The mean age of BDD onset is 16.4 ± 7 years, although most patients don’t seek treatment until their late thirties.^1,² The course of the disorder tends to be continuous rather than episodic and complete remission of symptoms appears to be rare, even after treatment. The disorder appears to affect men and women with equal frequency.^2,³ Male patients may be more likely to be unmarried.

Clinical features of BDD include varying degrees of preoccupation with perceived defects. Men may become preoccupied with their genitals, height, hair and body build, whereas women typically report concerns with their weight, hips, legs and breasts. Some patients may present with highly specific concerns (e.g. perceived asymmetry of a body part), whereas others may have vague complaints (e.g. concern that a body part just does not look right). Rhinoplasty, liposuction and breast augmentation are among the most frequently sought surgical procedures by the patients afflicted with BDD.^4,⁵ Seven to fifteen percent of cosmetic surgery patients meet criteria for BDD.

Medical History

Consumption of prescription, over-the-counter or herbal medications should be investigated carefully (Table 1.2). These may have deleterious effects on surgery and recovery by causing intraoperative bleeding, subsequent hematomas and delayed healing.

Table 1.2 Medications and food products that have deleterious effects on surgery

The condition and color of the skin is relevant to the successful outcome of the final surgery in pivotal ways. The patients with lighter skin (Fitzpatrick I or II) generally heal better and are more suitable candidates for laser resurfacing or chemical peel, although their dynamic lines, which appear on animation, would not respond favorably to resurfacing, while the static lines, which are present all the time, improve notably with resurfacing. However, those with light freckled skin and blue eyes, have a higher propensity to bleed excessively and develop hypertrophic scars after surgery. The patients who possess darker skin (Fitzpatrick V or VI) are not ideal candidates for resurfacing and any resurfacing on this group of patients will require additional consideration. This group of patients, on the other hand, usually does not exhibit deep dynamic lines.

Patients in the age group of 50 years or older, and those with known medical conditions that could potentially increase the risk of surgery, should undergo a full medical check up, or an ophthalmology examination within 1 year of surgery if eyelid surgery is being considered.

Completion of a comprehensive health form is the most effective way to record information regarding a patient’s medical history. Most seasoned surgeons have designed their own questionnaires to lead patients in disclosing medical problems that may have an adverse effect on the surgical outcome.

The most common medical condition that may have deleterious influence on an aesthetic surgery outcome is hypertension. Undoubtedly, controlling the hypertension plays a prodigious role in reducing the risk of postoperative hematoma development. The patient’s blood pressure must be normalized during the several weeks before surgery. If the patient is consuming medications that may contract the blood volume, the surgeon must exercise caution for any developing intraoperative hypotension and, if it occurs, it should be corrected before the incisions are closed. Otherwise, hypotension prevents visualization of the transected blood vessels since they do not bleed, which can start bleeding when the blood pressure rises to the normal level post operatively. In other words, it is the relative hypertension that may cause postoperative hematomas.⁶

Diabetes is another condition that may lead to postoperative complications.⁷ Patients with a positive family history of diabetes may have a weakened immune system without clinical or laboratory evidence of diabetes, causing infectious complications that would not otherwise occur under ordinary circumstances. A history of recurrent infection or poor healing on a patient with a family history of this condition, may aid in diagnosing previously undetected diabetes.⁷ When diabetes is suspected and the fasting blood glucose levels are normal, a simple glucose tolerance test can help uncover an unrecognized diabetes. History of easy bruising or prolonged bleeding, if no pharmaceutical products which can cause bleeding have been consumed, should raise the suspicion of some type of coagulopathy, such as Von Willebrand’s disease.^7a

Facial Analysis

In this chapter we will focus on facial analysis in detail. Analysis of the other parts will be incorporated within the related chapters. To analyze the face in an organized manner, the face is arbitrarily divided into three anatomic zones by three imaginary horizontal lines. The upper line lies at the hairline; the second is at eyebrow level; and the lower line passes through the columella-labial junction (Fig. 1.1). In a comely face these three horizontal lines divide the face into three equal sections. The components of these three zones are appraised individually from frontal and profile views, and likewise the relationships between these units are examined.

