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Temporal Rejuvenation
TARGET JOURNAL: DERMATOLOGY SURGERY
TYPE OF ARTICLE: INNOVATIVE TECHNIQUES
WORD COUNT: …… WORDS
FACECULPTURE®:
CURRENT TECHNIQUES FOR TEMPORAL REJUVENATION WITH
INJECTABLES AND FUTURE DEVELOPMENTS
Dr Hervé Raspaldo
Face and Neck Surgeon, member of the French society of plastic and reconstructive surgery
(SOFCPRE) -Facial Plastic Surgery Centre, Palais Armenonville,
Rond Point Duboys d’Angers, 06400 Cannes, France
CORRESPONDENCE AUTHOR:
Dr Hervé Raspaldo
Facial Plastic Surgery Centre
Palais Armenonville
Rond Point Duboys d’Angers, 9
06400 Cannes, France
Telephone: +33 492 986 530
[email protected]
RUNNING HEADER: ‘TEMPORAL REJUVENATION’
COMMERCIAL INTERESTS AND SOURCES OF FINANCIAL OR MATERIAL
SUPPORT: None
1
Temporal Rejuvenation
ABSTRACT
The temporal area is one of the facial areas to show signs of ageing, frequently forgotten by
patients and physicians to be assessed and treated. Temporal rejuvenation is a new
cornerstone area of interest for aesthetic practitioners and there is increasing demand,
particularly since it can be performed without the need for major surgery, and is associated
with a very short recovery period. Temporal rejuvenation with injectable products can
provide dramatic results and a youthful appearance lasting between 1 to 2 years.
Temporal lifting provides greatest benefits from young to old by repositioning the eyebrows,
reducing crow’s feet lines, firming the outer area of the eye and lightening the hooding of the
outer eyelid. Temporal and midface rejuvenation techniques have evolved significantly over
the past few decades and are now performed endoscopically or via a limited number of short
incisions in the hairline above the temple. Non-surgical approaches to temporal rejuvenation
comprise hyaluronic acid fillers, poly-L-lactic acid and botulinum toxin type-A, the latter very
recently being used to treat masseter hypertrophy in place of surgery. In order to achieve
optimal outcomes, the author recommends use of a 4-point baseline temporal ageing scale
which can be used to establish the most appropriate product and volume prior to treatment.
Changing the facial muscular balance with botulinum toxin, reshaping nicely the eyebrow
arch and volumizing the temporal aree the key points for a successful upperface rejuvenation.
Its combination with mid and lowerface treatment with injectable products complete our
method of global approach named the Faceculpture®.
Maximum Word Count: ….words (Maximum: 250 words)
KEYWORDS: Temporal, Midface, Facial Rejuvenation, volume, Faceculpture, Heart of
Face, eyebrow.Global approach
2
Temporal Rejuvenation
WHY PERFORM TEMPORAL REJUVENATION
The temporal area is the region situated above the zygomatic arch, limited upward by the
temporal crest (or linea temporalis, junction of the frontal, temporal and parietal bones) and
laterally by the hairline. It is one of the important facial areas to show signs of ageing. The
characteristic features associated with the ageing process occur due to a volume loss (or fat
sliding). As individuals age, the facial skeleton loses volume in all dimensions, and there is
diminished bony support and skin tone due to reduced collagen production and elastin fibre
breakdown. Also, a decline in sebaceous gland activity reduces the skin’s ability to retain
moisture and maintain suppleness. Fat and soft tissues sag downwards leading to widening of
the vertical orbital apertures, and there is less anterior projection in the cheek, temples and
brow regions (1). Descent of the Bichat fat pad over the upper mandible can increase lower
facial jowling, and there is evidence to show that the contour of the temporal fossa changes ,
as the maxilla undergoes changes over time (2). Thus, the ageing process results in temple
skeletonisation, lateral eyebrow ptosis, malar descent, drooping eyes and tear trough
deformity, a heavy jaw line and hypertonic contractions of the depressor muscles (3).
