Aesthetic plastic surgery of the east asian face (2016) PDF UnitedVRG

Aesthetic Plastic Surgery of the East Asian Face

Hon g Ryu l Jin , MD, Ph D
Professor an d Ch air
Depar t m en t of Otorh in olar yngology–Head an d Neck Su rger y
Boram ae Medical Cen ter
Seoul Nat ion al Un iversit y College of Medicin e
Seoul, Repu blic of Korea

956 illu st rat ion s

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Librar y of Con gress Cat alogin g-in -Pu blicat ion Dat a
Nam es: Jin, Hong Ryul, editor.
Title: Aesth et ic plast ic surger y of th e East Asian face / [edited by]
Hong Ryul Jin .
Descript ion : New York : Th iem e, [2016] | In clu d es bibliograp h ical
referen ces an d in dex.
Iden t ifiers: LCCN 2015048817| ISBN 9781626231436 (h ardcover :
alk. pap er) | ISBN 9781626231443 (eISBN)
Su bject s: | MESH: Recon st ru ct ive Surgical Procedu res | Cosm et ic
Tech n iques | Surger y, Plast ic--m eth ods | Face--surger y | Asian
Con t in en t al An cest r y Group
Classificat ion : LCC RD119 | NLM WO 600 | DDC 617.9/52—d c23
LC record available at h t t p://lccn .loc.gov/2015048817

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Dedicated to th ose p hysician s w h o believe th at a p h ilosophy is requ ired to ch ange even a sm all par t of th e face.

v



Contents
Forew ord ................................................................................................................................................................................................. ix
Dean M. Torium i

Forew ord .................................................................................................................................................................................................. x
Stephen S. Park

Preface ..................................................................................................................................................................................................... xi
Ack n ow ledgm en t s ..............................................................................................................................................................................xii
Con t r ib u tor s ........................................................................................................................................................................................xiii

I Intro ductio n
1. Th e Ch an gin g Face of Aest h et ic Facial Plast ic Su r ger y am on g East Asian s ........................................................................... 3
Keng Lu Tan and Hong Ryul Jin

II Rhino plasty
2. Au gm en t at ion Rh in op last y Usin g Silicon e Im p lan t s .................................................................................................................13
In-Sang Kim

3. Th e Use of Cost al Car t ilage for Dor sal Au gm en t at ion an d Tip Graft in g ...............................................................................26
Victor Chung and Dean M. Torium i

4. Nasal Tip Mod if cat ion in Asian s: Au gm en t at ion an d Rot at ion Con t rol ..............................................................................47
Hong Ryul Jin and Jong Sook Yi

5. Hu m p Resect ion ................................................................................................................................................................................... 60
Tae-Bin W on and Hong Ryul Jin

6. Cor rect ion of t h e Deviated , Tw isted Nose .....................................................................................................................................72
Hun-Jong Dhong

7. Cor rect ion of t h e Sad d le Nose .........................................................................................................................................................87
Keng Lu Tan and Chae-Seo Rhee

8. Alar Base Mod if cat ion .......................................................................................................................................................................99
Ian Loh Chi Yuan and Hong Ryul Jin

9. Aest h et ic Rh in op last y for Sou t h east Asian s...............................................................................................................................108
Eduardo C. Yap

10. Cor rect ion of t h e Sh or t , Con t racted Nose...................................................................................................................................122
Hong Ryul Jin

11. Man agem en t of Allop last -Related Com p licat ion s ....................................................................................................................135

Eunsang Dhong

III Blepharo plasty
12. Dou b le-Eyelid Su r ger y: Non in cision al Su t u re Tech n iqu es ....................................................................................................151
Jin Joo Hong and Hae W on Yang

13. Dou b le-Eyelid Su r ger y: In cision al Tech n iqu es ..........................................................................................................................162
Jae W oo Jang

14. Agin g-Related Up p er Blep h arop last y ...........................................................................................................................................173
Hok yung Choung and Nam ju Kim

15. Ep ican t h op last y an d Aest h et ic Lateral Can t h op la st y..............................................................................................................184
Yongho Shin

16. Low er Blep h arop last y ......................................................................................................................................................................196
Yoon-Duck Kim and Kyung In W oo

17. Cor rect ion of Ptosis ..........................................................................................................................................................................210
W oong Chul Choi and Juw an Park

18. Man agem en t of Dou b le-Eyelid Su r ger y Com p licat ion s ..........................................................................................................225
In-chang Cho and Aram Harijan

vii


viii

Content s

IV Facial Bo ne Surge ry
19. Zygom a Red u ct ion ............................................................................................................................................................................243
Sanghoon Park and Jihyuck Lee

20. Man d ible Red u ct ion .........................................................................................................................................................................254
Sanghoon Park and Seungil Chung

21. Aest h et ic Or t h ogn at h ic Su r ger y ....................................................................................................................................................268
Seong Yik Han and Kar Su Tan

22. Gen iop last y .........................................................................................................................................................................................286
Seong Yik Han and Kar Su Tan

V Facial Skin and Hair Rejuvenatio n
23. Man agem en t St rategies for t h e Agin g Asian Face: Ph ilosop h y an d Evolu t ion .................................................................303
Sam uel M. Lam

24. Facial Fat Graft in g ..............................................................................................................................................................................311
Kyoung-Jin (Saf ) Kang

25. En d oscop ic Foreh ead an d Brow Lift .............................................................................................................................................324
Tee Sin Lee and Stephen S. Park

26. Facial Reju ven at ion Usin g En er gy Devices .................................................................................................................................339
Un-Cheol Yeo

27. Hair Tran sp lan t at ion in East Asian s .............................................................................................................................................349
Sungjoo (Tom m y) Hw ang

28. Aest h et ic Laser Hair Rem oval for t h e Asian Face ......................................................................................................................364