Fig. 1.1 Lines passing through eyebrows and subnasale divide face into three equal zones.

Front view of the upper zone

The harmony of the upper aesthetic unit can be marred by a highpositioned hairline, leading to an elongated forehead. This finding is of particular significance when planning the incision for forehead rejuvenation on a patient with a senescent forehead (Fig. 1.2). When the forehead is long, the surgeon may forego a coronal incision or an endoscopic forehead rejuvenation and choose a pretracehial incision, using either the subcutaneous or subgaleal dissection to reduce the forehead height.^8,⁹

Fig. 1.2 Frontal view of a patient with elongated forehead and eyebrow ptosis who would be a better candidate for forehead rejuvenation with pretrichial incision rather than endoscopic forehead rejuvenation or coronal incision.

Deep wrinkles in the forehead area are commonly the result of compensation of the frontalis muscle to minimize the effects of eyebrow or eyelid ptosis (Fig. 1.3). Thus, it is critical for the surgeon to relax the forehead before selecting a forehead rejuvenation procedure. This can often be accomplished by asking the patient to smile. Usually a compensatory elevation of the eyebrow is eliminated while smiling. The second approach is to ask the patient to close the eyes tightly, and then gently start opening the eyes until the patient can see the viewer. The compensation will become evident as soon as the patient is asked to open the eyes at libre. Analyzing the type of existing wrinkles also aids in choosing a more effective forehead rhytidectomy procedure. In general, deep forehead wrinkles do not respond as favorably to a subgaleal forehead rhytidectomy or an endoscopic forehead rejuvenation. A subcutaneous approach may produce a more successful result in patients with pronounced forehead wrinkling.¹⁰ A combination of endoscopic forehead rejuvenation and laser resurfacing is a logical choice for those who exhibit eyebrow ptosis and many fine wrinkles.

Fig. 1.3 Patient with iatrogenic receding temple hairline as a consequence of rhytidectomy incision being placed at temple hairline.

Because of the role they play in the selection of suitable corrective procedures, the function of the corrugator and procerus muscles and their effect on the overlying skin deserve attention. Visible vertical frown lines may require removal of the corrugator muscle and subcutaneous placement of fat. An overactive depressor supercilii muscle results in oblique lines medial to the eyebrows.

Profile view of the upper zone

Reviewing the lateral portion of the forehead helps the surgeon to determine the position of the temple hair in relation to the lateral canthus. If the hairline is receding at the temple area and the patient is considering a facial rhytidectomy (Fig. 1.4), one may choose the anterior hairline temple incision^11,¹² over the incision placed within the hair-bearing temple.

Fig. 1.4 Patient with significant forehead wrinkles and eyelid ptosis; note eyebrow compensation.

The forehead profile contour should be smooth and pleasing. Any imperfections, such as frontal protrusion and recession, can be the result of a variety of pathologic conditions. Most commonly, the forehead contour abnormality results from bony protrusion caused by sinus hyperaeration (frontal bossing) (Fig. 1.5) and, less commonly, it results from soft tissue excess.¹³ Not only do these flaws reduce the desirability of the forehead contour; they may influence the outcome of other aesthetic procedures, such as rhinoplasty. A small ridge cranial to the eyebrow is an acceptable masculine characteristic. Presence of a ridge on a woman, or an exaggerated prominence on either gender, may require aesthetic contouring of the frontal bone. Additionally, as a consequence of aging, the round and slightly projected glabellar area may appear flat or even depressed to varying degrees. Correction of this flattening undoubtedly bestows a rejuvenated appearance to the forehead.

Fig. 1.5 Profile view of patient with frontal bossing caused by hyperaeration of frontal sinuses.