Aesthetic treatment of the ageing temporal fossa is a rather neglected element of overall facial
rejuvenation, since the complexity of the anatomy and pathophysiology remain rather
controversial, and therefore the search for the ideal long-lasting temporal rejuvenation
technique continues. Volume augmentation with autologous fat or fillers is an important
aspect of facial rejuvenation. Midface rejuvenation via open approaches using suspension
techniques traditionally has included either a temporal or a periorbital approach and these
continue to be an important option for surgeons when rejuvenating the ageing temples and
midface (4).
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Temporal Rejuvenation
Temporal rejuvenation is a new area of interest combined with midface and this is increasing
due to demand. Currently there is no universally acknowledged technique for temporal
facelift. Temporal lifting is of the greatest benefit to those in their mid-30’s or early 40’s who
are noticing the first signs of ageing around the eyes, and it helps to eliminate the ‘sad’ or
‘tired’ look without the need of undergoing major surgery. This procedure lifts the brows,
reduces crow’s feet lines, firms the outer area of the eye and lightens the hooding of the outer
eyelid. A major benefit of temporal lifting is that it is a very short procedure, with a minimal
recovery period. It can be performed as a day case procedure or under twilight anaesthesia
involving 12-24-hour hospitalisation, followed by a 7-15 day recovery period.
ANATOMY OF THE TEMPORAL AREA
Knowledge of the various layers and structures of the temporal area is essential to
understanding the ageing process in this region and its correction. Under the skin and its
strongly attached subcutaneous tissue, there are 3 fascial layers within the temporal region,
comprising the superficial temporal fascia (or temporo-parietal fascia), and the superficial and
deep layers of the deep temporal fascia, which attach the dermal roof to the bony floor. In
between those superficial and deep temporal fascia there a sliding space named the “Merkel
space”, very useful for the temporal dissection. Sensory innervation of temporal and midface
is supplied by the trigeminal nerve which penetrates the periosteum and preperiosteal fat (5).
A number of key studies have been performed which have contributed to a fuller
understanding of temporal area and midfacial anatomy and have led to safer and more
effective aesthetic treatments in this area. Stuzin et al conducted a study in facial soft tissue
anatomy to investigate the relationship of the superficial facial fascia (SMAS) to the mimetic
muscles, deep facial fascia, and underlying facial nerve branches. Results showed that the
facial soft tissue architecture is arranged in a series of concentric layers comprising skin,
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subcutaneous fat, superficial fascia, mimetic muscle, deep facial fascia (parotidomasseteric
fascia), and the plane containing the facial nerve, parotid duct, and buccal fat pad (6).
Rohrich and Pessa studied the histology of the septal boundaries between several adjacent
subcutaneous fat compartments. Their findings showed that subcutaneous fat is
compartmentalised by fibrous fascial condensations that travel from the superficial fascia to
the dermis. These septa form an interconnecting framework that limits shearing forces on the
face and provides a ‘retaining system’. This concept suggests that the face ages
3-dimensionally, with separate compartments changing relative to one another by both
position and volume (7).
Ghavami et al noted that some ambiguity existed regarding the exact anatomical limits of the
orbicularis retaining ligament, particularly its medial boundary in both the superior and
inferior orbits. A clear understanding of this anatomy is necessary during periorbital
rejuvenation. A ligamentous system was found that arises from the inferior and superior
orbital rim that is truly periorbital and may serve to act as a fixation point for the orbicularis
muscle of the upper and lower eyelids, and to protect the ocular globe. This ligament spans
the entire circumference of the orbit from the medial to the lateral canthus, with a fusion line
between the orbital septum and the orbicularis retaining ligament in the superior orbit,
indistinguishable from the arcus marginalis of the inferior orbital rim. Laterally, the
orbicularis retaining ligament contributes to the lateral canthal ligament (8).
Investigations of the courses taken by nerves supplying that region have been conducted.
Pitanguy and Ramos plotted the course of the frontotemporal nerve on the skin as a line
starting from a point 0.5cm below the tragus and passing 1.5cm above the lateral extremity of
the eyebrow. They established that, after the main division, 5 major branches of the facial
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nerve exist: temporal (frontal), zygomatic, buccal, mandibular, and cervical (9). Stuzin et al
examined the anatomy specifically of the temporal region, with particular reference to the
frontal branch of the facial nerve. Results showed that the frontal branch travelled in a
constant plane along the undersurface of the temporoparietal fascia and was quite superficial
as it crossed the zygomatic arch. The deep temporal fascia and superficial temporal fat pad are
anatomically important structures which adjoin the periosteum of the zygomatic arch and lie
deep to the frontal nerve. These findings were significant since they contributed to the
development of a safe method of dissection within the temporal region (10).
