 0.5–1 mL per side. Two rows of botulinum
Table 19.4 Summary of V-lifting

Injection Injection Injection
Code Location Injection layer tool technique amount Note
V1 Chin Bone/ Needle Bolus 1–4 mL 2–4
Subcutaneous points
V2 Prejowl sulcus Bone Cannula Fanning 0.2–0.3
mL/side
V3 Mandible angle Bone/ Needle Bolus 0.3–0.5 1–2
Subcutaneous mL/side points
V4 Mandible lower Subcutaneous Cannula Linear 0.5–1
margin beneath the mL/side
chin
V5 Mandible lower Subcutaneous Cannula Linear 0.5–1
margin mL/side
V6 Marionette line Subcutaneous Cannula Fanning 0.5–1
mL/side
V7 Preauricular Subcutaneous Cannula Fanning 0.5–1
mL/side
toxin injections over the platysma muscle with approximately 20–30 units per side
produce a synergistic effect.
V6: The Marionette line. This area frequently exhibits a sunken and saggy
appearance and is important in any rejuvenation protocol. Inject with 25G cannula
in a “fanning” fashion, and deposit 0.5–1 mL per side. The use of the cannula here
makes for a smoother contour of the lower face, and makes the jowls appear smaller.
V7: The Preauricular area. This area is another lateral vector area to achieve a
“lifting” effect. Inject with cannula in the subcutaneous layer, with a “fanning” tech-
nique over the whole area, depositing about 0.5 mL per side. In severe cases, up to
1 mL per side may be required (Table 19.4).
Masseter hypertrophy is a very common condition in Asian patients and creates
the commonly-seen “square” faced look. Botulinum toxin can induce atrophy in the
masseter muscles, and reshape the lower face [19, 20]. The usual dose would be
20–30 units of onabotulinum toxin A or another equivalent dose of other toxin per
side, spread out to 3–5 points [21]. Reduction of the hypertrophic masseter muscles
can help modify the mandibular and lower face contours, as shown in Fig. 19.7.
Care should be taken to avoid the variety of complications and sequelae that are
frequently encountered [21, 22]. Table 19.5 summarizes the possible masseter injec-
tion complications. (modified from Peng HP).
Conclusion
Using different HA products in different facial areas, and through the combination
of different injection techniques and treatment sequences, the MTV Lift treatment
can successfully reverse aging signs and achieve beautification in East Asian
women. With small modifications, this technique may also be suitable for other
facial shapes and skin types from other ethnicities.
Fig. 19.7 Before and 1 month after masseter botulinum toxin injection of 25 unit each side
Table 19.5 Summary of masseter injection complications

Author
Category Etiology/Cause Prevention/Treatment incidence
Nonmuscular origin
Bruising Damaged vessels Compression after injection 2.5%
Hematoma (rare) Trauma to arteriole or Compression after injection N/A
vein
Dizziness (rare) Unknown Rest N/A
Headache Unknown Rest 0.58%
Toxin effect related
Chewing weakness Transient muscle Abates within a week 30%
and aching weakness
Dose/level related
Poor or no effect Insufficient dosage or Good injection dose, depth, or No effect
overly superficial toxin resistance 0.1%
injection
Asymmetricity Same dose on Adjust dose according to muscular N/A
different sizes of size
hypertrophic muscle
Jowling/sagging High dosage in elderly Reduce dose, multiple treatments, 0.20%
patient injections in lower face depressors
(platysma)
(continued)
Table 19.5 (continued)

Author
Category Etiology/Cause Prevention/Treatment incidence
Paradoxical bulging Superficial masseter Injection over the superficial 0.49%
(muscle bulging m. fiber overactivity masseter if not abated after
during mastication) 1–2 weeks
Injection site related
Loss of full smile/ Injection too high or Inject in the injection safe zone, 0.15%
asymmetric smile anterior, effect on and ideally keep 1 cm from each
zygomatic major or border of the safe zone. Most
risorius muscles complications resolve
Sunken lateral cheeks Injection too high, spontaneously after some time. 0.44%
(infrazygomatic excess dose
sunken)
Difficulty in mouth Injection too high, N/A
opening effect on the lateral
pterygoid muscle
Xerostomia (rare) Injection too posterior, N/A
effect on parotid gland
function
Neurapraxia (very Injection too inferior, N/A
rare) damage to the
marginal mandibular
nerve
References
1. 2016 Cosmetic Surgery National Data Bank Statistics. From The American Society for
Aesthetic Plastic Surgery. https://www.surgery.org/sites/default/files/ASAPS-Stats2016.pdf
2. Fabi SG, Willett M. Youth versus femininity: What are we truly trying to achieve? J Cosmet
Dermatol. 2020 Feb;19(2):553–5.
3. Peng PH-L, Peng J-H. Treating the tear trough: A new classification system, a 6-step evalu-
ation procedure, hyaluronic acid injection algorithm, and treatment sequences. J Cosmet
Dermatol. 2018;17(3):333–9.
4. Rho NK, Chang YY, Chao YY, Furuyama N, et al. Consensus recommendations for optimal
augmentation of the Asian face with hyaluronic acid and calcium hydroxylapatite fillers. Plast
Reconstr Surg. 2015 Nov;136(5):940–56.
5. Kontis TC, Lacombe VG. Cosmetic injection techniques, 2nd ed. Thieme 2019.
6. Bartus CL, Sattler G, Hanke CW. The tower technique: a novel technique for the injection of
hyaluronic acid fillers. J Drugs Dermatol. 2011 Nov;10(11):1277–80.
7. de Maio M. Unlocking the code to facial revitalization: a step-by-step approach to using inject-
ables with the MD Codes. Produced and funded by Allergan 2017.
8. Micheels P, Sarazin D, Besse S, et al. A blanching technique for intradermal injection of the
hyaluronic acid Belotero. Plast Reconstr Surg. 2013 Oct;132(4 Suppl 2):59S–68S.
9. Mendelson B, Wong C-H. Changes in the facial skeleton with aging: implications and clinical
applications in facial rejuvenation. Aesthet Plast Surg. 2012;36(4):753–60.
10. Liew S, Wu WT, Chan HH, Ho WW, et al. Consensus on changing trends, attitudes, and con-
cepts of asian beauty. Aesthet Plast Surg. 2016 Apr;40(2):193–201.
11. Kim HS, Lee KL, Gil YC, Hu KS et al. Topographic anatomy of the infraorbital artery
and its clinical implications for nasolabial fold augmentation. Plast Reconstr Surg. 2018
Sep;142(3):273e–280e.
12. Torbeck RL, Schwarcz R, Hazan E, Wang JV, et al. In vitro evaluation of preinjection aspira-
tion for hyaluronic fillers as a safety checkpoint. Dermatol Surg. 2019 Jul;45(7):954–8.
13. Wong C-H, Hsieh MKH, Mendelson B. The tear trough ligament: anatomical basis for the tear
14. Yang C, Zhang P, Xing X. Tear trough and palpebromalar groove in young versus elderly
adults. Plast Reconstr Surg. 2013;132(4):796–808.
15. Scheuer JF 3rd, Sieber DA, Pezeshk RA, Campbell CF et al. Anatomy of the facial dan-
ger zones: maximizing safety during soft-tissue filler injections. Plast Reconstr Surg. 2017
Jan;139(1):50e–58e.
16. Carruthers J, Humphrey S, Beleznay K, Carruthers A. Suggested injection zone for soft tissue
fillers in the temple? Dermatol Surg. 2017 May;43(5):756–7.
17. Cotofana S, Mian A, Sykes JM, Redka-Swoboda W et al. An update on the anatomy of the
forehead compartments. Plast Reconstr Surg. 2017 Apr;139(4):864e–872e.
18. Soh J, Chew MT, Wong HB. An Asian community’s perspective on facial profile attractive-
ness. Community Dent Oral Epidemiol. 2007 Feb;35(1):18–24.
19. Kim NH, Chung JH, Park RH, Park JB. The use of botulinum toxin type A in aesthetic man-
dibular contouring. Plast Reconstr Surg. 2005;115:919–30.
20. Ahn J, Horn C, Blitzer A. Botulinum toxin for masseter reduction in Asian patients. Arch
Facial Plast Surg. 2004;6:188–91.
21. Peng HP, Peng JH. Complications of botulinum toxin injection for masseter hypertrophy: inci-
dence rate from 2036 treatments and summary of causes and preventions. J Cosmet Dermatol.
2018 Feb;17(1):33–8.
22. Yeh YT, Peng JH, Peng HP. Literature review of the adverse events associated with botu-
linum toxin injection for the masseter muscle hypertrophy. J Cosmet Dermatol. 2018
Oct;17(5):675–87.
Chapter 20
The Butterfly Technique: Puttipong
Poomsuwan and Rataporn Ungpakorn
Puttipong Poomsuwan and Rataporn Ungpakorn
Introduction
Individual Beauty Preference
Beauty preference is uniquely different between Asian and Caucasian faces. It is

generally accepted that Asians have thicker skin, a flat face with large cheekbones
and a round shape. Somehow people from south-east Asia have darker, thicker skin
and smaller, narrower facial skeletons compared to northern Asia, which makes the
beauty concept variable even among different Asian countries. The anatomical char-
acteristics and cultural differences should be an important part of assessment before
facial cosmetic treatments. Furthermore, people residing in metropolitan areas pre-
fer a trendier international look consisting of good facial definition, high cheekbone
and well-defined jawline. This is accepted as the westernized look of models and in
fashion magazines. However, this does not imply that they desire a complete
Western look but a blend to preserve personal identity while improving their appear-
ances. On the other hand, people in rural areas tend to like oval-facial shapes with
full cheeks. This kind of preference for beauty is also popular among Chinese ori-
gins and southern Asians.
During the last decade, there has been a tremendous increase in the number of
Hyaluronic acid (HA)-based fillers. Now treatments include more indications that
can range from filling the folds to lifting the soft tissues. Present knowledge about
the anatomy and facial aging process provides us with a better understanding in the
use of dermal fillers for non-surgical facial treatment and facilitates the new
approach and better injection techniques for the best outcome.
P. Poomsuwan (*)
AIC Clinic, Bangkok, Thailand
R. Ungpakorn
RAKxa & Vitallife Aesthetics, Bumrungrad International Hospital, Bangkok, Thailand

https://doi.org/10.1007/978-3-030-84099-0_20
336 P. Poomsuwan and R. Ungpakorn
Budget and Outcome
For a beginner or even experienced clinician, treatment with HA Fillers in Asians

sometimes is confusing. Many questions have been raised. Where is the initial point
of injection? Which areas should be included if budget is the main concern? There
are many injection techniques introduced by renowned dermatologists and plastic
surgeons. Some techniques offer no specific guideline to prioritize treatment plans
to create the best outcome for the patients on the first visit. These are among a few
objectives for developing the Butterfly technique as a guideline for all injectors to
use in their daily practice. Another objective is training purposes designed for inter-
mediate to advance injectors who want to improve and achieve more desirable out-
comes. My personal data indicates that 70–80% of the cases would get a satisfactory
result following this technique.
Concept
The Butterfly technique, in short definition, is a facial enhancement technique that

brings beautiful light and shadow to the face by enhancing and creating a lifting
effect on the middle and the lower face using Hyaluronic acid (HA)-based fillers
with high G* with targeted product integration property and injections into spe-
cific areas.
The Butterfly technique has been developed under the three pillars of knowledge:
1. First, the facial anatomy and aging process helps us to understand how to create
a lifting effect from the injection.
2. The second pillar is the understanding of the characteristic of filler material
helps us to improve the outcome. The properties of hyaluronic acid used (non-
animal stabilized hyaluronic acid (NASHA) mainly by the author) in specific
areas of the faces can ensure the predictable immediate and long-term outcome.
3. And lastly, the knowledge from makeup artists that applies light and shadow to
create facial enhancement.
Our face is constructed with five basic layers that are bound together by a system
of facial retaining ligaments. Regarding a functional point of view, the face has an
anterior and a lateral aspect. A vertical line descending from the lateral orbital rim
is a landmark division between the anterior and lateral parts of the face. The anterior
part of the face, particularly the middle and lower part, is a more mobile area that
allows fine movement of the face and is prone to develop laxity with aging [1]. From
a clinical point of view, the middle and the lower third of the face show signs of
aging first and are usually the main and primary concerns for the patients.
From this knowledge, the Butterfly technique focuses on improving the middle
and the lower third of the face. It is a fact that volume loss plays a major role in
facial aging. However, volume replacement may not be the answer for a good
20 The Butterfly Technique: Puttipong Poomsuwan and Rataporn Ungpakorn 337
esthetic outcome. While the use of HA-based fillers has been dramatically increased,
many over-filled injected cases resulting in unnatural look and chubbiness are quite
commonly seen in the past few years. Regarding facial retaining ligaments, true
ligaments attaching the soft tissue to the facial skeleton help to secure the soft tissue
of the face. These ligaments also are lined between soft tissue spaces (Fig. 20.1). If
volume replacement is done in the area of the soft tissue spaces located between two
ligaments, the overlying soft tissue will be supported and pushed back to its posi-
tion, creating a lifted look appearance.
Although filler products with similar G* properties may be considered, NASHA
gel-based fillers are my product of choice for the Butterfly technique. The key is to
use high G* product to create a strong effect in precise areas. NASHA gel-based
fillers contain homogenous gel particles that can stack upon each other to improve
lifting and enable the gel to stay in place for a long time due to its targeted product
integration property (Fig. 20.2). However, my personal observation revealed that the
Butterfly technique can be used with any other high G* HA fillers and can still get
good immediate results. HA gels containing variable particle sizes and cross-link
have a tendency to better integrate to surrounding areas; thus the initial well-defined
contour and lifting effect will not last as long. The initial effect will be seen for a
first few weeks and then gradually disappear, sometimes leaving some swelling and
chubby appearance on the face.
Fig. 20.1 Facial retaining

ligaments. Volume
replacement in the area of
the soft tissue spaces
located between two
ligaments causes supported
and lifted
Fig. 20.2 A demonstration

