Master Techniques in Facial

Rejuvenation - eBook PDF

Visit to download the full and correct content document:
https://ebooksecure.com/download/master-techniques-in-facial-rejuvenation-ebook-p
df/
Any screen.
Any time.
Anywhere.
Activate the eBook version
of this title at no additional charge.

Expert Consult eBooks give you the power to browse and find content,
view enhanced images, share notes and highlights—both online and offline.

Unlock your eBook today.

1 Visit expertconsult.inkling.com/redeem Scan this QR code to redeem your
eBook through your mobile device:
2 Scratch off your code
3 Type code into “Enter Code” box

4 Click “Redeem”
5 Log in or Sign up
6 Go to “My Library”
Place Peel Off
It’s that easy! Sticker Here

For technical assistance:

email expertconsult.help@elsevier.com
call 1-800-401-9962 (inside the US)
call +1-314-447-8200 (outside the US)
Use of the current edition of the electronic version of this book (eBook) is subject to the terms of the nontransferable, limited license granted on
expertconsult.inkling.com. Access to the eBook is limited to the first individual who redeems the PIN, located on the inside cover of this book,
at expertconsult.inkling.com and may not be transferred to another party by resale, lending, or other means.
2015v1.0
MASTER TECHNIQUES IN
FACIAL REJUVENATION
This page intentionally left blank
 SECOND EDITION

MASTER TECHNIQUES
IN FACIAL
REJUVENATION
Babak Azizzadeh, MD, FACS Guy G. Massry, MD
Clinical Director Clinical Professor of Ophthalmology
Center for Advanced Facial Plastic Surgery Keck School of Medicine
Beverly Hills, California; University of Southern California
Associate Clinical Professor Beverly Hills Ophthalmic Plastic & Reconstructive
Division of Head & Neck Surgery Surgery
David Geffen School of Medicine Beverly Hills, California
University of California, Los Angeles
Los Angeles, California
Rebecca Fitzgerald, MD
Private Practice & David Geffen School of Medicine
Mark R. Murphy, MD University of California Los Angeles
Director Los Angeles, California
Palm Beach Facial Plastic Surgery
West Palm Beach, Florida

Calvin M. Johnson Jr., MD

Clinical Associate Professor
Division of Facial Plastic & Reconstructive Surgery
Tulane University School of Medicine;
Director
Hedgewood Surgical Center
New Orleans, Louisiana

For additional online content visit ExpertConsult.com

Edinburgh London New York Oxford Philadelphia St Louis Sydney Toronto 2018
© 2018, Elsevier Inc. All rights reserved.
FIRST EDITION 2007

No part of this publication may be reproduced or transmitted in any form or by any means,
electronic or mechanical, including photocopying, recording, or any information storage and retrieval
system, without permission in writing from the Publisher. Details on how to seek permission, further
information about the Publisher’s permissions policies and our arrangements with organizations such
as the Copyright Clearance Center and the Copyright Licensing Agency, can be found at our website:
www.elsevier.com/permissions.

This book and the individual contributions contained in it are protected under copyright by the
Publisher (other than as may be noted herein).

Notices

Practitioners and researchers must always rely on their own experience and knowledge in
evaluating and using any information, methods, compounds or experiments described herein.
Because of rapid advances in the medical sciences, in particular, independent verification of
diagnoses and drug dosages should be made. To the fullest extent of the law, no responsibility is
assumed by Elsevier, authors, editors or contributors for any injury and/or damage to persons or
property as a matter of products liability, negligence or otherwise, or from any use or operation of
any methods, products, instructions, or ideas contained in the material herein.

ISBN: 978-0-323-35876-7
eBook ISBN: 978-0-323-37826-0

Content Strategist: Belinda Kuhn

Content Development Specialists: Trinity Hutton, Alexandra Mortimer
Project Manager: Julie Taylor
Design: Amy Buxton
Illustration Manager: Karen Giacomucci
Illustrator: Paul Kim
Marketing Manager: Melissa Fogarty

Printed in Canada

Last digit is the print number: 9 8 7 6 5 4 3 2 1

 CONTENTS

Video Contents ..................................................................................................................... vii

Preface ................................................................................................................................. viii
List of Contributors ............................................................................................................... ix
Acknowledgments ................................................................................................................. xii
Dedication ............................................................................................................................ xiii
1 Facial Embryology .......................................................................................................... 1
Carlo P. Honrado, Dewayne T. Bradley, and Wayne F. Larrabee Jr.

2 Applied Facial Anatomy .................................................................................................. 6

Jonathan M. Sykes, Gustavo A. Suárez, Patrick Trevidic, Sebastian Cotofana, and Hyoung Jin Moon

3 Addressing Facial Shape and Proportions With Injectable Agents in Youth

and Age ......................................................................................................................... 15
Rebecca Fitzgerald

4 Injectables and Resurfacing Techniques: Botulinum toxin (BoNT-A) ............................ 55

Michael A. C. Kane

5 Topical Skin Care and the Cosmetic Patient .................................................................. 68

Patricia K. Farris

6 Skin Resurfacing ........................................................................................................... 73

H. Ray Jalian, Andrew Breithaupt, and Mathew M. Avram

7 The Open Browlift ........................................................................................................ 80

Mark R. Murphy and Calvin M. Johnson Jr.

8 Endoscopic Foreheadplasty: A Twenty-Seven-Year Experience ...................................... 93

Gregory S. Keller, John W. Frederick, and Vishad Nabili

9 Nonsurgical Brow and Eyelid Rejuvenation ................................................................ 101

Catherine J. Hwang, Shani Golan, and Robert Goldberg

10 Minimally Invasive Complementary Adjuncts to Upper Blepharoplasty ...................... 107

César A. Briceño and Guy G. Massry

11 Ptosis Repair and Blepharoplasty ................................................................................ 120

Daniel Straka and Jill Foster

12 Transconjunctival Lower Blepharoplasty With and Without Fat Repositioning ........... 131
David B. Samimi and Guy G. Massry

13 Transcutaneous Lower Blepharoplasty ........................................................................ 142

Andrew A. Jacono and Melanie H. Malone

14 The Spectrum of Canthal Suspension Techniques in Lower Blepharoplasty ................. 152

Andrea Lora Kossler and Guy G. Massry

15 Aesthetic Rejuvenation in the Patient of Asian Ancestry .............................................. 166

Ramzi M. Alameddine, Bradford W. Lee, Wei Lu, Bobby S. Korn, and Don O. Kikkawa

16 The Deep Plane Facelift ............................................................................................... 173

Calvin M. Johnson Jr. and Mark R. Murphy

17 Deep Plane Rhytidectomy Modifications ..................................................................... 191

Andrew A. Jacono and Melanie H. Malone

v
vi Contents

18 Lateral SMASectomy Facelift ...................................................................................... 211

Daniel C. Baker and Steven M. Levine

19 Reshaping Rhytidectomy ............................................................................................. 219

Babak Azizzadeh

20 Tridimensional Endoscopic Facelift ............................................................................. 247

Oscar M. Ramirez and Charles R. Volpe

21 Midface Implants ........................................................................................................ 270

Joe Niamtu

22 Mentoplasty ................................................................................................................ 286

Robert A. Glasgold, Mark J. Glasgold, and Alvin I. Glasgold

23 Orthognathic Aesthetic Facial Surgery ........................................................................ 294

Jonathan M. Sykes and Gustavo A. Suárez

24 Facial and Cervical Lipectomy .................................................................................... 305

Jeannie H. Chung and Edwin F. Williams III

25 Complementary Fat Grafting ...................................................................................... 321

Robert A. Glasgold, Mark J. Glasgold, and Samuel M. Lam

26 Rhinoplasty in the Aging Patient ................................................................................. 333

Victor Chung, Neela Rao, and Dean M. Toriumi

INDEX ................................................................................................................................ 347

 VIDEO CONTENTS

Chapter 7 The Open Browlift

Video 7.1 Open Browlift/Deep Plane Facelift – Calvin M. Johnson Jr
Chapter 9 Nonsurgical Brow and Eyelid Rejuvenation
Video 9.1 Volumizing the Periorbita with Cannula – Catherine J. Hwang
Chapter 10 Minimally Invasive Complementary Adjuncts to Upper Blepharoplasty
Video 10.1 Surgical Adjuncts – Guy G. Massry
Chapter 11 Ptosis Repair and Blepharoplasty
Video 11.1 External Levator Advancement – Daniel Straka and Jill Foster
Video 11.1 Conjunctival Müller’s Muscle Resection – Daniel Straka and Jill Foster
Chapter 12 Transconjunctival Lower Blepharoplasty With and Without Fat Repositioning
Video 12.1 Transconjunctival Lower Blepharoplasty with Fat Repositioning – Guy G. Massry
and David B. Samimi
Chapter 14 The Spectrum of Canthal Suspension Techniques in Lower Blepharoplasty
Video 14.1 Canthal Suspension Procedures for Lower Blepharoplasty – Guy G. Massry and
Andrea Lora Kossler
Chapter 18 Lateral SMASectomy Facelift
Video 18.1 Lateral SMASectomy Facelift – Daniel C. Baker
Chapter 19 Reshaping Rhytidectomy
Video 19.1 Reshaping Rhytidectomy – Babak Azizzadeh
Chapter 20 Tridimensional Endoscopic Facelift
Video 20.1 Tridimensnional Endoscopic Facelift – Oscar M. Ramirez
Chapter 22 Mentoplasty
Video 22.1 Complete mentoplasty – Intraoperative prep and demo – Robert A. Glasgold,
Mark J. Glasgold, and Alvin I. Glasgold

vii
PREFACE
This latest edition of our Masters series revisits our initial
intention of providing those who seek to improve other’s
lives by rejuvenating their appearance, and thus them-
selves, with a thorough guide crafted by the acknowl-
edged experts in the field. The genesis of these volumes
was a desire to craft a comprehensive reference for all sur-
geons blessed with the charge of this art. Having emerged
from two excellent but different training programs we
felt the need to bring the various voices across multiple
specialties together in one source. By the grace and gener-
osity of our co-editors and contributing authors we were
successful attaining this goal ten years ago. During the
viii
ensuing decade we have been fortunate to see our field
blossom even further. The evolution of technologies to
manipulate tissue beyond the scalpel has enabled a new
wave of rejuvenation, while its limitations has reminded
us of the continued need for surgical options. By combin-
ing these modalities, we can now help our patients even
further. This text reflects the changes of the last decade
and hopefully will inspire those boundaries to be pushed
even further forward.
Babak Azizzadeh and Mark Murphy

The editors would like to acknowledge and offer grateful thanks for the input of all contributors to the previous
edition, without whom this new edition would not have been possible.
Ramzi M. Alameddine, MD
Assistant Professor, Division of Oculofacial Plastic
and Reconstructive Surgery, Department of
Ophthalmology, American University of Beirut
Medical Center, Beirut, Lebanon
Chapter 15, Aesthetic Rejuvenation in the Patient of Asian Ancestry
Mathew M. Avram, MD
Director, Massachusetts General Hospital Dermatology
Laser & Cosmetic Center, Boston, Massachusetts
Chapter 6, Skin Resurfacing
Daniel C. Baker, MD
Associate Professor, Department of Plastic Surgery,
New York University School of Medicine, New York,
New York; Attending Surgeon, New York University
Medical Center; Attending Surgeon, Department
of Plastic Surgery, Manhattan Eye, Ear & Throat
Hospital, New York, New York; Attending Surgeon,
Department of Plastic Surgery, Bellevue Hospital,
New York, New York
Chapter 18, Lateral SMASectomy Facelift
Dewayne T. Bradley, MD
Department of Otolaryngology-Facial Plastic Surgery,
The Polyclinic, Seattle, Washington
Chapter 1, Facial Embryology
Andrew Breithaupt, MD
Department of Medicine, David Geffen School of
Medicine, University of California, Los Angeles, Los
Angeles, California
Chapter 6, Skin Resurfacing
César A. Briceño, MD
Assistant Professor of Ophthalmology, Scheie Eye
Institute, University of Pennsylvania, Philadelphia,
Pennsylvania
Chapter 10, Minimally Invasive Complementary Adjuncts to Upper
Blepharoplasty
Jeannie H. Chung, MD
Associate Staff, Department of Otolaryngology-
Head and Neck Surgery, Massachusetts Eye and
Ear Infirmary, Boston, Massachusetts; Active Staff,
Department of Otolaryngology-Head and Neck
Surgery, North Shore Medical Center, Salem,
Massachusetts; Medical Director, North Shore
Dermatology and Cosmetic Surgery Center, Andover,
Massachusetts
Chapter 24, Facial and Cervical Lipectomy
LIST OF CONTRIBUTORS
Victor Chung, MD
Director, La Jolla Facial Plastic Surgery, San Diego,
California
Chapter 26, Rhinoplasty in the Aging Patient
Sebastian Cotofana, MD, PhD
Associate Professor, Department of Medical Education,
Albany Medical College, Albany, New York
Chapter 2, Applied Facial Anatomy
Patricia K. Farris, MD
Clinical Associate Professor, Department of
Dermatology, Tulane University School of Medicine,
New Orleans, Louisiana; Old Metairie Dermatology,
Metairie, Louisiana
Chapter 5, Topical Skin Care and the Cosmetic Patient
Jill Foster, MD, FACS
Associate Clinical Professor of Ophthalmology, The
Ohio State University Wexner Medical Center,
Columbus, Ohio; Attending Surgeon, Oculofacial
Plastic Surgery, Plastic Surgery Ohio, Columbus,
Ohio; Attending Surgeon, Division of Oculofacial
Plastic Surgery, Nationwide Children’s Hospital,
Columbus, Ohio
Chapter 11, Ptosis Repair and Blepharoplasty
John W. Frederick, MD
Division of Facial Plastic Surgery, Department of Head
and Neck Surgery, David Geffen School of Medicine,
University of California, Los Angeles
Chapter 8, Endoscopic Foreheadplasty: A Twenty-Seven-Year
Experience
Alvin I. Glasgold, MD
Clinical Professor Emeritus, Division of Facial
Plastic and Reconstructive Surgery, Department of
Otolaryngology-Head and Neck Surgery, Rutgers,
Robert Wood Johnson Medical School, New
Brunswick, New Jersey
Chapter 22, Mentoplasty
Mark J. Glasgold, MD
Clinical Associate Professor, Division of Facial
Plastic and Reconstructive Surgery, Department of
Otolaryngology-Head and Neck Surgery, Rutgers,
Robert Wood Johnson Medical School, New
Brunswick, New Jersey
Chapter 22, Mentoplasty
Chapter 25, Complementary Fat Grafting
ix
x List of Contributors
Robert A. Glasgold, MD
Clinical Assistant Professor, Division of Facial
Plastic and Reconstructive Surgery, Department of
Otolaryngology-Head and Neck Surgery, Rutgers,
Robert Wood Johnson Medical School, New
Brunswick, New Jersey
Chapter 22, Mentoplasty
Chapter 25, Complementary Fat Grafting
Shani Golan, MD
Clinical Fellow, Division of Oculofacial Plastic Surgery,
Jules Stein Eye Institute, University of California Los
Angeles, Los Angeles, California
Chapter 9, Nonsurgical Brow and Eyelid Rejuvenation
Robert Goldberg, MD
Professor, Division of Oculofacial Plastic Surgery, Jules
Stein Eye Institute, University of California Los
Angeles, Los Angeles, California
Chapter 9, Nonsurgical Brow and Eyelid Rejuvenation
Carlo P. Honrado, MD
Private Practice, Los Angeles, California
Chapter 1, Facial Embryology
Catherine J. Hwang, MD
Assistant Clinical Professor, Division of Oculofacial
Plastic Surgery, Cole Eye Institute, Cleveland Clinic
Foundation, Cleveland, Ohio
Chapter 9, Nonsurgical Brow and Eyelid Rejuvenation
Andrew A. Jacono, MD, FACS
New York Center for Facial Plastic and Laser Surgery,
Section Head of Facial Plastic and Reconstructive
Surgery, North Shore University Hospital, New York,
New York; Clinical Assistant Professor of Facial
Plastic and Reconstructive Surgery, New York Eye
and Ear Infirmary, New York, New York; Assistant
Clinical Professor, Facial Plastic Surgery, Albert
Einstein College of Medicine, New York
Chapter 13, Transcutaneous Lower Blepharoplasty
Chapter 17, Deep Plane Rhytidectomy Modifications
H. Ray Jalian, MD
Private Practice, Los Angeles, California
Chapter 6, Skin Resurfacing
Michael Kane, BS, MD
Attending Surgeon, Plastic Surgery, Manhattan Eye,
Ear, and Throat Hospital, New York, New York
Chapter 4, Injectables and Resurfacing Techniques: Botulinum
toxin (BoNT-A)
Gregory S. Keller, MD, FACS
Clinical Professor of Head and Neck Surgery, Division
of Facial Plastic Surgery, Department of Head and
Neck Surgery, David Geffen School of Medicine,
University of California, Los Angeles, Private
Practice, Santa Barbara, California
Chapter 8, Endoscopic Foreheadplasty: A Twenty-Seven-Year
Experience
Don O. Kikkawa, MD, FACS
Division of Oculofacial Plastic and Reconstructive
Surgery, UCSD Department of Ophthalmology, Shiley
Eye Institute, Division of Plastic and Reconstructive
Surgery, UCSD Department of Surgery, La Jolla,
California
Chapter 15, Aesthetic Rejuvenation in the Patient of Asian Ancestry
Bobby S. Korn, MD, PhD, FACS
Professor of Ophthalmology and Plastic Surgery,
Division of Oculofacial Plastic and Reconstructive
Surgery, Department of Ophthalmology, Shiley Eye
Institute, Division of Plastic and Reconstructive
Surgery, Department of Surgery, UC San Diego
School of Medicine, La Jolla, California
Chapter 15, Aesthetic Rejuvenation in the Patient of Asian Ancestry
Andrea Lora Kossler, MD
Assistant Professor of Ophthalmology, Director,
Oculofacial Plastic Surgery and Orbital Oncology,
Stanford School of Medicine, Byers Eye Institute at
Stanford, Palo Alto, California
Chapter 14, The Spectrum of Canthal Suspension Techniques in
Lower Blepharoplasty
Samuel M. Lam, MD
Director, Lam Facial Plastic Surgery Center and Hair
Restoration Institute, Plano and Dallas, Texas
Chapter 25, Complementary Fat Grafting
Wayne F. Larrabee Jr., MD, FACS
Clinical Professor, Department of Otolaryngology-Head
and Neck Surgery, University of Washington School
of Medicine, Seattle, Washington; Swedish Hospital;
Director, Larrabee Center for Facial Plastic Surgery,
Seattle, Washington
Chapter 1, Facial Embryology
Bradford W. Lee, MD, MSc
Assistant Professor, Division of Oculofacial Plastic and
Reconstructive Surgery, Bascom Palmer Eye Institute,
University of Miami Miller School of Medicine,
Miami, Florida
Chapter 15, Aesthetic Rejuvenation in the Patient of Asian Ancestry
Steven M. Levine, MD
Assistant Professor of Surgery (Plastic), Hofstra Medical
School, Northwell Health, New York, New York
Chapter 18, Lateral SMASectomy Facelift

