CURRENT THERAPY
J Oral Maxillofac Surg
An Overview of Facial Aesthetic Units
Tirbod T. Fattahi, DDS, MD*
One of the important considerations in any type of
facial surgery is the appearance of the final scar.
Regardless of the background training or surgical spe-
cialty, surgeons are constantly striving to produce the
most aesthetically pleasing incision and the most me-
ticulous skin closure and to use the most state-of-the-
art wound products to create the best surgical scar.
Surgical techniques of repairing facial deformities,
regardless of etiology (congenital, traumatic, patho-
logic, reconstructive, cosmetic, etc), will undoubt-
edly have social implications. Patients and their fam-
ilies will often concentrate solely on how “normal”
facial appearance is after surgery, ignoring all remain-
ing aspects of their surgical care. Patient’s self-identity
and perception are greatly influenced by a surgeon’s
manipulation and handling of facial tissues; if the final
result restores a sense of normalcy to the face with
appropriate sizes and proportions, then the patient’s
ability to maintain an active social interaction based
on appearance remains undisturbed. The goal of cre-
ating the best surgical scar coupled with the concept
of human perceptions has led surgeons to pursue the
tenets of the principle of facial aesthetic units.
Gonzales-Ulloa1 first described the regional aes-
thetic units of the face in an effort to emphasize the
need for restoring facial skin units in complete re-
gions as opposed to “patch” work. He believed that
superior surgical results can be obtained in complex
facial reconstruction by replacing lost skin with grafts
or flaps of similar histology, thickness, and texture.
Cadaver dissections were performed and final results
led to the development of 40 regions of the body and
14 regions of the face based on skin thickness and
histology.2-4 These facial regions were further classi-
fied by observing what Gonzales-Ulloa1 termed “relief
lines, folds, and evident changes in cutaneous tex-
*Assistant Professor and Director of Residency Program, Depart-
ment of Surgery, Division of Maxillofacial Surgery, University of
Florida–Jacksonville, Jacksonville, FL.
Address correspondence and reprint requests to Dr Fattahi:
Department of Surgery, Division of Maxillofacial Surgery, University
of Florida–Jacksonville, 653-1 W Eighth St, Jacksonville, FL 32209;
e-mail: Tirbod.Fattahi@jax.ufl.edu
© 2003 American Association of Oral and Maxillofacial Surgeons
0278-2391/03/6110-0017$30.00/0
doi:10.1016/S0278-2391(03)00684-0
1207
61:1207-1211, 2003
ture.” The original 14 aesthetic units as classified by
him included: forehead, right and left cheeks, nose,
right and left upper lids, right and left lower lids, right
and left ears, upper lip, lower lip, mental region, and
the neck.1,4 His brilliant and innovative investigation
allowed surgeons to inconspicuously hide surgical
margins within the natural borders of each facial unit.
Burget and Menick5,6 revitalized interest in the field of
aesthetic facial units by introducing the concept of
the “subunit theory.” Menick incorporated principles
of psychology and visual perceptions into surgical
techniques and eluded to the concept that when
observing another human being, most of us tend to
ignore minor visual details; rather, we tend to con-
centrate on the more conspicuously abnormal appear-
ances.7,8 He observed facial surfaces and described
ridges and valleys, which formed convex and concave
regions allowing different light reflection. He further
surmised that if a graft or a suture line is matched to
the shape of a particular subunit, the natural appear-
ance of lights and shadows is restored, thereby allow-
ing the reconstruction to remain imperceptible be-
cause the scars are perceived as normal facial
topography. Application of this principle led to the
establishment of nasal subunits by nasal reconstruc-
tive surgeons.5 Minor modifications of the nasal sub-
units have been proposed by others.9-11
The Facial Aesthetic Units
The currently accepted facial aesthetic units are
illustrated in Figure 1. Although based on the original
work of Gonzales-Ulloa,1 modifications have been
proposed for further classification of each facial re-
gion into specific subunits.12-16
FOREHEAD UNIT
The forehead unit is bounded by the hairline supe-
riorly and laterally, naision inferomedially, and an
imaginary line connecting the lateral orbital rims to
the sideburns inferolaterally. The eyebrows, central,
and lateral regions are the forehead subunits. Two
imaginary vertical lines separate the convex central
subunit from the concave lateral subunits. Contained
within this region are the horizontal and vertical rhyt-
ids formed by the actions of the frontalis and corru-
gator muscles as well as the retro-orbicularis oculi fat
(ROOF)pads and the brow/galeal fat pads.
1208 FACIAL AESTHETIC UNITS

FIGURE 1. Frontal A, and profile B, views of the aesthetic units and subunit of the face. 1, Forehead unit (1A, central subunit; 1B, lateral subunit;
1C, eyebrow subunit); 2, nasal unit; 3, eye lid units (3A, lower lid unit; 3B, upper lid unit; 3C, lateral canthal subunit; 3D, medical canthal subunit);
4, cheek unit (4A, medial subunit; 4B, zygomatic subunit; 4C, lateral subunit; 4D, buccal subunit); 5, upper lip unit (5A, philtrum subunit; 5B, lateral
subunit; 5C, mucosal subunit); 6, lower lip unit (6A, central subunit; 6B, mucosal subunit); 7, mental unit; 8, auricular unit; 9, neck unit.

