Injections in Aesthetic Medicine_ Atlas of Full-face and Full-body Treatment ( PDFDrive ).pdf

1. Injections in
Aesthetic Medicine
Mario Goisis Editor
Atlas of Full-face and
Full-body Treatment

2. Injections in Aesthetic Medicine

3. Mario Goisis
Editor
Injections in Aesthetic
Medicine
Atlas of Full-face and Full-body Treatment
123

4. Editor
Mario Goisis
Maxillo-Facial and Aesthetic Surgeon
Doctor’s Equipe
Milan
Italy
ISBN 978-88-470-5360-1 ISBN 978-88-470-5361-8 (eBook)
DOI 10.1007/978-88-470-5361-8
Springer Milan Heidelberg New York Dordrecht London
Library of Congress Control Number: 2013953897
Springer-Verlag Italia 2014
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5. Affectionately dedicated to my father Gianandrea

6. Preface
The Concept of Beauty
Beauty has a key role in human history. In ancient times Greeks held regularly beauty
contests for both male and female. Beauty was greatly admired and competitions were
serious. Annual contests were held at Lesbos, at Elis and in Arcadia.
But the first beauty contest in history was described in the Iliad. The marriage of
Peleus and Thetis was celebrated with a big banquet on Mount Olympus, home of the
gods. All the gods and goddesses were invited, except one, Eris, the Goddess of Strife
and Discord, in order to avoid problems. For this offense, Eris placed on the table, in the
middle of the banqueting hall, a golden apple with the inscription ‘‘For the Fairest’’.
All the three most important goddesses, Hera, Athena and Aphrodite had their eyes
on the apple, each wanting it for herself. They began to quarrel. Paris, the son of Priam,
King of Troy, was asked to judge. The three goddesses were involved in the final round
in what would become known as the World’s First Ever Beauty Contest! Hera promised
Paris dominions, wealth and power. Athena promised victory in battle. Aphrodite
promised the most beautiful woman in the world, Helen. Paris gave the Golden Apple to
Aphrodite, and that was the initial cause of Trojan War.
The beauty was a key concept in human history. In particular, Piero della Francesca
was one of the most original men of Italian renaissance. Piero had two passions—art
and geometry—and he integrated the two in the definition of beauty. In fact, renaissance
education placed exceptional value on mathematic rule of proportion.
Luca Bartolomeo Pacioli (c.1445–1517) was tutored in mathematics by Piero. Both
were born in Borgo San Sepolcro, and Luca even posed for Piero in the mid-1470s for
Madonna and Child with Saints and Angels.
He published the Summa de arithmetica, geometrica, proportioni et proportionalita
(1494) a summary of arithmetic, geometry, and algebra. It contains the first mention of
double-entry book-keeping, for which Luca is now known as the ‘‘Father of
Accounting.’’ Accounting has a great importance in management of the aesthetic medicine
office, but that’s not the reason of introducing Pacioli. In fact, in his De divina Pro-
portione published in 1509 he described the golden ratio ‘‘dal ciel mandata’’—heaven-
sent. He was inspired by the Platonic solids, and he related the Platonic solids to the
golden ratio:
As God created the four solids . . . earth, air, water, and fire … so our sacred proportion
gave shape to heaven itself.
The concept of divine proportion and the concept of perfect beauty was one of the most
important concept in art, and it inspired Leonardo, Durer and many others artists.
The research of ideal proportion and ideal beauty changes over time and in different
centuries people have different options for becoming beautiful. In Shakespearean times,
a woman was considered ideally beautiful if she had pale skin, light hair, intense eyes,
and red lips and cheeks [1]. Women went to extreme measures to have these
vii

7. characteristics, plastering their faces with white cream and coloring their cheeks red.
Shakespeare criticises ‘‘ideal’’ beauty in one of his sonnets, Sonnet 130:
My mistress’ eyes are nothing like the sun;
Coral is far more red than her lips’ red:
If snow be white, why then her breasts are dun;
If hairs be wires, black wires grow on her head.
As creams at time of Shakespeare, aesthetic medicine and aesthetic surgery involves
techniques intended for the ‘‘enhancement’’ of beauty. In fact, the aim of aesthetic
medicine and surgery is to change a part of the face and body through surgical and
medical techniques in order to increase beauty. Beauty is the key concept: the use of
aesthetic surgery and medicine must not be in contrast with this principle, also in case of
restoring or to maintaining youth. In fact, even though beauty is a complex concept, the
standards of attractiveness are similar across different genders and cultures [2, 3].
As described by Piero della Francesca and Pacioli, beauty is harmony of form and
proportions. Injecting an enormous amount of filler in the face of an old patient can
result in correction of wrinkles. But this correction is associated with an unnatural
result: in fact, the ‘‘pillow face’’ that we can obtain has probably a younger appearance,
but at the end there is not beauty in our result.
In this book are described many techniques: these techniques must be the instrument
to obtain a natural result. Avoiding excess is the key to success in aesthetic medicine.
Mario Goisis
References
1. Barroll JL (1984) Shakespearean tragedy: genre, tradition, and change in Antony and Cleopatra. Folger
Books, Washington D.C
2. Rhodes G (2006) The evolutionary psychology of facial beauty. Annu Rev Psychol 57:199–226
3. Zecchi S (2007) Le promesse della bellezza. Oscar Mondadori
viii Preface

8. Contents
Part I General Aspects
1 Fillers in Aesthetic Medicine. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Mario Goisis, Alessandro Di Petrillo, Claudio Rinna,
Chiara Brillante, Magda Guareschi, and Doris Ali Youssef
2 Aesthetic Analysis of the Face: The Maxillofacial Deformity . . . . . . . . . . . 25
Giada Anna Beltramini, Francesco Laganà, Alessandro Baj,
Michele Romano, Antonio Russillo, and Aldo Bruno Giannì
3 Standard Evaluation of the Patient: The Merz Scale . . . . . . . . . . . . . . . . . 33
Enrica Stella and Alessandro Di Petrillo
Part II Face and Body Treatments
4 Temporal Fossa . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
Mario Goisis and Alessandro Di Petrillo
5 Forehead, Glabella, and Crow’s-Feet . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
Alessandro Di Petrillo and Magda Guareschi
6 Malar Area . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73
Mario Goisis, Enrica Stella, and Alessandro Di Petrillo
7 Tear Trough . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89
Mario Goisis and Enrica Stella
8 Nasolabial Folds . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95
Enrica Stella and Magda Guareschi
9 Medical Rhinoplasty. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101
Mario Goisis
10 Marionette Lines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113
Enrica Stella, Alessandro Di Petrillo, and Mario Goisis
11 Lips . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125
Magda Guareschi and Enrica Stella
12 Chin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137
Magda Guareschi and Mario Goisis
ix

9. 13 Neck and Décolleté . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145
Enrica Stella and Mario Goisis
14 Arms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 155
Enrica Stella and Alessandro Di Petrillo
15 Hands . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 159
Mario Goisis and Alessandro Di Petrillo
16 Breast Augmentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 169
Mario Goisis
17 Gluteal Augmentation and Remodeling . . . . . . . . . . . . . . . . . . . . . . . . . . . 185
Mario Goisis and Magda Guareschi
18 Calf Augmentation and Remodeling . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 193
Mario Goisis and Enrica Stella
19 Scar Revision . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 203
Mario Goisis and Magda Guareschi
20 Full-body and Full-face Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 209
Mario Goisis
21 Complications in Aesthetic Medicine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 223
Enrica Stella, Mario Goisis, and Mariangela Giarda
Part III Miscellany
22 Quality Standards in Aesthetic Medicine. . . . . . . . . . . . . . . . . . . . . . . . . . 253
Mario Goisis and Andrea Goisis
23 Complementary Treatments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 261
Mario Goisis
24 Products . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 263
Magda Guareschi
x Contents

10. Contributors
Editor
Mario Goisis
Maxillo-facial and Aesthetic Surgeon, Doctor’s Equipe, Milan, Italy
Authors
Alessandro Di Petrillo, Maxillo-facial Surgeon, Doctor’s Equipe, Bologna, Italy
Bruno Giannì, Maxillo-facial Surgeon, University of Milan, Italy
Magda Guareschi, Ophthalmologist and Aesthetic Doctor, Doctor’s Equipe, Milan, Italy
Claudio Rinna, Maxillo-facial Surgeon, Doctor’s Equipe, Rome, Italy
Enrica Stella, Aesthetic Doctor, Doctor’s Equipe, Genova, Italy
Contributors
Alessandro Baj Maxillo-facial Surgeon, University of Milan, Italy
Giulia Beltrami Aesthetic Doctor, Doctor’s Equipe, Asti, Italy
Giada Anna Beltramini Maxillo-facial Surgeon, University of Milan, Italy
Gina Bianco Aesthetic Doctor, Doctor’s Equipe, Bologna, Italy
Chiara Brillante Ophthalmologist, Sapienza University, Rome, Italy
Doris Ali Youssef Maxillo-facial Surgeon, University of Milan, Italy
Andrea Goisis Software manager, Milan, Italy
Francesco Goisis Lawyer, University of Milan, Italy
Valentina Isgrò Aesthetic Doctor, Doctor’s Equipe, Rome, Italy
Francesco Laganà Maxillo-facial Surgeon, University of Milan, Italy
Chiara Lumini Aesthetic Doctor, Doctor’s Equipe, Torino, Italy
Giorgio Persichetti Aesthetic Doctor, Doctor’s Equipe, Rome, Italy
Michele Romano Maxillo-facial Surgeon, University of Milan, Italy
Antonio Russillo Maxillo-facial Surgeon, University of Milan, Italy
xi