Front view of the middle zone

Most imbalances involve the middle and lower areas of the face. The upper border of the eyebrows should be located at least 2.5 cm above the mid pupil level on a straight gaze.¹⁴ The medial end of a pleasing eyebrow is caudal to the lateral extreme, and the highest portion of the eyebrow arch is at the junction of the lateral third with the medial two-thirds of the eyebrow, corresponding to the lateral limits of the limbus in a straight gaze. Eyebrow ptosis results in crowding of the orbital region and must be differentiated from blepharodermachalasia. Any asymmetry in the level or the shape of the eyebrow arch may require differential eyebrow ptosis correction.

The distance between the medial canthi (intercanthal distance) that is normally approximately 31-33 mm, equals the distance between the medial and lateral canthi (orbital fissure width) (Fig. 1.6). This relationship becomes particularly important when dealing with rhinoplasty candidates who would benefit from refinement of the nasal dorsum and adjustment of the alar bases. Adding to the radix creates an illusion of reduced intercanthal distance, which is detrimental to those patients who exhibit hypotelorism, whereas reduction of the nasal dorsal projection produces the opposite effect.¹⁵ Even slight hypotelorism is undesirable and detracts significantly from the patient’s attractiveness. Narrowing the distance of the nasal bones spawns an illusion of decreased intercanthal distance.⁸

Fig. 1.6 Width of upper face is 5 times that of palpebral fissure. Of five equal segments, two are occupied by eyes, one by nose and two by temples.

The individual with a slight increase in the intercanthal distance may still be considered attractive. Yet, when the distance extends beyond 36 mm, it leads to a grossly abnormal and displeasing appearance. Presence of hypertelorism or telecanthus is also consequential when planning rhinoplasty because widening the distance between the nasal bones literally or by virtue of an optical illusion, such as adding a wide dorsal graft, will result in the appearance of more severe hypertelorism or telecanthus. While the surgeon must be conservative when widening the nasal bridge of a patient with a wide intercanthal distance, a wider bridge may prove salutary for the patient who has a shorter intercanthal distance.

The upper portion of the midface can be divided into five equal segments, two are occupied by the eyes; one extends from one medial canthus to another, containing the root of the nose; and two extend from the lateral canthi to the lateral boundary of the ipsilateral temple area (Fig. 1.6). Disharmony of this area has a significantly ruinous effect on the pulchritude of the face. Anteroposterior discrepancies of the eyes cannot be fully noticed on a frontal view, but are more perceptible on a basilar view. Detection of level and depth abnormalities of the eye is important so that the patient can be informed of structural abnormalities that may fail usual efforts at achieving balance in this part of the face.

Edema around the eyes in a blepharoplasty candidate may indicate abnormal thyroid dysfunction or renal failure (Fig. 1.7). Bilateral or unilateral exophthalmus may be the consequence of hyperthyroidism (Fig. 1.8). On patients who are contemplating blepharoplasty, vision and lacrimal function also should be assessed. A combination of slight proptosis and dry eyes or borderline tear production is inauspicious and can lead to a troublesome postoperative course.

Fig. 1.7 Patient presenting for blepharoplasty exhibits periorbital edema. Thyroid tests disclosed hypothyroidism.

Fig. 1.8 Patient seeking blepharoplasty to correct exophthalmus was discovered to have hyperthyroidism.

The optimal vertical opening of one eye is approximately 10 mm, placing the upper eyelid margin 1 mm below the upper limits of the limbus. In the aesthetic surgery patient population, mild-to-moderate upper eyelid ptosis is common, but can easily be missed. This condition is readily corrected using one of several available techniques. In a harmonious face the lateral canthus is generally 2° higher than the medial canthus, giving a slight slant to the eye fissure. The antipode of this relationship gives the patient a tired and sad appearance (Fig. 1.9), typically seen in patients with craniofacial deformities, such as Treacher-Collins syndrome, and in patients with lateral lid lag following lower blepharoplasty (Fig. 1.10).

Fig. 1.9 Patient with antimongoloid slant of orbital fissure, rendering sad and tired appearance.