NASAL UNIT ing the skin and palpebral portion of the orbicularis
The nasal complex is bounded by the naision supe- oculi (anterior lamella), orbital septum, and the tarsal
riorly, junction of the cheeks and nasal dorsal side plates (middle lamella), and the conjunctiva and
walls laterally, and the alar groove and columella retractors of the upper and lower lids (posterior
inferiorly. There are 9 clinically significant subunits
within this complex including the dorsum, right and
left dorsal side walls, tip, right and left alar side walls,
right and left alar bases, and columella (Fig 2).

UPPER AND LOWER EYELID UNITS

The eyelid units include the upper and lower lids as
well as the lateral and medial canthi subunits. The
upper eyelid region is bounded by the inferior aspect
of the brow subunits superiorly, lateral and medial
orbital walls laterally and medially, respectively, and
the gray line of the upper lid inferiorly. Lower lid
units are the smallest regions on the face. They are
bounded by the gray line of the lower lid superiorly,
lateral and medial orbital walls laterally and medially, FIGURE 2. Nasal unit. 1, Tip subunit; 2, columellar subunit; 3, 6,
right and left alar base subunits; 4, 5, right and left alar side wall
respectively, and the infraorbital rim inferiorly. Each subunits; 7, dorsal subunit; 8, 9, right and left dorsal side wall
lid unit contains the 3 lamellae of the eyelids, includ- subunits.
TIRBOD T. FATTAHI 1209

lamella). The lateral canthus subunit forms a triangle,

beginning at the lateral palpebral angle and diverging
laterally, ending at the lateral orbital rim. The limbs of
this triangle are formed by the lateral orbital rim and
2 imaginary lines representing continuation of the
ciliary margins. The lateral canthus subunit houses
the superficial lateral canthal tendon,17 the Eisler’s fat
pad,18 as well as the superior and inferior limbs of the
deep lateral canthal tendon and the lateral retinacu-
lum. The medial canthus subunit is bounded by the
medial orbital wall and the upper and lower lacrimal
puncta. In addition to the superior and inferior lacri-
mal puncta, the ampulla and the cannilicular system
are within the medial canthal subunit.