11. Part I
General Aspects

12. 1
Fillers in Aesthetic Medicine
Mario Goisis, Alessandro Di Petrillo, Claudio Rinna, Chiara Brillante,
Magda Guareschi, and Doris Ali Youssef
1.1 Permanent Fillers
Doris Ali Youssef
The pursuit of beauty and the effort to reverse the effects
of ageing dates back to many centuries. Facial volume
depletion and facial rhytids are a natural and inevitable part
of ageing. Over the last 100 years, various attempts to
restore volume to the face with the use of injectable devices
have been described.
The prologue to this story must start with the develop-
ment of the appropriate technology, namely the syringe.
The hollow needle was invented in 1844 by Irish physician
Francis Rynd [1].
The fillers history begins in 1830, when a German
chemist, Baron Karl Ludwig von Reichenbach, discovered a
material created by the dry distillation of beech-wood tar.
He noted this substance to be very unreactive and named it
paraffin, from the Latin parum (barely) and affinis (affinity).
The first reported use of a material injected into the body for
‘cosmetic’ purposes was by Robert Gersuny (1844–1924)
[2]; Gersuny injected mineral oil (liquid paraffin) to create a
testicular prosthesis in a patient with tuberculous epididy-
mitis who had been treated by castration. Paraffin was
enthusiastically embraced by the medical community and
became the treatment of choice for nasal augmentation.
However, in 1901, a case was reported of a 39-year-old
woman who underwent paraffin injection for urinary
incontinence and developed pulmonary and cerebral paraf-
fin emboli [3]. The sequelae associated with paraffin
injections were outlined in 1911 by Kolle [4], who descri-
bed inflammation, infection, embolism, and yellowish skin
plaques at the site of the injection. In the following years,
the term paraffinoma was used to describe the
granulomatous foreign-body reaction that developed as a
result of paraffin injection.
The most famous account of the complications of par-
affin injection was that of the Duchess of Marlborough [5].
This American-born, dazzling beauty was preoccupied with
the ‘kink’ of her nose and underwent paraffin injections to
her nasal dorsum. The paraffin subsequently migrated into
her chin producing paraffinomas throughout her face. She
became so disfigured she did not permit mirrors in her
house, and she died a recluse in 1977. The biology of
injected paraffin is now well understood. There is an initial
inflammatory phase, followed by a latent phase that can last
for decades [6] Over time, the fatty tissue calcifies and
develops hyaline sclerosis, producing yellowish skin nod-
ules. These lesions can become infected or fistulize.
Because the paraffin is inert, it remains completely
unchanged in the body and can migrate through the fatty
tissue, stopped only by fascial planes.
Over the subsequent years, similar injectables such as
vegetable oil, mineral oil, lanolin and beeswax have been
used for cosmetic injections but were abandoned due to
undesirable complications including migration, granuloma
formation and scarring. A tragic example of such injections
was described in the London Daily Telegraph (November
11, 2008). A Korean woman received silicone injections
from a physician who also gave her syringes to self-
administer. After she ran out of silicone, she substituted
cooking oil for self-injection and ultimately became
severely disfigured.
1.1.1 Liquid Silicone
In the 1960s, liquid silicone injection became a popular
cosmetic treatment [7–10]. Like paraffin, silicone is an inert,
clear, oily substance that is easily injected and, unfortu-
nately, had similar disastrous sequelae. Silicone, a polymer
of dimethylsiloxanes, was first used in Japan during the
1940s for breast augmentation. This practice spread to the
M. Goisis () A. Di Petrillo C. Rinna C. Brillante
M. Guareschi D. A. Youssef
Doctor’s Equipe, via Carducci 19, 20123 Milan, Italy
e-mail: mariogoisis@yahoo.it
M. Goisis (ed.), Injections in Aesthetic Medicine,
DOI: 10.1007/978-88-470-5361-8_1, Springer-Verlag Italia 2014
3

13. United States (California, Texas and Nevada), in 1965, Dow
Corning developed a purified silicone that could be used for
injection, called MDX4–4011. In subsequent years, it was
noted that the injected silicone would migrate and fistulize,
and it had resulted in several deaths. Some patients with
severe complications required mastectomies. Because of the
complications encountered in the Las Vegas showgirls
injected with silicone, Nevada was the first state to ban the
use of injectable silicone. In 1964, Weiner coined the term
siliconoma to describe the soft tissue granuloma that
developed from injected silicone. These disfiguring
inflammatory responses could sometimes be seen decades
after silicone had been injected. Although medical-grade
silicone was also used to treat facial wrinkles and augment
the lips, the U.S. Food and Drug Administration (FDA)
considered it an investigational device and never approved
silicone for cosmetic use. In 1964, the FDA regulated the
use of injectable silicone as a drug, and the Medical Device
Amendments of 1976 restricted the use of silicone as a
device. After reports of the sequelae of injected silicone, in
1979, the FDA and the American Medical Association
condemned the use of injectable liquid silicone. Although
today medical-grade silicone is available for ophthalmic use
in the treatment of detached retinas, its cosmetic use is
considered illegal in some states. In spite of the problems
encountered with injectable liquid silicone, silicone injec-
tions are still performed in Europe, Canada, Mexico and by
some physicians in the United States. Since 1994, two
medical-grade silicone products were available to treat
detached retinas, and use of these products cosmetically is
considered ‘off-label’. Even though the use of injectable
silicone for cosmetic purposes is federally banned and
illegal in some states, some physicians feel that in the hands
of experienced surgeons, injections can be extremely effi-
cacious. They purport the ‘microdroplet’ injection tech-
nique using a small needle and deep injection into the
dermis and subcutaneous fat. These injections are per-
formed in multiple treatments over 1- to 3-month intervals.
The authors strongly suggest not to use liquid silicon and to
consider this use illegal.
1.2 Collagen
1.2.1 Heterologous Collagen
Giorgio Persichetti, Valentina Isgrò
Bovine collagen has been the most widely used filler
material in the early 2000s (See Table 1.2). Three products
have been manufactured and distributed by Inamed:
Zyderm I, Zyderm II, and Zyplast. Inamed has been acquired
by Allergan at the end of 2005. Allergan continued marketing
these products until the end of 2010. In June 2008, Johnson
Johnson patented their own product, Evolence, derived from
porcine collagen. The production of Evolence has been
suddenly discontinued in November 2009.
Zyderm I corrected fine lines quite well, particularly fine
perioral and crow’s-feet lines. Zyderm II, designed to cor-
rect average lines, offers an average duration of 3–6 months.
Zyplast was designed to correct deep wrinkles in thick skin
and to restore facial volume (lips and outline of the face). It
generally lasted 6–12 months [11].
Evolence has been recommended for the treatment of
moderate to deep wrinkles, fold and lines, including hard-
to-treat nasolabial folds.
Due to the possible allergic reactions concerning the use
of heterologous collagen, a preliminary test was mandatory
before injection.
A double test was recommended because positive reac-
tions to treatment have been reported in 0.3–1.5 % of patients
even after clinical selection and initial testing [12, 13].
Pons-Guiraud [14] recommends the following protocol,
which can take up to 7 weeks to complete. The first injec-
tion (0.1 mL) is given in the anterior aspect of the forearm,
followed by a reading at 72 h. A positive reaction is char-
acterized by a change in the contour of the injected implant,
erythema, oedema, occasionally pruritus and, rarely, by an
indurated papule or inflamed dermal nodule. All positive
reactions contraindicate collagen injections. A second
injection is given 15 days later, followed by readings 3 days
and 4 weeks later. Any positive reaction to the test or
double test contraindicates the collagen injection. If there is
any doubt, bovine (ACACB) and human (ACACH) anti-
collagen antibodies must be measured.
Concerning complications, a study performed by Castrow
and Krull [15] on behalf of 316 practitioners, covering
approximately 7,000 patients who demonstrated negative test
results revealed a side-effect rate at the injection site of 1.5 %.
The reactions were mostly limited to the injection site:
erythema, induration, itching, and pain. In general, these
reactions lasted 4–6 months; in a few cases, they lasted
more than 1 year. Other reactions included arthralgia
(6.5 %) and local granulomas (5 %, confirmed in 4 of 5
cases through biopsy). In rare cases, severe allergic reaction
(anaphylactic shock) that requires immediate emergency
medical assistance occurred.
Abscesses were reported at a frequency of 4 cases per
10,000 patients [16]. These reactions develop, on average,
8–12 weeks after the injection, after 1 or more collagen
injections. They are characterized by a nodule or papule at
the injection site, severe swelling, erythema and induration
4 M. Goisis et al.

