**3. The units of the face**

The face consists of 6 major aesthetic units comprised of: forehead, eye/eyebrow, nose, lips, chin, and cheek. These aesthetic units can be subdivided into additional anatomical subunits. For example, the nose can be divided into nasal tip, dorsum, columella, soft-tissue triangles, sidewalls, and nasal alar regions. Correct orientation of planned incisions next to these mobile functional and aesthetic facial structures is important to avoid distortion when closing wounds.

In this chapter we focus on the hair bearing units of the male face which are designated as the mustache and beard namely units 4c, d, 5a, b, 7 and some part of unit 9 in the neck (Figures 7 and 8).

The shape of the hair follicle is thus believed to contribute to the appearance and the geometry

of the hair. Asian hair has a circular geometry, African hair has an elliptical shape, and hair of

Caucasians is of an intermediate shape. The chemical and protein composition of hair does not

vary across ethnic groups, and there is no difference in the keratin types. However, African hair

generally has less tensile strength and breaks more easily.

**Figure 6: Comparison of the cuticular patterns of scalp and beard hair, reprinted by Figure 6.** Comparison of the cuticular patterns of scalp and beard hair, reprinted by permission of The Society of Cos‐ metic Chemists

In this chapter we focus on the hair bearing units of the male face which are designated as the mustache and beard namely units 4c, d, 5a, b, 7 and some part of unit 9 in the neck (**Figures 7**

**Figure 8: The hair bearing units in the male face, used by permission of author Davide Brunelli**

**Figure 7: The human face units, used by permission of author Davide Brunelli M.D, www.med‐ Figure 7.** The human face units, used by permission of author Davide Brunelli M.D, www.med-ars.it

**ars.it**

**and 8**).

**M.D, www.med‐ars.it**

Caucasians is of an intermediate shape. The chemical and protein composition of hair does not vary across ethnic groups, and there is no difference in the keratin types. However, African

**Figure 5.** Asian beard hair, note the different contour of the beard hair from scalp hair, reprinted by permission of The

The face consists of 6 major aesthetic units comprised of: forehead, eye/eyebrow, nose, lips, chin, and cheek. These aesthetic units can be subdivided into additional anatomical subunits. For example, the nose can be divided into nasal tip, dorsum, columella, soft-tissue triangles, sidewalls, and nasal alar regions. Correct orientation of planned incisions next to these mobile functional and aesthetic facial structures is important to avoid distortion when closing

In this chapter we focus on the hair bearing units of the male face which are designated as the mustache and beard namely units 4c, d, 5a, b, 7 and some part of unit 9 in the neck (Figures

hair generally has less tensile strength and breaks more easily.

590 A Textbook of Advanced Oral and Maxillofacial Surgery Volume 2

**3. The units of the face**

Society of Cosmetic Chemists

wounds.

7 and 8).

**Figure 8.** The hair bearing units in the male face, used by permission of author Davide Brunelli M.D, www.med-ars.it

#### **3.1. The Mustache**

Loss of the mustache in the male patient causes cosmetic and psychological problems. The mustache also has the ability to cover the perioral scars and defects and is favored by the patients with scars around the mouth and upper lip such as cleft lip patients (Figure 9).

Full thickness defects of the units 5a and b or upper lip area in addition to esthetically unappealing elicit the functional problems such as drooling, speech disorders and poor oral hygiene, the partial thickness defects are more of an esthetic nature with asymmetrical structure.

The two potential sources of hair-bearing skin are the bearded face, neck and the scalp. The texture, hair bearing quality, and color match make local beard skin on the face a preferable donor site, but this is possible only for relatively small defects; otherwise, the resulting scar at the donor site is unacceptable. In these cases, local advancement or V-Y advancement flaps are

**Figure 10.** Flap prefabrication stages, vascular pedicle transferred under the skin paddle and the pedicle is wrapped by either Gore-Tex or silicone and a tissue expander is inserted for expansion, after proper expansion the flap is transfer‐ red as a free or island flap. The prelaminated flap can then be transferred to reconstruct the mustache or beard area. [23] Distant pedicled scalp flaps such as the extended midline forehead flap, transposition or island scalp flap, and bipedicle visor flap are other viable options.

used. Tissue expansion of this hair-bearing region to increase the surface area of the bearded face with Abbe and submental flaps have been described to bring hair-bearing tissue to the upper lip from the lower lip and bearded face and vice versa. [17] However, one must note the difference in hair distribution in the upper and lower lips when planning this flap.

The submental island flap reported by Martin et al is another source of hair bearing tissue with acceptable donor scar. [18]

The hair follicle match of the submental area is excellent and the follicle orientation is also correct, this flap can be transferred as a bipedicle type with limited arc of rotation and several other flap types reported by Tsur and Hyakusoku. [19]-[22]

The main drawback of submental flap is the need for several revision procedures, which have the potential risk of Alopecia due to too much thinning of the flap or damaging the vascular supply of the flap. [17, 22]

The flap prelamination is another option, in this technique a vascular pedicle is transposed under a random pattern flap and after maturation this composite tissue is transferred, it has some drawbacks such as the need for microvascular expertise and the potential risk of peripheral flap failure. (Figure 10)

#### **3.2. Beard and Sideburns**

**3.1. The Mustache**

structure.

Loss of the mustache in the male patient causes cosmetic and psychological problems. The mustache also has the ability to cover the perioral scars and defects and is favored by the patients with scars around the mouth and upper lip such as cleft lip patients (Figure 9).

**Figure 9.** The mustache unit, used by permission of the author Davide Brunelli M.D, www.med-ars.it

**Figure 8.** The hair bearing units in the male face, used by permission of author Davide Brunelli M.D, www.med-ars.it

592 A Textbook of Advanced Oral and Maxillofacial Surgery Volume 2

Full thickness defects of the units 5a and b or upper lip area in addition to esthetically unappealing elicit the functional problems such as drooling, speech disorders and poor oral hygiene, the partial thickness defects are more of an esthetic nature with asymmetrical

The two potential sources of hair-bearing skin are the bearded face, neck and the scalp. The texture, hair bearing quality, and color match make local beard skin on the face a preferable donor site, but this is possible only for relatively small defects; otherwise, the resulting scar at the donor site is unacceptable. In these cases, local advancement or V-Y advancement flaps are The male bearded region can be subdivided into a preauricular zone, which includes the sideburn and the buccomandibular zone (Figure 11).

The sideburn is an important anatomical structure determining the boundary between the head and the face and providing an aesthetic reference for balanced facial symmetry. The normal sideburn dimensions have been well described by Giraldo. [24] The sideburn shape is largely rectangular or trapezoidal. According to Juri, the most frequent causes for absence of the sideburn are trauma, burns, surgery, and infection. [25] Small defects within or involving the sideburn can be reconstructed with a single V-Y flap, opposing V-Y flaps, extended V-Y flaps, or double extended V-Y flaps. V-Y flaps are designed within hair-bearing regions and non–hair-bearing regions according to the characteristics of the tissue to be replaced. Addi‐ tional options for sideburn reconstruction include a scalp transposition flap. Larger defects

**Figure 11.** The side burn area, used by permission of author Davide Brunelli M.D, www.med-ars.it

including the sideburn and adjacent cheek or beard region can be reconstructed with a combination of any of these three primary options: the scalp transposition flap, the cervicofa‐ cial advancement flap, or the pedicled submental flap.