Ishikawa conducted a study in an attempt to define the distribution of the temporal branch of
the facial nerve in relation to surrounding tissues and found that the temporal branch generally
branched into 3 or 4 rami and its trajectory was either straight or curved, depending on the
relationship between the middle and the posterior ramus. The distances from the bony lateral
canthus to each point were relatively constant and there was no difference between the right
and the left side. As a consequence of these findings, it was possible to establish new
guidelines for protection of the entire temporal branch from surgical injury by dissecting and
undermining the superficial layer of the deep temporal fascia , including the deep temporal fat
pad (which is in continuity with the Bichat buccal fat pad)(11).
HISTORY OF TEMPORAL AND MIDFACE REJUVENATION
Upper and midface rejuvenation has evolved significantly over the past few decades. A
pioneer in field, Tessier, first described subperiosteal dissection of midface in the late 1970’s
(5). Tessier noted that the ‘facial mask’ comprises all of the tissues lying on top of the
skeleton: periosteum, deep adipose tissue, superficial musculo-aponeurotic tissue and skin.
The periosteum is the intermediate zone between the skeleton, responsible for the shape of the
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Temporal Rejuvenation
face, and the more superficial tissues which complete the shapes and, most importantly,
represent the mobile part of the face and the site of facial expression. An effective ‘mask-lift’
depends upon complete subperiosteal dissection of the malar bones, zygomatic arches and
orbital margins. Subperiosteal dissection via a coronal incision is useful to lift the facial mask
and to remodel the orbital margins, as well as to obtain bone grafts from the parietal area in
order to reinforce the glabella, check bones and nasogenial folds (12).
Hamra performed a composite rhytidectomy which added a midface component by elevating
the lateral part of the orbicularis oculi muscle and by fixating the temporal flap to the
temporal muscle by removing a squared part of the deep temporal fascia muscle (13). Isse was
the first to propose an endoscopic lateral myotomy of the Orbicularis Oculi to relax that
depressor muscle to help the Frontalis muscle to lift the tail of the eyebrow (333 ISSE)
(Raspaldo – in Midface enhancement). Ramirez extended the endoscopic forehead lift to the
midface, with the subperiosteal midface lift. The results obtained were excellent results and
he concluded that this type of facelift was a viable alternative to standard techniques (15).
PRINCIPLES OF TEMPORAL LIFT
The temporal facelift can be performed by a surgeon either endoscopically or via a limited
number of short incisions (up to approximately 4cm) in the hairline above the temple (hence
the term ‘temporal lift’). The incision is parallel to the hairline but behind the anterior
hairline in order to allow detachment of the anterior portion of forehead and temple skin,
eyebrow area and malar cheekbone skin areas. The area is pulled and deep stitches allow
repositioning. Since the incisions are small and scars are hidden in hair, they are not visible
and sutures are generally removed after 10 days. This procedure restores the eyebrows to their
natural position and elevates the temporal tissues by lifting up drooping cheek tissue over the
cheekbone to restore a more prominent, youthful contour. It reduces crow’s feet lines, firms
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outer eye areas and lightens hooding of the outer eyelid, and also has some effect on
nasolabial folds.
SURGICAL APPROACHES TO TEMPORAL REJUVENATION
Surgical approaches to temporal rejuvenation traverse deep into superficial temporal fascia
(superior most extension of SMAS layer) which is the most superficial of the temporal fascial
layers, and contains the frontal branch of the facial nerve, temporal artery and vein, so it is
important to ensure that care is taken to avoid injury to these structures. The subperiosteal
facelift, or ‘mask lift’ was first described by Tessier in 1979 and it provides a vertical lift to
the facial soft tissues to allow remodeling and repositioning at the level of their bony origins.
