the face recurve concept: medical and surgical …...the face recurve concept: medical and surgical...

The Face Recurve Concept: Medical and Surgical Applications

Claude Le Louarn, M.D.,1 Didier Buthiau, M.D.,2 and Jacques Buis, M.D.1

1Clinique Spontini, 68 bis rue Spontini, 75116 Paris, France2Institut de Radiologie de Paris, 118 boulevard Haussmann, 75008 Paris, France

Abstract. The application of the Face Recurve theory givesrise to new technical opportunities in the fields of both

aesthetic medicine and aesthetic surgery to block the actionof the age marker fascicules largely responsible for aging ofthe paramedian folds. With respect to aesthetic medicine,

the combination of botulinum toxin and soft tissue fillershas proven effective. On the basis of the authors� theory,however, two new technical refinements become pertinent.

First, the filler must be injected predominantly deep to themuscle to treat the skin depressions in a more naturalmanner, bringing restoration to the curve of the overlying

muscle. Second, a very low number of botulinum toxinunits (one-fourth to one unit) should be injected into spe-cific muscles to diminish their resting tone without dimin-ishing their maximal contraction strength. With respect to

aesthetic surgery, the authors present new techniques forthe treatment of early aging, specifically a combination ofsegmental muscular section, microliposuction, and retro-

muscular fat grafting, all of which can be performed readilywith the patient under local anesthesia. For more advancedaging, surgery offers new treatment opportunities that in-

clude the concentric malar lift for correction of the midfaceregion, with repositioning of suborbicularis oculi fat backonto the orbital rim from its descended eccentric displace-ment at the hands of repeated orbicularis oculi contrac-

tions. At the same time, specific muscles can be weakenedand fat volume restored. Each area can be studied in aspecific way and treated definitively. Currently, the skin

does not need to be tensioned to a maximum during a face-lift for treatment of the irregular jaw line, the palpebro-malar groove, and so forth. Skin tension can be moderated

to remove only the true excess of skin. Facial contour isimproved, whereas the specific glide is restored betweenmuscles and their underlying fat.

Key words: Age marker fascicule—Aging process—Botu-linum toxin—Face Recurve—Fat injection—Filler—Malar

lift—Mimetic muscles—Rejuvenation

We introduce a new approach to slow the onset offacial aging, and to rejuvenate the face with estab-lished aging. This strategy is based on our researchinto the major influence of age marker fascicules inthe genesis of structural aging. Our theory, calledFace Recurve, describes the role of these fascicules inthe progressive transfer of deep fat toward superficialfat over time, as presented in the previous article.This second article presents new specific medical andsurgical treatments based on this muscular theory ofstructural aging. Clinical results derived from thesenew techniques have proven favorable, as comparedwith earlier results.

Materials: Patient Study Group

This report describes the experience of injectinghyaluronic acid (Q med products: Restylane andPerlane, Q-Med AB, Uppsala, Sweden) as a fillersubstance. A total of 980 patients (1,960 orbital rimhollows) received injections over 8 years by the seniorauthor (C. L.) into the tear trough depression usingthe technique described in the following discussion[1]. Of these patients, 20 were injected in the equiva-lent depression of the upper eyelid, and 110 patientswere injected at the jaw line. Over 2 years, 21 patientsreceived autologous fat injection into the tear troughdepression, all during concomitant face-lift.

We describe a new rationale for using botulinumtoxin A, with a low quantity of toxin in a small vol-ume, which diminishes the resting tone of muscles

Correspondence to C. Le Louarn; email: [email protected]

Aesth. Plast. Surg. 31:219�231, 2007DOI: 10.1007/s00266-006-0025-8

without affecting the contraction at maximumstrength. We report on 120 patients who receivedinjections over 6 months. The indication of botulinumtoxin injection in the sectioned muscle to limit muscleregeneration also is new, with 34 patients injected thusin the past 4 months. Surgical weakening of thesuperciliary region (corrugator and procerus) and thelateral canthal region (orbicularis oculi) through a lidincision [2] has become a standard procedure duringour upper eyelid surgery when we wish to alter eye-brow position or address the glabella region.Similarly, over the past 3 years, 120 patients have

undergone surgical section of the depressor angulioris supplemented with fat injection. Over the past 12months, we have added sectioning of the levatoralaeque nasii for seven patients. During the past 3years, 132 patients (80% women) have undergone theconcentric malar lift technique.

