Analysis of Facial Aesthetics as Applied to Injectables

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<p>Copyright © 2015 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.</p><p>www.PRSJournal.com 11S</p><p>The goal of every facial enhancement should</p><p>be to mimic nature as aesthetically and as</p><p>reasonably as possible without the deleteri-</p><p>ous stigmata associated with bad cosmetic pro-</p><p>cedures. The driving force is to achieve a better</p><p>“blink” appearance, that is, to judge an outcome</p><p>instantaneously using the right brain (the artistic,</p><p>gestalt side of cerebral awareness) whether some-</p><p>one looks better or younger or simply does not.</p><p>Subtle and natural appearing changes should</p><p>be the rule with volumetric treatments. Unnatu-</p><p>ral results are often due to mistaking volume as</p><p>a goal rather than as a technique for achieving</p><p>a desired aesthetic endpoint. Fuller has become</p><p>better in place of understanding the goals of vol-</p><p>ume rejuvenation.</p><p>Every face is unique, but the shadows that</p><p>develop as we age are relatively consistent. Not every-</p><p>one develops every shadow, but there are typical pat-</p><p>terns of facial shadowing that signal advancing age.</p><p>The ease with which a charcoal artist can depict an</p><p>aging face with a few shadow strokes makes this the-</p><p>sis easy to grasp. These shadows are often defined by</p><p>facial attachments points, such as the facial retain-</p><p>ing ligaments and McGregor’s patch (zygomatico-</p><p>cutaneous ligaments), which tether the skin to the</p><p>underlying facial structures. As the volume of the</p><p>face deflates, these attachment points will define</p><p>most of the shadows that develop with age.</p><p>The goal of volume rejuvenation is the modi-</p><p>fication or elimination of age-specific shadow</p><p>patterns and restoring the balance of volume seen</p><p>in a youthful face. The shadowing effects on the</p><p>face will first be examined by analyzing the frames</p><p>of the face followed by a more detailed descrip-</p><p>tion of the specific changes in the face which</p><p>occur with aging and the shadows they engender.</p><p>FACIAL FRAMES</p><p>The 3 circular frames of the face constitute</p><p>a paradigm by which we may understand how</p><p>we can achieve a better blink rejuvenation. The</p><p>global facial frame (edge of the face from temple</p><p>to jawline) extends along the jawline to offset the</p><p>face from the neck and then flows up the lateral</p><p>contour of the face from the angle of the man-</p><p>dible along the contour of the buccal, zygomatic,</p><p>and temple line. The frame of the mouth (includ-</p><p>ing the marionette and nasolabial groove) and the</p><p>frame of the eyes (brow, upper eyelid, and lower</p><p>eyelid) complete the 3 circles that are the true</p><p>focus of attention for facial rejuvenation (Fig. 1).</p><p>The global facial frame strongly affects our per-</p><p>ception of a face on many levels: age, gender, and</p><p>attractiveness. A soft, upside-down, egg-shaped</p><p>lateral facial contour suggests youthful feminin-</p><p>ity, while a more angular/rectangular line is more</p><p>masculine. The scalloped (concave) appearance</p><p>of the temple and the subzygomatic recess, the</p><p>area below the zygomatic arch down to the buccal</p><p>and ending with the prejowl depression, renders</p><p>a much older appearance to the face. Achieving a</p><p>youthful appearance is highly dependent on rec-</p><p>reating an ideal oval of the face from the frontal</p><p>Disclosure: None of the authors has a financial in-</p><p>terest in any of the products, devices, or drugs men-</p><p>tioned in this article.Copyright © 2015 by the American Society of Plastic Surgeons</p><p>DOI: 10.1097/PRS.0000000000001746</p><p>Samuel M. Lam, MD</p><p>Robert Glasgold, MD</p><p>Mark Glasgold, MD</p><p>Dallas, Tx.; and New Brunswick, N.J.</p><p>Summary: Understanding the role of volume loss in the aging face has resulted</p><p>in a paradigm shift in facial rejuvenation techniques. Injectable materials for</p><p>volume restoration are among the most widespread cosmetic procedures per-</p><p>formed. A new approach to the aesthetics of facial aging is necessary to allow</p><p>the greatest improvement from volumetric techniques while maintaining natu-</p><p>ral appearing results. Examining the face in terms of facial frames and facial</p><p>shadows provides the fundamental basis for our injectable analysis. (Plast.</p><p>Reconstr. Surg. 136: 11S, 2015.)</p><p>From private practice; and the Division of Otolaryngology,</p><p>Department of Surgery, Robert Wood Johnson University</p><p>Hospital.</p><p>Received for publication March 25, 2015; accepted June 12,</p><p>2015.