14. of the surrounding tissues. The abscess is different from the
collagen hypersensitivity reaction, which is also character-
ized by induration and erythema but is not fluctuant. Cases
of necrosis have been reported at a rate of 9 per 10,000 [16].
The local necrosis reaction after injection of collagen is not
related to the implant itself but to obstruction of a blood
vessel or ischaemic necrosis.
According to ASAPS member statistics, use of heterol-
ogous collagen decreased starting from 2004 (Table 1.1).
During 2009, law firm McPhadden Samac Tuovi
announced a proposed class action against Johnson
Johnson and related companies relative to the injectable
collagen dermal filler Evolence. It is alleged that Johnson
Johnson and related companies failed to warn the public
about the potential of these adverse effects. Exactly, during
November 2009, Johnson Johnson announced that it
would be discontinuing the porcine collagen product.
The need of a double test and relative waiting time
together with the risk of side effects are probably the main
reasons leading to a gradual decrease in the mid of 2000s
and a definitive loss of popularity of heterologous collagen
between 2008 and 2010.
1.2.2 Human Collagen
Implantable materials containing autogenous or isogenous
human collagen have a limited presence because prepara-
tion of the injectable solutions is relatively difficult, and the
cost of these products is relatively high.
1.2.3 Autogenic Human Collagen
Introduced at the end of the 1980s, Autologen (Collagene-
sis, Inc., Beverly, MA) was the first autologous injectable
agent on the market. Autologen is a dispersion of intact
collagen fibres and a matrix of collagen tissue obtained
from the clean skin of the patient during a plastic surgery
procedure (mammaplasty, abdominoplasty, facelift and
blepharoplasty). A skin biopsy is inadequate. Because the
injected material is autologous and no allergic reactions
were reported in a sufficient number of patients, the United
States Food and Drug Administration (FDA) does not
consider it necessary to perform a test before Autologen
injection. The skin excision, placed in a sterile container, is
sent to the manufacturer’s laboratory for treatment. As a
general rule, 10–13 cm2
of excised skin is required to
produce 1 mL of Autologen 5 %.
At least 3 injections, a few weeks apart, are needed to
obtain a satisfactory result, provided that each treatment is
overcorrected by 30 % [17]. The duration of treatment
depends on the region treated, the injection technique and the
volumeofAutologenadministered. Nosignificantside effects
have been reported. It must be noted, however, that moder-
ately severe erythema may last for 48 h after the injection [18,
19]. Preparation of the autologous collagen from a patient-
tissue sample is expensive, and yield varies, depending on the
individual and the anatomic areas from which collagen is
harvested. Since 1998, autologous fibroblast cultures have
been used to correct wrinkles, scars and other skin defects.
Boss et al. [20] described a method of injecting autologous
fibroblasts obtained from a 3-mm skin excision from the
retroauricular area, an area protected from UV light. The
sample is immediately placed in a culture medium provided
by Isolagen Laboratories (Houston, TX) and must reach the
laboratory by the day after sampling in an isothermic con-
tainer. Six weeks after sampling, an injection test (0.1 mL) is
administered to the patient in the forearm; any sign of an
allergic reaction is recorded. Two weeks after the test,
approximately 1 mL of the autologous material is available
for implantation. Overcorrection of 300 % is recommended
for suitable aesthetic results [21, 22]. The level of correction
achieved depends on the defect, the patient’s age, and the
ability of the patient’s fibroblasts to create collagen. Patients
older than 60 years are not good candidates for this technique.
This technique has several disadvantages. The Isolagen
preparation must be injected within 48 h. It offers more
effective correction of periorbital wrinkles or perioral wrin-
kles than of deep furrows [23]. The improvement obtained is
poor compared with that of other techniques, such as hyalu-
ronic acid, and correction is not immediate. Fagien and Elson
[24] concluded that the results obtained with this technique
were rather disappointing. In addition, Isolagen is expensive.
1.2.4 Isogenic Human Collagen
Alloderm (LifeCell, Branchburg, NJ) has been used in the
treatment of burns and for transplantation in periodontal
surgery. In aesthetic surgery, it is used to increase lip vol-
ume, to correct nasolabial folds and to treat scars. Alloderm
Table 1.1 ASAPS member statistics year on year comparisons for dermal filler products
2006 versus 2007 (%) 2005 versus 2006 (%) 2004 versus 2005 (%)
Collagen -60 -27 -72
Hyaluronic acids -9 +33 +35
1 Fillers in Aesthetic Medicine 5

15. is an acellular dermal graft material obtained from cadavers
or from a tissue bank that provides an acellular matrix of
dermal components, including collagen, elastin and
glycosaminoglycans. The dermis skin is examined in
accordance with FDA requirements and regulations relating
to human tissue. No cases of transmissible viral disease
have been reported in patients who have received this
treatment since its introduction in 1992. Alloderm is offered
in the form of sheets that are implanted through an incision
in the treatment area. Infection of the incised/sutured sites
has been attributed to abscess formation around the suture
rather than to the graft itself. Cases of labial herpes have
also been reported; prophylactic antiviral therapy must be
prescribed for patients with a history of labial herpes.
Alloderm is also available in a micronized injectable form,
marketed under the name Cymetra (average particle size
123 lm). Cymetra is provided in the form of an aseptic
powder reconstituted with lidocaine 0.5 % with 1: 200,000
epinephrine immediately before injection. It is injected with
a 26-gauge needle [25]. Dermalogen (Collagenesis Corp.,
Beverly, MA) is obtained from cadaver tissues that have
been carefully selected to help eliminate the risks of viral
and bacterial infection. Clinical indications for the use of
Dermalogen include correction of obvious nasolabial folds,
perioral wrinkles, glabellar wrinkles and depressed scars, as
well as increasing lip volume. The injection technique for
Dermalogen is the same one used for Autologen: injection
into the middle dermis/deep dermis with a 30-gauge needle.
Because the injection is painful, use of a local anaesthetic is
recommended [26]. Overcorrection of 20–30 % is recom-
mended at each session. An average of 3 injection sessions
is required for satisfactory correction. Prolonged erythema
and acneiform rashes were noted in 10 % of patients in
a study of 130 patients. The manufacturer does not rec-
ommend a pretreatment allergy test, although 1 case of
foreign-body reaction 4 weeks after a test injection of 1 mL
of Dermalogen in the forearm has been described by
Moody and Sengelmann [27]. Klein [28] also reported
several positive skin tests with Dermalogen and 1 case of
secondary reaction characterized by redness, swelling, and
hyperpigmentation of the treated sites after Dermalogen
implantation.
1.3 Hyaluronic Acid
Chiara Lumini
Hyaluronic acid is a natural substance in the body that
was first described in 1934 by John Palmer and Karl Meyer
at Columbia University, New York. It was isolated from a
cow’s eye, and the name comes from hyalos (Greek word
for glass) and the uronic sugar found in the substance.
Hyaluronic acid is produced by the cells in the human body,
and it plays a key role in numerous functions. It facilitates
the cell-division process, it makes the skin elastic and it
lubricates the joints. In 2003, the U.S. Food and Drug
Administration (FDA) approved the first hyaluronic acid
dermal filler for the correction of moderate to severe facial
wrinkles and folds, such as nasolabial folds. In the last ten
years, numerous products for therapeutic and aesthetic uses
have been developed for this versatile natural substance.
1.3.1 What is Hyaluronic Acid?
Hyaluronic acid is a natural complex sugar found in all
living animals. It is one of the few elements that is virtually
identical in all living organisms. Hyaluronic acid has the
capacity to bind great quantities of water, absorbing more
than 1,000 times its weight In addition, hyaluronic acid
combines with collagen and elastin. The triple binding of
elastin, collagen and hyaluronic acid provides elasticity and
volume to the skin.
The body’s amount of hyaluronic acid is metabolized
quickly and must be newly produced constantly by the cells.
The ageing of the skin, and the exposure to oxidants, to
pollutants and to ultraviolet rays, reduce the ability of the
cells to produce hyaluronic acid. As a result, the skin begins
to reduce its volume, with subsequent formation of facial
wrinkles and folds.
1.3.2 What is Cross-Linked Hyaluronic Acid?
In its natural form, hyaluronic acid is a liquid composed of
individual polymers (chains) that are broken down in the
body in just 12 h. Cross-linking is a process in which the
individual chains of hyaluronic acid are cross-linked
(chemically bound) together, converting the liquid hyalu-
ronic acid into a gel, a soft solid. The hardness of the gel
depends on the degree of cross-linking of the individual
hyaluronic acid chains.
The body metabolizes cross-linked hyaluronic acid more
slowly than the natural individual chains, resulting in a
longer duration of effect.
For this reason, dermal fillers composed of cross-linked
hyaluronic acid are used in aesthetic medicine to tempo-
rarily replace lost hyaluronic acid and to restore volume of
the face and of the body.
Fillers are reticulated hyaluronic acid-based medical
devices. They are made of stabilized non-animal hyaluronic
acid obtained from bacterial fermentation of_Streptococcus
equi strains.
The cross-linking agent generally used for fillers is 1.4-
butanediol diglycidyl ether (BDDE), a small molecule that
6 M. Goisis et al.