Methods

The Face Recurve strategy can be divided into fourstages. During the prevention stage (stage 0), ToxinRecurving (around 25 years of age) uses botulinumtoxin to prevent muscular shortening and fat transfer.The muscle resting tone in the young patient ismaintained at a low level for a significant timewithout modification of the maximum contractionforce. During aging stage 1, Toxin Filler Recurving(around 35 years of age) treats the early stages ofaging by injection of the mimetic muscles to limittheir contractile force and filling of the depressionsresulting from the action of the age marker fascicules.Maintaining the resting tone of some muscles at a lowlevel also is useful at this stage. During aging stage 2,Facial Recurve (around 45 years of age) involvessurgical section of the age marker fascicules, with thepatient under local anesthesia, and autologous fatgrafting to restore deep fat. During aging stage 3,

Facial Recurve Lift (around 55 years of age and be-yond) combines cutaneous face-lift with section of theage marker fascicules and structural fat grafting, butwithout the need for major skin traction to efface thefurrows of structural aging. The stages then aremodified to best meet the rejuvenation requirementsof each patient in each specific locale.

Lateronasal Malar Rejuvenation

During the prevention stage of aging, botulinumtoxin is injected to prevent shortening of the levatoralaeque nasi and to limit fat transfer. Reduction ofthe superior nasolabial depression is achieved whilethe functional muscular elevation of the nasal ala ismaintained by a very small quantity (1 Vistabel unit)of toxin placed into the muscle near its motor endplates (mid portion of the muscle above the pyriformaperture).

At the first stage of aging, rejuvenation is enhancedby injection of filler deep to the levator labii superi-oris to increase anterior malar projection. Filler alsois injected deep to the levator alaeque nasii, the site ofthe paranasal smile dimple (Fig. 1), as well as in theoverlying subcutaneous plane. The depression seen atthe origin of the nasolabial fold is filled by injectingapproximately 0.8 ml of filler between the cutaneousinsertion of the levator alaeque nasi and the pyriformaperture (Fig. 2). During injection, an immediatefreeing of the depressed alar base can be seen. Wehave found that intradermal filling of the superioraspect of the nasolabial depression produces anunnatural look because dermal filling cannot prop-erly replace the retromuscular fat volume that hasdisappeared over time. Thus, intradermal filling isused only to fill the superficial wrinkles of the naso-labial sulcus.

At the second stage of aging, surgical weakeningof the levator alaeque nasi through an intranasal

Fig. 1. (A) ‘‘Paranasal smiledimple’’ seen as a depressioncaused by contraction of thelevator alaeque nasi muscle.(B) Profile of the face at restshowing anterior malar flatten-ing due to the resting tone of thelevator labii superioris alaequenasi muscle. The distance be-tween the bridge of the nose andthe anterior malar increaseswith age. (C) After injection ofPerlane 0.5 ml. The anteriormalar area is advanced, reduc-ing the distance between malarand nasal bridge.

220 The Face Recurve Concept

mucosal approach is available, with the patient underlocal anesthesia (Fig. 3). This muscle is identifiedthrough the upper part of the intercartilaginousincision used in rhinoplasty.

Malar Rejuvenation and the Tear Trough Depression

At the prevention stage of aging, 2 to 3 units ofbotulinum toxin are injected and spread over thelength of the orbicularis oculi superior malar part(4 injections of 0.25 Vistabel units) to reduce itsresting muscle tone while leaving its contractionstrength undiminished (Fig. 4). At the first stage ofaging, in association with the botulinum toxin injec-tion, filler is injected precisely on the bone to replacemissing retromuscular fat. The risk of blindness isminimized if the injection is performed with minimalpressure in the preperiosteal plane, which is relativelyavascular. We have no cases of visual disturbance inour series. Often, 1 ml of Perlane is necessary to fillthe orbital rim hollow from the medial to the lateralcanthus (Fig. 2). We first inject the deepest medialpart of the orbital hollow using a standard 27-gaugeneedle. The needle is marched along the rim towardthe lateral canthus using the ‘‘vacuum technique’’: thebevelled angle of the needle is placed on the rim; thenthe tip is elevated to create a depression, a vacuum,just below. The injected product will stay in thevacuum area and will have no risk to migrate lat-erally. Further injections along the depression aregiven medially and laterally as necessary. Any zygo-matic hollow visible toward the cheek is injected verysuperficially with Perlane (0.3 ml). Filling the linear

depressions of the orbital rim hollow and zygomatichollow can make the malar bag disappear. The malarbag caused by inflammation, on the other hand, istreated with a superficial injection of a limitedquantity of dexamethasone acetate. At a more ad-vanced stage of aging, malar rejuvenation is per-formed using the concentric malar lift technique.