W ooseok Koh

VI Minim ally Invasive Facial Plastic Surgery
29. Aest h et ic Facial Use of Bot u lin u m Toxin in East Asian s..........................................................................................................377
Kyle Seo

30. Facial Con tou r in g Usin g Filler s ......................................................................................................................................................392
Jongseo Kim

31. Man agem en t of Facial Filler In ject ion Com p licat ion s .............................................................................................................405
Hyoung Jin Moon and Jong Sook Yi

In d ex .....................................................................................................................................................................................................415


Forew ord
Th ere is n o p op u lat ion in th e w orld th at h as a h igh er
grow th of in terest in aesth et ic su rger y th an th e East Asian
pop u lat ion . It is repor ted th at on e in five w om en in th e
Repu blic of Korea h ave u n dergon e aesth et ic facial surger y.
Th is dram at ic in crease is m u lt ifactorial an d is in p ar t
driven by local p opu lar cu lt u re an d m edia. Th is t ren d h as
been n otable over recen t years, w ith th e adven t of Korean
pop u lar cu lt u re an d th e associated d esire to look like th e
fam ed K-pop st ars. Th e look is quite ch aracterist ic of Korean
aesth et ics, w ith m any pat ien ts sh ow ing th eir su rgeon
ph otos of th e sam e Asian m edia p erson alit ies. Th is t ren d
h as becom e so fash ion able th at it is n o longer a st igm a to
un dergo cosm et ic surger y in th e Rep u blic of Korea an d
Ch in a. In fact , it m igh t n ow be con sidered a stat u s sym bol

an d reflect u pw ard m obilit y in th e eyes of m any. Th is age
of th e “selfie” an d Facebook h as m ade “looking good” even
m ore im port an t to th is grow ing populat ion . Th ese social
ch anges h ave dram at ically in creased th e dem an d for Asian
cosm et ic surger y, st im u lat ing a sign ifican t in crease in th e
n um ber of su rgeon s perform ing th e su rger y.
Th e aesth et ics of th e Asian face are con st an tly ch anging,
an d surgical tech n iqu es m u st ch ange to accom m odate
such ch anges. Today, th ere is often th e desire for a roun der
foreh ead, h igh er n asal dorsum , n arrow er n asal t ip, an d a
less roun d, m ore angu lar m an dible an d ch in . Many of th ese
ch aracterist ics m ay in dicate a desire for a m ore “Western ”
look. How ever, th ere are differen t degrees of ch ange an d th is
m ust be recogn ized by th e surgeon . Hong Ryul Jin un derstan ds
th e im por t an ce of th is varian ce from p at ien t to p at ien t . Th is
requires th e su rgeon p erform ing en ough su rgeries to h ave
acquired a n um ber of tech n iques in th eir arm am en tarium .
In th is book, Dr. Jin h as com piled an out stan ding collect ion
of ch apters w rit ten by an exper t group of surgeon s. Th e
book covers th e m ost u pdated tech n iqu es on con touring th e
Asian face covering rh in oplast y, Asian eyelid su rger y, facial
con tou ring, an d aging-face surger y. Th e book also covers
th e rapid ly ch anging field of n on su rgical t reat m en t s, su ch
as bot u lin um toxin , fillers, an d lasers.
In the section on rhinoplast y, the authors discuss
the use of im plants and autologous m aterials for Asian
augm entation rhinoplast y. The difference in these techniques
is very significant and is reflected in these w ritings. Use of
im plants continues to be the m ost com m only used m ethod
to augm ent the nose. Nuances in the techniques are discussed

in great detail and are covered by several authors. Com bined
techniques using alloplastic m aterials for dorsal augm entation
and ear cartilage for the nasal tip have becom e popular
to avoid som e of the potential com plications of extending

alloplastic im plants into the nasal tip. The use of costal
cartilage for augm entation is discussed in detail, describing
techniques used to stabilize the nasal tip and augm ent the
nasal dorsum . Also covered are the nuances of perform ing
dorsal augm entation w ith costal cartilage and how to
m inim ize the likelihood of warping. Popular techniques, such
as diced cartilage for dorsal augm entation and tip grafting,
are covered as well.
Th e m any tech n iques available for m an aging th e Asian
eyelid are covered, in cluding in cision al an d n on in cision al
su t u re tech n iqu es, as w ell as conven t ion al in cision al
tech n iques. Precision m easu rem en t an d m arking, an esth et ic
inject ion s, in cision placem en t , m an agem en t of th e fixat ion
m eth od, postoperat ive care, an d m an aging com plicat ion s
are all discussed. Also covered is th e m an agem en t of th e
ep ican th al fold.
In the sect ion on facial contouring, the chapters cover
m anagem ent of the Asian m alar region, m andible, perialar
augm entation, chin augm entation, m asseter m uscle
contouring, forehead contouring, and com plications. Also
covered are the nuances of facial contouring that provide the
surgeon w ith m any options for creating a m ore aesthetically
pleasing Asian face.
Th e sect ion on n on surgical m an agem en t covers th e
u se of bot ulin u m toxin for facial m uscle con tou ring, brow

con tou ring, an d rhyt id m an agem en t . Th is sect ion also
covers fat inject ion s an d con tou ring u sing au tologou s fat .
Laser resu rfacing is discu ssed as w ell.
Dr. Jin h as been a st rong academ ic figure in Korea for
m any years an d h as becom e w ell kn ow n arou n d th e w orld.
He h as frequ en tly lect u red in th e Un ited St ates an d all
over Asia. He is n ow con sidered an in tern at ion al expert
on Asian rh in oplast y an d Asian facial cosm et ic surger y.
His in tern at ion al in flu en ce is reflected in th e d iversit y
of th e auth ors con t ribu t ing to h is book, an d h e h as don e
a m asterful job edit ing th is w ork. Readers w ill fin d th is
book com preh en sive in it s con ten t an d det ail of surgical
descript ion s an d u se of qu alit y op erat ive ph otography an d
illu st rat ion s. Th is book is an essen t ial referen ce for th e
su rgeon in terested in p roviding th e best ou tcom es in Asian
aesth et ic facial su rger y.
Dean M. Torium i, MD
Professor
Division of Facial Plast ic and Reconst ruct ive Surgery
Departm ent of Otolaryngology–Head and Neck Surgery
Universit y of Illinois
Chicago, Illinois

