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Aesthetic Facial Anatomy
Essentials for Injections
Aesthetic Facial Anatomy Essentials for Injections is the first title of a series to be published in partnership with PRIME Journal
and the World Society of Interdisciplinary Aesthetic & Anti-Aging Medicine (WOSIAM).

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The WOSIAM is a nonprofit organization based in Paris, and membership is available to anyone who has participated in any
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The WOSIAM board of directors includes Dario Bertossi, editor of Aesthetic Facial Anatomy Essentials for Injections, as well
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 Aesthetic Facial Anatomy
Essentials for Injections

Edited by

Ali Pirayesh, MD, FCC (Plast)

Plastic, Reconstructive and Aesthetic Surgeon
Founder, Amsterdam Plastic Surgery Clinic, the Netherlands
Consultant, Burns and Tissue Regeneration Unit
University Hospital, Gent, Belgium
Research Consultant, University College Hospital, London, UK

Dario Bertossi, MD
Associate Professor of Maxillofacial Surgery
Specialist in Maxillofacial Surgery, Otolaryngology
Facial Plastic Surgeon
Department of Surgery, Dentistry, Pediatrics and Gynaecology
Chief of Maxillofacial Plastic Surgery Unit
University of Verona, Verona, Italy
Professor of Practice, University of London
Centre for Integrated Medical and Translational Research, London, UK

Izolda Heydenrych, MD
Dermatologist, Founder and Director, Cape Town Cosmetic Dermatology Centre
Consultant, Division of Dermatology, Faculty of Health Sciences
University of Stellenbosch, Stellenbosch, South Africa

With Forewords from Mauricio de Maio, Pierfrancesco Nocini, and Foad Nahai
CRC Press
Taylor & Francis Group
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 CONTENTS
Preface.......................................................................................................................................................... vii
Forewords..................................................................................................................................................... viii
Contributors.................................................................................................................................................... ix

A Aesthetic Regions of the Face.............................................................................................................1

Alessandro Gualdi, Michele Pascali, Heidi A. Waldorf, Rene van der Hulst,
Philippe Magistretti, and Dario Bertossi

B Facial Layers..........................................................................................................................................7
Eqram Rahman, Yves Saban, Giovanni Botti, Stan Monstrey, Shirong Li, and Ali Pirayesh

C Aging of Skin, Soft Tissue, and Bone................................................................................................13

Daria Voropai, Steven Dayan, Luis Fernando Botero, Chiara Botti, Leonard Miller,
and Ali Pirayesh

D Myomodulation....................................................................................................................................17
Mauricio de Maio and Izolda Heydenrych

E Botulinum Toxins.................................................................................................................................33
Massimo Signorini, Alastair Carruthers, Laura Bertolasi, Neil Sadick,
Wolfgang G. Philipp-Dormston, and Dario Bertossi

F Absorbable Soft Tissue Fillers: Core Characteristics.................................................................... 44

Ali Pirayesh, Colin M. Morrison, Berend van der Lei, and Ash Mosahebi

G Complications of Absorbable Fillers................................................................................................ 54

Maurizio Cavallini, Gloria Trocchi, Izolda Heydenrych, Koenraad De Boulle,
Benoit Hendrickx, and Ali Pirayesh

1 Forehead..............................................................................................................................................70
Izolda Heydenrych, Fabio Ingallina, Thierry Besins, Shannon Humphrey,
Steven R. Cohen, and Ines Verner

2 Temporal Region and Lateral Brow...................................................................................................94

Krishan Mohan Kapoor, Alberto Marchetti, Hervé Raspaldo, Shino Bay Aguilera,
Natalia Manturova, and Dario Bertossi

v
 Contents

3 Periorbital Region and Tear Trough................................................................................................. 114

Colin M. Morrison, Ruth Tevlin, Steven Liew, Vitaly Zholtikov, Haideh Hirmand,
and Steven Fagien

4 Cheek and Zygomatic Arch..............................................................................................................132

Emanuele Bartoletti, Ekaterina Gutop, Chytra V. Anand, Giorgio Giampaoli,
Sebastian Cotofana, and Ali Pirayesh

5 Nose���������������������������������������������������������������������������������������������������������������������������������������������������152
Dario Bertossi, Fazıl Apaydın, Paul van der Eerden, Enrico Robotti,
Riccardo Nocini, and Paul S. Nassif

6 Nasolabial Region.............................................................................................................................171
Berend van der Lei, Jinda Rojanamatin, Marc Nelissen, Henry Delmar,
Jianxing Song, and Izolda Heydenrych

7 Lips����������������������������������������������������������������������������������������������������������������������������������������������������183
Ali Pirayesh, Raul Banegas, Per Heden, Khalid Alawadi, Jennifer Gaona,
and Alwyn Ray D’Souza

8 Perioral Region..................................................................................................................................198
Krishan Mohan Kapoor, Philippe Kestemont, Jay Galvez, André Braz,
John J. Martin, and Dario Bertossi

9 Chin and Jawline...............................................................................................................................211

Ash Mosahebi, Anna Marie C Olsen, Mohammad Ali Jawad, Tatjana Pavicic,
Tim Papadopoulos, and Izolda Heydenrych

10 Neck and Décolletage.......................................................................................................................226

Kate Goldie, Uliana Gout, Randy B. Miller, Fernando Felice, Paraskevas Kontoes,
and Izolda Heydenrych

Video Appendix: How I Do Regional Treatments.........................................................................................236

Index............................................................................................................................................................237

vi
 PREFACE
Anatomy has long been the compass guiding who enjoy passing on their passion, tips and tricks in
clinicians through the astounding complexity of the this ever expanding field.
human body.
This book by the Aesthetic Facial Anatomy group
Many textbooks of anatomy display the vital structures is a multi-author, cross-specialty consensus on the
and their anatomical relationships in order to guide essential knowledge of clinically relevant anatomy
medical students and physicians, thus enabling them and injection guidelines mandatory for safe, effective
to learn and execute medical treatments. and aesthetically pleasing application of aesthetic
medicine, and is encouraged to be regularly updated
online by the many authors.
We encountered a void in the plethora of anatomical
scripts where both essential clinical anatomy and The men and women who allowed us to explore
an aesthetic eye for beautification and rejuvenation their anatomical structures after their passing
need to merge. Only a paucity of mostly single- in order for us to pass on this knowledge to our
author texts exist on the essential anatomy for peers are the true hero educators which we should
aesthetic medicine. honour. It has been a privilege to work on this
ongoing project.
The global conference platform of Euromedicom and
its network provided us with unparalleled access to Ali Pirayesh, Dario Bertossi, and
the greatest minds in surgical and medical aesthetics Izolda Heydenrych