The Concentric Malar Lift

Background. In 1989, Tessier published the subpe-riosteal face-lift, which in addition to its well-knowneffects on the frontotemporal region, brought reju-venation to the malar region [3]. In 1989 and again in1992, Le Louarn published the malar musculofat flap[4,5], demonstrating that malar rejuvenation can beobtained during a subcutaneous face-lift that includessubperiosteal malar detachment. In 1996, a subpe-riosteal malar lift was described, which used the lat-eral, canthal part of a submuscular lower eyelidincision. Secondary lid retraction was avoided,whereas the arcus marginalis was left intact [2]. In1998 the concept of the concentric malar lift [6] waspublished, but with a technique more complex thanthat recommended currently. The simpler techniquefollowed in 2004 [7]. The concentric malar lift de-scribed in the following sections is an evolution of thelater, simplified technique. Only new or furtherrefinements are provided in this discussion.

Preoperative Markings. The curved line of the teartrough depression is first marked. Next, the centralprominence of the nasolabial fold (Fig. 5, point M) isindicated. The third marking (Fig. 5, point O) is the

Fig. 2. (A) Patient with a visible tear trough depressionextending from the one canthus to the other. The alar of thenose is depressed at the pyriform aperture and the corner ofthe mouth descends. (B) After administration of Perlane 1.3ml to the periorbital hollow, the depression has disap-peared, and there is no visible irregularity. The addition ofPerlane 0.8 ml over the pyriform aperture has opened upthe alar. Additionally, 0.33 ml also was injected verysuperficially into the vermilion and mucosa at the corner ofthe lower lip, resulting in lifting of the commissure.

Fig. 3. (A) A patient with a hollow superior nasolabialsulcus and elevated ala because of the high resting tone ofthe levator alaeque nasi muscle. The nasal ala is depressedagainst the pyriform aperture. (B) An intercartilaginousapproach. At this point, the levator alaeque nasi muscle isseen close to bone. (C) After surgical section of the levatoralaeque nasi muscle and injection of fat 0.7 ml over thepyriform aperture, the ala has descended, and depression ofthe upper nasolabial sulcus has diminished.

C. Le Louarn et al. 221

lower limit of the skin-orbicularis oculi dissection inthe parasagittal plane of the lateral canthus. Thispoint also indicates the lateral extent of the newsubtarsal furrow, which usually falls in the palpe-bromalar groove.Infiltration with 40 cc of saline per side, before

surgery, decreases drastically the post operationoedema duration.

Subcutaneous Dissection. The superficial dissectionextends from the subciliary incision to point 0 (Fig. 5)in the lateral part of the eyelid.

Subperiosteal Dissection. The deep dissection isperformed through a 1.5-cm oblique muscle incisionextending from the lateral canthus. To avoid the riskof secondary eyelid malposition, the muscle incisionshould not extend more than 2 mm medial to thelateral canthus. For the same reason, it is importantto free the orbital rim from all soft tissue attachmentswhile leaving the arcus marginalis intact. The muscleincision extends inferolaterally, parallel to the axis ofthe orbicular branches of the zygomatic nerve.A variation of this muscular incision is used sinceSeptember 2006 to achieve a better visualization of

the inferior orbital rim. The incision is parallel to theorbicularis fibers at the lower part of the lateralorbital rim just above point O. For these two types ofincision, submuscular tissues are carefully retractedbefore periosteal incision.

The Three Fixation Points. Point 1 (Fig. 6A) isdrilled in the lower orbital rim close to its junctionwith the lateral rim. Point 2 (Fig. 6B) is drilled in thelateral rim between the lateral canthus and point 1.Point 3 (Fig. 6C) is drilled at the level of the lateralcanthus such that there will be no elevation of theeyelid commissure.

Fixation. Fixation of the Malar Fat Pad and theDeep Malar Tissue on the Lower Orbital Rim(Figs. 6A and Fig. 7: point M to point 1). A Prolene3-0 suture on a straight needle is inserted throughthe lateral muscle opening into the freed subperio-steal plane. The tip of the needle is brought throughthe skin at point M, encompassing the deep fat as itis elevated by a finger (Fig. 7A). The straight needleis advanced but not withdrawn from the skin suchthat its suture-bearing end remains 1 cm within thecheek (Fig. 7B). The needle end is then pushedbackward, this time passing above the deep fat padand reentering the subperiosteal space, from which itis withdrawn via the same muscle opening (Fig. 7C).The straight needle is then shortened to a length of 1cm and curved with a needleholder so that theProlene suture can be passed through point 1 (Fig. 6A). It is then tied, bringing inferior volume backonto the orbital rim and improving the tear troughdepression.Using the same technique, a second

Fig. 5. Concentric malar lift markings and vectors. PointM is at the site of maximum malar fat pad volume. The teartrough depression is treated by lifting M to 1. The depres-sion of the lateral part of the orbital rim is treated by liftingthe deep fat (yellow arrows) in 2. Point O is the point on theskin that is transposed to 3 at the lateral canthus. This pointis the lower extremity of the skin-muscle dissection in thispatient (red arrow).