It is a deep technique which allows rejuvenation of the upper two-thirds of the face. Section
of the superficial leaflet of the temporal aponeurosis reveals the Deep Musculo Aponeurotic
System (DMAS) which can be used to raise all of the soft tissues of the face while protecting
the frontal branch of the facial nerve. Elevation of the tissues of the face is essentially vertical
and acts on the forehead, temporal region, gaze and cheekbones (19).
Psillakis and Ramirez amongst others, further extended subperiosteal dissection for treatment
of the midface, jawline and neck (20).
Krastinova-Lolov, fellow of Paul Tessier continues to develop the ‘mask lift’ with facial
aesthetic resculpturing as a facial aesthetic surgery technique based on a different approach to
the ‘ageing face’. This technique seeks to normalise, rejuvenate and embellish the face
through a sub-periosteal lift of the facial mask and transformation of the underlying structures
by facial aesthetic sculpturing of the facial skeleton (21).
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Thus it can be seen that improvements in surgical techniques have led to advances in temporal
rejuvenation. Stuzin et al noted that increased experience gained in face lifting has resulted in
refinements in the procedure that have led to increased consistency in results (22).
NON-SURGICAL APPROACHES TO TEMPORAL REJUVENATION
Facial aesthetics and rejuvenation are evolving rapidly due to changes in products, procedures
and patient demands. They ask for less aggressive treatments, no downtime but still effective
results. Clinicians can benefit from ongoing guidance on products, a new grading of facial
ageing, tailoring treatments to individual patients, treating multiple facial areas, and using
combinations of products to optimise outcomes. There are now a number of products
available for non-surgical temporal rejuvenation which are safe, effective and versatile.
Hyaluronic acid (HA):
Juvéderm Ultra® 4 is an effective hyaluronic acid (HA) dermal filler which provides
predictable and natural results that are long-lasting but temporary. It is easy to use by
practitioners and treatment is well-tolerated by patients since it contains lidocaine to reduce
the pain of injection (23) (+ Levy publications).
From a recent advisory board meeting comprising a panel of French experts from the field of
aesthetic enhancement who met to define a consensus regarding global facial rejuvenation,
Juvéderm Ultra® 4 was indicated for treatment of more superficial lines and folds. However,
its effectiveness in the temporal region was acknowledged since it was also considered
effective for the treatment of marked nasolabial folds and in the mid-facial area, such as the
cheek and eyebrows, as well as in young women requiring a small quantity of volumising
product, or as a supplement to Juvéderm VOLUMA™.
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Temporal Rejuvenation
Juvéderm VOLUMA™:
Juvéderm VOLUMA™ is the latest generation of cross-linked HA volumiser and clinical
studies have demonstrated its safety and high levels of satisfaction with the results of
treatment. It was specifically developed to restore lost facial volume (e.g. in the cheeks,
cheekbones and chin) and the product was developed to be very smooth, viscous and robust,
making it easier to inject during treatment and resulting in a fuller, smoother, natural look and
feel, with benefits lasting up to18 months post-treatment (24).
NewFill® / Sculptra®:
Sculptra® is a biocompatible, resorbable injectable filler composed of poly-L-lactic acid
(PLLA). It belongs to the class of stimulatory fillers that create their effect through
encouraging neocollagenesis when injected, and therefore differs from traditional, static fillers
such as HA and collagen. Both the natural method of volume restoration and the persistence
of results for up to 2 to 3 years make this product a worthy first-line treatment of choice for
cosmetic rejuvenation, as well as for reconstructive soft tissue deficits and lipoatrophy (26).
Sculptra® is effective and commonly used for the midface and temporal fossa, with more
limited use in the mental and prejowl areas.
Botulinum Toxin Type-A (BoNTA) to change the muscular balance:
The role of BoNTA in temporal rejuvenation was considered by Carruthers et al, and FagienRaspaldo (biblio 3333) who reported on a multidisciplinary group of aesthetic treatment
experts who convened to review the properties and uses of BoNTA and HA fillers and to
update consensus recommendations for facial rejuvenation. The group provided specific
recommendations by facial area, focusing on relaxing musculature, restoring volume, and
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recontouring using BoNTA and HA fillers alone and in combination. For the upper face,
BoNTA remains the cornerstone of treatment, with HA fillers used to augment results and to
restore volume. BoNTA and HA in combination can improve outcomes (28).