16. binds to two ends of an HA chain, generating a three-
dimensional structure.
The various HA-based fillers on the market have differ-
ent chemico-physical characteristics, such as particle size,
the cross-linking agent used, the degree of cross-linking, the
quantity of free HA and the elastic modulus G.
The quantity of hyaluronic acid in a product affects its
consistency and longevity. However, it is also important
to take into account the quantity of reticulated HA, the
quantity of non-reticulated HA and the degree of cross-
linking to consider the HA as fully or partially linked.
Often, some quantities of free hyaluronic acid are added
to increase its ease of injection as it functions as a
lubricant.
The cohesive property of the gel depends on the elastic
modulus G which measures its resistance to deformation
and, therefore, the strength of the gel. Fillers with a high G
are considered cohesive gels and are indicated for correc-
tion of deeper wrinkles, such as naso-labial folds or for
marionette lines, whereas fillers with a lower G0
are indi-
cated for the treatment of larger areas such as the cheek-
bones and cheeks (See Table 1.2).
Different properties of hyaluronic acid can be resumed in
a simple classification:
– low viscosity hyaluronic acid, useful for revitalization
and small wrinkles
– medium viscosity hyaluronic acid: useful for deeper
wrinkles, lines and lips
– high viscosity hyaluronic acid: useful for larger areas as
malar areas.
1.3.3 History of Hyaluronic Acid in Aesthetic
Medicine
1987 Q-Med was founded by Bengt Ågerup with a view to
commercializing the research that he had carried out around
hyaluronic acid.
1996 Restylane
obtained marketing authorization in
Europe for use as filler for wrinkles and lip augmentation.
2003 Restylane
is approved in the US.
2003 Corneal group introduces Juvaderm in Europe and
Canada.
In 2006, Q-Med launches a new product for lip
enhancement treatment, Restylane LippTM
, Q-Med’s first
product in the field of body augmentations, MacrolaneTM
, is
approved in Europe.
The JUVÉDERMTM
dermal filler family of products is
approved by the FDA.
2007 Restylane PerlaneTM
approved for sale in the USA.
2008 Q-Med’s Restylane VitalTM
and Restylane VitalTM
Light—were launched in Europe.
Allergan introduces in Europe Juvederm Ultra 2, 3 and 4.
2009 Restylane obtained registration approval in China
and became the first injectable non-animal hyaluronic acid
product on the Chinese market.
Q-Med introduced Restylane
Lidocaine and Restylane
PerlaneTM
Lidocaine.
Allergan introduces Juvaderm Voluma.
2010 By the beginning of 2010 FDA approved Restylane
and Restylane Perlane with added lidocaine in USA.
2011 Belotero Balance has been approved by FDA to treat
moderate to severe facial wrinkles and folds. De-listing of
Q-Med AB (publ) from NASDAQ OMX Stockholm. Q-med
is acquired by Galderma.
CE-approval of Restylane SubQ lidocaine.
2012 Glytone Range of Injectable Hyaluronic Acid
Products of Pierre Fabre Group was acquired by Merz
Aesthetics Inc.
Allergan introduces the new filler Juvederm Volbella
with lidocaine.
1.4 Macrofillers: Hyaluronic Acid for Body
Modelling
Giulia Beltrami
The use of liquid filler for body enhancement was first
described in 1899 by Gersuny, who injected silicone into
the scrotum of a patient in order to reconstruct a testicle
after an orchiectomy [29, 30]. Since then, there has been a
steady increase in the use of implants and filler substances
to reshape body defects. In particular, many permanent
liquids and gels have been injected for breast augmentation
(e.g. silicone, paraffin, polyalkylimide and polyacrylamide
hydrogel). However, the use of these materials has been
hampered by complications, such as chronic inflammatory
reactions, palpable nodule formation, granuloma formation,
and migration [29, 31–33]. As a consequence of these
complications, new materials on the market can face scep-
ticism, even if they are biocompatible and non-permanent.
Hyaluronic acid specifically produced for body remod-
elling was introduced in 2009, in particular Macrolane, a
new formulation of injectable stabilized hyaluronic acid–
based gel of non-animal origin (NASHA-based gel; Q-Med
AB, Uppsala, Sweden) have been developed for use in
breast enhancement, volume restoration and contouring
body surfaces [31, 34]. Since larger volumes are required
for body enhancement than for facial augmentation, the
Macrolane formulation has increased viscosity (i.e. a
thicker gel). With a high resistance to deformation, hyalu-
ronic acid gel augments body tissue simply by occupying
space (in a similar manner to permanent implants).
1 Fillers in Aesthetic Medicine 7

17. In 2010, Bioscence (Bioscence, Germany) introduced
Hyacorp for body enhancement, with exclusion of breasts.
Hyacorp is a specially designed cross-linked HA gel which
becomes less viscous under pressure (injecting force) and
returns immediately to the original viscosity upon pressure
release (injecting force). This is a characteristic of a system
(advanced thixotropic technology = ATT technique)
exhibiting a decrease in viscosity with an increase in the
rate of shear, usually a function of time.
Breast augmentation was Macrolane major indication.
Many women have undergone breast augmentation with
Macrolane in Europe and Asia. It has never been approved
for breast augmentation by the Food and Drug Adminis-
tration [31, 34]. In January 2010 Goisis et al. wrote a
contribution to Aesthetic Plastic Surgery [35]. Three major
questions were examined in this paragraph. The first ques-
tion is related to the duration and cost of Macrolane.
Macrolane is a resorbable material, and the study of P.
Heden et al. published in 2009 showed 30–50 % resorption
at 12 months [31]. The echographic measurements in the
study of Goisis et al. [35] showed a 60 % rate of resorption
after one year. Consequently, a second treatment was usu-
ally done 9 months after the first. The necessity of a touch-
up increases the cost of breast augmentation with NASHA
gel, which is as expensive as a single surgical treatment
with a prosthesis after three or four touch-ups. The second
problem is related to the radiological evaluation of patients.
Macrolane is a new material and it constitutes a diagnostic
challenge for radiologists. Indeed, the appearance of NA-
SHA gel may mimic a cyst on mammography and sonog-
raphy [31]. Therefore, it is important that radiologists
become familiar with the spectrum of imaging findings of
Macrolane. In particular, in order to make an accurate
diagnosis in these patients, it is important to send them to
specialized radiological centres. The last open question is
related to post-treatment adverse events. Goisis et al. had a
high rate of minor complications. Goisis et al. concluded in
this study that NASHA gel for breast volume augmentation
was an interesting treatment, although the three open
questions require more studies. P. Heden et al. answered
this paper with a letter, writing that Macrolane injection did
not reduce sensitivity and specificity in breast cancer
screenings [36]. After the paper of Goisis et al, some other
authors reported complications associated with the proce-
dure [32, 37]. In 2011, Goisis et al. wrote two papers about
difficulties on breast imaging, which were described by
manyauthors as the most important problem of breast aug-
mentation by hyaluronic acid [38–40]. To reduce these
problems, Goisis et al. stressed the importance to carry out
the injections under ultrasound guidance. In particular, they
suggested to inject a single deposit of hyaluronic acid gel.
A cavity with a uniform symmetrical globular shape must be
created in the space under the deep fascia of the breast,
anterior to pectoralis muscle. The gel can be also placed
posterior to the pectoralis muscle (submuscular plane) or
inside the pectoralis muscle (intramuscular plane) in order to
minimize visibility and palpability. In fact, in Goisis et al.
published experience, the overall incidence of complications
among patients receiving submuscular or dual-plane or
intramuscular injection appeared lower than in patients
receiving subglandular injection. Injection of gel into the
space between the glandular tissue and the deep fascia of the
breast may be related to a higher risk of displacement into
the gland tissue and into the subcutaneous fat, especially if
multi-pocket injection is performed without ultrasonography
guidance [41]. In April 2012, after reviewing the current
situation and in consultation with the regulatory authorities,
Q-Med has decided to discontinue the indication for breast
augmentation until consensus for best practices in breast
radiology examination following Macrolane treatment has
been reached. Q-Med announced that a safety reporting
system has been in place since launch and no safety concerns
have been identified. Despite this, Macrolane can interfere
with the reading of mammograms. Since no safety concerns
have been identified with the product itself, Q-Med
suggested that women who have undergone breast aug-
mentation with Macrolane do not need to take any additional
actions other than the routine follow-up consultations or as
directed by their doctors. As with any other breast prosthesis,
it is important to inform the healthcare professional of
previous Macrolane treatment before any breast assessment
is carried out.
1.5 Calcium Hydroxylapatite
Gina Bianco
Initially launched in the US in 2000 as Radiance FN, this
dermal filler was introduced in Europe in June 2004 under
the name RadiesseTM
. RadiesseTM
is a medical device
developed by Bristol-Myers Squibb and BioForm Medical
(since acquired by Merz Aesthetics).
Radiesse is an injectable filler material composed of
synthetic calcium hydroxylapatite microspheres (30 %)
suspended in an aqueous carrier gel (70 %). These uniform
microspheres (25–45 m) are smooth in shape and are
identical in composition to the mineral portion of human
bone and teeth [42].
Radiesse injectable implant is a steam sterilized, latex-
free, non-pyrogenic, semi-solid, cohesive completely bio-
degradable deep and sub-dermal implant. The principle
8 M. Goisis et al.

18. component is synthetic calcium hydroxylapatite. Calcium
hydroxylapatite is the primary mineral constituent of bone
and teeth. The semi-solid nature of the implant is created by
suspending calcium hydroxylapatite in a gel carrier that
consists primarily of water and glycerine. The gel structure
is formed by the addition of a small amount of sodium
carboxymethyl cellulose. It does not contain any animal- or
human-derived components. The gel is dissipated in vivo
and replaced with soft-tissue growth, while the calcium
hydroxylapatite remains at the site of injection.
Results from extensive in vitro and in vivo safety studies
and in several retrospective physician reports, including
toxicology assessments, standardized biocompatibility
testing, and a 3-year animal study, demonstrate that
injectable calcium hydroxylapatite is biocompatible, non-
toxic, non-irritating and non-antigenic. Patient sensitivity
testing is not required before use [43].
Calcium hydroxylapatite has been used for more than 20
years in various forms in surgery and dentistry. In the United
States, injectable calcium hydroxylapatite has been used for
several years for the correction of oral/maxillofacial defects,
for vocal fold augmentation and as a radiographic tissue
marker. In 2006, Radiesse was approved in the United States
for the correction of moderate to severe facial wrinkles and
folds, including the nasolabial folds, and restoration and/or
correction of the signs of facial fat loss (lipoatrophy) in
people with human immunodeficiency virus. In Europe,
RadiesseTM
is approved for plastic and reconstructive sur-
gery, including deep-dermal and sub-dermal soft-tissue
augmentation of the facial area.
When placed into soft-tissue, Radiesse provides imme-
diate correction. Over time, the carrier gel is gradually
absorbed and the calcium hydroxylapatite particles remain
(Figs. 1.1, 1.2, 1.3). Local histiocytic and fibroblastic
response at the site appears to result in the production of
new collagen around the microspheres [44]. Preclinical
canine studies (Fig. 1.4, above) have demonstrated histo-
logically progressive integration of collagen fibres in and
around the calcium hydroxylapatite microspheres up to 78
weeks after implantation (Fig. 1.4, centre and below).
Over time, calcium hydroxylapatite particles are broken
down into calcium and phosphate ions via normal metabolic
processes and eliminated through the body’s normal excre-
tory processes. In one long-term animal study in the bladder
neck, the particles remained intact at the site of injection
throughout the entire 3-year study period [45]. Our experi-
ence with calcium hydroxylapatite use for facial soft-tissue
augmentation has shown results lasting an average period of
a year or more in most patients. In vivo, durability depends
on factors such as injection technique, site of material
placement and patient age and metabolism. The study was
conducted on 357 patients and is not yet published.
1.5.1 Injection Technique
Due to its relatively low viscosity, calcium hydroxylapatite
is delivered with a small (e.g., 27-gauge) needle and local
anaesthesia improves patients’ comfort during procedures.
The choice of infiltration, nerve block anaesthesia, top-
ical anaesthesia, infiltration of tiny amounts of local
anaesthetic directly into the area, or some combination
thereof depends on the preferences of the operator and the
patient [46, 47]. When needed, the treatment site should be
marked before administration of anaesthetic, as infiltration
may distort the skin surface.
Practical skill: to reduce post-treatment pain, you can
mix radiesse with local anaesthesia (Figs. 1.5a, b, 1.6a, b).
Calcium hydroxylapatite should ordinarily be injected at
the sub-dermal plane, especially when filling creases,
wrinkles and deep lines. Injection depth can be just in the
subcutaneous space but superior to the periosteum. The
Fig. 1.1 When injected into soft-tissue, Calcium hydroxylapatite
provides immediate correction
1 Fillers in Aesthetic Medicine 9