Fig. 4. (A) High resting tone of the superior malar part ofthe orbicularis muscle. The skin is creased, and the muscleaccentuates the tear trough depression. (B) Reduction ofthe trough depression by injection of Perlane 0.3 ml into themedial tear. The resting tone of the superior malar part ofthe orbicularis muscle has been reduced by injection of2 units of Vistabel spread via four injection points.


suture is passed from the same point 1, but moresuperficially to encompass the malar fat pad andsuspend it like a hammock. The amount of verticalskin to be removed from the lower eyelid dependson the degree of elevation produced with these twosutures.

Fixation of the Lateral and Inferior Malar Tissues(Figs. 6B and Fig. 8). The inferolateral malar soft

tissue is engaged in similar fashion and elevated atan axis slightly oblique and medial as the needle ofthe 3-0 Prolene is passed through drill hole 2. Thiselevation visually fills the deep aspect of the lateralmalar area. It can be simulated by pulling with aGillies hook before suture fixation, with the hookengaged at the intersection of a vertical line throughthe lateral canthus and a horizontal line throughthe alar base. A second fixation can be performed

Fig. 6. The three holes throughinferior and lateral orbital rims.(A) Point 1 allows fixation of themedial and deep malar fat aswell as the superficial malar fatpad. (B) Point 2 allows fixationof the inferolateral malar vol-ume. (C) Point 3, at the canthus,allows fixation of the lateralmalar volume and the superiormalar part of the orbicularismuscle.

Fig. 7. Treatment of the teartrough depression. (A) Thestraight needle is held by a nee-dleholder in the subperiostealplane. It exits at point M, after afinger has elevated the fatty vol-umes. (B) The needle has notexited completely. It is pushedback toward the detachmentplane after it has encircled thedeep fat volume and the under-lying periosteum to be elevated.(C) The medial half of the malartissue is lifted. The suture is fixedto point 1 (Fig. 6A). Anotherneedle is passed more superfi-cially to lift, like a hammocksling, the malar fat pad. Thesuture also is fixed to point 1.


through the same hole and on the same line of ele-vation as the first, but at a higher level, near hole 2, toanchor the lateral lower eyelid elevation. The amountof vertical skin to be removed from the lateral lowerlid depends on the degree of elevation secured bythese sutures.

Fixation of the Lateral and Superior Malar Tissues atPoint 3 (Fig. 6C) and Closure of the OrbicularisIncision (Fig. 9). Preperiosteal tissue at point O(Fig. 5) is next fixed to the lateral orbital rim(Fig. 6C) at point 3 overlying the lateral orbital rimat the lateral canthus. Just above the inferior limit ofthe skin-muscle dissection (Fig. 5, point O), the deepsurface of the orbicularis oculi muscle is engaged witha 5-0 Vicryl mattress suture brought to the upperedge of the orbicularis oculi muscle incision nearpoint 3.

Orbicularis Oculi, Superior Malar Part, and MuscleWeakening. Three muscle myotomies are per-formed in this muscle segment through the skinopening with a pair of delicate scissors. Injection of2 Vistabel units blocks muscle regeneration.

Fat Excision. If there are excessive fat bags in thelower eyelid from a young age (genetic etiology), theycan be removed, but if the excess is recent and limited(aging etiology), then removal is unnecessary.

Skin Excision (Fig. 10). Eyelid skin excision,although significant, is reliably safe because of thesolid fixation at points 1 and 2. The amount of skin tobe removed is assessed as the excess at the cilia levelwhen downward traction is applied on the malar skin.However, if the palpebral margin descends more than3 mm, then the periosteal fixations need to be redone.This maneuver eliminates the risk of ectropion. Re-lease at the subperiosteal plane is the only soft tissue

release for which we consider reattachment to bestable. In our early cases, our skin excision was verymodest because we knew that residual excess could beremoved secondarily with the patient under localanesthesia.

Rejuvenation of the Superciliary Area

At the prevention stage of aging, botulinum toxincan be injected in the corrugator, procerus, andorbicularis oculi muscles at the superior palpebralhollow. Doses (1 unit per injection point) should besufficient to decrease the resting tone without lim-iting the maximum power of contraction. At thefirst stage of aging, injection of botulinum toxininto the corrugator [8] improves the glabella furrowsand, when associated with depressor superciliiinjection, elevates the medial eyebrow. Injection ofPerlane (0.1 ml) under the muscle further improvesrejuvenation of the area. In the presence of superiorpalpebral hollowing, the injection must be preciselyon the bone of the upper orbital rim, so as not beto be visible, thus replacing the fat that has beenexpelled by the muscle (Fig. 11). Nevertheless,injection must avoid the superior orbital rim andnot fill the levator palpebrae muscle, the source ofptosis.