Wei Lu, MD, PhD
Associate Professor of Ophthalmology, Director,
Department of Ocular Plastic and Reconstructive
Surgery, Dalian Medical University, Dalian, China
Chapter 15, Aesthetic Rejuvenation in the Patient of Asian Ancestry
Melanie H. Malone, MD
Assistant Professor, Division of Facial Plastic Surgery,
Albert Einstein College of Medicine, New York,
New York
Chapter 13, Transcutaneous Lower Blepharoplasty
Hyoung Jin Moon, MD
President, Dr. Moon’s Aesthetic Plastic Surgery Clinic,
Seoul, South Korea
Chapter 2, Applied Facial Anatomy
Vishad Nabili, MD, FACS
Associate Clinical Professor of Head and Neck Surgery,
Division of Facial Plastic Surgery, Department of
Head and Neck Surgery, David Geffen School of
Medicine, University of California, Los Angeles
Chapter 8, Endoscopic Foreheadplasty: A Twenty-Seven-Year
Experience
Joe Niamtu, MD, FACS
Private Practice, Cosmetic Facial Surgery, Richmond,
Virginia; Fellow, American Academy of Cosmetic
Surgery; Diplomat, American Board of Cosmetic
Facial Surgery; Diplomat American Board of Oral
and Maxillofacial Surgery
Chapter 21, Midface Implants
Oscar M. Ramirez, MD, FACS
Esthétique Internationale, Timonium, Maryland
Chapter 20, Tridimensional Endoscopic Facelift
Neela Rao, MD
Otolaryngology Resident-in-training, Department of
Otolaryngology – Head and Neck Surgery, University
of Illinois – Chicago, Chicago, Illinois
Chapter 26, Rhinoplasty in the Aging Patient
David B. Samimi, MD
Eyesthetica, Oculofacial and Cosmetic Surgery
Associate; Assistant Professor of Ophthalmology,
Keck School of Medicine, University of Southern
California, Los Angeles, California
Chapter 12, Transconjunctival Lower Blepharoplasty With and
Without Fat Repositioning
List of Contributors xi
Daniel Straka, MD
Assistant Clinical Professor of Ophthalmology, The
Ohio State University Wexner Medical Center,
Columbus, Ohio; Attending Surgeon, Oculofacial
Plastic Surgery, Plastic Surgery Ohio, Columbus,
Ohio; Attending Surgeon, Division of Oculofacial
Plastic Surgery, Nationwide Children’s Hospital,
Columbus, Ohio
Chapter 11, Ptosis Repair and Blepharoplasty
Gustavo A. Suárez
Department of Otolaryngology-Head and Neck Surgery,
University of Barcelona, Bellvitge University Hospital,
Barcelona, Spain
Chapter 2, Applied Facial Anatomy
Chapter 23, Orthognathic Aesthetic Facial Surgery
Jonathan M. Sykes, MD
Professor and Director Facial Plastic Surgery, University
of California, Davis Medical Center, Sacramento,
California
Chapter 2, Applied Facial Anatomy
Chapter 23, Orthognathic Aesthetic Facial Surgery
Dean M. Toriumi, MD
Professor, Division of Facial Plastic and Reconstructive
Surgery, Department of Otolaryngology-Head and
Neck Surgery, University of Illinois at Chicago,
Chicago, Illinois
Chapter 26, Rhinoplasty in the Aging Patient
Patrick Trevidic, MD
Expert2Expert Group, Paris, France
Chapter 2, Applied Facial Anatomy
Charles R. Volpe, MD
Esthétique International, Timonium, Maryland
Chapter 20, Tridimensional Endoscopic Facelift
Edwin F. Williams III, MD, FACS
Fellowship Director, American College of Surgeons,
Chicago, Illinois; Clinical Instructor and Fellow,
Department of Otolaryngology-Head and Neck
Surgery, University of Illinois, Chicago, Illinois; Chief,
Department of Facial Plastic and Reconstructive
Surgery, Clinical Associate Professor of Surgery,
Albany Medical Center, Albany, New York; Medical
Director and Founder, New England Laser &
Cosmetic Surgery Center; Medical Director, Williams
Center for Excellence, Latham, New York
Chapter 24, Facial and Cervical Lipectomy
ACKNOWLEDGMENTS
There are many people to whom we owe a great deal
of gratitude for the completion and inspiration of this
second edition of Master Techniques in Facial Rejuve-
nation. First and foremost are our patients, who have
entrusted us in the most personal way. We also thank
our family, office staff and fellows who have given us
the opportunity and freedom to take on this substantial
project. We want to acknowledge our mentors Norman
Pastorek, Mack Cheney, Albert Hornblass, John Holds,
Calvin M. Johnson, Frank Kamer, Mark Varvares, Daniel
Deschler, Keith Blackwell, Rinaldo Canalis, Thomas Cal-
caterra, and Usama Hamdan for their motivation and
inspiration, as well as our professional colleagues Babak
Larian, Ray Douglas, John Murray, Ray Jalian, Siamak
Tabib, Helen Fincher, Kamran Jamshidinia, Siamak
xii
Daneshmand, Jimmy Firouz, Kia Michel, Jennifer Kim,
Allen Putterman, Rick Anderson, David Lehman, and
Jonathan Cabin, whose unflinching support has aided
us in the pursuit of our passion. Additionally, we must
acknowledge the Elsevier team for the unbelievable
amount of work that they have put forth in making this
book a reality. Belinda Kuhn, Trinity Hutton, Alexandra
Mortimer, Julie Taylor, Amy Buxton, Karen Giacomucci
and Paul Kim have spent countless hours supporting our
ambitious venture and we cannot thank them enough.
Finally, this second edition would not have been the best
it can be if it weren’t for our new co-editors, Drs. Rebecca
Fitzgerald and Guy Massry, who are true masters of their
subspecialties.
 DEDICATIONS

To Jessica, my wife and best friend who has been

my everything for the past twenty years.
Babak Azizzadeh

To Sherry whose unwavering support has provided

a life of fulfillment, personally and professionally.
To our children Nick, Ned and Grayson, for being
a constant source of motivation to be better.
Mark R. Murphy

In our pursuit of knowledge and wisdom, we

all have much to learn and much to share. I
would like to dedicate this book to all of the
teachers, students, and patients who have given
me this opportunity. I am so grateful for all I
have learned from each of you. I would also like
to acknowledge my appreciation to Drs. Babak
Azizzadeh and Guy Massry for their tireless
dedication to excellence. Their enthusiasm,
discipline, energy, boundless curiosity, and love of
learning have made them truly amazing physicians.
They have been wonderful colleagues and friends,
and invaluable mentors.
Rebecca Fitzgerald

Creating this textbook has been a journey of highs

and lows. Its completion is a testament to my
amazing co-editors, and the staff at Elsevier, who
worked so hard, diligently and efficiently, until
the final page was typeset. Even with this amazing
team, I could not have given the consistent time
and effort needed to contribute my small part to
the project without the unwavering and selfless
support of my family (Shere, Alexis and my
parents and sisters) and office staff (Anna, Maria,
Norie, Jessica) who are always there and always
have my back.
Guy G. Massry

xiii
This page intentionally left blank

Facial Embryology
Carlo P. Honrado, MD, Dewayne T. Bradley, MD, and Wayne F. Larrabee Jr., MD, FACS
EMBRYOGENESIS
Embryogenesis is a dynamic multiple-step process that
begins when an oocyte from a female is fertilized by
the sperm from a male (the pre-embryonic period). The
first 2 weeks after fertilization focus on rapid prolif-
eration and differentiation of the embryo with subse-
quent implantation of the egg into the wall of the uterus.
Also, the development of the amniotic cavity and the
embryonic disc gives rise to the three germ layers of the
embryo during this period. The start of the third week
marks the beginning of the embryonic period (weeks 3–8)
and is characterized by the formation of the primitive
streak, notochord, and the three germ layers (ectoderm,
endoderm, and mesoderm) from which all embryonic
tissues and organs develop [1]. The ectoderm gives rise
to structures such as the epidermis and nervous system.
The linings of the respiratory system and gastrointestinal
tracts as well as certain glandular organs arise from the
endoderm layer. The mesoderm is the source of muscle,
bone, connective tissue, and blood vessels. The embry-
onic period is of particular importance because most
organ systems develop during this time, and by the end
of the eighth week the embryo has a distinctly human
appearance. However, because the origins of major struc-
tures are established during this critical phase, congenital
abnormalities may first appear at this time if there is any
teratogenic exposure to the embryo.
The fetal period spans from the ninth week after fertil-
ization to the birth of the fetus. This period is character-
ized by rapid growth and maturation of the developing
organ systems. Head growth slows significantly in com-
parison to growth of the fetal body.
This chapter focuses on aspects of embryogenesis
that pertain to facial plastic and reconstructive surgery.
Embryology of the branchial/pharyngeal arches and their
derivatives, orbit/eyelid complex, auricle, face, nose, and
palate will be discussed in detail. A description of facial
anatomy will follow.
EMBRYOLOGY
The Branchial/Pharyngeal Apparatus
The branchial, or pharyngeal, apparatus greatly contrib-
utes to the formation of the head and neck, and begins to
form during the fourth week of gestation [2]. This appa-
ratus consists of branchial arches, pharyngeal pouches,
branchial grooves, and branchial membranes. By the end
of the fourth week of gestation, four well-defined arches
are visible on the external surface of the embryo. The fifth
C H A P T E R
1
arch (also referred to as the sixth arch, depending on the
theory one follows) is also present but is not externally
visible (Fig. 1.1A). Each arch is composed of mesoderm-
derived mesenchymal tissue and contains an aortic arch
artery, a branchiomeric nerve, a cartilaginous bar, and
a muscle component [3]. These arches are separated by
prominent grooves, or clefts, which are derived from
the ectoderm, and pharyngeal pouches that are lined by
endoderm. As the grooves develop, they push medially
through the surrounding mesenchyme and approach the
medially positioned pharyngeal pouches.
The first branchial arch is often referred to as the
mandibular arch and plays a significant role in the devel-
opment of the face. This arch develops one small promi-
nence, which forms the maxilla, zygoma, and squamous
portion of the temporal bone, and one large prominence,
which forms the mandible. Important structures that
arise from this arch are the muscles of mastication, the
maxillary artery, and cranial nerve V3. Other derivatives
from the first arch are listed in Table 1.1.
The second branchial arch is also known as the hyoid
arch. Around the fifth week of development, this arch
will overgrow the third and fourth arches, resulting in the
formation of the cervical sinus of His (Fig. 1.1B). This
sinus and the second, third, and fourth branchial grooves
subsequently obliterate, resulting in the smooth contour
of the neck. Failure of this area to fully obliterate may
possibly lead to the formation of a branchial sinus [4].
Table 1.1 lists the second through fifth arch derivatives.
Corresponding to each branchial groove are pharyn-
geal pouches, which represent outpouchings of the primi-
tive pharynx. These pouchings are lined by endoderm and
also push through the surrounding mesenchyme during
the fourth and fifth weeks of the embryonic period. Each
pouch contains a ventral and dorsal wing, and gives
rise to several important organs such as the parathyroid
glands and thymus [5].
Embryology of the External Ear
The first sign of the developing ear is seen by the presence
of the otic disc, which appears as a thickening on the
surface of the ectoderm at the end of the third week of
gestation [6]. The disc soon invaginates and is called the
otic pit. Six small elevations known as hillocks develop
at the dorsal ends of the first and second arches (Fig.
1.2). The first branchial groove, which is located between
the first and second arches, deepens and canalizes to
form the external auditory canal. The first three hillocks
arise anteriorly from the mandibular arch, and the other
three hillocks develop from the hyoid arch [7]. These
1
2 MASTER TECHNIQUES IN FACIAL REJUVENATION

A B
Figure 1.1 (A) Lateral view of a human embryo at approximately 4 weeks. (B) During the fifth week of development, the second arch overgrows
the third and fourth arches, forming the cervical sinus of His.

TABLE 1.1 Structures Derived From the Branchial (Pharyngeal) Arches

Arch Cranial Nerve Skeletal Structure Muscles Ligaments
I (mandibular) Trigeminal (V3) Meckel’s cartilage: malleus head Muscles of mastication, tensor Anterior ligament of malleus,
and neck, incus short process tympani, tensor veli palatini, sphenomandibular
and body, mandible stylohyoid, anterior belly of ligament
digastric
II (hyoid) Facial (VII) Reichert’s cartilage: malleus Muscles of facial expression, Stylohyoid ligament
manubrium, incus long process stapedius, stylohyoid,
and lenticular process, stapes, posterior belly of digastric,
styloid process, lesser cornu of buccinator
hyoid, upper part of hyoid body
III Glossopharyngeal Greater cornu of hyoid, lower Stylopharyngeus, superior and
(IX) part of hyoid body middle constrictors
IV Superior Thyroid cartilage, cuneiform Inferior constrictor,
laryngeal (X) cartilage cricopharyngeus, cricothyroid
V/VI Recurrent Cricoid, arytenoid, and corniculate Intrinsic laryngeal muscles
laryngeal (X) cartilages, trachea (except cricothyroid)

hillocks will gradually fuse to form the auricle of the
external ear. Although there is much controversy, it is
generally accepted that the tragus, helical crus, and helix
are formed from the mesodermal components of the first
arch, corresponding to the first, second, and third hill-
ocks, and that the fourth through sixth hillocks from the
second arch give shape to the antihelix, antitragus, and
lobule, respectively. By the 20th week of development, an
anatomically complete ear can be seen. The final shape
of the auricle is determined by the intrinsic and extrinsic
muscles of the ear that cause plical folding of the carti-
lage [8].
Initial positioning of the auricle lies in the ventrocau-
dal part of the neck region [1]. However, as the mandible
develops, the developing ear is pushed in a dorsocranial
direction and subsequently lies on the side of the head at
the level of the eyes by approximately the 32nd week of
gestation. Most abnormalities of the ear, such as anotia
or microtia, arise from insults that occur during the first
7 weeks of gestation.
Embryology of the Eye
Eye formation is evident by the beginning of the fourth
week and has its origins from the neuroectoderm, ecto-
derm, and mesoderm. Thickening of the surface ectoderm
in the area of the future eye occurs in response to signals
produced by the optic vesicles, which are evaginations
from the brain. This thickening results in the formation
of the lens placodes. The central portion of the placode
invaginates to form the lens pit, which subsequently sepa-
rates from the surface epithelium to form a spherical lens
vesicle, the precursor of the lens of the eye.
During the fifth week of embryogenesis, small depres-
sions develop above and below the eye, forming the prim-
itive upper and lower eyelids [9]. As they become more
distinct during the embryonic period, the lids approach

3 3
4
5
2
1 6
6
3
C
Figure 1.2 (A–C) Formation of the external ear during the sixth week of development. Shown are the six hillocks.
each other and subsequently fuse by the ninth week. Prior
to fusion, the lacrimal gland and its ducts also develop.
Mesodermal components are responsible for the forma-
tion of the ocular muscles, orbicularis oculi muscle, and
tarsus, which develop while the eyelids are fused. Separa-
tion of the eyelid complex begins during the 20th week in
an anterior to posterior fashion and takes approximately
3 weeks [3].
Embryology of the Face and Nose
The embryology of the face begins early in the fourth
week around a large stomodeum, which becomes the
future mouth. Proliferation of neural crest cells occurs in
the developing brain, which migrates to form, together
with mesodermal cells, the facial primordia. These neural
crest cells play a major role in forming the bone, cartilage,
1 Facial Embryology 3
4
5
1
B
and ligaments of the facial region. Five facial primordia
appear as prominences around the stomodeum: the single
median frontonasal prominence and the paired maxillary
and mandibular prominences (Fig. 1.3).
Facial development continues until around the eighth
week of gestation. The frontonasal prominence is primar-
ily responsible for forming the forehead and the nose.
However, the first part of the face to form is the mandible
and lower lip. This occurs from the medial migration and
fusion along the median plane of the two mandibular
prominences. Toward the end of the fourth week, bilat-
eral thickenings, called nasal (olfactory) placodes, occur
on the surface of the ectoderm on the ventrolateral part of
the frontonasal prominence. The nasal placodes initially
are convex but subsequently invaginate during the sixth
week. Mesenchymal proliferation also occurs around
4 MASTER TECHNIQUES IN FACIAL REJUVENATION
Frontal process
Nasal placodes
Maxillary prominences
Mandibular prominences
Figure 1.3 The five facial primordia comprise the frontal prominence,
the paired maxillary prominences, and the paired mandibular promi-
nences. The nasal placodes are also shown.
Nasal pit
Lateral nasal prominence
Medial nasal prominence
Maxillary prominence
Figure 1.4 Appearance of the nasal pits from growth of the medial
and lateral nasal processes.
the rim of the placodes, creating elevations known as
the medial and lateral nasal prominences. The depressed
nasal placodes are now referred to as nasal pits, which are
the primordia of the nostrils and nasal cavities (Fig. 1.4).
Owing to the continuing proliferation of the nasal promi-
nences, the nasal pits deepen and are called nasal sacs.
Proliferation of the paired maxillary prominences also
occurs during this period. They migrate medially and
contact the medial and lateral nasal processes. Lying
between the maxillary prominence and the lateral nasal
process is the nasal groove, which marks the future site
of the nasolacrimal duct. Merging of the medial nasal
process and maxillary prominences results in continuity
of the lip and upper jaw with formation of the philtrum,
premaxilla, and primary palate (Fig. 1.5). Separation of
the nasal pits from the stomodeum also occurs. Failure
of the maxillary prominences to fuse results in cleft lip
and palate deformities.
Proliferation of mesenchyme from the first and second
branchial arches results in formation of the muscles in
the face. Mesenchyme from the first arch differentiates
Maxillary prominence
Mandibular prominence
Nasolacrimal groove
Philtrum
Figure 1.5 The nasolacrimal groove forms between the lateral nasal
process and maxillary prominence.
into the muscles of mastication, which are innervated
by the fifth cranial (trigeminal) nerve. The muscles of
facial expression arise from mesenchyme from the second
branchial arch, with their nerve supply coming from the
seventh cranial (facial) nerve.
Embryology of the Nasal Cavity and Paranasal Sinuses
As mentioned in the earlier section, the nasal placodes
become depressions called nasal pits. Proliferation of the
mesenchyme around the pits results in formation of the
medial and lateral nasal prominences and deepening of
the pits to form nasal sacs. The nasal sacs lie ventral to
the developing forebrain and they migrate in a dorsal-
caudal direction. An oronasal membrane separates the
sacs from the oral cavity. This membrane subsequently
ruptures, allowing the oral cavity to communicate with
the nasal cavity in the area of the nasopharynx.
The inferior, middle, and superior turbinates arise
from elevations on the lateral nasal wall. Diverticuli also
occur along the lateral nasal walls, which will give rise
to the future sinuses, which are pneumatic extensions
of the nasal cavities. Only the maxillary and ethmoid
sinuses are present at birth. The frontal sinus develops
from an anterior ethmoid air cell at about 2 years of age.
The sphenoid sinus also develops around age 2 years and
arises from a posterior ethmoid air cell.
The nasal septum arises from portions of the merged
medial nasal prominences. In addition, ectoderm along
the roof of the nasal cavities differentiates to form the
olfactory epithelium. Some of these cells become receptor
cells and form the olfactory bulb of the brain.
Embryology of the Palate
The formation of the palate occurs between the 6th and
12th weeks of gestation. The primary palate, also known
as the median palatine process, begins to form from the
innermost portion of the intermaxillary segment of the
maxilla. This segment is formed by the fusion of paired
median nasal processes and maxillary prominences. The
primary palate ultimately forms the premaxilla and