19. injection can also be placed on the periosteum if the intent
is to augment the facial bony skeleton. Placement on the
periosteum will not stimulate bone growth in the area.
Depending on the area being treated, calcium hydroxylap-
atite may be injected in a retrograde fashion using a linear,
threading, fanning and/or crosshatching technique. Massage
or moulding of material follows injection to desired effect.
Post-treatment care involves immediate placement of ice
onto the injected areas to reduce and limit tissue oedema
and ecchymosis.
Practical skill: a lesser volume of calcium hydroxylap-
atite is required to provide the same degree of correction
as hyaluronic acid and collagen
Two studies support the finding of smaller volumes in
calcium hydroxylapatite than in several other soft-tissue
fillers. For example, in a split-face study of calcium
hydroxylapatite versus collagen for the nasolabial folds, on
average, the collagen-treated side of the face required twice
the volume of material (2.35 ml) to produce optimal cor-
rection as compared with the calcium hydroxylapatite–
treated side 1.22 ml) (p 0.0001) [48]. In another study,
approximately 30 % less volume of calcium hydroxylapatite
was required than hyaluronic acid for full correction of the
nasolabial folds [49].
1.6 Botulin
Claudio Rinna, Chiara Brillante
1.6.1 History
Botulinum toxin (BoNT) is a neurotoxin. The symptoms of
intoxication by botulinum were first described two centuries
ago by Justinus Kerner [50, 51]. He observed these symp-
toms after eating sausages, and the term botulism derived
from the latin botul (sausage).
BoNT is produced by the anaerobic micro-organism
Clostridium botulinum. There are 7 different known sero-
logical types, indicated with the letters from A to G [51]. In
1937, the ophthalmologist Alan B. Scott used for the first
time the botulinum toxin A (BTXA) in experiments on
monkeys. In 1946, Edward Schantz in Fort Detrick pro-
duced the first botulin toxin in crystals [50].
Only in the 1970s, it was approved as a therapeutic agent
[51], and in 1989, the BTX-A was approved by the Food
and Drug Administration for the treatment of strabismus,
blepharospasm and hemifacial spasm in patients over the
age of 12. In 1991, it was used to treat spasticity, both in
Fig. 1.3 Local histiocytic and fibroblastic response at the site appears
to result in the production of new collagen around the microspheres
Fig. 1.2 Over time, the carrier gel is gradually absorbed and the
calcium hydroxylapatite particles remain
10 M. Goisis et al.

20. Fig. 1.4 Scanning electron
photomicrographs of (above, left)
calcium hydroxylapatite
microspheres in sodium
carboxymethylcellulose gel. Note
the consistent, smooth, round
shape (500 magnification).
Above, right Calcium
hydroxylapatite microspheres
30 months after implantation into
bladder neck (350 magnification).
Note the slowly dissolving
particles. Centre and below
Histological evaluation of
calcium hydroxylapatite gel
injected intradermally into canine
skin over a period of 4–78 weeks.
Sections stained with picrosirius
red denote progressive collagen
integration in and around the
white spherule calcium
hydroxylapatite particles.
Collagen deposition (centre,
right) 16 weeks, (below, left)
32 weeks, and (below, right)
78 weeks after calcium
hydroxylapatite injection
(Photographs and illustrations
courtesy of BioForm Medical,
Inc.)
Fig. 1.5 a, b 0, 5 cc of local
anesthetic (2% lidocaine or 2%
mepivacaine) are inspired in a
2, 5 cc syringe
1 Fillers in Aesthetic Medicine 11

21. adults and in children and in 2000 for the treatment of
cervical dystonia. Jean Carruthers first describes in 1996 the
use of botulin toxin for aesthetic treatment of the face.
In 2002, the use of BTX-A in aesthetic medicine was
approved for the temporary improvement of glabellar frown
lines [52].
The use of BoNT, which has been approved, varies
widely depending on the type of toxin, the type of marketed
product and the country, even within the European Union.
This means that, in some cases, its clinical use is off-label,
even if supported by scientific literature. BTXA is marketed
in the form of various pharmaceutical products: Botox,
Dysport, Xeomin, Vistabex, Bocoture, etc. BoNT B is
instead marketed under the name of Neurobloc or myobloc.
1.6.2 Different Toxins
Botulinum neurotoxins are synthesized together with differ-
ent haemagglutinins and/or non-toxic non-haemagglutinin
proteins that form a protein complex called progenitor toxin
(See Table 1.2). The protein complex is used to stabilize and
protect neurotoxin from degradation. The size and composi-
tion of nontoxic proteins in the complex vary depending on
the bacterial strain. Different bacterial strains also produce
different serotypes of boluninum toxin, known as types A, B,
C1, D, E, F and G. The various serotypes form protein com-
plexes of different sizes, in which only the type A forms the
larger complex of approximately 900 kd. In all complexes,
the portion of active neurotoxin is approximately the same
size (150 kd) [53].
The neurotoxin is first synthesized as a single-chain
protein that, in order to be active, must be cleaved or
affected by the protease. The proteolytic cleavage yields a
double-chain active molecule consisting of a heavy chain
(approx. 100 kd) and a light chain (approx. 50 kd).
At present, different medicinal products are registered
and marketed and although they are all based on type A
BoNT, they are manufactured according to different bio-
logical processes and obtained through different isolation
and purification processes. Each type of BoNT has its own
unit of measurement and the different units of measurement
are not interchangeable.
In 2009, the US Food and Drug Administration estab-
lished that BoNTs should be identified unequivocally by
means of a specific common denomination for each
medicinal product marketed in the United States [52].
BoNTs have been named as follows:
• onabotulinumtoxin A (equivalent to the medicinal product
BOTOX or Vistabex);
• abobotulinumtoxin A (equivalent to the medicinal product
Dysport or Azzalure);
• incobotulinumtoxin A (equivalent to the medicinal prod-
uct Xeomin or Bocouture);
• rimabotulinumtoxin B (equivalent to the medicinal prod-
uct Myobloc or Neurobloc in Europe).
This need arose from the consideration that, since BoNT
is a product of biological origin, its biological activity,
defined potency, cannot be determined with a standard
methodology. In fact, potency should be determined for each
product lot and, due to its high sensitivity, must be precisely
Fig. 1.6 a, b 1, 5 cc of Radiesse
is mixed with the anaesthetic
solution
12 M. Goisis et al.