of targeted product
integration in the tissue
with more pronounced
lifting capacity which
enables projection and
definition
Fig. 20.3 Photograph comparing before and after makeup effect. Note the highlighting on the left
cheekbone and shadow on the lateral cheek creating a contour. The effect expecting from the
Butterfly technique
Nevertheless, for patients with thinner skin and subcutaneous layer or patients
who like a softer look, filler products with high degree of cross-linking and medium-
sized gel particles may be more suitable.
Makeup artists use the knowledge of light and shadow to create beautiful faces.
The beautiful light and shadow from highlighting and shading can create a slim and
lifted look (Fig. 20.3). A precise injection can create highlighting and shading that
enhances beauty (Fig. 20.4).
Patient Selection
The Butterfly technique is designed for lifting and enhancing the middle and lower
face. Patients with heavy-looking or round-shaped contours are the best candidates
for the technique. The technique helps to create better facial contours by enhancing
facial definition in younger patients. Those who have signs of aging with mild to
moderate volume loss and sagging are also good candidates with the exception to
individuals with severe volume loss. This technique can also create a slimmer con-
tour for patients with large-wide cheekbones when professionally performed.
Patients who prefer round-shaped with fuller cheeks may not benefit from this tech-
nique. It is important to clarify and understand patients’ expectation and desires
before performing the procedure.
Fig. 20.4 A butterfly

diagram on the face
simulating areas of
injection in the Butterfly
technique
Injection Technique
Related Anatomy
The Orbicularis retaining ligaments and the Zygomatic cutaneous ligaments are true
ligaments arising from the bone and attach to the dermis. These ligaments play a
major role in supporting tissue of the mid face. As we age, bone resorption and loss
of deep tissue support cause sagging of these ligaments and the overlying tissue [2,
3]. Placement of HA-based fillers on the bone between these two ligaments will
give back the support and lift up the overlying tissue. We can identify the Orbicularis
retaining ligaments as they line along the palpebral-malar groove and the Zygomatic
cutaneous ligaments line under the mid-cheek groove (Figs. 20.5 and 20.6).
On the lower face, the true ligaments that play this role are the mandibular liga-
ments (Fig. 20.5). Here we support the ligaments by placing HA fillers anteromedi-
ally to the mandible.
Fig. 20.5 Shows facial ligaments
Technical Steps
To get a better outcome, I recommend a blunt cannula for injection because this
allows consistent HA filler placement and avoids irregularities and lumps (Fig. 20.7).
The exceptional areas where sharp needles should be used for precise injection are
at the chin and at the area of the mandibular ligaments. My preferences cannulas are
23G* 50 mm Pix’L, 25G* 40 mm Pix’L and 25G* 38 mm Steriglide™.
There are two entry points on each side of the face. The landmark to the upper
entry point consists of an imaginary line descending from the lateral canthus until it
meets the mid-cheek groove. The lower entry point is at least 2 cm from the oral
commissure to avoid injury to the underlying Superior labial artery [4] (Fig. 20.6).
Butterfly Technique minimizes vascular injury in this area by injecting superficially
for marionette augmentation and superficially from the entry point to the deep plane
for nasolabial injection, thus avoiding possible SLA injury.
Fig. 20.6 Photograph

shows the landmarks of
entry points for cannula
injection

comparing injection using
sharp needle size 29 G and
Cannula 23 G. Using
cannula yields a better
distribution of the product
in the tissue

showing placement points
where the filler is placed
deeply onto the bone
The first injection is at the upper entry point. Insert the cannula perpendicularly
until the tip touches the bone. Start a slow bolus injection of 0.2–0.4 ml of Restylane
Lift (Fig. 20.8). Then slide the cannula upwards and medially pointing to the malar
area at the mid pupillary line to place another 0.1–0.3 ml bolus. Do not go beyond
the mid pupillary line because it may cause an unnatural lump at the medial orbital
rim when smiling. These two injections are to place the product on the supra-
periosteum of the malar bone between the Orbicularis retaining ligament and the
Zygomatic cutaneous ligament. This creates a lifting effect of the mid-cheek. The
second injection will also support the lid-cheek junction and improve hollowness
under the eye areas. Usually, the first injection needs more products than the second
injection. The amount of product placed in the first and the second injection may be
different in some cases. Patients with flat faces who need more anterior projection
may need more products at the second injection point.
The third injection is also a deep injection with multiple small boluses along the
upper border of the Zygomatic arch. This injection not only helps to lift the soft tis-
sue of the cheek but also to create a highlight definition of the cheekbone and shad-
ing on the subzygomatic areas simultaneously. Please be aware that the angle of the
cheekbone in females is slightly higher than those in males. Patients with prominent
cheekbone should be taken in consideration when performing the third injection.
The technique is to create a new apex of the malar bone that makes the cheekbones

shows placement points
using the cannula to the
canine fossa where the
filler is placed deeply on
the bone. Placement areas
at the chin and along the
mandibular border under
the mandibular ligaments
using a sharp needle on the
bone (red circles).
Injection at the marionette
area (white arrows) is in
the subcutaneous layer
look more defined and slimmer. Wrong placement of the fillers may widen the
cheekbone and broaden the face.
The lower entry point is for treatment of the nasolabial fold and the marionette
area (Fig. 20.9). Upon entry, insert the cannula pointing towards the canine fossa
until the tip touches the bone, then inject a 0.3–0.5 ml bolus to give a support to the
mid-cheek. The depth of the cannula from the entry to the canine fossa is superficial
to deep. This is in order to prevent accidental injection into the facial artery, which
runs deeply from the area of the entry to more superficially at the base of the nose.
Even though there are many studies showing that injection with blunt cannula
reduces a chance of accidental intravascular injection in comparison to sharp nee-
dles, extra precaution is required when injecting to the areas with large blood ves-
sels [5–8]. For the marionette area, use the same entry point but glide the cannula
downwards and medially to the target area and inject more superficially to the sub-
cutaneous layer. Usually, 0.3–0.5 ml of the product is required here. It is advisable
to perform small aliquots of superficial injections to avoid lumps and bumps. The
injection with retrograde fanning technique will help to spread the product smoothly
and evenly (Fig. 20.9).
The next areas of injection are at the chin and the mandibular retaining ligament
(Fig. 20.9). Here using sharp needle size 27 G or 29 G is easier and more precise.
Injection at the chin does not necessarily mean elongation or augmentation. This
injection will create the apex of the lower face and makes it easier to get a landmark
for symmetry when injecting on both sides of the mandibular retaining ligament
areas. Inject a bolus of 0.2–0.4 ml midline deep on the bone at the lower part of the
pogonion. Chin augmentation for those who require it should be discussed sepa-
rately as they will need more products.
For supporting the mandibular retaining ligament, 2–3 boluses of 0.05–0.1 ml
are injected deep on the border of the mandible, inferior to the mandibular retaining
ligament (Fig. 20.9). This injection not only creates an uninterrupted jawline but
also supports the mandibular retaining ligament and gives a lifting effect to the
marionette and the corner of the mouth.
All the above injection points are to enhance and create lifting by using high G*
with targeted product integration property. The final step is to bring glow and radi-
ance to the face. This is just like a makeup artist using a rounded blush brush for the
smoothening finish.
For glow, radiance, and smoothening effect, the technique is using NASHA gel-
based filler with hydro-balance property that gives hydration to the skin without
swelling when injected superficially. Filler containing the smallest gel particle with
low HA concentration is suitable for the lower orbital and the medial malar areas.
With the same upper entry point, a smaller 25G cannula is more preferable as the
injection plane lies on the superficial subdermal layer. To simplify, I divide the
lower orbital area into three parts as medial, mid, and lateral orbital rim by using an
imaginary line drawn from the medial and lateral limbus (Fig. 20.10). The lower
eyelid area is well-known as an “unforgiving area,” particularly the medial and the
mid orbital rim. Many cases end up with swelling and bluish discoloration from the
Tyndall effect after injection. The smart click system incorporated with the product
allows injectors to place the product precisely and evenly at a 0.01 ml drop per click.
The first step is placing about 3–5 drops of the product to the medial part of the
lower eyelid, followed by another 10–15 drops to the entire area of the middle part
of the lower eyelid. The intention is to blend the lid-cheek junction. The next step is
to inject 15–20 drops into the lateral part and followed by 10 drops to the medial
malar area (Fig. 20.10). The total volume of the product used is about 0.5 ml per
side. If there are more products available, this technique can be applied to the cheek-
bone, nasolabial, and marionette areas. The overall effect is a better glowing finish-
ing look in addition to the Butterfly technique of contouring and lifting.
Results
Usually, patients can notice the improvement immediately after the treatment
(Fig. 20.11). They can expect the better facial definition of their cheekbone and
jawline. Their faces look fresher, lifted, and slimmer. This overall result imitates the
effect of makeup but with equivalent or better appearance (Fig. 20.12). Patients with
thin subcutaneous tissue may experience initial sharp and strong edges of their

shows subdermal injection
at the lower orbital and
medial malar areas using
25 G cannula
Fig. 20.11 Photographs comparing before and after injection using 7 ml of Hyaluronic acid (HA)
based fillers with the Butterfly technique on the front and oblique views
cheekbone, however, the look will be softened spontaneously within 2–4 weeks. On
the other hand, patients with thick subcutaneous tissue usually need more products
and see less effect after 2–4 weeks. Patients in this group should be informed of
possible touching up treatment after 4 weeks for better and longer outcomes. We
can expect longer lasting effects at areas of the face where the fillers are placed
deeply onto the bone [9].
Fig. 20.12 Photographs comparing before injection, after makeup and after injection on the front
and oblique views
Complications
Sequelae such as bruising may be seen in the areas injected with a sharp needle.
Possible mild swelling of the cheekbone for a few days should be informed, but
wrong placement of the filler that causes widening of the cheekbone may result in
unsatisfaction. Injection with blunt cannula is generally considered to be safe from
vascular complication [5–8]. But precaution is required when injecting to the areas
with large blood vessels. With this technique, the depth of the cannula from the
entry point to the canine fossa is superficial to deep. This is opposite to the course
of the facial artery, which runs deeply from the area of the entry to more superfi-
cially at the base of the nose. The right injection technique will prevent any compli-
cations that might occur. Injection with sharp needle must be aspirated with caution,
inject slowly and always stay deep in touch-bone position.
Pearls and Pitfalls
Advantages
The technique brings many advantages to injectors as follows.

1. Clinician with less experience in facial analysis can easily follow the technique
and brings good outcome to most patients from the first visit.
2. Apart from using a blunt cannula, the technique minimizes risks from vascular
complications as most of the injection lines are supra-periosteal in depth and far
away from the danger zone.
3. Minimal two entry points for multiple target areas on each side of the face with
accessibility to large areas of treatment.
Disadvantages
However, there may be a few disadvantages.

1. First of all, the technique addresses many areas of the face, which requires at
least 5–6 ml of products to complete all areas. This could be a big financial issue
for patients with a limited budget. In such cases, the treatment plan may be
divided into two sessions. Most cases, treatment of the upper part, including
cheekbone area and nasolabial fold, are prioritized. The treatment of the lower
face, which are the marionette, chin, and mandibular ligament areas, may follow
in due course.
2. The Butterfly technique uses both blunt cannula and sharp needle. However, the
outcome is much reliable with the proper use of cannulas. Clinicians with less
cannula skills may not get an optimally good outcome as expected.
Conclusion
The Butterfly technique is a strategic injection protocol for the improvement of

facial definition by enhancing and creating a lifting effect with high G* products to
large areas accessible by two entry points. With the use of cannulas, the technique
is anatomically relatively safer from major complications creating a lifting, con-
toured, slimmer face when products are placed accurately. Light and shadow effects
can be an additional enhancement benefit with hydro-balanced NASHA gel-based
filler injection resembling a professional makeup.
The technique helps the clinician to prioritized treatment plans suitable to indi-
vidual patient’s needs to create the best outcome on the first visit. However, facial
analysis is an important skill to optimize different personal, cultural, and fashion-
able preferences. Understanding individual desires through thorough discussions on
outcome to meet up with expectations must be a priority for best satisfaction.
References
1. Peter C. Neligan, Richard J. Warren. Plastic surgery, 3rd edn, Vol. 2, Elsevier; 2013: 78–91.
2. Foad Nahai, The Art of Aesthetic Surgery, Principles &Techniques, 2nd edn, Quality Medical
Publishing, 2011; 1355.
3. Aston SJ, Steinbrech DS, Walden JL. Aesthetic plastic surgery. Elsevier. 2009:61–70.
literature review. Aesthet Surg J. 2019;39(11):1225–35.
5. Jani A. J. van Loghem, Dalvi Humzah, and Martina Kerscher. Cannula Versus sharp needle for
placement of soft tissue fillers: an observational cadaver study. Aesthet Surg J 2016, 1–16.
6. Grunebaum LD, Allemann IB, Dayan S, Mandy S, Baumann L. The risk of alar necrosis asso-
ciated with dermal filler injection. Dermatol Surg. 2009;35:1635–40.
7. Zeichner JA, Cohen JL. Use of blunt tipped cannulas for soft tissue fillers. J Drugs Dermatol.
2012;11(1):70–2.
8. Fulton J, Caperton C, Weinkle S, Dewandre L. Filler injections with the blunt-tip microcan-
nula. J Drugs Dermatol. 2012;11(9):1098–103.
9. Mashiko T, Mori H, Kato H, Doi K, Kuno S, Kinoshita K, Kunimatsu A, Ohtomo K, Yoshimura
K. Semipermanent volumization by an absorbable filler: onlay injection technique to the bone.
Plast Reconstr Surg Glob Open 2013 May 7;1(1).
Chapter 21
Threadlift for Facial Contouring
Fei Han and Souphiyeh Samizadeh
Introduction
Threadlifting can be used as a sole or adjunctive treatment for facial rejuvenation

and recontouring. This chapter summaries the basic principles behind use of threads,
including indications and contraindications, treatment design and landmarks, pre-
procedure preparation, procedure process, and post procedure care are explained.
Common complications and prevention are discussed.
Aging face could be result from the combination of losing skeletal system, facial
soft tissue changed or volume reduction which caused by facial ligament system
loosen or collagen churn. By using thread lifting methods, we can relocate the
ptotic tissue to the desired location. Thread lifting is popular in East Asia for facial
rejuvenation and contouring. Various tread types, shapes and materials and tech-
niques have been introduced to the market and evolving. In this chapter some of the
techniques for facial contouring will be described.
F. Han (*)
Szechwan Bravou Medical Plastic Surgery Hospital, Chengdu City, Sichuan Province, China
West China School Of Medicine, Sichuan University, Chengdu, China
Yi Mei Kang Medical Group, Chengdu, China
S. Samizadeh
University Colleague London, London, UK

https://doi.org/10.1007/978-3-030-84099-0_21
350 F. Han and S. Samizadeh
The Principles of ThreadLifting
Indications
The indications of thread lifting for facial rejuvenation.