vii
 FOREWORDS
“We shall not cease from exploration Fillers and toxins have proven to be affordable
And the end of all our exploring and safe treatments for the aging face. Injectables
Will be to arrive where we started continue to gain popularity and are by far the most
And know the place for the first time…” sought after cosmetic treatments worldwide. With
—from TS Eliot, “Little Gidding”, Four Quartets, this increase in demand and popularity, there arises
with permission from Faber & Faber Ltd. the need for appropriate training; a need to assure
safety as well as efficacy of results.
The ancient art of anatomy, which has long I congratulate the editors Dr Pirayesh, Dr. Bertossi
fascinated the human mind, has in recent years and Dr. Heydenrych for bringing together such an
been considerably expanded by the field of aesthetic illustrious group of thought leaders to share their
medicine. This book beautifully demonstrates knowledge and expertise in this book which is
the fascinating detail beneath the surface of our designed to improve results and enhance safety.
everyday work and should form an invaluable The most feared and devastating complication of
practical resource for those passionate about the injectables is intra-arterial injection of fillers leading
field of medicine. to tissue necrosis and vision loss. The chapters
This initiative is aimed at elevating both procedural organized by facial regions accurately describe the
safety and clinical excellence. anatomy in minute detail, with beautiful medical
illustrations and immaculately clear cadaver
I am proud to be part of it.
dissections which highlight the location and course
Mauricio de Maio, MD of blood vessels at risk. The risk to blood vessels
in each location is outlined and safe injection
During my 40 years of practice, I have trained many techniques are recommended that reduce risk.
residents, some of them who are now masters in the This book will be invaluable not only to the novice
field of facial aesthetics, where they are witnesses eager to perfect their injection technique but also to
of the impressive growth this field has undergone those of us who have had years of experience. As
during the last few decades. As a teacher, my someone with a long career as a surgical educator
role has always been to accurately evaluate the and proponent of patient safety, I plan to put this
international scientific production. As I received the book in the hands of all our trainees.
first draft of this comprehensive book, I realized
that its impact on the medical aesthetic field will be Foad Nahai, MD FACS FRCS (Hon)
great as it will provide the reader a solid scientific
knowledge and a practical tool for beginners as well
as for the advanced injectors.
I wish for all readers to understand the deepest
meaning of this work. If culture and learning are
made to light up our minds before our hands, the
result has been achieved.
Pierfrancesco Nocini, MD

viii
 CONTRIBUTORS
Shino Bay Aguilera Emanuele Bartoletti
Dermatologist Plastic Surgeon
Assistant Professor of Dermatology Studio Bartoletti-Cavalieri
Shino Bay Cosmetic Dermatology Fatebenefratelli Hospital
and Laser Institute Rome, Italy
and
Dermatology Department Laura Bertolasi
NOVA Southeastern University Department of Neurosciences
Fort Lauderdale, Florida, USA Unit of Neurology AOUI
Verona, Italy
Khalid Alawadi
Consultant Plastic and Hand Surgeon Thierry Besins
Department of Hand and Reconstructive Plastic Surgeon
Microsurgery Private Clinic
Rashid Hospital Nice, France
Dubai Health Authority
Dubai, United Arab Emirates Luis Fernando Botero
Plastic Surgeon
Clinica Quirofanos El Tesoro
Chytra V. Anand
Medellín, Colombia
Chief Cosmetic Dermatologist
Kosmoderma Clinics
Chiara Botti
Bangalore, India
Plastic Surgeon
Villa Bella Clinic
Fazıl Apaydın Salo, Italy
ENT Surgeon
Department of Otorhinolaryngology Giovanni Botti
Ege University Plastic Surgeon
Izmir, Turkey Villa Bella Clinic
Salo, Italy
Raul Banegas
Plastic Surgeon Koenraad De Boulle
Director of Centro Arenales Dermatologist
Medical Center Aalst Dermatology Clinic
Buenos Aires, Argentina Aalst, Belgium

ix
 Contributors

André Braz Wolfgang G. Philipp-Dormston

Dermatologist Dermatologist
Private Practice Medical Director, Department for Dermatology,
Rio de Janeiro and São Paulo, Brazil Dermatosurgery and Allergology
Clinic Links vom Rhein
Alastair Carruthers Cologne, Germany
Dermatologist
Clinical Professor of Dermatology Paul van der Eerden
University of British Columbia ENT/Facial Plastic Surgeon
and Lange Land Hospital
Private Practice Zoetermeer, the Netherlands
The Carruthers Clinic
Steven Fagien
Vancouver, British Columbia, Canada
Oculoplastic Surgeon
Maurizio Cavallini Aesthetic Eyelid Plastic Surgery
Plastic Surgeon Private Practice
Unit of Plastic Surgery and Dermatology Boca Raton, Florida, USA
CDI Hospital Fernando Felice
Milan, Italy Associate Professor in Anatomy
University of Buenos Aires
Steven R. Cohen
Aesthetic Plastic Surgeon, Private Practice
Plastic Surgeon
Buenos Aires, Argentina
Clinical Professor of Plastic Surgery
University of California, San Diego and Jay Galvez
Private Practice Facial Plastic Surgeon
FACES+ Galvez Clinics
La Jolla, California, USA Makati City, the Philippines
Sebastian Cotofana Jennifer Gaona
Associate Professor of Anatomy Plastic and Reconstructive Surgeon
Department of Clinical Anatomy Founder of Keraderm and INTI Foundation
Mayo Clinic Private Practice
Rochester, Minnesota, USA Bogota, Colombia
Steven Dayan Giorgio Giampaoli
Facial Plastic Surgeon Resident in Maxillofacial Surgery
Clinical Assistant Professor Maxillofacial Surgery Department
University of Illinois University of Verona
Chicago, Illinois, USA Verona, Italy