Fig. 1.10 Patient with iatrogenic displacement of lateral portion of lower eyelid and lateral canthus.

As stated, unilateral or bilateral proptosis is an important finding that may present as only a slight asymmetry and excessive opening of one eye or both eyes, or as a significant prominence of the globes. Often this finding is an indication of a thyroid dysfunction and, therefore, it necessitates a careful medical evaluation before blepharoplasty. Generalized thickening of the upper and lower eyelids may be a reflection of hypothyroidism, which should be investigated thoroughly before any periorbital surgical endeavor. Occasionally the lacrimal glands are ptotic and present as an excessive bulk along the lateral portions of the upper eyelids. In this case, lacrimal gland suspension should be discussed with the patient. Neither this condition nor suspension of the gland is of functional significance.¹⁶

Ideally, the supratarsal fold is visible about 3-4 mm above the lid margin on a straight gaze while this distance is about 10-11 mm when the eyelids are closed. A levator dehiscence is suspected when the tarsal show is increased in the cephalocaudal dimension with a more pronounced supratarsal crease. If eyelid ptosis is diagnosed, levator function must be checked because it is a crucial factor in the selection of a corrective approach. Presence of Bell’s phenomenon indicates a reduced risk of exposure keratitis if complications, such as lid lag, occur. To conduct the test for Bell’s phenomenon, the examiner asks the patient to force the eyes closed while the examiner attempts to open the eyelid by lifting the lid with a finger. With a positive Bell’s phenomenon, the globe rolls cephalad, protecting the cornea under the upper lid (Fig. 1.11). A negative Bell’s phenomenon may be indicative of a potential for an increase in corneal exposure; hence, dryness and ulceration of the cornea should a lid lag ensue post eyelid surgery.

Fig. 1.11 A, Positive Bell’s phenomenon demonstrated by cephalad rotation of globe when examiner attempts to separate eyelids against patient’s resistance. B, Negative Bell’s phenomenon depicted by failure of globe to rotate cephalad when examiner tries to separate eyelid and patient attempts to keep them closed.

A pleasing lower eyelid is located at the caudal limits of the limbus or minimally overlaps it. An increased distance between the lower lid and the limbus, with excessive sclera visible through the lids, is an indication of a lower lid lag, which should be evaluated carefully. The lower lid support system weakness could be congenital. Whether it is congenital, iatrogenic or due to senescence, this condition should alert the aesthetic surgeon to undertake a conservative lower lid surgery or to incorporate a procedure that fortifies the lid support, such as canthoplasty or canthopexy. A lower lid lag should be differentiated from an ectropion. The latter is characterized by outwards rotation of the lid margin and the eyelashes. Checking the tone of the lower lid with a pinch and traction test may aid the examiner in differentiating a congenital caudal lower lid malposition from a weak lower lid support. Swift return of the lid to its previous position, after it is pulled caudally or pinched and released, indicates good muscle tone. Motility (cephalocaudal moveability) of the lateral canthus should be less than 7–8 mm and the maximum distance from the globe while the lid is pulled anteriorly should not exceed 7 mm.

The quality of the skin and the types of existing wrinkles guide the surgeon in deciding between skin/muscle flap, conjunctive blepharoplasty, a lower lid laser resurfacing procedure, a chemical peel, or a combination of these techniques. Generally, patients with thin skin and fine wrinkles do not experience long-lasting results from laser resurfacing, even though the initial improvement may be significant. On the other hand, patients with thicker skin usually experience a lesser degree of improvement that is of longer duration.

Any depression in the nasojugal area or cephalad to the infraorbital rim may necessitate soft tissue repositioning or fat grafting. Malar bone hypoplasia, although better judged in the profile view, may be detected in the frontal view as well. When evaluating the nose, the examiner must observe the width, direction and smoothness of the dorsal contour. The cephalocaudal nose length, defined as the distance from the nasion to the caudal border of the infra tip lobule, is twice the distance from the columella-labial junction (subnasale) to the junction of the lips (stomion) and equals the distance from the stomion to the menton (base of the chin) (Fig. 1.12). The nasal dorsum and the tip should be in line with the midline of the other facial structures. Any abnormalities can be easily ascertained by drawing an imaginary vertical line starting from the glabella. The nose tip, the philtum dimple and the center of the chin should all fall on the same line.