1. Dermatochalasis.
2. Facial asymmetry.
3. Eyebrow ptosis.
4. Malar fat descent.
5. Expansion and ptosis of jowl fat.
6. Pretarsal roll.
7. Nose.
8. Nasolabial folds, Marionette lines, pre-jaw sulcus, palpebromalar groove, tear
through and nasojugal groove.
9. Periorbital or perioral area rhytids.
10. Temporal fat pad atrophy.
11. Submalar depression.
12. Buccal fat pad ptosis.
13. Expansion of preplatysmal and subplaysmal fat.
Contraindication
1. Allergy to any of the materials or atopic patients.

2. Acute skin inflammation or infection.
3. Immunologically compromising diseases, for example cancer, HIV.
4. Systemic disease, like diabetes mellitus, Systemic Lupus Erythematosus (SLE),
tuberculosis.
5. Anticoagulants or antiplatelet medication.
6. Pregnancy or lactation.
7. Mental disorder.
8. Bleeding disorders, e.g. haemophilia.
9. Body dysmorphic disorder or those with unrealistic expectations.
Safe Region and Safe Layers
A thorough knowledge of anatomy is crucial. While performing facial threadlifting,

injuring the facial vasculature and innervation should be avoided. For example
superficial temporal vein, superficial temporal artery, facial artery, facial nerve
branches are at high risk of damage if care is not taken. Moreover, injury to the
parotid gland, the duct of parotid gland or muscles should be avoided with correct
technique and placement of the threads.
21 Threadlift for Facial Contouring 351
When the thread passes through the anterior buccinator ligament, need to be
careful around the zygomatic fat pad and buccal fat pad due to the presence of zygo-
matic (supply the orbicularis oculi) and buccal branch (innervating orbicularis oris,
buccinator, and zygomaticus muscles) of the facial nerve. The nerves pass through
deeply into zygomatic and buccal fat pads.
reoperative Assessment, Communication, Examination,

P
and Preparation
Preoperative Evaluation and Communication
Facial assessment and communication are key to treatment planning and optimal
outcome. Facial asymmetry and the need for multidisciplinary care and treatment
should be discussed.
Determine whether there is a history of previous facial trauma, facial surgery,
facial thread lifting, facial fat transplantation or liposuction treatment as there are
often varying degrees of adhesions and fibrosis between tissues, which will increase
the difficulty of detachment and tissue threading and hence increase the difficulty of
accurate positioning.
Preoperative Examination
1. Routine preoperative examination in plastic surgery.

2. General physical examination: especially the skin and soft tissue of the face
(treatment area), excluding dermatitis, skin allergy, local infection, tumours,
and so on.
3. Laboratory tests: such as blood routine, complete set of blood coagulation, bio-
chemical, blood glucose, infectious disease testing and other tests including
ECG if intravenous anaesthesia is considered.
Preoperative Photography
It is recommended to take pictures in 7 standard positions, pay attention to keeping

the spine straight, relax both shoulders, and relaxed lips.
• Pay attention to the distance from the camera. It is recommended to maintain a
distance of more than 1 metre to avoid distortion caused by being too close.
• Pay attention to the standardization of lighting, for both before and after pictures.
• Three-dimensional photography can be carried out if possible, which would also be
convenient for preoperative design and post-operative curative effect evaluation.
Fig. 21.1 Perform a manual simulated lifting and confirm the position and degree of the lifting
with the patient
Body Position
Generally, adopt sitting position for assessment, treatment planning and determin-
ing the landmarks, supine position for disinfection and anaesthesia.
Design
• Perform a manual simulated lifting and confirm the position and degree of the
lifting with the patient (Fig. 21.1).
• Mark the nasojual groove, the nasolabial folds and the marionette line, in the
natural head position and while relaxed, and mark the corresponding target tis-
sues that needs to be improved, such as the buccal fat pad ptosis and the malar fat
(Fig. 21.2).
• While opening the mouth, the extent of the protuberance of the temporoman-
dibular joint, the zygomatic ligament and the anterior edge of the masseter mus-
cle can be marked (Fig. 21.2).
• Mark the fixation points (anchor points), insertion and exit points for the thread
(Fig. 21.2).
Fig. 21.2 Mark the

nasojugal groove, the
nasolabial folds and the
marionette line, in the
natural state, and mark the
corresponding target
tissue that needs to be
improved
Considerations
1. Anchor Point.
• Ligaments (Fig. 21.3).
–– True ligament: zygomatic cutaneous ligament, platysma-auricular liga-
ment, mandibular cutaneous ligament and supra-orbital ligament.
–– False ligament: Masseteric (masseter) cutaneous ligament.
• Muscle Fascia.
–– Temporalis fascia.
• Periosteum.
–– Mastoid periosteum.
• Bone.
–– Zygomatic arch of zygomatic bone.
2. Target Region for Lifting.
• Fat compartment.
• False ligaments.
Temporal ligamentous adhesion
zygomatic ligament
Messeteric cutaneous ligament
Mandibular retaining ligament
Fig. 21.3 True ligament: zygomatic cutaneous ligament, platysma-auricular ligament, mandibular cuta-
neous ligament and supra-orbital ligament. False ligament: Masseteric (masseter) cutaneous ligament
• Deep fat pads.

• True ligaments.
• Subcutaneous tissue.
3. Entry and Exit Point Selection.
• Invisible/Hidden.
–– The entry and exit points are selected in hairline, peri-auricular area or
margin of the mandible.
• Visible.
–– The entry and exit points all located on the face.
4. Design and Layer.
• Linear shape (Fig. 21.4).
• Curve shape (Fig. 21.5).
• Circle shape (Fig. 21.6)
• Vertical method S shape (Fig. 21.7).
• V shape(Fig. 21.8).
• Y shape (Fig. 21.9).
• Z Shape and multiple Z shape (Fig. 21.10).
• X shape (Fig. 21.11).
Fig. 21.4 “Linear shape”

(Fig. 21.4), with four entry
points (marked by red
circle) around the hairline
in the front of ear, and
place four threads with
barbs in opposite
directions inserted in each
point. The distance
between these adjacent
points is suggested to be
1–1.5 cm
Fig. 21.5 The “curve

shape” insertion pattern
(Fig. 21.5) is usually used
for the mandibular
margin area. Place the
threads from the entry
point (marked by red
circle) in the front of
the ear, insert along the
mandibular margin to the
two exit points (marked by
green circle) near
marionette lines. This
method can make the
contour of mandibular
margin more clear, and
reduce the appearance of
marionette lines
Fig. 21.6 The “circle

shape” pattern- from the
threads are extruded from
the exit points (marked by
yellow circle) and
then reinserted at the same
point and looped back to
the entry point (marked by
red circle) (Fig. 21.6)
Fig. 21.7 Vertical method

“S shape” (Fig. 21.7).
This approach helps to lift
the tissues with only one
thread, however, the
quality of threads should
be good to avoid breaking
Fig. 21.8 The V shape

(Fig. 21.8), Y shape
(Fig. 21.9) and X shape
(Fig. 21.11) have the same
design concept. According
to the degree of ptosis and
jowling (light (V Shape),
medium (Y Shape) and
heavy (X Shape)), these
methods can be used. V
Shape can be used for
targeting minimal ptosis
Fig. 21.9 The V shape

(Fig. 21.8), Y shape
(Fig. 21.9) and X shape
(Fig. 21.11) have the same
design concept. Y Shape
can be used for targeting
minimal ptosis
Fig. 21.10 Single long thread

(36–45 cm) for soft tissue
repositioning, facial contouring
and rejuvenation
Fig. 21.11 The V shape (Fig. 21.8), Y shape (Fig. 21.9) and X shape (Fig. 21.11) have the same
design concept. X Shape can be used for targeting minimal ptosis
Fig. 21.12 Other patterns and loops (Figs. 21.11, 21.13, and 21.14) are used for repositioning
of malar fat descent and improving the jawline. Figure 21.13 place the threads from the entry point
(marked by red circle, named 1st point) in the front of ear, through the malar fat to the exit point
(marked by yellow circle, named 2nd point) which is kept 1 cm distal (perpendicular) to the naso-
labial fold, and return into the same point (2nd point) to the exit point (marked by yellow circle,
named 3rd point). Then place the thread across the subcutaneous tissue from the point (marked by
yellow circle, named 3rd point) to the point (marked by yellow circle, named 4th point) near the
malar fat, and return to the exit point (marked by green circle, named 5th point) which is located
at the line between the lateral canthus and the earlobe (1 cm away from the lateral canthus). This
technique can be used to lift the malar fat. Other more advanced techniques are presented in Figs.
21.14 and 21.15
• Irregular shape/loops (Fig. 21.12).

• Staggered placement (Fig. 21.13).
• Rake shape (Fig. 21.14).
• R-V Shape (Fig. 21.15).
The design for placement of threads will depend on the indications and patient
expectations. While designing the thread landmarks, it is important to consider if
the ptotic soft tissues can be “lifted” optimally and effectively to the desired posi-
tion with the chosen threads. In addition, the relationship between threads should be
kept in mind so the intended forces do not work against each other.
In order to achieve the resultant overall force more effectively, the first author has
designed the thread lifting method of “cable-stayed bridge” according to the archi-
tectural principle of the mechanical design of “cable-stayed bridge,” such as
Fig. 21.13 In order to achieve the resultant overall force more effectively, the first author has
designed the thread lifting method of “cable-stayed bridge” according to the architectural principle
of the mechanical design of “cable-stayed bridge,” such as staggered placement (Fig. 21.13) and
Rake shape (Fig. 21.14). Like a cobweb, it is composed of main thread (2–0, 1–0, 0) and thin
thread (5–0, 4–0), which are interlaced and interlocked to passing into the target layer and layout
to form a whole system to lift and tighten the facial regions. Yellow arrow indicates the main direc-
tion of facial lifting
a b
Fig. 21.14 (a) Multiple threads (b) single long thread (36–45 cm)
staggered placement (Fig. 21.13) and Rake shape (Fig. 21.14). Like a cobweb, it is
composed of main thread (2–0, 1–0, 0) and thin thread (5–0,4–0), which are inter-
laced and interlocked to passing into the target layer and layout to form a whole
system to lift and tighten the facial regions. Moreover, this method can also induce
the foreign body reaction to stimulates the body to make the fibrous capsule named
“Autogenous ligament” around the thread netting, keeping the “lift” effect after the
threads are absorbed. For other parts, threads can be anchored to the zygomatic fat
pad and buccal fat pad for facial lifting.
Rake shape (Fig. 21.14b) is a special method and uses a much longer (36–45 cm)
unidirectional barbed thread which is attached to a cannula or long needle. In differ-
ent layers or tissue, we fold the thread only one or several times to lift and tighten
the target tissue. The advantage of this method is lifting the multiple adjacent
regions of the face. However, compared with surgical knot fixation, the lifting
strength of this fixation is weak. According to the current understanding of the pre-
masseteric space, we can fold the thread through the superficial layer. Thus, the
SMAS fascia and superficial fat compartment can be taken together, enhancing the
lifting and tightening effect, so as to form the V-shaped jaw line effect.
Moreover, the R-V shaped (Fig. 21.15) is based on the curve shape (Fig. 21.5)
and circle shape (Fig. 21.6) designs. This design is patent enter in China. It belongs
to the traditional method similar to purse string suture, to locate the thread in and
out through tissues and structures, such as deep temporal fascia, periosteum, zygo-
matic arch to form a suspended or loop around the tissue to achieve precise tissue
tightening and lifting. This method in general requires a thread length 36–45 cm
or longer.
The closed circle of the upper part of the R is designed at the top edge of the
temporal muscle, at the junction of the temporal deep fascia and the skull
Fig. 21.15 Single long thread (36–45 cm)

periosteum, and both sides are designed to be in the superficial layer of the temporal
deep fascia. They would meet with the posterior part of the closed circle above the
auricle margin 1 to 1.5 cm and extend down to the superficial fat compartment of the
mandibular margin.
V-shaped threadlift in the R-V shaped system methods is placed by two threads
from the same entry point near the junction of the upper margin of the zygomatic
arch and the frontal edge of the temporal hairline, one of the threads crosses the
middle cheek fat to the deep middle cheek fat, the other thread crossed the space
between the zygomatic arch and temporal bone, and get through the buccal fat pad,
to lift the middle cheek fat and the buccal fat pad. Knot the remaining threads at the
entry point to make sure all are fixed at the zygomatic arch.
Tissue Relocation and Fixation
The Significance of Tissue Relocation
The ideal treatment would be to correct the position and volume of the superficial
fat compartments, zygomatic fat pad and buccal fat pad to their original, youthful
position. It is important to correct according to anatomical location of the tissues to
avoid increasing bizygomatic width and malar over-projection.
The Fixation of the Relocated Tissue
Generally, the tissue relocation and lifting could be done simultaneously. Once the
ptotic tissue is relocated to the ideal location, the spring, spiral, and smooth threads
could all be combined to fix surrounding tissue after relocation. This method could
be used to increase the adhesion of the relocated tissue and surrounding tissue and
a longer lasting result.
Static Facial Lifting and Dynamic Adaption
Treatments are mainly carried out while the patient is static with no facial expres-
sions. Excessive tightening of the threads could result in a great immediate effect
but short-lasting due to facial expressions and soft tissue movement post-treatment
and, therefore, patient dissatisfaction. During normal movements such as speaking,
chewing, and yawning, it is unavoidable to open the mouth and furthermore, it may
lead to decease in the stability of the thread which crossed the temporomandibular
joint. Moreover, it also causes dislocation and breakage of the thread. Hence, we
should consider thread stability while designing and choosing threads and landmarks.
Simple or Complex Thread Design
With the increasing demand for immediate effects, minimal to none post-treatment
discomfort and increased longevity, threads and techniques are evolving, including
progression of simple techniques to overly complicated patterns and techniques.
However, more simple but effective methods are being preferred by the practitio-
ners’ due to the ease of understanding, placement, evaluation, and complication
prevention.
Factors Affecting Longevity and Post-Operational Comfort
Thread Material
Maintenance of effective tension is an important factor and arguably more impor-

tant than the absorption time of the thread.
Thread Surface Characteristics, E.G. Barbs (Fig. 21.16)
Although more expensive, the protruding surface characteristics of the thread, for
example barbs, resulting in better stability. However, because the barbs are thin and
relatively small, they get absorbed quicker than the main body of the thread.
However, approximately after near a month, the barbs can become round, blunt, and
loss their holding power.
CUT
PRESS
PRESS
Fig. 21.16 Example of barbed threads and manufacturing process