represents only a portion of the hard palate that lies
anterior to the incisive foramen.
The secondary palate is embryologically distinct from
the primary palate and begins to develop during the
eighth week. Formation of the secondary palate results
from inferior and medial growth and migration of the
mesenchymal projections called the lateral palatine proc-
esses of the maxilla, also known as the palatal shelves.
The palatal shelves are initially separated by the tongue.
With growth of the mandible, the tongue moves anteri-
orly, allowing the shelves to assume a more horizontal
orientation [10].
The sequence of normal palatal formation begins
when the nasal septum and the palatal shelves come into
contact. Closure occurs in an anterior to posterior direc-
tion starting at the incisive foramen. Bone formation also
occurs during this period, completing the rest of the hard
palate. Posteriorly, this area does not become ossified,
resulting in the soft palate.
The degree of clefting that can occur from failure of
proper fusion can range from a bifid uvula to a complete
cleft of the secondary palate.
CONCLUSION
The anatomy of the face is the foundation upon which
procedures for rejuvenation of the face are laid. Detailed
1 Facial Embryology 5
knowledge of facial embryology has led to a better under-
standing of the layered anatomy of the face. This knowl-
edge is most clearly of value in all aspects of facial plastic
and reconstructive procedures.
REFERENCES
1. Moore KL, Persaud TVN. The developing human: Clinically ori-
ented embryology. 5th ed. Philadelphia: WB Saunders; 1993.
2. Larrabee WF, Makielski KH, Henderson JL. Surgical anatomy of
the face. 2nd ed. Philadelphia: Lippincott Williams & Wilkins;
2004.
3. Goding GS, Eisele DW. Embryology of the face, head and neck. In:
Papel ID. Facial plastic and reconstructive surgery. 2nd ed. New
York: Thieme; 2002.
4. Davies J. Embryology of the head and neck in relation to the
practice of otolaryngology. Rochester, Minn: American Academy
of Ophthalmology and Otolaryngology; 1965.
5. Lee KJ. Essential otolaryngology: Head and neck surgery. 7th ed.
Norwalk, Conn.: Appleton & Lange; 1999.
6. O’Rahilly R. The timing and sequence of events in the development
of the human eye and ear during the embryonic period proper. Anat
Embryol (Berl) 1983;168:87–99.
7. Siegert R, Weerda H, Remmert S. Embryology and surgical anatomy
of the ear. Facial Plast Surg 1994;10(3):232–43.
8. Zerin M, van Allen MI, Smith DW. Intrinsic auricular muscles and
auricular form. Pediatrics 1982;69:91–3.
9. Pearson AA. The development of the eyelids. Part I. External fea-
tures. J Anat 1980;130(1):33–42.
10. Sykes J. Diagnosis and treatment of cleft lip and palate deformities.
In: Papel ID. Facial plastic and reconstructive surgery. 2nd ed. New
York: Thieme; 2002.
 C H A P T E R
2
Applied Facial Anatomy
Jonathan M. Sykes, MD, Gustavo A. Suárez, MD, Patrick Trevidic, MD, Sebastian Cotofana, MD, PhD, and
Hyoung Jin Moon, MD
INTRODUCTION
The anatomy of the face is fairly constant. Variant
anatomy is seen in the thickness of the soft tissue layers,
and in the size and orientation of cartilaginous structures
such as the nasal cartilages (nose), tarsal plates (eyelids),
and facial bones (maxilla, mandible, zygoma, etc.). The
relationships of nerves, vessels, and muscles of the face
are fairly uniform. The facial anatomy combines to give
the face form and function.
Plastic surgical procedures can significantly affect facial
form and function. The vast array of surgical and inject­
able procedures have expanded in recent years as the
want and need to improve facial function and appearance
has increased. To successfully perform these procedures,
a thorough knowledge of the variant facial anatomy is
required.
This chapter will discuss the common anatomical rela­
tionship of the face. The layered anatomy of the face will
be outlined, as will the typical position of muscles and
neurovascular structures. Applied anatomy as related to
surgical and injectable procedures will be highlighted.
LAYERS OF THE FACE
Although a few exceptions exist, the skin, subcutaneous
tissues, and superficial and deep fascial layers of the face
are consistent in their relationships and can be designated
with a common numbering system. These layers can be
numbered I to V (Figs. 2.1–2.2). Although the names
of the individual layers differ from various regions of
the forehead, temple, face, and neck, the relative rela­
tionships of these layers remains constant. The muscles,
nerves, and vascular structures, however, vary in their
position and relationship to the layers.
The layering system of the facial levels can be seen
in Table 2.1. The various names of each layer within a
given facial region are described throughout the chapter,
making note of the designated numbering system.
Layer I: Skin
The skin varies in thickness, pigmentation, dermal
appendages, and adherence to the subcutaneous tissues
between different areas of the face [1]. The skin is thick­
est over the mentum and in the region of the forehead
and eyebrows, and is thinnest over the eyelids. In the
infraorbital region and medial to the midpupillary line,
the skin is thin and usually contains no subcutaneous fat.
The skin is firmly attached to the underlying muscles of
the oral commissure and in the region of the nasal tip,
6
while it is loosely adherent to the underlying soft tissue
in the eyelids and at the root of the nose. As the dermis
of the skin thins with age, the underlying muscles cause
rhytids, which generally are perpendicular to the direc­
tion of facial muscle contraction (Fig. 2.3). The amount
of skin wrinkling is variable, and relates to the skin thick­
ness and elasticity.
Layer II: Subcutaneous Tissue
The subcutaneous tissue varies in amount in relation to
the patient’s genetics, ethnicity, and body weight [2]. In a
given individual, the thickness of the subcutaneous tissue
is different based on the facial region. In the forehead
and over the mentum, the fat layer is thick and the over­
lying skin is densely adherent. However, in the eyelids,
the fat layer is almost nonexistent and the skin is loosely
adherent. In the midface, the subcutaneous fat is highly
vascularized and compartmentalized by various fibrous
septae (Fig. 2.4).
Layer III: Superficial Fascia
The superficial fascia of the face is fairly adherent to the
overlying skin and subcutaneous tissues of the face in
most regions, and therefore must be dissected sharply
from the skin in order to surgically separate these tissue
planes. This is in contradistinction with the relationship of
the superficial fascia with the underlying deep fascia [3].
In most regions, the superficial fascia is loosely attached
to the underlying deep fascia. Surgical dissection between
the superficial and deep fascia is therefore usually blunt
and easily performed.
The superficial fascia has different designations in dif­
ferent regions of the scalp, temple, face, and neck. In
the forehead, the superficial fascia is called the galea
aponeurosis. This layer envelopes the frontalis muscle
in the forehead, and splits to encompass the occipitalis
muscle at the posterior aspect of the scalp. In the temple,
the superficial fascial layer is termed the temporoparietal
fascia (TPF; see Fig. 2.1). This layer is a thin, pliable, and
vascular layer that is well suited for facial and auricu­
lar reconstruction. In the midface, the superficial fascia
is the superficial muscular aponeurotic system (SMAS).
The SMAS and TPF are contiguous structures, but are
discontinuous at the level of the zygomatic arch. In the
neck, the superficial fascia provides a fascial sleeve for
the platysma muscle (Fig. 2.5).
Layer IV: Deep Areolar Layer
In all regions of the head and neck, the superficial fascia
(III) is connected to the deep fascia (V) by a loose areolar

III
V 2. Subcutaneous
I  II
VI
FP
Figure 2.1 Layers of the temple. FP, Fat Pad.
TABLE 2.1 Layers of the Face
I Skin
II Subcutaneous tissue/superficial areolar tissue
III Superficial fascia
IV Loose areolar tissue
V Deep fascia
layer. This connection is variable and differs by age,
genetics, and body weight. The attachments are typically
comprised of loose connective tissue, and surgical dis­
section of this plane is therefore usually blunt [4]. The
specific structures that traverse this layer vary by region,
and are covered later.
Layer V: Deep Fascia
The deep, or investing, fascia is a dense connective tissue
that is usually immobile. It is connected to the overlying
mobile superficial fascia (III) by loose connective tissue
(IV). The deep fascia of the forehead is the frontal bone
periosteum. The periosteum is densely adherent to the
frontal bone, and becomes continuous at the superior
orbital rim with the septum orbitale. The thickening at
the orbital rim is termed the arcus marginale. The deep
fascia of the temple is designated deep temporal fascia
(DTF) or temporalis muscle fascia. This fascia overlies,
and is densely adherent to, the underlying temporalis
muscle (see Fig. 2.1) [5].
The deep fascia of the lateral midface is termed the
parotidomasseteric fascia. This fascia covers the parotid
2 Applied Facial Anatomy 7
3 2 1
5 4
1. Skin
3. Musculo-aponeurotic
4. Retaining ligaments
and space
5. Periosteum
and deep fascia
5
4
3 2
1
Figure 2.2 Layers of the face.
gland and the parotid duct, and includes the buccal
branches of the facial nerve. As this fascia travels towards
the temple over the zygomatic bone, it becomes con­
tinuous with the superficial lamina of the DTF. The deep
fascia of the neck is designated deep investing fascia. All
deep fascial layers (V) are relatively fixed to the structures
they overlie, and become good fixation points for repo­
sitioning of soft tissues and surgical procedures such as
rhytidectomy or browlifting.
REGIONAL CONSIDERATIONS
Forehead
The boundaries of the forehead are the frontal hairline
(superiorly), the eyebrows and the nasal root (inferiorly),
and the temples (laterally). The transition between the
forehead and the temporal regions are the superior tem­
poral lines, or the anterosuperior extent of the temporalis
muscles. In this region, the fascial planes fuse and are
termed the conjoined tendon (see Fig. 2.5B).
The layers of the forehead consist of a thick skin layer
(I) overlying a densely attached subcutaneous tissue (II).
The skin is thick, averaging almost 2400 µm [2]. Just
deep to the subcutaneous fat is the galea aponeurosis (III).
8 MASTER TECHNIQUES IN FACIAL REJUVENATION

This superficial fascia of the forehead envelopes the

paired frontalis muscle (Figs. 2.6–2.7). The frontalis
muscle is the only elevator of the eyebrow. Contraction
of this muscle tightens the scalp, elevates the brow, and
creates horizontal forehead rhytids. Deep to the galea
aponeurosis/frontalis muscle is loose areolar tissue (IV)
and the pericranium (V). The pericranium is the deep
fascia of the forehead and is densely attached to the
underlying frontal skull. As the frontalis muscle con­
tracts, the superficial layers of the forehead slide over
the underlying periosteum. This glide plane of layer III
sliding over layer V affects how individuals age and how
surgeons rejuvenate faces by elevating ptotic soft tissues.
The inferior extent of the frontalis muscle interdigi­
tates with the orbicularis oculi muscle (OOM) (Fig. 2.8).
The OOM is a sphincteric muscle that is supplied by the
facial (7th) nerve and acts as a protractor to the eyelids
and a depressor of the eyebrows. Multiple branches of the
facial nerve provide motor innervation to the OOM. The
medial and inferior portions of the muscle are innervated
by the zygomatic branch, and the lateral and central por­
tions of the muscle are innervated by the anterior portion
of the temporal branch of the facial nerve. The OOM is
located immediately subcutaneously. Some of this muscle
gives involuntary action to the eyelids (blink), while other
fibers provide voluntary action (squeeze or squint). The
muscles are separated into pretarsal (superficial to the
Figure 2.3 Relaxed skin tension lines of the face. tarsal plates), preseptal (superficial to the orbital septum),

Sup. temporal
septum
A B

C
Inf. temporal
septum

D Orbicularis
retaining
F ligament
E

H
Sup. cheek
G I septum
(zygomatic Epidermis
cutaneous Dermis
ligaments)
J

Platysma auricular
K
ligament

Masseteric
cutaneous
Mandibular ligaments
Mandibular
A septum
cutaneous ligament

A. Central forehead compartment F. Lateral orbital compartment

B. Middle forehead compartment G. Nasolabial compartment
C. Lateral temporal cheek H. Medial cheek compartment
compartment I. Middle cheek compartment
D. Superior orbital compartment J. Superior jowl compartment
E. Inferior orbital compartment K. Inferior jowl compartment B Muscle Septae Fat
Figure 2.4 (A) Superficial fat compartments of the face. (B) Fibrous septae. Inf., Inferior; Sup., superior.
 2 Applied Facial Anatomy 9

Sub-galea plane
Galea
Superior
temporal septum
Temporal adhesion
Inferior
temporal septum
Lateral orbital
thickening

Zygomatic
ligament
Skin

SMAS

Masseteric
ligament

Sub-SMAS plane
Mandibular ligament
Platysma

B Parotidomasseteric fascia
Parotid gland
A (deep fascia)
Figure 2.5 (A) SMAS. (B) SMAS and retaining ligaments of the face. SMAS, Superficial muscular aponeurotic system.

FM

FM

Figure 2.7 Frontalis muscle and galea aponeurotica. Arrow, central

area of forehead where no muscle is present. FM, Frontalis muscle.
Figure 2.6 Frontalis muscle. FM, Frontalis muscle.

and orbital (more peripheral) portions (Fig. 2.9). These
designations are not true anatomic separations of muscle,
but rather names that identify the muscle location. In
fact, there are no true separations or septi distinguish­
ing these muscle segments. Injection of the OOM with
botulinum toxin can decrease dynamic lateral canthal
lines, decrease rhytids of the lower eyelid, and elevate the
lateral or tail of the brow.
The origins and insertions of the orbicularis muscles,
as well as its anatomical relationships with adjacent
structures, are complex. The muscle primarily travels in
the soft tissues of the eyelids, but is fixed medially and lat­
erally to the bony orbital wall by the orbicularis retaining
ligaments (ORLs). The ORL medially to the midpupillary
line is termed the tear trough ligament, and is respon­
sible in some individuals for adding to the concavity just
10 MASTER TECHNIQUES IN FACIAL REJUVENATION

Frontalis m.
Temporalis m.

Corrugator m.
Orbicularis oculi m.
Procerus m.
Levator labii aleque nasi m.
Levator labii superioris m.
Zygomaticus minor m.
Zygomaticus major m. Levator anguli oris m.
Orbicularis oris m.
Depressor anguli m. Buccinator m.

Depressor anguli oris m.

Depressor labii inferioris m. Mentalis m.

Figure 2.8 Muscles of the face. m., Muscle.

Orbital

O Preseptal

PS Pretarsal

PT

Preseptal
Orbital

A B
Figure 2.9 Orbicularis oculi muscle portions. (A) Cadaver photograph of orbicularis oculi muscle with skin removed. (B) Schematic drawing of
orbicularis oculi muscle. O, Orbital; PS, preseptal; PT, pretarsal.

inferior to the convex medial orbital fat (Figs. 2.10–2.11).
The orbicularis muscles interdigitate with the corrugator
and frontalis superiorly (Fig. 2.12). Laterally, the orbicu­
laris muscles travel superficial to the temporalis fascia;
medially, the muscle covers the depressor supercilii; and
inferiorly, the muscles travel between the superficial and
deep suborbicularis oculi fat (SOOF) pads of the cheek.
The inferomedial extent of the lower eyelid orbicularis
muscles covers the levator labii superioris and the levator
labii superioris alaeque nasi muscles.
Upper Eyelid Anatomy
The upper eyelid is composed of very thin skin, structur­
ally dense fibrous tissue (tarsal plate), and muscles that
close (protractors) and open (retractors) the lids. The
upper eyelid crease is a horizontal indentation formed
by the attachment of the superficial levator aponeurosis
fibers into the orbicularis oris intermuscular septa and
subcutaneous tissue. The crease is located approximately
7 to 10 mm above the eyelid margin centrally in most
Caucasians. When present, the upper lid crease in Asians
is located at 4 to 6 mm [6]. In patients with dehiscence
of the levator aponeurosis, the eyelid crease is usually
elevated and the eyelid is thin.
The eyelid is covered by very thin skin, usually only
400 to 500 µm in thickness [1]. There is almost no sub­
cutaneous tissue in the eyelids. The OOM are located
just deep to the skin. The orbital septum is located just
deep to the OOM (see Fig. 2.11). The septum is a thin,
multilayered connective tissue beginning at the arcus
 2 Applied Facial Anatomy 11

Preaponeurotic
fat pad
Lacrimal gland

Interpad septum

Upper lid fold

Upper lid crease

Nasal fat pad
Lateral Medial canthus
canthus Lower lid crease

Canthal tilt Nasojugal groove

Inferior oblique
Lid-cheek junction muscle

Temporal
fat pad Central fat pad
Interpad septum
(arcuate expansion of
Lockwood’s ligament)

A B

Whitnall’s ligament
Lateral horn
of levator
Levator muscle

Muscle
aponeurotic
junction

Levator
aponeurosis

Medial horn
of levator

Superior tarsus

Inferior tarsus

Inferior retractors
(capsulopalpebral fascia)
C
Figure 2.10 Orbital fat pads. Schematic drawings indicating (A) surface eyelid anatomy, (B) location of orbital fat pads and (C) retractors of
eyelid after fat pads removed.

marginalis along the orbital rim. The septum is a con­
tinuation of the periorbita within the orbit and contains
the eyelid fat pads, which lie just deep to the septum. The
upper eyelid has a nasal, or medial, fat pad and a central
fat pad. In the lateral portion of the upper eyelid is the
lacrimal gland. The medial and central fat pads are sepa­
rated by the superior oblique muscle and the trochlea.
The nasal fat pad is whiter and contains more fibrotic fat
than does the central pad (see Fig. 2.10).
The eyelid fat pads are termed preaponeurotic, because
they are located just superficial to the levator aponeurosis
(upper eyelid retractor). The levator palpebrae superioris
(LPS) muscle originates from the lesser wing of the sphe­
noid just above the annulus of Zinn and superolateral to
the optic canal. The muscle travels within the orbit in a
relatively horizontal orientation in close approximation
to the superior rectus muscle. At a point just posterior
to the superior orbital rim, the LPS widens and changes
orientation to horizontal at a fascial condensation. This
fascial thickening is termed Whitnall’s ligament (supe­
rior tarsal ligament). The fascia attaches medially to the
fascia around the trochlea and laterally to the capsule of
the lacrimal gland and the frontal bone periosteum. As
the upper eyelid retracts, the fascial sheet helps elevate
12 MASTER TECHNIQUES IN FACIAL REJUVENATION