ix


Forew ord
Hon g Ryu l Jin h as le d t h e w ay in creat in g a u n iqu e book on
aest h et ic facial su rge r y for t h e East Asian p at ie n t . Th e re
are m any u n iqu e var ian ces w it h p at ie n t s from t h is region

of t h e w orld , an d t h ey h ave p u t toget h e r a colle ct ion of
ch ap t e r s t h at cove r all asp e ct s of facial aest h et ic su rge r y
as it p e r t ain s to t h e Asian face. Th e book h igh ligh t s t h e
m any n u an ces in facial aest h et ic su rge r y in t h is grou p ,
an d any su rge on w h o h as t h e occasion al Asian p at ie n t
w ill b e w ell se r ve d to h ave t h is e d it ion in h is or h e r
refe re n ce librar y.
A solid p or t ion of th is book is dedicated to th e
tech n iqu es of Asian rh in oplast y. It is n ot lim ited to st rictly
alloplast ic dorsal im plan ts, bu t covers m any subtlet ies th at
are often required w ith Asian pat ien t s. Th e th ird sect ion
is ded icated to th e p eriorbit al rejuven at ion of th e Asian
pat ien t , in clu ding ptosis an d th e dou ble eyelid procedu re.
Th ere are in t ricacies to th is p rocedu re th at dist ingu ish

x

a good from a great result , an d th is book capt ures th em
w ell. Th e rem ain ing sect ion s touch on oth er procedu res
perform ed in facial aesth et ic su rger y, in clu ding facial
bon e con tou ring, m in im ally invasive an d office based
procedu res, an d h air rejuven at ion .
Herein is a collect ion of m any au th ors w ith vast
exp erien ce in facial aesth et ic su rger y in th e Asian
pop u lat ion . It is com p reh en sive, eloqu en tly w rit ten , an d
w ill ser ve as an invaluable resource for years to com e. Dr.
Jin is to be congrat ulated for a terrific book.
Stephen S. Park , MD
Professor and Vice-Chairm an
Depart m ent of Otolaryngology

Director, Division of Facial Plast ic Surgery
Universit y of Virginia
Charlottesville, Virginia


Preface
Aesth et ic facial plast ic surger y h as com e un der th e spotligh t
in East Asian coun t ries in th e p ast t w o decades. Korea cam e
un der th e spotligh t in th is field recen tly an d in t rigued m any
from all corn ers of th e w orld to com e, learn , an d u p date
th eir tech n iqu es. It is m y h ope th at th is kn ow ledge can be
sh ared far an d w ide w ith th e English speaking crow d, w h o
h as been fin ding it difficu lt to access in form at ion th at h as
been p assed on in variou s Asian langu ages.
Th e ch apters in th is book describe m ost of w h at you
n eed to kn ow abou t aesth et ic plast ic surger y on th e face.
Th e ch apters w ere w rit ten by m y ren ow n ed colleagu es in
th eir resp ect ive sp ecialt ies, det ailing special tech n iqu es an d
poten t ial pitfalls. Th ese det ails do n ot com e from overn igh t

en ligh ten m en t , bu t rath er reflect experien ce an d learn ing
accum ulated over decades of su rgeries. Th e con ten t in th is
book is h igh ly scien t ific an d eviden ce based, w h ich m ean s
it h as proven to be safe an d efficien t . Th is book n ot on ly
focu ses on in t roducing tech n iqu es th at are n ew, but teach es
th e basic con cept s of h ow -to-do-it in a st ru ct u red m an n er
to en sure th at readers are able to clearly con cept u alize th e
tech n iqu es an d th eories beh in d ever y m an euver.
I sincerely hope and expect that this book w ill guide the
new surgeons venturing into aesthetic plastic surgery of the

Asian face, as well as provide valuable inform ation to the others.
Hong Ryul Jin

xi


Acknow ledgments
It w as n ot an easy journ ey for th e publicat ion of th is book,
an d I w ould like to express m y m ost h ear tfelt grat it ude to
all m y colleagu es w h o h ave con t ribu ted to it .
I thank Thiem e Publishers and its people for allow ing m e to
publish this. Due to their great work, this book changed from
an ugly duckling into a swan. Doctors w ho contributed their
valuable expertise to this book need special acknow ledgm ent

xii

for their patience in allow ing and enduring my continuous
requests. I also w ish to thank my fellows, Woo-Seong Na, Hahn
Jin Jung, and Som asundran Mutusamy, for helping m e to edit
the m anuscript. Our excellent illustrator, Mrs. Hyun-Hang Lee,
w ho devoted her tim e and talents to this book, did a wonderful
job in expressing the details in every draw ing per the requests
of each contributor. I give my sincere thanks to her.