The Layer for Thread Lifting
The traditional method for the superficial fat compartment threadlifting method is
not suitable for all indications. Therefore, patient assessment and evaluation are
fundamental in understanding which tissues need to be repositioned.
The Numbers of the Thread To Be Used
The indications, patient tissue type and desired outcome will determine the number
of threads to be used.
Number of threads should be determined according to the characteristics of the
thread used and the area of tissue re-alignment. When small number of threads are
used, although the initial result may appear optimal, the results would be shortlist-
ing. However, the disadvantage of more threads being used is more pain and swell-
ing immediately post-treatment and longer recovery period. The new thread
technologies such as the single long moulding thread (36–45 cm), enable placement
of less threads with better results and comfort for the patients, and the duration
maintained more than 8 months to 12 months.
Fixation of the Threads
The post-operative result also depends on management and fixation of the threads.
Bi-directional, smooth, and spiral threads do not need to be fixated. The threads
with uni-direction barbs can be tied ideally to a fixed position rather than mobile
tissue. Even though we used effective methods for fixation, post-treatment and
facial expression, some laxity and ptosis can be noted after one month.
Thread lift Procedure
Anaesthesia
Nerve Block and Local Anaesthesia
• Most patients accept thread lifting under local anaesthesia only. The choice of nerve
block and/or local anaesthesia lies on clinical judgement of the practitioner.
• Nerve block: 2% lidocaine 5 ml–10 ml + epinephrine (1: 200000).
• Infraorbital nerve and mental nerve block mainly, combined with buccal nerve,
zygomaticotemporal nerve (trigeminal nerve) and auriculotemporal nerve block,
if necessary.
• Local anaesthesia: 2% lidocaine 10 ml + 2.0 mg/ml ropivacaine 20 ml + epi-
nephrine (1: 200000).
• To prolong and enhance the effect of local anaesthetics and to help reduce swell-
ing, dexamethasone can be added to local anesthetics.
• The total amount of local anaesthetic injection on the whole face should be
within 10–15 ml range and not more.
•
Sedation can be considered for duration injection of local anaesthesia for
extremely nervous patients.
• It is not recommended to carry out the complete procedure under sedation.
• After the first half of the face is treated, the practitioner can show to the patient
and communicate with the patient to improve satisfaction.
Pain Relief and Comfort Management
• The night before the procedure, the patient is advised to get adequate sleep, if
necessary, medication can be given to ensure sleep quality.
• Before the operation, topical anaesthetics can be applied, 3 mm thickness, cov-
ered with cling film, generally lasting for 40 min, which can help reduce the
pain caused by injection during local anaesthesia. It is noteworthy not to leave
the topical anaesthetics for longer than one hour to avoid localized allergic
reactions.
• Analgesics can be taken orally half an hour before treatment.
• A sterile ice pack can be used to apply ice during the operation.
• 34G needle and 1 ml syringe, 23G 7cm blunt cannula and the 1 ml syringe are
selected for anaesthetic injection (Fig. 21.17).
• Moderate bandages and fixation after the operation can reduce post-operative
pain and swelling.
• Injection of botulinum toxin into the temporal muscle can relieve the post-
operative pain after to a certain extent (when this area is used for insertion and
exit points and fixation).
• Operate gently, keep in touch with patients post-operatively.
Sterility and aseptic technique are extremely important during thread lifting pro-
cedure (Fig. 21.18).
Fig. 21.17 34G needle and 1 ml syringe, 23G 7cm blunt cannula and the 1 ml syringe, are selected
for anaesthetic injection
Fig. 21.18 Procedure setup
Entry Point
ntry Point Using a Needle, 11 # Sharp Surgical Blade or

E
Puncture Instrument
The direction of skin puncture point: perpendicular to skin or 15° from the skin
surface (Fig. 21.19.). The skin at the incision point should be lifted.
Various techniques can be used for blunt dissection of the region, including using
pliers or other devices. Selective blunt dissection, for example in the subzygomatic
area, can be carried out to prevent post-treatment soft tissue depression (Fig. 21.20).
Thread Insertion
Insert the needle at 15°to the surface of the skin. Then the thread is passed inferiorly
step by step from superficial to the desired depth. For example in the temporal
region, subcutaneous tissue, superficial temporal fascia, innominate fascia, superfi-
cial layer of deep temporal fascia, temporal fat pad, and superficial deep temporal
fascia. Be careful not to insert the thread into the temporalis muscle. Another exam-
ple is the midface area; the direction of the needle should be changed from superfi-
cial to deep cheek fat compartments (Fig. 21.21). If the thread is placed in the
subcutaneous layer only, this may cause skin depression near the tip of the needle,
and it can only tighten the skin with insufficient soft tissue lifting effect.
Fig. 21.19 Skin punctured

by acupotomy
a b
Fig. 21.20 Mark the hollow areas and shadowing in the cheek below the zygomatic arch (a). The
16G-18G cannula is not only used to place the threads but also used for blunt dissection (b), this is
done to prevent depression of the soft tissues post thread insertion, and also to increase the effect
for lifting of the malar soft tissues
Operative Key Points: Non-Dominant Hand
The non-dominant hand and the dominant hand coordinate with each other. It is
particularly important to improve tactile sensation and hand-eye coordination.
During dissection and thread placement, use the non-dominant hand to ascertain
whether the thread insertion layer is correct and to guide placement.
Use the non-dominant hand to immobilise the skin and soft tissues during the
needle entry and to lift the soft tissues to check the depth when placing the thread
into each layer. Gently and carefully push the tissue against the direction of needle/
cannula, to assist the ease of movement. In the whole process from needle inserting,
a b c
Fig. 21.21 (a) and (b)-Assessment (c)-Insert the needle at 15°to the surface of the skin. Then the
thread is passed inferiorly step by step from superficial to the desired depth. For example in the
temporal region, subcutaneous tissue, superficial temporal fascia, innominate fascia, superficial
layer of deep temporal fascia, temporal fat pad, temporal fat pad, and superficial deep temporal
fascia. Be careful not to insert the thread into the temproralis muscle. Another example is the mid-
face area, the direction of the needle should be changed from superficial to deep cheek fat compart-
ments at appropriate place (Fig. 21.21)
Fig. 21.22 Operative key

points- The non-dominant
hand guides thread
placement
thread placement, to the exit, the non-dominant hand is acting as a guide

for both thread placemnet and tissue realignment. Do not remove the hand before
re-confirming that the target tissue has been firmly lifted by the barbed thread
(Fig. 21.22).
After the barbed thread with cannula is inserted into the target tissue, reverse pull
the thread lightly to confirm the end of the barbed thread has engaged the target tis-
sue. After it is confirmed, gently and slowly remove the cannula and guide pin-
approximately 3 mm–5 mm, then pull the thread to reconfirm, continue this action
gently several times until the cannula is fully out, remove the cannula, so that the
target tissue is locked and lifted. The placement of the barbed thread and smooth
thread in “feather shape” (see Fig. 21.14) or cross hatching is more effective than
placement of barbed threads alone. The fixation of target tissue with the “O” or” R”
shape designs is more effective, even with when thread without barbs are used. To
avoid skin tethering, the thread should not be placed or fixed too superficially.
Placement of the Remaining Thread at the Exit Point
The options include:
• No knots-inserted subcutaneously.
• Kont(s) and insert subcutaneously.
• The single direction barbed thread with cannula, insert into the subcutaneous
layer, cannula to be removed and reinserted at a different direction (30–60°),
repeat the placement of thread (single or multiple “Z” shape or “Rake” shape)
until the thread completely placed subcutaneously.
• When using the multiple direction barbed threads, it is recommended to knot any
two threads.
• When using bi-direction barbed threads, cut off the excess end of the thread.
(Fig. 21.23.)
After the completion of treatment of half of the face, it is recommended to con-
sult (show) to the patient and take pictures in the sitting position for both the doctor
and patient’s reference (Fig. 21.24.).
Fig. 21.23 Thread exit

point
Fig. 21.24 Show the effect

once treatment of one side
of the face is completed
Post-Operative Management
After the procedure, apply ice immediately for half an hour, and then ice application
for up to 72 hours intermittently to reduce edema and bruising.
Facial elastic sleeve is recommended to be worn immediately after and for 7 days
with 24 hours each day, after 7 days, wear the facial elastic sleeve for 1–3 months
daily intermittently (should not bee too tight).
On days 1,7, and 14 after the procedure, review visits are recommended to
review, reinfoce aftercare, provide professional guidance and psychological support
during the recovery period if required. One, three and six months post procedure
review appointments are recommended.
The thread lift is an outpatient procedure. By educating patients on what to
expect during and after the procedure, importance of good aftercare, providing
extended care services, and actively reviewing patients and answering any questions
or doubts they may have, their recovery can be smooth and eventless.
Complications and Precautions
Common Complications
1. Exposed Thread-This can happen (Fig. 21.25) due to movement of thread without
fixation, or the gradual movement of a torn/broken thread. Under the aseptic tech-
nique, the exposed part of the thread can be removed and the wound treated.
2. Thread Migration-In this case the contour of the thread can be seen under the
skin, or sometimes the thread can move in the subcutaneous tissue. This is due to the
too superficial placement of the threads. If it has little effect on the appearance and
Fig. 21.25 Exposed

Thread
no discomfort for the patient, regular massage and hot compress can promote
decomposition and absorption of the thread. It usually disappears in about 2 months.
When the appearance is affected, or the patients insists on treatment, non-crosslinked
hyaluronic acid can be injected locally, or the thread removed by making a small
incision.
3. Abnormal appearance-Due too much lifting, too much tight ending of the
threads or change of face shape or expressions. Best to reflect on the design step.
Generally, no special treatment is required and within 2–3 months this would
resolve. In case the change is needed, threads can be cut or removed.
4. Facialasymmetry-It is important to take a note of pre-existing asymmetry and
discuss it with the patient prior to treatment. In such cases, multi-modal treatment
may be required. In addition, carry out the treatment in a sitting position can reduce
the possibility of exacerbating asymmetry due to thread lifting. Mild asymmetry
post-procedure can be addressed by adjusting the threads, adding more threads or
use of injectables.
5. Local Distortion Or Local Buildup of Soft Tissue-Avoid too complex thread-
ing and complex designs, especially multiple designs in the same region, correctly
grasp the “relay lift” and “multi-direction lift”methods prior to treating patients, do
not overtighten. Local massage sometimes can help. In moderate-severe cases, care-
ful dissection may be needed.
6. Skin Lacerations and Local Unevenness-Unevenness or skin lacerations post
treatment in these three regions are the most common: buccal sulcus, zygomatic fat
pad area, junction with masseter muscle skin ligament, and lower zygomatic arch
ligament. The skin lacerations are strip lacerations along the thread direction, while
the strip depressions are mostly perpendicular to the thread direction. (Fig. 21.26)
Pay attention to the depth of the thread insertion, when too superficial, remove the
Fig. 21.26 Unevenness

Post Thread Placement
thread and replace it. Immediately after the treatment, the mild unevenness and
bumps can be massaged and gradually recover in 2–4 weeks. In cases of severe dim-
pling or unevenness, a small needle can be used to release local adhesions or cut off
the barbed thread and correct it with dermal fillers.
7. Hematoma-The possibility of deep hematoma should be considered for
any abnormal local swelling which can be caused by puncture injury of blood ves-
sels. (Fig. 21.27) Find out if the patient is taking anticoagulant medications. Local
anaesthetics mixed with the appropriate amount of epinephrine can effectively con-
tract blood vessels and reduce the occurrence of hematoma. Familiarize yourself
with anatomy and avoid danger zones. Apply ice immediately after the procedure,
and advise the patient to wear an elastic face sleeve. Chinese doctors recommend
not to do the treatment during the menstruation period. Bleeding during the proce-
dure should be dealt with immediately prior to continuing treatment. Patients should
be educated regarding symptoms of delayed bleeding and haematoma and instruc-
tions given, including cold compress and pressure and going to the hospital if severe.
Fig. 21.27 Haematoma

post treatmeny
a b c d
Fig. 21.28 (a) A 36 years old Female, presented with infection from the temporal area to zygo-
matic arch region after having threadlifting 1 month prior. (b) Local debridement, and cleaning of
the infected region, the threads were completely removed. (c) One week after treatment. (d) One
month after treatment
8. Infection-Local effusion, skin redness, pain and swelling with or without pus
from the entry/exit points are indicative of infection (Fig. 21.28). Patient selection
is important; there should be no local inflammation or infection. To prevent infec-
tion, the strict aseptic technique should be observed and treatment carried out in a
clinical environment, oral antibiotics can be given for 1–3 days after the treatment.
Treatment sequence is as follows:
1. A diagnostic puncture for bacterial culture and drug sensitivity test. Broad-
spectrum antibiotics are used in the early stage. After obtaining the results of the
bacterial culture, the antibiotics are adjusted.
2. Local debridement, remove the thread and clean the infected lesion, the infection
can extend along the thread tunnel. In principle, the thread should be removed
completely while avoiding unnecessary trauma, rinse with hydrogen peroxide
solution and abundant saline. Place a drainage strip if needed. If necessary, con-
tinuous negative pressure drainage can be placed. Periodically alter the medica-
tion if needed and according to the drainage until the infection is under control
and wound healing ensues. If necessary, PRP can be injected into the periphery
of the infected area and infiltrated with PRP in the infected centre.
3. If there is no bacterial growth in bacterial culture and no improvement after the
above treatment, delayed healing or recurrence after healing, the possibility of
non-tuberculosis mycobacterium infection should be considered and consult rel-
evant specialists.
Other Complications
Persistent or Intermittent Post-Operative Pain
Post-operative persistent or intermittent pain, more than 1 week, often occurs during
chewing and specific expressions and facial movements. The degree and duration of
pain are significantly different from the pain caused by the trauma response. To
prevent this, select relatively soft threads with the appropriate thickness. The
thread placement layer should be strictly in the SMAS layer or above, and not too
deep. After the treatment, the elastic face sleeve should be worn in accordance with
the doctor’s advice. Treatment includes local hot compress, wear elastic face sleeve
to avoid excessive movement of muscles of expression. Generally, these subside and
resolve in 2–3 months as the threads are well into their dominant degradation period.
If PPDO threads are used, non-crosslinked hyaluronic acid can be injected to accel-
erate the degradation of the threads.
Neurological Injuries
Sensory nerve injury is characterized by hypersensitivity or dullness; motor nerve