CHEEK UNITS
The cheek region is bounded superiorly by the
infraorbital rims and the superior aspects of the zygo-
matic arches, laterally by the preauricular creases,
inferiorly by the jaw line, and medially by the nasola-
bial and melolabial (labiomandibular) grooves and the
lateral aspects of nasal dorsal side walls. An imaginary
line connecting the lateral orbital rim to the oral
commissures divides the medial and lateral subunits.
Zygomatic and buccal subunits are separated by the
inferior border of the zygomatic arch and the anterior
border of the masseter muscle. The cheek unit en-
compasses the parotid gland and duct, as well as the
major fat pads of the face, including the buccal fad
pads, the malar fat pads, and the sub-orbicularis oculi
fat (SOOF) pads.
UPPER LIP UNIT
The upper lip is bounded by the alar grooves and
columella superiorly, the nasolabial grooves laterally,
and the interlabial gap inferiorly. Subunits of the up-
per lip include the mucosal, philtral, and lateral,
which are formed by the vermilion border and the
philtrum ridges/columns. The cupid’s bow is formed
by the subunits of the upper lip.19
LOWER LIP UNIT
The lower lip is bounded by the interlabial gap
superiorly, the melolabial grooves laterally, and the
mentolabial groove inferiorly. The vermilion border
forms the boundary of the mucosal subunit of the
lower lip and separates it from the central subunit.
MENTAL UNIT
The chin unit starts at the mentolabial groove su-
periorly, forming a curvilinear border laterally, and
ending at the submental crease, just inferoposterior to
the jaw line. The “chin button” formed by the influ-
ences of the mandible, lower lip, the chin fat pads,
and the mentalis muscles is the major component of
this unit.
FIGURE 3. Auricular unit. 1, Helical subunit; 2, antihelical subunit; 3,
triangular fossa subunit; 4, conchal subunit; 5, lobe subunit.
AURICULAR UNITS
The auricular units comprise the right and left ears
that have been further classified into helical rim, an-
tihelix, triangular fossa, concha, and lobe subunits or
regions (Fig 3). The cartilaginous rim separates the
helical subunit from the lobe subunit, which lacks
cartilage. The antihelix includes the anterior and pos-
terior crura that surround the triangular fossa. Tragus,
antitragus, cymba, and cavum are within the concha
subunits.
NECK UNIT
The cervical unit is inferior to the jaw line and
encircles the entire circumference of the neck, termi-
nating at the sternal notch and the medial aspect of
clavicles inferiorly. The neck unit includes the
platysma and all of the suprahyoid and infrahyoid
muscles, as well as the neck viscera.
Clinical Application and Discussion
It is imperative for surgeons operating on the facial
region to have a thorough understanding of the facial
units and subunits. Clinical significance of this ana-
tomic description is helpful in ablative, reconstruc-
tive, and aesthetic surgery. Due to the alternating
convex and concave surfaces of each subunit and the
resulting light reflections, surgical incisions and re-
constructive plans can be modified to produce more
aesthetically pleasing results. By hiding incisions
along and within each facial unit, one can distract
attention away from the final result of a surgical pro-
1210
cedure, simulating the illusion of normal anatomic
architecture. Numerous examples of the application
of this principle are found in the head and neck
surgery literature dealing with ablative and recon-
structive procedures such as the McGregor incision in
lower lip splits along the junctions of the lower lip
and chin units, Altemir modification of Weber-Furgu-
son incision along the philtrum ridge, gull-wing and
open-sky approaches for the frontonasoethmoidal in-
juries along the junction of the brow subunit of the
forehead and the upper eyelid units, nasolabial flap
elevation along the junction of the cheek, nose, and
upper lip units, bilobed nasal flap rotation within the
nasal subunits for nasal tip reconstruction, and ex-
tending the margins of an excision to include an
entire facial subunit rather than a small portion of it to
facilitate a more aesthetic reconstructive out-
come.5,9,20-27 Other examples include the transcolu-
mellar incision in open structure rhinoplasty at the
junction of the nasal tip and columellar subunits,
dermabrasion of an entire facial unit to create a nat-
ural transition into adjacent aesthetic units in order to
camouflage a single, prominent scar, and regional
facial laser resurfacing.28-30
Oftentimes, when evaluating patients for facial aes-
thetic procedures, the clinician performs a focused,
“top-to-bottom” examination of the facial region
based on the needs of each specific facial unit. For
example, when examining the forehead unit for the
presence of horizontal and vertical rhytids, one also
looks at the brow subunits to determine the location
and the arch of the brow in relation to the supraor-
bital rim. In fact, specific brow measurements have
been proposed based on the relationship of the brow
subunit to the upper lid units and the supraorbital
rims.31
When treatment planning patients for rhinoplasty
procedures, specific subunits such as the tip, or the
dorsum, receive special attention to maximize the
final result. Surgical maneuvers, such as tip plasty, tip
rotation or projection, dorsal augmentation, reduc-
tion, or camouflage, focus on specific nasal subunits
and allow for a balanced final outcome.
A variety of alloplastic facial implants have been