BoNTA for Masseter Hypertrophy:
A recent development in the field of midface enhancement is BoNTA treatment of masseter
hypertrophy which is generally caused by bruxism (grinding teeth), temporo-mandibular joint
disorders, or misaligned jaws. The condition may cause discomfort or simply present an
asymmetrical appearance. Furthermore, Asian persons, particularly those of Korean and
Japanese descent, often seek correction of masseter hypertrophy for aesthetic reasons since
their characteristic appearance of high cheekbones and distinct mandibular contour are
features valued in the West, but because of the more delicate topography of the typical Asian
face, zygomas and mandibular angles that are overly prominent upset the balance, rendering
the face overly flat, wide and square. In addition to its undesirable aesthetic appearance, in
some East Asian cultures the prominent zygoma and mandibular angle have traditionally been
associated with negative personal characteristics. Therefore, Asian patients who might
hesitate to have other types of surgery are willing to undergo reductive correction of these
areas in order to create a more delicate jaw line and reduced mandibular angle.
Several studies of BoNTA as a treatment for masseter hypertrophy show good results, with
high satisfaction rates. This procedure is a simple alternative to surgery providing predictable
results. Kim et al investigated retrospectively the long-term treatment effects of BoNTA by
analysing the follow-up data of masseter hypertrophy patients. Results showed that BoNTA
injections had a long-term effect on masseter muscle hypertrophy and a positive correlation
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was found between the number of injections and the decrease of muscle volume (30). With
respect to the recommended BoNTA injection technique for masseter hypertrophy, the author
advises 1 or 2 injections at sites located away from the facial nerve and deep under the
aponevrosis of the masseter muscle. We use 16 up to 20 units of Onabotulinum toxin per side,
through 1 up to 3 injection sites. The consequence is a functional reduction of the masseter
muscle mass (volume) who softens the lowerface. Consequently, when the patient masticate,
chew or bite he will use more his temporal muscle. That creates a volume augmentation of the
temporal muscle. And it helps to enhance the vertical attractive triangle of beauty (the Heart
of Face®) (biblio Raspaldo, in Monduzzi editore).
TECHNIQUE OF INJECTION IN THE TEMPORAL AREA:
The key points are to know where to inject, how to inject, how deep, which quantity and what
kind of product.
-WHERE TO INJECT: BASED ON CLINICAL CORRELATION WITH TEMPORAL
ANATOMY (FIG. X)
That creates a volume augmentation
-HOW DEEP (FIG. XX)
That creates a volume augmentation SUPERFICIAL, MERKEL,DEEP TF
-QUANTITY (TABLE #)
That creates a volume augmentation
RESULTS OF TEMPORAL REJUVENATION
Whatever technique is used, temporal rejuvenation using non-surgical techniques can produce
dramatic results. The main benefits include a youthful appearance lasting some 1 to 2 years,
with minimal or no scarring, reduced bleeding, no hair loss and shorter recovery time
compared to surgical techniques. It can provide the ‘chiselled’, ‘model look’ combining
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Temporal Rejuvenation
midface rejuvenation. This highly successful procedure can provide some tension to the
cheekbones and result in a more attractive gaze, just as when one’s hair and temple is pulled
back and up.
INDICATIONS:
In order to provide an objective pre-treatment assessment of the patient to determine
suitability for temporal rejuvenation, the author recommends the use of his 4-point temporal
ageing scale at baseline comprising:

Stage 1: Normal, convex or straight temporal fossa

Stage 2: Early signs of a slight depression (i.e. hollow)

Stage 3: Concavity of temporal fossa, with some visible temporal vessels.

Stage 4: Skeletonisation of the temporal fossa, bones are visible; severely visible veins
and artery; severe concavity of the fossa
Depending upon the stage of temporal ageing at baseline, the optimum aesthetic product and
volume required can then be roughly established in advance of treatment. The following
guideline is recommended buy the author to obtain maximum benefits:

Stage 1: No treatment

Stage 2: 0.4cc-0.8cc of Juvéderm Ultra® 4 per side +/- OnaBonTa 16U/ Masseter

Stage 3: 1-2cc of Juvéderm VOLUMA™ per side +/- OnaBonTa 16-18U/ Masseter

Stage 4: 2-4cc Juvéderm VOLUMA™ per side
Superficial lines can then be managed using superficial injections of Juvéderm Ultra® 4.