injury is characterized by muscle weakness, mouth, and eye deviation, facial paraly-
sis and so on. Understanding of anatomy and correct techniques are important to
prevent such injuries.
Oral medications can be considered (oryzanol, adenosine coenzyme B12, etc.),
in addition to acupuncture and hot compress. Mild symptoms improve in 3 to
4 weeks. For moderate to severe pain, further diagnosis and treatment is required.
Taking care of the patient and their mental wellbeing is necessary.
Vascular Compromise and Necrosis
This is very rare. But based on the particularity of the nasal skin, thread augmenta-
tion rhinoplasty may lead to vascular compromise. Be familiar with anatomi-
cal structures, layers, and techniques used. It is advisable to place a safe number of
threads. Too many threads and too closely placed result in increase local tension and
complications. If there is vascular compromise, timely diagnosis and treatment
are paramount. In case of necrosis, treatment includes removal of the threads, local
debridement, antibiotics, autologous platelet-rich plasma compress on the wound
and injection in the peripheral area, and/or autologous platelet-rich fibrin applica-
tion once a week. Wounds with less than 1 cm diametre usually heal after 1–2
treatments. The larger wounds may need further surgical intervention, and local flap
a after inflammation is controlled.
Parotid Gland and Parotid Duct Injuries
The possibility of parotid duct injury should be considered if there is consistent dif-
fuse swelling and pain in the parotid region. The swelling can enlarge when eating,
and reduce in size when pressing it. Understanding anatomy is crucial. Treatment
includes consultation with oral and maxillofacial surgeons, use of local compres-
sion bandage, oral atropine 0.6 mg half an hour before a meal, to reduce chewing
and eating acidic food and surgical intervention may be required.
Recurrent Skin Redness
Recurrent redness and swelling in the treated area, which could be accompanied by
itching, elevated skin temperature, and other inflammatory responses. Use safe and
certified threads, and carry out the procedure under strict aseptic technique. Allergy
and infection should be excluded.
Local Pigmentation
Localised and irregular patchy pigmentation in the thread insertion site can
appear after the surgical trauma reaction subsides. In most cases, these fade gradu-
ally after a few months. During the consultation, ask patients regarding their normal
healing post-trauma and scar formation. Check for history of postinflammatory pig-
mentation and keloid formation. After the procedure, the area should be kept very
clean, and cold compress used. Plasters with anti-inflammatory effects and wound
repair formulations can be used externally to prevent infection and promote healing.
Post procedure, sunscreen should be used and face protected from the sun.
Post-Ttreatment Instruction
• One week after the procedure, the entry points should not be touched or moist-
ened. These should be disinfected, and antibiotic ointment placed daily. The
insertion and exit points can also be sealed with biological glue.
• Oral antibiotics for 1–3 days to prevent infection.
• There will be some pain and tenderness for a few days, painkillers can be
taken orally.
• Application of make-up should be avoided immediately after; the makeup parti-
cles, bacteria in the makeup and their chemical composition can easy cause
infection.
• Intermittent cold compress for 72 hours after the procedure can help prevent and
reduce bruising and swelling. Educate patients to prevent frostbite.
• Post surgery compression face mask is recommended for one week after the pro-
cedure and intermittently for 2–3 months after.
• Do not rub or massage the face for one month after the procedure. Avoid opening
the mouth widely and making exaggerated expressions such as excessive chew-
ing and laughing. Avoid seeing the dentist or having dental treatment if possible.
• For one month after, no cosmetic treatments or facials. These may lead to infec-
tion, thread degeneration and other complications.
• Try to avoid the mesotherapy in the treated area for 2 months, and any other treat-
ments such as facials, injectables, and lasers.
Conclusion
Thread lifting can be part of multidisciplinary treatment protocols for facial con-
touring and rejuvenation in all nationalities. Botulinum toxins, dermal fillers, fat
grafting, lasers and PRP can be effectively used in combination with threadlifting.
PRP can be injected at the same time to promote healing.
Cases
Before and After
Threadlift (Rake shape)-No other treatment-Before, half face, and After

Threadlift (Rake shape)-No other treatment-Before and After
Threadlift (R-V shape)-No other treatment-Before and After

Threadlift (R-V shape)-Before and After
Threadlift (R-V shape)-No other treatment-Before and After

Threadlift (R-V shape) Before and After
Face: SVF injections, Nose: threads placed Before and After

Face: SVF injections Nose: threads Before and After
Ultrasonic lipolysis and threadlift (R-V shape) Before and After

Ultrasonic lipolysis and threadlift (R-V shape) Before and After

Chapter 22
Endotine Ribbon Lower Face Lift
Wei-Chung Liang
Indication and Contraindication
This technique is indicated for patients with mild to moderate lower face component
descent. It is ideal for patients with isolated jowl and early losing jawline. The tech-
nique is not ideal for either patients with severe facial skin laxity nor for patients
who have objects for the significant change after the operation.
Many patients have set the noninvasive technologies as the first line treatment
currently. Despite this, some of the results are less than desired. A well-performed
classical face lift rhytidectomy continues to provide significant and lasting results
compared to its nonsurgical alternatives. Between this two end, ribbon lower face
lift provides a novel choice in the middle position. Its invasiveness and the results
are in the middle of those treatment.
The advantages of this technique include shorter operative times, quicker recov-
ery, and less patient morbidity. In the right patient, and executed concurrent with
proper liposculpture, this procedure can produce a satisfied patient then expectation.
Satisfaction is still high after repeat procedure with the interval around 3–6 years,
which is just the average endurance in my series. The oldest patient of my series is
68 Y/O so far.
W.-C. Liang (*)

Board-certified Plastic Surgeon, Taipei, Taiwan
Liang Wei-Chung’s Cosmetic Clinic, Taipei, Taiwan

https://doi.org/10.1007/978-3-030-84099-0_22
384 W.-C. Liang
Introduction
Various SMAS procedures [1] are the mainstream treatment for lower face rejuve-
nation. For patients who are adverse to preauricular scars, or who prefer a fast
recovery, Endotine Ribbon lower face lift is the alternative. The results rely not
solely on mechanical fixation, tissue dissection and tissue reposition make a great
contribution. Considering the reliable Endotine Ribbon holding strength and the
dissected plane readherence, this procedure should not be confused with thread lifts.
Endotine Ribbon was designed for minimally invasive jowl and neck lift; however,
the manufacturer’s suggested operation technique is different from the author’s
technique. In this chapter, the author would like to put emphasis on this new appli-
cation of the Endotine Ribbon for lower face lifts.
The Device
MicroAire’s Endotine Ribbon [2] is a bioabsorbable fixation device. It features tines

with tips that are 2.5 mm above the platform. The multipoint fixation tines are fash-
ioned on a uniquely flexible platform. The multiple tines distribute the tension and
avoid the “cheese-cutting” phenomenon. This platform can curve along the lower
face contour, which results in smooth and close contact with the face. The device
was designed with a protective cover to facilitate a smooth insertion process; thus,
its application is straightforward.
My Method
A 2 cm-length incision is made along the postauricular groove (Fig. 22.1). The skin
flap is raised in a very thick fashion (Fig. 22.2). A thick flap avoids future palpable
stich nodes. The exposed fascia structure beneath the skin flap is prepared for later
Fig. 22.1 A 2 cm-length

incision is made along the
postauricular groove
22 Endotine Ribbon Lower Face Lift 385
Fig. 22.2 The skin flap is

raised in a very thick
fashion. A thick flap avoids
future palpable stitch
nodes. Blunt dissection is
applicated posterior to the
ear lobe to preserve the
postauricular nerves
Fig. 22.3 Anterior dissection is kept at a certain depth so that the subSMAS plan may be accessed.
It is an effortless step because of the naturally existing premasseter space with only loose areolar
tissues in between. Dissection will be stopped upon resistance, at that time, the pocket will have
been well prepared for the Endotine Ribbon device placement
Endotine Ribbon fixation. During the raising of the flap, a few postauricular nerve
branches might be encountered. Efforts to save them by blunt dissection is sug-
gested. Further anterior dissection is kept at a certain depth so that the subSMAS
plan may be accessed (Fig. 22.3). Located two centimeters anterior to the ear lobe,
the subSMAS plan is virtually synonymous to the premasseter space [3]. At this
stage, blunt dissection proceeds without resistance, and the space will expand and
be created within a few seconds because it is a naturally existing space with only
loose areolar tissues in between. In inexperienced hands, initial misdissection deep
into the parotid glands is possible, but once returning to a more superficial and non-
resistant plan, it causes no sequela. The premasseter space dissection will be stopped
upon resistance, and the pocket will have been well created by that time. Within this
space, gentle dissection takes place naturally, and there is no nerve injury risk
throughout the procedure. After the subSMAS premasseter space is prepared and
the tunnel beneath the ear lobe is widened enough, one subcutaneous bite by 2-O
Prolene suture is made a centimeter in front of the ant. Earlobe sulcus (Fig. 22.4).
386 W.-C. Liang
Fig. 22.4 One

subcutaneous bite by 2-O
Prolene suture is made a
centimeter in front of the
ant. Earlobe sulcus. This
skin-anchoring suture is
prepared to tighten the skin
later on
Fig. 22.5 Preoperative

marking: The dotted line
indicates the mandibular
rim. The blue lines indicate
the Endotine Ribbon
devices. The lower strip
sits 1.5 cm above the
mandibular rim, the upper
piece 1 cm above the lower
strip. This upper strip rests
at the same horizontal level
as the corner of the mouth
This skin-anchoring suture is prepared to the skin suspension later on. Then, guid-
ing by the preoperative markings (Fig. 22.5), two Endotine Ribbon devices with its
protective cover are inserted to the very distal end of the created pocket (Figs. 22.6,
22.7). Proper length of the device’s fixation section is adjusted before the device
application. For average female faces, leaving seven pairs of tines is common,
which means the platform holding 10 pairs of tines is cut and discarded. The length
of the remaining tines fit the mobile portion of the SMAS flap. Extended contact and
fixation with tines cause zero mobility of SMAS. Two of the devices are inserted
one by one and are arranged in parallel fashion. The first, lower one is placed along
the mandibular rim and is about 1 cm above the rim. The second one is placed about
1.5–2 cm above the first one. The tines are placed facing upward in order to hold the
SMAS flap. They are engaged by the digital pressure to the inf. Surface of SMAS
tissue after removal of the protected covers. After tissue engagement with the tines,
the distal leash is pulled and each device is fixed in the mastoid fasciae by 3-O
Prolene in the lower face under certain tension (Fig. 22.8). The platform was
designed with a series of holes, each stitch goes through each hole. Four fixations
are done for each device. The two devices are overlapped and fixed because of
Fig. 22.6 Two Endotine

Ribbon devices with its
protective cover are
inserted to the very distal
end of the created pocket.
The tines are placed facing
upward in order to hold the
SMAS flap
Fig. 22.7 The Endotine

Ribbon device, in the
premasseter space, utilizes
an average of seven pairs
of tines for optimal
tissue-pulling mobility
limited space. Before the fixation, several trials of pulling are performed to confirm
the tissue engagement. Significant improper contour irregularities should be avoided
because they will require lengthy recovery. To readjust the device, withdrawing the
devices is not difficult either by retrograde to resheath or by using the dissector to
free each tine from engagement. At the time the device’s leash is fixed with proper
tension, to achieve better skin tightening, the pre-set subcutaneous anchored suture
is fixed in the mastoid fasciae. A dimple in front of the ear lobe is unavoidable after
this subcutaneous suspension fixation. This dimple, covered easily by hair, will
388 W.-C. Liang
Fig. 22.8 The leash part

of the devices is fixed over
the mastoid fascia or over
any deep soft tissues
Fig. 22.9 A 62-year-old female underwent the Endotine Ribbon lower face lift. She also had lipo-
suction of jowl and hyaluronic acid filler injection for the nasolabial fold. Preoperative views
(right); one year postoperative (left)
Fig. 22.10 A 50-year-old female underwent Endotine Ribbon lower face lift. She also had lipo-
suction of jowl and hyaluronic acid filler injection for the melolabial fold. Preoperative views
(right); eight months postoperative (left)
disappear in approximately 4 weeks. The operation is done after the wound closure.
Figures 22.9, 22.10, 22.11, 22.12 are patients’ preoperative and postoperative
photographs.
The Traditional Method
When the Endotine Ribbon was launched on the market, the company suggested for
the surgeons to place one piece on each side under the subcutaneous plane (not
under the SMAS plane) with tines facing downward. Without SMAS dissection, the
Fig. 22.11 A 43-year-old female underwent Endotine Ribbon lower face lift and liposuction of
jowl. Preoperative views (right); three years postoperative (left)
Fig. 22.12 A 58-year-old female underwent Endotine Ribbon lower face lift. She also had lipo-
suction of jowl and autologous fat grafting for the melolabial fold. Preoperative views (right); one
and half years postoperative (left)
pulling of the device caused limited mobility. Also, there is no tissue reposition and
readherence after healing.
Advantages of the Author’s Technique
In contrast to the traditional method, by employing the author’s technique of access-