The tarsal plates are dense fibrous tissue that give

structural integrity and form to the upper eyelid. The
upper lid tarsal plate measures 8 to 12 mm centrally and
tapers medially and laterally to 2 to 3 mm as the plate
Orbital septum
inserts into the canthal tendons. The levator apparatus
attaches to the tarsal plate on its superficial and superior
Orbicularis m. surfaces. The palpebral conjunctiva is densely attached
and bound to the undersurface of the tarsal plate.
Levator apononeurosis
Lower Eyelids
Müller’s m. The lower eyelid is composed of very thin skin, a small
tarsal plate, and muscles that close (protractors) and open
Tarsus (retractors) the lid. The shape of the lower eyelid is deter­
mined by the attachment of the medial and lateral canthal
tendons as well as the tone and contraction of the OOM.
The lateral canthal angle is usually positioned 1 to 2 mm
above the medial canthal angle. The infratarsal crease of
Tarsus the lower eyelid is variable, but is often most noticeable at
Capsulopalpebral the inferior border of the short lower eyelid tarsal plate.
fascia The lower eyelid is also covered by very thin skin with
Septum almost no subcutaneous tissue being present. The OOM
is located just deep to the skin, with the pretarsal OOM
contributing to the tone and shape of the lower eyelid.
The septum orbitale of the lower eyelid is located just
deep to the lower OOM. This septum covers and con­
Figure 2.11 Upper and lower eyelid. m., Muscle. tains the three fat pads of the lower eyelid. Herniation of
these fat pads is associated with unsightly bulges of the
lower eyelid. The medial (nasal) and central lower lid fat
pads are separated by the inferior oblique muscle. The
central and lateral (temporal) fat pads are separated by
FM the arcuate extension of the oblique muscle. The inferior
oblique muscle is the most superficial extraocular muscle,
and injury to this should be avoided during lower blepha­
roplasty (see Fig. 2.10).
CSM The retractors of the lower eyelid arise from fibers
of the inferior rectus and inferior oblique muscles. The
retractors begin as a fibrous sheet and emanate from the
superior tarsal ligament (Lockwood’s ligament) and fuse
with fibers from the orbital septum approximately 5 mm
below the inferior border of the tarsal plate. These con­
joined fibers insert onto the inferior border of the tarsal
plate (see Fig. 2.11).
The lower lid tarsal plate is shorter than the upper
tarsal plate, and measures approximately 4 mm centrally
Figure 2.12 Corrugator and frontalis muscle relation. Arrow, point­ and tapers medially and laterally to 2 mm as the plate
ing to supraorbital neurovascular bundle. CSM, Corrugator supercilii
muscle; FM, frontalis muscle. inserts into the canthal tendons. Again, the palpebral
conjunctiva of the lower eyelid is densely adherent to the
deep surface of the lower eyelid tarsal plate.
the upper eyelid fat pockets, preventing unsightly eyelid
bulging. Midface
At the level of Whitnall’s ligament, the levator muscle The skin (layer I) of the midface is variable in thickness
separates into anterior (superficial) aponeurosis and pos­ and adherence to the underlying subcutaneous fat. The
terior (deep) muscle components. The retractor complex skin of the lower eyelid is thin and loosely attached to
also changes from a horizontal orientation to a vertical the underlying tissue, while the skin of the midface is
one. The deep muscle is termed Müller’s muscle and moderately bound to the deeper tissues. The skin of the
is innervated by sympathetic nerve fibers. These fibers perioral complex (medial and inferior to the melolabial
course with the third (oculomotor) cranial nerve. Müller’s fold and medial to the marionette fold) is densely bound
muscle attaches to the superior border of the tarsal plate, to and not easily separated from the immediate subcuta­
while the majority of aponeurotic fibers insert onto the neous tissues.
lower one-third of the anterior surface of the tarsal plate The subcutaneous fat compartments of the midface
(see Fig. 2.11) [7]. (layer II) are separated by fibrous septae that connect

the overlying skin with the underlying superficial fascia
of the midface. The fat compartments are well vascular­
ized with small vessels, which course within these septae
(see Fig. 2.4).
As stated earlier, the superficial fascia of the midface
(layer III) is SMAS. The SMAS envelopes the facial mus­
culature and has connections to the overlying subcutane­
ous fat and the deep fascia of the face (layer V) beneath.
The SMAS of the midface is continuous with the nasal
SMAS medially and continuous with the platysma muscle
of the neck. The SMAS is contiguous with the superficial
fascia of the temple (TPF). This discontinuity occurs at
the zygomatic arch.
The layer between the superficial and deep fascia of
the face is the deep areolar layer (layer IV). This layer
envelopes and covers the deep fat compartments of the
face. The central deep fat compartments are termed the
medial and lateral SOOF. The deep lateral fat compart­
ment lies just inferior to the two SOOF fat compart­
ments. These three fat compartments are bounded by
the facial vein (medially) and the zygomatic ligament
(laterally). Another deep fat compartment is termed the
deep medial fat of the face. This compartment lies just
medial to the facial vein. Injection of soft tissue fillers
or autologous fat is usually performed in these deep fat
compartments.
The attachment of the superficial (III) and deep fascia
(V) of the face is variable in different individuals and in
different portions of the face. The connections between
these layers contain distal branches of the facial nerve
(CN VII) and are points of fixation of the suspensory liga­
ments (e.g., zygomatic ligament, ORL) of the face. Layers
III and V are densely attached in the lateral midface
(preauricular region). The connections of these layers is
a blunt dissection plane where looser attachments are
found (see Fig. 2.5B). In the region anterior to the parotid
gland, the premasseteric space is found. The floor of
this space is the parotidomasseteric fascia and the roof
is the SMAS.
Layer V of the midface is the parotidomasseteric
fascia, or deep fascia, of the face. This fascia covers the
parotid gland and the parotid duct, and includes the
buccal branches of the facial nerve. This fascia continues
towards the temple over the zygomatic bone, where it
is referred to as the superficial lamina of the DTF. The
masseteric ligaments connect the buccinator muscle to
layer III. These ligaments form the anterior boundary
of the premasseteric space. The parotid duct exits the
anterior border of the parotid gland and courses within
the parotidomasseteric fascia and traverses the premas­
seteric space. The duct then pierces the buccinator muscle
to enter the oral cavity opposite the upper second molar
tooth [8].
Lips and Perioral Region
The skin covering the perioral region is moderately thick
and is densely bound to the underlying soft tissue. The
upper and lower lips are comprised of the sphincteric
orbicularis oris muscle, which is covered externally by
skin and internally by mucosa. The junction between
the mucous membrane and the cutaneous skin is the
2 Applied Facial Anatomy 13
MM
Figure 2.13 Orbicularis oris muscle. Black arrow, facial artery, red
arrow, depressor anguli oris muscle, blue arrow, orbicularis oris muscle.
MM, Masseter muscle.
vermillion border. The orbicularis oris muscle contributes
to the form and shape of the lips. Contraction of this
muscle closes and protracts the lips (Fig. 2.13).
The position and movement of the lips is acted upon
by several mimetic muscles that elevate and depress the
lips. These muscles attach to a connective tissue thicken­
ing at the oral commissures referred to as the modiolus.
Elevators of the upper lip include the levator labii supe­
rioris and the levator labii superioris alequae nasi muscle.
Levator muscles attach to the lower lip at or near the
modiolus to elevate the lips or oral commissure.
Various depressors of the lower lip attach to the modi­
olus and the skin of the lip. These include the platysma
muscle, which is a flat muscle originating from the neck
and inserting into the chin at the commissures of the
mouth and into the anterior one-third of the oblique line
of the mandible. Other lower lip depressors include the
depressor anguli oris (DAO), depressor labii inferioris
(DLI), and the mentalis muscles. The zygomaticus major
and risorius muscles elevate the angle of the mouth.
Injection of botulinum toxin in perioral muscles can
help diminish upper lip rhytids, lessen the hyperdynamic
function of muscles, and create symmetry in patients with
perioral asymmetry. The DAO is a triangular muscle that
arises from the inferior border of the mandible and inserts
into and depresses the corner of the mouth. It is overlaid
by the more medial and triangular DLI, which depresses
the lower lip (see Fig. 2.13). Injection of muscles that
depress the corner of the mouth and the lower lip (DAO)
with botulinum toxin can elevate the corner of the mouth.
When injecting toxin into the DAO, the DLI should be
circumvented in order to avoid creating an asymmetric
smile [9].
14 MASTER TECHNIQUES IN FACIAL REJUVENATION
Facial Artery and Vein
The facial artery is a branch of the external carotid artery
and crosses the mandible just anterior to the masseter
muscle at a depression in the mandible termed the ante­
gonial notch. The artery is located just anterior to the
facial vein. After crossing the mandibular border, the
artery and vein separate and the artery becomes very
tortuous as it travels toward the oral commissure. It gives
off the superior and inferior labial arteries and usually
becomes the angular artery travelling in the nasofacial
crease. The artery and vein are located at the anterior
border of the masseter muscle and just posterior to the
posterior border of the DAO muscle (see Fig. 2.13). Injec­
tion of toxin or fillers in this region should avoid injury
to the facial vessels.
SUMMARY
To evaluate and treat facial aging, a thorough knowl­
edge of facial anatomy is required. Understanding facial
anatomy enhances the practitioner’s ability to diagnose
facial deformities and to create procedures to rejuve­
nate the face. Knowledge of anatomy maximizes the
efficiency of facial injections and surgery, and helps avoid
complications.
REFERENCES
1. Bennett R. Anatomy and physiology of the skin. In: Papel ID. Facial
plastic and reconstructive surgery. New York: Thieme; 2009.
2. Frohm ML, Durham AB, Bichakjian CK, et al. Anatomy of the skin.
In: Baker Shan. Local flaps in facial reconstruction. Philadelphia:
Elsevier; 2014.
3. Stuzin JM, Baker TJ, Gordon HL. The relationship of the superficial
and deep facial fascias: relevance to rhytidectomy and aging. Plast
Reconstr Surg 1992;89(3):441–9, discussion 450–1.
4. Baker SR. Deep plane rhytidectomy and variations. Facial Plast Surg
Clin North Am 2009;17(4):557–73, vi.
5. Sykes JM, Cotofana S, Trevidic P, et al. Upper face: clinical anatomy
and regional approaches with injectable fillers. Plast Reconstr Surg
2015;136:204S–18S.
6. Jeong S, Lemke BN, Dortzbach RK, et al. The Asian upper eyelid:
an anatomical study with comparison to the Caucasian. Arch Oph­
thalmol 1999;117(7):907–12.
7. Knize DM. An anatomically based study of the mechanism of
eyebrow ptosis. Plast Reconstr Surg 1996;97(7):1321–33.
8. Cotofana S, Schenck TL, Trevidic P, et al. Midface: clinical anatomy
and regional approaches with injectable fillers. Plast Reconstr Surg
2015;136:219S–34S.
9. Braz A, Humphrey S, Weinkle S, et al. Lower face: clinical anatomy
and regional approaches with injectable fillers. Plast Reconstr Surg
2015;136:235S–57S.

Addressing Facial Shape and
Proportions With Injectable Agents
in Youth and Age
If I had an hour to solve a problem, I’d spend 55 minutes thinking about the problem
and 5 minutes thinking about the solutions.
HISTORY AND INTRODUCTION
As noted by Pessa, “there are many arbitrary definitions
of what constitutes a youthful face but the appearance of
youth is not arbitrary; it is simply difficult to define” [1].
In an effort to solve any problem, one must first define
the problem, come up with a solution, and then suc-
cessfully execute the solution. The progression of facial
shape with aging is the subject of many theories and
hypotheses, but much remains to be understood. Current
understanding of the facial aging process remains largely
empirical, given that it has traditionally been based on
the effectiveness of various treatments aimed at rejuve-
nation, some resulting in an odd or “done” appearance.
Defining the problem has proved challenging, as facial
aging is a complex process that is the cumulative effect
of simultaneous changes of the many components of the
face, as well as the interaction of these components with
each other.
A growing understanding of this complex process has
been ongoing in the world of surgery and surgical tech-
niques since its inception, and has informed and driven
the change from an empiric approach to an anatomic one,
enabling improved and more natural-appearing results.
Fig. 3.1, adapted from an article on facial aging from
Cotofana et al., provides an impressive illustration of
how innovation and advances in technology, which have
given us newer and faster ways to both gather and share
information, are accelerating our understanding of facial
anatomy [2]. As a result our understanding of the ana-
tomic changes observed in the aging face has progressed
considerably over the last couple of decades, leading to a
paradigm shift in the way we both perceive and approach
these changes. The answer to the question of whether we
sink or we sag has become a “yes” to both, as we begin
to see aging as a complex and interdependent interplay
between all structural layers culminating in the collapse
of a three-dimensional (3D) construct. Newer under-
standing of volume loss as a critical component of facial
aging and the integration of volume replacement into the
C H A P T E R
3
Rebecca Fitzgerald, MD
ALBERT EINSTEIN
surgical and nonsurgical therapeutic algorithm is argu-
ably the most significant recent development in the field
of facial rejuvenation. The ability to accurately recognize
where volume has been lost (or sometimes lacking in the
first place) in each individual at a given point in time
will greatly enhance our ability to address the loss with
site-specific corrections in order to achieve optimal and
natural-looking results. However, most of us would agree
with Glasgold that the recent rapid and widespread adop-
tion of “off the shelf” volume replacement has outpaced
a sophisticated understanding of its goals, resulting in a
new and different, but equally undesirable category of
“looking done” [3].
So the problem can be defined as the attainment of
natural-looking results in the rejuvenation of the aging
face, and the solution to that problem, as well as its
execution, lies in understanding its pathogenesis, which
is anatomic. Recent insights and gains in our anatomic
understanding enhance our current ability to come closer
to this goal. For this reason, this chapter is not written
on the various types of fillers or techniques of filler injec-
tion, about which much has been written, but rather
on how to decide where to use it and why in differ-
ent faces, using anatomy as a guide. This approach is
rational, practical, teachable, and reproducible, as it is
simply the result of the recognition, and targeted correc-
tion, of currently recognized specific anatomic deficien-
cies. Using this approach has improved my results and
resulted in much higher patient satisfaction. That said, it
is not the only way. Many other approaches have been
employed successfully (using specific landmarks or masks
or phi ratios, for example), in order to obtain pleasing
results; however, some aspects of these approaches also
use anatomy. The purpose of this chapter is to provide
an introduction and brief summary of some of the recent
literature concerning facial anatomy and the anatomy of
facial aging, which serve as the basis and foundation for
predictable, specific, reproducible, and natural-appearing
results with the use of injectables. This summary of current
concepts will be presented along with clinical examples
15
16 MASTER TECHNIQUES IN FACIAL REJUVENATION

2002 2007
1801 1959 Prezygomatic space Subcutaneous fat compartments
Buccal fat pad Zygomatic lig- (McGregor’s patch) B.Mendelson R. Rohrich
X Bichat M.McGregor 2008
1976 2000 Premasseter space
1909 1973 SMAS LOT B. Mendelson
ROOF (Charpy’s fat pad) Lorés fascia V.Mitz J.Moss
2008 2012
M.Charpy J.Lore 1995 DMCF Tear trough lig-
SOOF Ristow space CH.Wong
A.Aiache R.Rohrich

1800 1900 1910 1920 1930 1940 1950 1960 1970 1980 1990 2000 2010
1989 2013
Mandibular lig- Premaxillary space
Platysma-cutaneus lig- CH.Wong
1912 1951 DW.Fumas 2009
Modiolus Intra-orbital fat pads Deep chin fat
1992 2012
P.Eisler S.Castanares Masseteric lig- R.Rohrich
1945 DLCF
JM.Stuzin 2008 M.Gierloff
1885 Buccal space 2002 Mandibular septum
Juxtaoral organ J.Kostrubala Orbicularis retaining lig jowl fat
J.Chievitz AZ.Muzaffar E.Reece
Figure 3.1 Timeline from 1800 to present, showing the date of the first description of important structures in the human face. DLCF, Deep lateral
cheek fat; DMCF, deep medial cheek fat; LOT, lateral orbital thickening; ROOF, retro-orbicularis oculi fat; SMAS, superficial musculoaponeurotic
system; SOOF, suborbicularis oculi fat. (Reproduced with permission from Cotofana S, Fratila AA, Schenck TL, Redka-Swoboda W, Zilinsky I,
Pavicic T. The anatomy of the aging face: a review. Facial Plast Surg 2016;32(3):253–60.)

exhibiting primarily congenital absence or aging changes
in the tissue layer discussed in order to better illustrate
the discussion. The practical use of these concepts in
injectable treatment of the face will then be illustrated
using a number of case reports of patients of different
ages, gender, and ethnic backgrounds along with a short
description of where each face was treated and why, using
both a layered anatomic (tissue structures) and regional
approach (upper, mid, and lower face, shape, propor-
tions). In order to look at a number of cases, as well as
to compare and contrast different faces, these cases are
presented in a “composite” format. This smaller format
additionally makes it easier to recognize facial shape and
proportions, and to determine what is present or missing
that may be moving the face away from the ideal shape
and proportions, which will be discussed below.
Finally, as aging is a complex multimodal process,
multimodal therapy must be used to address it. Despite
the widespread popularity of injectable treatments as an
“immediate gratification no downtime option,” they have
their limitations and risks like everything else, and are not
a panacea (or stand alone) treatment of the aging face.
PERSONAL PHILOSOPHY
individuals are judged and treated [4]. Research has
shown that facial beauty is perceived and processed
rapidly by the brain, and this perception biases subse-
quent cognitive processes [5]. A recent extensive review
of research on facial beauty determined that four charac-
teristics emerge as the most statistically significant deter-
minants of attractiveness: averageness (prototypicality),
sexual dimorphism, youthfulness, and symmetry [6].
Not surprisingly, all of these have something to do with
optimizing mate selection. Youth and sexual dimorphism
are obvious. Prototypicality likely signifies a good mix of
genes (avoiding autosomal recessive disease), while sym-
metry may indicate a history of maternal stability and
health during development. Additionally, changes seen
with aging may lead to an unintended and undesirable
misinterpretation of mood by others that is unwelcome to
most all of us as we age and is one of the most common
presenting complaints, i.e., “I don’t mind getting older
I just don’t want to look mad, sad, and tired.” This
can often be remedied with glabellar neuromodulators as
well as fillers infraorbitally as well as around the mouth,
resulting in a surprisingly different first impression of a
face, as seen in Fig. 3.2. Looks matter because they can
have a great impact on quality of life.

Although a new patient may present pointing to a wrinkle,
line, or fold they have noticed seemingly overnight, as
stated above, we are now increasingly aware that these
first obvious signs of aging noted by the patient are in
fact downstream markers of a slow progressive change
taking place in all structures of the face. This represents
a paradigm shift in our current approach to facial reju-
venation. This concept will be addressed, discussed, and
illustrated in this chapter.
Facial beauty and attractiveness are important cross-
cultural social concepts as they tend to dictate how
FACIAL ANATOMY: INTRODUCTION AND OVERVIEW
The traditional approach to assessing the face is to con-
sider the upper, middle, and lower thirds, regionally.
Other newer useful approaches using structural layers
or functional differences reflect our recognition that the
pathogenesis of facial aging is a multifactorial process
that can be explained on an anatomic basis, and likely
accounts for the variations in the onset and outcome of
aging seen in different individuals. We will look at the
face with these different approaches in the next section.
 3 Addressing Facial Shape and Proportions With Injectable Agents in Youth and Age 17

Figure 3.2 Changes commonly seen with aging may also communicate an unintended message of anger, sadness, or fatigue. Removing this negative
message results in a surprisingly different first impression of the same aged face. Photographs courtesy of Rebecca Fitzgerald MD.

Figure 3.3 Individuals from several decades of life arranged in chronological progression are traditionally used to illustrate the deepening of indi-
vidual folds and lines seen with aging. However, these same images also illustrate how all structural tissue layers are affected by aging, leading to
morphological changes seen in the topography, shape, and proportions of the entire face, showing these lines and folds to be downstream markers
of the collapse of the entire 3D structure. (Reproduced with permission from Fitzgerald R, Vleggaar D. Facial volume restoration of the aging face
with poly-L-lactic acid. Dermatol Ther 2011;24:2–27.)