Henry Delmar Kate Goldie

Plastic Surgeon Aesthetic Physician
Clinique Del Mar Medical Director, European Medical Aesthetics Ltd
Antibes, France London, UK

x
 Contributors

Uliana Gout Fabio Ingallina

Aesthetic Physician Plastic Surgeon
London Aesthetic Medicine Clinic and Academy Private Practice
London, UK Catania, Italy
Alessandro Gualdi
Plastic Surgeon Mohammad Ali Jawad
Clinical Professor Plastic, Reconstructive and
Vita-Salute San Raffaele University Burn Surgeon
Milano, Italy R5 Aesthetic and Healthcare
Karachi, Pakistan
Ekaterina Gutop
Dermatologist Krishan Mohan Kapoor
Actual Clinic Consultant Plastic Surgeon
Yaroslavl, Russia Plastic and Cosmetic Surgery
Per Heden Fortis Hospital
Plastic Surgeon Mohali, India
Associate Professor in Plastic Surgery and
Karolinska Institute
Stockholm, Sweden Honorary Senior Clinical Lecturer
University of London
Benoit Hendrickx London, UK
Plastic Surgeon
Associate Professor Philippe Kestemont
University Hospital Brussels Facial Plastic Surgeon
Brussels, Belgium Saint George
Haideh Hirmand Aesthetic Medicine Clinic
Plastic Surgeon Nice, France
Clinical Assistant Professor of Surgery
Cornell-Weill Medical College Paraskevas Kontoes
New York-Presbyterian Hospital Plastic Surgeon
New York City, New York, USA DrK Medical Group
Athens, Greece
Rene van der Hulst
Head and Professor of Plastic Surgery
Maastricht University Medical Center Berend van der Lei
Maastricht, the Netherlands Plastic, Reconstructive and Aesthetic
Surgeon
Shannon Humphrey Professor, Aesthetic Plastic Surgery
Clinical Assistant Professor Department of Plastic Surgery
Department of Dermatology and Skin Science University Medical Centre Groningen
University of British Columbia Bey Bergman Clinics
Vancouver, Canada Groningen, the Netherlands

xi
 Contributors

Shirong Li Leonard Miller

Professor of Plastic Surgery Plastic Surgeon
Department of Plastic Surgery Founder, Boston Center for Facial Rejuvenation
Third Military Hospital Brookline, Massachusetts, USA
Chongking, China
Randy B. Miller
Steven Liew Plastic Surgeon
Plastic Surgeon Miller Plastic Surgery
Medical Director Shape Clinic Miami, Florida, USA
Darlinghurst, Australia
Stan Monstrey
Philippe Magistretti Professor in Plastic Surgery
Consultant Radiologist and Aesthetic Plastic Surgery, Burns and Tissue Regeneration Unit
Physician Gent University Hospital
The Summit Clinic Gent, Belgium
Crans Montana, Switzerland
Colin M. Morrison
Mauricio de Maio Consultant Plastic Surgeon
Plastic Surgeon St. Vincent’s University Hospital
MD Codes™ Institute Dublin, Ireland
São Paulo, Brazil
Ash Mosahebi
Natalia Manturova Professor of Plastic Surgery
Plastic Surgeon Royal Free Hospitals and University College Hospital
Head, Department of Plastic and Reconstructive London, UK
Surgery
Cosmetology and Cell Technologies Paul S. Nassif
Russian National Research Medical Facial Plastic and Reconstructive Surgery
University Assistant Clinical Professor
Moscow, Russia Department of Otolaryngology – Head and Neck
Surgery
Alberto Marchetti Division of Facial Plastic and Reconstructive Surgery
Plastic Surgeon University of Southern California Keck School of
San Francesco Clinic Medicine
Verona, Italy Los Angeles, California, USA

John J. Martin Marc Nelissen

Oculoplastic Surgeon Plastic Surgeon
Oculo-facial Plastic Surgery Global Care Clinic
Miami, Florida, USA Heusden-Zolder, Belgium

xii
 Contributors

Riccardo Nocini Hervé Raspaldo

ENT Surgery Facial Plastic Surgeon
Department of Otolaryngology Chef de Clinique des Universités
Department of Surgical Sciences, Dentistry, Face Clinic Genève
Gynecology and Pediatrics Geneva, Switzerland
University of Verona
Verona, Italy Enrico Robotti
Plastic Surgeon
Anna Marie C Olsen Chief, Department of Plastic Surgery
Dermatologist Papa Giovanni XXIII Hospital
Private Practice Bergamo, Italy
London, UK
Yves Saban
Tim Papadopoulos Facial Plastic Surgeon
Plastic Surgeon Private Practice
Private Practice Nice, France
Sydney, Australia
Neil Sadick
Michele Pascali Dermatologist
Plastic Surgeon Sadick Dermatology
Plastic Surgery Academy Roma New York City, New York, USA
Rome, Italy
Massimo Signorini
Tatjana Pavicic Plastic Surgeon
Dermatologist Studio Medico Skin House
Private Practice for Dermatology Milano, Italy
and Aesthetics
Munich, Germany Jianxing Song
Professor of Plastic and Reconstructive Surgery
Eqram Rahman Changhai Hospital, Second Military Medical
General Surgeon University
Associate Professor Shanghai, China
Division of Surgery and Interventional
Science Alwyn Ray D’Souza
University College London Plastic Surgery
London, UK London Bridge Hospital
London, UK
Jinda Rojanamatin
Dermatologist Ruth Tevlin
Head of Dermatosurgery and Laser Department Department of Surgery
Institute of Dermatology Stanford University School of Medicine
Bangkok, Thailand Stanford, California, USA

xiii
 Contributors

Gloria Trocchi Heidi A. Waldorf

Specialist in Internal Medicine Dermatologist
Aesthetic Medicine Department Waldorf Dermatology Aesthetics
Fatebenefratelli Hospital Nanuet, New York, USA
Rome, Italy
and
Ines Verner
Dermatologist Associate Clinical Professor
Department of Dermatology and Regenerative Department of Dermatology
Medicine Icahn School of Medicine of Mount Sinai
Verner Clinic New York City, New York, USA
Tel Aviv, Israel
Daria Voropai Vitaly Zholtikov
Aesthetic Physician Plastic Surgeon
AEGIS London Private Practice “Atribeaute Clinic”
London, UK Saint Petersburg, Russia

xiv
A AESTHETIC
REGIONS OF
THE FACE
Alessandro Gualdi, Michele Pascali, Heidi A. Waldorf,
Rene van der Hulst, Philippe Magistretti, and Dario Bertossi