ing the premasseter space, the Endotine Ribbon is placed well within the subSMAS
pocket. The lower SMAS flap, the key structure, is anchored by a multiple-point
fixator after it has been mobilized. No other minimally invasive facial rejuvenation
technique includes these key procedures, which are crucial to these significant
results.
The Adjunct Procedures
The jowl deformity and perioral mound [4] are amenable to fine contouring with
liposculpturing during the Endotine Ribbon lower face lift. The Jowl liposculptur-
ing is approached from the submental region with 2 mm cannula. The perioral
390 W.-C. Liang
mound is approached on site with 1.2 mm cannula. Avoid too aggressive liposculp-
turing over the mandibular rim because it might cause injury to the marginal branch
of facial nerve. Injection Marionette lines with hyaluronic acid or fat graft also
benefit the result.
Complications
With the implementation of the author’s technique, there is no nerve injury, nor
extrusion. The device remains undetectable through palpitation. Those suffering
from pain may require an approximate two-day recovery. Some patients may expe-
rience ear numbness for months. Temporary visible contour irregularity in the early
period of recovery may also be a result of this procedure.
How to Prevent Complication
Even though the devices are not placed under the skin, it is beneath the SMAS tis-
sue, skin irregularity will occur without caution. Tips to prevent the skin irregularity
includes, (1) Avoid too aggressive jowl liposuction, (2) do not place the Ribbon
device too anterior. To avoid minor complication of numbness around the ear, pre-
serve the major nerve trunk [5] (lobular branch of the great auricle nerve) is possible
by partial blunt dissection just posterior to the ear lobe after the post auricle incision.
Further Application
The manufacturers of Endotine Ribbon produced this device for two primary pur-
poses: lower face and neck lifts. However, some surgeons also apply it in forehead
lifts or various SMAS procedures.
Conclusion
The traditional SMAS procedure is the most powerful technique for lower face lift-
ing. For those surgeons wishing to avoid such complex operations, the Endotine
Ribbon lower face lifting technique is the best choice when compared to other pro-
cedures. This minimally invasive procedure avoids preauricular scars and has a rea-
sonable satisfaction rate. As a practical issue, the greatest barrier to doctor application
will be the cost of the devices, which is currently substantial.
References
1. Derby BM, Codner MA. Evidence-based medicine: face lift. Plast Reconstr Surg.
2017;139(1):151e–67e.
2. Daniel Knott P, Newman J, Keller GS, Apfelberg DB. A novel bioabsorbable device for facial
suspension and rejuvenation. Arch Facial Plast Surg. 2009;11(2):129–35.
3. Mendelson BC, et al. Surgical anatomy of the lower face: the premasseter space, the jowl, and
the labiomandibular fold. Aesthet Plast Surg. 2008;32(2):185–95.
4. Sullivan PK, Hoy EA, Mehan V, Singer DP. An anatomical evaluation and surgical approach to
the perioral mound in facial rejuvenation. Plast Reconst Surg. 2010;126(4):1333–40.
5. Sharma, Vicki S, Stephens, Robert E, Wright, Barth W, Surek, Christopher C. What is the
lobular branch of the great auricular nerve? Anatomical description and significance in rhytid-
ectomy. Plast Reconst Surg. 2017;139(2):371e–378e.
Chapter 23
AI Technologies Being Developed
for Esthetic Practices
Chih-Wei Li and Chao-Chin Wang
Background
Becoming more attractive is one of the most important reasons to receive cosmetic
treatments [1]. Attractiveness is, in turn, strongly associated with facial expression
[2], which also greatly contributes to the first impression [3]. A happy facial expres-
sion is usually connected to positive moods and is seen as more attractive, whereas,
in contrast, sad and angry facial expressions are considered negative and therefore
less attractive. This means that enhancing positive facial features and reducing the
negative ones is a nice strategy for beautification. However, some micro-expressions
are difficult for the human eye to detect, even the eye of the trained cosmetic sur-
geon. Here, AI-assisted facial analytic systems such as FaceReader(Noldus,
Wageningen, The Netherlands) [4] (Fig. 23.1) may play a role. We proposed a novel
protocol Customized Precision Facial Assessment (CPFA), based on this system, to
evaluate and quantify micro-expressions of aesthetic concern. This pilot study
aimed to demonstrate if CPFA can objectively recognize and quantify the facial
action units associated with negative emotions in order to serve as a guide for physi-
cians to customize their treatments for individuals accordingly.
C.-W. Li (*)
Delicate Clinic, Taishan Dist, New Taipei City, Taiwan
C.-C. Wang
Tainan Vigor Clinic, Central-West Dist, Tainan City, Taiwan
Liberal Vigor Clinic, Zouyin Dist, Kaohsiung City, Taiwan

https://doi.org/10.1007/978-3-030-84099-0_23
394 C.-W. Li and C.-C. Wang
Fig. 23.1 AI-assisted facial analytic systems such as FaceReader
Method
Customized Precision Facial Assessment (CPFA) comprises both static and dynamic
analyses. Initially, patients were instructed to make no facial expression for 30 s for
static analysis while their facial action units were continuously monitored by
CPFA. Second, patients were then asked to make six basic facial expressions for
subsequent dynamic analysis, including disgust, sadness, happiness, fear, anger, and
surprise. With CPFA, the muscle actions leading to these expressions were analyzed
and denoted by the facial action coding system [5, 6], and the degree of each facial
expression was quantitatively recorded as “facial expression score.”
In this small pilot study, the goal of treatment is set at reducing the negative facial
expressions, such as sadness and anger. Once a negative facial expression is detected
by CPFA, the severity is recorded as “facial expression score,” and its activated
action units become the targets of intervention, consisting of neuromodulators and
injectable fillers. This is CPFA-facilitated treatment. CPFA is conducted at baseline,
1 week and 3 weeks after the treatment to determine the effectiveness of the inter-
vention, and facial expression scores are once more measured.
After a 12 month washout period for previous intervention, negative facial
expression scores of the same group of patients were once more scored as baseline,
but this time the assessment was made by the same physician, who is blinded to the
scores and without the guidance of CPFA, made his own assessment and interven-
tions to these patients to reduce the perceived negative facial expressions. This we
called human-facilitated treatment. In the same way, as for the CPFA assessment,
the facial expression scores were then measured at 1 week and 3 weeks after the
intervention (Fig. 23.2).
The results of the CPFA-facilitated treatment and human-facilitated treatment
were presented, and the degree of reduction in negative facial expression scores of
both groups was compared (Fig. 23.3).
23 AI Technologies Being Developed for Esthetic Practices 395
Assessment = Static + Dynamic
3 cases
Assessment
CPFA Human
1 yr washout
1 Week
Assessment
3 Weeks
Assessment
Fig. 23.2 Case report study design
What Is the Facial Action Coding System (FACS)?
Neuromodulators and injectable fillers have been used to soothe wrinkles, facial
creases, restore volume loss and address excessive muscle movement. However,
precise evaluation before treatment is crucial to natural and successful results. In
addition to the conventional evaluation by static photography, a dynamic imaging
system for standardized evaluation could be a breakthrough. However, a coding
system that is able to mark the result of dynamic evaluation efficiently is of vital
importance. The Facial Action Coding System (FACS), a system to taxonomize
human facial movements by their appearance on the face [5, 7, 8], has been exten-
sively used by first psychiatrists and then animators over the past decades to study
facial expressions and their relationship with emotions. FACS has been developed
into AI systems more recently, and among these programs, FaceReader™ is both
able to recognize facial expressions in real-time and had its performance validated
using datasets ADFES and WSEFEP [4, 9].
Fig. 23.3 An example of facial coding system. Action Units (AUs) and their corresponding facial
expression muscles
Case 1: Sadness
CPFA recognized sadness on her face, and further analysis of the action units indi-
cated that the inner brow raiser (action unit 1, AU1, medial frontalis muscle) was
responsible for this appearance of sadness. After injecting eight units of abobotu-
linumtoxin A to the medial frontalis muscle (AU1), we found the sadness score
decreased from 13.9% to 8.4% at 1 week and to 0% at 3 weeks after treatment
(Figs. 23.4, 23.5).
In the human-facilitated treatment group, the physician thought the sadness was
related to her downturned eyes and injected 8 units of abobotulinumtoxin A in each
side of her orbicularis oculi muscles. As a result, the sadness score decreased
from6.8% to 5.1% at 1 week and 6.7% at 3 weeks after treatment (Fig. 23.6).
Case 2 Sadness and Anger
CPFA showed a 14.1% angry score, which resulted from the activation of lip corner
depressors (AU15) and chin raiser (AU17). And it also recognized sadness that
came from the activity of AU1 and AU4. AbobotulinumtoxinA was injected into
Fig. 23.4 Sadness score decreased form 13.9% to 8.4% at 1 week after treatment
Fig. 23.5 CPFA recognized sadness on her face and further analysis of the action units indicated
that the inner brow raiser
AU1 (8 U), AU15 (4 U/side) and AU17 (4 U), respectively. Hyaluronic acid (Perlane,
Galderma LP, Fort Worth, TX) 1 ml was injected over AU17 to create a synergistic
mechanical obstacle to the over-contracting mentalis muscle [10] (Figs. 23.7, 23.8).
Fig. 23.6 Case 1 CPFA Static analysis and Human assessment Static analysis
Fig. 23.7 CPFA showed 14.1% angry score which resulted from the activation of lip corner
depressors (AU15) and chin raiser (AU17)
Fig. 23.8 Abobotulinumtoxin A was injected into AU1, AU15, AU17

In the group of human-facilitated treatment, the case was regarded by the physi-
cian to have a sad face. And she received abobotulinumtoxinA on depressor anguli
oris muscle (4 U/side) and hyaluronic acid (Perlane) 1 ml over the mentalis muscle
(Fig. 23.9).
Case 3 Sadness and Anger
CPFA identified 14% angry score caused by lip corner depressors (AU15, depressor
anguli oris muscle) and chin raiser (AU17, mentalis muscle) in case 3 (with abob-
otulinumtoxin A injected into AU15 (4 U/side) and AU17 (4 U).
In the human group, the physician only injected the depressor anguli oris mus-
cles (AU17, 4 U/side). It is noteworthy that the anger score was 10.9% at baseline,
became 5.9% at 1 week and then increased to 13.9% when evaluated at 3 weeks
after treatment (Fig. 23.10).
Discussion
Customized Precision Facial Assessment (CPFA) , a novel protocol based on the

FaceReader software, is the first esthetic application of a well-established system in
psychiatry. Through the detection of micro-expressions and the active action units
of facial muscles, physicians are more likely to optimize the treatment with minimal
intervention by precise localization of the foci of esthetic concern.
In this study, the foci of treatment identified by CPFA are not identical to those
identified by the evaluation of the physician. In case 1, CPFA indicated the sad face
was caused by activation of the medial frontalis while the physician considered the
sadness related to the downturned eyes and therefore treated her obicularis oculi
muscle. In case 2, CPFA identified sadness caused by activation of the medial fron-
talis, in addition to anger, common findings between CPFA and the evaluation by
the physician. When evaluating the result 3 weeks after treatment, we found nega-
tive facial expressions decreased in all three cases in the CPFA group while decreas-
ing in only case 1 and case 2 in the group of human-facilitated treatment. The anger
score of case 3 in the human treatment group initially improved at week 1 but
rebounded at week 3, probably due to inadequate doses of neuromodulators to
strong muscle activity. In addition, the group of CPFA-oriented treatment has a
more significant decrease in negative facial expression scores than that of human-
facilitated treatment.
CPFA shows a wide variety of potential applications in the esthetic field. CPFA
can first simply serve as a quantitative measurement of the facial expression scores
before and after treatment. For physicians in training, CPFA could provide a possi-
ble guide to treatment. Moderately experienced physicians may be able to further
improve their treatment outcomes through the identification and better
understanding of the micro-expressions which are too small to be detected by

human eyes. CPFA also has the potential to develop into a training program that
trains physicians to precisely identify micro-expressions. Through CPFA, physi-
cians may have not only static and dynamic assessments of the patients but also
quantitative measurements before and after the treatments. The core feature of
CPFA in detecting and quantifying facial micro-expressions may be a game changer
in the strategy of esthetic treatments which lead to more natural-looking results.
However, this initial study does have several limitations. The study only evalu-
ates the capability of CPFA-oriented treatments in reducing negative facial expres-
sions; further studies would be needed to evaluate whether it works as well in
enhancing positive facial expressions. Due to its small case number, the study is too
preliminary to conclude whether it is universal that the CPFA-oriented treatments
lead to greater reductions in negative facial expressions than human-facilitated
ones. And the washout period of 12 months may not be adequate for complete deg-
radation of previous hyaluronic acid placement, which may be a confounding factor
to precise evaluation.
Conclusion
We proposed Customized Precision Facial Assessment (CPFA)—a novel protocol

based on an AI-assisted analytic system to reveal and quantify the static and dynamic
facial micro-expressions for advanced esthetic treatment. This pilot study demon-
strates that CPFA can objectively recognize and quantify the facial action units
associated with negative emotions, and the physician may be able to customize the
treatment for individuals accordingly with promising results. Further studies are
needed to validate and explore the potential uses of this system.
References
1. Furnham A, Levitas J. Factors that motivate people to undergo cosmetic surgery. Can J Plast
Surg. 2012;20:e47–50.
2. Golle J, Mast FW, Lobmaier JS. Something to smile about: the interrelationship between
attractiveness and emotional expression. Cogn Emot. 2014;28:298–310.
3. Ritchie KL, Palermo R, Rhodes G. Forming impressions of facial attractiveness is mandatory.
Sci Rep. 2017;7:469.
4. Stockli S, Schulte-Mecklenbeck M, Borer S, Samson AC. Facial expression analysis with
AFFDEX and FACET: a validation study. Behav Res Methods. 2018;50:1446–60.
5. Friesen E, Ekman P. Facial action coding system: a technique for the measurement of facial
movement. Palo Alto; 1978.
6. Kohler CG, Turner T, Stolar NM, et al. Differences in facial expressions of four universal emo-
tions. Psychiatry Res. 2004;128:235–44.
7. Hjortsjö C-H. Man’s face and mimic language. 1969: Studen litteratur.
8. Ekman P, Friesen W, Hager J. Facial action coding system: the manual on CD-ROM. Instructor’s
Guide. Network Information Research Co, Salt Lake City; 2002.
9. Lewinski P, den Uyl TM, Butler C. Automated facial coding: validation of basic emotions and
FACS AUs in FaceReader. J Neurosci Psychol Econ. 2014;7:227.
10. De Maio M. Myomodulation with injectable fillers: an innovative approachto addressing facial
muscle movement. Aesth Plast Surg. 2018;42:798–814.
Chapter 24
The Cosmetic Patient: Psychology
Souphiyeh Samizadeh
Traditionally, the persuit of cosmetic procedures or even their thought/discussion was