</p><p>Analysis of Facial Aesthetics as Applied</p><p>to Injectables</p><p>INJECTABLES</p><p>D</p><p>ow</p><p>nloaded from</p><p>http://journals.lw</p><p>w</p><p>.com</p><p>/plasreconsurg by B</p><p>hD</p><p>M</p><p>f5eP</p><p>H</p><p>K</p><p>av1zE</p><p>oum</p><p>1tQ</p><p>fN</p><p>4a+</p><p>kJLhE</p><p>Z</p><p>gbsIH</p><p>o4X</p><p>M</p><p>i0</p><p>hC</p><p>yw</p><p>C</p><p>X</p><p>1A</p><p>W</p><p>nY</p><p>Q</p><p>p/IlQ</p><p>rH</p><p>D</p><p>3i3D</p><p>0O</p><p>dR</p><p>yi7T</p><p>vS</p><p>F</p><p>l4C</p><p>f3V</p><p>C</p><p>4/O</p><p>A</p><p>V</p><p>pD</p><p>D</p><p>a8K</p><p>K</p><p>G</p><p>K</p><p>V</p><p>0Y</p><p>m</p><p>y+</p><p>78=</p><p>on 07/03/2024</p><p>Copyright © 2015 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.</p><p>12S</p><p>Plastic and Reconstructive Surgery • November Supplement 2015</p><p>view. When performing volume rejuvenation, it is</p><p>imperative to constantly evaluate the frontal view</p><p>of the face as it is the best perspective to ensure</p><p>that the shadows of senescence are most effec-</p><p>tively diminished. Too often, surgeons are used to</p><p>seeing the face from the lateral or oblique per-</p><p>spectives, which are important vantages, but are</p><p>not the most critical perspectives (Fig. 2).</p><p>Many women are frightened that if they fill the</p><p>temple and the subzygomatic recess, they will look</p><p>wider or fatter, which is not the case if the area</p><p>is filled appropriately. When these 2 adjoining</p><p>concavities are managed along with the anterior</p><p>prejowl region, the face can actually look thinner</p><p>as the absence of upper facial volume with some</p><p>early gravitational descent of the lower outer face</p><p>is the combination that makes the face heavier in</p><p>appearance with aging. By filling the upper and</p><p>outer face, albeit in a tasteful and controlled fash-</p><p>ion, the face can actually regain improved shape</p><p>and thereby look slimmer in many cases (Fig. 3).</p><p>The eye frame can be thought of simply as</p><p>another circle that over time becomes progres-</p><p>sively absent. Traditional rejuvenation techniques</p><p>that remove periorbital volume have led to an</p><p>appreciation of creating a “done” or aged appear-</p><p>ance. Volume augmentation with an appropriate</p><p>amount of volume to create a frame of light around</p><p>the eye restores a youthful attractive appearance.</p><p>Thinking of the aging eyelid and the eyelid shape</p><p>like 2 opposing triangles with the short arm of the</p><p>upper triangle being medial and the short arm of</p><p>the lower triangle being lateral (Fig. 1) is a recent</p><p>conceptualization that has been particularly help-</p><p>ful when injecting the periorbita. The slanted</p><p>triangular appearance of the upper and lower eye-</p><p>lids renders an aged appearance, and when they</p><p>are properly augmented (filling both the short</p><p>and the long triangular limbs), the eyes resume</p><p>a horizontal fullness that is much more youthful</p><p>in shape. When evaluating the eyelids in this fash-</p><p>ion, the physician can fill either or both triangular</p><p>limbs that may be contributing to aging.</p><p>The frame of the mouth area is a very impor-</p><p>tant area to volumetrically fill. However, often-</p><p>times we think only of the obvious 2 landmarks of</p><p>the nasolabial grooves and the marionette lines.</p><p>Instead, it is better to think of the circular depres-</p><p>sion that circumscribes the entire mouth region</p><p>and causes the mouth/lips to appear floating in</p><p>a circular shadow. Accordingly, the areas of this</p><p>circle include the nasolabial groove (with a focus</p><p>on the upper recess of the groove, known as the</p><p>canine fossa), the marionette line, the anterior</p><p>chin depression (especially laterally just medial to</p><p>the marionette line), and the prejowl depression</p><p>along the jawline (that overlaps with the above-</p><p>described outer facial frame). Adding volume to</p><p>the lips without addressing the surrounding area</p><p>serves to deepen the shadows and further discon-</p><p>nect the lip and mouth from the perioral region,</p><p>resulting in many of the odd lip appearances that</p><p>patients fear.</p><p>UPPER FACE</p><p>A youthful upper eyelid demonstrates a uni-</p><p>form fullness from the eyelid fold inferiorly to</p><p>the</p><p>brow superiorly. This creates a seamless transition</p><p>Fig. 1. This schematic shows the 3 (dashed) circles for facial</p><p>framing that would ideally be filled: the perimeter around the</p><p>face that includes the temple, subzygomatic arch, buccal area,</p><p>and prejowl sulcus; around the mouth that includes the canine</p><p>fossa, nasolabial groove, marionette, prejowl sulcus, and ante-</p><p>rior chin; and the eyes, which can be more explicitly thought of</p><p>as 2 asymmetric triangles. The upper triangle has a short limb</p><p>medially and the lower triangle has a short limb laterally (as dis-</p><p>cussed in the text). By filling the medial upper triangle, in par-</p><p>ticular, the slanted eyelid is converted to a horizontal shape that</p><p>is much more youthful in appearance. Photograph courtesy of</p><p>Samuel M. Lam, MD.