At the second stage of aging, improvement maybe gained by surgical resection of the depressormuscles via an upper eyelid approach [2]. Thetransverse head of the corrugator can be readilyincluded in this ablation. Eyebrow position is thusmodified without the need for a frontal lift. Theorbicularis oculi muscle fascicule corresponding tothe supraorbital hollow is also sectioned in three. Atthe same time, fat deficiency is addressed by eitherinjection or transposition. With respect to the latter,the medial and central palpebral fat bags can be

Fig. 8. Fixation of the lateraland inferior malar tissues atpoint 2 (Fig. 6B). (A) A Gillieshook placed in the subperiostealplane checks the correct posi-tion before placement of thesuture traction. (B) The liftedtissues are fixed to point 2 (Fig.6B). This fixation is performedthrough the muscle incisionwithout crossing the skin.


transposed toward the supraorbital hollow and fixedwith 5-0 Vicryl [2]. To elevate the tail of theeyebrow, the lateral orbital part of the orbicularisoculi (which contains a high density of motor endplates) is denervated by a C-shaped myotomy per-formed via the upper eyelid incision. Dissection atthe undersurface of the orbicularis muscle must beperformed with caution to preserve motor branchesaddressed to the superior orbital part. To avoidtension pulling down the lateral brow after closureof the upper blepharoplasty incision, very little lat-eral skin is resected. To induce a more almond-shaped eye, botulinum toxin commonly is injected atthe lateral extremity of the pretarsal orbicularis, but

a more permanent result can be achieved by a lim-ited resection of muscle in this area.

Rejuvenation of the Bitterness Fold

At the prevention stage of aging, botulinum toxininjections decrease the resting tone of the depressoranguli oris in its midportion, where the motor endplates are located, limiting development of the mari-onette fold. At the first stage of aging, filler can beinjected into the depression of the bitterness fold, aswell as into the anterior prejowl depression abovethe mandibular border. Superficial injection of the

Fig. 9. Treatment of thesuperolateral part of the orbitalrim hollow and muscle fixation.(A) The superolateral malartissues (point O) are fixed atpoint 3. (B) The superior malarpart of the orbicularis oculimuscle at point O (Fig. 5) isvertically fixed to the upper edgeof the orbicularis oculi incisionnear point 3.

Fig. 10. Treatment of the lower eyelid skin excess. (A) As a result of the concentric nature of the malar lift, the cutaneousexcess is centered on the eyelid and not laterally. An efficient tissue elevation through point 1 induces a nice correction of thetear through depression. (B) The quantity of available skin that can be resected at the lower eyelid safely relates to the amountof elevation to point 1. To keep the excision conservative, the amount is determined while downward traction is applied on themalar skin. (C) There is no overcorrection. Neither the palpebral fissure nor the lateral canthus is elevated. There is notemporal skin excess.


vermilion and mucosa at the lower lip commissureunfolds the lower lip and lifts the commissure(Fig. 2). Further improvement is gained by injectingbotulinum toxin into the depressor anguli oris at itsmidportion. The mentalis often is included in thisinjection because it is noted frequently to contract inconjunction with the depressor anguli oris. Likewise,lateral platysma contraction is frequently associatedwith depressor labii inferioris contraction. Thus thelateral platyma also can be injected. We suggesttesting before injection that it be determined whetherthe descent of the corner of the mouth stems morefrom the depressor anguli oris or from the lateralplatysma.At a more advanced stage of aging, the depressor

anguli oris can be sectioned transversely at the lowerborder of its upper quarter via a transoral mucosalapproach, with blunt separation through the bucci-nator fibers to reach the more superficial depressor(Fig. 12). The mandibular branch of the facial nerve(ramus mandibularis) is ascending at this point toinnervate the depressor labii inferioris and can be

safely avoided by using this highmucosal incision. Themost effective part of the depressor anguli oris is itsanterior part, which must be specifically sought outand sectioned (Fig. 13). At the same time, liposuctioncan be performed to reduce the jowl, whereas fatinjectionmay be carried out beneath the bitterness foldand prejowl depression over the mandibular border.

Neck Rejuvenation

At the prevention stage of aging, low doses of botu-linum are injected into the anterior and lateral seg-ments of the platysma as well as the depressor angulioris. At the first stage of aging, botulinum toxin isinjected at standard doses (2 to 3 points of injectionper segment with 2 units per point) in the anteriorand lateral segments of the platysma. Hyaluronic acidinjected into transverse neck creases also can bebeneficial in the early stages of aging. Botulinumtoxin injection of the platysma is most effective at thelevel of the cervicomandibular angle, but also may beused along the lateral platysma. The depressor angulioris also can be injected.