considered vanity. It was generally associated with celebrities and public figures and
at times attributed to psychopathology [1]. Nowadays, surgical and non-surgical cos-
metic procedures are growing in popularity. Social acceptance of cosmetic procedures
and media coverage of the results are some of the contributing factors to this change
in attitude [2]. Individual motivations to seek cosmetic procedures may include the
desire to improve self-confidence, self-esteem, and social interactions [3]. Social
media channels and the internet also play an important and growing role in the popu-
larity of cosmetic procedures [4]. However, these factors may also create unrealistic
expectations. It is important for clinicians and patients to reach a mutual understand-
ing that information from the internet or social media cannot replace face-to-face con-
sultation [4]. Greater media exposure, vicarious experience of cosmetic surgery, and
more importance of appearance to self-worth were found to be contributing factors
towards future cosmetic surgery with no difference between ethnic groups [5]. Factors
that affect the likelihood of undergoing cosmetic procedures vary by procedure and
culture. However, in general, there is an increased awareness, acceptance, and popu-
larity of cosmetic procedures as the desire for, and sociocultural emphasis on, beauty
are broadcasted more widely than ever. Furthermore, a strong, growing economy in
Asia and the associated rapid social changes have resulted in an increased acceptance
and popularity of cosmetic procedures in this region. As clinicians, our understanding
of patient motivations is evolving, and supporting studies are increasing in number.
Devloping an understanding of patient psychology, spoken and hidden desires, and
expectations are of utmost importance for aesthetic physicians.
S. Samizadeh (*)

https://doi.org/10.1007/978-3-030-84099-0_24
406 S. Samizadeh
The development of excellent communication skills and a structured interview

technique are invaluable capabilities that aesthetic practitioners should develop.
Patient screening will enable practitioners to have a more patient focussed practice,
and identify patients who have unrealistic expectations or motivations, and those
who will not be satisfied even with a well-planned and implemented procedure with
a desirable and optimal clinical outcome. Some influencing factors behind poor out-
comes include [3, 6]:
• Unrealistic expectations (for example regarding spousal relationships or job
opportunities).
• External motivation (parent, spouse).
• Psychological disorders.
• Vulnerability.
Motivational factors and psychological processes underlying the persuit of cos-
metic procedures include: [7]
• Aesthetic appearance.
–– Beautiful skin and a youthful, attractive appearance
Physical health.
• Preventing worsening of condition or symptoms
Psychosocial well-being.
• Desire to feel happier
• Desire to feel more confident
• Improve total quality of life
• Treat oneself or celebrate
• Look good professionally
Most individuals considering cosmetic surgery seem psychologically healthy
[8]. However, it has been reported that around half of patients seeking elective cos-
metic surgery may have important psychiatric health issues [3]. Narcissistic and
histrionic personality disorders and body dysmorphic disorder are reported to be the
most common psychiatric conditions encountered in those seeking cosmetic sur-
gery [9]. Patients with psychological issues and/or inappropriate expectations or
motivations are at risk of increased appearance-related distress regardless of the
treatment outcome. Therefore, screening and identification of these patients prior to
treatment is highly important [3].
A review of psychosocial outcomes among patients seeking cosmetic surgery,
published in 2007, reported that [8]:
• Overall, patients are satisfied.
• Some patients exhibit transient or longer lasting psychological disturbance.
• Factors associated with poor psychological outcome:
–– Age: young
24 The Cosmetic Patient: Psychology 407
–– Gender: male
–– Expectations from the procedure: unrealistic
–– History of cosmetic surgery: previous unsatisfactory cosmetic surgery
–– Concern: minimal deformity
–– Motivation for the procedure: based on relationship issues (e.g. physical
changes would save a relationship, disagreement on the need for the procedure)
–– Mental well-being: history of depression, anxiety, or personality disorder
A useful tool for screening patients is the “SAFE” acronym [10].
• Self-evaluation of attractiveness
• Anxiety
• Fear
• Expectation
It is pertinent for aesthetic physicians to understand that although physical and
psychological well-being are intertwined, they are two different issues. There is
evidence of improvement in self-confidence and self-esteem post positive physical
changes. However, although patients may report satisfaction with the outcome and
appearance change, no changes in their psychological characteristics may be expe-
rienced [8]. Aesthetic doctors should have a clear referral pathway. It should be
determined if the patient is expecting unrealistic social/life changes from the
requested procedure [6].
The expectations of the patient requesting cosmetic treatments are frequently
much greater than other patients. Pre- and post-procedures require high interper-
sonal communication skills [11]. Comprehensive patient education and consulta-
tion, including providing them with all surgical and non-surgical options, are key
and ensures realistic expectations. A systematic and comprehensive aesthetic analy-
sis of patients’ needs and concerns will lead to a personalised treatment plan and
hence ensure success. Such plan would also ensure patient loyalty and entails [12]:
• Establishing trust.
• Producing positive outcomes.
• Provision of safe treatments.
• Creating an engaging experience.
Understanding the Psychology of Cosmetic Patients in Asia
Beauty has a special place in the hearts of Asians throughout Asia and, for centuries,
white “pearl” skin has been admired. This has led to a social disregard for dark skin,
avoidance of sun (UV protective umbrellas, UV protective clothing), to whitening
topical and medical-grade products (topicals, ingestible, and injectables). The most
408 S. Samizadeh
popular treatments in Asia include skin whitening, surgical/non-surgical rhino-

plasty, and double-eyelid surgery.
A belief in facial physiognomy and the importance of first impressions also plays
a big role in the demand for cosmetic procedures in Asia. There are culturally inher-
ent beliefs that even though an individual may not think they believe in a certain
concept, they are not immune from it. Beauty and beautiful faces are seen as an
“investment,” or a “weapon” to provide a competitive edge in the job market and
marriage; “Beautiful ones get chosen first!”
In China, it is not uncommon for someone to face negative and unkind comments
publicly if they do not fit the “ideal” aesthetic standards, such as having a delicate
face and being slim. There are reports of people being mistreated due to their skin
colour or being overweight. Another example is the term “leftover woman” that is
still in use in China and refers to unmarried women above the age of 27. The sen-
tence “you are so fat” will commonly be directed to a person perceived as being
overweght without hesitation and even in a professional context. This has a negative
psychological impact and can be a motivating factor for seeking cosmetic
procedures.
Furthermore, more people across Asia are obtaining the same educational level
in a job market and society that is very competitive with a huge population. Gender
imbalance, with approximately 30 million more men than women, may also be dis-
advantageous to some. Surveys conducted by the Author among Chinese laypersons
and aesthetic practitioners revealed a belief that being “beautiful” improves quality
of life [13, 14]. This reflects that beauty and taking care of appearance are part of
the culture. As such, with rapidly increasing wealth, sophistication, improved qual-
ity of life, disposable income, and improved/enhanced accessibility, plastic surgery
and cosmetic procedures have become very common and popular in Asia. It is
known that surgeries such as eyelid surgery are frequently given as a “high school
graduation gift” by Asian parents and is considered an “investment” into their chil-
dren’s future.
Although beauty is praised everywhere, in Asia it is done so openly with no
taboos. Strict rules about appearance at workplace or otherwise also put extra pres-
sure on women. For example, job applications often require a headshot to be
included in the curriculum vitae/resume. In fact, it is not unusual to be asked for a
photo and date of birth, and once that is proceeded, then the curriculum vitae/
resume. It is also not uncommon or unheard of for Asian or Chinese employers to
have a list of aesthetic requirements, e.g. fair skin, large eyes, V-shaped face, slim,
etc. Such requirements may be for positions that do not rely on a candidate’s appear-
ance. Employment agencies often organise events that are similar to “fashion
shows” where employees can see and choose employers according to their
appearance.
Traditional ideals of beauty support the current boom in surgical and non-surgical
procedures. “Medical tourism”, or medical travel, is a growing industry being
aggressively marketed across Asia [15].
Therefore, the following are some of the contributing factors to the growing pop-
ularity of cosmetic medicine in Asia:
• Social pressure
• Competition: education/marriage/job prospects
• Influence of media and Korean pop culture
• Not a taboo or against traditional cultures anymore
• Easily accessible
Body Dysmorphic Disorder (BDD)
The diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR™)

defines BDD as “the preoccupation with an imagined or exaggerated defect in
physical appearance” [16]. It is observed in 5–15% of cosmetic surgery patients
[17, 18]. There is evidence suggesting that this disorder may be overrepresented
among those seeking cosmetic medical treatments. Individuals with BDD do not
benefit from cosmetic treatments and, conversely, they frequently experience a
worsening of their BDD symptoms following treatment [19]. In addition, BDD is
a predictor of poor treatment outcome [8]. Thus, identification and diagnosis of
BDD has become an important part of the consultation and patient screening pro-
cess in cosmetic medicine. A report from 1997 revealed that approximately 25% of
patients with BDD will have attempted suicide [20]. Diagnosis of BDD is not
simple, but the following diagnostic criteria for BDD from DSM-IV-TR™ can be
used [16]:
• Preoccupation with an imagined defect in appearance. If a slight physical anom-
aly is present, the person’s concern is markedly excessive
• The preoccupation causes clinically significant distress or impairment in social,
occupational, or other important areas of functioning
• The preoccupation is not better accounted for by another mental disorder (e.g.
dissatisfaction with body shape and size in anorexia nervosa)
The body dysmorphic disorder questionnaire dermatology version from Malick,
F., Howard, J. and Koo, J. (2008), Understanding the psychology of the cosmetic
patients, can be found in Fig. 24.1.
410 S. Samizadeh
Are you very concerned about the appearance of some part of your body, which you consider especially unattractive? Y N
If no, thank you for your time and attention. You are finished with this questionnaire.
If yes. do these concerns preoccupy you? That is you think about them a lot and they’re hard to stop thinking about? Y N
What are these concerns? What specifically bothers you about the appearance of these body parts?
What effect has your preocuupation with your appearance had on your life?
Has your defect often caused you a lot of distress, torment or pain? How much? (circle best answer)
1 2 3 4 5
No distress Mild, and not Moderate and Severe, and Extreme, and
too disturbing disturbing but very disturbing disabling
still manageable
Has your defect caused you impairment in social, occupational, or other important areas functioning? How much?
(circle best answer)
1 2 3 4 5
No limitation Mild interference Moderate, definite Severe, causes Extreme,
but overall per interference, but substaintial incapacitating
formance not still manageable impairment
impaired
Has your defect often significantly interfered with your social life? Y N
If yes, how?
Has your defect often significantly interfered with your school work, your job, or your ability to function in your role? Y N
Are there things you avoid because of your defect? Y N
*A positive screening for body dysmorphic disorder = answering yes to the presence of a preoccupation + having at
least moderate distress or impairment in functioning.
(Reproduced, with permission, from Dufresne et al.) (25).
Fig. 24.1 Body dysmorphic disorder questionnaire-dermatology version* from Malick, F.,
Howard, J. and Koo, J. (2008), Understanding the psychology of the cosmetic patients.
Dermatologic Therapy, 21: 47–53 [6].
References
1. Sarwer DB, et al. Psychological investigations in cosmetic surgery: a look back and a look
ahead. Plast Reconstr Surg. 1998;101(4):1136–42.
2. Brown A, et al. Factors that affect the likelihood of undergoing cosmetic surgery. Aesthet Surg
J. 2007;27(5):501–8.
3. Wildgoose P, et al. Psychological screening measures for cosmetic plastic surgery patients: a
systematic review. Aesthet Surg J. 2013;33(1):152–9.
4. Montemurro P, et al. The influence of social media and easily accessible online information on
the aesthetic plastic surgery practice: literature review and our own experience. Aesthet Plast
Surg. 2015;39(2):270–7.
5. Delinsky SS. Cosmetic surgery: a common and accepted form of self-improvement? J Appl
Soc Psychol. 2005;35(10):2012–28.
6. Malick F, Howard J, Koo J. Understanding the psychology of the cosmetic patients. Dermatol
Ther. 2008;21(1):47–53.
7. Maisel A, et al. Self-reported patient motivations for seeking cosmetic procedures. JAMA
Dermatol. 2018;154(10):1167–74.
8. Honigman RJ, Phillips KA, Castle DJ. A review of psychosocial outcomes for patients seeking
cosmetic surgery. Plast Reconstr Surg. 2004;113(4):1229–37.
9. Shridharani SM, et al. Psychology of plastic and reconstructive surgery: a systematic clinical
review. Plast Reconstr Surg. 2010:126(6).
10. Lavell S, Lewis CM. SAFE: a practical guide to psychological factors in selecting patients for
facial cosmetic surgery. Ann Plast Surg. 1984;12(3):256–9.
11. Rohrich RJ. The importance of cosmetic plastic surgery education: an evolution. Plast Reconstr
Surg. 2000;105(2):741–2.
12. !!! INVALID CITATION !!! {}.
14. Samizadeh S, Wu W. Ideals of facial beauty amongst the Chinese population: results from a
15. Whittaker A. Pleasure and pain: medical travel in Asia. Glob Public Health. 2008;3(3):271–90.
16. Cooper J. Diagnostic and statistical manual of mental disorders (4th edn, text revision) (DSM–
IV–TR.) Washington, DC: American Psychiatric Association 2000. 943 pp.£ 39.99 (hb). ISBN
0 89042 025 4. The British Journal of Psychiatry, 2001. 179(1):85–85.
17. Wilson JB, Arpey CJ. Body dysmorphic disorder: suggestions for detection and treatment in a
surgical dermatology practice. Dermatol Surg. 2004;30(11):1391–9.
18. Veale D. Body dysmorphic disorder. Postgrad Med J. 2004;80(940):67–71.
19. Sarwer DB, Crerand CE, Didie ER. Body dysmorphic disorder in cosmetic surgery patients.
20. Phillips KA, Diaz SF. Gender differences in body dysmorphic disorder. J Nerv Ment Dis.
1997;185(9):570–7.
Index
A B
Aesthetic assessment, 393, 395 Beauty preference, 335
clinical, 108 Blackcurrant, 141
cosmetic procedures, 110 Body dysmorphic disorder (BDD), 409
dentofacial, 110 Botulinum toxin A (BNT-A), 30, 304, 305
facial analysis, 109 antagonist muscles, 190–191
infra-orbital rims, 119 chin, 239
mandibular plane, 120 classification, 239
natural head position, 111 injection techniques, 240, 242
oblique view, 118 muscle anatomy, 240
para-nasal region, 119 classification, 215, 219, 221, 223–224, 234
subunit analysis, 111, concentration, 185–186
113, 116 considerations, 184, 232
symmetry, 117, 118 dose, 184–185
upper lip, 119 facial rejuvenation, 183–184
Alcohol consumption, 110 forehead lines, 214
Anti-aging, 154 frown types, 228, 233
Anti-photoaging, 135, 136 injection depth, 186–189
Artificial intelligence, 395 injection site, 185
Asian aesthetics, 4 injection technique, 216, 230–231
Asian beauty, 21 muscle strength, 189
attractiveness, 30 nasal dorsal striae, 234
botulinum toxin, 30 oral commissures, 241, 243–246
desired facial features, 24 periocular rhytids, 219
facial beauty, 30 platysma
facial morphologies, 21 classification, 248
generalisation, 21 injection technique, 248
ideals, 24 related muscle anatomy, 246, 247
oval face shape, 25, 28 typical cases, 248
time to enhance, 21 synergist, 190–191
Asian plastic surgery, 30 typical cases, 229
Asian skin, 161, 162 upper face, 214
Averageness, 4 Buccinator muscle, 75