Fig. 1.12 Proportions of the middle to lower facial areas.

The quality of the nasal skin is a significant factor in planning surgery and achieving the intended objectives.¹⁰ Patients who have thicker skin usually are not optimal candidates for rhinoplasty because the tip would not be as well-defined post operatively. On the other hand, patients who have very thin skin tend to reveal every imperfection in the nasal frame. Both extreme cases require a change in the surgical planning, and the incidence of revisional surgery could be higher on these patients because of these adverse conditions. A thorough explanation of the reasons for potential revisional surgery may result in lesser postoperative dissatisfaction in these patients.

The nasal bones should line up symmetrically, allowing a graceful transition of shadow from the eyebrows to the nasal tip through a pair of smooth and pleasing dorsal lines. Any excess or deficiency of nasal bone width, unilateral or bilateral may distort these lines.¹⁷

A portion of the nostril opening should be visible on the frontal view. Inadequate nostril show may be an indication of a long nose or caudally positioned ala, whereas excessive nostril show may denote a short nose or retracted alar rims. Most rhinoplasty candidates have wide and asymmetric nostrils. This becomes even more apparent when the individual smiles. This imperfection has significant surgical connotations and must be elicited by asking to the patient to smile. Tip overlap on the upper lip becomes more noticeable on animation. Furthermore, the form, symmetry and particularly the width of the lower lateral cartilages can be judged easily on the front view.

The distance between the alar bases, as measured from the lateral border of one alar base to its opposite counterparts, should be slightly wider than the intercanthal distance. An imaginary line drawn vertically from the medial canthi should pass 1-2 mm on the inside of the alar base, providing that the intercanthal distance is normal (Fig. 1.13). If the intercanthal distance is abnormal, the alar base distance should be 2 mm wider than the orbital fissure width (from the medial to the lateral canthus).¹⁸ The pleasing nasal tip has two highlights. The distance between these two points matches the width of optimal nasal dorsal lines.

Fig. 1.13 Width of alar base is slightly wider than intercanthal distance. Distance from eyelid to eyebrow and position of eyebrow arch in relation to iris are shown.

Profile view of the middle zone

On the frontal view, the lateral boundaries of the ears are visible with the helix slightly more projected lateral to the antihelix. The entire ear contour creates a parallel vertical line relative to the face. Excess ear projection results in greater visibility of the helix and disappearance of the antihelical fold. The length of the ear equals that of the nose. A horizontal line drawn from the subnasale touches the caudal border of the earlobes. The ears are more precisely assessed on the lateral view. The overall configuration, helix size, development of antihelical folds, earlobe size, and cephaloconchal angle are observed. The normal angle between the patient’s body and long ear is approximately 30°, with the cephalic portion of the ear tilting posteriorly.

On the profile view, the supraorbital rims are about 10-15 mm anterior to the globes. The nasion, the most depressed portion of the nasal dorsum, is located at the level of the upper lid margin on a straight gaze and is 4-6 mm deep in relation to the glabella. The nasal dorsum creates a 34° angle with the vertical facial plane on a woman and a 36° angle on a man. In both men and women there is a gentle and gradual curve of the dorsum extending from the nasion to the tip; the deepest portion is 0.5-1 mm for a man and 1-1.5 mm for a woman. The nasolabial angle measures 105-108° for a woman and 95-100° for a man.¹⁹ A desirable tip definition includes a small supratip break on the profile view. The inferior border of the columella is approximately 4 mm caudal to the alar rim on the lateral view and the alar base is about 2 mm cephelad to the subnasale.²⁰