Contributors
In-chang Cho, MD
Bio Plast ic Surger y Clin ic
Seou l, Repu blic of Korea

Woo ng Chul Cho i, MD
Director of Myou ng Ocu loplast ic Su rger y
Clin ical At ten ding Professor
Depar t m en t of Op h th alm ology
St . Mar yʼs Hospital
Cath olic Un iversit y of Korea
Seou l, Repu blic of Korea
Ho kyung Cho ung, MD, PhD
Assistan t Professor
Depar t m en t of Op h th alm ology
Boram ae Medical Cen ter
Seou l Nat ion al Un iversit y College of Medicin e
Seou l, Repu blic of Korea
Se ungil Chung, MD, PhD
Division of Facial Bon e Su rger y
Depar t m en t of Plast ic Surger y
ID Hospital
Seou l, Repu blic of Korea

Aram Harijan, MD
Academ ic Con sultan t
Well Plast ic Surger y Clin ic
Seoul, Repu blic of Korea
Jin Jo o Ho ng, MD, PhD
Head
JJ Medical Group
Seoul, Repu blic of Korea
Sung jo o (To m m y) Hw ang, MD, PhD
Director
Dr. Hw angʼs Hair Tran splan tat ion Clin ic

Seoul, Repu blic of Korea
Jae Wo o Jang, MD, PhD
Vice Presiden t
Oph th alm ic, Plast ic, an d Recon st r u ct ive Surger y
Kim ’s Eye Hospit al
Konyang Un iversit y
Seoul, Repu blic of Korea

Victo r Chung, MD
Director
La Jolla Facial Plast ic Surger y
San Diego, Californ ia

Ho ng Ryul Jin, MD, PhD
Professor an d Ch air
Depart m en t of Otorh in olar yngology–Head an d
Neck Surger y
Boram ae Medical Cen ter
Seoul Nat ion al Un iversit y College of Medicin e
Seoul, Repu blic of Korea

Eunsang Dho ng, MD, PhD
Professor
Depar t m en t of Plast ic an d Recon st ru ct ive Su rger y
Gu ro Hospit al, Korea Un iversit y Medical Cen ter
Seou l, Repu blic of Korea

Kyo ung-Jin (Safi) Kang, MD, PhD
Director
Educat ion al Cen ter of KCCS

Seoul Cosm et ic Surger y Clin ic
Bu san , Rep ublic of Korea

Hun-Jo ng Dho ng, MD, PhD
Professor
Depar t m en t of Otorh in olar yngology–Head an d
Neck Su rger y
Sam su ng Medical Cen ter
Seou l, Repu blic of Korea

In-Sang Kim , MD
Ch ief Execut ive
Depart m en t of Facial Plast ic Su rger y
Doctor Be Aesth et ic Clin ic
Seoul, Repu blic of Korea

Se o ng Yik Han, MD, DDS, PhD
Director
Facial Plast ic Surger y
Sim m ian Maxillofacial Plast ic Surger y Un it
Seou l, Repu blic of Korea

Jo ngseo Kim , MS
Director
Depart m en t of Plast ic Surger y
Kim -Jongseo Plast ic Su rger y Clin ic
Seoul, Repu blic of Korea

xiii

xiv

Contributors
Nam ju Kim , MD, PhD
Associate Professor
Dep ar t m en t of Oph th alm ology
Seou l Nat ion al Un iversit y Bu n dang Hosp ital
Seongn am -Si, Kyeonggi-Do, Repu blic of Korea
Yo o n-Duck Kim , MD, PhD
Director
Oculop last ic an d Orbital Su rger y Division
Professor
Dep ar t m en t of Oph th alm ology
Sam su ng Medical Cen ter
Sung Kyu n Kw an Un iversit y Sch ool of Medicin e
Seou l, Repu blic of Korea
Wo o se o k Ko h, MD
Director
Dep ar t m en t of Derm atology
JMO Hair Rem oval Derm atology Clin ic
Seou l, Repu blic of Korea
Sam uel M. Lam , MD, FACS
Director
Willow Ben d Welln ess Cen ter
Plan o, Texas
Jihyuck Lee, MD
Ch ief
Division of Facial Bon e Su rger y
Dep ar t m en t of Plast ic Surger y

ID Hospit al
Seou l, Repu blic of Korea
Te e Sin Le e, MBBS (S’po re), MRCS (Edin), MMed (ORL),
FAMS (ORL)
Dep ut y Director an d Con su ltan t
Facial Plast ic an d Recon st ru ct ive Su rger y Ser vice
Dep ar t m en t of Otorh in olar yngology–Head an d
Neck Su rger y
Ch angi Gen eral Hosp ital
Clin ical Lect u rer
Yong Loo Lin Sch ool of Medicin e
Nat ion al Un iversit y of Singap ore
Singapore
Hyo ung Jin Mo o n, MD
Presiden t
Dr. Moon Aesth et ic Su rger y Clin ic
Seou l, Repu blic of Korea

Juw an Park, MD, PhD
Associate Professor
Depar t m en t of Oph th alm ology
Yeou ido St . Mar y’s Hosp ital
Th e Cath olic Un iversit y of Korea
Seoul, Rep ublic of Korea
Sangho o n Park, MD
Ch airm an
Depar t m en t of Plast ic Su rger y
ID Hospit al
Seoul, Rep ublic of Korea
Ste phe n S. Park, MD

Professor an d Vice- Ch air
Depar t m en t of Otolar yngology
Un iversit y of Virgin ia
Ch arlot tesville, Virgin ia
Chae-Seo Rhee, MD, PhD
Professor
Depar t m en t of Otorh in olar yngology–Head an d
Neck Su rger y
Seoul Nat ion al Un iversit y College of Medicin e
Seoul Nat ion al Un iversit y Bu n dang Hospital
Seongn am -Si, Kyeonggi-Do, Repu blic of Korea
Kyle Seo, MD, PhD
Clin ical Associate Professor
Depar t m en t of Derm atology
Seoul Nat ion al Un iversit y College of Medicin e
Seoul, Rep ublic of Korea
Yo ngho Shin, MD, PhD
Director of Bio Plast ic Surger y Clin ic
Clin ical At ten ding Professor
Depar t m en t of Plast ic Su rger y
Korea Un iversit y
Seoul, Rep ublic of Korea
Kar Su Tan, MBBS (S’po re ), MRCS (Edin), MMed (ORL),
FAMS (ORL)
Medical Director
Th e Rh in oplast y Clin ic ENT Facial Plast ics
Singapore
Keng Lu Tan, MD, MRCS, MS (ORLHNS)
Ear, Nose, an d Th roat , Head an d Neck Surgeon
Facial Plast ic an d Recon st ru ct ive Surgeon

