Novel Approach for Midface Attractiveness : Plastic and Reconstructive Surgery – Global Open

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Craniofacial/Pediatric: Original Article

Novel Approach for Midface Attractiveness

Yamamoto, Koji DDS

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Plastic and Reconstructive Surgery - Global Open 10(11):p e4632, November 2022. | DOI: 10.1097/GOX.0000000000004632
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Question: Various treatments for midface depression, including nasal ala base depression, have been devised, such as Le Fort II osteotomy and prosthesis implantation; however, each method has its own disadvantages, such as invasiveness, economic burden, bone resorption, and prosthesis dislocation. Can a new technique be developed to solve these problems?

Findings: We developed a minimally invasive method (A-10 surgery), in which an artificial dermis is inserted into the base of the nasal ala in combination with the Point A-Koji method that we also recently developed.

Meaning: In addition to being safe and minimally invasive, A-10 surgery yielded a three-dimensional appearance of the midface.


We recently reported a new treatment method, the Point A-Koji method, which focuses on improving the nasolabial angle.1 Many patients are concerned about the flatness and concavity of their midface, a characteristic Asian facial feature. Several of them also tend to prefer a more anteriorly sculpted midface from the base of the nasal column to the base of the nasal ala similar to that of Westerners. Currently, in addition to injection therapies such as hyaluronic acid2–4 and fat injections,5 artificial bone implantation, prosthesis placement,6 and Le Fort II osteotomy7,8 have been proposed for the treatment of nasal ala base depression. However, Le Fort II osteotomy is associated with some problems, such as invasiveness, financial burden, and side effects, including nerve palsy, nasal deformity, and occlusal changes.8,9 Insertion of foreign bodies, including solid objects, such as prostheses, is associated with bone resorption,10,11 insert dislocation, foreign body sensation, and insert exposure when the facial muscles are moved.12 Injection therapy poses significant challenges in terms of lifting volume limitations, diffusion to other sites owing to muscle movement, vascular embolization, and case persistence. Meanwhile, the Point A-Koji method improves the narrowness of the nasolabial angle that indicates protrusion of the mouth.1 In this technique, some improvement in the depression of the nasal ala base can be expected because the soft tissue Sn point and the base of the nasal column are moved forward, and the skin of the nasal ala base is pulled. However, this effect is insufficient. Therefore, we devised a new surgical technique (A-10 surgery), in which the mucosa around the base of the nasal ala is bluntly dissected, and an artificial dermis (Terudermis) is inserted into the gap created while performing the Point A-Koji method. Herein, we report the results of A-10 surgery performed in a patient showing substantial depression of the midface and base of the nasal column and alar region.


A-10 Surgery

A 34-year-old woman presented to our clinic with a chief complaint of mouth protrusion. She showed substantial depression of the midface and base of the nasal column and alar region. The patient underwent A-10 surgery. On the day of the procedure, the patient was in good general condition and had no nasal symptoms. First, we marked the depressed area with a skin pen. The preoperative CT should be used to determine the number of millimeters of depression compared with the thickness of the cheek area. Surgery was performed under infiltration anesthesia with 6 × 1.8 mL xylocaine. Initially, a 5-mm incision was created in the mucosa equivalent to the third root tip on the left and right sides, and the mucosal layer was bluntly dissected toward the base of the nasal ala. After dissection of the base of the nasal ala, a pouch-like pocket was created to insert an artificial dermis into the depressed area. Next, the Point A-Koji method was performed as usual. After incision and gingival mucosal dissection from the left and right sides of the gum-buccal junction of the maxilla using blade no. 15, the condition of the bone was confirmed to be good. The morphology of a 1.0-mm-thick, 30-mm-long titanium plate (Stryker, Mich.) was modified. The plate was trial-fitted to the bone surface, and the anterior migration of the soft tissue Sn point was visually confirmed from outside of the mouth. Two screws (diameter: 2.0 mm and length: 6.0 mm) were then placed on the bony surface for fixation (Fig. 1A). Subsequently, dental cone beam computed tomography (CBCT) was performed to confirm the presence or absence of contact between the placement screw and the root of the tooth. The wound was carefully cleaned, and a bone substitute material (REFIT Dental, HOYA Technosurgical, Tokyo, Japan) was used to fill the small gap between the bone and titanium plate surfaces. An artificial dermis (Terudermis) was inserted into the pocket formed at the base of the nasal ala (Fig. 1B), and lifting of the depressed area from outside of the mouth was confirmed. The tissue surrounding the pocket was sutured in a drawstring manner to prevent the Terudermis from coming out of the formed pocket. The dermal suture was performed using 6-0 Bicryl and the gingival suture using 5-0 silk thread. Antibiotics and analgesics were prescribed, and the stitches were removed 2 weeks later.