At a later stage of aging, a transverse incision ofthe platysma at the level of the cervicomandibularangle, associated with a Vistabel injection, bringsmore lasting relief because it induces a stable anteriorneck by limiting the advancement of neck skin whenthe anterior platsyma contracts. Application of 4-0Prolene horizontal plication sutures to the anteriorand lateral platysma decreases the neck girth, sup-ports the ptotic submandibular gland, and elongatesthe lateral platysma muscle (Fig. 14). Median hori-zontal plication of the submental plastyma reducessubmental bulging. This cervical lift does not rely onposterior or superior platysma traction to rejuvenatethe neck, as do traditional techniques. Our rejuve-nation process decreases the neck diameter at thecervicomandibular junction, recreating the hourglassshape. The sternocleidomastoid aponeurosis is liftedvertically and fixed with five sutures of 4-0 Prolene.The dissection plane between the skin and muscle isclosed with 4-0 Prolene quilting sutures to eliminatedead space. As these sutures are placed, the skin is

Fig. 11. (A) Patient with a visi-ble upper eyelid hollow and alimited tear trough depression.(B) The upper eyelid hollow andtear trough have been filled withPerlane injected on the bone.The upper eyelid required 1.2ml, and the lower eyelid re-quired 0.4 ml. Botulinum toxininjection elevates the tail of theeyebrow and improves the skinof the lower eyelid.

Fig. 12. Rejuvenation of the bitterness fold. Red lines:Projection on the skin of the depressor anguli oris muscle.Blue line: Level of the mucosal approach for horizontaltransection of the depressor anguli oris and the lateral plat-ysmamuscles.Yellow line:Highest possible projection of themandibular branch of the facial nerve (ramus marginalis).


advanced slightly in the cephalad direction. Anysmall dimples that develop are eliminated by the nextjudiciously placed suture. Our aim is to reduce bothtension and postoperative edema as well as the risk ofhematoma, and of course, to obtain long-lastingstability.

Results

We have used the concentric malar lift and palpebralmuscle resection for more than 10 years. However,our experience with levator labii superioris section isonly 6 months long, and hence our reported evalua-tion is only preliminary. Nevertheless, our rejuvena-tion procedures follow scientifically based conceptsas we attempt to regain the natural appearance ofyouth.Figures 15, 16, and 17 show representative results

for patients who have undergone various surgicaltechniques to rejuvenate, from the early to the more

advanced changes of aging. All surgery carries therisk of complications. Complications encounteredwith the concentric malar lift have been limited totwo areas of concern: lateral overcorrection andprolonged postoperative edema. Over-elevation ofmalar tissues and the lateral canthus occurred in twopatients early in our series. Better fixation has in-creased the stability of our results, and we havelearned to avoid overcorrection at the time of sur-gery. We have not seen ectropion.

Our second area for concern has been the occa-sional patient with protracted recovery, the fre-quency of which has significantly diminished withuse of the refinements detailed earlier. We tell allpatients of the possibility of edema lasting up to 1month. We have found it useful to include antiin-flammatory medication, manual lymphatic drainageand massage, and camouflage makeup in aftercare.In our hands, lateral orbicularis weakening to in-duce eyebrow tail elevation stays the main cause ofchemosis.

Fig. 13. (A,B) A woman whostill is unhappy after two face-lifts due to persistence of thebitterness fold. The fold is visi-ble even when the face is at restdue to constant contraction ofher depressor anguli oris. Dur-ing forced contraction, the cor-ners of her mouth descend, andthe folds become more numer-ous. (C,D) Appearance5 months after surgical sectionof the patient�s depressor angulioris muscles. Note that they nolonger contract at rest. Thefolds are diminished, and theregion is no longer hollow.During forced contraction, thecorners of her mouth no longerdescend, and the folds are re-duced. The patient is very com-fortable with this change.

Fig. 14. (A) Submandibulargland ptosis creates a visiblebulge during surgery. (B) Hori-zontal plication sutures restorethe concave young cervicoman-dibular angle.


When the cervical lift is performed, there may beearly irregularity from the quilting sutures. This isminimized by using a subtle rather than a forcedelevation with each stitch placed. Should signs of skinischemia appear behind the ear, a trinitrine patchplaced over the area may be of help.