Depar t m en t of Otorh in olar yngology
Un iversit y of Malaya
Ku ala Lum p ur, Malaysia


Contributors
Dean M. To rium i, MD
Professor
Dep ar t m en t of Otolar yngology–Head an d Neck Su rger y
Un iversit y of Illin ois at Ch icago
Ch icago, Illin ois

Facial Plast ic Su rgeon
Belo Medical Grou p
Man ila, Ph ilip pin es

Tae-Bin Wo n, MD, PhD
Associate Professor
Dep ar t m en t of Otorh in olar yngology—Head an d
Neck Su rger y
Seoul Nat ion al Un iversit y Hospital
Seoul, Repu blic of Korea

Un-Cheo l Ye o, MD, PhD
Ch airm an
S an d U Derm atologic Clin ic
Clin ical Professor
Depar t m en t of Derm atology
Sam su ng Medical Cen ter
Su ngkyu n kw an Un iversit y

Seou l, Republic of Korea

Kyung In Wo o , MD, PhD
Professor
Dep ar t m en t of Op h th alm ology
Sungkyu n kw an Un iversit y Sch ool of Medicin e
Sam su ng Medical Cen ter
Seoul, Repu blic of Korea

Jo ng So o k Yi, MD
Assist an t Professor
Depar t m en t of Otorh in olar yn ology–Head an d
Neck Surger y
Bu n dang CHA Medical Cen ter
Seongn am -si, Repu blic of Korea

Hae Wo n Yang, MD
Ch ief
Division of Plast ic an d Recon st r u ct ive Su rger y
JJ Medical Group
Seoul, Repu blic of Korea

Ian Lo h Chi Yuan, MBBS, MRCS, MMED, FAMS
Director
Facial Plast ic an d Recon st r u ct ive Ser vice
Depar t m en t of Otorh in olar yngology–Head an d
Neck Surger y
Ch angi Gen eral Hosp ital
Singap ore

Eduardo C. Yap, MD

xv



I
Introduction



1 The Changing Face of Aesthetic Facial Plastic Surgery
among East Asians
Keng Lu Tan and Hong Ryul Jin

Pearls
• Asian s, part icularly th ose in East Asia, h ave seen

•

•

rapid developm ent in th e eld of aesth et ic facial
plast ic surger y, especially in th e re n em en t of
Asian -speci c tech n iques, over th e past t w o decades.
Th e t ypical Asian belief in n ot altering th e physical
ap pearan ce of on e’s face, at t ribu ted to resp ect for
th e elderly an d on e’s an cestors, h as evolved w ith
globalizat ion , resu lt ing in a m ore n eu t ralized Asian
cult ure, w h ich is a cross bet w een East an d West .

More Asian s realize th at to be at th e leading edge of
societ y, an at t ract ive ap pearan ce p lays an im p ort an t
role in d eterm in ing success. Th ere h as been a sh ift
in social accept an ce of aesth et ic su rger y, an d w e see
m ore dem an d for it th an ever before.
East Asian feat ures of th e face are discussed in detail
in th e follow ing ch apters, w ith par t icular at ten t ion
to single-eyelid, sm all palp ebral ap ert u re, at n asal
bridge and t ip, m alar prom in en ce, broad m an dible,
ret ruded prem axilla, an d m any oth er Asian -speci c
aesth et ic su rgeries.

■ Introduction
The recent surge in the n um ber of people seeking aesthet ic
facial surger y is a testam en t to th e em ph asis placed on on e’s
looks as a w ay to gain con siderable leverage in societ y. The
n ew m ovem en t also involves the con cept of etern al youth fuln ess; being young is con sidered at tract ive, an d looking
younger can im prove th e com pet it iven ess of a w orker.1,2
This t rend, w hich started in Western count ries around the
en d of th e t w en t ieth cen t ur y, is fast becom ing w orldw ide.
As of th is w rit ing Asia is th e m ost act ively grow ing
econ om y in th e w orld. With m ore th an h alf of th e w orld’s
popu lat ion residing on th is con t in en t , th e im pact of any
m ovem en t in Asia w ill be in u en t ial.3 With th e populat ion
get t ing m ore a u en t an d w ith th e in creasing a ordabilit y
of a h igh er st an dard of living, th e past 10 years h ave seen
m any Asian s seeking aesth et ic p rocedures to en h an ce th eir
facial feat u res or to at ten u ate th e aging p rocess. Alth ough
th e broad term Asians is gen erally used to den ote people
w h o origin ate from Asia, in t ruth various eth n icit ies an d

races w ith d i eren t facial m orp h ologies reside in Asia.
West an d Sou th Asia st retch es to Tu rkey an d In dia, w h ere
Cau casoid p eop le (i.e., Tu rks an d In dian s) are fou n d . In

• Com m on aesth et ic surgeries of East Asian s also

•

•

in clude double-eyelid surger y, ep ican th oplast y,
rh in oplast y, facial bon e con touring surger y, fat
inject ion , an d m any oth er tech n iques discu ssed in
th is book.
New er tech n iqu es, in clu ding th e com bin at ion
of n on su rgical tech n iques in facial rejuven at ion
su ch as llers an d bot u lin u m toxin , an d laser h air
rem oval and h air t ran sp lan t at ion sp eci c to East
Asian ch aracterist ics, are discu ssed in det ail. Th e
pros an d con s of n on surgical tech n iques su ch as
laser an d ult rasoun d for facial rejuven at ion are also
th orough ly described to keep readers updated w ith
th e latest tech n ologies an d th e opt ion s available to
ach ieve desired ou tcom es.
Most im p or tan t , th is book n ot on ly con t ain s su rgical
tech n iqu es an d pearls from surgeon s w h o are
exp er ts in th eir resp ect ive elds of aesth et ic facial
plast ic surger y, but also in corporates com m en t s on
pitfalls an d com plicat ion s, an d h ow to overcom e
th em , in detail.