22. determined and calculated during the entire production
process of the toxin itself, from the bulk to the final lot.
Potency is measured as units of biological activity using
the test lethal dose 50 (DL50) defined as the quantity of a
substance, per unit of body weight, that will kill 50 % of
test animals.
In recent years, Allergan Inc. has announced the approval
of a test based on in vitro cells to be used for testing the
stability and potency of the Allergan BoNT, thereby elimi-
nating the need to perform tests on animals. This new assay
is the first to be developed and approved and specifically
applies to the type A BoNT manufactured by Allergan.
A different name allows to confirm that the BoNTs are
manufactured according to different biological processes,
are obtained with different isolation and purification tech-
niques and derive from different strains of the C. Botulinum.
The different formulation and molecular structure can
affect both the local diffusion of the toxin from the inocu-
lation site and its potency characteristics which may affect
its efficacy, safety profile as well as the antigenic potential
of the product.
The BoNT produced by Allergan derives from the
clostridium strain called ‘Hall’ which undergoes several
purification and crystallization steps (using the method
developed by Schantz) which allow to obtain a homogenous
neurotoxin complex with a molecular weight of 900kDA
given by the presence of auxiliary proteins (haemaggluti-
nins and non-haemagglutinins) that form complexes with
the neurotoxin and are used to stabilize and protect the toxin
from degradation [54].
As regards the other available preparations, one derives
from the clostridium strain called NCTC 2916 which
undergoes purification steps using chromatography, a
technique that has been proven to generate a more hetero-
geneous compound, while the other contains pure neuro-
toxin with a molecular weight of 150Kda, free from
complexing proteins [55, 56].
1.6.3 Use in Clinical Practice and Aesthetic
Medicine
BoNTs used in aesthetic medicine are of type A and are
indicated for the treatment of expression wrinkles (dynamic
wrinkles). The effect of proper treatment with BoNT is to
mitigate these signs at rest without affecting the mimicry of
the patient or inhibiting muscles contraction.
1.6.4 Clinical Evaluation of the Patient
Before the injection of the toxin it is important to perform a
careful physical examination of the upper third of the face
considering asymmetries, position of the eyelids and the
presence of ptosis produced by the levator muscle of the
eyelid. To exclude a ptosis, ask the patient to look forward,
to put a hand on his forehead to block the frontal muscle in
order to evaluate the actual activity of the levator muscle of
the eyelid.
The next step is to assess wrinkles in a sitting position
and during mimic efforts look for possible contraindica-
tions. Once the suitability of the subject to injection has
been established, photograph the face both in static and
dynamic position to have a documentation prior to
treatment.
To proceed with the injection, it is necessary to inform
the patient of the possible risks of side effects and let him/
her sign an informed consent to treatment.
1.6.5 Contraindications to Treatment
Contraindications to treatment with BoNT -A are:
• diseases of the neuromuscular junction (myasthenia gra-
vis, Lambert–Eaton syndrome);
• allergy to human albumin and sodium chloride;
• skin lesions of treated areas;
• infection of the planned site for the injections;
• recent surgical treatments;
• pregnancy and lactation;
• recent use of aminoglycoside antibiotics or other agents
that interfere with neuromuscular transmission (specti-
nomycin, tubocurarin-type muscle relaxants).
1.6.6 Informed Consent
It is important to inform the patient about the good rules to
follow during the hours after treatment, such as avoiding
alcohol, avoiding excessive pressure on the affected area
and exposure to excessive heat.
The patient should be informed of possible side effects
from the injection of BoNT, such as pain, weakness, itch-
ing, swelling or bruising at the injection site.
The patient should be informed of the side effects that
may occur in the hours following the treatment to enable
him to associate the disorder to treatment and inform their
doctor if necessary. These effects are divided into categories
based on the frequency with which they occur:
• Very common (1 in 10 patients): headache, local muscle
movement disorders and feeling of heaviness in the upper
part of the face;
• Common (1–10 in 100 patients): eyelid oedema, eyelid
ptosis, eyelid inflammation, eye pain, blurred vision,
nausea, dizziness, dry mouth, cramps and muscle con-
traction, flu-like symptoms, itching and burning sensation
1 Fillers in Aesthetic Medicine 13

23. in the treated area, infection, sensitivity to light, bron-
chitis, dry skin, fatigue, insomnia, depression;
• Rare (1–10 in 10,000 patients): swelling, redness or rash
and allergic reaction to the product;
• Very rare (less than one in 10,000 patients): excessive
muscle weakness, difficulty swallowing, and difficulty
swallowing after inhalation of foreign bodies or inhaled
irritants.
The practitioner must also be aware of the possible
reaction of the patient caused by fear, such as light-
headedness, nausea and ringing in the ears.
The practitioner must compulsorily check the patient after
about one week in order to evaluate the response to the toxin
and any asymmetries correctable with a second injection.
1.6.7 Safety of Botulinum: Open Questions
and State of the Art
Does botulinum toxin migrate to the brain?
BoNT relaxes muscles peripherally, its direct effect on
the brain has not been demonstrated.
Some experimental data [57–59], concerning animal
studies, assume a possible migration effect of the toxin.
However, this effect is observed if using massive doses of
toxin well above the therapeutic doses that are commonly
used and recommended. As of today, this data have not
been confirmed by clinical studies on humans.
Does botulinum toxin determine distant effects from the
injection site?
BoNT sometimes can diffuse distally from the injection
site [60] according to some investigations. However, this
does not determine significant clinical consequences. Clin-
ical symptoms that might be observed and attributed to the
diffusion phenomena are mainly fatigability and asthenia
[61, 62]. However, at the standard recommended doses, the
diffusion has been observed only very rarely and has never
resulted in serious consequences [63].
Does botulinum toxin block muscles and cause neuronal
damages?
BoNT blocks muscles since this represents its thera-
peutic effect inducing a temporary chemical denervation.
This determines a muscle relaxation whose entity might be
modulated according to the dose, the targeted muscles and
desired therapeutic and aesthetic effect.
The key benefit of the toxin is based on its temporary and
totally reversible effects [64–66] and thus it cannot provoke
either neurologic permanent or long-term damages.
Does botulinum toxin cause undesired/side effects that
are irreversible?
No. Actually, due to its mechanism of action and its
pharmacological characteristics, the side effects that have
been observed are totally reversible and temporary [67, 68].
Does botulinum toxin freeze the expression of the face?
No, if the toxin is administered according to the appro-
priate dosage and after an accurate preliminary evaluation
[69].
A frozen expression might be observed if the toxin is
used at high doses/dilutions or if the injection is not prop-
erly done.
Is botulinum toxin a poison?
‘All things are poisons and there is nothing that is
harmless, the dose alone decides that something is no poi-
son’—Paracelsus (1493–1541).
Yes, it is commercially available as a pharmaceutical
product, and a pharmaceutical product is, at the end, a
poison [70].
Can botulinum toxin kill?
A review of scientific literature shows that death after
Botox administration for cosmetic indications had never
been documented with standard approved formulations.
Li et al. [71] reported the first death associated with a
Botox–lidocaine mixture given to a woman for chronic neck
and back pain. The cause of death was determined to be
anaphylaxis to the Botox–lidocaine mixture. Chertow et al.
[72] described botulism after cosmetic injections of BoNT in
four patients. An unlicensed and highly concentrated prepa-
ration was used with Doses 2,857 times the estimated human
lethal dose of BoNT. Pretreatment serum toxin levels in 3 of
the 4 case-patients were equivalent to 21–43 times the esti-
mated human lethal dose, a box of toxin taken from the same
manufacturer’s lot contained a toxin amount sufficient to kill
approximately 14,286 adults. The obvious alert is that botulin
toxin is a drug and that black or grey market products can kill!
1.7 Platelet-Rich Plasma
Alessandro Di Petrillo
Platelet-rich plasma (PRP) is an autologous concentration
of human platelets in a small volume of plasma. Since it is a
concentration of platelets, it is also a concentration of the
protein growth factors contained in platelets. Those factors
are proven to be important to initiate all wound healing [73].
Table 1.2 Definition of PRP—FDA specified standards for PRP
pH over 6.2
Mean platelet recovery C50 %
The platelet viability and integrity must be demonstrated by the
ability to:
••Express P-selectin upon specific ADP stimulation
••Resist to a hypotonic stress
••Aggregate in response to collagen
14 M. Goisis et al.

24. PRP is more than just a platelet concentrate (Table 1.2),
and it also contains proteins in plasma known to act as a
matrix for bone, connective tissue and epithelial migration
(fibrin itself, fibronectin and vitronectin) (Table 1.3).
There are many different PRP kits. A brief revision of the
main commercially available kits is reported.
It should be noted that really high platelet concentrations
are not necessarily associated with better results. Some
studies demonstrated that not so high concentration PRP
show better results for wound healing than too highly
concentrated PRP, with better results when platelets where
2.5 times more concentrated than physiologically [74–77].
Therefore preparation devices that yield higher concen-
trations should be avoided. Devices containing separating
gel allow regulation of concentration.
Results are probably more associated with the total number
of available platelets recovered then with their concentration.
1.7.1 Mechanism of Action
PRP works trough the degranulation of the granules con-
tained in platelets (Table 1.4). The active secretion of these
growth factors is initiated by the clotting process of blood
and begins within 10 min after clotting. More than 95 % of
the pre-synthesized growth factors are secreted within 1 h.
Therefore, PRP must be developed in an anticoagulated state
and should be used within 10 min of clot initiation (Fig. 1.7).
After the initial burst of PRP-related growth factors, the
platelets synthesize and secrete additional growth factors
for the remaining 7 days of their life span. Once the platelet
is exhausted and dies off, the macrophage, which has
reached the region via the vascular in-growth stimulated by
the platelets, assumes the function of wound healing regu-
lation by secreting some of the same growth factors as well
Table 1.3 Comparison of medical devices for PRP preparation
Technology Device
name
Concentration
factor
Platelet
recovery
(%)
Blood
vol.
(ml)
Vol.
of
PRP
(ml)
Specific
apparatus
Product
Floating buoy or
shelf
Biomet 6-9 X 70 27 3 Yes Buffy coat product: concentrated
platelets, concentrated white blood cells
and variable amount of red blood cells
GPS III
Harvest 4 X 70 18 3 Yes
SmartPrep2
Computer aided
systems
Cytomedix 4 X 70 40 4 Yes
Angel
Arteriocyte 5 X 65 26 6 Yes
Magellan
Separating gel Cascade
Fibrinet
1.2 X 65 8 4.5 No Platelet suspension in plasma,
physiological or lower value of white
blood cells, very low contamination of
red blood cells
Selphyl
RegenTHT 1.7 X 95 8 4.5 No
RegenBCT 1.6 X 80 8 4.5 No
Centrifugation and
manual aspiration
Arthrex
ACP
2 X 60 10 3 Yes No physical separation of red blood
cells. Operator dependant results
BTI PRGF 2-3 X 50 8 4 No
Endoret
Table 1.4 Growth factors in PRP
TGF-
beta
Transforming growth
factor b
Stimulates cell proliferation
Promotes extracellular matrix
production
Stimulates angiogenesis
PDGF-
AB
Platelet-derived
growth factor
Stimulates cell proliferation
Stimulates fibroblasts chemotaxis
bFGF Fibroblast growth
factor
Stimulates fibroblasts
proliferation
IGF Insulin-like growth
factor
Stimulates cell proliferation
Promotes collagen synthesis
Stimulates fibroblasts migration
VEGF Vascular endothelial
growth factor
Stimulates endothelial cell
proliferation and migration
EGF Epidermal growth
factor
Stimulates angiogenesis
Regulates extra cellular matrix
turnover
Stimulates fibroblasts migration
and proliferation
1 Fillers in Aesthetic Medicine 15

