“V-Effect” Concept in Cosmetic Face Sculpting in Asians

An effective and a minimally invasive Non Surgical Lower face contouring in young Asians

By Dr. Peter Kim — Asian Cosmetic Surgery, FACCS, FIBCS

Simply Beautiful Cosmetic Surgery & Laser Clinic 
 Suite 4, Level 1, “Epica Building” 9 Railway Street 
 Chatswood NSW 2067 02 9411 4880 and

Dr. Wong CH, FACCS

The Cosmetic Surgery & Skin Cancer Centre 
 Brendale, Brisbane, Australia

Introduction

A stereotypical facial shape in female Asians commonly includes prominent cheeks, benign masseteric hypertrophy (BMH) and micrognathia (MG). These features in combination produces a facial shape that appears disproportionately wide and short creating a squarish and a masculine facial shape which is distant from the desired oval and inverted triangular facial shape often described as a youthful face in reference to “the triangle of beauty”.

According to the triangle of beauty1, “the younger face is characterized by the harmony and balance captured in the classic heart shape or inverted triangle”. There is a reversal of this “triangle of beauty” as aging proceeds and this is generally considered as less attractive. With these changes, the convexities typical of a youthful appearance tend to flatten and droop and produce a squarish facial shape. Although this type of facial contour is commonly seen as an aging phenomenon, the concept of a triangle of beauty is sound and useful in describing the popularity behind the young Asians seeking V-Effect procedures — creating a V line lower face contour with a sharper and pointier chin at the peak of the V (Figure 1). The V effect can be created by the correction of MG (by producing a longer face and a more projected focus on the chin) and with correction of BMH (by producing a longer and a slender appearing jawline). In this way, we can produce an end result, which is in effect restoring the triangle of beauty.

These series of cases will describe the“V-Effect in young female Asians”, a simple non surgical technique of sculpting the lower third of the Asian face by correcting MG using filler chin injections and by correcting BMH using botulinum neurotoxin type A (BoNT-A) injections.

CASE STUDIES

Case Study 1

A young Asian woman with a request to produce a V-effect. This case illustrates a typical example of a young Asian woman with squarish jaw and relatively flat chin. 90 units of Dysport® was injected to each Masseter and 2mL of SubQ® was used to augment the chin. She also received a nose filler enhancement.

Figure 1. Drawing illustrating the mechanism of V-effect in lower face contouring in Asians. Refer to Case 3 for the end outcome.

Case Study 2

A young Asian woman with a request to produce a V-effect. 90 units of Dysport® was injected to each Masseter and 2mL of SubQ® was used to augment the chin. She also received a filler injection for the nose and forehead enhancement as an adjunctive treatment.

Case Study 3

A young Asian woman with a request to produce a V-effect. 90 units of Dysport® was injected to each Masseter and 2mL of Sub Q® was used to augment the chin. She also received a filler injection for nose enhancement and a non-surgical double eyelid procedure using “Durable Suture Technique”2.

DISCUSSION

Defining Asian’s Beauty

There are numerous models and theories available in quantitatively and qualitatively assessing and defining a beautiful face. Currently, an “average attractiveness model” created by a computer morphing technique using Balanced Angular Proportional Analysis seems to be the standard paradigm as its result concur widely with the universal acceptance on what an average Asian would consider an attractive Asian face to be.

Rhee et al3 produced a composite average image of the 20 top Korean entertainers. Numerous standardised landmarks on the face were located and measure on these 20 individuals and then they were averaged. Averaging the position of these landmarks produced an image that is the “averageness” of the top 20 Korean entertainers. The final composite image (Figure 2) shows that in Korea in 2007, this facial shape is what average Koreans have considered to be attractive.

Aesthetic Implications

The Result of Rhee’s article shows that female Asians have a preference towards having overall oval shaped face shape but a distinct V line with a well-projected chin and a slim jaw line. This visual insight into what Asians consider to be a beautiful face gives cosmetic injectors guidance on how we can use our injectables to produce such an outcome. Specific to the contouring of the lower face of a female Asian, when MG & BMH is prevalent amongst Asians, a V-Effect procedure to produce an aesthetically pleasing V-Line is popular and highly sought. The authors also found that there is an increasing trend among the young female Asian population in Australia to seek out procedures that would transform plain facial features to a more distinctive look. BMH and MG do not have to be present in a severe manner before V-effect procedures can be offered, however clear boundaries of achievable goals should be clarified.

Cultural expectations

Asian men also have a cultural predilection for V-effect in the face contour. MH produces a prominent jaw line and is seen as a masculine and “stubborn” image, both of which are unattractive feminine images. An under-prominent chin is also seen as a poor-man’s image. It is surprising to note that these shamanic interpretations are still prevalent in Asian communities and influence their aesthetic ideas (Figure 3).

Figure 3. This photograph5 highlights the similarities of successful candidates with v-effect features. Extensive media and entertainment exposure to the public pushes the newer generation to be reluctant to accept the norm.

Figure 4. Landmark papers on the BonTA masseteric injections (6–10).

Botox jaw injection

BonTA Masseteric injections are one of the more rigorously and scientifically studied topics in the field of cosmetic botulinum injections. Satisfactory results are achievable and no significant long-term side effects have been reported (Figure 4).