Fig. 1.:
Intraoperative images. A, Image showing plate fixation in the bone. B, Image showing the Terudermis placed in the pocket.

Evaluation of the Three-dimensionality of the Facial Features and Protrusion of the Mouth

Cephalometric analysis was performed preoperatively and 6 months postoperatively using facial photography and cephalometric radiography. The following indices were used to evaluate the three-dimensionality of the facial features and mouth protrusion (Fig. 2A–C).

Fig. 2.:
Soft tissue cephalometric reference points and analyses.

Index of Facial Three-dimensionality

  • Total facial convexity (glabella-pronasal-pognion)
  • Facial convexity (glabella-subnasal-pognion)

Index of Mouth Protrusion

  • Nasolabial angle (columella-subnasal-labrale superius)
  • Burstone’s line (the shortest distance between the subnasal-pognion and labrale superius)
  • E-line to lower lip (the shortest distance between the pronasal-pognion and lower lip)
  • THL (subnasal-labrale superius-ground in the natural head position)

Evaluation of the Soft Tissue Thickness and Tissue Changes in the Depression

The soft tissue changes due to insertion of the artificial dermis (Terudermis) were measured using dental CBCT. The minimum soft tissue thickness was measured at the most depressed area of the nasal ala base on the axial image, 6 mm above the palatal plane through the anterior nasal spine and posterior nasal spine. Preoperative and postoperative soft tissue changes were also examined on the basis of the CT values (Hounsfield units [HUs]).


Changes in the Facial Appearance

A comparison of the preopeartive and postoperative facial images of the patient who underwent A-10 surgery showed that the perinasal area moved forward, and the midface became more three-dimensional, resulting in a more attractive facial appearance (Fig. 3A–F). Next, preoperative and postoperative cephalometric analyses were performed using lateral cephalometric radiography (Fig. 4). The total facial convexity changed from 34.5 degrees preoperatively to 35.9 degrees postoperatively, while the facial convexity changed from 10.3 degrees preoperatively to 14.0 degrees postoperatively. The nasolabial angle changed from 91.1 degrees preoperatively to 93 degrees postoperatively; Burstone’s line from 8.2 mm preoperatively to 5.9 mm postoperatively; E-line to lower lip from 2.9 mm preoperatively to 2.5 mm postoperatively; and THL from 71.5 degrees preoperatively to 75.5 degrees postoperatively as an index of mouth protrusion (Table 1). These results suggest that the protrusion of the mouth was reduced, and a three-dimensional impression of the midface was successfully achieved.

Table 1. - Changes in Major Items and Their Means before and after A-10 Surgery
Analysis Items Mean ± SD Pretreatmet Posttreatmet
Asian White
Index of facial three-dimensionality
 Total facial convexity (Gla-Prm-Pog) (°) 34.5 35.9
 Facial convexity (Gla-Sn-Pog) (°) 7.6 14.79 10.3 14
Index of mouth protrusion
 Nasolabial angle (°) 87.86 102 91.1 93
 Burston-line (mm) 6.5 8.2 5.9
 E-line (Rickett’s) (mm) 2 2.9 2.5
 THL (º) 71.5 75.5

Fig. 3.:
Preoperative and postoperative assessments: photographs of the facial features. A-C, Postoperative lateral (A), three-quarter (B), and frontal (C) views. D-F, Preoperative lateral (D), three-quarter (E), and frontal (F) views.
Fig. 4.:
Preoperative and postoperative assessments. Lateral cephalometric radiographs. A, Before surgery. B, After surgery (6 M).