https://doi.org/10.1007/978-3-030-84099-0
414 Index
Butterfly technique anatomical variations, 269

advantages, 347 beauty requests, 267
beauty preference, 335 calcium hydroxyapatite fillers, 256, 257
budget, 336 chin, 288–290
complications, 346 collagen, 254, 255
concept, 336–338 cultural aspects, 269
disadvantages, 347 facial contouring, 269, 271
injection technique, 339, 340, 342–344 facial structure, 267
patient selection, 338 forehead, 278, 279
results, 345 hyaluronic acid dermal fillers, 259
lips, 284–286
medial cheek, 280, 282, 284
C polycaprolacton, 258, 259
Characteristics, Asian face polymers, 257
brachycephalic head shapes, 44 polymethyl methacrylate, 255, 256
Caucasian, 44, 45, 48, 50 silicone, 254
China, 45, 50 temples, 272–274, 276
bizygomatic and bigonal widths, 46, 47 Dimethylaminoethanol (DMAE), 141
craniofacial morphology, 47, 48
Han Chinese population, 46
national face database, 46 E
classification task vs. human East Asian faces
accuracy, 42, 44 color, 299
English-language publications, 42 curvilinear beauty, 298
Japan, 48 dermal fillers, 312, 314, 316
vs. Caucasian adults, 49 facial assessment, 300, 301
three-dimensional anthropometry, 50 facial wrinkles, 302
Korea, 51, 53, 55, 56 injectables, 304, 306
Mongoloid ancestry, 41, 42 lower face ageing, 303
physical features, 41, 43 masseter hypertrophy, 308
Chin, 239–241 masseter injection, 311
China, 45 proportionality, 298, 299
Chinese women, 21, 27, 98, 104 symmetry, 299
Chinese aesthetics, 14 Extracellular matrix (ECM), 142, 143
Collagen, 254
Concentration, 185–186
Consultation, 405 F
Cosmeceuticals, 134 Facial Action Coding System (FACS), 395
Cosmetics, 405–407 Facial ageing, 85, 86, 97, 100
aesthetics, 406 bone structures, 86
body dysmorphic disorder, 409 dentition, 91
consultation, 405 lower face third, 91, 92
psychology, 408 middle face, 89, 90
Crow's feet, 308 morphological changes, 87, 88
Customized Precision Facial Assessment relationships, 86, 93, 94
(CPFA), 394, 400, 403 upper third face, 88
Facial beauty, 3
biologically based standards, 4
D cultural variations, 15
Deep Intradermal Injection (IDP), 151 mathematical models, 7
Dentofacial, 110 canons, 7, 8
Depressor labii inferioris muscle, 75 golden proportions, 10–14
Dermal fillers, 60, 98 Hogarth's serpentine line, 8
Index 415
neoteny, 7 pico-laser, 169, 170

partner selection, 3 pigmentation change, 162
positive attribute, 6 post-inflammatory hyperpigmentation, 164
self-perception, 3 skin texture change, 170
sexual attractiveness, 3 Lentigines, 162
sexual dimorphism, 5 Levator anguli oris muscle, 75
social interactions, 3 Ligaments, 67
Facial features, 97 Lower face lift
Facial profile, 113 adjunct procedures, 390
Facial rejuvenation, 98 complications, 390
Facial skeleton, 100 contraindication, 383
Fat grafting, 98 device, 384
Flavenoids, 140 indication, 383
Forehead, 278 method, 384, 386
Fractional laser treatment, 174 traditional method, 388
Front contour line, 316
Frown types, 228
M
Masseter hypertrophy, 308, 330
G Masseter muscle, 76
Glabellar, 100 Matrix metalloproteinases (MMPs), 143
complex, 227 Maxilla, 100, 101
wrinkles, 306 Melasma, 165–168
Golden ratio, 10 Mesotherapy, 148, 155, 156
Growth factors/cytokines, 142 biorevitalization, 147
classification, 148–151
complications, 155
H local lipolysis, 152
Harmony, 299 oily skin, 153
Hematoma, 372 pigmentation, 154, 155
Hyaluronic acid (HA), 154, 177, 259, 260 skin rejuvenation, 152
Hydroxy acids, 138 Microneedle radiofrequency, 177
Middle face, 89
Midface augmentation, 322, 325
J Minimally invasive
Japan, 48 facial units, 59
Jawline, 383 forehead, 60, 61
nose, 70, 72
parotid glands, 77, 79
K periorbital area, 66, 67, 69
Korea, 51 subunits, 60
temporal fossa, 61–66
temporal region, 60
L upper face, 60
Laser treatments Monopolar radiofrequency, 176
combination of procedures, 178, 179 MTV lift, 322
fractional laser, 168, 175, 176 anterioinferior cheek area, 325
freckles, 165 eyebrow tail, 326
IPL treatment, 169, 171 lower face, V lifting, 329, 330
lentigines, 164 masseter injection complications, 331–332
melasma, 165, 166 nasolabial folds, 325
microneedle radiofrequency, 177 nose radix, 326
non-ablative, 172, 174, 175 palpebromalar groove, 324
416 Index
MTV lift (Cont.) S

subzygomatic area, 325 Sexual dimorphism, 4, 5
T areas, 326–328 Silicone, 254
tear trough area, 325 Skin aging, 98
temporal area, 326 broad-spectrum ultraviolet protection,
zygomatic arch area, 323 132, 133
Muscle anatomy, 227 cosmeceuticals, 134
dimethylaminoethanol, 141
environment, 128
N extrinsic aging, 126
Nasal dorsal striae, 234 hydroxy acids, 138
Nasolabial fold, 304 infrared light, 131
intrinsic, 125
N-acetyl-glucosamine, 138
O photoaging features, 126
Oommen, 36 pollution, 132, 133
Oral commissures, 241, 243–246 production, 132
Orbicularis oris muscle, 74 ultraviolet light, 128–130
Orbital, 100 visible light, 131, 133
Skincare, 126, 144
Skin-lightening agents, 142
P Skin rejuvenation, 152
Parotid glands, 76 Skin texture, 98
Peptide, 141 Symmetry, 4, 111, 117, 299
Photoageing, 155
Phrenology, 35
Physiognomy, 33 T
application, 35 Temporal fossa, 61
Asia, 37 Threadlift
character design, 37 body position, 352
China, 37 complications, 370–373
Chinese facial, 34 considerations pre-thread-lifting
Korean facial, 34 design, 353
phrenology, 35 contraindication, 350
Pigmentation, 162, 164 design, 352
Platelet-rich plasma dermal injections indications, 350
(PRP), 153 layer, 354, 359, 361, 362
Platysma, 76, 247, 249 local pigmentation, 375
Poly-L-lactic acid, 257, 258 neurological injuries, 374
Polymers, 257 post operational comfort, 363, 364
Polymethyl methacrylate (PMMA), 255 postoperative management, 370
Polyphenols, 140 preoperative assessment, 351
preoperative examination, 351
preoperative photography, 351
R principles, 350
Recurrent redness, 375 procedure, 365–368
Resveratrol, 139 recurrent redness, 375
Retinaldehyde, 135 safe region, 350, 351
Retinol, 135 single thread, 369
Retinyl palmitate, 135 tissue relocation, 362, 363
Risorius muscle, 76 Tranexamic acid (TA), 154
Index 417
U W
Upper third face, 88 Wrinkles, 149, 154
V Z
Vedic face reading, 33 Zygomatic cutaneous ligaments, 339, 342
Vitamin B3, 137 Zygomaticus major muscle, 74
Vitamin C, 136 Zygomaticus minor muscle, 74
Vitamin E, 137
V-lifting, 330

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Non-Surgical

ISBN 978-3-030-84098-3 ISBN 978-3-030-84099-0 (eBook)

© Springer Nature Switzerland AG 2022

comprises multiple ethnicities. The information will be relevant to clinicians prac-

London, UK Farhad B. Naini

4. Recent media and trends have an effect

How Is This Relevant to International Aesthetic Doctors?

London, UK Souphiyeh Samizadeh

Part I Trend of Asian Beauty Standards: Past Present, Future

Part II Anatomy and Ageing

Part III Technologies and Techniques

10 Mesotherapy �������������������������������������������������������������������������������������������� 147

© Springer Nature Switzerland AG 2022 3

Fig. 1.1 Adapted from

Body type Averageness

Fig. 1.2 Smiling influences perception of attractiveness

Preferences for Neoteny in Humans

Mathematical Models of Beauty

Fig. 1.3 Rule of facial

Hogarth’s Serpentine Line

William Hogarth, an eighteenth-century English artist and author, published The

Golden Proportions/“Divine Proportion”

The idea of Golden proportions is attributed to Plato and Pythagoras (a philosopher,

Fig. 1.5 Illustration of the

The concept of BeautiPHIcation was developed by plastic surgeons Arthur Swift

Cultural Variations of the Standards of Beauty

It is not a single attribute that makes a face beautiful or attractive. A combination of

1. Thornhill R, Gangestad SW. Human facial beauty. Hum Nat. 1993;4(3):237–69.

78. Milutinovic J, Zelic K, Nedeljkovic N. Evaluation of facial beauty using anthropometric

© Springer Nature Switzerland AG 2022 21

Fig. 2.1 Map of Asia

Fig. 2.3 Goose egg-Facial shape preferred in China. An oval shape

Item Layperson [8] Aesthetic Practitioners

Fig. 2.7 Asian beauty

• Small bigonial width

harmonisation, enhancement of their facial features, self-improvement, and preser-

© Springer Nature Switzerland AG 2022 33

Fig. 3.2 Korean facial

Fig. 3.3 Phrenology

others, and make judgments about characteristics such as attractiveness, likeability,

© Springer Nature Switzerland AG 2022 41

a b Asian features Clinical Features

Increased width: Result in wider:

Low nasal bridge Nose: flat, short, retruded

Bimaxillart protrusion The upper and lower jaws are

Hypoplastic mandible Retruded chin

Fig. 4.6 Bizygomatic and

In comparison to Caucasians, on average, the Japanese are retrognathic, with a

A comparison of cephalometric norms between Japanese and Caucasian adults

In comparison to Caucasians, Koreans generally have a significantly wider face

Fig. 4.12 A traditional Korean wedding. Photos by M Ameen

Table 4.1 Comparison of selected facial dimensions among ethnic groups

Asian Facical Type Asian Facical Type

15. Li Y, Zheng L, Yu K, Lu S, Zhang X, Li Y, et al. Variation of head and facial morphological

Sheng-Kang Luo, Wei-Jin Hong, Chun-Lin Chen, Li-Yao Cong,

Facial Units and Subunits

© Springer Nature Switzerland AG 2022 59

Upper Face and Temporal Region

Fig. 5.2 Temporal Fossa

Fig. 5.3 Cadaveric

London, UK Farhad B. Naini

London, UK Souphiyeh Samizadeh

Part I Trend of Asian Beauty Standards: Past Present, Future

Part II Anatomy and Ageing

Part III Technologies and Techniques

10 Mesotherapy �� 147

Preferences for Neoteny in Humans

Mathematical Models of Beauty

Hogarth’s Serpentine Line

Golden Proportions/“Divine Proportion”

Cultural Variations of the Standards of Beauty

Facial Units and Subunits

Upper Face and Temporal Region

Lymphatic Drainage of the Face

Relationship of Facial Structures

Functional Matrix Concept

orphological Changes in the Bone Structures of the Face

Upper Third Face

Jaw Changes, Orbit and Piriform Opening

Lower Face Third

elationship of the Facial Bones to each Other and to the Base

What Is Facial Analysis?

Medical, Dental, Social, and Cosmetic History

History of Dentofacial Dysmorphology

Natural Head Position

Craniofacial Soft Tissue Landmarks

Analysis: Frontal View

Basic Facial Shape-Frontal View

Basic Facial Shape-Profile View

Basic Facial Shape-Parasagittal Profile

Basic Facial Shape-Vertical

Facial Curves and Curvilinear Relationships (Fig. 8.4)

Vertical Facial Proportions (Fig. 8.5)

Ear Shape and Position

Assess the Relationship Between

Analysis: Oblique View

Lower Lip and Chin

Lower Lip to Submental Plane Angle

Mandibular Plane Angle