Injected BoNTA produces masseteric atrophy hence causing a face slimming effect. There is a dose dependent muscle atrophy. In our experience the maximum benefit can be expected when 90U of Dysport or 30U of Botox is injected into each Masseter. There is a steady reduction of the Masseter volume to the maximum clinical effect in 4–6 weeks after the injection. The slimming effect tends to last for a period of 6–9 months, which is considerably longer than the time at which the muscle regains its strength, which is typically around 4–6 months.

Those patients with larger and stronger Masseter do not respond as well with the first treatment and these patients are offered another injection at 6 weeks follow up. Usually, patients are asked to return in 6–9 months for subsequent treatment of BMH. We see complications in the order of 2 %, and two important complications

are asymmetric smile and pseudo bulging of jaw. They are self limiting but, assymetric smiles, can be distressful for patients during the recovery process.

Chin injection

Chin enhancement is one of those cosmetic procedures that are becoming increasingly popular both by surgery and by injections11. Filler chin injection should lengthen the lower third of the face, project the chin anteriorly, flow smoothly with the jawline to produce a slender and longer jaw line, and to produce a distinct boundary from the neck by way of producing a more acute mentocervical angle. Among the various fillers we have tried, in our experience Sub-Q tend to produce the optimum result as it is a harder filler, greater volumiser, easier to sculpt a nice chin shape. It predictably lasts 9–12 months.

It is very important to maintain the midline and symmetry in the chin filler enhancement and this can be done through 3 bolus injections down to the periosteum. Filler material is directed in a deep preperiosteal position. The non-injecting hand can be use to guide and mold the skin to achieve a seamless transition from jowl to chin.

Ancillary Procedures

Ancillary procedures can be added to supplement the V-effect such as nasal bridge augmentation (case one), cheek augmentation and buccal cheek fat removal. A sharp nasal bridge, slim jaw and prominent chin reinforce the triangle of beauty enhancing a more mature and distinctive look.

Permanence

As with any cosmetic injection, the temporary nature of the cosmetic result is a downside. However this is well accepted by patients as there is almost no downtime and it does not limit their daily lives. For those who wish a more permanent result, silicone chin implant is a relatively simple procedure that we regularly offer to our patients. However we do recommend that they do filler first to ascertain the desired chin projection and shape and this produces a good preoperative guide to choosing the correct implant size and shape.

Conclusion

The synergistic effect of BoNTA jaw reduction and filler chin augmentation produces a powerful contouring of the lower one third of the female Asian face. The simplicity, an easiness, as well as the reproducibility and the effectiveness of V effect enables us to produce a powerful image change, which makes this combined procedure highly popular and desirable in female Asians.

Reference

1. Raspaldo H. Volumizing effect of a new hyaluronic acid sub-dermal facial filler: A retrospective analysis based on 102 cases. Journal of Cosmetic Laser Therapy. 2008 Vol 10 (3): 134–142.

2. Kim P, Ahn JT. A Simple technique in Creating Double Eyelid in Asians using Buried Suture Technique and Chung’s Forceps. Journal of Cosmetic Surgery & Medicine 2010: 5(3); 20.

3. Rhee SC, Dhong ES, Yoon ES. Photogrammetric Facial Analysis of Attractive Korean Entertainers. Aesth Plast Surg (2009) 33:167–174 4. Image Source downloaded from http://beautyportal.co.kr/index.php?mm_

code=45&sm_code=191 5. Image Source downloaded from http://missosology.info/forum/viewtopic.

php?f=3&t=189188 6. ToEW,AhujaAT,HoWSetal:Aprospectivestudyoftheeffectofbotulinum

toxin A on masseteric muscle hypertrophy with ultrasonographic and

electromyographic measurement. Br. J. Plast.Surg. 54:197,2001. 7. Kim HJ, Yum KW, Lee S et al: Effects of botulinum toxin type A on bilateral masseteric hypertrophy evaluated with computer tomographic

measurement. Dermatol Surg.29:484,2003. 8. Choe SW, Cho WI, Lee CK, Seo SJ. Effects of Botulinum Toxin Type A on

Contouring of the Lower Face. Dermatol Surg 2005;31:502–508. 9. Lee CJ, Kim SG, Kim YJ, Han JY, Choi SH, Lee SI : Electrophysiologic change and facial contour following botulinum toxin A injection in square

faces. Plast. Reconstr. Surg.Sept 1 2007;120 (3):769–778. 10. kim JH, Shin JH, Kim ST, Kim CY. Effects of Two Different Units of Botulinum Toxin Type A Evaluated by Computed Tomography and Electromyographic Measurements of Human Masseter Muscle. (Plast. Reconstr. Surg. 119: 711, 2007. 11. 2011 Plastic Surgery Statistics Report. American Society of Plastic Surgeons. Downloaded from http://www.plasticsurgery.org/News-and-Resources/2011-Statistics-.html

Dr. Peter Kim is a Cosmetic Surgeon specifically trained for Cosmetic Surgery. Dr. Kim specializes in Asian Cosmetic Surgery. Please visit him on his websites;

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