East Asia, w h ere Ch in a, Korea, an d Japan are located, people possess East Asian feat u res. Alth ough East Asian s are
grouped in th e Mongoloid st rain along w ith th e Sou th east
Asians (In don esian s, Th ai, Polyn esian s, etc.), th e facial feat ures am ong th e Mongoloids are st ill quite dist in ct from
each oth er.3 Fig. 1.1 d ep icts th e average of di eren t beau t ifu l Asian faces as d escribed by Rh ee.4 In dian s, Ch in ese, an d
Jap an ese are all con sidered Asian s; h ow ever, th eir facial
feat u res can be qu ite di eren t .
Du e to Asia’s long-st an d ing t rade rou tes con n ect ing
East an d West , m odern Asian cit ies are often com prised
of m ult iple eth n ic groups, re ect ing th e m odern t ren ds of
in terracial m arriages an d globalizat ion . Th ere is a rapidly
t ran sform ing e ect of globalizat ion on facial feat ures as
w ell, alth ough at th is t im e w e st ill see rath er ch aracterist ic
Orien t al feat u res am ong East Asian s.
Aesth et ic facial su rger y in East Asia h as exp an ded an d
developed at an exp on en t ial rate in th e p ast t w o decades.
Su ch rap id p rogress h as en abled u s to develop su rgical
tech n iqu es suitable for Asian s an d to accum ulate a con siderable am ou n t of exp erien ce (Fig. 1.2). Th e n ew skill
set s an d exp erien ce h ave been t ran slated in to tech n ical
advan cem en t an d bet ter su rgical ou tcom es. Th ose exp erien ces an d advan ces in aesth et ic facial su rger y m ore su ited

3


4

I Introduction

Fig. 1.1 At tractive composite faces of di erent races. At tractive famous female entertainers’ faces were morphed by sequentially mixing
photographs at the mean values to generate the composite faces. (Used with permission from Rhee et al. At tractive composite faces of

di erent races. Aesthetic Plast Surg 2010;34:800–801.)

Hair rem oval or
transplantation

Fat injection

Blepharoplast y

Botox and fillers

Rhinoplast y

Facial bone
contouring
Fig. 1.2 Typical surgeries and nonsurgical procedures to improve facial aesthetic appearance in East Asians. These various techniques will
be addressed throughout this textbook, with speci c modi cations for Asians.


1 The Changing Face of Aesthetic Facial Plastic Surgery am ong East Asians
for Asian s are becom ing m ore an d m ore p opu lar, especially
am ong th e m ore a u en t Asian s living in th e Western cou n t ries. Au th ors of th is book believe th ere is n o bet ter t im e
th an now to h ave ou r kn ow ledge an d experien ce gath ered
an d sh ared to st im u late m ore develop m en t in th is eld.
Many years h ave p assed sin ce th e in t rodu ct ion of
speci c tech n iqu es for Asian aesth et ic su rger y. Mu ch h as
evolved over th e years, an d th e cu rren t focu s seem s to be
on re n ing th e tech n iques to address th e st igm a faced by
Asian pat ien t s. Alth ough w e st ill n d a h an dfu l of pat ien t s
com ing to th e surgeon w an t ing to look like a part icular pub lic gu re, m any are steering aw ay from th at t ren d. Pat ien t s

th ese days often request a n at ural-looking face an d w ish
to en h an ce th eir curren t appearan ce w h ile ret ain ing th eir
facial ch aracterist ics, an d th ey especially w an t to preven t
th eir plast ic su rgeries from being n ot iced by oth ers. W h ile
em bracing th eir exist ing facial ch aracterist ics, p at ien t s p refer n ot to look th e sam e as oth ers w h o desire th e ideal com p osit ion of a beau t ifu l face, albeit all sim ilar looking. Th is
h as resu lted in su rgeon s reinven t ing th em selves an d m oving in to th e n ext level of aesth et ic facial su rger y, com bin ing
less invasive p rocedures w ith su rger y w h en ever possible.
Th e art of com bin ing n on surgical an d surgical tech n iqu es
to create a beaut iful face w ill n o longer be based on a gu t
feeling bu t w ill be object ively described in th is book.

■ The Change in Cultural

Beliefs and the Modernization
of Asian Thinking

Th e Asian desire for a pleasan t face is h eavily in u en ced by
facial physiogn om y in th e past . Th e com bin at ion s of pleasan t-looking feat u res described in th e an cien t books w ere
illu st rated w ith pict ures of faces th at dict ated th e fut ure of
a p erson , dow n to th e p osit ion of m oles on th e face an d
body.5 Th ere w as a realizat ion of th e n eed for an aesth et ically pleasing face, bu t few oth er th an Sh usrat a ven t ured
in to th e aesth et ic su rgical eld. In dividuals w ith pleasan tlooking faces w ere m ore likely to be ju dged to h ave a good
life an d a good job, an d th ose w ith u np leasan t-looking
feat u res w ere often associated w ith socially less resp ectable jobs or even crim in alit y. Th e lat ter t yp es of faces w ere
d eem ed in au sp iciou s an d st ill ver y m uch in uen ce h ow
a p erson is ju dged in m odern societ y. Desp ite th is, th ere
w as lit tle develop m en t in th is eld. Few w an ted to ch ange
th eir looks surgically, par tly due to the un re n ed state of
su rgical skills at th at t im e an d th e st rong in u en ce of Con fu cian ism all over Asia, w h ich em ph asized th e san ct it y of
th e physical body as a sacred gift from our paren t s. Altering