TEMPORAL CASE STUDIES
Dr Raspaldo: please provide ‘before’ and ‘after’ photographs and any information
regarding treatment technique used for patients who have undergone temporal rejuvenation
13
Temporal Rejuvenation
COMPLICATIONS OF TEMPORAL INJECTIONS
The risks associated with non-surgical techniques comprises bruising and pin-prick bleeds.
CONCLUSION
Temporal, or midface, enhancement has evolved significantly over the past few decades.
Temporal rejuvenation is a new area of interest for aesthetic practitioners and its popularity is
increasing due to demand from patients, particularly since it can now be performed without
the need for major surgery, and it is associated with a very short recovery period. The
benefits of temporal facelifts are greatest for those in their mid-30’s or early 40’s, and in this
group of patients the results of this highly successful procedure can be dramatic.
It is essential to have a full knowledge of the anatomy of midface in order to understand the
ageing process and its associated correction. In this paper, different techniques for temporal
rejuvenation have been discussed, as well as consideration of a range of effective products
available, including HA fillers, poly-L-lactic acid and BoNTA. According to the stage of
temporal ageing at baseline, the optimum product and volume required can be established in
advance of treatment to achieve maximum benefits. Juvéderm VOLUMA™ is particularly
recommended for temporal rejuvenation by the author due to its high rates of safety and
efficacy, lack of downtime post-injection, and long-lasting results which can be up to 18-24
months.
ACKNOWLEDGMENTS
Medical writing support for this paper was provided by Debbie Jordan.
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REFERENCES
1. Finn JC, Cox SE, Earl ML (2003) Social implications of hyperfunctional facial lines.
Dermatol Surg 29:450-455
2. Vikram ZP, Pessa JE (2000) Biological arches and changes to the curvilinear form of
the aging maxilla. Plast and Reconstr Surg 106(2):460-466
3. Raspaldo H (2007) Facial design, architecture and volume - the new 3D sculpture
using botulinum toxin and deep injectable fillers: facial rejuvenation using Btx
expertise combined with injectable fillers in upper, mid and lower face. Allergan
Academy, Poster session, London April 13
4. LaFerriere KA, Castellano RD (2009) Surgical approaches to the midface complex.
In: Papel ID, Frodel JL, Holt GR, Larrabee WF, Nachlas NE, Park SS, Sykes JM,
Toriumi DM Facial plastic and reconstructive surgery. Third edition. Thieme
Medical Publishers Inc, New York
5. Stuzin JM, Baker TJ, Gordon HL (1992) The relationship of the superficial and deep
facial fascias: relevance to rhytidectomy and aging. Plast Reconstr Surg 89(3):441449
6. Rohrich RJ, Pessa JE (2008) The retaining system of the face: histologic evaluation of
the septal boundaries of the subcutaneous fat compartments. Plast Reconstr Surg
121(5):1804-1809
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7. Ghavami A, Pessa JE, Janis J, Khosla R, Reece EM, Rohrich RJ (2008) The
orbicularis retaining ligament of the medial orbit: closing the circle. Plast Reconstr
Surg 121(3):994-1001
8. Pitanguy I, Ramos AS (1966) The frontal branch of the facial nerve: the importance of
its variations in face lifting. Plast Reconstr Surg 38(4):352-356
9. Stuzin JM, Wagstromn L, Kawamoto HK, Wolfe SA (1989) Anatomy of the frontal
branch of the facial nerve: the significance of the temporal fat pad. Plast Reconstr
Surg 83(2):265-271
10. Ishikawa Y (1990) An anatomical study on the distribution of the temporal branch of
the facial nerve. J Craniomaxillofac Surg 18(7):287-292
11. Tessier P (1989) Subperiosteal face-lift. Ann Chir Plast Esthet 34(3):193-197 [Article
in French]