25. as others. Therefore, the number of platelets in the blood
clot within the graft sets the rate of wound healing. PRP
merely increases this number.
Pro-inflammatory and growth factors also contained in
white blood cells play an important role. In particular,
monocytes and lymphocytes are capable of producing
growth factors (VEGF and TGFb) and other proangiogenic
factors that play an essential role in neo vascularization and
granulation tissue formation. They are also involved in
matrix remodelling and resolution of fibrosis.
Neutrophils are instead associated with tissue damage,
delayed rates of healing and increased risk of scar.
1.7.2 Indications
In Aesthetic Medicine and surgery PRP is indicated for:
• Biorejuvenation of the skin, when injected intradermally.
• Hair regrowth in male and female with alopecia
androgenetica.
• Hair thickening in both sexes.
• Mixed with fillers and graft of alloplastic biomaterials.
• Mixed with fat graft in lipo-sculpturing.
1.7.3 How To
Important tip: the patient should be asked to interrupt any
Non-Steroideal Anti-Inflammatory Drugs (NSAIDs) for at
least 3 days before the treatment (7 days would be better)
since this drugs inhibit Platlet Activation and hence PRP
effect.
Atypical NSAIDs such as Acetaminophene (Paraceta-
mol) or Metamizole (Noramidopirine) can be used instead if
necessary.
In this section, we explain how to obtain a PRP. Re-
genLab
RegenACR
EXTRA Kit were used.
1.7.4 Methods
Step 1: Collecting whole blood
Perform a venous puncture using the butterfly needle
connected to the collection holder.
Wait for the presence of blood in the flexible tube, under
the yellow plastic section (the blood is visible over
1–2 mm). Pierce the stopper of the tube to fill with the
whole blood using the internal needle of the collection
system. The vacuum within the tube will enable automatic
collection of the necessary volume of blood (about 8 ml).
Carefully turn the tube upside down several times
(Figs. 1.8, 1.9, 1.10, 1.11, 1.12).
Step 2: Centrifugation
It is essential to always correctly balance the centrifuge
before starting it. If necessary, fill a counterbalance tube
with water until it reaches the same volume as the blood in
the collecting tube. Insert the filled tubes into the centrifuge
facing each other to balance the machine.
Fig. 1.7 Process of wound
healing
Fig. 1.8 Picture of the kit
16 M. Goisis et al.

26. Fig. 1.9 Illustration of the
content of the kit
Fig. 1.10 Instructions for whole
blood collection and
centrifugation
Fig. 1.11 Picture of venous access Fig. 1.12 Venous blood collection
1 Fillers in Aesthetic Medicine 17

27. Centrifuge for 5–10 min at 1,500 g.
Pay attention: centrifugation speed (expressed in Revo-
lutions Per Minute, rpm) does not match with the centri-
fugation power (expressed in g). Check your centrifuge
manual to find the correspondence (Fig. 1.13).
Step 3: Centrifugation results
After centrifugation, the blood is fractionated; the red
blood cells are trapped under the gel, and cellular elements
settle on the surface of the gel (Fig. 1.14).
Step 4: Homogeneization
By gently inverting the Regen BCT tubes several times,
proceed to the re-suspension of the cellular deposit in the
supernatant. About 4 ml of PRP will be obtained for each
tube (Fig. 1.15).
Step 5: Collecting the (PRP) in a syringe
Collect the desired quantity of PRP with a 5-ml Luer-
Lock syringe previously screwed to the transfer device
(Fig. 1.16a, b).
Step 6: (Optional): Addition of Calium Gluconate:
Calcium gluconate is a pro-coagulant and inhibits the
effects of the sodium citrate anticoagulant used in the tube.
Theoretically, calcium gluconate should enhance PRP
effects by inducing a fast clotting formation.
Calcium gluconate is sold as a 10 % sterile solution or
can be found in commercial kits. Calcium gluconate is
preferable to calcium chloride (10 %) since it contains 3
times less calcium per mL and is much easier to calibrate.
An excess of calcium in the solution inhibits the clotting
formation, hence the PRP effect.
Stimulating the clotting formation through calcium
should instead enhance the platelet activation and create a
solution that will coagulate immediately after the injection.
Clotting formation in dermis creates a ‘growth factor rich-
matrix’ which must be reabsorbed through granulation tis-
sue formation and monocyte activation, multiplying the
effect of the PRP.
The maximum calcium gluconate addition should be
0.1 mL for each millilitre of PRP obtained (Fig. 1.17)
(Table 1.5).
This ‘calcium gluconate/PRP’ ratio yields the fastest
clotting formation, obtaining a clot in 3–10 min depending
on individual factors. This time is sometimes is too short
and implies intra-syringe clotting formation and loss of the
product contained in the syringe. Hence, lower ratios are
recommended, such as 0.05 mL calcium gluconate per
millilitre of PRP, which results in a 10–20 min clotting
formation time (Figs. 1.17, 1.18, 1.19).
Fig. 1.13 Centrifugation
Fig. 1.14 Results of centrifugation
18 M. Goisis et al.

28. Fig. 1.15 Platelets and plasma homogeneization
Fig. 1.16 a, b Collecting the (PRP) in a syringe Fig. 1.17 Aspiration of 0.09 mL of CaGlu in a 1 mL syringe
1 Fillers in Aesthetic Medicine 19

29. Step 7: Injection
PRP can be used on scalp for hair regrowth, intrader-
mally for skin rejuvenation, or as filler when mixed with
calcium hydroxylapatite.
For biorejuvenation
With or without calcium gluconate addition, injected
superficially, in the dermis. Multiple small injections, pi-
cottage technique.
For scalp
With or without calcium gluconate addition, injected
superficially, in the dermis. Multiple small injections, pi-
cottage technique (Fig. 1.20).
1.8 Combining PRP with Calcium
Hydroxylapatite (Radiesse) as a Filler
A large number of publications document the efficacy of
PRP, especially on bone graft transplantation. Several stud-
ies, especially those conducted by Marx et al., document a
reducedhealingtimeandabetterengraftmentinalveolarbone
grafting using auto-transplantation, xeno-transplantation,
Porous polyethylene [Medpor
] or the use of heterologous
calcium hydroxylapatite sponge matrix [78–84].
The combination of calcium hydroxylapatite (Radiesse
)
with PRP has the aim inducing collagen formation. Due to
the elevated content of growth factors, PRP should induce
new collagen matrix formation and possibly transform a
filler in a cell-populated autologous tissue [85].
1.8.1 How To
A detailed discussion on how to perform a malar area
augmentation with this technique is reported in Chap. 6.7.
1.9 Summary
An overview of the materials most commonly used in
aesthetic medicine is given in Table 1.6, with some exam-
ples of their trademarks and the areas where they are
commercialized.
Fig. 1.18 Transfer of 0.91 mL
of PRP in the previously CaGlu
loaded 1 mL syringe
Fig. 1.19 The 1 mL syringe is
loaded with 0.09 mL of CaGlu
and 0.91 mL of PRP
Table 1.5 Calcium gluconate
Calcium gluconate 10 % (mL)/
PRP (mL) ratio
Mean empiric coagulation
time (min)
[0.1 Massive uncontrolled clotting
formation
0.1 (0.1 mL CaGlu per mL PRP) 3–10 min
0.05 (0.05 mL CaGlu per mL PRP) 10–20 min
Fig. 1.20 Injection in the scalp
20 M. Goisis et al.

30. Table 1.6 Overview of the most common materials used in aesthetic medicine as fillers and some examples of their commercial name
class Commercial name Company Commercialization Chapter
PARAFFIN Liquid paraffin No company Do not use 1.1
SILICONE Liquid silicone No company Do not use 1.1.1
BOVINE
COLLAGENE
Zyderm I, II and Zyplast Inamed an Allergan division not available 1.2.1
PORCINE
COLLAGENE
Evolence Johnson and Johnson not available 1.2.1
AUTOGENIC
HUMAN
COLLAGEN
Autologen Collagenesis USA 1.2.3
ISOGENIC HUMAN
COLLAGEN
Alloderm, Cymetra Lifecell USA, European Union 1.2.4
Isogenic human
collagen
Dermalogen Collagenesis USA 1.2.4
Low viscosity
Hyaluronic Acid
Belotero soft Merz Europe 24.2
Emervel touch Galderma Europe 24.4
Glytone 1 and 2 filler MerzPharma Europe 24.5
Hyacorp fine BioSience GmbH Europe, Japan and Middle
East
24.6
Ephyal BioSience GmbH Italy, Russia, Ukraine 24.6
Juvederm Hydrate ALLERGAN Europe 24.7
NEWEST and IALEST MASTELLI SRL Europe and Russia 24.15 and 24.18
Restylane Vital and Vital Light Galderma Europe 24.21
Surgiderm 18XP Allergan Europe 24.22
Medium viscosity HA Belotero basic and B.intense Merz Europe 24.2
Emervel classic, deep, and lips Galderma Europe 24.4
Glytone 3 amd 4 filler MerzPharma Europe 24.5
Hyacorp face and lips BioSience GmbH Europe, Japan and Middle
East
24.6
Juvederm ULTRA 2 ,3 and 4,
ultra smile,VolbellaamdVolift
ALLERGAN Europe 24.8- 24.12
Haequo and haequo plus Genethia Europe 24.13
Restylane, R. Perlane,
R.Lip volume and R.Refresh
Q-med a Galderma division Europe and USA 24.20
Surgiderm 24XP and 30XP Allergan Europe 24.22
Hight viscosity HA Emervel Volume Galderma Europe 24.4
Hyacorp H/S 500 and Hyacorp L BioSience GmbH Europe, Japan and Middle
East
24.6
JuvedermVoluma ALLERGAN Europe 24.10- 12
Restylane Sub Q Q-med a Galderma division Europe and USA 24.20
Glytone 4 Filler MerzPharma Europe 24.5
(continued)
1 Fillers in Aesthetic Medicine 21

31. Acknowledgement Heartfelt thanks go to Marco Zoccolan of Regen
Lab
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class Commercial name Company Commercialization Chapter
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24 M. Goisis et al.