Regardless of approach, cumulative changes in all struc-
tural tissue layers of the face with time lead to a change
in the morphology of the entire face in terms of its shape,
proportions, and topography. Morphologic changes seen
in women from different decades of life (30s to 60s) are
illustrated in Fig. 3.3. Although these types of figures were
initially used to visualize the differences in the depth of
a tear trough (TT), nasolabial fold (NLF), or marionette
line with advancing age, they can now be appreciated
as evidence that these folds and lines are downstream
markers of a global change rather than isolated entities.
This figure also illustrates how changes in facial topog-
raphy seen with aging sharpen the once smooth transi-
tion between anatomic units, by greatly magnifying light
reflection and/or shadow. This concept is critical to our
understanding, as seemingly subtle changes in light and
shadow over time can have an enormous impact on our
perception of a face in an almost indiscernible way. The
rationale behind restoring 3D contours to the face as it
ages, whether by lifting, tightening, or volume restora-
tion, is easy to appreciate when looking at photographs
illustrating how aging takes us from 3D to 2D, as shown
in the woman in Fig. 3.4 shown at college graduation and
30 years later, both before and after injectable treatment.
The youthful oval face dramatically flattens with age,
and restoration of previous arcs and convexities restore
youthful light and shadow patterns.
Although the sequence of events observed in aging is
somewhat predictable, its pace among individuals is vari-
able and progresses in each person from a unique start-
ing point. Additionally, changes in different tissue layers
within a single individual occur interdependently. The
lack of, or loss, of structural integrity in one area may
worsen the appearance of a neighboring area. Conversely,
18 MASTER TECHNIQUES IN FACIAL REJUVENATION

Figure 3.4 The rationale behind restoring three-dimensional contours to the face as it ages, whether by lifting, tightening, or volume restora-
tion, is easy to appreciate when looking at photographs illustrating how aging takes us from three-dimensional to two-dimensional, as seen in
this 51-year-old woman shown at college graduation, and again 30 years later both before and after injectable treatment. Photographs courtesy of
Rebecca Fitzgerald MD.

Figure 3.5 The less volumized side of the face in this patient with mild asymmetry simulates the effects of volume loss in all layers seen with
aging. (Reproduced with permission from Fitzgerald R, Vleggar D. Using Poly-L-lactic acid (PLLA) to mimic volume in multiple tissue layers. J
Drugs Dermatol 2009;8:s5–s14.)

the presence, or restoration, of structural integrity in
one area may improve the appearance of a neighboring
area [7].
We know that almost all faces develop with slight
asymmetry following development of the neural tube
embryologically, and the aforementioned concept can be
readily appreciated when looking at the facial asymmetry
in the woman in Fig. 3.5 who appears more aged on her
right, “sunken,” side compared with her fuller left side.
Note that the less volumized side (right) of her face shows
a clear delineation of her temple, lid, and cheek as sepa-
rate entities, while the more volumized side (left) does
not—one area seems to blend seamlessly with another,
reflecting light uninterrupted by the shadows seen on
the right. Note that the amount of volume loss with
aging on the initially smaller right side has now resulted
in an outer skin envelope slightly too large for its now
“smaller” face, and contributes to a more pronounced
ptosis and loss of jawline contour on this side earlier than
on the left side (which commonly has more solar elastosis
because its the driver’s side window). Less bony support
and soft tissue leads to a lower brow position, leading
to lid lag laterally and an early hollowing “A-frame”
deformity somewhat camouflaged by a slackened upper
 3 Addressing Facial Shape and Proportions With Injectable Agents in Youth and Age 19

1⁄5 1⁄5 1⁄5 1⁄5 1⁄5

1⁄3

1⁄3

1⁄3

1⁄3
2⁄3

A B

Figure 3.6 Facial proportions. The vertical proportions are generally broken down into fifths based on the width of an eye (A). The horizontal
facial proportions are divided into thirds as measured from the hairline to the glabella, from the glabella to the subnasale, and from the subnasale
to the menton (B). The lower third can be further broken down to the upper one-third, from the subnasale to the junction of the lips, and the lower
two-thirds, from the junction of the lips to the menton.

lid. A TT and lid-cheek junction are seen only on the
less volumized side. There is also less anterior and lateral
cheek projection, a slightly deeper nasal sulcus, a longer
upper lip, and an increased mental hollowing on the less
volumized side, whereas no such demarcation is visible
on the more volumized side. This combines to make the
perioral proportions in the lower third of her face look
slightly less youthful on the less volumized side. Finally,
the peripheral contours on the less volumized side of
her face are more abrupt than those on the fuller side.
The convexity of the temple and the preauricular volume
on the full side lends an overall oval shape to that side
of her face that is lost due to the atrophy on the right.
Compare this with the ideal proportions of a youthful
face, as shown in Fig. 3.6, depicting a width of five eyes
across in vertical fifths and an equal volume in the upper,
mid, and lower face when measured in horizontal thirds.
Additionally, this schematic depicts the golden phi ratio
of 1:1.6 in the perioral region of the lower third of the
face. Note that the fuller side of the face in Fig. 3.5 is
closer to these ideal proportions, providing a “roadmap”
of where to revolumize the other side.
Over a decade ago, in an effort to visualize the aging
face in linear examples, Lambros used computer anima-
tion to compare current photographs of patients matched
for light and position with photographs taken 10 to 50
years previously to gain insight into midfacial aging,
showing that deflation can mimic descent [8]. Recent
work by Lambros and Amos now provides an invaluable
tool to visualize the facial aging process using 3D facial
averaging [9]. They have published animations made
from 3D facial images amassed over the past 10 years,
using a 3D camera system (Vectra; Canfield Scientific,
NJ, USA). These are shown as static images in Fig. 3.7.
The image on the left shows the average of the 3D facial
surfaces of 116 female subjects aged 20 to 30 years, and
the image on the right shows the average of the 3D facial
surfaces of 100 female subjects aged 68 to 91 years. The
static images illustrate the differences seen in the mor-
phology of the younger and older averages well; however,
this image may be viewed in animation online at http://
links.lww.com/PRS/B922. It is interesting to compare the
similarities between the youngest and oldest women in
Fig. 3.3 to the 3D-averaged image of similar age. Look
at the shape of the orbits, the bony support under the
brow and the nose, the flattening of the midface and
lateral cheeks, and the change in proportions in the lower
third of the face. Note how the TT and NLF deepen as
the craniofacial support changes and the cheek flattens.
Look at the eversion versus inversion of the lips. Look at
20 MASTER TECHNIQUES IN FACIAL REJUVENATION
Figure 3.7 (Left) The average of the facial surfaces of 116 female
subjects aged 20 to 30 years. (Right) The average of the facial surfaces
of 100 female subjects aged 68 to 91 years (average, 76 years). (Repro-
duced with permission from Lambros V, Amos G. Three-dimensional
facial averaging: a tool for understanding facial aging. Plast Reconstruct
Surg 2016;138.6:980e–982e.) This image may be viewed in animation
online at http://links.lww.com/PRS/B922.
light and shadow, and how it plays off areas of depression
and prominence (convexities and concavities) in both the
younger and older face. Do not focus on just “lines and
folds,” but consider all the structural changes in the face.
Consider the interdependency between them by treating
the whole face as a 3D interlocking puzzle where losing
or correcting one component may have a negative or
positive impact on another.
FACIAL ANATOMY AND AGING: REGIONAL
THIRDS OF THE FACE
The traditional regional approach to assessing the face is
to consider the upper, middle, and lower thirds (as shown
in Fig. 3.6B). Glasgold, Glasgold, and Lam have greatly
increased our appreciation that a detailed examination
of the shadows and shadow patterns that develop in all
areas of the face with volumetric facial aging will lead to
a better understanding of how to apply volumetric tech-
niques to create a natural-appearing result. Although they
have worked mostly with fat augmentation, the same
concepts apply to filler (although filler may not be a cost-
effective option for those needing a lot of volume) [10].
Although every face is unique, the shadows that develop
as we age are consistent. Not everyone develops every
shadow, but the typical shadows of aging are universal.
Glasgold notes the ease with which an artist can depict
an aging face with a few shadow strokes makes this con­
cept easy to grasp. Studies documenting the consistent
patterns of volume loss in the aging face are reviewed in
the following sections. The skin of the face has consistent
attachment points to the underlying structures through
the facial retaining ligaments, and as the volume of the
face deflates, these attachment points will define most of
the shadows that develop with age [3]. Advancing age
accounts for specific areas of volume loss in all thirds
of the face. These changes in each third of the face are
summarized here, paraphrasing the (“can’t be improved
upon”) descriptions published by Glasgold, Glasgold,
and Lam. Compare characteristics of younger and older
faces as you read through these by looking again at the
women pictured in Figs. 3.3, 3.4, and 3.5 and the aver-
ages of the 3D facial surfaces in Fig. 3.7.
Upper Face
In the upper face the young eye appears full, the bony
orbit is not visible, the skin is elastic and thick, and most
of the upper lid is concealed by the full brow, with only
a few millimeters of upper lid show. The youthful upper
lid sulcus lacks a shadow, and the eye has an overall
“almond” configuration, with the lid margin, lid crease,
and eyebrow all parallel. As the upper lid deflates, a fold
of skin develops where there was once fullness, and the
shadow of the upper lid sulcus emerges. With increasing
age, this fold of upper lid skin often droops and may
encroach on the lash line, completely effacing any vis-
ibility of the upper lid (“hooding”). The eyelid skin may
also slip into the lid crease, revealing the upper lid veiled
in youth by the full brow. Often this is initially most pro-
nounced medially, resulting in the so-called “A-frame”
deformity [11]. With aging, shadows also develop in the
temple and upper orbit. A deep shadow of the temple sets
off the lateral orbital rim and zygomatic arch. Filling the
temple and lateral brow will affect the appearance of the
tail of the brow as well as the upper lid. The temple addi-
tionally relates to the entire lateral face contour including
the zygoma, buccal regions, and lateral mandible.
Midface
The manifestations of midfacial aging are largely due
to changes in facial volume that transition the midface
from a youthful convex platform dominated by highlights
to an aged flattened platform segmented by shadows
(concavities) [12]. Younger midfaces have an unbroken
convexity running from the lower eyelid to the NLF,
creating a dominant cheek highlight. Soft tissue covers
the bony skeletal components of the midface, providing
a softer appearance; the inferior orbital rim is masked,
minimizing any delineation between the lower eyelid and
cheek [13]. The zygomatic arch, providing the founda-
tion of lateral cheek volume, is adequately covered by
soft tissue to hide the shadows that delineate its superior
and inferior margins [14]. Advancing age is associated
with a generalized deflation of the midface, particularly
in the upper aspects. The combination of volume loss
and the effect of underlying facial retaining ligaments
contribute to the hallmarks of midface aging. As we will
see in the next section, the most relevant ligaments in
the midface are the orbicularis retaining ligament (ORL),
malar septum (zygomaticocutaneous ligament), and the
McGregor patch (zygomatic ligament) [15]. Volume loss
at the inferior orbital rim creates a concavity and over­
lying shadow, separating the lower eyelid from the cheek.
Volume loss in the anterior cheek converts the youthful
convexity into a concavity with its base tethered by the
malar septum (zygomaticocutaneous ligament). Lateral
cheek volume loss diminishes the dominance of midface
volume and skeletonizes the zygomatic arch, creating a
 3 Addressing Facial Shape and Proportions With Injectable Agents in Youth and Age
harsh submalar shadow [16]. In the midface, augmenta-
tion of the cheek alone will worsen the separation from
the eye, upper lip, buccal area, and temple, often con-
tributing to an unnatural appearance. Addressing the
shadow group of the midface as a whole will allow the
creation of a unified cheek highlight with no separation
between the cheek, the eye, and the upper perioral unit.
Adding volume in the inferior orbital rim will reunify
the lower eyelid and cheek segments. Filling the cheek,
with a focus on the malar septal (zygomaticocutaneous
ligament) depression, will recreate a convex cheek with
a strong highlight. Volume may need to be added to the
lateral cheek when there is deficient lateral projection,
but most important is filling around the zygomatic arch
to restore youthful soft contours. The buccal region tran-
sitions the lateral facial contour of the zygoma into the
lateral mandible [12].
Lower Face
The lower face has two distinct components, the jawline
and the perioral region. The hallmarks of a youthful
lower face include a smooth transition from the cheek
to chin, devoid of shadowing at the labiomandibular
fold. The jawline is well defined by a curvilinear shadow
coursing from the mandibular angle to the anterior chin;
on oblique view the shadow framing the jawline has
a “hockey stick” shape. This youthful jawline shape is
dependent on an adequate bony foundation providing
sufficient volume at the prejowl sulcus and angle of man-
dible. In the perioral area the labiomental hollow creates
an upside down U-shaped shadow that separates the
lower lip from the chin and the labiomental fold creates
a distinct shadow that typifies the frown. The prejowl
sulcus appears as volume loss progresses at the inferior
portion of the mandible, anterior to the jowl, and cor-
responds to the attachment of the mandibular ligament
causing a shadow in front of the jowl. The typical jowl
can be thought of as a highlight that exists between the
shadows of the prejowl sulcus and (if present) shadowing
of the lateral mandible. Congenital lower face volume
deficiencies are most common in the chin and mandibular
angle. Deficiencies in the anterior chin and prejowl sulcus
create a relative middle jawline dominance, which mani-
fests in an appearance of early jowl formation. These
patients tend to present at an earlier age for lower face
rejuvenation as even early volume changes more easily
highlight their skeletal deficiencies [17].
Finally, Glasgold et al. have introduced an additional
regional concept they term the “three dominant frames in
the face” [10]. The first is the global facial frame, which
extends along the jawline to offset the face from the neck
and then flows up the lateral contour of the face from the
angle of the mandible along the contour of the buccal,
zygomatic, and temple line. The global facial frame
strongly affects our perception of a face on many levels:
aging, gender, and attractiveness. A sharp, uninterrupted
shadow separating the face from the neck is desirable. A
soft inverted egg-shaped lateral contour suggests youth-
ful femininity, while a more angular/rectangular line is
more masculine. The other two frames highlight the eyes
and the mouth. As noted earlier, the traditional surgical
21
approach to the eyes has been of volume and tissue
removal, typically leaving the eye offset in deep shadows
looking aged and unhealthy. Volume replacement to the
upper eye, particularly the medial orbit A-frame shadow,
is, in the opinion of Glasgold, one of the most effective
uses of volume in the face, as it eliminates these aging
shadows. In the perioral region the natural aging process
invariably creates a ring of shadow around the lips and
mouth, which contribute to an aged appearance. The
effect of creating a frame of light in as many of the small
subunits of the perioral region as possible will enhance
the beauty of the mouth. Conversely, adding volume to
the lips without addressing the surrounding area serves
to deepen the shadows and further disconnect the lip and
mouth from the perioral region, resulting in one of the
odd appearances that patients fear [3]. Many of these
changes have been described earlier on the smaller, more
aged-appearing side of the patient pictured in Fig. 3.5.
FACIAL ANATOMY AND AGING: FUNCTIONAL
AND STRUCTURAL
Despite the recent advances revealing the aging changes
seen in facial soft tissue anatomy, and it’s underlying skel-
etal support, our understanding of this complex process
is still in its infancy. Mendelson and Wong suggest that
in addition to the traditional assessment of facial thirds, a
more global understanding is facilitated by distinguishing
between the different functional regions of the face, as
well as by considering the anatomy in terms of a layered
construct. They consider the face can be divided into
the highly mobile anterior face, which is functionally
adapted for facial expressions and the fixed lateral face,
which overlies masticatory structures [15]. A vertical line
of retaining ligaments separates the anterior and lateral
face (Fig. 3.8). These ligaments are, from above: tempo-
ral, lateral orbital, zygomatic, masseteric, and mandibu-
lar ligaments. The orbicularis retaining ligament is seen
running along the inferior orbital rim, and the zygomati-
cocutaneous ligament along the inferior zygoma. In the
anterior face, the midcheek is split obliquely into two
separate functional parts by the midcheek groove (which
runs along the inferior zygoma correlating to the zygo-
maticocutaneous ligament) related to two cavities: the
periorbital part above and the perioral part below. The
transitions between these areas, while not seen in youth,
become increasingly evident with aging. This is illustrated
in Fig. 3.9, where the ligaments themselves can be seen in
the parotidomasseteric area in an emaciated face in Fig.
3.9A, and the pull on the skin from the various ligaments
can be appreciated in both a thin and a full face in Fig.
3.9B and C. These transitions (or their lack) can also be
appreciated in the faces in Figs. 3.3, 3.4, 3.5, and 3.7.
These authors conceptualize the soft tissues of the
face as arranged concentrically into five basic layers that
are bound together by a system of facial retaining liga-
ments, as first hypothesized by Stuzin et al. [18]. The
layers are pictured in Fig. 3.10 and consist of (1) skin;
(2) subcutaneous fat; (3) the musculoaponeurotic layer;
(4) areolar tissue, including facial retaining ligaments and
22 MASTER TECHNIQUES IN FACIAL REJUVENATION
Figure 3.8 Regions of the face. The mobile anterior face is function-
ally adapted for facial expressions and is separated from the relatively
fixed lateral face (shaded), which overlies masticatory structures. A
vertical line of retaining ligaments (red) separates the anterior and
lateral face. These ligaments are, from above: temporal, lateral orbital,
zygomatic, masseteric, and mandibular ligaments. In the anterior face,
the midcheek is split obliquely into two separate functional parts by
the midcheek groove (dotted line) related to two cavities: the periorbital
part above (blue) and the perioral part below (yellow). (Reproduced
with permission from Mendelson B, Wong C. Anatomy of the aging
face. Section I, Chap 6. Aesthetic Surgery of the Face. Elsevier; 2013.)
A B
Figure 3.9 A vertical line of retaining ligaments separates the anterior and lateral face. The transitions between these areas, while not seen in
youth, become increasingly evident with aging as illustrated in the following examples. The ligaments themselves can be seen in the parotidomas-
seteric area in an emaciated face in (A), and the pull on the skin from the various ligaments can be appreciated in both a thin and a full face in (B
and C). Photographs courtesy of Rebecca Fitzgerald MD.
facial spaces; and (5) periosteum and deep fascia [19]. As
noted earlier, to secure the superficial fascia (defined as
the composite flap of layers 1–3) to the facial skeleton,
a system of retaining ligaments binds the skeleton to the
dermis, and the components of this system pass through
all layers, as illustrated in Fig. 3.11. Like a tree, these
ligaments start as a thicker trunk, and subsequently fan
out in a series of thinner branches as they insert into the
subcutaneous fat and the dermis. At different levels of
dissection, the ligament system is given different names,
such as the retinacula cutis in the subcutaneous layer
and ligaments under the superficial musculoaponeurotic
system (SMAS) level, as seen in Fig. 3.12. The density
of these branches determine the difficulty encountered
when dissecting the tissue and accounts for the fact that
it is easier to dissect in the deep subcutaneous layer than
the dermis. The nerves and vessels are always located
in close proximity to the retaining ligaments, as these
vital structures are protected by traveling through other
layers in concert with these structures. The retinacula
cutis fibers are not uniform across the face, but vary
in orientation and density according to the anatomy of
the underlying deeper structures. As will be apparent
when the anatomy of the underlying layer 4 is described,
at the location of the retaining ligaments, the vertically
orientated retinacula cutis fibers are the most dense and
are the most effective in supporting the overlying soft
tissues, and in so doing, form the anatomic boundaries
that compartmentalize the subcutaneous fat [15]. Addi-
tionally, Mendelson and Wong’s extensive work support
that a large part of the sub-SMAS layer 4 consists of
soft tissue “spaces” that have defined boundaries that
are strategically reinforced by retaining ligaments. As
the roof of each space is the least supported part, it is
more prone to developing laxity with aging, compared
with the ligament-reinforced boundaries. This differential
laxity accounts for much of the characteristic changes
that occur with aging of the face.
C
 3 Addressing Facial Shape and Proportions With Injectable Agents in Youth and Age 23