Discussion

Muscle-Sectioning Surgery

The effects of muscle surgery are powerful and can bemodulated from total muscle resection to partial,staged muscle incision. The main drawback of musclesectioning is the potential for functional recoverywithin 6 months. Such risk of recurrence depends onthe anatomy of the muscle. Corrugator section alonedoes not produce separation between the two seg-ments, so spontaneous functional recovery is high.At least a partial resection is necessary to suppressfunction.On the other hand, section of the depressor anguli

oris instantly creates a large separation with a lowrisk of functional recovery. A key point is that caremust be taken to section the most anterior part of

depressor anguli oris, its strongest part. Otherwise,depressor function may recover. It is important toassess properly the muscle function that requiresweakening. In the case of the descending oral com-missure, for example, vertical descent is caused bythe depressor anguli oris, whereas posterior obliquedescent is caused by the lateral platysma. From suchan assessment, it can be determined which muscleaction needs to be modified by section. It is wellknown that injured (or sectioned) skeletal musclecan repair itself via spontaneous regeneration.However, the overproduction of extracellular matrixand excessive collagen deposition lead more often tofibrosis than to functional muscular healing [9].Stretching exercises after a muscle laceration injuryhave a strong antifibrotic effect, and some studiessuggest than the best time to begin stretching exer-cises is 14 days after laceration for muscle regener-ation with minimal fibrosis [10]. From Jarvinenet al. [11], we know that overimmobilization aftermuscle injury results in a poor functional muscleoutcome. Hence, to slow the muscle regenerationand discourage functional healing, we inject themuscle area with botulinum toxin after the surgicalprocedure, favoring nonfunctionnal fibrosis overmuscular regeneration.

Fig. 15. (A,B,C) A 57-year-oldwith skin excess and hollowingin the medial part of the uppereyelid. There is a visible hol-lowing at the inferior orbitalrim, mainly laterally, and des-cent of the lower eyelid. Thepatient�s lower eyelid is nolonger supported because thelateral malar volume has des-cended at the midcheek level(oblique view). (D,E,F)Appearance 6 months aftersurgery including an upperblepharoplasty and a lowereyelid concentric malar lift.There has been no associatedprocedure (e.g., no temporal lift,no fat filling, no filler, no botu-linum toxin). The upper eyelidhollow is less visible. Weakeningof the corrugator muscle hassmoothed the glabella. Thelower eyelid skin excess hasdisappeared, and the orbital rimhollow is improved with fattransposition.


Neck Rejuvenation

Traction on the platysma and skin in an oblique,upward, posterior direction will not effectively reju-venate a neck because it does not restore a definedcervicomandibular angle with proper jawline defini-tion, nor support a ptotic submandibular gland,hence, the often reported need for partial sub-mandibular gland resection. The better solution is torestore youthful anatomy by decreasing the diameterof the cervicomandibular junction with horizontalplication sutures, which also support the sub-mandibular gland as they restore a youthful neckcontour (Fig. 14).

Malar Lift

Many authors [12,13] advocate a temporal lift incombination with a malar lift. In our opinion, a lat-eral malar lift is effected through the placement ofsuspension sutures fixed in the temporal region.Furthermore, the medial malar region is enhanced bystructural fat grafting.In tying the suspension sutures, it is imperative to

overcorrect the pull to compensate for predictableslackening that occurs in the early postoperativeperiod. The amount of overcorrection is a variable

that presents a certain imprecision to the suspensionbecause we cannot predict the precise time whenslackening will abate and scar adhesion will be suffi-cient to maintain our correction. However, directfixation, as used in the concentric malar lift, canavoid the need for such overcorrection. The vectorsof suspension at the orbital rim hollow must be per-pendicular to the curved rim and thus converge to-ward the pupil. In conventional surgery, the vector ofsuspension typically extends from the lateral malar tothe temple. However, this direction transposes malarvolume vertically and laterally and may lead to anunnatural appearance [14].

Another surgical alternative to concentric malar liftis fat extrusion and septal reset [15]. But with thistechnique, to decrease the risk of secondary eyelidmalposition, it is mandatory to perform a canthopexyand, frequently, an injection of triamcinolone. Therisk of secondary eyelid malposition is the conse-quence of a large dissection in a very mobile area.Moreover, septal reset does not restore the structureto a youthful position. This technique may furtheraccentuate the fatty ptosis and perhaps worsen theenophtalmos, whereas, as argued by Mendelson [14],‘‘in aesthetic facial surgery, the objective is to restorethe youthful position.’’ Barbed sutures have yet toprove their effectiveness in facial rejuvenation. In fact,these sutures pull the tissues upward and outward for

Fig. 16. (A,B,C) A 46-year-oldwoman with high resting toneof her corrugator, orbicularisoculi, levator alaeque nasi, anddepressor anguli oris muscles.(D,E,F) Appearance 5 monthsafter a cervico facial lift and aneyelid procedure associated withmultimuscle weakening and aconcentric malar lift. The tail ofthe eyebrow is lifted (obliqueview), the infraorbital hollow isreduced, and the anterior malarprojection has improved(oblique and profile views). Thispatient did not receive anyadditional treatment (e.g., hyal-uronic acid, Vistabel, laser).


an antigravity effect. However, our concept proposesthat gravity plays little or no role in early aging.Consequently, in our opinion, barbed sutures areineffective on their own and, worse still, create thetype of malar elevation that will, in fact, accentuatethe inferior hollow orbital. Also, barbed sutures de-crease the mobility of the surgically managed area.