FOREHEAD During the aging process, the forehead surface

increases due to progressive hairline recession and
widening of the orbital rims, with subsequent descent
The superior forehead margin lies at the hairline, whilst of the eyebrows. The lateral forehead aspect remains
the lateral border is formed by the temporal crest where relatively unchanged.
the frontalis and temporalis muscles fuse. The glabella,
frontonasal groove (central), and the eyebrows over- Insightful understanding of the forehead and gla-
lying the supraorbital ridges form the inferior bound- bella is of great clinical importance. The frontalis is
ary (Figure A.1). The forehead does not demonstrate a very superficial muscle which may demonstrate
overt ethnic variations, but is usually shorter in South several anatomical variants which need be taken into
American and Asian patients whilst Caucasians and account for effective treatment with neuromodulators.
Africans have a higher, yet variable forehead height. The corrugator, one of the most important targets for
neuromodulator treatment, lies at the medial orbital
rim. Its medial origin is deep on bone, after which it
courses superolaterally to insert into the skin over the
lateral brow. Here it fuses with inferior frontalis fibers.
Procerus is a vertical, medial muscle lying deep at the
radix of the nose. The supratrochlear and supraorbital
vessels are the major vessels in this area. They are
delineated by overlying creases, and knowledge of
their anatomical depth is of paramount importance
as communications between internal and external
carotid circulations pose a high risk for blindness
after inadvertent intravascular filler injection. Nerves
Figure A.1 The frontal area. and vessels generally follow an adjacent course.

1
 Aesthetic Regions of the Face

It is important to note that a deep branch of the supra- temporal vein. This is a very large vein draining retro-
orbital nerve runs approximately 1 cm medial to the gradely to the jugular vein and inadvertent injection may
temporal crest. To minimize pain or nerve damage, it cause embolism and death. The middle temporal vein
is advisable to avoid injecting this region with sharp anastomoses with the sentinel vein. Injections should
needles. be either very deep or very superficial, and done with
knowledge of the course of the middle temporal vein,
which runs 1–2 cm above the zygomatic arch.

TEMPORAL REGION
EYE AND PERIORBITAL REGION
The temporal region is a well-defined region extend-
ing from the temporal crest to the zygomatic arch
(Figure A.2). The orbital margin forms the anterior The periorbital region extends from beneath the
and hairline the posterior limit. There is little ethnic eyebrow to the zygomatico-malar ligament, and lies
variation in the extent of the temporal region, but in between the nasojugal sulcus and lateral aspect of
African skulls, the temporal bone is very thick, mak- the orbicularis retaining ligament (Figure A.3).
ing temporal hollowing uncommon. The temporal
area contributes to the aging process due to wid- The periorbital region is the area demonstrating the
ening of the lateral orbital margin and concomitant most pronounced age and ethnic variation. In African
underlying bone resorption, thus causing a hollowed, skulls, the orbits are wider and more rectangular,
aged or diseased appearance. The temporal artery and demonstrate earlier onset of bone resorption.
courses from deep to superficial through the tempo- The scant subcutaneous fat and protruded superior
ral fossa. It passes close to the ear, near the root of orbital margin causes a hollow-eyed look due to sig-
the helix, before running in the temporoparietal fascia nificant retraction of the periorbital tissues. Although
to pass approximately 2 cm lateral to the brow. It may the bone structure in Asian patients is similar to
anastomose with the supratrochlear and supraorbital Caucasians, the tendon structure differs and the
vessels, thus comprising another danger zone for upper eyelid forms an epicanthic fold.
potential blindness after inadvertent filler injection.
During the aging process, underlying bone resorp-
The temporal area contains important veins, the tion leads to progressive widening of the orbit. The
most important and dangerous of which is the middle

Figure A.2 The temporal area. Figure A.3 The periorbital area.

2
 Cheek

eyebrows descend, and eyelid skin laxity may cause The deep subcutaneous branch divides close to the
blepharochalasis and ptosis, thus impairing vision. alar nasal sulcus to form the lateral nasal and angular
The site for the neuromodulator injection is usually arteries. In Africans, short noses with large nostrils
in the lateral preseptal orbicularis oculi muscle where and tips are characteristic. The central maxilla is well
there is no vascular danger zone. The use of neuro- developed and protrudes anteriorly. The nasal dor-
modulators in the upper eyelid is not recommended, sum is usually flat and the radix is located slightly
because of the high risk of upper eyelid ptosis. The above the intercanthal line. Asian patients have a flat
upper lid is a highly dangerous zone for filler injec- nose, low radix and underrepresented dorsum. The
tions as connections between the supratrochlear, nostrils are thin, and the tip is usually very short and
medial palpebral and ophthalmic arteries may lead to rounded. With aging, the nasal cartilage enlarges and
blindness after inadvertent intravascular filler place- the nasal bone cavity widens. The cartilage becomes
ment. It is thus imperative to have insightful anatomy thinner and the tip falls downward. Although the bony
knowledge and to use a cannula when treating the dorsum does not change in older patients, it may
A-frame deformity of the upper eyelid. become thinner, with a “sharper” edge. The lateral
nasal vessels run above the alar groove to provide
vascularization to the tip of the nose, together with
an artery coming from the superior labial artery and
NOSE passing through the columella. The tip is highly vas-
cularized, especially in the superficial plane.
The nose is ethnically distinct, with variable bone
structure and cartilage development. The radix of the nose is also a dangerous area due
to the arborization of vessels. It is important to inject
It extends from the radix superiorly, to the nostrils on the periosteum to avoid embolization or compres-
and the columella inferiorly, and naso-jugal grooves sion of especially the dorsal branch of the supra-
laterally (Figure A.4). trochlear artery. Close to the radix, just below the
medial canthus, the angular and facial veins anas-
The nose represents a vascular danger area. Above tomose before draining into the cavernous sinus,
the modiolus, the facial artery superficializes and making this an important danger zone. It is advised
branches in two. that injections are placed from lateral to medial, with
massage toward the more medial location. Using a
cannula may prevent complications. The mid-third
dorsal aspect of the nose is considered the safest
injection area.

CHEEK

The cheek lies in the infraorbital region, extend-

ing laterally from the ear to the nose (above) and
mouth (below) in the medial aspect (Figure A.5).
Figure A.4 The nasal area. African patients have larger cheeks and pronounced

3
 Aesthetic Regions of the Face

the medial limbus. It is important to avoid intravascular

injection by placing injections lateral to the foramen.
Avoid embolization into the facial vein, which runs from
the mandibular angle to the medial orbital canthus.

LIPS AND PERIORAL REGION

The perioral region comprises the lips and area

­corresponding to the orbicularis oris muscle (Figures
A.6 and A.7).