3 2 1
5 4

1. Skin

2. Subcutaneous

3. Musculoaponeurotic

4. Retaining ligaments
and space

5. Periosteum
and deep fascia

5
4 system of retaining ligaments binds the dermis to the skeleton, and
3 2
1
Figure 3.10 The face is constructed of five basic layers. This five-
layered construct is most evident in the scalp but exists in the rest of
the face, with significant modification and compaction for functional
adaptation. Layer 4 is the most significantly modified layer, with alter-
nating facial soft tissue spaces and retaining ligaments. Facial nerve
branches also transition from deep to superficial in association with the
retaining ligaments through layer 4. (Adapted from Mendelson B, Wong
C. Anatomy of the aging face. Section I, Chap 6. Aesthetic Surgery of
the Face. Elsevier; 2013.)
Each of the aforementioned layers will be discussed
in more detail (with an emphasis on fat and bone as it
relates to injectable treatments) in the sections here.
PREPROCEDURAL ASSESSMENT
As all structural tissues play a role in the aging face,
restoring youthful characteristics (or establishing them
where they are congenitally absent) starts from the skel-
etal framework and builds progressively to the canvas of
the face. Therefore, current literature pertaining to the
morphological changes of the facial skeletal framework,
retaining ligaments, facial muscles, fat compartments,
and skin envelope will be presented in the next section.
All contribute to facial aging in variable degrees, some
of it primary, some secondary, and what is known about
which is which, as well as the relative contributions of
Figure 3.11 To secure the superficial fascia to the facial skeleton, a
the components of this system pass through all layers. There are three
morphological forms of retaining ligaments of the face. SMAS, Super-
ficial musculoaponeurotic system. (Reproduce with permission from
Mendelson B, Wong C. Anatomy of the aging face. Section I, Chap 6.
Aesthetic Surgery of the Face. Elsevier; 2013.)
Dermis
Retinacula
cutis
SMAS
Retaining
ligament
Periosteum
Bone
Figure 3.12 The retaining ligaments of the face can be likened to a
tree. The ligaments attach the soft tissues to the facial skeleton or deep
muscle fascia, passing through all five layers of the soft tissues. It fans
out in a series of branches and inserts into the dermis. At different levels
of dissection, it is given different names, such as the retinacula cutis in
the subcutaneous layer and ligaments in the sub-SMAS level. SMAS,
Superficial musculoaponeurotic system. (Adapted from Mendelson B,
Wong C. Anatomy of the aging face. Section I, Chap 6. Aesthetic
Surgery of the Face. Elsevier; 2013.)
24 MASTER TECHNIQUES IN FACIAL REJUVENATION
each, is in a constant state of evolution and refinement.
Even with those limitations in mind, with careful evalua-
tion some specific age-related changes or congenital defi-
ciencies can now be addressed in a site-specific manner
to achieve natural-looking results.
This section on assessment will discuss the importance
of patient selection and introduce an approach to evalu-
ating the face. As noted by Pessa, although anatomy is
remarkably consistent between individuals, the variable
sizes and shapes of the different structures in each individ-
ual gives everyone their own unique appearance and has
tremendous influence on the variations in the onset and
outcome of aging seen in different individuals [20]. This
is made more complex by the recognition that although
the sequence of events as we age is somewhat predictable,
its pace is variable between individuals and even between
tissue layers in one individual. Subsequently, there is no
one algorithm to address facial aging. As mentioned
earlier four characteristics emerge as the most significant
determinants of attractiveness: prototypicality (average-
ness), sexual dimorphism, symmetry, and youthfulness
[6]. Averageness requires harmony of all regions of the
face. Sexual dimorphism requires recognition of gender
differences. A detailed discussion of gender differences is
out of the scope of this chapter, but a few well-accepted
norms are worth mentioning here. Males often have a
stronger forehead and straighter brow, a cheek apex that
is lower and more medial, and a stronger chin and jawline
than females. Conversely, female faces have a higher,
more lateral cheek apex and a more tapered lower face
than males. Obviously, you do not want to feminize a
male face with high lateral cheekbones, or fail to treat a
masculinizing masseter hypertrophy in a female. Regard-
ing symmetry, after the neural tube develops early in
our embryologic development, the two sides of the body
develop like siblings, not twins, and the vast majority of
us have a shorter fuller side and a thinner longer side. The
discrepancy between these sides becomes more apparent
with aging. The contribution of symmetry to beauty is
often maligned by showing a photograph of a face next
to photographs made using the two right and two left
sides of that face, often showing a bizarre looking thin
face and fat face. However, this results from comparing
the two sides of an asymmetric face. If the original face
photographed is truly symmetric, then all three photo-
graphs would be identical. It is interesting to note that
the fuller shorter side is usually the more attractive side
in youth, and the younger appearing side with age. Look
back at Fig. 3.5. In my experience, augmenting volume
around the temple, brow, orbit, and zygomatic arch just
enough to restore more symmetrical light reflection from
both sides can make a surprising difference in our percep-
tion of that face.
In relatively young faces with early aging changes
(including the face pictured in Fig. 3.5), addressing a
TT, NLF, or marionette line as an isolated entity will
often yield good results. However, as these folds represent
downstream markers of global changes, in those individ-
uals with congenital deficiencies, and those further along
in the aging process, this approach may yield suboptimal
results by taking one area of the face out of harmony with
another. Figuring out what you want to treat is a process
of observation and palpation/provocation that allows us
to determine the nature and extent of the structural tissue
changes affecting the face in front of us at that particular
point in time, as well as how those structural changes
have affected the shape, proportions, topography, and
frames of the entire face. It is, of course, more of a “read”
than a “recipe,” as there is no one algorithm that fits
all faces. It is useful to think of what is deviating that
face from the ideal proportions shown in Fig. 3.6, which
shows an ovalized “upside down egg” shape, an anterior
convexity, an oval frame, youthful proportions of “five
eyes across” and three relatively equal thirds of the face.
What you choose to address depends on the extent of the
changes seen in each structural layer or region, and the
parity of these changes between layers or regions. Try to
figure out “which tissue is the biggest issue” or, if region-
ally, “one of these things is not like the other.” If there is
just a little change in all layers, almost any interventional
approach will work. If there is regional disparity, try to
blend them all back to a more similar place. The most
common disparities are creating young lips or cheeks that
“stick out” rather than blend in to an otherwise aging
face, or placing too much filler too high under the eyes,
which looks odd.
Figs. 3.13 and 3.14 may help clarify this approach.
The faces pictured in Fig. 3.13 all have a clear-cut “one
tissue issue” (see figure legend), while the face in Fig. 3.14
has a discrepancy in the size of her upper, mid and lower
face. The lack of volume in the lower two-thirds of her
face make her forehead seem too large in the before
picture, while it looks quite normal following treatment
of the cheeks and chin in the after photo.
This kind of optical illusion is not uncommon in the
face. It is termed a “perspective illusion” and is illustrated
well in the classic three cars example seen in Fig. 3.15. If
there is a lot of loss of integrity in multiple layers, then
multiple interventions and a great deal of product may
be needed to obtain optimal results, as seen in Fig. 3.16.
It is interesting to note on the cropped close-up view of
this face shown in Fig. 3.17 how treatment of the areas
of skeletal remodeling and fat loss in this patient affected
the overall shape, topography, and proportions of this
face towards the ideal proportions pictured in Fig. 3.6.
Recognize that a patient’s final outcome, and the
amount of product and work it will take to get there,
is a reflection of the quality of tissues with which they
start. Wasted faces (associated with HIV or endurance
exercise) are harder to fill, and it is harder to sustain
the fill. Older faces with advanced craniofacial remodel-
ing, fat loss, and very poor skin quality can be treated
successfully; however, fillers of any kind may not be the
most cost-effective choice in a patient who would best
benefit from fat augmentation and a face lift. Discussing
this and setting realistic expectations before treatment
will decrease frustration for both the patient and the
practitioner. Conversely, fuller and younger faces “bring
in their own volume” and are therefore easily reshaped
with a conservative amount of filler of any kind. This is,
of course, an issue of patient selection and not product
selection. For these reasons, for the novice, I strongly
 3 Addressing Facial Shape and Proportions With Injectable Agents in Youth and Age 25

A B C
Figure 3.13 Individual variations in the onset and outcome of aging are commonplace. While many of us age with relative parity in all structural
tissue layers, some individuals are a mostly “one tissue issue.” (A) Shows a young man with good bone structure and good skin, but extreme loss
of fat. (B) Shows a young woman with good skin and soft tissue volume, but a congenital lack of craniofacial support. (C) Shows an elderly woman
who has good bone structure and ample soft tissue, but very elastotic skin. Photographs courtesy of Rebecca Fitzgerald MD.

with any procedure, the patient must demonstrate suf-

ficient “psychosocial maturity” to weather any potential
complications. The patient should be educated and a
true informed consent obtained. Manage expectations.
Anxious, demanding, or unhappy patients are poor can-
didates. Although there are no absolute contraindica-
tions, patients with active autoimmune disease, poor
dental hygiene, or a history of previous permanent filler
(especially if done outside the USA) may be at increased
risk for complications.

CURRENT CONCEPTS IN THE ANATOMY OF AGING

Figure 3.14 Although on first glance you notice this young woman’s
large forehead, it seems proportional after augmenting the suboptimal
cheekbone and chin in the lower two-thirds of the face. Photographs
courtesy of Rebecca Fitzgerald MD.
recommend starting with younger patients with mild-to-
moderate volume changes.
Finally, as with any procedure, there is no guaran-
tee of a specific or perfect result, and serious complica-
tions such as delayed nodules, ischemia and necrosis, or
even blindness, although extremely rare, can occur. As
Skin: Layer 1
Skin appearance (including elasticity, the absence of
wrinkles, a smooth texture, and clarity and evenness of
color) is a primary indicator of age. The epidermis is a
cell-rich layer composed mainly of differentiating keratin-
ocytes and a smaller number of pigment-producing mela-
nocytes and antigen-presenting Langerhans cells. The
dermis comprises predominantly the extracellular matrix
secreted by fibroblasts. Type I collagen is the most abun-
dant protein. Other collagen types (III, V, VII), elastin,
proteoglycans, and fibronectins are present in smaller
quantities. A rich vascular plexus is an important compo-
nent of the dermis and it provides support and nutrients
to the epidermis. The thickness of the dermis relates to
its function and tends to be inversely proportionate to
its mobility. The dermis is thinnest in the eyelids and
thickest over the forehead and the nasal tip. The thinner
the dermis, the more susceptible it is to qualitative dete-
rioration aging changes [15]. The vast majority of skin
aging is photoaging from exposure to ultraviolet (UV)
light [21]. The shorter UVB rays cause a pathognomonic
lesion (thymine dimers) in the epidermal keratinocytes,
which may lead to the development of skin cancers. The
longer UVA ray exposure causes oxidative damage in the
dermis, leading to the elaboration of collagenase (matrix
metalloproteinases [MMPs]), which fragments existing
26 MASTER TECHNIQUES IN FACIAL REJUVENATION

Figure 3.15 Optical illusions are defined as something that deceives the eye by appearing to be other than it is. A change in perspective, such as
that seen in the classic 3 parked cars example pictured above, can make an object appear smaller or larger than it actually is. This type of illusion
may be seen in the face.

Figure 3.16 Older female with a “multiple tissue issue,” that is, relative parity of loss of integrity in multiple tissue structural layers is seen here
before and after nonsurgical panfacial treatment. Older faces with advanced craniofacial remodeling, fat loss, and very poor skin quality can be
treated successfully; however, fillers of any kind may not be the most cost-effective choice in a cosmetic patient who would best benefit from fat aug-
mentation and a face lift. (Reproduced with permission from Jones DH. Injectable Fillers: Principles and Practice. Wiley-Blackwell, London 2010.)
 3 Addressing Facial Shape and Proportions With Injectable Agents in Youth and Age
Figure 3.17 Note on this cropped close-up view how treatment of the areas of skeletal remodeling and fat loss in this patient affected the overall
shape, topography, and proportions of this face toward the ideal proportions pictured in Fig. 3.6. Photographs courtesy of Rebecca Fitzgerald MD.
Figure 3.18 The vast majority of skin aging is photoaging from expo-
sure to ultraviolet light, which is well illustrated in the photograph
above showing both sun-protected and sun-exposed skin in an elderly
female. Photographs courtesy of Rebecca Fitzgerald MD.
collagen [22]. Research now reveals that collagen deficit
in both photoaged and chronologically aged human skin
derives primarily from altered mechanical properties of
the fragmented collagenous extracellular matrix of the
dermis rather than from time and/or UV irradiation-
derived genetic damage to fibroblasts [23].
Intact type I collagen fibrils in the dermis provide
mechanical stability and attachment sites for fibroblasts,
which is critical for normal, balanced production of
collagen and collagen-degrading enzymes. Without this
attachment the fibroblasts collapse, and collapsed fibro-
blasts exacerbate the situation by producing more MMPs,
advancing the aging process into a self-perpetuating, del-
eterious cycle. This phenomenon is well illustrated in Fig.
3.18, showing both sun-protected and sun-exposed skin in
an elderly female. Sunscreen, antioxidants, and retinoids
help mitigate collagen loss [24]. Microneedling, peels,
and various energy devices work by inducing new col-
lagen formation. There is some evidence that hyaluronic
acid fillers may provide a “stretch effect” on fibroblasts
27
[25] and speculation on whether the collagen-stimulating
fillers or stem cells from fat augmentation may play a
similar role, leading to the skin improvement commonly
seen after these procedures.
Be aware that it is very difficult to fill an elastotic
outer skin envelope with volume augmentation of any
kind, and these patients will require surgical intervention
to both lift and fill. On the other hand, if the under­
lying craniofacial support and fat volume is good, and
the skin still has a fair amount of collagen, any procedure
that can effectively tighten skin will make an enormous
difference, as seen in the patient in Fig. 3.19 who under-
went a nonfractionated CO2 laser resurfacing procedure
as monotherapy.
Fat: Layer 2
The recent description of the superficial and deep fat
compartments of the face by Rohrich and Pessa (utiliz-
ing dye sequestration in cadaveric dissections) [26] and
radiological confirmation by Gierloff et al. (utilizing radi-
opaque dye and computed tomography [CT]) [27,28] has
provoked great interest in both the role that these com-
partments play in the layered and spatial relationships
existing in the face, as well as to what role this might
contribute to the theory of facial deflation with aging.
It should be noted that the theory of facial deflation is
not universally accepted. It has been observed that inver-
sion photographs of aging patients (either in a supine
or Trendelenburg position) demonstrate an appearance
consistent with that of photographs taken approximately
10 to 15 years prior [29]. These authors feel that aging
must, therefore, be partially gravitational: much of the
volume in the face must be retained and not lost, because
volumes drift back into position when the supine position
is assumed.
The 3D technique employed by Gierloff et al. [27,28]
allowed these compartments to be simultaneously
28 MASTER TECHNIQUES IN FACIAL REJUVENATION

A B
Figure 3.19 Older woman with minimal aging changes noted in her craniofacial skeletal support or soft tissue volume, shown (A) before and
(B) after a nonfractionated CO2 laser skin-tightening procedure. (Reproduced with permission from Obagi S. Specific techniques for fat transfer.
Clin Facial Plastic Surg 2008;16(4):401–7.)

identified and measured, as well as viewed from several

angles. This allowed the investigators to further define the
deep subcutaneous fat of the midcheek into a medial and Superior orbital fat
lateral compartment, as well as define the isolated buccal Lateral orbital fat
extension of the buccal fat pad. This finding—the discrete
nature of buccal fat lobes—is of tremendous importance Inferior orbital fat
clinically to avoid a potential complication of augmenta- Nasolabial fat
tion of deep medial cheek fat (DMCF). Although injec-
Medial orbital fat
tion of filler into the central lobe of buccal fat specifically
augments that region alone, inadvertent injection of filler Middle cheek fat
into the inferior lobe of buccal fat may lead to the cre- Lateral
ation of a more prominent jowl, and should therefore temporal-cheek fat
be avoided.
Schematics of the superficial and deep fat compart-
ments of the midface (adapted from this first radiologic
study) are shown in Fig. 3.20.
Gierloff et al. additionally concluded from their study
(albeit with a small sample size) that aging leads to an
inferior migration of the midfacial fat compartments and
an inferior volume shift within the compartments [27]. Sub-orbicularis oculi fat
They also noted that a deflation of the compartmental- Lateral part
ized buccal extension of the buccal fat aggravates the Medial part
inferior migration of the fat compartments superior to
Deep medial cheek fat
it—the medial cheek fat, middle cheek fat, and subor-
Lateral part
bicularis oculi fat (SOOF).
Medial part
Clinical observation suggests that these compartments
may age variably, both between individuals and between Ristow’s space
compartments in one individual. The reasons behind this
are not yet understood and it is thought that many factors
may play a role here, including vascular patterns or endo-
crine functions of fat. Recall that certain disease states
(such as diabetes, human immunodeficiency virus, and
progeria) have a pathognomonic distribution of fat. An Figure 3.20 Schematic of the superficial and deep fat compartments.
example of two patients aging with changes in different The superficial layer is composed of the nasolabial, the medial cheek,
fat compartments is illustrated in Fig. 3.21. The first is of the middle cheek, and the lateral temporal cheek compartments, as well
a patient with congenital lipoatrophy, who despite a lack as the three orbital compartments. The deep layer is composed of the
suborbicularis oculi fat (medial and lateral parts) and the deep medial
of superficial fat, has retained a good deal of her deep cheek fat (medial and lateral parts). A deep compartment termed Ris-
fat (in the pattern illustrated in the previous schematic) tow’s space is located posterior to the most medial aspect of the deep
and therefore has good anterior projection of her midface medial cheek fat and lateral to the pyriform aperature.
 3 Addressing Facial Shape and Proportions With Injectable Agents in Youth and Age 29

with no NLF or TT, despite an otherwise hollow and

A B
Figure 3.21 Clinical correlation of superficial and deep midfacial
facial fat compartments. In the face pictured in (A), deep midfacial fat
is visible clinically. There is no visible undereye hollowing or nasolabial
fold, and there is a convex contour to her midface. However, due to a
congenital lipodystrophy, there is a striking lack of superficial fat. This is
most obvious in her lateral temporal cheek compartment and her upper
periorbital area; however, on closer observation the lack of superficial
fat in her midface is causing a good deal of shadowing in her lower
lateral cheeks. Compare this face with ample deep midfacial fat, and an
extreme lack of superficial fat to the face (B). This endurance exercise
patient has a normal amount of superficial fat, without shadowing in
her temples and lateral cheeks, but appears to have lost a good deal of
fat in her deep midfacial compartments, leading to a lack of midfacial
projection and a very visible lid-cheek junction. Photographs courtesy
of Rebecca Fitzgerald MD.
skeletonized appearance. This can be treated using the
superficial fat compartments as a guide to placement. In
the next example, we see an endurance exercise patient
who does not have the skeletonized appearance the pre-
vious patient has in her temples and lateral cheek, but
instead has lost a good deal of deep midfacial fat, leading
to a lack of anterior projection in the midface, with a
visible TT and NLF. Her TT is not really the problem—
the problem is that it has been revealed because she no
longer has midfacial projection. This can be resolved with
the use of filler in the area of the deep midfacial compart-
ments. Likewise, the NLF is a secondary phenomenon
that will soften as the midfacial fat is filled.
Rohrich and colleagues have defined many superficial
and deep fat compartments of the face and described and
demonstrated their clinical importance [30–35]. They
observed that superficial adipose tissue is compartmental-
ized by vascularized membranes arising from superficial
fascia, but deep fat is compartmentalized by nonvascular-
ized fascial boundaries that most likely represent fusion
zones of various fascias.
The superficial compartments of the midface are
shown in the cadaveric dissection with dye sequestration
from the original study in Fig. 3.22. The preauricular
compartments are shown in the schematic superimposed
on a cadaveric specimen in Fig. 3.23. These superficial
fat compartments offer a roadmap for achieving spe-
cific results using site-specific techniques. This is illus-
trated with a few clinical examples accompanying a