</p><p>D</p><p>ow</p><p>nloaded from</p><p>http://journals.lw</p><p>w</p><p>.com</p><p>/plasreconsurg by B</p><p>hD</p><p>M</p><p>f5eP</p><p>H</p><p>K</p><p>av1zE</p><p>oum</p><p>1tQ</p><p>fN</p><p>4a+</p><p>kJLhE</p><p>Z</p><p>gbsIH</p><p>o4X</p><p>M</p><p>i0</p><p>hC</p><p>yw</p><p>C</p><p>X</p><p>1A</p><p>W</p><p>nY</p><p>Q</p><p>p/IlQ</p><p>rH</p><p>D</p><p>3i3D</p><p>0O</p><p>dR</p><p>yi7T</p><p>vS</p><p>F</p><p>l4C</p><p>f3V</p><p>C</p><p>4/O</p><p>A</p><p>V</p><p>pD</p><p>D</p><p>a8K</p><p>K</p><p>G</p><p>K</p><p>V</p><p>0Y</p><p>m</p><p>y+</p><p>78=</p><p>on 07/03/2024</p><p>Copyright © 2015 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.</p><p>Volume 136, Number 5S • Analysis of Facial Aesthetics</p><p>13S</p><p>Fig. 2. This 52-year-old woman shown schematically in Figure 1 presents before (left) and 1 year</p><p>after (right) facial fillers along with neuromodulators and skin-care therapy during that time. Pho-</p><p>tograph courtesy of Samuel M. Lam, MD.</p><p>Fig. 3. This 42-year-old woman is shown before (left) at 35 years of age and after (right) 7 years of</p><p>progressive facial fillers into her face along with neuromodulators and skin-care therapy. Photo-</p><p>graph courtesy of Samuel M. Lam, MD.</p><p>D</p><p>ow</p><p>nloaded from</p><p>http://journals.lw</p><p>w</p><p>.com</p><p>/plasreconsurg by B</p><p>hD</p><p>M</p><p>f5eP</p><p>H</p><p>K</p><p>av1zE</p><p>oum</p><p>1tQ</p><p>fN</p><p>4a+</p><p>kJLhE</p><p>Z</p><p>gbsIH</p><p>o4X</p><p>M</p><p>i0</p><p>hC</p><p>yw</p><p>C</p><p>X</p><p>1A</p><p>W</p><p>nY</p><p>Q</p><p>p/IlQ</p><p>rH</p><p>D</p><p>3i3D</p><p>0O</p><p>dR</p><p>yi7T</p><p>vS</p><p>F</p><p>l4C</p><p>f3V</p><p>C</p><p>4/O</p><p>A</p><p>V</p><p>pD</p><p>D</p><p>a8K</p><p>K</p><p>G</p><p>K</p><p>V</p><p>0Y</p><p>m</p><p>y+</p><p>78=</p><p>on 07/03/2024</p><p>Copyright © 2015 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.</p><p>14S</p><p>Plastic and Reconstructive Surgery • November Supplement 2015</p><p>devoid of an infrabrow shadow, analogous to</p><p>the absence of the inferior orbital rim shadow</p><p>between the lower eyelid and cheek in younger</p><p>faces.1,2 A youthful upper face lacks shadowing</p><p>from a temporal fossa concavity, the youthful vol-</p><p>ume masking the senescent skeletal margins, that</p><p>is, lateral cephalic margin of the superior orbital</p><p>rim, the superior margin of the zygoma, and the</p><p>temporal line (Fig. 4).</p><p>The degree of visible pretarsal skin is variable</p><p>in a youthful upper eyelid. Most commonly, a</p><p>minimal strip of pretarsal skin is visible between</p><p>the upper-eyelid fold superiorly and the lash line</p><p>inferiorly (Fig. 4: type 1 upper eyelid1). There</p><p>exists a smaller subset of people who have a</p><p>greater degree of pretarsal skin show and a more</p><p>sculpted upper eyelid at a young age (Fig. 5: type</p><p>2 upper eyelid1). This can be evaluated by look-</p><p>ing at youthful photographs of the patient and</p><p>should be respected in designing facial rejuvena-</p><p>tion procedures.</p><p>Volume loss in the superior orbital rim</p><p>and upper eyelid creates infrabrow hollowing</p><p>manifesting as a deep shadow under the orbital</p><p>rim. The upper eyelid often appears deflated,</p><p>and the eyelid fold no longer flows seamlessly</p><p>up to the brow. Volume loss is most significant</p><p>above the medial upper eyelid, where there is</p><p>a greater degree of bone remodeling and/or</p><p>resorption.3,4 As the bony medial rim elevates, it</p><p>retracts the medial upper-eyelid fold superiorly</p><p>and increases exposure of the medial pretarsal</p><p>skin (Fig. 6). Temporal volume loss creates a</p><p>progressive concavity and shadowing in the tem-</p><p>poral fossa. This volume loss exposes the tem-</p><p>poral margin of the superolateral orbital rim</p><p>and superior margin of the zygoma, eliminating</p><p>the softer, less-shadowed appearance typical of a</p><p>youthful face (Fig. 7).</p><p>We purposely do not define the appearance of</p><p>a youthful upper face by the height of the brow.</p><p>The purported “ideal” brow position is classically</p><p>defined relative to the bony superior orbital rim.5</p><p>In a youthful face, the superior orbital rim is gener-</p><p>ally not visible due to upper-eyelid volume (Figs. 4</p><p>and 5). Aging is associated with soft-tissue volume</p><p>loss, exposing the superior orbital rim and increas-</p><p>ing infrabrow shadowing. Studies have suggested</p><p>Fig. 4. This 18-year-old woman demonstrates the hallmarks of</p><p>a youthful upper face. The Type 1 upper eyelid has uniform full-</p><p>ness from eyelid fold to brow, absent an infrabrow shadow, and</p><p>a thin span of visible pretarsal lid skin exposed between 2 paral-</p><p>lel lines (the eyelid fold and eyelash line). Youthful volume in the</p><p>temporal fossa masks delineation of the temporal line, supraor-</p><p>bital ridge, and zygomatic arch. Photograph courtesy of Robert</p><p>Glasgold, MD. Reprinted with permission from Glasgold Group,</p><p>Plastic Surgery, 2010.</p><p>Fig. 5. This 20-year-old woman demonstrates the upper-eyelid</p><p>variant (type 2) seen in a small subset of the general popula-</p><p>tion. Instead of fullness spanning from eyelid fold to brow, it</p><p>is characterized by a higher placed and deflated eyelid fold, a</p><p>greater degree of pretarsal skin visibility, and a shadow below</p><p>the superior orbital rim that runs parallel to the lash line. Photo-</p><p>graph courtesy of Robert Glasgold MD. Reprinted with permis-</p><p>sion from Glasgold Group, Plastic Surgery, 2013.