Rigidity, it must be remembered, is a sign of age,mobility a sign of youth.

The Concentric Malar Lift

The first suspension suture (Fig. 6A, point 1 for malarfat pad elevation) could compress a part of the

Fig. 17. (A,B,C) A 60-year-oldwoman who underwent a four-lid blepharoplasty 5 years pre-viously with septal orbicularisoculi fixation to the lateral can-thal periosteum. She has a highresting tone of her corrugator,procerus, depressor supercilii,orbicularis oculi superior malarpart, levator labii superioris,depressor anguli oris, and plat-ysma anterior and lateral seg-ments. There is excessive skinaround the facial oval and in theneck. (D,E,F) View 5 monthsafter a cervico facial lift, four-lidblepharoplasty (including aconcentric malar lift), and sec-tion of all the mimetic musclesdescribed previously to reduceresting tone. The patient did notreceive any injection (filler orbotulinum toxin) or skin resur-facing treatment. The rejuvena-tion effect, while significant,remains natural.

Fig. 18. (A) Paramedian foldsand age marker fascicules.(B) Different areas of section(red) and platysma plications(white).


zygomatic or buccal branch of the facial nerve, forexample, that supplies the levator labii superioris. Therisk of such damage is minimized by elevation of themalar fat pad and the deep fat pad with the finger suchthat the straight needle passes through the tissues wellabove the zygomatic bone. In this location, the risk offacial nerve damage is minimal (we have had no facialnerve damage in our series). Using this procedure, thearcus marginalis [14,15] is not sectioned, thus avoid-ing interruption of the lower lid lymphatics [13],prolonged extension of the lid scar inferiorly (in whichscar formation can be unpredictable), and persistentlower lid malposition [16].

Conclusion

We describe a new concept in facial rejuvenation,which we call Face Recurve. This approach bringsspecific interventions to the age marker fasciculesresponsible for most of the aging paramedian folds(Fig. 18). In a patient with early aging, for example,the tear trough depression might be filled with hyal-uronic acid, while Vistabel injections are placed in thesuperiormalar part of the orbicularis oculi to reduce itsresting muscle tone. Sectioning of the depressor angulioris under local anesthesia can be added, along withstructural fat grafting to areas of loss, thus softeningthe facial oval. Light skin resurfacing treatments couldbring improved skin texture. The curves and dynamicfunctions of a younger face may then be recovered.The solution for a patient with more advanced

aging would involve more surgery. The periorbitalregion would be improved by a concentric malar lift,whereas the jugal skin excess could be removed using aclassical periauricular face-lift incision, but with lim-ited subcutaneous dissection made possible by plat-ysma plication with sectioning of that muscle, togetherwith the depressor anguli oris. Muscle weakening isstabilized with Vistabel injection. The aim is always toreestablish the original anatomy of youth includingcurved muscle, weak resting muscle tone, sufficientunderlying fat, and good skin tone. We can thus planthe best strategy and predict the likely improvementfor each patient, and for each facial region of thatpatient. By integrating the Face Recurve concept intoour practice, we can recapture the natural facial curvesthat define a youthful appearance.

Acknowledgment. We acknowledge the kind assistancegiven by Dr. Graeme Southwick, OAM, MBBS, FRACS,FACS, plastic surgeon, Melbourne, Australia, who greatlyhelped in the preparation of this article and its translationfrom French to English. Figures 13 and 14 are reprinted

from Aesthetic Surgery Journal Vol. 26, Le Louarn C, BuisJ, Buthiau D ‘‘Treatment of Depressor Anguli OrisWeakening with the Face Recurve Concept’’, pages603�611, copyright 2006 with permission from TheAmerican Society for Aesthetic Plastic Surgery, Inc.

References

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14. Mendelson BC. Discussion of paper by Barton FE, HaR, Awada M. Fat extrusion and septal reset in patientswith a tear trough triad: A critical appraisal. PlastReconst Surg 113(7):2122�2123, 2004

15. Hamra ST: Arcus marginalis release and orbital fatpreservation in midface rejuvenation. Plast ReconstrSurg 96:354�362, 1995

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