ORL
SCS
ORL

SOOF

ZM

A B C D
Nasalabial Medial cheek Middle cheek Temporal & lateral cheek
Figure 3.22 Superficial fat compartments. Rohrich and Pessa have performed multiple cadaver studies supporting the concept that subcutaneous
fat is compartmentalized, specifically by fascial extensions that travel from superficial fascia to dermis. These fascial extensions form a framework
that provides a “retaining system” for the human face. Implicit in this concept is the suggestion that the face ages three dimensionally, with sepa-
rate compartments changing relative to one another by both position and volume. (A) The nasolabial fat compartment is the most medial of the
major cheek compartments. Blue dye has stained this region. The ORL is the superior boundary (black arrow). Additional black arrows point
to the SOOF and the ZM muscle. (B) The medial cheek fat compartment lies adjacent to the nasolabial fat. The superior boundary is again the
ORL. The red area designates a zone of fixation where this fat compartment intersects with the inferior orbital fat compartment. (C) The middle
cheek fat compartment is found anterior and superficial to the parotid gland. This compartment is lateral to the medial fat compartment, medial
to the lateral temporal cheek fat, and inferior to the SCS. The red arrow designates a zone of fixation between adjacent compartments. The lateral
temporal cheek compartment is the most lateral compartment of cheek fat and connects the temporal fat to the cervical subcutaneous fat (D). The
STS and ITS represent the superior boundaries, and it has an identifiable septal barrier medially called the LCS. ITS, Inferior temporal septa; LCS,
lateral cheek septum; ORL, orbicularis retaining ligament; SCS, superior cheek septum; SOOF, suborbicularis oculi fat; STS, superior temporal
septa; ZM, zygomaticus major (Reproduced with permission from Rohrich RJ, Pessa JE. The fat compartments of the face: anatomy and clinical
implications for cosmetic surgery. Plast Reconstr Surg 2007;119:2219–27 [discussion: 2228–31].)
Another random document with
no related content on Scribd:
Milly's face crimsoned. "Not till I'm grown up," she exclaimed eagerly. "I can't leave Emily
for a good while yet."

"I suppose the Hindoos are not very neat."

"Oh, no! I never thought about it till I came here; but the bungalows are awfully dirty. The
people have to bathe in the water tanks made for them. That is one of their laws; but they
are filthy after all."

"That is true," said grandma, "of all people who do not have the Bible to guide them. One
of the first changes which the poor heathen make when they learn about God our heavenly
Father, and his Son our Saviour, is cleanliness."

Milly started up and clasped her hands, her eyes shining like stars.

"I know it I know it! One of our women went to the sahibs, that means missionaries, and
learned to read the Bible. Everybody said she was better than before. She always wore
such clean sarrees, that's the kind of dress Hindoo women have. I used to wear them, too.
And she kept her hair smooth. I never thought though about its being the Bible that made
her so much nicer."

"Yes, Milly, that is always the effect of true godliness."

CHAPTER VIII.
THE MISSIONARIES.

"SHALL I tell you a story about an Indian girl, who lived this side of the Rocky Mountains?"

"Is that near Calcutta, ma'am?"

"No, it is our own country. She belonged to a tribe called Cherokees, and her name was
Iwassee."

"Until some good missionaries went to her tribe to tell them about the great God who
made the sun and moon, the boundless forests and the swift running rivers, Iwassee knew
nothing what would become of her soul when her body was tied up in a tree for the birds
to pick the flesh from the bones. She lived in a kind of tent without glass, with a hole in
the top to let out the smoke when they kindled a fire on the heap of stones inside."

"Her parents had no money; but her father used to go out to the forest with his bow and
arrows, and bring home some wild fowl or a deer on his back. Her dresses, when it was
cold enough for her to wear dresses, were made from the bark of trees. On her feet, she
wore moccasins of deer skin. In the winter, her mother worked moccasins with wampum or
bead-work, to be sold to visitors."

"Iwassee, as she grew older, helped her mother to tan the skins of the bears, wolves and
deer, which her father killed. These skins were their beds and seats. They were thrown on
the floor or ground inside the tent. Iwassee herself, her father, mother and all her tribe
were savages. They lived from day to day only to eat, sleep and carouse. They knew
nothing of the pleasures which Christians enjoy. They quarrelled, stole from each other,
told lies to cover their guilt, and broke every one of God's commands. They were filthy,
too, filthy in their own persons, in their dress, in their food, and in their tents. They
thought it quite too much trouble to wash their clothes often, or to keep their tents in
order."

"Their arrows were hung in a quiver near their bows, on a peg in their tents. The kettle
they cooked their venison in, was hung there too, unwashed from month to month. They
would have thought it very foolish to sweep out the floor of the tents, about which the
vermin were running, or to have washed and cleansed their own bodies. They much
preferred, when their work was done, to lounge on the grass in the sun and think of
nothing."

"Poor Iwassee lived year after year in this way, until the missionaries, I spoke of, went to
the tribe. It was a terrible trial for the wife, who had been brought up so delicately, to
settle down in the midst of such pollution. Even the touch of the filthy women and girls,
whose soiled garments were alive with vermin, was dreadful. Nothing but their love to
Jesus Christ, and their desire to tell these poor heathen about him could have induced this
intelligent Christian lady to remain there a day."

"But this love was so strong, they were glad to obey his command to preach the gospel of
salvation to every creature. The missionary put up his tent in the wilderness, and then
called the people together to talk to them in their own language about God. Iwassee was
one of the first who went to hear the talk. When she learned of the love of Jesus Christ for
poor sinners, tears of joy ran down her swarthy cheeks. Her heart began to swell with love
and gratitude to him. She could not leave the spot. She went to the missionaries' tent
early and late to beg them to tell her more; and when Mrs. Johnson assured her that
Christ was waiting to be her friend, she threw herself on the ground in a transport of joy.
She was the first of the tribe who accepted Jesus as her Saviour; but she was not the last;
for the labors of the good missionaries were greatly blessed."

"When Iwassee had once felt her need of pardon and had found her Saviour, she did not
stop there. She saw how comfortably the tent of the Christians looked; what a contrast to
the filth and confusion in her father's. She told the Missionary's wife her trouble, and the
lady encouraged her to strive after cleanliness, as one of the first of Christian virtues. She
opened the book which contains God's word and read: 'Wo to her that is filthy!' She told
her that everywhere in the Bible, sin and uncleanliness are named together, while order
and cleanliness follow holiness."

"Iwassee listened and remembered. The next time she went to the Missionaries' tent, she
looked so different, that the lady scarcely knew her. She had always been in the habit, like
other women of her tribe, of oiling her face with bear's or other grease, and staining her
nails. Now she had bathed in the stream which ran through the settlement, and in the best
manner she could, had made herself tidy."

"This was very cheering to Mrs. Johnson. She took courage to talk with other women of the
tribe. In two or three years, there was a wonderful change. Many of the men and women
had become earnest Christians, and took the Bible for their guide. It was of course very
hard for them to give up their old habits; but when they found that God requires it, when
Mrs. Johnson read to them such passages as these: 'Then will I sprinkle clean water upon
you, and ye shall be clean; from all your filthiness and all your idols will I cleanse you;'
they did make great efforts to be clean. If any stranger visited the tribe, and walked along
by the tents, it was not necessary to tell him:"
"'Here lives a man who has become a Christian.' He could see that for himself. Everything
about the small home looked thriving and attractive. The tents were better too. Sometimes
a log hut had been made, set in a small garden. Sometimes too, there were bright-colored
blossoms before the doors. When the people assembled on the Sabbath either under a tree
or a large tent, Mr. and Mrs. Johnson no longer shrank from their touch. They were clean
and dressed according to their fashion, in neat garments."

CHAPTER IX.
ORDER FROM CONFUSION.

"So you are at your old business of telling stories, grandma," exclaimed Mr. Morgan.

Milly caught the old lady's hand, kissed it, and ran from the room.

After half an hour, her aunt found her in a grand hurly burly of clearing up. Her cheeks
were brilliant with excitement as she cried out:

"Oh, Aunt Priscilla! I'm going to make my room look as nice as Emily's. I never knew
before that only the heathen were so disorderly. That's the reason Emily is so neat, and
has her drawers all fixed up, because she is so very good a Christian."

"But, Milly, it will take a day at least to restore your clothes to their places. Why did you
not arrange one drawer, or one shelf at a time?"

"Because," answered Milly, her eyes sparkling, "I wanted to do it quick. Do you think when
I'm done, Emily's grandma will look at it?"

"Yes, indeed, it was her story, then, that suggested such a grand overturn?"

"Yes, aunty; and I'm going to try real hard to keep my things in order."

"That's right, dear. Did grandma repeat to you this verse? 'Let all things be done decently
and in order?'"

"I didn't hear it. I wish the Hindoos knew about the Bible. They're awful; but I didn't think
about its being bad, till I came here. When I go back, I shall tell them what God says."

"Milly, Milly, where are you?"

It was Emily's voice in the hall. Naturally amiable and affectionate, she had become greatly
attached to her cousin, whose ardent, impulsive nature, and stronger traits harmonized
well with her gentler ones.

Mrs. Morgan with a glance of dismay around the chamber into which one could scarcely
find a standing place, was just returning to the parlor, when she stopped to see what Emily
would say to all this confusion.

"Why, Milly Lewis! What are you doing?" exclaimed the little girl, holding up her hands in
surprise.
"I'm fixing my room up," answered Milly, coloring at Emily's tone.

"Don't you want me to help you? But I forgot, Papa's going to take us to ride, I came to
call you."

"Oh, dear! What shall I do? I'm sorry I began to be neat to-day."

"Come and ride," suggested Emily, "then I'll help you put away your things."

"Well, I will."

"You must make yourself look nicely, you know," urged Emily, archly. "Where's your
brush?"

"I don't believe anything is anywhere," was the mournful reply. "I laid my sack down; but I
can't find it, nor my hat either."

"Emily! Milly! Come, now, if you're going with me," called papa from below.

Milly flew about throwing the clothes with which the chairs were covered upon the floor.

"Oh, that is not the way to find anything! Where did you see your sack last?"

"Milly," said her aunt, coming to her aid, "I will give you your choice to go to ride and leave
your room in this confusion, or to stay at home and take a lesson from me in order."

"I want to go with Emily," began the child. Then with a face full of resolution, she added:

"No, Aunt Priscilla, I'll stay at home."

"That's a dear child," said her aunt, kissing her. "Now run and carry this shawl to grandma
to tuck around her, and then we'll go to work in earnest."

"Now," added the lady, when Milly returned, "We will make a beginning by hanging all the
dresses in the closet. After this, remember that it is not a good way to turn closets and
drawers inside out. Take one thing at a time; or what is better yet, keep everything in
place so that there is no need of such an overturn."

"I must put all the skirts in the closets, too," exclaimed Milly. "Oh, here's my lost sack!
Where shall I hang that?"

"Fix upon one hook and always hang it there. Then you will not be in danger of losing a
drive, because you can't find it."

"I'll keep it on this one, because it's low, and my thick sack can go on the next hook."

"Here are two shelves, Milly. I would take the upper one for my school hat, and the lower
for shoes. There, the closet begins to look in order. Run to Hannah for her hand brush and
pan. The bits of paper must be swept up."

CHAPTER X.
 MILLY'S CHAMBER.

"OH, Aunt Priscilla! You're so kind to help me. Doesn't it look beautifully? What shall we do
next?"

Mrs. Morgan paused and looked around her. They had made a beginning; but it was only a
beginning. Every article was taken from the drawers; the books from the rack were
tumbled over the floor.

"Why did you take down the books, my dear?" she asked mildly.

"I saw Emily dusting hers this morning, so I—"

"But you did not see her throw down the volumes in this way. You should take down two or
three at a time, dust them and then put them back. You'll remember after this."

"Yes, indeed, Aunty."

"Perhaps we had better do the drawers first; and then we can have space to walk around.
But what is this? Crumbs?"

"I put my cake there, the day my head ached; and then I forgot it."

"Oh, what a pity! See how it has soiled this pretty ribbon. I wouldn't bring cake up stairs.
Hannah will take care of any such thing for you."

"I won't do it again. I'm going to be real good. Do you think, Aunt Priscilla, that I can be as
good us Emily?"

"In what particular do you mean?"

"Why, as good a Christian. If I was, I'd be neat and kind as she is, of course."

"I hope, Milly, that you already love the Saviour. You know he came to wash and cleanse
us from all sin. If you pray to him to help you conquer all your bad habits, he will do it. He
always helps those who try to obey his commands; and you are trying now to do all things
'decently and in order.' You must remember that Emily has been taught to be neat from
her babyhood."

"And I had nobody to tell me about anything good," exclaimed the child, with a burst of
feeling.

"God our Father knows all that. He never expects from us more than we can do. While you
were ignorant of the duty of cleanliness and order, he was not displeased with you for
being untidy."

"But now he will be. But what if I forget?"

"No doubt you will occasionally; but every day your habit of neatness will be strengthening
until it will never occur to you to throw your hat on one chair, your sack on the hall table,
and your books somewhere else. You will hang your sack on this hook, put your hat on the
shelf, and your books in the place I gave you for them."

"Oh, aunty! There's the door-bell. I do hope nobody will call to see you; but I could go on
by myself now; at any rate I'd 'try, try again,' as the verse says."
"Mrs. Lang to see you, ma'am," said Hannah, opening the door.

Mrs. Morgan looked as though she was sorry; but Milly insisted that she could do the rest.

"Finish one drawer at a time then," said her aunt. "Find all the articles that go in it, and
then take another."

"I'll sweep up your room for you," said Hannah, kindly. "There'll be a good many scraps
about."

"Thank you, Hannah," and Milly began to sing at the top of her voice one of her favorite
songs:

"Flowers, wild wood flowers."

At length, the upper drawer is in order. The child stands and gazes into it with pride.

"It looks just like Emily's," she murmurs. "Now, if I can only keep it so; but it is so hard
when I am in a hurry, to stop and put back the things. I'll lock it till Emily comes. I'll ask
her to bring grandma in here. Oh, what a nice grandma she is! What good stories she tells.
Oh, here is the Chinese puzzle, Uncle George gave me!"

On the floor, she drops to put together the pieces of the game. Five, ten, fifteen minutes
fly quickly away; but she is so absorbed in making squares and oblongs and
parallelograms out of the smooth, ivory pieces, that she knows nothing about the time.

"Are you ready for me?" asks Hannah, coming in with a broom and dust pan. "Why, Milly,
what are you doing?"

"I'm sorry, Hannah." The child's tone was humble, and her countenance expressed such
real regret that the girl could not scold, as at first she felt inclined to do.

"I've done one drawer, and it looks real nice; but then I found my puzzle, and I forgot. I'll
fix the rest just as quick as I can."

"Well," said Hannah, "you ought not to have stopped to play till your work was done; but it
can't be helped now. You just bring me all the under clothes, and I'll fold them for you.
Seems to me I wouldn't toss everything about so again."

"No, I never shall. I'm beginning to be neat, now. Grandma has been telling us a story
about it. You know the Hindoos and the Indians, and everybody who don't have the Bible,
are filthy. The Bible says so," she added, earnestly, seeing Hannah smile. "And just as soon
as they begin to be good, they clean their houses and wash themselves, and make their
hair smooth. I knew a girl who did so in Calcutta. Her name was Waroo. She used to
worship an idol. It was a little brass thing. She kept it hung on the wall. After she learned
of the missionaries about God, she threw away her idol; and then she began to look real
nice. Her sarree was clean; and her face washed. Papa asked her what had come over her,
and she said 'I'm trying to be like the missionaries and worship their God.'"
 CHAPTER XI.
A DRIVE TO THE BEACH.

By the time Mr. Morgan, grandma, Cousin Mary and Emily, returned from their drive, Milly's
room looked as neat as possible. Hannah seemed almost as pleased as Milly; and when the
little girl, in an ecstasy of delight kissed her thanks, she said, encouragingly:

"It's a picture to see. If I were you, I'd keep it just so."

To complete her pleasure, grandma and Mrs. Roby came in, on their way to their own
chambers, and praised the little girl for her own self-denial in staying to arrange her room
rather than to go out for a drive.

Every drawer and shelf were opened for inspection, and received great praise.

The next morning, at the breakfast table, Mr. Morgan, after a roguish glance at Milly, said:

"This afternoon, I propose to take you all to the seashore. We must have dinner at twelve,
so that we may have time enough for a ramble on the beach."

"Can we all go in one carriage?" asked mamma.

"I will provide seats enough," Uncle George answered, adding in a mysterious tone, "If
there are any persons here who have been housecleaning of late, those persons are
especially invited."

"I know who you mean, papa," said Emily, laughing. "You mean Milly."

"I mean any little girl who is trying hard to correct her faults."

Milly's face crimsoned with pleasure, while her poor little heart fluttered and beat fast with
love to everybody.

"It's a beautiful world to live in," she said to herself, running to bring her uncle's daily
paper from the door, "and God is just as good to me as he can be."

During the forenoon, Mrs. Ward, a relative of Mrs. Morgan, called to see grandma, who
was a kind of aunt to her.

"We have been anticipating a visit to the beach for a long time," she said, when she heard
of the contemplated drive. "I'll go directly to my husband's office, and ask him to go this
afternoon. Why can't we have a fish chowder on the beach?"

"We can. I'll go at once, and tell cook to pack whatever will be necessary."

"I'll carry a hamper of crackers, cake and coffee, with milk for the children. Ernest will be
crazy with delight, when I tell him. We'll meet at Ruggles street, where we turn off for the
beach. Whoever gets there first will wait for the other. By the way, I'll send over directly, if
William can't go; but I hope he can. Good-by, till afternoon."