Figure A.5 The cheek area. Whilst the extent of the mouth region does not vary
among ethnicities, lip proportions do. African and
Mediterranean patients generally have bigger lips,
zygomatic bones, both frontally and laterally, whilst a while Asian, North European, and North American
prominent central maxilla often prevents a flat-faced patients have thinner lips.
appearance.

Asian patients also have pronounced cheekbones,

but the flatter nose and small maxillary bones con-
tribute to the typically flatter Asian face. The cheek
fat compartment is usually well developed.

With aging, widening of the orbital and nasal cavi-

ties and thinning of bone cause soft-tissue sagging,
thus enhancing the nasolabial folds, tear troughs and
marionettes lines.

The facial nerve originates near the ear lobe, deep

to the parotid gland, after which it divides into five Figure A.6 The perioral area.
branches after emerging from the anterior parotid
border. The frontal nerve superficializes above the
zygomatic arch, where it accompanies the superficial
temporal artery. This represents a danger area.

The facial fat compartments are very well defined

and may be divided into superficial and deep groups.
Volumizing certain compartments ensures maximal
projection, whilst injecting into others may induce sag-
ging (see Cheek chapter). The infraorbital nerve enters
the face via the infraorbital foramen which lies 6–8 mm
below the infraorbital rim on a perpendicular line at Figure A.7 The lip area.

4
 Jaw

Elderly patients also present with thinner lips. In the

case of total or partial edentulism, there may be
moderate to severe alveolar crest atrophy, causing a
retraction of the lips and perioral tissue with shorten-
ing of the nose-chin length.

Several muscles insert into the modiolus to exert

an effect on smiling. Zygomaticus major is stronger
in effecting an upwards or zygomatic smile. As the
elevators weaken with age, risorius may dominate Figure A.8 The chin and jawline area.
to cause a more horizontal smile. Eventually, the
depressor anguli oris (DAO) may dominate to cause
a downwards smile. The zygomaticus minor, levator mandible. In elderly or edentulous patients, the fora-
labii superioris, and levator labii superioris aleque men is usually closer to the alveolar ridge. Injecting
nasi insert into the upper lip. the mental nerve may cause permanent dysesthesia,
paresthesia, or anesthesia of the lower lip.
After passing below the commissure, the facial artery
superficializes and divides into superior and inferior
labial branches. The superior labial artery penetrates JAW
the orbicularis oris to enter the lip, running at the junc-
tion of the dry and wet mucosae. The inferior labial
artery originates from the facial artery below the The jaw area extends from the DAO (anteriorly) to
commissure, and runs from deep to superficial close the temporomandibular joint posteriorly; inferiorly, it
to the mucosa. Inferiorly, there is more variation in is defined by the bony margin of the jawline (Figure
morphology. A.9). There are no technically specific aging changes
other than soft-tissue sagging. The facial artery
crosses the mandible approximately 1 cm anterior to
the anterior border of the masseter. The latter is the
CHIN strongest muscle in the body.

The chin lies between the DAO (laterally), inferior

margin of the orbicularis oris (superiorly) and man-
dibular margin inferiorly (Figure A.8). African patients
have a wider chin, thicker bone, and more prominent
lower maxilla.

Asians often present a retracted maxilla and smaller

chin. Apart from soft-tissue sagging, aging does not
affect the chin area directly. However, anterior protru-
sion may result due to loss of occlusion in edentulous
patients. Although the chin is a relatively safe area
to treat, it is important to note the emergence of the
mental nerve just below the two premolars of the Figure A.9 The neck.

5
 Aesthetic Regions of the Face

NECK the anterior border of the sternocleidomastoid, the

midline of the neck, and inferior border of the man-
dible. The posterior triangle is defined as the area
The neck is defined as the anatomical area o­ riginating bounded by the posterior border of the sternocleido-
anteriorly from the inferior surface of the mandible, mastoid (SCM), anterior border of the trapezius and,
running to the superior surface of the manubrium inferiorly, the lateral third of the clavicle. The visible
sterni. The posterior neck borders are bounded anterior triangle is the predominant focus of aesthetic
superiorly by the occipital bone of the skull and infe- treatments. With aging, the neck develops increased
riorly by the intervertebral disc between CVII and T1. soft tissue laxity, excess skin, fat accumulation and
The neck is further divided into anterior and poste- loss of the cervicomental angle.
rior triangles. The anterior triangle is bounded by

6
B FACIAL LAYERS
Eqram Rahman, Yves Saban, Giovanni Botti,
Stan Monstrey, Shirong Li, and Ali Pirayesh

The face, with its diverse ability to portray emotions However, Mendelson and Wong (2013) have posed
whilst communicating, is one of the most uniquely that a more global understanding is facilitated by
recognizable areas of the human body. An increasing distinguishing between functional regions and con-
interest in facial aesthetics, coupled with consider- sidering the anatomy in terms of a layered construct
able research, has extended our understanding of bound together by retaining ligaments.
the facial layers and the subtle physical variations
resulting from underlying bone structure and genetic Seven major layers may be differentiated [2] (see
factors. With progressive aging, the face undergoes Figure B.1):
asynchronous changes which may present unique
surgical challenges. Insightful understanding of facial 1. Skin
anatomy as pertaining to the aging process facilitates 2. Superficial fat
treatment planning and predictable outcomes [1]. 3. Superficial muscular aponeurotic system (SMAS)
Traditionally the face has been divided into upper, 4. Muscle
middle and lower horizontal thirds with the upper face 5. Vasculature
extending from the trichion to the glabella, the mid- 6. Deep fat
face from glabella to the subnasale, and lower face 7. Bone
extending to the menton.

Figure B.1 The schematic illustration of the facial layers.

7
 Facial Layers

SKIN The superficial and deep layers are separated by

the superficial muscular aponeurotic system (SMAS).
Superficial fat is understood to be separated into
The skin represents the superficial layer of the face unique compartments, which are divided by fascial
and is an important indicator of age. In youth, the skin septae containing vascular structures [2,5]. The
is smooth, firm, unblemished, and retains a uniform major role of the fat layers is as a gliding plane for
texture [3]. The skin may be histologically divided into the facial mimetic muscles [5].
epidermis and dermis, with the dermis consisting of
collagen, elastic fibers, and ground substance com- The superficial fat compartments comprise the
prising mucopolysaccharides, hyaluronic acid, and nasolabial, medial, middle, and lateral temporal-
chondroitin sulphate [3]. cheek, central, middle, and lateral temporal-cheek
(found within the forehead) and superior, inferior,
Cutaneous aging often escalates from the fourth and lateral orbital fat pads. The nasolabial fat,
decade under the influence of contributory genetic, located medial to the cheek fat pads, plays a pro-
hormonal, behavioural and environmental factors nounced role in sagging of the nasolabial fold. The
[3,4]. During soft tissue aging, the two distinct pro- orbicularis retaining ligament (ORL) is situated
cesses of deflation and descent manifest as excess 2–3 mm below the inferior orbital rim and forms the
skin [5]. Wrinkles start to appear in the lower eyelids superior border of both the nasolabial and medial
and lateral orbital areas, along with the development cheek fat compartments. The middle cheek fat com-
of dyschromia, textural changes, pigmentation, dry- partment, juxtaposed between the medial and lat-
ness, thinning, folds, drooping, and mimetic lines [3]. eral temporal-cheek fat compartments, contains a
The midface is particularly susceptible to UV-induced superior fascial border known as the superior cheek
aging, with the subsequent development of rough, septum [2].
wrinkled and leathery skin carrying a higher inci-
dence of telangiectasias, premalignant conditions The individual fat compartments age at different
and malignancies. Other causes of extrinsic aging tempi and vary metabolically, thus contributing to
include smoking, pollution, infrared-A radiation and segmental loss of fullness and the stigmata of aging.
also visible light [3,4]. Recent advances in the under- The periorbital, forehead, malar, temporal, mandibu-
standing of volume loss as a critical component of lar, mental, glabellar, and perioral sites are prone to
facial aging, and the subsequent integration of vol- volume loss, whilst the nasolabial and inferior jowl
ume replacement into both surgical and non-surgical compartments may hypertrophy. The infraorbital and
treatment algorithms, arguably represents one of the malar fat pads often become more prominent, with
most significant advances in the field of facial reju- anterior protrusion of the malar fat causing it to bulge
venation [6]. against the nasolabial crease, thus emphasizing the
nasal fold [6]. It is important to understand that indi-
vidual fat pads behave differently after injection with
fillers, with inferior displacement of the superficial
SUPERFICIAL FAT nasolabial, middle cheek, and jowl compartments
after injection. However, injection into the medial and
In youth, the facial fat consists of a diffuse, bal- lateral cheek and superficial temporal compartments
anced spread of superficial and deep fat which cre- lead to an increase in local projection without inferior
ate the different arcs and convexities of the face. displacement.

8
 Muscle

SUPERFICIAL MUSCULAR should be performed deep to the superficial tempo-

APONEUROTIC SYSTEM (SMAS) ral fascia in order to avoid accidental denervation-
related injuries [2].

The SMAS, which has been recognized since 1799,

is a unique subcutaneous fascia which is continu-
ous with the platysma below and galea above. It DEEP FAT
acts as an investing fascia for the facial mimetic
muscles, thus playing an important role in facial
expression [2,5]. The SMAS is firmly adherent to The deep fat comprises the medial and lateral sub-
the parotid–masseteric fascia in the lateral aspect, orbicularis oculi fat (SOOF), and the deep medial
where it is known as the immobile SMAS. The facial cheek fat. Whilst the majority of the SOOF is found
retaining ligaments, which originate from either the inferior to the lateral aspect of the infraorbital rim, it
periosteum (zygomatic and mandibular retaining is also found underneath the orbicularis oculi muscle
ligaments) or underlying muscle fascia (masseteric [7]. Other deep fat compartments include the tem-
and cervical retaining ligaments) transmit through poral fat pad and a deep addition of this pad known
the SMAS to the overlying skin and serve as barri- as Bichat’s fat pad [3]. The deep, supraperiosteal
ers between the superficial and deep facial fat com- fat layer is located beneath the SMAS. Although the
partments [12]. Neurovascular structures, or “facial SMAS is sandwiched between fat layers, there are
danger zones,” are located between these retaining bilaminar connecting membranes or fusion zones
ligaments [4]. containing neurovascular structures [7]. Compared
with the superficial fat layer, the deep fat layer is com-
Superiorly, the SMAS passes over the zygomatic posed of segmental, large white lobules containing a
arch to meet with the superficial temporal fascia [5]. scant system of thin fibrous septae [3]. With aging,
The SMAS is considerably thicker over the parotid the deep fat layers may disintegrate and descend,
gland, but thins substantially as it courses medially. resulting in a more prominent appearance of the infe-
Superior to the zygomatic arch, the SMAS is known rior border of the orbicularis oculi which may accen-
as the superficial temporal fascia where it splits to tuate the malar crescent and the nasojugal fold [6].
accommodate the temporal branch of CN VII and the Post-menopausal changes due to decreased estro-
intermediate temporal fat pad [2,7]. gen may cause increased fat deposition in combina-
tion with decreased superficial fat [3].
Degenerative changes in the viscoelastic proper-
ties and three-dimensional structure of the SMAS
result in ptosis. Researchers have hypothesized
MUSCLE
that there is earlier and more progressive aging in
the midface due to a decreased amount of SMAS
[4]. With increasing age, retaining ligaments are The facial muscles can be categorized as periocular
at risk of weakening, thus leading to further pto- and perioral and broadly organized into four layers,
sis of the masseteric SMAS and resultant jowl where CN VII runs between the deepest and third
­formation [2]. layer. The first, superficial layer consists of the orbi-
cularis oculi, the zygomaticus minor, and the depres-
Due to the proximity of the SMAS to the temporal sor anguli oris. The second layer contains the levator
branch of CN VII, any dissection in this location labii superioris alaeque nasi, the zygomaticus major,

9
 Facial Layers

the risorius, the depressor labii inferioris, and the medial to lateral at the junction of the proximal third
platysma. The third layer includes orbicularis oris after which it becomes the angular artery which anas-
and levator labii superioris. The final, deepest layer tomoses with the superficial temporal artery (STA).
consists of the buccinator, the levator anguli oris, and
the mentalis [8]. Whilst the major function of facial The ophthalmic artery is the major artery supplying
muscles relates to facial movement, they also play a the orbit. Originating from the internal carotid artery
significant role in maintaining soft-tissue support. The in the middle cranial fossa, this artery traverses
SMAS unites and advances the facial muscles, espe- the optic foramen and subdivides into numerous
cially the zygomaticus major and orbicularis oris [2,5]. branches inside the orbital cavity [7].
The mimetic muscles of the cheek are separated into
a superficial and deep layer. The superficial layer The superficial temporal artery represents the final
consists of zygomaticus major and minor, levator branch of the external carotid artery. This artery
labii superioris, risorious, depressor anguli oris, orbi- arises inside the parotid gland at the point where
cularis oculi, and the orbicularis oris. The deep layer the maxillary artery branches off the external carotid
contains the levator anguli oris, buccinator, depressor artery. Bilaterally, this artery supplies a large area of
labii inferioris, and the mentalis [5]. facial skin, including the lateral forehead, the temple,
the zygoma, and the ear. One prominent branch that
Muscular aging can cause prominent changes such stems from the superficial temporal artery includes
as declining muscle mass and strength. An example the transverse facial artery (also originating from the
of this can be seen in the midface, where the orbi- parotid gland) [7].
cularis oris thins with age while the orbicularis oculi
does not. Extensive investigations of facial MRIs at
The forehead is supplied by the supraorbital and
different ages have shown that the midface mus-
supratrochlear arteries (branches of the ophthalmic
cles start to shorten and straighten simultaneously.
artery). The nose has a particularly intricate vascu-
Researchers have hypothesized that this, in addition
lar network of tiny arteries within the alae, tip and
to a lifetime of facial contractions, may cause pro-
columella. Most of this is supplied by the lateral
lapse of the deep midfacial fat compartments [4].
nasal artery (originates from the facial artery) or
superior labial artery (also originates from the facial
artery). The upper lip is supplied primarily by the
VASCULATURE superior labial artery, while the lower lip is supplied
by three labial arteries. The chin’s main vasculature
Three major arteries originating directly from the is the mental artery (branch of the inferior alveolar
external carotid artery or subsequent branches pro- artery) [7].
vide arterial supply to the face: the facial, transverse
facial, and infraorbital arteries [7,9]. The facial artery, The majority of veins are located close to the simi-
which is the largest, crosses the inferior border of larly named arteries. After crossing the inferior man-
the mandible just anterior to the masseter, where its dibular border with the facial artery, the facial vein
pulsation may be felt, after which it travels in a coiled takes a direct path to the medial canthus. The lateral
fashion towards the pyriform fossa [9]. It runs from forehead and temporal/parietal regions usually drain
deep on the mandible, over the buccinator, beneath via the superficial temporal vein, while the middle
risorius and zygomaticus major, under or over zygo- forehead and upper eyelid drain via the angular or
maticus minor, crosses the nasolabial fold from ophthalmic veins within the cavernous sinus. Venous

10
 Bones

drainage of the midface is via the infraorbital vein and The greater auricular nerve is found approximately
pterygoid plexus; certain structures, such as the lips 5 cm inferior to the external auditory meatus, running
and cheeks drain into the facial vein [7]. deep within the superficial cervical fascia. The men-
tal nerve, a branch of the inferior alveolar nerve, exits
The location, size and origin of the major arteries may the mental foramen where it can be seen and pal-
vary between individuals and races [7,9]. With aging, pated when the oral mucosa is stretched. This nerve
random degenerative changes can occur in individual provides innervation to the lower lip and the man-
vessels, including increased diameter, decreased dible. The buccal mucosa and the skin on the cheek
elasticity, and arterial hypertension. These changes is innervated by the buccal branch of the mandibular
can result in elongation and further tortuosity of these nerve, while the anterior two-thirds of the tongue is
arteries [9]. innervated by the lingual nerve (a branch of the man-
dibular division of the trigeminal nerve) [2].
The facial artery crosses the inferior border of the
mandible just anterior to the masseter, where its pul- Face transplants have rapidly blossomed into a fea-
sation may be felt, after which it travels in a coiled sible management for patients with extreme disfig-
fashion towards the pyriform fossa [9]. It runs from urements. To help repair damaged facial expression
deep on the mandible, over the buccinator, beneath muscles and preserve their function, it is vital also
risorius and zygomaticus major, under or over zygo- to understand that these muscles do not contain
maticus minor, crosses the nasolabial fold from proprioceptive receptors, compared with mastica-
medial to lateral at the junction of the proximal third tion muscles (which are innervated by the trigeminal
after which it becomes the angular artery which anas- nerve and thus contain proprioceptors) [7].
tomoses with the superficial temporal artery (STA).

BONES
NERVES
Youthful features have been said to be optimally
present at a point in time when a specific set of skel-
Cranial nerve (CN) VII—the facial nerve—is the main
etal proportions are ideal for their soft-tissue enve-
motor innervation of the facial muscles, with damage
lope. The skeletal framework forms the basis on
to CN VII being one of the most dreaded (but rare)
which unique facial characteristics are built, render-
complications of surgery. After exiting the stylomas-
ing underlying bone vital in providing and preserving
toid foramen, an upper and lower division develops
ideal soft-­tissue relationships.
as it passes through the parotid gland before trav-
elling to the facial muscles [3]. This nerve harbors
Important facial bony constituents include the fron-
significant clinical implications during facial surgery
tal, maxillary, zygomatic, palatine, nasal, temporal,
[5]. Another significant clinical consideration during
lacrimal, ethmoidal and mandibular bones. Bone
a mandibular block (CN Vll), is potential hemifacial
provides structural support and attachment sites for
paralysis, otherwise known as Bell’s palsy [7].
the muscles of facial expression and mastication, and
also protects certain structures such as the eyes.
Other important innervations include CN V (trigemi-
nal nerve), which has three branches as well as addi- The facial skeleton undergoes both expansion and
tional branches from the cervical plexus. selective resorption throughout life, with the pyriform

11
 Facial Layers

and orbital apertures being particularly susceptible by the aging process. This layered structure provides
to age-related resorption. Maxillary recession and a an intricate canvas, adding to the functional and artis-
10° decrease in the maxillary angle have been noted tic imagery required during aesthetic treatments.
after 60 years of age [11]. Midface skeletal involution
also occurs from the sixth decade, occurring more By first breaking the anatomy down into basic layers,
frequently in women than men [4]. Skeletal regres- it is easier to visualize the integral structural an func-
sion of particularly the inferolateral orbital rim and tional components before attempting to brainstorm
alveolar ridges, contributes to loss of midfacial sup- novel aesthetic solutions.
port and also loss of overall facial height.
Age-related changes within the nasal aperture,
References
paired nasal bones, and ascending processes of
maxillae may lead to prominent changes, including 1. Kumar N et al. Plast Reconstr Surg Glob Open.
nasal lengthening, sagging of the tip, and posterior 2018;6(3):e1687.
displacement of the columella and lateral crura [11]. 2. Prendergast PM. Anatomy of the face and neck.
Selective resorption of the upper jaw may lead to a In: Cosmetic Surgery: Art and Techniques.
subsequent loss of dentition, with Bartlett et al. [13] Shiffman, MA and Di Giuseppe, A. eds. Springer:
demonstrating that decreasing height of the maxilla Belin, Heidelberg, 2013.
and mandible correlate strongly with eventual loss 3. Khazanchi R et al. Indian J Plast Surg. 2007;
of dentition. 40(2):223–9.
4. Wulc AE et al. The anatomic basis of midfacial
Loss of teeth generally affects the mandible more aging. In: Hartstein M et al., eds. Midfacial Reju-
than the maxilla, with women at a higher risk of this venation. New York, NY: Springer; 2012: 15–28.
loss [4]. 5. Barton FE. Aesthetic Surg J. 2009;29(6):449–63.
6. Coleman SR and Grover R. Aesthetic Surg J.
Individuals with prominent bony features, including a
2006;26(1S):S4–9.
supraorbital bar, strong cheekbones, and prominent
7. Von Arx T et al. Swiss Dent J. 2018;128:382–92.
jawlines have been said to age more favorably [11].
8. Freilinger G et al. Plast Reconstr Surg. 1987;
80(5):686–90.
9. Soikkonen K et al. Br J Oral Maxillofac Surg.
1991;29(6):395–8.
CONCLUSION
10. Mangalgiri A et al. Indian J Otolaryngol Head
Neck Surg. 2015;67(1):72–4.
The face is unique in its profound ability to communi- 11. Mendelson B and Wong CH. Aesthetic Plastic
cate, express emotion and masticate. As a result of Surgery. 2012;36(4):753–60.
this intricate functionality, it is imperative that medical 12. Rohrich R et al. Plast Reconstr Surg Glob Open.
practitioners have an insightful understanding of appli- 2019;7(6):2270.
cable anatomy. Each facial layer is morphologically 13. Bartlett SP et al. Plast Reconstr Surg. 1992;90(4):​
and clinically distinct and may be differentially affected 592–600.

12
C AGING OF SKIN,
SOFT TISSUE,
AND BONE
Daria Voropai, Steven Dayan, Luis Fernando Botero,
Chiara Botti, Leonard Miller, and Ali Pirayesh

Facial aging is a complex, multifactorial process of the skeletal base, it is of great importance to know
involving multiple facial layers. Changes in the skin, the relationships between the different bones, transi-
skull, and soft tissues play contributory roles. Loss tions, and landmarks.
of collagen and elastin, combined with epidermal
thinning, contributes to the appearance fine rhytides. The face may be divided into thirds (upper face, mid-
Distributional changes in the superficial and deep fat face, and lower face) in order to identifying important
pads, in addition to bone remodeling, constitute key bony and soft tissue landmarks (Figure C.1).
morphological factors and result in the characteristic
inverted heart shape of the aging face. Understanding The upper face consists of mainly the frontal bone,
these multifactorial aging pathways facilitates effec- which forms the upper third of the anterior adult skull
tive aesthetic treatments. giving the forehead an aesthetically pleasing curva-
ture. The frontal bone can be divided into three parts
The main function of the facial skeleton is to protect (see also Chapter 1, Forehead):
the brain and important sensory organs of smell,
sight, and taste, and to provide a foundation for the 1. Squamous part of the frontal bone
face. The skull is subdivided into two main parts: the 2. Glabella and nasion
cranial vault, which protects the brain and houses 3. Supraorbital ridge
the middle and inner ear structures, and the facial
bones, which form the support for the soft tissues of The important aesthetic landmark of the upper
the face, the nasal cavity, the eyeballs, and the upper third is the nasion, defined as the suture between
and lower teeth. the frontal and nasal bones in the midsagit-
tal plane. Together with the nasion, the glabellar
The adult skull comprises 22 separate bones, of which angle (the line connecting the maximal glabellar
only one, the mandible, is mobile and not fused as a prominence with the nasofrontal suture, as com-
single unit. In order to understand the aging process pared to the horizontal or nasal-sellar line) is used

13
 Aging of Skin, Soft Tissue, and Bone

Upper Third

Middle Third

Lower Third Figure C.2 Skeletonized facial features.

to the more skeletonized appearance of the face of

Figure C.1 Facial bone sutures. the older individual, hence the prominent lateral orbital
rims, temporal crest, and zygomatic arch.
as an anthropometric measurement in facial and
­cephalometric analysis. Soft tissue changes in the aging upper face are also
of note. A well-accepted theory is that of volume loss
There is no clear understanding as to which aging due to lipo- and muscle atrophy [3]. Foissac et al. [11]
changes occur in the cranium and the upper face. looked at magnetic resonance imaging scans of 85
A well-researched change is the decrease in glabel- female Caucasians (age 18 to >60 years) to analyze
lar angle [2,3]. However, Cotofana et al. [1] studied the volume and distribution of the central forehead
computed tomographic multiplanar scans of 157 and the temporal fat compartments. They concluded
Caucasian individuals between the ages of 20 and that there is an increase in fat volume in the older
98 years and found significant results, which comple- group, with an increased basal expansion of the
mented the results of Yi’s [8,9] study looking at aging compartments (central fat compartment increasing
changes of the frontal eminence and the concavity of by 155% and temporal fat compartment by 35.5%).
the forehead (however, limited to the Korean popula- Combinations of these findings result in visual aes-
tion). Yi’s study concluded that in both genders, aging thetic implications for the aging upper face, which
was associated with increasing length of the c­ oncavity include enhanced forehead concavity, brow ptosis,
(Figure C.2). Cotofana [1] documented a decrease in temporal hollowing, and a more prominent supraor-
sagittal diameter in men (−2.24%), an increase in bital ridge due to a decreased glabellar angle.
transverse diameter in both women and men (1.97%
vs 2.22%), and a decrease in calvarial volume in men The midface is a merging of the following bony
and women (5.4% vs 5.1%) (Figure C.2). Furthermore, structures: nasal, lacrimal, ethmoid, maxillary, zygo-
lateral expansion of the skull [1] could also contribute matic, and palatine bones [5]. The main function of

14
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Notices 210

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355 human

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374

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