12. Hamra ST (1990) The deep-plane rhytidectomy. Plast Reconstr Surg 86(1):53-61
13. Ramirez OM, Pozner JN (1996) Subperiosteal minimally invasive laser endoscopic
rhytidectomy: the SMILE facelift. Aesthetic Plast Surg 20:463-470
14. Cornette de Saint Cyr B (1994) Subperiosteal face lift or ‘mask lift’. Ann Chir Plast
Esthet 39(5):557-570
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15. Ramirez OM, Maillard GF, Musolas A (1991) The extended subperiosteal face lift: a
definitive soft-tissue remodeling for facial rejuvenation. Plast Reconstr Surg
88(2):227-236
16. Krastinova-Lolov D (1995) Mask lift and facial aesthetic sculpturing. Plast and
Reconstr Surg 95(1):21-36)
17. Stuzin JM, Baker TJ, Baker TM (2000) Refinements in face lifting: enhanced facial
contour using vicryl mesh incorporated into SMAS fixation. Plast Reconstr Surg
105(1):290-301
18. Raspaldo H (2008) Volumizing effect of a new hyaluronic acid sub-dermal facial
filler: a retrospective analysis based on 102 cases. J Cosmet Laser Ther 10(3):134142
19. Lacombe V (2009) Sculptra: a stimulatory filler. Facial Plast Surg 25(2):95-99
20. Carruthers JD, Glogau RG, Blitzer A [Facial Aesthetics Consensus Group Faculty]
(2008) Advances in facial rejuvenation: botulinum toxin type a, hyaluronic acid
dermal fillers and combination therapies – consensus recommendations. Plast
Reconstr Surg 121(5 Suppl):5S-30S
21. Kim NH, Park RH, Park JB (2010) Botulinum toxin type A for the treatment of
hypertrophy of the masseter muscle. Plast Reconstr Surg 125(6):1693-1705
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22. Levy PM, De Boulle K, Raspaldo H. A split-face comparison of a new hyaluronic
acid facial filler containing pre-incorporated lidocaine versus a standard hyaluronic
acid facial filler in the treatment of naso-labial folds. J Cosmet Laser Ther
2009;11(3):169-73
23. Raspaldo H, De Boulle K, Levy PM. Longevity of effects of hyaluronic acid plus
lidocaine facial filler. J Cosmet Dermatol 2010;9(1):11-15
24. Schaverien MV, Pessa JE, Rohrich RJ. Vascularized membranes determine the
anatomical boundaries of the subcutaneous fat compartments. Plast Reconstr Surg
2009;123(2):695-700
25. Raspaldo H. New Era of Facial-3D Rejuvenation using injectable products and how
to measure the results Heart of Face®. European Annual Congress of Facial Plastic
Surgery; 24-28 September 2008, Monduzzi Editore (Italie) 2009
26. Fagien S, Raspaldo H. Facial rejuvenation with botulinum neurotoxin: an anatomical
and experiential perspective. J Cosmet Laser Ther 2007;9(suppl 1):23-31
27.
Herve – you mentioned the following papers but I can’t find them. Please can you either
provide the full reference for me or add in the text you want associated with each one in the
main manuscript? Thanks.

Raspaldo H. Lifting harmonieux: Technique - Philosophie = Harmonious
rhytidectomy. Journal français d'oto-rhino-laryngologie. ISSN 0398-9771.
Symposium de Chirurgie Plastique de la Face, Lyon , FRANCE,1996 ;45(4), (88
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p) (28 ref):255-267 [please provide translation of paper which is in French and not
available via Internet]

Raspaldo H. Midface enhancement (in ‘Facial plastic and reconstructive surgery’ –
Book edited by Hodder Arnold, 2006 ) [cannot find this reference on Medline or via
Internet]

Mendelsohn PRS anatomy of the temporal area [cannot find this reference on Medline
or via Internet]

Santini J, Raspaldo H, Kestemont P, Magnani M. Surgical planes of dissection of the
face: anatomic basis for composite face lifts. In: FACE (Facial Aesthetic
Communication in Europe), 1994 [cannot find this reference on Medline or via
Internet]
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CONFLICT OF INTEREST DISCLOSURE
Dr Raspaldo is a consultant for Allergan Inc.
20