fabricated by different manufacturers to augment spe-
cific regions of the cheek unit. For example, a Terino
Malar Shell implant (Implantech Inc, Ventura, CA)
mainly augments the zygomatic and portions of the
medial subunits of the cheek, whereas a Flowers Tear
Trough implant (Implantech Inc) focuses on the me-
dial subunit of the cheek in patients with submalar
hypoplasia.
Although relatively small, the chin unit has received
considerable attention in aesthetic literature. The
FACIAL AESTHETIC UNITS
“witch’s chin deformity,” commonly seen in many
older female patients, has been the focus of many
innovative surgical maneuvers.32-36 This degree of at-
tention to such an aesthetically alluring problem truly
underscores the clinical significance of each facial
unit.
Regardless of the type of facial surgery performed,
favorable surgical outcomes can be obtained if inci-
sions and reconstructive options can be planned
within and/or along the borders of a particular facial
subunit. Following the tenets of regional and/or facial
aesthetic units and subunits can dramatically improve
the final appearance of facial scars and surgical out-
comes, gratifying the surgeon and his or her patient.
References
1. Gonzales-Ulloa M: Restoration of the face covering by means of
selected skin in regional aesthetic units. Br J Plast Surg 9:212,
1956
2. Gonzales-Ulloa M, Castillo A, Stevens E, et al: Preliminary study
of the total restoration of the facial skin. Plast Reconstr Surg
13:151, 1954
3. Gonzales-Ulloa M, Stevens E: Reconstruction of the nose and
forehead by means of regional aesthetic units. Br J Plast Surg
13:305, 1961
4. Gonzales-Ulloa M: Regional aesthetic units of the face. Plast
Reconstr Surg 79:489, 1987
5. Burget GC, Menick FJ: The subunit principle in nasal recon-
struction. Plast Reconstr Surg 76:239, 1985
6. Burget GC, Menick FJ: Aesthetic Reconstruction of the Nose. St
Louis, MO, Mosby, 1994, p 1
7. Menick FJ: Artistry in aesthetic surgery: Aesthetic perception
and the subunit principle. Clin Plast Surg 14:723, 1987
8. Thompson S, Menick FJ: Aesthetic facial reconstruction: Blend-
ing human perception and the facial subunit theory. Plast Surg
Nursing 14:211, 1994
9. Becker FF, Langford FP: Local flaps in nasal reconstruction.
Facial Plast Surg Clin North Am 4:505, 1996
10. Becker FF, Hillstrom RP: Reconstruction of the nose and mid-
face, in Papel I (ed): Facial Plastic and Reconstructive Surgery.
St Louis, MO, Mosby, 1992, p 407
11. Millard DR: Aesthetic aspects of reconstructive surgery. Ann
Plast Surg 1:533, 1978
12. Engrav LH, Donelan MB: Face burns: Acute care and recon-
struction. Opin Tech Plast Reconstr Surg 4:53, 1997
13. Maillard GF, Clavel PR: Aesthetic units in skin grafting of the
face. Ann Plast Surg 26:347, 1991
14. Larrabee WF, Sherris DA: Principles of Facial Reconstruction.
Philadelphia, PA, Lippincott-Raven, 1995
15. Baker SR, Swanson NA: Local Flaps in Facial Reconstruction. St
Louis, MO, Mosby, 1995
16. Menick FJ: Subunit reconstruction of the chin. Opin Tech Plast
Reconstr Surg 6:212, 1999
17. Knize DM: The superficial lateral canthal tendon: Anatomic
study and clinical application to lateral canthopexy. Plast Re-
constr Surg 109:1149, 2002
18. McCord CD, Codner MA, Hester TR: Redraping the inferior
orbicularis arc. Plast Reconstr Surg 102:2471, 1998
19. Mulliken JB, Pensler JM, Kozakewich HP: The anatomy of
Cupid’s bow in normal and cleft lip. Plast Reconstr Surg 92:
395, 1993
20. Hayter JP, Vaughan ED, Brown JS: Aesthetic lip splits. Br J Oral
Maxillofac Surg 34:432, 1996
21. Warren SM, Longaker MT, Zide BM: The subunit approach to
nasal tip hemangiomas. Plast Reconstr Surg 109:25, 2002
TIRBOD T. FATTAHI
22. Haddad-Tame JL, Chavez-Abraham V, Rodriguez D, et al: Re-
construction of the aesthetic units of the face with microsur-
gery: Experience in five years. Microsurgery 20:211, 2000
23. Dzubow LM, Zack L: The principle of cosmetic junctions as
applied to reconstruction of defects following Mohs surgery. J
Dermatol Surg Oncol 16:353, 1990
24. Becker FF, Langford FP: Deep-plane cervicofacial flap for re-
construction of large cheek defects. Arch Otolaryngol Head
Neck Surg 122:997, 1996
25. Converse JM, Hogan UM: Opensky approach for reduction of
naso-orbital fractures. Plast Reconstr Surg 46:396, 1970
26. Herbert DC, Harrison RG: Nasolabial subcutaneous pedicle
flaps. I: Observations on their blood supply. Br J Plast Surg
28:85, 1975
27. McGregor JC, Soutar DS: A critical assessment of the bilobed
flap. Br J Plast Surg 34:197, 1981
28. Toriumi DM, Johnson CM: Open structure rhinoplasty. Facial
Plast Surg Clin North Am 1:1, 1993
1211
29. Bradley DT, Park SS: Scar revision via resurfacing. Facial Plast
Surg 17:253, 2001
30. Weinstein C: Ultrapulse carbon dioxide laser removal of peri-
ocular wrinkles in association with laser blepharoplasty. J Clin
Laser Med Surg 12:205, 1994
31. Evans TW: Browlift. Atlas Oral Maxillofac Surg North Am 6:111,
1998
32. Brennan HG, Giammanco PF: The ptotic chin syndrome cor-
rected by mentopexy. Ann Plast Surg 18:200, 1987
33. Feldman JJ: The ptotic (witch’s) chin deformity: An excisional
approach. Plast Reconstr Surg 90:207, 1992
34. Peterson RA: Correction of the senile chin deformity in face
lift. Clin Plast Surg 19:433, 1992
35. Bernardi C, Amata PL, Dura S: Witch’s chin: A progressive,
three step technique. Plast Reconstr Surg 104:552, 1999
36. Hamra ST: Surgery of the again chin. Plast Reconstr Surg 94:
388, 1994