on e’s physical appearan ce w as con sidered disrespectful to
on e’s an cestors.1
As globalizat ion an d Western izat ion exerted m ore
in uen ce in Asian societ y via Western m edia, th e de n it ion of beaut y becam e associated w ith w h ite Caucasian fea-

t ures, such as double eyelids an d t all, w ell-de n ed n oses.
Fair skin is seen as th e m arker of class. On e an cien t saying
in Jap an ese, Korean , an d Ch in ese societ ies goes, “A w h ite
com plexion overrides th ree appearan ce aw s,”6 em ph asizing th e long-st an ding im port an ce of ligh t-colored skin in
m u lt iple cou n t ries across Asia. Th is w as rein forced d u ring
th e Western colon izat ion period, w h en th e European s w ere
presen t in Asia an d enjoyed h igh social st at u s. In “Th e Histor y of W h ite People,” Neil Pain ter even argued th at Caucasian s produce “th e m ost beau t ifu l race of m en” an d th at
Ch in ese eyes are an “o en ce to beau t y.”7 Th e ideal beau t y
of Cau casian s w as on ce th e w ell-accepted de n it ion of
beaut y in Asia.
Recen tly, Asian coun t ries h ave becom e st ronger an d
m ore in u en t ial econ om ically. Sch olars h ave started to
debate about “Eurocen t ric” beaut y an d th e ph en om en on
in Asia w h ere it h as becom e th e n orm to alter on e’s facial
ap pearan ce u sing p last ic su rger y to be m ore Western ized.
With grow ing con den ce w ith in Asian societ y, h ow ever,
Asian s h ave started to em brace th eir ethn ic feat ures. Th e
fu sion of cert ain desirable Western feat u res w ith Asian
feat u res is n ow seen as th e id eal form of beau t y in Asia.
Th e key con cept n ow is to blen d at t ract ive feat ures rath er
th an h aving a cert ain de n ed tem plate, a con cept th at h as
been h eavily crit icized an d is rapidly falling out of favor.
Th e good-looking feat u res are, of cou rse, th ose th at suit a
person’s facial st ru ct u re, person alit y, an d th e person as a
w h ole. En h an cem en t rath er th an alteration of th e facial

feat u res h as becom e th e n ew t ren d .
Stat ist ics sh ow th at up to 58% of w om en in Korea h ave
plast ic surger y by th e age of 50.1,8 Th e percen tage is grow ing in th eir m ale coun terpar t s too. Th e desire to obtain
aesth et ic p last ic su rger y is often driven by th e psych osocial aspirat ion of th e pat ien t . Rapid developm en t in th is
eld is largely driven by th e n eed to app ear m ore at t ract ive in order to be bet ter accepted in a societ y th at places
a lot of em p h asis on beau t y an d pleasan t app earan ce.
Looking m ore beau t ifu l becom es an invest m en t to ach ieve
h igh er socioecon om ic st at u s an d to en su re on e w ill n d a
w ealthy rom an t ic p ar t n er. Th u s a n ew cu lt u re or t ren d h as
em erged, u n stop p able by past cu lt u ral beliefs an d t aboos,
an d st rongly d riven by n ovel con cept of beau t y, w ealth , an d
a good life. As th is con cept h as grow n , th e su bject s seeking
cosm et ic en h an cem en t h ave becom e younger an d younger.
As Korean dram as an d m ovies h ave becom e m ore popular
th rough ou t Asia, so h as th e in u en ce of th e Korean de n it ion of beaut y spread all across Asia. Th is ph en om en on of
“Han Ryu ” (th e Korean t ren d) w as p op u lar am ong view ers
of all ages. With at t ract ive actors an d act resses port rayed
as h eroes an d h eroin es, m any fan t asized becom ing like on e
of th em , w h ich could be ach ieved by altering th eir looks.
Th is t ren d becam e a st rong driving force in th e developm en t of aesth et ic surger y in Asia, en abling surgeon s to
grow an d ach ieve a n ew level of u n d erst an ding of aesth et ic
su rgeries. How ever, it is u p to th e con scien ce of in dividu al
pract it ion ers to guard th e san ct it y of th is eld, preven t ing

5


6

I Introduction

th e dou ble-edged sw ord of h arm to our pat ien t s an d to th e
p ract ice of aesth et ic surger y, by prescribing on ly approp riate an d scien t i cally soun d procedu res to pat ien t s an d
p roviding th e best su rgical pract ices tested by t im e an d
exp erien ce.

■ Anatomic Di erences and
Their Implications

Most East Asians share the phenot ypic features represented
by the Mongoloid pro le. It is currently the m ost w idely distributed physical t ype, constituting over a third of the hum an
species. Therefore, it is not surprising to nd that m any living
throughout Asia share the sam e facial features. Mongoloid
features are t ypically represented by epicanthal folds and
neoteny. While som e of the features, such as the single eyelid
and m axillary retrusion, are not com m on am ong Westerners, they are w idely encountered in Asians, w ith doubleeyelid surgery being the m ost popular plastic surgery sought
(Fig. 1.3). High cheekbones, a broad m andibular angle, and
a low nasal pro le are features in Asians that are not highly
favored, and are often associated w ith aggression or m anliness. Generally, a well-projected nose is preferred.
A low n asal bridge is n ot lim ited to Mongoloids. Th e
Malay people fou n d in m ost of Sou th east Asia across
th e Ph ilippin es, Malaysia, Th ailan d, an d In don esia often
requ est ch anges to address a low n asal bridge an d w ide
aring ala (Fig. 1.4).
Becau se th e an atom y of th e eyelids, n ose, an d facial
bon es in Asian s di ers sign i can tly from th at of Caucasian s,
a u n iqu e m an agem en t st rategy is requ ired to su ccessfu lly
im p rove th e aesth et ic ou tcom e. Th e m an agem en t st rategy
sh ou ld be aim ed at h an dling an atom ic issu es speci c to th e
Asian face such as th e follow ing:
1. Th e pret arsal skin of the upper eyelid is n ot at tach ed

to th e levator palpebrae m uscle, leading to a poorly
d e n ed superior p alp ebral fold. Th e con st ruct ion of a
d ou ble eyelid th at su it s th e m orph ology of an Asian
face is di eren t from p ract ice involving Cau casian s.
2. Excessive fat is dist ributed bet w een th e orbicularis
oculi m uscle an d th e levator m uscle w ith relat ively
th ick palpebral skin an d orbicularis oculi m uscles.
3. Orbits are sm aller w ith a m ore prot ruding orbital
m argin com p ared w ith Western ers. Th erefore,
recreat ing th e feat u res of Caucasian eyelids h as
p roven u n su it able. Aesth et ic eye surger y sh ou ld be
re n ed an d subtle rath er th an dram at ic, or it can
give rise to a th ick, deep u pp er eyelid, w h ich is n ot
su itable for sm aller orbit s.
4. Th e n asal sclera t riangle is rou n ded due to th e
p rom in en t m edial epican thal fold. A variet y of
tech n iqu es (an d th eir pros an d con s) to elim in ate
th e obt un ded angle w ill be described in detail in th e
ch apter on epican th oplast y.

5. Th e n arrow an d relat ively sm all palpebral aper t ure
result s in sm all eyes. Th is h as resulted in m any
tech n iqu es inven ted an d m odi ed over th e past
decade to in crease th e palpebral apert ure by lateral
can th oplast y. Proper con siderat ion of th e an atom y
involved in lateral an d m edial epican th oplast y
sh ou ld be given before th e su rger y is don e to preven t
later com plicat ion s su ch as low er eyelid ect ropion .
6. A at n asal bridge and a poorly de n ed cart ilagin ous
st ru ct u re of th e n ose resu lts in poor p roject ion of th e

n ose.
7. Th ere is a sm aller n asal pyram id w ith sh orter
n asal bon e length in Asian s com p ared w ith oth er
eth n icit ies. A st u dy don e by Naser an d Boroujen i
con clu ded th at th e n asal bon e length st udied in
th e skulls of Korean s w as sm aller th an in Am erican
In dian s, An atolian s, Iran ian s, an d African Am erican s.9
Th e soft an d sm all n asal sept um en coun tered
som et im es p oses di cu lt y to th e su rgeon n eed ing
a cart ilage graft from th e n asal sept u m . Du e to th is,
th e use of h om ologous an d autologous rib cart ilage
graft s h as becom e popular w h en syn th et ic im plan t s
are n ot su it able or n ot preferred by p at ien t s. Pat ien t s
sh ou ld be adequ ately cou n seled , as th e likelih ood of
n eeding a rib graft is h igh er in Asian pat ien t s.
8. Th e n asal skin is th ick w ith abun dan t sebaceous
glan ds. Th is m akes m an euvering th e n asal t ip
su bst an t ially m ore tech n ically dem an ding.
9. Asian s possess di eren t skin proper t ies com pared
w ith oth er racial groups. Asian s are kn ow n to h ave
a th in n er st rat u m corn eu m , th e sm allest in term s of
p ore size an d pore n u m bers, an d th e h igh est w ater
an d lip id con ten t in th e st rat u m corn eu m com p ared
w ith oth er peoples. Th eir skin is also kn ow n
to h ave th e w eakest ch em ical barrier. All th ese
ch aracterist ics sign ify th at topical drug pen et rat ion
is th e best in Asian skin an d th at th e form at ion
of w rin kles is less in Asian s. Such an atom ical
d i eren ces in th e epiderm al layer of th e Asian skin
m ake m an agem en t of scars an d skin lesion s di eren t

in th e Asian popu lat ion .
10. Asian s h ave a h igh m alar prom in en ce due to a
p rom in en t zygom at ic body or arch .
11. Th e broad m an dibular angle is associated w ith
m asseter hyp ert rop hy.
12. Asians’ hair is th ick and coarse, is round in shape, and
grow s faster. Asian s also h ave a h igh er prevalen ce of
curly hair, but th ick and st raight hair is predom inan t
am ong East Asian s. Th ese an atom ic di eren ces in
Asian h air com pared w ith Caucasian hair require
h air t ran splan t equipm en t an d procedu res th at are
di erent from those that are convent ionally used.
To successfully address th e above issu es, on e sh ould
un derst an d th e u n ique an atom ic presen t at ion of th e Asian
face to p rop erly m odify an d m ake re n ed adju st m en t s to
th e gen eric tech n iques presen ted in earlier textbooks.


1 The Changing Face of Aesthetic Facial Plastic Surgery am ong East Asians

a

b

c

d

e

f

Fig. 1.3 Typical East Asian wom an who had rhinoplast y with blepharoplast y. (a–c) Typical East Asian face, illustrating the wide mandibular angle, high cheekbones, poorly de ned upper eyelid crease, broad and low nasal dorsum, and poorly de ned nasal tip. (d–f) The same
individual after rhinoplast y and blepharoplast y. Her appearance greatly enhanced, the individual seems more approachable and attractive,
with softening of the unfavorable wide angle of the mandible.

7