The malar soft tissue is projected anterior to the most prominent portion of the optical globe. Reversal of this relationship produces a negative lower lid vector, potentiating the chance of lid retraction and postoperative dry eye syndrome.²¹

Front view of the lower zone

In the frontal view of the lower facial zone, the upper lip length, as measured from the base of the columella to the stomion, should be half the distance from the stomion to the horizontal line, passing through the most caudal portion of the chin. On a patient with a normal underlying maxillary and mandibular frame, dentitions and patent airway, the lips are sealed in repose. Lip incompetence, which is habitual failure to close lips in repose, often is seen on patients with a long face deformity on those who are mouth breathers due to nasal blockage, patients with an open bite, or patients with iatrogenic or muscular dystrophy related lower lip ptosis.

The upper lip is slightly thinner than the lower lip. The width of the oral commissure equals the distance from one medial limbus to the other side. On frontal view the lower jaw line is well defined in a symmetric fashion, with the superficial musculoaponeurotic system (SMAS) being tight and smooth. Ptosis of the SMAS and fat is an integral part of gravity effects and the aging process, which causes jowls to develop and the lower face to widen. A horizontal line connecting the oral commissures runs parallel to the lines connecting the canthi. The oral commissures are located horizontally on young patients, whereas senescent patients demonstrate claudal tilt of the oral commissures. The philtrum dimple is bordered with a well-defined cupid’s bow. Excess submental fat may obscure the chin definition and hide enlarged or ptotic submaxillary glands and they can only be detected by palpation.

A congruous tooth alignment is a material component of an attractive smile. When the lips are slightly apart, 2-3 mm of the upper incisors should be visible between the lips. Any excess incisor show may infer a long face deformity or a short upper lip. When the patient is asked to smile, there is usually minimal gum show. Excess gum show may indicate a long face deformity or a short upper lip. Normally the central incisors and canines are slightly longer than the lateral incisors. Crowding is an indication of discrepancy between the width and number of teeth and the size of the dental arch. Patients with this type of dental flaw may require orthodontic correction or combined orthodontic preparation and orthognathic surgery. Dental occlusion should be examined to ensure the presence of a normal relationship between the mandible and the maxilla. Abnormal jaw growth and speech difficulties can be the consequence of a large tongue, detection of which is an integral part of a thorough facial evaluation.

Profile view of the lower zone

On patients with a hypoplastic anterior maxillary region or a deficient nasal spine, cephalad portion of the upper lip is retruded on the profile view. Augmentation of the anterior maxilla, nasal spine and caudal septum improves this relationship noticeably. In a harmonious face either the upper and lower lips are lined up evenly in a vertical plane or the lower lip is slightly posterior to the upper lip. The lips are sealed in a relaxed position. Any substantial imbalance between the upper and lower lips often indicates a skeletal abnormality.

The labiomental groove is often well defined and approximately 4 mm deep. This is one of the most underestimated features of the face. An imaginary line touching the most projected portions of the upper and lower lips should touch the most anterior portion of the chin (Reidel’s plane) (Fig. 1.14).²² A deficient or excessive chin may be easily detected by this simple examination. Patients with receding chins who already exhibit a deep labiomental groove often have retrognathia and usually are not good candidates for genioplasty alone. Commonly, mandibular advancement, with or without a genioplasty, serves these patients best.

Fig. 1.14 Reidel’s plane of lip and chin line-up is straight line connecting most prominent portion of upper lip to lower lip. In pleasing profiles, line usually contacts most prominent portion of soft tissue chin.

The cervical region

Ellenbogen has described the attributes of an aesthetically pleasing neck whereby a 100 angle is created between the chin and the neck.²³ This angle can be altered by a variety of neck flaws. These could include: excess skin, presence of platysmal muscle bands, excess subplatysmal and supraplatysmal fat, a malpositioned hyoid bone (Fig. 1.15),²⁴ a receding chin, or a varying combination thereof. A ptotic or enlarged submaxillary gland may also disturb the balance of the cervicomental region.