Changes in the Nasal Ala Base Thickness

A-10 surgery is a new surgical technique that combines the Point A-Koji method with artificial dermal insertion. Therefore, to evaluate the effectiveness of artificial dermal insertion during A-10 surgery in improving nasal ala base depression, we compared the data with those of a patient treated with the Point A-Koji method alone. Patient A underwent A-10 surgery, while patient B claimed to have recently undergone the Point A-Koji method only. Data were obtained from patients A and B at 6 and 5 months postoperatively, respectively. The thickness around the nasal ala base in patient B was 7.86 and 8.5 mm before and after surgery on the right side, respectively, and 7.72 and 8.28 mm before and after surgery on the left side, respectively, showing an average increase of 0.6 mm (8%) after surgery on both sides. Meanwhile, the thickness of the nasal ala base in patient A was 7.15 and 9.7 mm before and after surgery on the right side, respectively, and 7.13 and 8.75 mm before and after surgery on the left side, respectively, showing an average increase of 2.085 mm (29%) after surgery on both sides (Fig. 5; Table 2). Patient A, who underwent dermal transplantation, had a greater postoperative increase in the nasal ala base thickness than patient B, who did not undergo dermal transplantation.

Table 2. - Changes in Skin Thickness at Mandibular Condyle Position in the Axial Planes before and after Surgery
Thickness (mm) Pretreatmet Posttreatmet Percentage Increase in Soft Tissue Thickness
R L Average R L Average R L Average
Patient A 7.15 7.13 7.14 9.7 8.75 9.225 136 123 129
Patient B 7.86 7.72 7.79 8.5 8.28 8.39 108 107 108

Fig. 5.:
Evaluation of the minimum soft tissue thickness at the most depressed area of the nasal ala base on the axial image, 6 mm above the palatal plane via ANS and PNS. A, Patient A pretreatment. B, Patient A posttreatment. C, Patient B pretreatment. D, Patient B posttreatment.

Changes in the Soft Tissue

In patient A, the soft tissue CT values for the depression ranged from −263 to −203 HU and 27 to 138 HU on the right side preoperatively and postoperatively, respectively, and from −230 to −142 HU and 37 to 119 HU on the left side preoperatively and postoperatively, respectively. In patient B, the values ranged from −122 to 13 HU and −55 to 50 HU on the right side preoperatively and postoperatively, respectively, and from −60 to 72 HU and −65 to 61 HU on the left side preoperatively and postoperatively, respectively. The preoperative CT values of patients A and B were both suggestive of the presence of adipose tissue, while the postoperative CT values of the soft tissue in the area where the artificial dermis was inserted ranged from 27 to 119 HU in patient A only, suggesting the presence of dermal-like tissue (Table 3). (See figure, Supplemental Digital Content 1, which shows the evaluation of preoperative and postoperative soft tissue changes at the nasal ala using CT values (HUs) (patient A), (See figure, Supplemental Digital Content 2, which shows the evaluation of preoperative and postoperative soft tissue changes at the nasal ala using CT values (HUs) (patient B),

Table 3. - Changes in CT Values at the Nasal Wing before and after Surgery
CT values (HU) Pretreatmet Posttreatmet
Patient A Max -203 -142 138 119
Min −263 −230 27 37
Patient B Max 13 72 50 61
Min −122 −60 −55 −65