</p><p>D</p><p>ow</p><p>nloaded from</p><p>http://journals.lw</p><p>w</p><p>.com</p><p>/plasreconsurg by B</p><p>hD</p><p>M</p><p>f5eP</p><p>H</p><p>K</p><p>av1zE</p><p>oum</p><p>1tQ</p><p>fN</p><p>4a+</p><p>kJLhE</p><p>Z</p><p>gbsIH</p><p>o4X</p><p>M</p><p>i0</p><p>hC</p><p>yw</p><p>C</p><p>X</p><p>1A</p><p>W</p><p>nY</p><p>Q</p><p>p/IlQ</p><p>rH</p><p>D</p><p>3i3D</p><p>0O</p><p>dR</p><p>yi7T</p><p>vS</p><p>F</p><p>l4C</p><p>f3V</p><p>C</p><p>4/O</p><p>A</p><p>V</p><p>pD</p><p>D</p><p>a8K</p><p>K</p><p>G</p><p>K</p><p>V</p><p>0Y</p><p>m</p><p>y+</p><p>78=</p><p>on 07/03/2024</p><p>Copyright © 2015 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.</p><p>Volume 136, Number 5S • Analysis of Facial Aesthetics</p><p>15S</p><p>that age-related bone loss of the superomedial</p><p>orbital rim elevates the position of the medial bony</p><p>orbital rim.1,3 A more natural rejuvenation strategy</p><p>should restore the volume deficiency below the</p><p>brow and not elevate the brow to the higher posi-</p><p>tion of the bony orbital rim (Fig. 7).</p><p>Fig. 6. Left, A woman in her mid twenties with a youthful type 1 upper eyelid. Center, The same woman presenting in her mid-</p><p>sixties for upper-eyelid rejuvenation. Right, Following upper-eyelid blepharoplasty (10 months) to remove skin and autologous fat</p><p>transfer to the upper eyelid, the characteristics of a youthful upper eyelid are restored. Photograph courtesy of Robert Glasgold,</p><p>MD. Reprinted with permission from Glasgold Group, Plastic Surgery, 2012.</p><p>Fig. 7. This woman demonstrates significant volume loss, particularly in the upper face; she is</p><p>shown at age 18 (left) and age 60 (right). Temporal lipoatrophy exposes the surrounding bony</p><p>landmarks. Her significant upper-eyelid volume loss is more typical with aging in individuals with</p><p>a type 2 upper eyelid. Photograph courtesy of Robert Glasgold, MD. Reprinted with permission</p><p>from Glasgold Group, Plastic Surgery, 2009.</p><p>D</p><p>ow</p><p>nloaded from</p><p>http://journals.lw</p><p>w</p><p>.com</p><p>/plasreconsurg by B</p><p>hD</p><p>M</p><p>f5eP</p><p>H</p><p>K</p><p>av1zE</p><p>oum</p><p>1tQ</p><p>fN</p><p>4a+</p><p>kJLhE</p><p>Z</p><p>gbsIH</p><p>o4X</p><p>M</p><p>i0</p><p>hC</p><p>yw</p><p>C</p><p>X</p><p>1A</p><p>W</p><p>nY</p><p>Q</p><p>p/IlQ</p><p>rH</p><p>D</p><p>3i3D</p><p>0O</p><p>dR</p><p>yi7T</p><p>vS</p><p>F</p><p>l4C</p><p>f3V</p><p>C</p><p>4/O</p><p>A</p><p>V</p><p>pD</p><p>D</p><p>a8K</p><p>K</p><p>G</p><p>K</p><p>V</p><p>0Y</p><p>m</p><p>y+</p><p>78=</p><p>on 07/03/2024</p><p>Copyright © 2015 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.</p><p>16S</p><p>Plastic and Reconstructive Surgery • November Supplement 2015</p><p>MIDFACE</p><p>The midface, which extends from the lower</p><p>eyelid to the oral commissure, demonstrates</p><p>changes that are predominantly volume depen-</p><p>dent. Aging leads to an overall change in facial</p><p>shape as volume shifts from the upper midface</p><p>to the lower face transitioning the youthful,</p><p>heart-shaped face into a more aged, rectangular</p><p>shape.1,6,7 Specific patterns of age-related volume</p><p>transform the midface from a youthful convex</p><p>platform dominated by unified highlights to an</p><p>aged platform segmented by shadows (concavi-</p><p>ties) (Fig. 8).</p><p>Younger midfaces have a convexity running</p><p>from the lower eyelid to the nasolabial fold, creat-</p><p>ing a uniform cheek highlight. In a youthful face,</p><p>soft tissue covers the bony skeletal components of</p><p>the midface providing a softer appearance; the</p><p>inferior orbital rim is masked, minimizing any</p><p>delineation between the lower eyelid and cheek.1,6,7</p><p>The zygomatic arch, providing the foundation of</p><p>lateral cheek volume, is adequately covered by soft</p><p>tissue to hide the shadows that delineate its supe-</p><p>rior and inferior margins (Fig. 8, left).</p><p>Advancing age is associated with a general-</p><p>ized deflation of the midface, particularly in the</p><p>upper aspects. The combination of volume loss</p><p>and the effect of underlying facial retaining liga-</p><p>ments contribute to the hallmarks of midfacial</p><p>aging (Figs. 8 and 9). The most relevant ligaments</p><p>in the midface are the orbital retaining ligament,</p><p>malar septum (zygomatico-cutaneous ligament),</p><p>and McGregor’s patch (zygomatic ligament).8–11</p><p>Volume loss at the inferior orbital rim creates a</p><p>concavity and overlying shadow, separating the</p><p>lower eyelid from the cheek.</p><p>Outside the scope of this article, albeit impor-</p><p>tant to assess, is the contribution of pseudoher-</p><p>niated lower eyelid fat on this concavity. The</p><p>youthful convexity of the anterior cheek changes</p><p>into a concavity of the midface hollow. Volume</p><p>loss and tethering of the malar septum create</p><p>this shadow that runs parallel to the nasolabial</p><p>fold and is the hallmark of midface aging. Lateral</p><p>cheek volume loss diminishes the dominance of</p><p>midface volume and skeletonizes the zygomatic</p><p>arch, creating a harsh submalar shadow. When</p><p>present, buccal volume loss accentuates an aged</p><p>and unhealthy appearance. Finally, recession at</p><p>the precanine fossa due to bony volume loss con-</p><p>tributes to depth of the nasolabial fold.9</p><p>Volume rejuvenation of the midface is focused</p><p>on restoring the dominance of midface volume to</p><p>give a more heart-shaped face and minimizing the</p><p>segmenting shadows seen with age. Adding vol-</p><p>ume into the inferior orbital rim should reunify</p><p>the lower eyelid and cheek segments. Filling the</p><p>cheek, with a focus on the malar septal depres-</p><p>sion, should recreate a convex cheek with a strong</p><p>highlight (Fig. 9). However, filling of the lower</p><p>eyelid and of the anterior cheek to excess has</p><p>been problematic in contributing to the overfilled</p><p>Fig. 8. Left, A woman in her twenties demonstrates the ideal volume and lack of midface shadows</p><p>in conveying a youthful appearance. Right, A woman in her sixties demonstrates the aging effect</p><p>of volume loss, as the midface is dominated by segmented shadows. Photographs courtesy of</p><p>Mark Glasgold, MD. Reprinted with permission from Lam SM, Glasgold MJ, Glasgold RA. Comple-</p><p>mentary Fat Grafting. Philadelphia, Pa.: Lippincott Williams & Wilkins; 2007.</p><p>D</p><p>ow</p><p>nloaded from</p><p>http://journals.lw</p><p>w</p><p>.com</p><p>/plasreconsurg by B</p><p>hD</p><p>M</p><p>f5eP</p><p>H</p><p>K</p><p>av1zE</p><p>oum</p><p>1tQ</p><p>fN</p><p>4a+</p><p>kJLhE</p><p>Z</p><p>gbsIH</p><p>o4X</p><p>M</p><p>i0</p><p>hC</p><p>yw</p><p>C</p><p>X</p><p>1A</p><p>W</p><p>nY</p><p>Q</p><p>p/IlQ</p><p>rH</p><p>D</p><p>3i3D</p><p>0O</p><p>dR</p><p>yi7T</p><p>vS</p><p>F</p><p>l4C</p><p>f3V</p><p>C</p><p>4/O</p><p>A</p><p>V</p><p>pD</p><p>D</p><p>a8K</p><p>K</p><p>G</p><p>K</p><p>V</p><p>0Y</p><p>m</p><p>y+</p><p>78=</p><p>on 07/03/2024</p><p>Copyright © 2015 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.</p><p>Volume 136, Number 5S • Analysis of Facial Aesthetics</p><p>17S</p><p>look. Instead, filling the lateral cheek can at times</p><p>already contribute to a partially if not entirely</p><p>improved lower-eyelid appearance (through a lift-</p><p>ing action of the filler) and avoid the necessity of</p><p>filling very much in the anterior cheek as well.</p><p>LOWER FACE</p><p>Aging is associated with a volume shift from</p><p>the upper to lower facial regions. The youthful</p><p>heart shape converts into a rectangular shape sec-</p><p>ondary to volume loss in the midface (periorbital,</p><p>malar, submalar, and buccal) and an increase in</p><p>jowl volume and descent. Despite this big-picture</p><p>shift in volume toward the lower face with aging,</p><p>targeted addition of volume to the lower face is an</p><p>integral component of an optimal facial rejuvena-</p><p>tion strategy.</p><p>The hallmarks of a youthful lower face</p><p>include a smooth transition from the cheek to</p><p>chin, devoid of shadowing at the labiomandibu-</p><p>lar fold. The jawline is well defined by a curvi-</p><p>linear shadow coursing from the mandibular</p><p>angle to the anterior chin; on oblique view, the</p><p>shadow framing the jawline has a “hockey stick”</p><p>shape (Fig. 8, left).11,12 This youthful jawline shape</p><p>is dependent on an adequate bony foundation,</p><p>providing sufficient volume at the prejowl sulcus</p><p>and angle of mandible.</p><p>Volume loss in the labiomandibular fold man-</p><p>ifests as a shadow anterior to the jowl from oral</p><p>commissure to jawline. The prejowl sulcus appears</p><p>as volume loss progressing along the inferior por-</p><p>tion of the mandible and extending anterior to</p><p>the jowl. Cephalic retraction in the prejowl sulcus</p><p>is due to fixation of the skin to the underlying</p><p>resorbing bone via the mandibular ligament.11–14</p><p>Shadowing in the labiomandibular fold and pre-</p><p>jowl sulcus is accentuated by increased fullness</p><p>and descent of the jowl. The lateral portion of the</p><p>jawline experiences volume loss at the mandibular</p><p>angle. The combination of anterior and posterior</p><p>mandibular volume loss, in conjunction with jowl</p><p>descent, converts the youthful “hockey stick”–</p><p>shaped jawline to an irregular W shape (Fig. 10).</p><p>Congenital lower facial volume deficien-</p><p>cies, most common in the chin and mandibu-</p><p>lar angle, can create an aging appearance in a</p><p>young person. Deficiencies in the anterior chin</p><p>and prejowl sulcus will create relative mid-jaw-</p><p>line dominance, manifesting as early jowl forma-</p><p>tion (Fig. 11). These patients tend to present at</p><p>an earlier age for lower face rejuvenation as the</p><p>early volume changes will more easily highlight</p><p>their skeletal deficiencies. In contrast, individu-</p><p>als with a better baseline skeletal structure will</p><p>manifest more discrete areas of volume loss as</p><p>they age. In these individuals, the early manifes-</p><p>tations of lower face aging are often more easily</p><p>addressed with a smaller, more focused volume-</p><p>added strategy (Fig. 10).</p><p>Fig. 9. Preoperative (left) and postoperative (6 months) (right) photographs of a woman in her</p><p>mid-fifties. The youthful cheek highlight and elimination of midface shadowing were achieved</p><p>through combination of lower-eyelid transconjunctival blepharoplasty and autologous fat trans-</p><p>fer to the inferior orbital rim and cheek. Photograph courtesy of Robert Glasgold, MD. Reprinted</p><p>with permission from Glasgold RA, Glasgold MJ, Lam SM. Complementary fat grafting. In: Carniol</p><p>P, Sadick N, eds. Clinical Procedures in Laser Skin Rejuvenation. New York, N.Y.: Informa; 2007.</p><p>D</p><p>ow</p><p>nloaded from</p><p>http://journals.lw</p><p>w</p><p>.com</p><p>/plasreconsurg by B</p><p>hD</p><p>M</p><p>f5eP</p><p>H</p><p>K</p><p>av1zE</p><p>oum</p><p>1tQ</p><p>fN</p><p>4a+</p><p>kJLhE</p><p>Z</p><p>gbsIH</p><p>o4X</p><p>M</p><p>i0</p><p>hC</p><p>yw</p><p>C</p><p>X</p><p>1A</p><p>W</p><p>nY</p><p>Q</p><p>p/IlQ</p><p>rH</p><p>D</p><p>3i3D</p><p>0O</p><p>dR</p><p>yi7T</p><p>vS</p><p>F</p><p>l4C</p><p>f3V</p><p>C</p><p>4/O</p><p>A</p><p>V</p><p>pD</p><p>D</p><p>a8K</p><p>K</p><p>G</p><p>K</p><p>V</p><p>0Y</p><p>m</p><p>y+</p><p>78=</p><p>on 07/03/2024</p><p>Copyright © 2015 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.</p><p>18S</p><p>Plastic and Reconstructive Surgery • November Supplement 2015</p><p>As aging continues into the late forties and</p><p>beyond, the degree of jowl fullness and descent</p><p>become an increasingly important factor in</p><p>facial rejuvenation. Merely adding volume in</p><p>the jawline will be insufficient to mask a heavier</p><p>jowl. In these individuals, a lower face-lift has a</p><p>Fig. 10. Preoperative (left) and postoperative (2 months) (right) lower face volume rejuvenation</p><p>with injectable fillers. The aging “W”-shaped jawline was converted to a more youthful jawline</p><p>by filling the prejowl sulcus and lateral jawline (mandibular angle). The labiomandibular fold was</p><p>also addressed to help camouflage the anterior border of the jowl. Photograph courtesy of Robert</p><p>Glasgold, MD. Reprinted with permission from Glasgold Group, Plastic Surgery, 2011.</p><p>Fig. 11. Left, This woman in her late twenties presented with signs of lower aging at a young</p><p>age. Right,</p><p>Facial rejuvenation (6 months postoperative) of the lower face was accomplished by</p><p>adding volume via autologous fat transfer to the prejowl sulcus and mandibular angle as well as</p><p>mentoplasty with a silastic implant. The overall facial rejuvenation was aided by reduction of the</p><p>buccal fat pad and autologous fat transfer to the midface and upper eyelid. Photograph courtesy</p><p>of Robert Glasgold, MD. Reprinted with permission from Glasgold Group, Plastic Surgery, 2013.</p><p>D</p><p>ow</p><p>nloaded from</p><p>http://journals.lw</p><p>w</p><p>.com</p><p>/plasreconsurg by B</p><p>hD</p><p>M</p><p>f5eP</p><p>H</p><p>K</p><p>av1zE</p><p>oum</p><p>1tQ</p><p>fN</p><p>4a+</p><p>kJLhE</p><p>Z</p><p>gbsIH</p><p>o4X</p><p>M</p><p>i0</p><p>hC</p><p>yw</p><p>C</p><p>X</p><p>1A</p><p>W</p><p>nY</p><p>Q</p><p>p/IlQ</p><p>rH</p><p>D</p><p>3i3D</p><p>0O</p><p>dR</p><p>yi7T</p><p>vS</p><p>F</p><p>l4C</p><p>f3V</p><p>C</p><p>4/O</p><p>A</p><p>V</p><p>pD</p><p>D</p><p>a8K</p><p>K</p><p>G</p><p>K</p><p>V</p><p>0Y</p><p>m</p><p>y+</p><p>78=</p><p>on 07/03/2024</p><p>Copyright © 2015 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.</p><p>Volume 136, Number 5S • Analysis of Facial Aesthetics</p><p>19S</p><p>primary role in obtaining an optimal, natural</p><p>rejuvenation. Despite the shift in importance to</p><p>face-lifting in this age group, failure to address</p><p>underlying volume loss may result in inadequate</p><p>lower face rejuvenation. If volume is not restored</p><p>in the prejowl sulcus at the time of face-lift, the</p><p>patient may appear to have incomplete correc-</p><p>tion of the jowl. In addition, inadequate base-</p><p>line mandibular angle volume may account for</p><p>incomplete jawline rejuvenation following a face-</p><p>lift (Fig. 12).</p><p>PERSONAL PERSPECTIVES</p><p>“The difference between an education and an</p><p>excuse is only that an education is given before</p><p>a procedure and an excuse is given afterward.”</p><p>Unfortunately, many physicians and surgeons</p><p>are not fully aware of the limitations of volume</p><p>restoration and set themselves up for problems</p><p>following a procedure because they failed to</p><p>counsel a patient adequately beforehand. This is</p><p>particularly true with facial fat grafting (as com-</p><p>pared with fillers) as there is variable resorption</p><p>of the fat that cannot be 100% predicted, and the</p><p>patient should be counseled about this limitation</p><p>in advance.</p><p>Volumetric analysis and treatment are much</p><p>more effective when we look more globally at</p><p>the shadow groups and facial frames and think</p><p>of adding smaller volumes over larger areas to</p><p>blend highlights together. Every time we add vol-</p><p>ume on the face, the flow of light across the face</p><p>will be affected. Any interruption in contour will</p><p>introduce or accentuate a shadow. It becomes</p><p>necessary to think about transitions from light to</p><p>shadow within a region and between the subre-</p><p>gions. Particular care to transitions must be taken</p><p>when filling the subzygomatic/buccal region and</p><p>temple (global facial frame). The patient will be</p><p>viewing these areas tangentially in a mirror, and</p><p>the slightest irregularity will become evident</p><p>(Fig. 13). The area that has been of principle</p><p>concern as the volume revolution began about a</p><p>decade ago is filling of the anterior cheek. With-</p><p>out a doubt, the anterior cheek offers incredible</p><p>results as far as femininity and can be construed</p><p>as an extended frame to the eye. However, there</p><p>are several potential pitfalls with the anterior</p><p>cheek. First, isolated augmentation of the ante-</p><p>rior cheek without filling the adjacent regions</p><p>can look unnatural in appearance because it is</p><p>not properly blended. More importantly, with</p><p>the trend toward a more liberal overvolumizing</p><p>of the anterior cheek, we are seeing a rash of</p><p>people who look too “cheeky” when they smile.</p><p>This dynamic problem really has caused the issue</p><p>of a pervasive deformity; whereas before people</p><p>used to look too pulled, we are now seeing more</p><p>patients who look too inflated.</p><p>Fig. 12. Left, Preoperatively this woman in her sixties had presented for facial rejuvenation. Center, Following deep plane face-lift</p><p>and autologous fat transfer (1 year postoperative) to the midface, she still had incomplete jawline rejuvenation due to mandibular</p><p>insufficiency. Right, Autologous fat transfer (1 year post fat transfer, 2 years post primary surgery) to the prejowl sulcus and lateral</p><p>mandible aided in jawline contouring by further masking the residual jowl. Photograph courtesy of Mark Glasgold, MD. Reprinted</p><p>with permission from Glasgold Group, Plastic Surgery, 2013.</p><p>D</p><p>ow</p><p>nloaded from</p><p>http://journals.lw</p><p>w</p><p>.com</p><p>/plasreconsurg by B</p><p>hD</p><p>M</p><p>f5eP</p><p>H</p><p>K</p><p>av1zE</p><p>oum</p><p>1tQ</p><p>fN</p><p>4a+</p><p>kJLhE</p><p>Z</p><p>gbsIH</p><p>o4X</p><p>M</p><p>i0</p><p>hC</p><p>yw</p><p>C</p><p>X</p><p>1A</p><p>W</p><p>nY</p><p>Q</p><p>p/IlQ</p><p>rH</p><p>D</p><p>3i3D</p><p>0O</p><p>dR</p><p>yi7T</p><p>vS</p><p>F</p><p>l4C</p><p>f3V</p><p>C</p><p>4/O</p><p>A</p><p>V</p><p>pD</p><p>D</p><p>a8K</p><p>K</p><p>G</p><p>K</p><p>V</p><p>0Y</p><p>m</p><p>y+</p><p>78=</p><p>on 07/03/2024</p><p>Copyright © 2015 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.</p><p>20S</p><p>Plastic and Reconstructive Surgery • November Supplement 2015</p><p>The desire for symmetry is one of the most</p><p>important goals to address in consultation. Typi-</p><p>cally, patients do not perceive the significant</p><p>asymmetry in their faces, and trying to demon-</p><p>strate this in a mirror is often difficult. Review-</p><p>ing standardized photographs with the patient</p><p>is an extremely effective process. As a general</p><p>rule, correcting asymmetry is not possible, and</p><p>in fact, asymmetry may be accentuated by vol-</p><p>ume. The physician should not allow the patient</p><p>to make this a goal; it is creating an unrealistic</p><p>expectation.</p><p>The 2 ways that I (S. Lam) judge my aes-</p><p>thetic results are as follows: (1) the moment</p><p>I walk into the room do I believe my patient</p><p>looks better without time for elaborate scru-</p><p>tiny (if not why?) (2) how many compliments</p><p>have the patient attained from others regarding</p><p>their improved appearance, for example, “Wow,</p><p>you really look great.” These are my standards,</p><p>albeit qualitative, for my outcomes (in addition</p><p>to comparative review of their before-and-after</p><p>results) and not just how a patient sees one’s</p><p>own face because many women in particular</p><p>use their left brains to evaluate their results,</p><p>that is, I still have asymmetry, I still have these</p><p>fine lines, etc. Prior to embarking on any cos-</p><p>metic procedure, I spend considerable time</p><p>with every prospective patient to have that indi-</p><p>vidual understand my philosophy and the goals</p><p>of the procedure. I state in advance that I will</p><p>fail to achieve symmetry or to improve small</p><p>details but that I should be able to improve</p><p>their socioprofessional standing among their</p><p>peers if they allow me to exercise an artistic</p><p>eye to achieve that objective. Those individuals</p><p>who are attracted to this perspective become my</p><p>patients and those who do not will be an unsuit-</p><p>able match for my clinical practice.</p><p>This monograph represents the combined</p><p>and separate observations of the authors when</p><p>it comes to beauty, aging, and approaches to</p><p>achieve facial rejuvenation based on an espoused</p><p>paradigm and derived from personal experience</p><p>rather than on a rigorous, retrospective case-study</p><p>evaluation. We are not zealots of methodology</p><p>and fully recognize the limitations of any singular</p><p>approach. In many skilled hands, fat reposition-</p><p>ing with face-lifting rather than strictly volume</p><p>restoration can achieve comparable results that</p><p>are natural, long lasting, and excellent. We hope</p><p>that this article will help a prospective surgeon</p><p>gain insight into improved patient communica-</p><p>tion, perception of youth and aging, and methods</p><p>that can be incorporated to achieve natural facial</p><p>rejuvenation.</p><p>Fig. 13. This 36-year-old woman is shown before (left) and 6 months after (right) facial fillers into her</p><p>face along with consistent neuromodulators and skin-care therapy. Of note, her initial lip augmenta-</p><p>tion was performed elsewhere. Photograph courtesy of Samuel M. Lam, MD.</p><p>D</p><p>ow</p><p>nloaded from</p><p>http://journals.lw</p><p>w</p><p>.com</p><p>/plasreconsurg by B</p><p>hD</p><p>M</p><p>f5eP</p><p>H</p><p>K</p><p>av1zE</p><p>oum</p><p>1tQ</p><p>fN</p><p>4a+</p><p>kJLhE</p><p>Z</p><p>gbsIH</p><p>o4X</p><p>M</p><p>i0</p><p>hC</p><p>yw</p><p>C</p><p>X</p><p>1A</p><p>W</p><p>nY</p><p>Q</p><p>p/IlQ</p><p>rH</p><p>D</p><p>3i3D</p><p>0O</p><p>dR</p><p>yi7T</p><p>vS</p><p>F</p><p>l4C</p><p>f3V</p><p>C</p><p>4/O</p><p>A</p><p>V</p><p>pD</p><p>D</p><p>a8K</p><p>K</p><p>G</p><p>K</p><p>V</p><p>0Y</p><p>m</p><p>y+</p><p>78=</p><p>on 07/03/2024</p><p>Copyright © 2015 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.</p><p>Volume 136, Number 5S • Analysis of Facial Aesthetics</p><p>21S</p><p>Mark Glasgold,</p><p>MD</p><p>31 River Road</p><p>Highland Park, NJ 08904</p><p>drmark@glasgoldgroup.com</p><p>PATIENT CONSENT</p><p>Patients provided written consent for the use of their</p><p>images.</p><p>REFERENCES</p><p>1. Glasgold RA, Lam SM, Glasgold MJ. Periorbital fat grafting.</p><p>In: Massry G, Azzizadeh B, Murphy M, eds. Master Techniques</p><p>in Blepharoplasty and Peri-orbital Rejuvenation. New York, N.Y.:</p><p>Springer; 2011.</p><p>2. Buckingham ED, Glasgold RA, Kontis T, et al. Volume rejuvena-</p><p>tion of the facial upper third. Facial Plast Surg. 2015;31:43–53.</p><p>3. Glasgold RA, Glasgold MJ, Gerth DJ. Upper eyelid volumiza-</p><p>tion with hyaluronic acid. In: Hartstein M, Massry G, Holds J,</p><p>eds. Pearls and Pitfalls of Cosmetic Oculoplastic Surgery. 2nd ed.</p><p>Springer. In press.</p><p>4. Kahn DM, Shaw RB. Overview of current thoughts on facial</p><p>volume and aging. Facial Plast Surg. 2010;26:350–355.</p><p>5. Freund RM, Nolan WB 3rd. Correlation between brow lift</p><p>outcomes and aesthetic ideals for eyebrow height and shape</p><p>in females. Plast Reconstr Surg. 1996;97:1343–1348.</p><p>6. Lam SM. The perception of beauty after facial plastic sur-</p><p>gery. JAMA Facial Plast Surg. 2015;17:208.</p><p>7. Buckingham ED, Glasgold RA, Kontis T, et al. Volume man-</p><p>agement of the middle third – lower orbit/midface. Facial</p><p>Plast Surg. 2015;31:55–69.</p><p>8. Muzaffar AR, Mendelson BC, Adams WP Jr. Surgical anat-</p><p>omy of the ligamentous attachments of the lower lid and</p><p>lateral canthus. Plast Reconstr Surg. 2002;110:873–884;</p><p>discussion 897.</p><p>9. Mendelson BC, Muzaffar AR, Adams WP Jr. Surgical anat-</p><p>omy of the midcheek and malar mounds. Plast Reconstr Surg.</p><p>2002;110:885–896; discussion 897.</p><p>10. Pessa JE, Garza JR. The malar septum: the anatomic</p><p>basis of malar mounds and malar edema. Aesthet Surg J.</p><p>1997;17:11–17.</p><p>11. Furnas DW. The retaining ligaments of the cheek. Plast</p><p>Reconstr Surg. 1989;83:11–16.</p><p>12. Glasgold RA, Meier JD, Glasgold MJ. Volumetric approach</p><p>to rejuvenation of the lower face. In: Sadick N, Carniol P,</p><p>eds. Illustrated Manual of Injectable Fillers: a Technical Guide to</p><p>Volumetric Approach to Whole Body Rejuvenation. New York, N.Y.:</p><p>Informa; 2011.</p><p>13. Buckingham ED, Glasgold RA, Kontis T, et al. Volume reju-</p><p>venation of the lower third, perioral and jawline. Facial Plast</p><p>Surg. 2015;31:70–79.</p><p>14. Mendelson BC, Freeman ME, Wu W, et al. Surgical</p><p>anatomy of the lower face: the premasseter space, the</p><p>jowl, and the labiomandibular fold. Aesthetic Plast Surg.</p><p>2008;32:185–195.</p><p>D</p><p>ow</p><p>nloaded from</p><p>http://journals.lw</p><p>w</p><p>.com</p><p>/plasreconsurg by B</p><p>hD</p><p>M</p><p>f5eP</p><p>H</p><p>K</p><p>av1zE</p><p>oum</p><p>1tQ</p><p>fN</p><p>4a+</p><p>kJLhE</p><p>Z</p><p>gbsIH</p><p>o4X</p><p>M</p><p>i0</p><p>hC</p><p>yw</p><p>C</p><p>X</p><p>1A</p><p>W</p><p>nY</p><p>Q</p><p>p/IlQ</p><p>rH</p><p>D</p><p>3i3D</p><p>0O</p><p>dR</p><p>yi7T</p><p>vS</p><p>F</p><p>l4C</p><p>f3V</p><p>C</p><p>4/O</p><p>A</p><p>V</p><p>pD</p><p>D</p><p>a8K</p><p>K</p><p>G</p><p>K</p><p>V</p><p>0Y</p><p>m</p><p>y+</p><p>78=</p><p>on 07/03/2024</p><p>mailto:drmark@glasgoldgroup.com</p>