Everything turned out in the most satisfactory manner. Mr. Ward declared himself delighted
with the project, said it was just the day for the shore and for chowder. The hampers were
packed, not forgetting a great iron pot and the potato-cutter. On reaching Ruggles street,
Mr. Morgan saw Mr. Ward looking out of a carriage which contained his wife, his sister, and
his three children.

Mr. Ward called out as he turned his horses out of the street, "We've only been here five
minutes. All right. Drive on."

When, after a delightful ride, the party came in sight of the ocean, with the foamy billows,
rolling up, and breaking on the sand, Milly could not restrain her delight. She laughed and
clapped her hands exclaiming:

"I love you, good old ocean!"

Emily, who was much less enthusiastic, gazed at her cousin with some surprise, asking, at
last:

"Why do you love it, Milly?"

"Because it's so blue and so beautiful. Oh you don't know at all by seeing it now, how the
water looks at sea! The waves are as high as mountains, and instead of looking quiet and
blue like this, it is dark green. The ship goes up and down this way. You couldn't help
loving the sea, if you had sailed on it as long as I have."

"Uncle George," whispered the happy child, catching him by the coat as he was helping her
out last of all, "I've got a basket for mosses. Please, don't tell anybody when you see me
picking them."

CHAPTER XII.
MILLY'S ESCAPE.

THE person to be thought of first of all was grandma, who was an old lady, and not very
strong. Mrs. Morgan proposed that she should have a room in the public house close by
the beach, and lie down while the gentlemen caught fish, and others made ready for the
famous chowder. But she said the salt air strengthened her; and she wished to breathe all
she could of it.

So, instead of having the horses taken out at the stable, Uncle George drove down to a
great rock close by the high water mark, and then had the hostler unharness and lead the
horses back.

Mr. Ward thought this a capital idea, and did the same. Then, with the cushions of both
carriages, they made a most comfortable lounge on the back seat, where grandma could
lie and watch everything that was going on.

Mr. Morgan and Mr. Ward then took their fish tackle, and started off for the rocks to catch
rock perch, while the ladies unpacked the baskets, and the children gathered stones into a
heap to set the kettle on, and plenty of sticks for the fire.
All were amused to watch Milly, running here and there in search of a stone of the right
size, then tugging it toward the pile, her eyes shining, her checks rosy, her hat off, and her
hair streaming behind her.

At last, the small chimney, as Ernest called it, was built. And Milly took her basket and
wandered off in search of bright mosses; leaving Emily and Ernest to gather sticks to make
the pot boil.

The other children being too young to run round by themselves, played around the
carriages, or gathered stones and shells within their reach. Emily and Ernest wandered
here and there till they were almost out of sight of the great rock near which the carriages
stood. They had each gathered an armful of broken pieces and were about to return with
them for the fire, when Ernest threw his down and kneeled upon the sand, calling out to
Emily to come and see what he had found.

There, on the smooth, silvery beach, lay a large, round, slippery-looking creature, basking
itself in the sun. Earnest did not know what it was; but by the description, his father
afterwards told him, it was called a jelly fish. It was a disgusting creature; but the boy
didn't care for that. He took one of his sticks, and punched it; and then, as it did not stir,
he told Emily it was dead. When they had examined it as long as they wished, and Emily
had filled her pocket with smooth, bright stones, Ernest picked up his sticks again, and
they went back to the rock.

"Where is Milly?" inquired Mrs. Morgan.

"He took one of his sticks, and punched it."

"I thought she would be back here by this time," answered Emily. "She did not go with us."

"Which way did she go?"

"Round the other side of the rock."

The lady looked very anxious. "I'm afraid she will be lost," she said. "Some of us must go
and look for her."

Cousin Mary Roby, and also Mrs. Ward's sister Jennette, at once volunteered to make the
search. So taking the sun umbrellas, they started off in the direction Emily had seen her
cousin go.

But neither in this, nor in any other direction, could they find her. They inquired of children
coming and going, if they had seen a little girl with a basket; but no one had noticed her.
At last, they were obliged to return without any intelligence of the wanderer.

"What shall we do?" exclaimed her aunt, in real distress. "It was very wrong of her to go
out of sight."

"Oh, mamma! Don't say so," urged Emily. "I'm sure she didn't mean to do wrong."

"Did you call her name, Mary?"

"We tried to; but the roaring of the water quite drowned our feeble voices."

"I must go at once," said Mrs. Morgan, taking a broad rimmed hat from the carriage. "I do
wish George would come."

Just at this moment, there was a loud shout from behind the rock.

"Emily! Emily!"

"Oh, that's Milly!" screamed her cousin. "I'm so very glad."

"So am I," added her mother. "I was really alarmed."

"Why, what have you been doing!" exclaimed Emily, as she caught sight of her cousin
whose clothes were dripping with wet; but whose face was beaming with delight.

"I was almost drowned," said Milly calmly. "But I've got some beauties. Look here!"

She held up her basket, lifting two or three bright red pieces of moss.

"But, Milly, you'll take cold with those wet clothes. Come right to mamma."

"Well, I will, if you'll put this under Uncle George's seat. Don't let any body see you. I'll
show them to you when we get home."

Poor Milly was indeed a sight to behold. She had lost the ribbon that tied back her hair.
And by constantly putting up her wet hands to push the locks from her face, she had
covered her forehead with sand; her boots were saturated with water, and her skirts
dripped with wet. Nobody seemed to know what to do with her, till grandma proposed to
take off her wet garments, wrap her in a shawl, and let her stay in the carriage till her
clothes dried, which they would in a few minutes, if hung in the hot sun.

Lying on the seat beside grandma, with the roaring of the billows to lull her, Milly's tender
heart was at rest.

She told the old lady that she jumped on a rock to look at the waves, and staid there so
long that the water came up all around her. At first, she thought it would go away again;
but it came up higher and higher, until it covered her feet on the rock.
"How did you feel?" asked grandma, greatly moved. "Were you afraid?"

"I was at first, but not after I asked God to take care of me. He knows I've been trying to
be good. Then I thought of Emily; and I felt awful bad when I said 'I shall never see her
again.' So I shut my eyes, and jumped right into the water, and a great wave came and
pushed me right up on the beach. Wasn't God real good to answer my prayer so quick? It
makes me love him dearly, dearly."

"He was indeed, my dear child, I hope you will never forget it."

"No, ma'am, I never shall. When I go back to India, I shall tell my father. I know he'll be
glad, too. I mean to go as soon as I can, so as to tell the poor Hindoos about God. When
they know how to read the Bible they'll learn to be neat, you know."
 *** END OF THE PROJECT GUTENBERG EBOOK GEM OF
NEATNESS ***

Updated editions will replace the previous one—the old editions will
be renamed.

Creating the works from print editions not protected by U.S.

copyright law means that no one owns a United States copyright in
these works, so the Foundation (and you!) can copy and distribute it
in the United States without permission and without paying copyright
royalties. Special rules, set forth in the General Terms of Use part of
this license, apply to copying and distributing Project Gutenberg™
electronic works to protect the PROJECT GUTENBERG™ concept
and trademark. Project Gutenberg is a registered trademark, and
may not be used if you charge for an eBook, except by following the
terms of the trademark license, including paying royalties for use of
the Project Gutenberg trademark. If you do not charge anything for
copies of this eBook, complying with the trademark license is very
easy. You may use this eBook for nearly any purpose such as
creation of derivative works, reports, performances and research.
Project Gutenberg eBooks may be modified and printed and given
away—you may do practically ANYTHING in the United States with
eBooks not protected by U.S. copyright law. Redistribution is subject
to the trademark license, especially commercial redistribution.

START: FULL LICENSE

THE FULL PROJECT GUTENBERG LICENSE
 PLEASE READ THIS BEFORE YOU DISTRIBUTE OR USE THIS WORK

To protect the Project Gutenberg™ mission of promoting the free

distribution of electronic works, by using or distributing this work (or
any other work associated in any way with the phrase “Project
Gutenberg”), you agree to comply with all the terms of the Full
Project Gutenberg™ License available with this file or online at
www.gutenberg.org/license.

Section 1. General Terms of Use and

Redistributing Project Gutenberg™
electronic works
1.A. By reading or using any part of this Project Gutenberg™
electronic work, you indicate that you have read, understand, agree
to and accept all the terms of this license and intellectual property
(trademark/copyright) agreement. If you do not agree to abide by all
the terms of this agreement, you must cease using and return or
destroy all copies of Project Gutenberg™ electronic works in your
possession. If you paid a fee for obtaining a copy of or access to a
Project Gutenberg™ electronic work and you do not agree to be
bound by the terms of this agreement, you may obtain a refund from
the person or entity to whom you paid the fee as set forth in
paragraph 1.E.8.

1.B. “Project Gutenberg” is a registered trademark. It may only be

used on or associated in any way with an electronic work by people
who agree to be bound by the terms of this agreement. There are a
few things that you can do with most Project Gutenberg™ electronic
works even without complying with the full terms of this agreement.
See paragraph 1.C below. There are a lot of things you can do with
Project Gutenberg™ electronic works if you follow the terms of this
agreement and help preserve free future access to Project
Gutenberg™ electronic works. See paragraph 1.E below.
1.C. The Project Gutenberg Literary Archive Foundation (“the
Foundation” or PGLAF), owns a compilation copyright in the
collection of Project Gutenberg™ electronic works. Nearly all the
individual works in the collection are in the public domain in the
United States. If an individual work is unprotected by copyright law in
the United States and you are located in the United States, we do
not claim a right to prevent you from copying, distributing,
performing, displaying or creating derivative works based on the
work as long as all references to Project Gutenberg are removed. Of
course, we hope that you will support the Project Gutenberg™
mission of promoting free access to electronic works by freely
sharing Project Gutenberg™ works in compliance with the terms of
this agreement for keeping the Project Gutenberg™ name
associated with the work. You can easily comply with the terms of
this agreement by keeping this work in the same format with its
attached full Project Gutenberg™ License when you share it without
charge with others.

1.D. The copyright laws of the place where you are located also
govern what you can do with this work. Copyright laws in most
countries are in a constant state of change. If you are outside the
United States, check the laws of your country in addition to the terms
of this agreement before downloading, copying, displaying,
performing, distributing or creating derivative works based on this
work or any other Project Gutenberg™ work. The Foundation makes
no representations concerning the copyright status of any work in
any country other than the United States.

1.E. Unless you have removed all references to Project Gutenberg:

1.E.1. The following sentence, with active links to, or other

immediate access to, the full Project Gutenberg™ License must
appear prominently whenever any copy of a Project Gutenberg™
work (any work on which the phrase “Project Gutenberg” appears, or
with which the phrase “Project Gutenberg” is associated) is
accessed, displayed, performed, viewed, copied or distributed:
 This eBook is for the use of anyone anywhere in the United
States and most other parts of the world at no cost and with
almost no restrictions whatsoever. You may copy it, give it away
or re-use it under the terms of the Project Gutenberg License
included with this eBook or online at www.gutenberg.org. If you
are not located in the United States, you will have to check the
laws of the country where you are located before using this
eBook.

1.E.2. If an individual Project Gutenberg™ electronic work is derived

from texts not protected by U.S. copyright law (does not contain a
notice indicating that it is posted with permission of the copyright
holder), the work can be copied and distributed to anyone in the
United States without paying any fees or charges. If you are
redistributing or providing access to a work with the phrase “Project
Gutenberg” associated with or appearing on the work, you must
comply either with the requirements of paragraphs 1.E.1 through
1.E.7 or obtain permission for the use of the work and the Project
Gutenberg™ trademark as set forth in paragraphs 1.E.8 or 1.E.9.

1.E.3. If an individual Project Gutenberg™ electronic work is posted

with the permission of the copyright holder, your use and distribution
must comply with both paragraphs 1.E.1 through 1.E.7 and any
additional terms imposed by the copyright holder. Additional terms
will be linked to the Project Gutenberg™ License for all works posted
with the permission of the copyright holder found at the beginning of
this work.

1.E.4. Do not unlink or detach or remove the full Project

Gutenberg™ License terms from this work, or any files containing a
part of this work or any other work associated with Project
Gutenberg™.

1.E.5. Do not copy, display, perform, distribute or redistribute this

electronic work, or any part of this electronic work, without
prominently displaying the sentence set forth in paragraph 1.E.1 with
active links or immediate access to the full terms of the Project
Gutenberg™ License.
1.E.6. You may convert to and distribute this work in any binary,
compressed, marked up, nonproprietary or proprietary form,
including any word processing or hypertext form. However, if you
provide access to or distribute copies of a Project Gutenberg™ work
in a format other than “Plain Vanilla ASCII” or other format used in
the official version posted on the official Project Gutenberg™ website
(www.gutenberg.org), you must, at no additional cost, fee or expense
to the user, provide a copy, a means of exporting a copy, or a means
of obtaining a copy upon request, of the work in its original “Plain
Vanilla ASCII” or other form. Any alternate format must include the
full Project Gutenberg™ License as specified in paragraph 1.E.1.

1.E.7. Do not charge a fee for access to, viewing, displaying,

performing, copying or distributing any Project Gutenberg™ works
unless you comply with paragraph 1.E.8 or 1.E.9.

1.E.8. You may charge a reasonable fee for copies of or providing

access to or distributing Project Gutenberg™ electronic works
provided that:

• You pay a royalty fee of 20% of the gross profits you derive from
the use of Project Gutenberg™ works calculated using the
method you already use to calculate your applicable taxes. The
fee is owed to the owner of the Project Gutenberg™ trademark,
but he has agreed to donate royalties under this paragraph to
the Project Gutenberg Literary Archive Foundation. Royalty
payments must be paid within 60 days following each date on
which you prepare (or are legally required to prepare) your
periodic tax returns. Royalty payments should be clearly marked
as such and sent to the Project Gutenberg Literary Archive
Foundation at the address specified in Section 4, “Information
about donations to the Project Gutenberg Literary Archive
Foundation.”

• You provide a full refund of any money paid by a user who

notifies you in writing (or by e-mail) within 30 days of receipt that
s/he does not agree to the terms of the full Project Gutenberg™
License. You must require such a user to return or destroy all
 copies of the works possessed in a physical medium and
discontinue all use of and all access to other copies of Project
Gutenberg™ works.

• You provide, in accordance with paragraph 1.F.3, a full refund of

any money paid for a work or a replacement copy, if a defect in
the electronic work is discovered and reported to you within 90
days of receipt of the work.

• You comply with all other terms of this agreement for free
distribution of Project Gutenberg™ works.

1.E.9. If you wish to charge a fee or distribute a Project Gutenberg™

electronic work or group of works on different terms than are set
forth in this agreement, you must obtain permission in writing from
the Project Gutenberg Literary Archive Foundation, the manager of
the Project Gutenberg™ trademark. Contact the Foundation as set
forth in Section 3 below.

1.F.

1.F.1. Project Gutenberg volunteers and employees expend

considerable effort to identify, do copyright research on, transcribe
and proofread works not protected by U.S. copyright law in creating
the Project Gutenberg™ collection. Despite these efforts, Project
Gutenberg™ electronic works, and the medium on which they may
be stored, may contain “Defects,” such as, but not limited to,
incomplete, inaccurate or corrupt data, transcription errors, a
copyright or other intellectual property infringement, a defective or
damaged disk or other medium, a computer virus, or computer
codes that damage or cannot be read by your equipment.

1.F.2. LIMITED WARRANTY, DISCLAIMER OF DAMAGES - Except

for the “Right of Replacement or Refund” described in paragraph
1.F.3, the Project Gutenberg Literary Archive Foundation, the owner
of the Project Gutenberg™ trademark, and any other party
distributing a Project Gutenberg™ electronic work under this
agreement, disclaim all liability to you for damages, costs and
expenses, including legal fees. YOU AGREE THAT YOU HAVE NO
REMEDIES FOR NEGLIGENCE, STRICT LIABILITY, BREACH OF
WARRANTY OR BREACH OF CONTRACT EXCEPT THOSE
PROVIDED IN PARAGRAPH 1.F.3. YOU AGREE THAT THE
FOUNDATION, THE TRADEMARK OWNER, AND ANY
DISTRIBUTOR UNDER THIS AGREEMENT WILL NOT BE LIABLE
TO YOU FOR ACTUAL, DIRECT, INDIRECT, CONSEQUENTIAL,
PUNITIVE OR INCIDENTAL DAMAGES EVEN IF YOU GIVE
NOTICE OF THE POSSIBILITY OF SUCH DAMAGE.

1.F.3. LIMITED RIGHT OF REPLACEMENT OR REFUND - If you

discover a defect in this electronic work within 90 days of receiving it,
you can receive a refund of the money (if any) you paid for it by
sending a written explanation to the person you received the work
from. If you received the work on a physical medium, you must
return the medium with your written explanation. The person or entity
that provided you with the defective work may elect to provide a
replacement copy in lieu of a refund. If you received the work
electronically, the person or entity providing it to you may choose to
give you a second opportunity to receive the work electronically in
lieu of a refund. If the second copy is also defective, you may
demand a refund in writing without further opportunities to fix the
problem.

1.F.4. Except for the limited right of replacement or refund set forth in
paragraph 1.F.3, this work is provided to you ‘AS-IS’, WITH NO
OTHER WARRANTIES OF ANY KIND, EXPRESS OR IMPLIED,
INCLUDING BUT NOT LIMITED TO WARRANTIES OF
MERCHANTABILITY OR FITNESS FOR ANY PURPOSE.

1.F.5. Some states do not allow disclaimers of certain implied

warranties or the exclusion or limitation of certain types of damages.
If any disclaimer or limitation set forth in this agreement violates the
law of the state applicable to this agreement, the agreement shall be
interpreted to make the maximum disclaimer or limitation permitted
by the applicable state law. The invalidity or unenforceability of any
provision of this agreement shall not void the remaining provisions.
1.F.6. INDEMNITY - You agree to indemnify and hold the
Foundation, the trademark owner, any agent or employee of the
Foundation, anyone providing copies of Project Gutenberg™
electronic works in accordance with this agreement, and any
volunteers associated with the production, promotion and distribution
of Project Gutenberg™ electronic works, harmless from all liability,
costs and expenses, including legal fees, that arise directly or
indirectly from any of the following which you do or cause to occur:
(a) distribution of this or any Project Gutenberg™ work, (b)
alteration, modification, or additions or deletions to any Project
Gutenberg™ work, and (c) any Defect you cause.

Section 2. Information about the Mission of

Project Gutenberg™
Project Gutenberg™ is synonymous with the free distribution of
electronic works in formats readable by the widest variety of
computers including obsolete, old, middle-aged and new computers.
It exists because of the efforts of hundreds of volunteers and
donations from people in all walks of life.

Volunteers and financial support to provide volunteers with the

assistance they need are critical to reaching Project Gutenberg™’s
goals and ensuring that the Project Gutenberg™ collection will
remain freely available for generations to come. In 2001, the Project
Gutenberg Literary Archive Foundation was created to provide a
secure and permanent future for Project Gutenberg™ and future
generations. To learn more about the Project Gutenberg Literary
Archive Foundation and how your efforts and donations can help,
see Sections 3 and 4 and the Foundation information page at
www.gutenberg.org.

Section 3. Information about the Project

Gutenberg Literary Archive Foundation