34. 2
Aesthetic Analysis of the Face: The Maxillofacial
Deformity
Giada Anna Beltramini, Francesco Laganà, Alessandro Baj,
Michele Romano, Antonio Russillo, and Aldo Bruno Giannı̀
2.1 Facial Analysis
Facial analysis involves evaluation of functional and aes-
thetic disharmonies. It is important to appreciate what
constitutes ones own perceptions of beauty and how the
clinician can translate this into successful clinical results
[1–4]. Facial analysis together with clinical bite examina-
tion should provide good diagnosis and treatment plan.
Facial analysis identifies positive and negative facial traits
and dictates how the bite will be corrected to optimize
aesthetic facial goals. ‘The bite indicates a problem; the
face indicates how to treat the bite’ Arnett affirms [5]. Ideal
occlusal harmony is achieved with the desired cosmetic
facial changes. These facial changes dictate what ortho-
dontic or surgical procedures or medical aesthetic treatment
should be chosen [6]. Natural head position, centric relation,
first tooth contact and relaxed lip position are necessary to
accurately assess the face. The patient should be in relaxed
lip position to demonstrate the relationship of soft tissues
relative to hard tissues without muscular compensation for
dentoskeletal abnormalities. The clinical examination starts
from the oral cavity: the occlusal classification is deter-
mined, and the degrees of incisor overlap and overjet are
quantified (Table 2.1), (Figs. 2.1, 2.2, 2.3).
The maxillary and mandibular dental midlines are
assessed to determine whether they are congruent with each
other and with the facial midline. Deviations are noted and
quantified. The presence and degree of dental compensation
is also recorded. Dental compensation is the tendency of
teeth to tilt in a direction that minimizes the dental mal-
occlusion. Compensation will camouflage the deformity and
restore proper overjet and overlap. If orthodontic tooth
movement cannot produce the necessary facial changes,
then surgery should be indicated.
G. A. Beltramini F. Laganà A. Baj M. Romano A. Russillo
A. B. Giannì ()
Maxillofacial Surgery, Ospedale Maggiore Policlinico,
via Sforza 35, 20123 Milan, Italy
e-mail: aldo.gianni@unimi.it
Table 2.1 Occlusal classifications and orthodontic terminology
Class I occlusion The mesiobuccal cusp of the first permanent
maxillary molar occludes in the buccal groove
of the permanent mandibular first molar
See Fig. 2.1
Class II
malocclusion
The mesiobuccal cusp of the first permanent
maxillary molar occludes mesial to the buccal
groove of the permanent mandibular first molar
See Fig. 2.2
Class III
malocclusion
The mesiobuccal cusp of the first permanent
maxillary molar occludes distal to the buccal
groove of the permanent mandibular first molar
See Fig. 2.3
Overjet Overjet is a horizontal (anterior-posterior)
distance, of the upper incisors ahead of the
lower incisors. Normal overjet is between
1 and 3 mm
Negative overjet Negative overjet or reverse overjet is where the
upper incisors are behind the lower incisors
See Fig. 2.3
Overbite Overbite is a vertical distance, the maxillary
incisors overlap the mandibular incisors.
Normal overbite is between 3 and 5 mm
Open bite or
apertognathia
Overbite B0 mm. Is a type of malocclusion
characterized by the occlusion of posterior
teeth without anterior occlusion
See Fig. 2.5
Deep bite Deep bite is an increase of the overbite
([5 mm)
See Fig. 2.7
Crossbite Crossbite is an occlusal irregularity where a
tooth (or teeth) has a more vestibular or lingual
position than its corresponding antagonist tooth
in the upper or lower arcade
See Fig. 2.5
M. Goisis (ed.), Injections in Aesthetic Medicine,
DOI: 10.1007/978-88-470-5361-8_2, Springer-Verlag Italia 2014
25

35. 2.2 What’s Beauty?
Clinical facial analysis [7] defines appearance, proportions,
volumes, symmetry and visible deformities; it is a crucial
phase of surgical planning that can visualize, evaluate and
prioritize existing problems. But what determines beauty?
The canons of beauty have changed over time. The harmony
of shapes related to ‘gold number’ or ‘divine proportion’ to
which artist were inspired in every period of history for
their representations (Da Vinci, Vitruvio, Botticelli). Some
features symbolize an idea or feeling and inspire emotions
absolutely unique in the observer. ‘Regions of Interest’, or
‘facial points of interest’, theorized from Yarbus, are angles,
maximal curvature points and unpredictable curve of the
outline (curve that change in the different positions of
vision): the lip commissure and the lateral and medial
Fig. 2.1 Intraoral photograph of Class I occlusion (a). Despite normal
interdental relationships, the aesthetical examination of the same
patient (b) documents a jaws biprotrusion. The surgical correction
consisted of superior and inferior dentoalveolar osteotomies. (c) Post-
operative lateral view
Fig. 2.2 Class II malocclusion
Fig. 2.3 Class III malocclusion
1/3
1/3
1/3
1/3
Fig. 2.4 Frontal facial analysis. The ideal face is vertically divided
into equal thirds by horizontal lines adjacent to trichion, glabella, nasal
base, and menton. The lower third is divided into two parts: the upper
lip makes up the upper third, and the lower lip and chin compose the
lower two-thirds
26 G. A. Beltramini et al.

36. canthus are angular points of interest; the root of the nose
and the labial-mental furrow are concavities and the tip of
the nose, superior and inferior lip and chin are convexities.
In the past, notions of beauty were envisaged as arbitrary
cultural conventions with no uniformly accepted standard of
what constitutes an attractive face. However, during the last
decade, a greater understanding of the shared preferences
for attractive faces has led researchers to regard certain
aspects of facial attraction as inherent and definable, tran-
scending social and cultural fashions. Some studies sug-
gested that female face attractiveness is greater when the
face is symmetrical, is close to the average, and has certain
features (e.g. large eyes, prominent cheekbones, thick lips,
thin eyebrows and small nose and chin) [8, 9]. Symmetry is
a characteristic of attractive faces, but there are some
exceptions to the rule. Under certain conditions, symmetry
can be completely unattractive; the visual impact of sym-
metry on the perception of beauty increases significantly
when approaching the midline [10]. The frontal facial view
(Fig. 2.4) [11] provides information on the midlines, levels,
outline and heights of the face. In particular, orbital rim,
subpupil and alar base contours are noted. Vertical facial
planning of facial or occlusal cants, midline deviations and
general facial outline is determined by information gained
from the clinical facial examination. The facial evaluation
begins with assessment of these vertical facial thirds:
trichion to glabella, glabella to subnasale, and subnasale to
menton; each of these facial thirds should be about equal
(Figs. 2.5, 2.6). The most important factor in assessing the
vertical height of the maxilla is the degree of incisor
showing while the patient’s lips are in repose. A man should
show at least 2–3 mm, whereas as much as 4–5 mm is
considered attractive in a woman. If the patient shows the
correct degree of incisor in repose, but shows excessive
gingival in full smile, the maxilla should not be impacted
(Fig. 2.7). The intercanthal distance should be the same as
the distance between the medial and lateral canthus of each
eye. The inferior orbital rims, malar eminence, and piriform
areas are evaluated for the degree of projection. If these
regions appear deficient, maxillary advancement is indi-
cated. The alar base width should also be assessed prior to
surgery since Le Fort I osteotomy may alter the width.
Asymmetries of the maxilla and mandible are documented
on physical examination, and the degree of deviation from
the facial midline is noted. The soft-tissue envelope of the
upper face is evaluated for descent of the malar fat pads, the
severity of the nasolabial creases and folds. These changes
are associated with aging; however, skeletal movements of
the maxilla will affect these areas. It is important for the
Fig. 2.5 Long face syndrome. A ‘long face’ is a long, narrow face,
with anterior and posterior maxillary overgrowth, a narrow alar base
and lip incompetence. Cephalometric analysis demonstrates steep
mandibular and occlusal planes in relationship to the cranial base, and
increase in facial height and retroposition of the mandible. Evaluation
of study models exhibits increased alveolar bone height, a high palatal
vault, and a narrow maxillary arch. The dental relationship may be
Class I, II or III (with Class II being the most common), with or
without open bite. Clinical (a) and intraoral (b) views of long face, II
class, transversalmaxillaryhypoplasia. The treatment plan is divided in
two steps: first an orthosurgical expansion, second a Le Fort I
maxillary osteotomy for superior repositioning of the maxilla, BSSO
and mentoplasty. c and d pictures show the aesthetic and occlusal
improvements after surgery
Fig. 2.6 Short face syndrome. A ‘short face’ is marked by Class II
malocclusions with skeletal deep bite and reduced facial height.
Treatment is aimed at establishing a proper lip–incisor relationship.
The facial skeleton should be expanded to the degree that provides
optimal soft-tissue aesthetics. Inferior repositioning of the maxilla and
clockwise mandibular rotation is indicated to improve facial aesthetics
and function. Clockwise mandibular rotation leads to posterior
positioning of the chin; the surgeon needs to assess the new chin
position on the cephalometric tracing to determine whether an
advancement genioplasty is necessary. Pre-operative facial (a) and
occlusal (b) analysis of a short face syndrome. Frontal (c) and intraoral
(d) appearance after a two-jaw surgery
2 Aesthetic Analysis of the Face: The Maxillofacial Deformity 27