Cephalometric analysis of the patient with midface depression who underwent A-10 surgery showed that the facial convexity, an important indicator of the three-dimensionality of the face, changed from 10.3 degrees preoperatively to 14.0 degrees postoperatively. In general, the average facial convexity of Asian people is 7.6 degrees, while that of White people is 11–14.79 degrees.13–15 These results suggest that surgery improves the facial convexity with an anterior shift of the soft tissue Sn point, leading to a more three-dimensional facial appearance. Meanwhile, the nasolabial angle, an important indicator of mouth protrusion, changed from 91.1 degrees preoperatively to 93 degrees postoperatively in our patient. Generally, the mean nasolabial angle is 87.86 degrees in Asian people and 109 degrees in White people.13,14,16,17 Herein, the nasolabial angle was enlarged by surgery and reached the White mean angle. The mean Burstone’s line is 6.5 mm in Japanese women, 6.3 mm in Japanese men, and 3.0 mm in White people.17,18 In our study, the preoperative and postoperative measurements were 8.2 and 5.9 mm, respectively. A THL between 79 degrees and 85 degrees is generally considered to yield the most attractive appearance18; herein, the patient had preoperative and postoperative THLs of 71.5 degrees and 75.5 degrees, respectively. These results indicate that surgery reduced the protrusion of the mouth. Conversely, the E-line to lower lip of our patient changed from 2.9 mm preoperatively to 2.5 mm postoperatively. The E-line to lower lip was already esthetically and appropriately positioned preoperatively; therefore, it is unlikely that the surgery yielded any marked change in the patient’s E-line to lower lip. Similar to a previous report regarding treatment using the Point A-Koji method alone,1 the lateral facial appearance of our patient showed reduction in mouth protrusion and a three-dimensional effect on the midface. These effects may be attributed to the anterior shift of the Sn point using the implant titanium plate rather than to the insertion of the artificial dermis. Cephalometric analysis is used to determine the angle and amount to be produced to some extent. The amount is ultimately determined in the surgical field, taking into account the elongation of the surrounding soft tissues. The amount will be limited depending on the elongation of the skin. In most cases, the Sn point is set to move forward 2 mm, and the limit to widen the nasolabial angle will depend on the elongation of the tissue.

Based on the CBCT values, patient B, in whom the artificial dermis was not used, showed an average increase of 0.6 mm in the thickness of the nasal ala base on the left and right sides after surgery; meanwhile, patient A, in whom the artificial dermis was used, showed an average increase of 2.085 mm. The presence of the plate is thought to have allowed the nasal ala base to gain space and to be retained more easily when the artificial dermis was inserted. The increase in the thickness of the nasal ala base is thought to be attributed to the effect of the insertion of the artificial dermis. The preoperative CT values of patient A ranged from −263 to −142 HU, whereas the preoperative and postoperative CT values of patient B ranged from −122 to 13 HU and from −65 to 61 HU, respectively; all these CT values were close to those suggestive of the presence of adipose tissue. Only patient A had postoperative CT values ranging from 27 to 138 HU, suggesting that the inserted artificial dermis had replaced the dermal-like tissue. Compared with that in fat or hyaluronic acid injections, the acquired dermal-like tissue was firm and is thought to be superior in preserving the morphology. The Terudermis has been used for a long time, mainly for gingival growth, extraction socket preservation, and hemostasis, and is considered safe.19 The collagen layer of the Terudermis is a less antigenic collagen made via protease treatment of young bovine dermis and digestive cleavage of the telopeptide portion. Collagen without this telopeptide is called atelocollagen, which is known to be less antigenic because it has no telopeptide moiety.20–22

Various methods have been recommended and performed to yield a facial morphology that is closer to the patient’s ideal image. However, at the nasal ala base, it is generally difficult for foreign bodies such as hyaluronic acid, fat, and cartilage to continue to function without retroversion owing to muscle movement. If an excess amount of solid material such as a prosthesis is placed, it may cause problems such as floating out of the surrounding tissues, but because it is a sponge, even if an excess amount is placed, it is unlikely to swell excessively due to the tension of the surrounding skin, resulting in a natural-looking result. Terudermis promotes wound healing,22 acting as a scaffold to facilitate infiltration from the surrounding tissue, which disappears in 4 weeks,23 and connective tissue grows much faster than bone.24 According to the article, it has been shown that even in highly invasive osteotomies, the swelling disappears well within 6 months.25 However, the face is very delicately shaped, and we need to pay attention to its future progress.

A-10 surgery is a minimally invasive and safe procedure with minimal tissue regression at 6 months postoperatively. In our study, only one patient was included. In the future, we plan to increase the number of cases and examine postoperative stability over a longer period.

The base of the nasal ala is also the site of depression due to enlargement of the piriform aperture as a result of age-related changes.25,26 Therefore, A-10 surgery may be applicable as an antiaging treatment for middle-aged patients.


A-10 surgery, a new treatment method for midface sculpting, is similar to Le Fort II osteotomy; however, unlike Le Fort II osteotomy, A-10 surgery is safe and minimally invasive. With the use of a titanium plate as a frame in combination with an artificial dermis, it is possible to fill the depression with autologous tissue, without postoperative retroversion at 6 months postoperatively.


The patient provided written consent for the use of her image.


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Supplemental Digital Content

Copyright © 2022 The Author. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons.