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Title: Aesth et ic plast ic surger y of th e East Asian face / [edited by] are eith er rarely used or h ave been n ew ly released on the m arket .
Hong Ryul Jin . Ever y dosage sch edule or ever y form of app licat ion u sed is en t ire-
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Su bject s: | MESH: Recon st ru ct ive Surgical Procedu res | Cosm et ic p rod u ct descript ion p age.
Tech n iques | Surger y, Plast ic--m eth ods | Face--surger y | Asian Som e of th e produ ct n am es, p aten t s, an d registered design s
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v
Contents
Forew ord ................................................................................................................................................................................................. ix
Dean M. Torium i
Forew ord .................................................................................................................................................................................................. x
Stephen S. Park
Preface ..................................................................................................................................................................................................... xi
Ack n ow ledgm en t s ..............................................................................................................................................................................xii
Con t r ib u tor s ........................................................................................................................................................................................xiii
I Intro ductio n
1. Th e Ch an gin g Face of Aest h et ic Facial Plast ic Su r ger y am on g East Asian s ........................................................................... 3
Keng Lu Tan and Hong Ryul Jin
II Rhino plasty
2. Au gm en t at ion Rh in op last y Usin g Silicon e Im p lan t s .................................................................................................................13
In-Sang Kim
3. Th e Use of Cost al Car t ilage for Dor sal Au gm en t at ion an d Tip Graft in g ...............................................................................26
Victor Chung and Dean M. Torium i
4. Nasal Tip Mod if cat ion in Asian s: Au gm en t at ion an d Rot at ion Con t rol ..............................................................................47
Hong Ryul Jin and Jong Sook Yi
5. Hu m p Resect ion ................................................................................................................................................................................... 60
Tae-Bin W on and Hong Ryul Jin
6. Cor rect ion of t h e Deviated , Tw isted Nose .....................................................................................................................................72
Hun-Jong Dhong
7. Cor rect ion of t h e Sad d le Nose .........................................................................................................................................................87
Keng Lu Tan and Chae-Seo Rhee
8. Alar Base Mod if cat ion .......................................................................................................................................................................99
Ian Loh Chi Yuan and Hong Ryul Jin
9. Aest h et ic Rh in op last y for Sou t h east Asian s...............................................................................................................................108
Eduardo C. Yap
10. Cor rect ion of t h e Sh or t , Con t racted Nose...................................................................................................................................122
Hong Ryul Jin
11. Man agem en t of Allop last -Related Com p licat ion s ....................................................................................................................135
Eunsang Dhong
vii
viii Content s
IV Facial Bo ne Surge ry
19. Zygom a Red u ct ion ............................................................................................................................................................................243
Sanghoon Park and Jihyuck Lee
20. Man d ible Red u ct ion .........................................................................................................................................................................254
Sanghoon Park and Seungil Chung
21. Aest h et ic Or t h ogn at h ic Su r ger y ....................................................................................................................................................268
Seong Yik Han and Kar Su Tan
22. Gen iop last y .........................................................................................................................................................................................286
Seong Yik Han and Kar Su Tan
In d ex .....................................................................................................................................................................................................415
Forew ord
Th ere is n o p op u lat ion in th e w orld th at h as a h igh er alloplastic im plants into the nasal tip. The use of costal
grow th of in terest in aesth et ic su rger y th an th e East Asian cartilage for augm entation is discussed in detail, describing
pop u lat ion . It is repor ted th at on e in five w om en in th e techniques used to stabilize the nasal tip and augm ent the
Repu blic of Korea h ave u n dergon e aesth et ic facial surger y. nasal dorsum . Also covered are the nuances of perform ing
Th is dram at ic in crease is m u lt ifactorial an d is in p ar t dorsal augm entation w ith costal cartilage and how to
driven by local p opu lar cu lt u re an d m edia. Th is t ren d h as m inim ize the likelihood of warping. Popular techniques, such
been n otable over recen t years, w ith th e adven t of Korean as diced cartilage for dorsal augm entation and tip grafting,
pop u lar cu lt u re an d th e associated d esire to look like th e are covered as well.
fam ed K-pop st ars. Th e look is quite ch aracterist ic of Korean Th e m any tech n iques available for m an aging th e Asian
aesth et ics, w ith m any pat ien ts sh ow ing th eir su rgeon eyelid are covered, in cluding in cision al an d n on in cision al
ph otos of th e sam e Asian m edia p erson alit ies. Th is t ren d su t u re tech n iqu es, as w ell as conven t ion al in cision al
h as becom e so fash ion able th at it is n o longer a st igm a to tech n iques. Precision m easu rem en t an d m arking, an esth et ic
un dergo cosm et ic surger y in th e Rep u blic of Korea an d inject ion s, in cision placem en t , m an agem en t of th e fixat ion
Ch in a. In fact , it m igh t n ow be con sidered a stat u s sym bol m eth od, postoperat ive care, an d m an aging com plicat ion s
an d reflect u pw ard m obilit y in th e eyes of m any. Th is age are all discussed. Also covered is th e m an agem en t of th e
of th e “selfie” an d Facebook h as m ade “looking good” even ep ican th al fold.
m ore im port an t to th is grow ing populat ion . Th ese social In the sect ion on facial contouring, the chapters cover
ch anges h ave dram at ically in creased th e dem an d for Asian m anagem ent of the Asian m alar region, m andible, perialar
cosm et ic surger y, st im u lat ing a sign ifican t in crease in th e augm entation, chin augm entation, m asseter m uscle
n um ber of su rgeon s perform ing th e su rger y. contouring, forehead contouring, and com plications. Also
Th e aesth et ics of th e Asian face are con st an tly ch anging, covered are the nuances of facial contouring that provide the
an d surgical tech n iqu es m u st ch ange to accom m odate surgeon w ith m any options for creating a m ore aesthetically
such ch anges. Today, th ere is often th e desire for a roun der pleasing Asian face.
foreh ead, h igh er n asal dorsum , n arrow er n asal t ip, an d a Th e sect ion on n on surgical m an agem en t covers th e
less roun d, m ore angu lar m an dible an d ch in . Many of th ese u se of bot ulin u m toxin for facial m uscle con tou ring, brow
ch aracterist ics m ay in dicate a desire for a m ore “Western ” con tou ring, an d rhyt id m an agem en t . Th is sect ion also
look. How ever, th ere are differen t degrees of ch ange an d th is covers fat inject ion s an d con tou ring u sing au tologou s fat .
m ust be recogn ized by th e surgeon . Hong Ryul Jin un derstan ds Laser resu rfacing is discu ssed as w ell.
th e im por t an ce of th is varian ce from p at ien t to p at ien t . Th is Dr. Jin h as been a st rong academ ic figure in Korea for
requires th e su rgeon p erform ing en ough su rgeries to h ave m any years an d h as becom e w ell kn ow n arou n d th e w orld.
acquired a n um ber of tech n iques in th eir arm am en tarium . He h as frequ en tly lect u red in th e Un ited St ates an d all
In th is book, Dr. Jin h as com piled an out stan ding collect ion over Asia. He is n ow con sidered an in tern at ion al expert
of ch apters w rit ten by an exper t group of surgeon s. Th e on Asian rh in oplast y an d Asian facial cosm et ic surger y.
book covers th e m ost u pdated tech n iqu es on con touring th e His in tern at ion al in flu en ce is reflected in th e d iversit y
Asian face covering rh in oplast y, Asian eyelid su rger y, facial of th e auth ors con t ribu t ing to h is book, an d h e h as don e
con tou ring, an d aging-face surger y. Th e book also covers a m asterful job edit ing th is w ork. Readers w ill fin d th is
th e rapid ly ch anging field of n on su rgical t reat m en t s, su ch book com preh en sive in it s con ten t an d det ail of surgical
as bot u lin um toxin , fillers, an d lasers. descript ion s an d u se of qu alit y op erat ive ph otography an d
In the section on rhinoplast y, the authors discuss illu st rat ion s. Th is book is an essen t ial referen ce for th e
the use of im plants and autologous m aterials for Asian su rgeon in terested in p roviding th e best ou tcom es in Asian
augm entation rhinoplast y. The difference in these techniques aesth et ic facial su rger y.
is very significant and is reflected in these w ritings. Use of
im plants continues to be the m ost com m only used m ethod Dean M. Torium i, MD
to augm ent the nose. Nuances in the techniques are discussed Professor
in great detail and are covered by several authors. Com bined Division of Facial Plast ic and Reconst ruct ive Surgery
techniques using alloplastic m aterials for dorsal augm entation Departm ent of Otolaryngology–Head and Neck Surgery
and ear cartilage for the nasal tip have becom e popular Universit y of Illinois
to avoid som e of the potential com plications of extending Chicago, Illinois
ix
Forew ord
Hon g Ryu l Jin h as le d t h e w ay in creat in g a u n iqu e book on a good from a great result , an d th is book capt ures th em
aest h et ic facial su rge r y for t h e East Asian p at ie n t . Th e re w ell. Th e rem ain ing sect ion s touch on oth er procedu res
are m any u n iqu e var ian ces w it h p at ie n t s from t h is region perform ed in facial aesth et ic su rger y, in clu ding facial
of t h e w orld , an d t h ey h ave p u t toget h e r a colle ct ion of bon e con tou ring, m in im ally invasive an d office based
ch ap t e r s t h at cove r all asp e ct s of facial aest h et ic su rge r y procedu res, an d h air rejuven at ion .
as it p e r t ain s to t h e Asian face. Th e book h igh ligh t s t h e Herein is a collect ion of m any au th ors w ith vast
m any n u an ces in facial aest h et ic su rge r y in t h is grou p , exp erien ce in facial aesth et ic su rger y in th e Asian
an d any su rge on w h o h as t h e occasion al Asian p at ie n t pop u lat ion . It is com p reh en sive, eloqu en tly w rit ten , an d
w ill b e w ell se r ve d to h ave t h is e d it ion in h is or h e r w ill ser ve as an invaluable resource for years to com e. Dr.
refe re n ce librar y. Jin is to be congrat ulated for a terrific book.
A solid p or t ion of th is book is dedicated to th e
tech n iqu es of Asian rh in oplast y. It is n ot lim ited to st rictly Stephen S. Park , MD
alloplast ic dorsal im plan ts, bu t covers m any subtlet ies th at Professor and Vice-Chairm an
are often required w ith Asian pat ien t s. Th e th ird sect ion Depart m ent of Otolaryngology
is ded icated to th e p eriorbit al rejuven at ion of th e Asian Director, Division of Facial Plast ic Surgery
pat ien t , in clu ding ptosis an d th e dou ble eyelid procedu re. Universit y of Virginia
Th ere are in t ricacies to th is p rocedu re th at dist ingu ish Charlottesville, Virginia
x
Preface
Aesth et ic facial plast ic surger y h as com e un der th e spotligh t en ligh ten m en t , bu t rath er reflect experien ce an d learn ing
in East Asian coun t ries in th e p ast t w o decades. Korea cam e accum ulated over decades of su rgeries. Th e con ten t in th is
un der th e spotligh t in th is field recen tly an d in t rigued m any book is h igh ly scien t ific an d eviden ce based, w h ich m ean s
from all corn ers of th e w orld to com e, learn , an d u p date it h as proven to be safe an d efficien t . Th is book n ot on ly
th eir tech n iqu es. It is m y h ope th at th is kn ow ledge can be focu ses on in t roducing tech n iqu es th at are n ew, but teach es
sh ared far an d w ide w ith th e English speaking crow d, w h o th e basic con cept s of h ow -to-do-it in a st ru ct u red m an n er
h as been fin ding it difficu lt to access in form at ion th at h as to en sure th at readers are able to clearly con cept u alize th e
been p assed on in variou s Asian langu ages. tech n iqu es an d th eories beh in d ever y m an euver.
Th e ch apters in th is book describe m ost of w h at you I sincerely hope and expect that this book w ill guide the
n eed to kn ow abou t aesth et ic plast ic surger y on th e face. new surgeons venturing into aesthetic plastic surgery of the
Th e ch apters w ere w rit ten by m y ren ow n ed colleagu es in Asian face, as well as provide valuable inform ation to the others.
th eir resp ect ive sp ecialt ies, det ailing special tech n iqu es an d
poten t ial pitfalls. Th ese det ails do n ot com e from overn igh t Hong Ryul Jin
xi
Acknow ledgments
It w as n ot an easy journ ey for th e publicat ion of th is book, for their patience in allow ing and enduring my continuous
an d I w ould like to express m y m ost h ear tfelt grat it ude to requests. I also w ish to thank my fellows, Woo-Seong Na, Hahn
all m y colleagu es w h o h ave con t ribu ted to it . Jin Jung, and Som asundran Mutusamy, for helping m e to edit
I thank Thiem e Publishers and its people for allow ing m e to the m anuscript. Our excellent illustrator, Mrs. Hyun-Hang Lee,
publish this. Due to their great work, this book changed from w ho devoted her tim e and talents to this book, did a wonderful
an ugly duckling into a swan. Doctors w ho contributed their job in expressing the details in every draw ing per the requests
valuable expertise to this book need special acknow ledgm ent of each contributor. I give my sincere thanks to her.
xii
Contributors
Eunsang Dho ng, MD, PhD Kyo ung-Jin (Safi) Kang, MD, PhD
Professor Director
Depar t m en t of Plast ic an d Recon st ru ct ive Su rger y Educat ion al Cen ter of KCCS
Gu ro Hospit al, Korea Un iversit y Medical Cen ter Seoul Cosm et ic Surger y Clin ic
Seou l, Repu blic of Korea Bu san , Rep ublic of Korea
xiii
xiv Contributors
Te e Sin Le e, MBBS (S’po re), MRCS (Edin), MMed (ORL), Yo ngho Shin, MD, PhD
FAMS (ORL) Director of Bio Plast ic Surger y Clin ic
Dep ut y Director an d Con su ltan t Clin ical At ten ding Professor
Facial Plast ic an d Recon st ru ct ive Su rger y Ser vice Depar t m en t of Plast ic Su rger y
Dep ar t m en t of Otorh in olar yngology–Head an d Korea Un iversit y
Neck Su rger y Seoul, Rep ublic of Korea
Ch angi Gen eral Hosp ital
Clin ical Lect u rer Kar Su Tan, MBBS (S’po re ), MRCS (Edin), MMed (ORL),
Yong Loo Lin Sch ool of Medicin e FAMS (ORL)
Nat ion al Un iversit y of Singap ore Medical Director
Singapore Th e Rh in oplast y Clin ic ENT Facial Plast ics
Singapore
Hyo ung Jin Mo o n, MD
Presiden t Keng Lu Tan, MD, MRCS, MS (ORLHNS)
Dr. Moon Aesth et ic Su rger y Clin ic Ear, Nose, an d Th roat , Head an d Neck Surgeon
Seou l, Repu blic of Korea Facial Plast ic an d Recon st ru ct ive Surgeon
Depar t m en t of Otorh in olar yngology
Un iversit y of Malaya
Ku ala Lum p ur, Malaysia
Contributors xv
Pearls
• Asian s, part icularly th ose in East Asia, h ave seen • Com m on aesth et ic surgeries of East Asian s also
rapid developm ent in th e eld of aesth et ic facial in clude double-eyelid surger y, ep ican th oplast y,
plast ic surger y, especially in th e re n em en t of rh in oplast y, facial bon e con touring surger y, fat
Asian -speci c tech n iques, over th e past t w o decades. inject ion , an d m any oth er tech n iques discu ssed in
• Th e t ypical Asian belief in n ot altering th e physical th is book.
ap pearan ce of on e’s face, at t ribu ted to resp ect for • New er tech n iqu es, in clu ding th e com bin at ion
th e elderly an d on e’s an cestors, h as evolved w ith of n on su rgical tech n iques in facial rejuven at ion
globalizat ion , resu lt ing in a m ore n eu t ralized Asian su ch as llers an d bot u lin u m toxin , an d laser h air
cult ure, w h ich is a cross bet w een East an d West . rem oval and h air t ran sp lan t at ion sp eci c to East
More Asian s realize th at to be at th e leading edge of Asian ch aracterist ics, are discu ssed in det ail. Th e
societ y, an at t ract ive ap pearan ce p lays an im p ort an t pros an d con s of n on surgical tech n iques su ch as
role in d eterm in ing success. Th ere h as been a sh ift laser an d ult rasoun d for facial rejuven at ion are also
in social accept an ce of aesth et ic su rger y, an d w e see th orough ly described to keep readers updated w ith
m ore dem an d for it th an ever before. th e latest tech n ologies an d th e opt ion s available to
• East Asian feat ures of th e face are discussed in detail ach ieve desired ou tcom es.
in th e follow ing ch apters, w ith par t icular at ten t ion • Most im p or tan t , th is book n ot on ly con t ain s su rgical
to single-eyelid, sm all palp ebral ap ert u re, at n asal tech n iqu es an d pearls from surgeon s w h o are
bridge and t ip, m alar prom in en ce, broad m an dible, exp er ts in th eir resp ect ive elds of aesth et ic facial
ret ruded prem axilla, an d m any oth er Asian -speci c plast ic surger y, but also in corporates com m en t s on
aesth et ic su rgeries. pitfalls an d com plicat ion s, an d h ow to overcom e
th em , in detail.
3
4 I Introduction
Fig. 1.1 At tractive composite faces of di erent races. At tractive famous female entertainers’ faces were morphed by sequentially mixing
photographs at the mean values to generate the composite faces. (Used with permission from Rhee et al. At tractive composite faces of
di erent races. Aesthetic Plast Surg 2010;34:800–801.)
Facial bone
contouring
Fig. 1.2 Typical surgeries and nonsurgical procedures to improve facial aesthetic appearance in East Asians. These various techniques will
be addressed throughout this textbook, with speci c modi cations for Asians.
1 The Changing Face of Aesthetic Facial Plastic Surgery am ong East Asians 5
for Asian s are becom ing m ore an d m ore p opu lar, especially t ures, such as double eyelids an d t all, w ell-de n ed n oses.
am ong th e m ore a u en t Asian s living in th e Western cou n - Fair skin is seen as th e m arker of class. On e an cien t saying
t ries. Au th ors of th is book believe th ere is n o bet ter t im e in Jap an ese, Korean , an d Ch in ese societ ies goes, “A w h ite
th an now to h ave ou r kn ow ledge an d experien ce gath ered com plexion overrides th ree appearan ce aw s,”6 em ph asiz-
an d sh ared to st im u late m ore develop m en t in th is eld. ing th e long-st an ding im port an ce of ligh t-colored skin in
Many years h ave p assed sin ce th e in t rodu ct ion of m u lt iple cou n t ries across Asia. Th is w as rein forced d u ring
speci c tech n iqu es for Asian aesth et ic su rger y. Mu ch h as th e Western colon izat ion period, w h en th e European s w ere
evolved over th e years, an d th e cu rren t focu s seem s to be presen t in Asia an d enjoyed h igh social st at u s. In “Th e His-
on re n ing th e tech n iques to address th e st igm a faced by tor y of W h ite People,” Neil Pain ter even argued th at Cau-
Asian pat ien t s. Alth ough w e st ill n d a h an dfu l of pat ien t s casian s produce “th e m ost beau t ifu l race of m en” an d th at
com ing to th e surgeon w an t ing to look like a part icular pub - Ch in ese eyes are an “o en ce to beau t y.”7 Th e ideal beau t y
lic gu re, m any are steering aw ay from th at t ren d. Pat ien t s of Cau casian s w as on ce th e w ell-accepted de n it ion of
th ese days often request a n at ural-looking face an d w ish beaut y in Asia.
to en h an ce th eir curren t appearan ce w h ile ret ain ing th eir Recen tly, Asian coun t ries h ave becom e st ronger an d
facial ch aracterist ics, an d th ey especially w an t to preven t m ore in u en t ial econ om ically. Sch olars h ave started to
th eir plast ic su rgeries from being n ot iced by oth ers. W h ile debate about “Eurocen t ric” beaut y an d th e ph en om en on
em bracing th eir exist ing facial ch aracterist ics, p at ien t s p re- in Asia w h ere it h as becom e th e n orm to alter on e’s facial
fer n ot to look th e sam e as oth ers w h o desire th e ideal com - ap pearan ce u sing p last ic su rger y to be m ore Western ized.
p osit ion of a beau t ifu l face, albeit all sim ilar looking. Th is With grow ing con den ce w ith in Asian societ y, h ow ever,
h as resu lted in su rgeon s reinven t ing th em selves an d m ov- Asian s h ave started to em brace th eir ethn ic feat ures. Th e
ing in to th e n ext level of aesth et ic facial su rger y, com bin ing fu sion of cert ain desirable Western feat u res w ith Asian
less invasive p rocedures w ith su rger y w h en ever possible. feat u res is n ow seen as th e id eal form of beau t y in Asia.
Th e art of com bin ing n on surgical an d surgical tech n iqu es Th e key con cept n ow is to blen d at t ract ive feat ures rath er
to create a beaut iful face w ill n o longer be based on a gu t th an h aving a cert ain de n ed tem plate, a con cept th at h as
feeling bu t w ill be object ively described in th is book. been h eavily crit icized an d is rapidly falling out of favor.
Th e good-looking feat u res are, of cou rse, th ose th at suit a
person’s facial st ru ct u re, person alit y, an d th e person as a
■ The Change in Cultural w h ole. En h an cem en t rath er th an alteration of th e facial
feat u res h as becom e th e n ew t ren d .
Beliefs and the Modernization Stat ist ics sh ow th at up to 58% of w om en in Korea h ave
of Asian Thinking plast ic surger y by th e age of 50.1,8 Th e percen tage is grow -
ing in th eir m ale coun terpar t s too. Th e desire to obtain
Th e Asian desire for a pleasan t face is h eavily in u en ced by aesth et ic p last ic su rger y is often driven by th e psych oso-
facial physiogn om y in th e past . Th e com bin at ion s of pleas- cial aspirat ion of th e pat ien t . Rapid developm en t in th is
an t-looking feat u res described in th e an cien t books w ere eld is largely driven by th e n eed to app ear m ore at t rac-
illu st rated w ith pict ures of faces th at dict ated th e fut ure of t ive in order to be bet ter accepted in a societ y th at places
a p erson , dow n to th e p osit ion of m oles on th e face an d a lot of em p h asis on beau t y an d pleasan t app earan ce.
body.5 Th ere w as a realizat ion of th e n eed for an aesth et i- Looking m ore beau t ifu l becom es an invest m en t to ach ieve
cally pleasing face, bu t few oth er th an Sh usrat a ven t ured h igh er socioecon om ic st at u s an d to en su re on e w ill n d a
in to th e aesth et ic su rgical eld. In dividuals w ith pleasan t- w ealthy rom an t ic p ar t n er. Th u s a n ew cu lt u re or t ren d h as
looking faces w ere m ore likely to be ju dged to h ave a good em erged, u n stop p able by past cu lt u ral beliefs an d t aboos,
life an d a good job, an d th ose w ith u np leasan t-looking an d st rongly d riven by n ovel con cept of beau t y, w ealth , an d
feat u res w ere often associated w ith socially less resp ect- a good life. As th is con cept h as grow n , th e su bject s seeking
able jobs or even crim in alit y. Th e lat ter t yp es of faces w ere cosm et ic en h an cem en t h ave becom e younger an d younger.
d eem ed in au sp iciou s an d st ill ver y m uch in uen ce h ow As Korean dram as an d m ovies h ave becom e m ore popular
a p erson is ju dged in m odern societ y. Desp ite th is, th ere th rough ou t Asia, so h as th e in u en ce of th e Korean de n i-
w as lit tle develop m en t in th is eld. Few w an ted to ch ange t ion of beaut y spread all across Asia. Th is ph en om en on of
th eir looks surgically, par tly due to the un re n ed state of “Han Ryu ” (th e Korean t ren d) w as p op u lar am ong view ers
su rgical skills at th at t im e an d th e st rong in u en ce of Con - of all ages. With at t ract ive actors an d act resses port rayed
fu cian ism all over Asia, w h ich em ph asized th e san ct it y of as h eroes an d h eroin es, m any fan t asized becom ing like on e
th e physical body as a sacred gift from our paren t s. Altering of th em , w h ich could be ach ieved by altering th eir looks.
on e’s physical appearan ce w as con sidered disrespectful to Th is t ren d becam e a st rong driving force in th e devel-
on e’s an cestors.1 opm en t of aesth et ic surger y in Asia, en abling surgeon s to
As globalizat ion an d Western izat ion exerted m ore grow an d ach ieve a n ew level of u n d erst an ding of aesth et ic
in uen ce in Asian societ y via Western m edia, th e de n i- su rgeries. How ever, it is u p to th e con scien ce of in dividu al
t ion of beaut y becam e associated w ith w h ite Caucasian fea- pract it ion ers to guard th e san ct it y of th is eld, preven t ing
6 I Introduction
th e dou ble-edged sw ord of h arm to our pat ien t s an d to th e 5. Th e n arrow an d relat ively sm all palpebral aper t ure
p ract ice of aesth et ic surger y, by prescribing on ly appro- result s in sm all eyes. Th is h as resulted in m any
p riate an d scien t i cally soun d procedu res to pat ien t s an d tech n iqu es inven ted an d m odi ed over th e past
p roviding th e best su rgical pract ices tested by t im e an d decade to in crease th e palpebral apert ure by lateral
exp erien ce. can th oplast y. Proper con siderat ion of th e an atom y
involved in lateral an d m edial epican th oplast y
sh ou ld be given before th e su rger y is don e to preven t
■ Anatomic Di erences and later com plicat ion s su ch as low er eyelid ect ropion .
6. A at n asal bridge and a poorly de n ed cart ilagin ous
Their Implications st ru ct u re of th e n ose resu lts in poor p roject ion of th e
n ose.
Most East Asians share the phenot ypic features represented
by the Mongoloid pro le. It is currently the m ost w idely dis- 7. Th ere is a sm aller n asal pyram id w ith sh orter
tributed physical t ype, constituting over a third of the hum an n asal bon e length in Asian s com p ared w ith oth er
species. Therefore, it is not surprising to nd that m any living eth n icit ies. A st u dy don e by Naser an d Boroujen i
throughout Asia share the sam e facial features. Mongoloid con clu ded th at th e n asal bon e length st udied in
features are t ypically represented by epicanthal folds and th e skulls of Korean s w as sm aller th an in Am erican
neoteny. While som e of the features, such as the single eyelid In dian s, An atolian s, Iran ian s, an d African Am erican s.9
and m axillary retrusion, are not com m on am ong Western- Th e soft an d sm all n asal sept um en coun tered
ers, they are w idely encountered in Asians, w ith double- som et im es p oses di cu lt y to th e su rgeon n eed ing
eyelid surgery being the m ost popular plastic surgery sought a cart ilage graft from th e n asal sept u m . Du e to th is,
(Fig. 1.3). High cheekbones, a broad m andibular angle, and th e use of h om ologous an d autologous rib cart ilage
a low nasal pro le are features in Asians that are not highly graft s h as becom e popular w h en syn th et ic im plan t s
favored, and are often associated w ith aggression or m anli- are n ot su it able or n ot preferred by p at ien t s. Pat ien t s
ness. Generally, a well-projected nose is preferred. sh ou ld be adequ ately cou n seled , as th e likelih ood of
A low n asal bridge is n ot lim ited to Mongoloids. Th e n eeding a rib graft is h igh er in Asian pat ien t s.
Malay people fou n d in m ost of Sou th east Asia across 8. Th e n asal skin is th ick w ith abun dan t sebaceous
th e Ph ilippin es, Malaysia, Th ailan d, an d In don esia often glan ds. Th is m akes m an euvering th e n asal t ip
requ est ch anges to address a low n asal bridge an d w ide su bst an t ially m ore tech n ically dem an ding.
aring ala (Fig. 1.4). 9. Asian s possess di eren t skin proper t ies com pared
Becau se th e an atom y of th e eyelids, n ose, an d facial w ith oth er racial groups. Asian s are kn ow n to h ave
bon es in Asian s di ers sign i can tly from th at of Caucasian s, a th in n er st rat u m corn eu m , th e sm allest in term s of
a u n iqu e m an agem en t st rategy is requ ired to su ccessfu lly p ore size an d pore n u m bers, an d th e h igh est w ater
im p rove th e aesth et ic ou tcom e. Th e m an agem en t st rategy an d lip id con ten t in th e st rat u m corn eu m com p ared
sh ou ld be aim ed at h an dling an atom ic issu es speci c to th e w ith oth er peoples. Th eir skin is also kn ow n
Asian face such as th e follow ing: to h ave th e w eakest ch em ical barrier. All th ese
ch aracterist ics sign ify th at topical drug pen et rat ion
1. Th e pret arsal skin of the upper eyelid is n ot at tach ed
is th e best in Asian skin an d th at th e form at ion
to th e levator palpebrae m uscle, leading to a poorly
of w rin kles is less in Asian s. Such an atom ical
d e n ed superior p alp ebral fold. Th e con st ruct ion of a
d i eren ces in th e epiderm al layer of th e Asian skin
d ou ble eyelid th at su it s th e m orph ology of an Asian
m ake m an agem en t of scars an d skin lesion s di eren t
face is di eren t from p ract ice involving Cau casian s.
in th e Asian popu lat ion .
2. Excessive fat is dist ributed bet w een th e orbicularis
10. Asian s h ave a h igh m alar prom in en ce due to a
oculi m uscle an d th e levator m uscle w ith relat ively
p rom in en t zygom at ic body or arch .
th ick palpebral skin an d orbicularis oculi m uscles.
11. Th e broad m an dibular angle is associated w ith
3. Orbits are sm aller w ith a m ore prot ruding orbital
m asseter hyp ert rop hy.
m argin com p ared w ith Western ers. Th erefore,
recreat ing th e feat u res of Caucasian eyelids h as 12. Asians’ hair is th ick and coarse, is round in shape, and
p roven u n su it able. Aesth et ic eye surger y sh ou ld be grow s faster. Asian s also h ave a h igh er prevalen ce of
re n ed an d subtle rath er th an dram at ic, or it can curly hair, but th ick and st raight hair is predom inan t
give rise to a th ick, deep u pp er eyelid, w h ich is n ot am ong East Asian s. Th ese an atom ic di eren ces in
su itable for sm aller orbit s. Asian h air com pared w ith Caucasian hair require
h air t ran splan t equipm en t an d procedu res th at are
4. Th e n asal sclera t riangle is rou n ded due to th e
di erent from those that are convent ionally used.
p rom in en t m edial epican thal fold. A variet y of
tech n iqu es (an d th eir pros an d con s) to elim in ate To successfully address th e above issu es, on e sh ould
th e obt un ded angle w ill be described in detail in th e un derst an d th e u n ique an atom ic presen t at ion of th e Asian
ch apter on epican th oplast y. face to p rop erly m odify an d m ake re n ed adju st m en t s to
th e gen eric tech n iques presen ted in earlier textbooks.
1 The Changing Face of Aesthetic Facial Plastic Surgery am ong East Asians 7
a b c
d e f
Fig. 1.3 Typical East Asian wom an who had rhinoplast y with blepharoplast y. (a–c) Typical East Asian face, illustrating the wide mandibu-
lar angle, high cheekbones, poorly de ned upper eyelid crease, broad and low nasal dorsum, and poorly de ned nasal tip. (d–f) The same
individual after rhinoplast y and blepharoplast y. Her appearance greatly enhanced, the individual seems more approachable and attractive,
with softening of the unfavorable wide angle of the mandible.
8 I Introduction
a b c
Fig. 1.4 (a–c) The face of a t ypical Southeast Asian woman, with natural double eyelid crease, wide nasal alar, broad nasal bridge and
bulbous nose with a voluminous lip. These are some of the features associated with the Southeast Asian t ype of face.
t h e op e n ap p roach . Tip rot at ion ach ieved w it h a sept al w ou ld p rove too drast ic an d dest ru ct ive. It also plays an
exten sion graft an d t h e u se of m u lt ip le laye rs of au tolo - im port an t role as an adjun ct to m any cosm et ic procedu res.
gou s m ater ial su ch as m u scle fascia an d car t ilage cou - Fat graft ing tech n iques h ave progressed from th e use of
p le d w it h som e su t u re tech n iqu es are t h e m ost p op u lar cru de fat lobules to m icrofat grafts, giving rise to im proved
opt ion s em p loye d n ow . Bot h p at ien t s an d su rge on s h ave longevit y in th e recipien t site. Th e use of fat graft s is also
sh ied aw ay from syn t h et ic m ater ial for t ip w ork d u e to ver y p op u lar to im p rove th e con tou r of facial top ograp hy,
t h e h igh ext r u sion rate an d t h e su bsequ e n t d isast rou s proving to be ver y versat ile in creat ing w h atever topogra-
sequ elae of an in fect ion . Au tologou s m ate r ial is t im e phy is desired. With th eir expert ise in th is eld, th e auth ors
tested an d sh ow n to h ave t h e least com p licat ion s an d of th is book are able to sh are m any of th eir valuable experi-
b est resu lt s so far. Th e ove raggressive t ip w ork associated en ces in re n ing an d perfect ing th e u se of th is tech n iqu e to
w it h ove ram bit iou s m an eu vers is h igh ly advised again st , im prove surgical outcom es.
as too m u ch of a good t h in g in any circu m st an ces w ill on ly Hair restorat ion h as also becom e a p opu lar procedu re
resu lt in t h e op p osite of t h e d esired e ect . Over p rojec- don e for aesth et ic purposes in Asia in recen t years. It is
t ion an d rot at ion of t h e t ip is associated w it h a d efor m ed not on ly popu lar for m ales experien cing an drogen ic h air
t ip in t h e lon g r u n as a cer t ain d egree of resor pt ion of loss but also for fem ales w h o w ish to resh ape th e face
t h e car t ilage graft u sed an d scar r in g of soft t issu e w ill an d to soften th e ou tlin e of th e face by altering th e h air-
cau se in st abilit y of t h e t ip con st r u cted . Th erefore, from lin e. More fem ales are seeking h air t ran splan t procedures
ou r exp er ien ce, ju d iciou s adju st m en t of t h e d orsu m w it h to exten d th e h airlin e at th e tem p oral region , th u s redu c-
a m atch in g t ip sh ou ld be t h e lim it to su ch augm en t at ion ing th e m uscularit y of th e face, or to ch ange th e face to a
p roced u res, alt h ough it m ay be ver y invit in g in t raop era- m ore favorable “oval” sh ape. Hair t ran splan t at ion is qu ite
t ively to ach ieve a m a xim u m e ect . di eren t in Asian s. Th is is due to th eir th icker an d coarser
Un d e rst an d in g t h e sp eci c an atom ic d i eren ces hair st ruct ure, a broad er base for th e follicles, an d a h igh er
in Asian s h as e n abled u s to com bin e t h e u se of var iou s in ciden ce of keloid-form ing scars com pared w ith Cau -
adju n ct ive su rger ies an d p roced u res w it h rh in op last y to casian s. Th erefore, follicular un it ext ract ion an d use of a
p rod u ce a m ore favorable ou tcom e t h an is p ossible w it h m icropu n ch d esign ed to m in im ize scarring an d m axim ize
ju st rh in op last y alon e. Som e of t h ese p roce d u res in clu d e hair follicle ext ract ion h ave becom e m ore popular th an th e
p aran asal im p lan t , ch in im p lan t , n asal alar resect ion , an d conven t ion al single-st rip h ar vest ing tech n ique. Due to th e
colu m ella-len gt h en in g ap s to ad d ress issu es like m a xil- th icker an d coarser h air foun d in Asian s, during follicular
lar y ret r u sion , ret rogn at h ia, w id e n asal ala, an d sh or t col- un it ext ract ion th e direct ion an d depth of th e scorings
u m ella, resp ect ively, w h ich are com m on p roble m s fou n d m u st be precise an d th e base h as to be broad en ough so
in Asian s. Asian su rge on s h ave also p er fe cted t h eir skills th at th e germ in al un it of th e h air w ill n ot be dam aged. As
in m alar red u ct ion , w h ich is a m ore com m on p roced u re curly hair is m ore com m on in Asian s th an in Caucasian s,
in t h e East com p ared w it h t h e West . Previou s exp er ien ce th e direct ion of th e im plan tat ion h as to be con sidered so as
h as resu lted in som e cases of facial saggin g, facial asym - not to h ave un n at u ral h air grow ing in di eren t d irect ion s.
m et r y, an d d ow nw ard m ovem e n t of t h e m alar p oin t . Th e Th ese an d m any oth er pearls related to h air restorat ion in
red u ct ion of t h e an gle of t h e m an d ible is also a com m on th e Asian populat ion w ill be presen ted in th e correspond-
aest h et ic su rger y in Asia as op p osed to t h e West , as a ing ch apters.
softe r look an d a “V-sh ap e d ” face are st ron gly favored We w ill also d eal w it h facial h air re m oval u sin g laser
in Asia. Asian su rgeon s h ave su bst an t ially m ore exp e- for aest h et ic p u r p oses. Th e w id t h of t h e foreh ead for m s
r ie n ce w h en it com es to t h is kin d of skelet al re d u ct ion t h e sh ap e of t h e face in t h e su p e r ior t h ird . Th e foreh ead
w ork. Ot h er skelet al alterat ion su rger ies t h at are p op u - is also t h e locat ion of t h e “ch akra” w h ere t h e t h ird eye
lar in Asia in clu d e or t h ogn at h ic su rger y su ch as bim a x- or sixt h sen se resid es as p e r San skr it scr ipt u res. A n ar-
illar y advan ce m en t /red u ct ion or m an d ibu lar red u ct ion / row foreh ead p u t s too m u ch em p h asis on t h e m id d le an d
ad van cem en t , w h ich can be solely for cosm et ic p u r p oses. low er p ar t s of t h e face an d is often associated w it h lack
Th ese su rge r ies w ere or igin ally in ten d ed to cor rect con - of rad ian ce. A balan ced foreh ead can be created w it h p er-
gen it al d efor m it ies relate d to fu n ct ion al p roblem s su ch m an e n t rem oval of t h e ap p rop r iate am ou n t of h air w it h
as m alocclu sion . As t h e ap p earan ce of a p rot r u d in g m an - least p roblem of d ysp igm en t at ion in Asian s, w h o ge n er-
d ible or ret r u d in g m a xilla is u n at t ract ive, p at ien t s t h ese ally h ave d arker skin ton e. Nd :YAG lase r h as p roven to be
d ays are w illin g to u n d e rgo su rger ies even w it h ou t fu n c- a good ch oice for h air re d u ct ion in Asian s, com p ared w it h
t ion al p roblem s, an d even w h e n t h e r isk of associated conven t ion al d iod e laser, an d w as fou n d to be su p er ior in
com p licat ion s ou t w eigh s t h e ben e t . h air re d u ct ion .12 Many st u d ies are st ill bein g con d u cte d
The grow ing popularit y of fat graft ing h as im proved on laser h air rem oval regard in g t h e p arad oxical e ect of
p at ien t sat isfact ion t rem en dously. Fat graft ing produces a n e h air grow t h p ost rem oval. An excit in g jou r n ey lies
long-last ing e ect in facial rejuven at ion . Th is is esp ecially ah ead , w it h m ore d et ails revealed in t h e ch ap ter on lase r
t rue in th e you nger pat ien t s in w h om a su rgical face lift h air re m oval.
10 I Introduction
Pearls
• For East Asian noses, m ajor augm entation is • Proper select ion of a t ip tech n ique is im port an t .
frequen tly required for th e n asal dorsu m an d th e t ip. Accord ing to th e t ip tech n iqu e, th e design of an
• Th e silicon e im plan t is w idely used in Asian im plan t varies. Th e im plan t sh ould be con n ected to
coun t ries becau se it is easy to use, lim itless in th e augm en ted t ip sm ooth ly an d seam lessly.
volu m e, cost-e ect ive, an d su p erior to th e au to- or • Do n ot t r y to augm en t th e t ip w ith th e im plan t .
h om ograft from th e aesth et ic view poin t . Un like th e relat ively im m obile dorsum , th e t ip
• Th ere are t w o sources of problem s related to th e is h igh ly m obile. Th erefore, on ly au tologou s
allop last ic im p lan t . On e is th e problem s in h eren t cart ilage m ust be used for th e t ip, w ith appropriate
in th e m aterial itself, w h ich can be m in im ized. Th e tech n iqu es to preven t ext rusion an d skin problem s.
oth er is p roblem s from tech n ical or ju dgm en t al An im plan t p laced on th e t ip is aesth et ically
errors, w h ich are m ore com m on an d m u st be u npleasing because it alw ays leads to a rot ated t ip
avoided. w ith an u n n at urally th ick in frat ip lobule.
• In fect ion is a seriou s p roblem th ough u n com m on . • With th e u se of on ly au tologou s cart ilage for th e
Th orough san it izat ion of th e operat ion eld, t ip, skin problem s are preven ted and m ore n at ural
in clu ding th e n asal vest ibule an d an terior n asal outcom es are en sured.
cavit y, is im por tan t . Care sh ould be t aken n ot to tear • Stacking of m ult iple layers of on lay graft s is
th e m ucosal barrier using at raum at ic tech n iques. com m on ly required for su cien t t ip project ion
Operat ion t im e sh ou ld be redu ced to decrease in Asian s. Th e w ing graft sh ou ld be used in
th e ch an ce of in fect ion . Th e im plan t m ust be com bin at ion w ith th e st acked on lay graft to preven t
im m ersed in an t isept ic solu t ion before an d after any n ot iceabilit y of th e on lay graft an d pin ch ing
m an ip u lat ion . deform it y.
• Design ing an im p lan t m u st be in d ivid u alized . Th e • Com plicat ion rates of alloplast ic im plan t s are
su rgeon sh ou ld h ave in m in d th e desired sh ape of m edically accept able. Com p licat ion s are m ore
th e n ose. In dividu al an atom ic ch aracterist ics m ust frequ en tly th e resu lt of th e su rgeon’s tech n ical an d
be con sidered such as th e n asofron t al angle, dorsal judgm en t al errors, rath er th an th e fault of in h eren t
con tour, an d t ip project ion . ch aracterist ics of th e m aterial it self.
m aterials, w ith n o t issu e ingrow th or vascu larizat ion Profession al recom m en dat ion s sh ould be given to th e
seen after im p lan t at ion . Becau se of it s n onp orou s n at u re, pat ien t after a th orough an alysis of th e face. Th e relat ion -
it is n on ad h esive to su rroun ding t issue an d en closed in a sh ip of th e n asal dorsu m , t ip , p h ilt ru m , lips, an d m en t u m
brou s cap su le. Also, it is free from deform at ion , easy to w ith th e ver t ical facial axis sh ou ld be invest igated. In an a-
sterilize, an d easy to rem ove w h en n ecessar y. It is relat ively lyzing the face, any facial asym m et r y m ust be n oted an d
ch eap an d available in a range of soft n ess values. revealed to th e pat ien t before th e surger y, because th e
Expan ded polytet ra uoroethylen e (ePTFE) is com - augm en tat ion rh in op last y m ay w orsen or accen t u ate a
p osed of n od ules of Te on in tercon n ected by brils of pre-exist ing facial asym m et r y. W h en th e vert ical facial
p olytet ra u oroethylen e an d h as a m icrop orous arch itec- axis is skew ed or de ected, th e augm en ted n ose can n ot
t ure, w ith pore sizes ranging from 10 to 30 m m . It s poros- be absolutely ver t ical an d st raigh t . In pat ien t s w ith sign i -
it y m akes it easily m alleable an d su scept ible to long-term can t facial asym m et r y, it is bet ter to augm en t th e n ose in a
com pression , result ing in volum e decrease or deform at ion di eren t ver t ical axis from th e an atom ic dorsum . In th ese
of th e im plan t . Its hydroph obic an d porou s n at ure m akes pat ien t s, n asal bon es on th e t w o sides are frequen tly asym -
th e sterilizat ion process using an an t isept ic or an t ibiot ic m etric in term s of th e w id th an d th e slope. W h en th e bony
solu t ion di cu lt . Relat ively h igh cost is an oth er disadvan - asym m et r y is sign i can t , th e bot tom of th e im p lan t is bet-
t age. For th e revision cases, som et im es it is ver y di cult ter car ved asym m et rically accordingly.
to rem ove th e previou s ePTFE im plan t , especially w h en th e Facial asym m et r y com m on ly accom pan ies asym m et-
im plan t is th in , an d th e durat ion of im p lan t at ion is long. ric n asal alae. Pre-exist ing alar asym m et r y m akes th e n ose
W h en th e surroun ding soft t issue is rem oved togeth er look deviated even after augm en tat ion to th e correct axis.
w ith th e im plan t , th e result ing soft t issue irregularit y is Asym m et ric alar resect ion in th ese pat ien t s m ay n ot cor-
ext rem ely d i cu lt to repair. rect th e problem sat isfactorily. Alar asym m et r y relat ing to
Porous polyethylen e (Medpor) con sists of a con t in uous facial asym m et r y is d i cu lt to correct becau se of it s m u lt i-
system of in tercon n ect ing p ores of size 125 to 250 m m . Th e dim en sion al n at ure.
vascu lar an d brou s ingrow th leads to in tegrat ion an d st a- A system ic exam in at ion of th e n ose is p erform ed from
bilizat ion of th e im plan t . Th e ten sile st rength of th e m ate- top to bot tom (Fig. 2.1). Th e relat ion sh ip of th e foreh ead
rial is ver y h igh , con t rar y to th e case for ePTFE. Becau se of w ith th e n asal root is im port an t for a su ccessful dorsal aug-
it s st i n at u re, it sh ou ld be used w ith ut m ost caut ion in m en t at ion . Th e Asian foreh ead is relat ively at an d less p ro-
m obile areas su ch as th e m em bran ou s sept u m or t ip. t ruding. Gen erally, Cau casian s are m ore dolich oceph alic
Syn th et ic im plan ts in rh in oplast y h ave been a topic of
great con t roversy. In part icular, silicon e, w h ich is th e single
m ost com m on ly u sed im p lan t m aterial in Asian cou n t ries,
is a poin t of w orldw ide con ten t ion .1 Asian n oses are con sid-
ered m ore recept ive to allop last ic im p lan ts becau se of th eir
th ick skin .2 Th is is t rue to som e exten t , but even th icker
skin can n ot resist long-term th in n ing, ext ru sion , in am -
m at ion , an d in fect ion . Th erefore, p roper tech n iqu es u sing
an adequ ately design ed im plan t m u st be execu ted .
W h en an experien ced surgeon uses proper tech n iques,
th e com plicat ion rate for alloplast ic im plan t s is su rpris-
ingly low and in a m edically accept able range. Recen t st ud-
ies about th e com plicat ion rates of alloplast ic im plan t s for
augm en tat ion rh in op last y sh ow th at th ey are m u ch low er
th an th ose in st udies from th e 1960s an d 1970s.3 Th ese
ch anges are due to im provem en t s in im plan t design, con -
ser vat ive su rgical tech n iqu es, su rgeon s h aving m ore exp e-
rien ce, an d th e u se of softer silicon e.
■ Patient Evaluation
Th e sh ape an d pro le of th e n ose requ ested by th e pat ient ,
an d th eir feasibilit y or desirabilit y are discu ssed in th is
sect ion . Advan t ages an d disadvan t ages of u sing allop last ic Fig. 2.1 Key areas that should be considered for successful aug-
im p lan t s an d p ossible altern at ives to alloplast ic m aterials mentation rhinoplast y: forehead slope, nasofrontal transition, pro-
are also discu ssed . jections of the nasal tip, prem axilla, and chin.
2 Augm ent ation Rhinoplast y Using Silicone Im plant s 15
an d augm en t at ion rh in op last y m ay accen t u ate th e devi- is required. Any blood or secret ion in th e oral an d ph ar yn -
ated look of th e n ose. geal cavit y is su cked ou t rep eatedly u sing a su ct ion cath eter
Th erefore, th e surgeon m ust set a ver t ical lin e for th e th rough th e oral air w ay during th e operat ion . To redu ce th e
augm en tat ion . Th e lin e th at looks th e st raigh test is care- secret ion , in t raven ou s inject ion of glycopyrrolate before
fu lly ch osen for th e lin e of augm en tat ion (Fig. 2.3). W h en th e surger y is recom m en ded. Oxygen supplem en t at ion
th e dorsu m an d t ip are ver t ically m isalign ed, u sually a ver- th rough th e oral air w ay also can be h elpful.
t ical lin e exten ded upw ard from th e t ip is m ore appropriate
for th e lin e of augm en tat ion , rath er th an th e lin e along th e
d orsu m , alth ough th is is n ot alw ays th e case. Preparation of the Implant
Th e n asal start ing poin t is set an d a h orizon t al lin e is
m arked, u su ally at th e h eigh t of th e ciliar y m argin s. In gen - Before local an esth et ic inject ion , an im plan t is prep ared
eral, w h en th e p at ien t w an t s a h igh er dorsu m , th e lin e m ay an d t ried on th e d orsu m (Fig. 2.4). Th e su rgeon m u st ch eck
be draw n at th e h eigh t of th e su prat arsal crease. W h en th e w h eth er it is suit able for th e desired h eigh t an d desired
p at ien t w an t s a m ore n at ural look, th en th e lin e is draw n n asal pro le, w h eth er it is w ell t ted for th e n asofron t al
bet w een th e ciliar y m argin an d th e pupil. How ever, it is angle, an d th e d orsal con gu rat ion . Th en in it ial car ving is
in dividualized according to th e pat ien t’s facial ch aracter- perform ed using a n o. 15 surgical blade before th e surger y.
ist ics. Th is h orizon t al lin e also provides a lan dm ark for th e A correctly design ed im plan t is crucial for a su ccessful
ceph alic exten t of th e subperiosteal dissect ion . outcom e. Any single im plan t m ust be custom ized accord-
ing to in dividu al an atom y. Th e th ickn ess of th e im plan t is
decided rst . Im plan t s w ith 4 to 5 m m of th ickn ess are m ost
Anesthesia and Positioning frequ en tly ch osen am ong th e 2 to 10 m m th ickn ess range.
How ever th e th ickn ess is n ot u n iform an d varies along th e
Th e pat ien t is put un der an esth esia in a supin e posit ion dorsu m after car ving according to th e in dividual’s an a-
an d drap ing is don e. Augm en tat ion rh in oplast y u sing allo- tom ic ch aracterist ics. In gen eral, w h en th e n ose is low in
plast ic im plan ts is don e un der gen eral an esth esia or in t ra- radix an d th e t ip is w ell projected, the im plan t is car ved
ven ou s an esth esia w ith sedat ion . W h en it is don e u n der proxim ally th ick an d dist ally th in . On th e con t rar y, w h en
in t raven ou s an esth esia, close m on itoring of th e respirat ion th e n ose is adequ ately h igh in radix an d th e t ip is low, th e
is cru cial. Main t ain ing th e oral air w ay du ring th e surger y im plan t is car ved proxim ally th in an d dist ally th ick. W h en
a h u m p is p resen t , th e im plan t is often car ved th in n er in
th e rh in ion area (Fig. 2.5).
Th e im plan t’s sh ape, especially th e distal por t ion , is
also variable according to th e preferred t ip augm en t at ion
tech n iqu e.
Th e in it ially car ved im plan t is im m ersed in an t isept ic
solu t ion su ch as hyp och lorou s acid u n t il it s later u se. Th e
Fig. 2.3 Skin marking is done in a sit ting position using a straight Fig. 2.4 The implant is tried on the dorsum for the initial carving.
wooden stick. A vertical line is drawn. The nasal starting point,
rhinion, and nasal tip are marked.
2 Augm ent ation Rhinoplast y Using Silicone Im plant s 17
Fig. 2.5 The initial carving is done using a no. 15 surgical blade. Creation of the Periosteal Pocket
The three most common shapes of implant s are shown (top, proxi-
mally thin and distally thick; middle, proximally thick and distally As dissect ion proceeds on th e n asal bon e, th e plan e is
thin; bottom, anatomically carved). Implants are further custom -
ch anged again to th e subperiosteal plan e (Fig. 2.7). It is
ized during the surgery.
ver y im p or t an t to accu rately raise th e periosteal ap from
th e n asal bon e. W h en th e im plan t is n ot correctly placed in
th e subperiosteal space, th e im plan t ten ds to be m ore m ov-
able an d m ore visible. To elevate th e periosteu m p recisely,
hypoch lorous acid is suit able for th is purpose because it is it is bet ter to u se a sh arp an d n arrow t ip elevator, su ch as
clear in n at ure an d relat ively less toxic, n on irritat ing, an d th e Joseph elevator, at rst . W h en th e subperiosteal space is
p oten t . correctly raised par t ially, th en a w ider elevator is in serted
an d th e sp ace is w id en ed . If a w ide an d blu n t in st ru m en t is
used from th e st art , th e periosteum is easily torn .
Harvest of Ear Cartilage Close to th e n asofron t al su t u re lin e, bleeding is likely
to en su e becau se of p roxim it y of vessels to th e su t u re lin e.
After local an esth et ic inject ion s at th e n ose an d th e ear,
con ch al car t ilage is h ar vested rst w h en it is expected to
be n ecessar y. Con ch al car t ilage is h ar vested com m on ly
th rough a postauricular in cision . An d it is h ar vested from
th e cavum con ch a an d cym ba con ch a separately, leaving
th e cru s of h elix as a bridge. Th is valuable an atom ic land-
m ark of th e au ricle is best preser ved for aesth et ic p u rposes
an d st ru ct u ral su p p or t , an d to m ain t ain th e abu n dan t n eu -
rovascular su pp ly of th is area. Th e h ar vested con ch al cart i-
lages are p reser ved in th e an t ibiot ic solut ion .
Fig. 2.11 The same length of the silicone implant as the stacked
onlay cartilage tip graft is cut out from the caudal end.
Fig. 2.12 The wing graft s are applied on both sides of the onlay
graft.
e ect of th e graft w ill abate w ith th e collap se of colu m ella
an d m em bran ou s sept u m , requ iring m ore am ou n t s of car-
t ilage, an d th e colum ellar-lobular rat io w ill deteriorate.
cases of alar rim ret ract ion , because it is secu rely xed to
th e on lay graft to provide st rong suppor t again st ret ract ion ,
Insertion of the Uni ed Graft and com pared w ith the alar rim graft .
Implant Hybrid In a w idely u sed tech n iqu e for alloplast ic augm en t at ion
in Asia, th e t ip of th e im plan t (st raigh t or L-sh aped) is placed
The uni ed graft an d im plant hybrid is inserted into th e on top of th e alar car t ilages, an d th en a piece of autologous
dorsal pocket , and the pro le is closely exam ined again. cart ilage is laid on top of (on lay-like) or in fron t of (sh ield-
The surgeon has to exam ine the nose carefully, tem porar- like) th e dist al im plan t in an at tem pt to decrease th e risk of
ily closing the incision by pulling dow n the colum ellar ap, skin p roblem s su ch as ext ru sion . Th ese tech n iqu es p rovide
because the pro le can be changed due to the tension on the t ip project ion an d rot at ion w ith relat ive ease, an d produce
skin . Repeated car ving m ay be required at th is stage also. fair ou tcom es in selected cases, esp ecially in th ose w ith
W h en th e desired sh ape of th e n ose is n ally obt ain ed, u n der-p rojected an d un der-rot ated n asal t ips. How ever,
th e on lay graft is xed to th e alar cart ilages w ith sut ures. th ese tech n iqu es h ave apparen t disadvan t ages. Th e resul-
Th e n al n e m odi cat ion of th e t ip an d t ip lobules is tan t t ip ten ds to be over-rotated an d u n n at ural, because
don e by car ving an d addit ion al graft ing. A sh ield graft in th e project ion an d rotat ion in crease w ith out proport ion al
fron t of th e graft or addit ion al on lay grafts can be added elongat ion of th e t ip. Th e in frat ip lobule becom es un n at u-
as n ecessar y. rally th ick w ith a decreased colum ellar-lobular rat io. Fin e
t ip m odi cat ion is also di cult using th ese tech n iques, an d
th e t ip often looks sh arp an d poin ted. In addit ion , th e piece
Placement of the Wing Grafts of cart ilage on th e dist al im plan t is likely to becom e con -
spicu ou s w ith t im e.
After obt ain ing a n al t ip sh ap e, so-called w ing graft s are In con t rast , for th e previou sly described tech n iqu e
ap plied bilaterally on th e lateral sides of th e on lay graft u sing th e st acked on lay graft , it is easy to elongate th e t ip .
(Fig. 2.12). Th e w ing graft is sh ap ed to assim ilate th e lat- Fin e t ip sh aping is possible w ith addit ion al car ving an d
eral cru ra of th e alar cart ilages, to corresp on d w ith th e graft ing. Com bin ing th e w ing graft s, it is m ore n at u rally
dom e n ew ly created by th e stacked on lay graft . Auricu lar sm ooth in sh ape, an d th ere are n o visibilit y or con sp icu it y
cart ilage is best suited to th is purpose because of it s n at u- problem s of on lay graft s over t im e.
ral cu r vat ure. Th e pu rpose of th e w ing graft is to preven t
th e collapse or pin ch ing deform it y on th e lateral sides of
th e on lay graft . With out th e w ing grafts, th e t ip is cen t rally Variant Techniques
prom in en t on ly n ear th e on lay graft , an d laterally t ip lob -
u les are collapsed an d pin ch ed. Th e w ing graft p rovides a Th e aforem en t ion ed procedures can be don e using th e
sm ooth t ran sit ion from th e t ip to th e lobu les, soften s th e en don asal app roach . How ever, gen erally th is m akes it m ore
m argin s of th e on lay graft , an d act s as a st ru ct u ral su pp or t di cult to m an ipulate th e graft s an d to con t rol th e ten sion
again st soft t issu e collapse. Th e w ing graft is also h elp ful in on th e t ip skin . For m ore visualizat ion an d m ore release
2 Augm ent ation Rhinoplast y Using Silicone Im plant s 21
of ten sion , a m argin al in cision is exten ded m edially over Closure and Splinting
th e foot plate to th e n asal sill, an d laterally to th e piriform
ligam en ts. For th e n al procedure, m et iculous sut ure closure is don e.
W h en th e h eight di eren ce bet w een th e t ip an d th e Th en irrigat ion w ith an t ibiot ic an d an t isept ic solut ion s is
an terior septal angle is sign i can t an d th e in clin at ion of perform ed using a syringe after th e closure.
lateral cru ra is con siderable, a varian t tech n ique can be Taping is don e to decrease th e edem a an d to decrease
u sed (Fig. 2.13). Th e su bst an t ial t ip -to-sept u m h eigh t d if- th e m obilit y of th e im plan t an d grafts. Th en a th erm o-
feren ce an d lateral cru ral in clin at ion are com m on ly created plast ic splin t is applied on th e dorsum . Th e splin t ing is
by th e st rong t ip project ion w ith th e sept al exten sion graft; im port an t to im m obilize th e im plan t an d to preven t edem a
h ow ever, a con siderable t ip -to-sept u m h eigh t d i eren ce is an d h em atom a on th e rad ix area in th e im m ed iate p ost-
presen t even prior to surger y in som e pat ien ts. In th is sit u - operat ive period. Th e splin t sh ould be applied along th e
at ion , th e dist al im plan t is car ved in a w edge sh ape w ith pre-m arked ver t ical lin e of th e augm en t at ion . Th e splin t is
ap prop riate th ickn ess to t in th e cep h alic divergen ce of m ain t ain ed for at least 7 days.
alar car t ilages. Th e im p lan t m ay be su t u red to th e cep h alic
m argin s of th e alar cart ilages.
For som e pat ien t s, on ly th e low n asal bridge, n ot th e
t ip, is th e problem an d th eir con cern . Th en on ly a correctly ■ Key Technical Points
car ved im plan t according to th e in dividual dorsal an atom y
w ill su ce. Th e im plan t is in serted th rough th e m argin al 1. Design ing an im p lan t is th e rst an d m ost crit ical
or in tercar t ilagin ous in cision . In adequ ately n arrow, sm all, step. Based on th e d esired sh ape an d in dividu al
or asym m et ric dorsal pockets w ill predispose to ext rusion . an atom y, th e im p lan t sh ou ld be car ved correctly.
For th e sym m et r y of th e dorsal pocket , bilateral in cision 2. Th e subperiosteal pocket is created. Th e pocket
an d dissect ion are recom m en ded. Th e dist al en d of th e sh ou ld be sym m et ric an d ap prop riately w ide for
im plan t is t apered to be p aper th in to sm ooth ly cont in u e th e im plant to be sn ugly placed in side an d n ot be
to th e ceph alic port ion of th e alar cart ilages. An im plan t excessively m obile.
of excessive length , in a sm all or asym m et ric pocket , m ay 3. For th e sept al exten sion graft , excessive ten sion on
ext ru de, esp ecially w h en th e dist al im p lan t is in direct con - th e graft is un desirable, especially w h en th e sept al
tact w ith th e in cision site. In th is regard, m argin al in cision cart ilage is frail. It provides a st able platform for
is m ore app ropriate for th e alloplast ic im p lan tat ion . With th e on lay t ip graft , w h ich is u sed for furth er t ip
th e m argin al in cision , addit ion al t ip graft ing or oth er t ip project ion an d de n it ion , com m on ly required in
m an ipu lat ion s are also p ossible. Asian pat ien t s.
a b
Fig. 2.13 (a,b) When the gap is signi cant bet ween the tip and the anterior septal angle, the implant m ay be carved in a wedge shape
and suture xed to the cephalic margins of the alar cartilages.
22 II Rhinoplast y
Infection
Alloplast ic im plan t s are su scept ible to in fect ion an d , w h en
in fected, exh ibit t ypical sym ptom s such as er yth em a, sw ell-
Fig. 2.14 The outer and lateral surfaces of the silicone implant are
ing, an d puru len t secret ion . How ever, tem p orar y er yth em a
covered with a dermal graft.
an d sw elling in th e form of su bclin ical in fect ion can occu r
rep eatedly. Subclin ical in fect ion is th ough t to occur w h en
th e n u m ber of bacteria is sm all, or if bacteria are presen t in
th e form of bio lm on th e su rface of silicon e.
Th orough sterilizat ion of th e surgical eld is n ecessar y
Problems Caused by Technical or for redu cing in fect ion , especially in th e n asal vest ibule an d
Judgmental Errors of the Surgeon th e en t ran ce part of th e n asal cavit y. Du ring surger y, it is
im port an t to preven t disru pt ion of n at ural barriers su ch as
Extrusion and Thinning of Tip Skin th e m ucou s m em bran e. A lengthy surgical t im e m ay reduce
blood ow to th e t issue an d increase th e risk of in fect ion .
Ext r u sion rates of silicon e im p lan t s rep or ted ly var y from Im p lan ts m u st be im m ersed in sterilizing solu t ion du ring
0.48% to 50%, p robably d u e to t h e d i e ren ces in su rgi- procedures.8
cal tech n iqu e, im p lan t sh ap e, an d t h e su rgeon ’s level of
exp er ien ce.3 W h en excessive ten sion is ap p lied to t h e
n asal t ip ’s skin w it h t h e in ten t ion of givin g a ten t -p ole
e ect u sin g t h e im p lan t , esp ecially t h e L-sh ap ed silicon e
■ Case Studies
im p lan t w it h a lon g colu m ellar segm en t , t h e r isks of skin
d am age an d im p lan t ext r u sion in crease. An im p lan t of Case 1
excessive le n gt h m ay t h in t h e n asal t ip skin over t im e,
an d m ay even t u ally ext r u d e. Th e im p lan t can also A 22-year-old fem ale visited th e clin ic for a rh in oplast y
ext r u d e in to t h e n asal cavit y t h rough t h e m u cou s m em - (Fig. 2.15). Sh e sh ow ed t ypical Asian facial feat u res su ch as
bran e. Ch ron ic in am m at ion an d in fect ion are also com - a at foreh ead, sh allow n asofron t al angle, at n asal bridge
m on cau ses of ext r u sion . Ext r u sion is a com p licat ion t h at w ith w eak t ip project ion , an d m axillar y ret rusion .
can be avoid e d by u sin g an ap p rop r iately size d im p lan t , Con sidering th e sh allow n asofron tal angle an d u n der-
t ip graft in g w it h au tologou s car t ilages, an d in fect ion an d projected t ip, a silicon e im plan t w as car ved to be proxi-
in am m at ion p rotect ion . m ally th in an d dist ally th ick. Bilateral m edial an d lateral
osteotom ies w ere perform ed. For su cien t project ion ,
a th ree-layer st acked on lay graft w ith w ing graft s u sing
Implant Displacement and Movement con ch al cart ilage, an d a sept al exten sion graft w ere used
in com bin at ion for th e t ip. For m ore de n it ion of th e t ip,
Im p lan t deviat ion is a frequ en t side e ect . To preven t defat t ing of th e soft t issue on th e t ip w as don e.
displacem en t , th e im plan t sh ou ld be placed in th e sub - On e-year p ostop erat ive p ict u res sh ow adequ ate t ip
periosteal pocket . Silicon e im plan t s h ave a h igh er risk of project ion , a m ore de n ed n asal t ip, an d an augm en ted,
m ovem en t com pared w ith m aterials w ith pores, su ch as narrow ed n asal bridge. Th e st igm a of rh in oplast y, in cluding
Gore-Tex. Th erefore, it is im port an t to im m obilize th e sili- th e un n at urally at n asofron tal t ran sit ion , visible im plan t
con e im plan t for th e period of t im e using a splin t after sur- con tour in th e radix, an d sh arp poin ted t ip, are barely
ger y. Som e su rgeon s m ake w edge excision s or h oles on th e not iceable.
24 II Rhinoplast y
a b
c d
a b
c d
Pearls
• Rhinoplast y in an East Asian patient requires • Age is th e m ost im port an t factor to con sider w h en
at tention to a di erent set of aesthetic goals than car ving cost al car t ilage.
for a Caucasian patient. Digital im age m orphing • On e of th e m ost im portan t con cepts in su ccessful
soft w are is very im portant to be able to com m un icate costal cart ilage grafting is to car ve th e m aterial
proposed changes to the patient population. sequ en tially w ith repeated cycles of car ving, soaking,
• Th e East Asian n ose is de cien t in st ruct u ral an d dr ying th e graft to iden tify its n at ural ben d.
su p p or t . Augm en tat ion is n ecessar y to ach ieve th e • Alth ough cross-h atch ing an d sp lin t ing are u sefu l,
desired re n em en t . A st ruct ural approach to East it is im por tan t to u n derst an d th at th ese tech n iqu es
Asian rh in oplast y allow s th e surgeon to accom plish can n ot overcom e th e select ion of an in appropriate
th e est ablish ed goals. piece of costal cart ilage.
• Alth ough allop last ic im plan t s h ave been w id ely u sed • In th e set t ing of East Asian dorsal augm en tat ion ,
in East Asian rh in op last y, autologou s costal cart ilage osteotom ies are u sually un n ecessar y.
is being used m ore frequen tly in th e East Asian n ose • Serial car ving, perich on driu m cam ou age, an d rigid
as a desirable altern at ive. xat ion are key st rategies in p erform ing dorsal
• A th orough h istor y, in clu ding previou s su rger y, augm en tat ion .
in fect ion , im plan ts, or injectable llers, is n ecessar y • Tip augm en tat ion , accom p lish ed w ith sh ield or
to elu cidate factors th at w ill in crease th e com plexit y h orizon tal on lay grafts, creates project ion an d
of th e surger y. re n em en t; h ow ever, a st able fou n dat ion is required
• For safe an d successfu l costal cart ilage h ar vest , th e to con t rol length an d rot at ion .
su rgeon m u st be fam iliar w ith th e an atom y of th e • In th e East Asian n ose, w ith it s w ide air w ay an d
rib cage to select th e rib w ith th e best con tou r for th icker lateral sidew alls, alar bat ten an d alar rim
th e n ecessar y graft s. graft s are in frequ en tly in dicated.
• Th e barrier to m astering cost al car t ilage graft ing is • After st ru ct u red rh in op last y w ith au tologou s cost al
learn ing to ju dge w h ere to u se each poten t ial graft cart ilage augm en t at ion , tech n ically di cult base
an d h ow to p rop erly p rep are th e grafts. redu ct ion s m ay be required to balan ce th e n ose.
26
3 The Use of Cost al Cartilage for Dorsal Augm ent ation and Tip Grafting 27
a b c
Fig. 3.1 Native East Asian characteristics: thick skin, wide and low dorsum, retracted colum ella, underprojected and amorphous tip.
(a) Frontal view; (b) lateral with midpupillary horizontal line; (c) base view.
■ Surgical Techniques
Th e sen ior auth or (DMT) perform s augm ent at ion rh in o-
Fig. 3.2 L-shaped silicone implant rem oved in revision surgery.
plast y th rough a st an dard extern al rh in oplast y approach
u n der gen eral an esth esia w ith en dot rach eal in t u bat ion in
an ou t p at ien t su rgicen ter. Th e su rgeon injects th e ch est
an d n ose w ith 1% lid ocain e w ith 1:100,000 ep in ep h rin e
prior to prepping an d draping to allow for opt im al vaso- Th e n asal sept um is exposed by lateral ret ract ion of th e
con st rict ion . W h ile inject ing th e sept um , th e surgeon can low er lateral car t ilages an d sh arp dissect ion to th e an terior
in it iate th e elevat ion of m ucoperich on drial aps via hydro- septal angle. Bilateral m u cop erich on drial ap s are raised
stat ic d issect ion . At th e sam e t im e, n eed le palp at ion can in the appropriate subperich on drial plan e to decrease th e
di eren t iate cart ilagin ous versus bony n asal sept um , for risk of septal perforat ion . Again , as m ost Asian pat ien t s do
an est im at ion of available m aterial for graft ing. Th e n ose n ot requ ire a h u m p redu ct ion , a su bm u cou s resect ion m ay
is p acked w ith cot ton pledget s soaked in 0.05%oxym et azo- be perform ed at th is t im e, w h ile preser ving 15-m m caudal
lin e, for fu rth er vasocon st rict ion . an d dorsal st ru t s. Th e septal cart ilage h ar vest w ill p rovide
a sm all volu m e of graft ing stock th at is n ot p ar t icu larly
st rong bu t is at low risk for w arp ing.
Opening the Nose After decon st ru ct ing th e n asal fram ew ork, th e su rgeon
su r veys th e n ose an d review s th e graft s an t icip ated to be
By op en ing th e n ose rst , th e su rgeon can m ake a clear n ecessar y to resu pp or t th e n ose, augm en t th e dorsu m , an d
assessm en t of th e am ou n t of car t ilage graft ing m aterial re ne th e n asal t ip before ch anging gloves an d t u rn ing to
requ ired to com plete th e case. A m idcolum ellar inver ted-V th e chest .
in cision is d em arcated w ith an t icipat ion of th e t ip projec-
t ion outcom es. If th ere is a plan n ed in crease of project ion ,
th e in cision is draw n sligh tly (1 m m ) posterior to th e m id- Costal Cartilage Harvest
colum ella. Th e colum ellar in cision is m ade w ith a n o. 11
blade scalpel. Margin al in cision s an d colum ellar in cision Prior to th e costal cart ilage h ar vest , th e surgeon m ust con -
exten sion s are m ade bilaterally w ith a n o. 15 blade scal- sider several pat ien t factors, in clu ding age, breast an atom y,
pel. Using Converse scissors, th e in cision s are con n ected an d excessive scarring. Despite variabilit y in n asal an atom y,
sh arp ly. Part icu lar at ten t ion is d irected to preser ving th e cost al car t ilage an atom y is relat ively con sisten t across dif-
soft t issu e t riangles as w ell as m ain t ain ing an adequ ate cu feren t eth n ic backgrou n ds. Th e m ost im port an t factor is
of t issue separat ing th e m argin al in cision from th e alar rim , th e age of th e pat ien t .6,7,8 You nger pat ien t s are at h igh er
~ 3 m m . Carelessn ess h ere can resu lt in n otch ing of th e alar risk for graft w arp ing. Older p at ien t s are at h igh er risk for
m argin . Using th ree-p oin t ret ract ion , th e skin envelop e is fract u ring du ring h ar vest or graft m an ipu lat ion . Pat ien t s
raised sh arply. Preser ving th e subderm al plexus by m in i- bet w een th e ages of 30 and 50 are gen erally at low er risk
m izing blu n t sp reading im p roves h em ostasis an d m in i- of w arping, an d fract uring can usu ally be preven ted w ith
m izes p ostop erat ive edem a. Sh arp d issect ion con t in u es careful h an dling of th e graft s. In th e East Asian pat ien t
from th e low er lateral cart ilages su p eriorly to th e car t ilagi- popu lat ion , th e average volum e of breast t issu e obligates
n ou s dorsu m an d bony-cart ilagin ous ju n ct ion . A key poin t th e su rgeon to m in im ize the in cision length for th e sake of
is to u se th e Josep h periosteal elevator in a lim ited fash ion , a sm aller scar th at can n ot be h idden in an in fram am m ar y
preser ving a t igh t pocket in an t icipat ion of a dorsal graft . A crease (Fig. 3.3).
t igh t pocket w ill rest rict graft m ovem en t an d aid in rapid With th e in creased p revalen ce of breast augm en tat ion ,
xat ion to p reven t w arping.5 Ad dit ion ally, as m ost Asian in cision s h idden in th e in fram am m ar y crease m ay risk
pat ien t s do n ot require a h um p redu ct ion , w ide subperios- pun ct ure or t raum a to the breast im plan t . Fur th erm ore,
teal dissect ion is n ot w arran ted. ribs directly u n der an im p lan t (t ypically rib 6) p rovide
3 The Use of Cost al Cartilage for Dorsal Augm ent ation and Tip Grafting 29
a b
Fig. 3.3 Scar comparison. (a) Harvested costal cartilage and chest incision intraop-
eratively. (b) Right scar marked with t wo dots is the costal cartilage harvest site after
5 years. Left scar is a breast augmentation scar (arrow).
im p ort an t st ru ct ural su pp ort to th e breast im plan t . Har vest 3.75-cm (1.5-in ), 27-gauge n eedle localizes th e osseocar-
of a support ing rib m ay resu lt in u n desired asym m et ries of t ilagin ou s jun ct ion an d determ in es the degree of ossi ca-
th e breast posit ion or discom for t from th e w eigh t of th e t ion . Be forew arn ed: Blin d n eedle pokes m ay pu n ct ure th e
im p lan t lying on th e m an ipu lated rib. Hyper t roph ic scar- pleura an d lung paren chym a, result ing in a closed ten sion
ring an d keloid form at ion sh ou ld be elu cidated from th e pn eum oth orax.
p at ien t’s h istor y for appropriate coun seling preoperat ively. On ce th e id eal rib h as been selected an d ch aracterized,
Abn orm al ch est w all an atom y an d elevated body m ass th e overlying skin is m arked an d th e surroun ding area is
in dex m ay also in crease th e com plexit y of th e h ar vest . injected w ith 1% lidocain e w ith 1:100,000 epin eph rin e.
W h en select ing a rib to h ar vest , on e m ust be fam iliar Cost al cart ilage from th e righ t side is preferred to avoid
w ith th e relat ion sh ips of th e in dividual ribs to on e an oth er. inju r y to th e pericardium an d con fusion of postoperat ive
Th e fth rib h as a free superior an d in ferior m argin ; h ow -
ever, it can lie u n d ern eath breast t issu e or p ectoralis m u s-
cle. It is also relat ively sh or t an d cur ved an d m ay n ot be of
adequ ate size for dorsal augm en tat ion . Th e sixth rib t yp i-
cally h as a free su perior m argin , but th e in ferior m argin is
con n ected to th e seven th rib m edially. Th e sixth rib is usu-
ally at an ideal depth , bu t it h as a sligh t gen u th at m ay n ot
be ideal if a long st raigh t segm en t is n eeded (Fig. 3.4).
Th e seventh rib is st raighter and w ill usually h ave con -
n ection s w ith th e surrounding ribs on both the superior and
1
in ferior borders. The eighth an d greater n on oating ribs 2
w ill h ave signi cant connect ions to surroun ding ribs an d 3
are th in n er an d m ay n ot be of adequate w idth for a dorsal 4
graft. Th e seven th an d eigh t ribs are located sligh tly deeper 5
Incision 6
u n dern eath the skin com pared w ith th e sixth rib. As the ribs
are follow ed m edially, th ey course deeper un der th e subcu- Infram am m ary fold
taneous t issue. Ult im ately, the rib w ith the best contour for
the necessar y grafts should be selected, but generally the
cartilage com ponent of the seventh rib has the best contour.
After th ese con siderat ion s, th e surgeon sh ould m an u-
ally p alpate th e ch est w all arou n d th e poten t ial ribs for
h ar vest . On ce orien ted, carefu l n eedle p alp at ion w ith a Fig. 3.4 Harvest incision placement.
30 II Rhinoplast y
discom fort w ith angin a. Th e don or site is a separate sterile Having op en ed th e n ose, th e su rgeon sh ou ld h ave in
eld, an d cross-con t am in at ion w ith n asal ora sh ou ld be m in d th e graft s th at w ill be u sed to st ru ct u re th e n ose. Th e
avoided by ch anging gloves an d using a separate set of sur- h ar vested costal cart ilage sh ou ld be taken in dim en sion s
gical in st ru m en t s. ap prop riate for th e plan n ed graft s. Usu ally 3 to 4 cm of cos-
Du e to th e sen ior au th or’s experien ce, h e is able to tal car t ilage is h ar vested. To en su re an in t act h ar vest site
start w ith a 10-m m in cision th at m ay st retch to a n al an d avoid violat ion of th e pleu ra, th e rst in cision sh ou ld
length of 12 or 13 m m . Th e ch est in cision is m ade sm all start by u sing th e sh arp en d of th e Freer elevator to cu t 0.5
to m inim ize th e visible scar an d m orbidit y to th e pat ien t . m m from th e su perior an d in ferior m argin s of th e rib. After
For pat ien t safet y, surgeon s sh ould con t inu e to use a larger 50% pen et rat ion th rough th e depth of th e car t ilage, th e
in cision u n t il th ey are fam iliar w ith th e dissect ion .5 After a in cision is com pleted w ith th e blun t en d of th e Freer eleva-
skin in cision is m ade, sh arp dissect ion con t in u es th rough tor. Th e goal is to m ain tain a p rotect ive cu of car t ilage th at
th e subcu tan eous fat to th e fascia overlying th e m uscle. For gu ides th e dissect ion in to a safe p lan e above th e p osterior/
h em ostasis, bip olar cau ter y is u sed to m in im ize postop - deep perich on drium an d pleura. Medial an d lateral boun d-
erat ive p ain . A n o. 15c scalpel is u sed in th e sm all w in d ow aries of th e car t ilage are rst sh arply in cised w ith a n o. 15c
to sh arply in cise th e m uscle fascia. Th e m u scle is blun tly blade th rough 10% of th e th ickn ess, follow ed by a sh arp
spread to decrease bleeding an d postop erat ive p ain . Th e Freer elevator th rough 70%; th e blun t Freer elevator com -
keyh ole p ersp ect ive is m ain tain ed w ith ret ractors to view pletes th e n al 30%. On ce m obilized on in ferior, superior,
th e perichon drium overlying th e rib. Th is w in dow can be lateral, an d m edial borders, th e un dersu rface of th e rib is
t ran slated m edially an d laterally along th e course of th e freed w ith a Freer elevator u sing a lift ing m ot ion (Fig. 3.5).
rib. Recall th at th e rib’s cou rse is n ot a st raigh t lin e, bu t Follow ing th e h ar vest , th e m edial an d lateral edges of th e
an obliqu e an d th ree-d im en sion al arc th at ch anges depth rem ain ing cart ilage are sm ooth ed w ith Takah ash i forceps.
as it cu r ves from lateral to m ed ial. Th rough th e process of Th e w oun d bed sh ould be in spected for violat ion s of
exp osing th e rib, th e bou n daries of th e rib sh ou ld be con - th e perich on drium or pleura, w ith poten t ial inju r y to th e
rm ed by carefu l n eed le p alp at ion . lung paren chym a an d a result ing pn eu m oth orax. Th e
On ce exp osed , th e an terior p erich on d riu m is in cised w oun d bed is lled w ith salin e. A Valsalva m an euver con -
w ith a n o. 15c scalpel along th e lateral lim it , superior bor- rm s an in t act h ar vest site, if th e salin e volu m e is con st an t
d er, an d in ferior border of th e rib. Th e perich on drium is an d th ere are n o bu bbles. Any defect s sh ou ld be repaired
m obilized w ith a Freer elevator an d h ar vested sh arply. Th e im m ediately. To repair su ch defects, th e lung is de ated
rest of th e perich on driu m w ill rem ain in t act to en sure th e an d a cath eter is placed in th e defect . A p u rse-st ring st itch
in tegrit y of th e h ar vest site. sh ould be p laced arou n d th e defect an d t ied after th e cath -
Fig. 3.5 Costal cartilage harvest technique. (a) Blunt dissection through
muscle to the perichondrium on the anterior surface of the rib. (b) Lifting-
technique with Freer elevator to preserve the posterior perichondrium.
(c) Removal of costal cartilage en bloc. (Used with permission from Tori-
umi DM, Pero CD. Asian rhinoplast y. Clin Plast Surg 2010;37:335–352.)
c
3 The Use of Cost al Cartilage for Dorsal Augm ent ation and Tip Grafting 31
eter is p laced on su ct ion , an d rem oved w h en th e lu ng h as less th an th e periph eral slices; h ow ever, it m ay be brit tle
been m axim ally reexpan ded. A repeat in spect ion an d Val- an d pron e to fract u re in older p at ien t s. With th e prop er t ies
salva m an euver are w arran ted . Inju r y to th e lu ng p aren - of th e cen t ral an d outer/ brou s com pon en t in m in d, th e
chym a m ay require a ch est t ube in sert ion . su rgeon m ay begin to car ve th e cost al car t ilage.
The chest harvest site rem ains open for the duration of On e of th e m ost im port an t con cept s in su ccessfu l cos-
the operation as a contingency for m ore graft m aterial or peri- tal car t ilage graft ing is to car ve th e m aterial sequen t ially.
chondrium . The site is protected w ith an antibiotic-soaked Repeat ing soaking an d dr ying cycles bet w een car vings
gauze sponge and blue towel. After com pleting the rhino- en cou rages th e car t ilage to reveal any ten den cy to ben d in
plast y, the surgeon again changes gloves. The rib harvest site 30 to 60 m in utes. First th e h ar vested segm en t is cut in to
is irrigated and inspected. Closure begins w ith 3–0 PDS suture th ree pieces along th e longest axis, creat ing an terior, cen -
to reapproxim ate the m uscle and its fascia. Careful attention is t ral, an d posterior slices. Th ese pieces are allow ed to soak
paid to this layer of closure to ensure the separation of m uscle an d th en th ey are car ved in to th in n er p ieces. After allow -
and fascia from the overlying subcutaneous tissue. A suture ing th e fresh ly car ved car t ilage to sh ow it s n at ural ben d ,
spanning the t wo layers w ill result in tethering of the overly- th e key is to ut ilize th at ben d w h en select ing in dividual
ing tissue to the deeper fascia, inhibiting independent m otion. pieces for speci c grafts. Most graft s require som e degree
The subcutaneous fat is reapproxim ated w ith 4–0 PDS suture. of cu r vat ure for opt im al fun ct ion . Th e in h eren t st rength of
The deep derm al layer is closed w ith 5–0 PDS suture. The cost al car t ilage allow s it to be car ved ver y th in to decrease
subcuticular layer is closed w ith 6–0 Monocryl suture. The th e bulk in th e n ose; h ow ever, a th ickn ess less th an 1 m m
cutaneous layer is reapproxim ated and everted w ith 5–0 in creases th e risk of torqu ing. At tem pt ing to car ve th e car-
fast-absorbing gut suture. Finally, cyano acrylate adhesive is t ilage in to a st raigh t piece is n ot advised, as it m ay result in
applied super cially to seal the wound. unpredict able w arping after xat ion .
Th e sen ior auth or recom m en ds rout in e postoperat ive Lim ited m an ipu lat ion of th e cost al car t ilage is possible
ch est X-ray an d a period of obser vat ion after cost al cart ilage an d is part icu larly u sefu l if w arping is a con cern . Th e t w o
h ar vest u n t il th e su rgeon is fam iliar w ith th e p rocedu re. tech n iques available to th e surgeon are cross-h atch ing an d
For pat ien ts w ith a p ropen sit y for keloids or hyper t ro- sp lin t ing, w h ich m ay be u sed sep arately or in com bin at ion .
p h ic scars, Ken alog (10 m g/m L) m ay be injected at th e cos- Cross-h atch ing con sist s of part ial-th ickn ess cu ts in to th e
t al cart ilage h ar vest site. After th e skin glue falls o , silast ic con cave side of a cur ved piece of cart ilage to release th e
sh eet ing m ay be u t ilized to h elp m in im ize th e visibilit y of bow ing forces on th e graft . Th e degree of release is di -
an u n sigh tly scar. cult to predict , an d overzealous cross-h atch ing m ay result
in overcorrect ion an d cur vat u re in th e opposite direct ion .
Part ial-th ickn ess cu t s on th e convex side in crease th e exist-
Costal Cartilage Carving ing cur vat ure. Splin t ing involves th e sum m at ion of cur ves.
Tw o cur ved pieces are sut ured togeth er w ith opposing con -
At th is p oin t of th e p roced u re, th e su rgeon n eeds to focu s cavit ies to create a single st raigh t graft (Fig. 3.6). Alth ough
on th e crit ical step of cart ilage car ving. Regardless of th e cross-h atch ing an d splin t ing are useful, it is im port an t to
am ou n t of en ergy exp en ded on th e h ar vest or com p lica- un derst an d th at th ese tech n iques can n ot overcom e th e
t ion s en coun tered during th e h ar vest , th e surgeon can n ot select ion of an in ap prop riate p iece of costal cart ilage.
lose con cen t rat ion . Th e barrier to m astering costal car t i-
lage graft ing is learn ing to ju dge w h ere to u se each p oten -
t ial graft an d h ow to properly prepare th e graft . Prior to any Management of the Bony Vault
car ving, th e surgeon sh ou ld repeat th e sur vey of th e n ose
an d p lan all of th e n ecessar y graft s; on e sh ou ld n ot car ve Th e im port an ce of addressing th e bony vault in th e East
th e graft s as th ey are n eeded in th e procedure. If a large Asian n ose lies in set t ing th e foun dat ion for dorsal aug-
dorsal augm en tat ion is plan n ed, an appropriately th ick m en t at ion . Mism an agem en t of th e bony vau lt w ill resu lt
piece of cost al car t ilage stock n eeds to be preser ved for th e in failure to create a n at u ral-appearing dorsu m . Start ing
dorsal graft , start ing w ith th e rst cut in to th e cost al car- w ith a low, w ide n asal dorsum , it seem s coun terin t uit ive
t ilage. Im proper car ving, select ion , or xat ion of th e cost al to forgo n arrow ing osteotom ies. In fact , th e exist ing w ide
cart ilage graft s could poten t ially create m ore deform it y bony dorsum w ill create a desirable pyram idal sh ape w h en
th an th e de cien cy on e is t r ying to repair. a dorsal augm en t at ion graft is st acked on top of it . A bony
Again , age is th e m ost im por tan t factor to con sider vau lt n arrow ed by aggressive osteotom ies w ill p rovide ver-
w h en car ving th e cost al cart ilage. Th e cart ilage w ill h ave t ically orien ted sidew alls an d create an un n at ural t ubular
a w h iter-ap pearing ou ter p ort ion , w h ich con t ain s a brou s sh ape w h en com bin ed w ith a dorsal augm en tat ion graft
com pon en t . In th e younger pat ien t , th e outer por t ion of th e (Fig. 3.7). Addit ion ally, excessive n arrow ing of th e bony
rib h as an in creased ten den cy to ben d. In th e older p at ien t , upp er th ird m ay prove to be too m uch for th e an atom ic lim -
th e ou ter brou s com pon en t is less pron e to fract ure, in it at ion s of th e n asal base, creat ing an im balan ce bet w een
w h ich case it is preser ved.9,10 Th e cen t ral piece m ay ben d th e w idth s of th e ceph alic an d caudal port ion s of th e n ose.
32 II Rhinoplast y
Con ser vat ion of a low, w ide n asal dorsal fou n dat ion
sh ould n ot preclu de th e su rgeon from m an ip u lat ing th e
n asal bon es. Osteotom ies to address bony deviat ion m ay
be necessar y. Excessive w idth m ay require judicious n ar-
row ing osteotom ies. Depressed bony segm en t s m ay n eed
outfract ure. Avoiding m edial osteotom ies w ill h elp preven t
excessive n arrow ing. If th ick cort ical bon e is p reven t ing
back fract ure from th e lateral osteotom y sites, laterally fad-
ing m edial osteotom ies m ay be n ecessar y. Lateral osteoto-
m ies are p erform ed in a h igh -low -h igh fash ion . Th e sen ior
au th or p refers to u se a st raigh t 3-m m osteotom e to lim it
soft t issu e t rau m a. An d th e su rgeon sh ou ld lim it th e force
ap plied by th e dom in an t h an d w h en m an u ally adju st ing
th e nasal bon e to avoid a tellt ale “th um bprin t” sign .
Plane of
illustration
a b Osteotomy
Fig. 3.7 Dorsal augmentation graft without osteotomies. (a) Plane of Illustration. (b) When the dorsal augmentation graft is placed on
a wide base the outcome is a favorable contour with a smooth transition from graft to maxilla. Osteotomies that inappropriately narrow
the base disrupt this transition, creating a vertical drop-o from the graft to the cheek. (Used with permission from Toriumi DM, Pero CD.
Asian rhinoplast y. Clin Plast Surg 2010;37:335–352.)
3 The Use of Cost al Cartilage for Dorsal Augm ent ation and Tip Grafting 33
a b c
w h ich requires close at ten t ion to avoid palpable an d visible palpation is m ore im portant than visual inspection, as soft
d eform it ies of th e brow –t ip aesth et ic lin e. tissue swelling can be deceptive. Slight overcorrection is rec-
Unless addressing a saddle or weak L-strut, the spreader om m ended on the side of the depression.
grafts m ay be fashioned or carved from less desirable carti- Spreader grafts are secured w ith 5–0 PDS sut ure to th e
lage stock. It is m ore com m on to use the central portion of the dorsal septal strut. Extended spreader grafts are sut ured to
costal cartilage harvest for the spreader grafts unless the sur- the caudal septal extension graft or caudal septal replace-
gery is for a younger patient, w here the central com ponent m en t graft . Th e relat ion sh ip bet w een th e exten ded spreader
m ay be better for the dorsal graft. The nasal anatom y m ay grafts an d caudal septal exten sion /replacem en t graft can be
be m easured from the bony-cartilaginous junction on the adjusted to alter tip project ion , n asal length , dorsal h eigh t,
dorsum to the tip -de ning point to extrapolate the appro- an d tip rotation . Th is is carefu lly set to avoid overprojection ,
priate graft length. Dim ensions of spreader grafts vary from excess length, and a sh ort or over-rotated tip.
patient to patient, but t ypically are 15 to 20 m m in length.. Th e upper lateral cart ilages are sut ured to th e spreader
The spreader grafts are tapered at each end. The inferior edge graft s to avoid an inverted-V deform it y. Care is t aken to
is trim m ed to avoid obstruction of the valve. One should avoid en t rapping n asal m ucosa th at m ay blun t th e in tern al
note any deviations requiring for sm all adjustm ents of the nasal valve, an d clocking sut ures m ay be placed to adjust
tip. The spreader grafts are t ypically oriented w ith opposing for t ilt .12 On ce th e spreader grafts are secured to a st able
convexities.11 Multiple or asym m etric grafts m ay be placed to m idlin e n asal base, th e dorsal augm en tat ion graft can be
account for m iddle vault w idth or collapse. To assess, digital reliably set on top of th at st rong foun dat ion .
34 II Rhinoplast y
a b c
Fig. 3.9 Caudal septal extension graft splinted and secured with slivers. (a) Frontal view. Caudal septal extension graft external to nose.
(b) Frontal view. Caudal septal extension graft with supporting slivers. (c) Surgeon’s view. Caudal septal extension graft is secured to native
caudal septum with supporting slivers.
3 The Use of Cost al Cartilage for Dorsal Augm ent ation and Tip Grafting 35
Perichondrium
Perichondrium
Fig. 3.11 Perichondrium on undersurface of dorsal augmentation graft for xation. (a) Lateral view with concave surface facing down.
(b) Lateral view with superior undersurface of the graft covered in perichondrium. (c) Drawing showing the appropriate placement of
perichondrium on the undersurface of the dorsal augmentation graft in contact with the nasal bone for strong graft xation. (Used with
permission from Toriumi DM, Pero CD. Asian rhinoplast y. Clin Plast Surg 2010;37:335–352.)
a b c
Fig. 3.12 Kirschner wire placement. (a) Vertical incision with a no. 11
blade. (b) Placement of Kirschner wire. (c) Clipping Kirschner wire with
d cut ter. (d) Lateral view of Kirschner wire cut to length.
3 The Use of Cost al Cartilage for Dorsal Augm ent ation and Tip Grafting 37
t ion graft en sure rm con t act for in tegrat ion an d bony xa- or replacem ent graft. Desirable tip projection and rotation
t ion (Fig. 3.13). Fin al xat ion occu rs after t ip m an ip u lat ion are con rm ed before securing the m edial and interm ediate
is com pleted to p erm an en tly set th e dorsal h eigh t in pro- crura w ith 5–0 PDS sut ure. Tip bulbosit y due to convex lat-
p ort ion to th e n asal t ip posit ion . eral crura is addressed w ith lateral crural strut grafts.16 The
strut grafts at ten the crura. It is rare that repositioning is
needed in the Asian patient unless they have alar retraction.
Tip Contouring Due to cam ou aging thick skin , th e East Asian n ose rarely
requires repositioning of the lateral crura, regardless of tip
Typically, th e East Asian n ose w ill require t ip augm en t at ion cartilage orientation. The Asian sit uation is the opposite of
an d n arrow ing to add ress th e n at ive ch aracterist ics: sm all the hanging colum ella-tip lobule and retracted ala fam iliar
an d w eak lateral cru ra, th ick sebaceou s skin , t ip bu lbosit y, in the Caucasian nose. More often East Asian noses have
ret racted colum ella, an d h anging alar lobules.2 Favorable retracted colum ella and hanging alar lobules. Repositioning
t ip con tour can be ach ieved w ith au tologous costal cart i- of the low er lateral cartilages is a powerful m aneuver that
lage in th e East Asian n ose. could exacerbate the patient’s inherent problem . How ever, if
Using 4–0 plain gut sut ure on a Keith n eedle, the m edial the ala is retracted or notched, lateral crural strut grafts w ith
crura are reapproxim ated to the caudal septal extension repositioning can bring it dow n.
a b c
Fig. 3.13 Transnasal suture placement. (a) 16-gauge needle passed through nasal bones.
(b) Suture needle placed in lumen of 16-gauge needle. (c) Suture passed transnasally from
left to right. (d) Suture crosses back to the left side under the skin envelope and over the
d dorsal augmentation graft.
38 II Rhinoplast y
To prepare the site for lateral crural strut grafts, the th in -sliver alar bat ten grafts m ay be n eeded to support th e
tightly adherent vestibular skin is dissected o of the under- valve area previou sly h eld open by ceph alically orien ted
surface of the native lateral crura. Hydrodissection w ith 1% low er lateral cart ilages.
lidocaine w ith 1:100,000 epinephrine m akes this task easier. Tip augm en t at ion w ith autologous cost al car t ilage cre-
The plane of dissection is continued laterally tow ard the pir- ates addit ion al project ion an d re n em en t . St retch ing th e
iform apert ure to create a pocket for the grafts. The carved skin creates t ip d e n it ion . Th is can be accom p lish ed w ith
costal cartilage sh ould be evaluated for ideal pieces 25–30 sh ield, lateral cru ral, an d bu t t ress graft s. Th e sh ield graft
m m × 4–5 m m × 1–2 m m w ith a sligh t curve. Wom en w ill provides th e project ion , but th e lateral crural an d but t ress
have shorter grafts than m en. After selecting ideal pieces graft s st abilize th e t ip graft , p reven t ing rot at ion cau sed by
of costal cartilage w ith the concave side facing the vestib- th e ceph alic pulling force of a th ick skin envelope. Adjust-
ular skin, the m edial edge is cut at 45 degrees and placed ing th e posit ion of th e sh ield graft varies th e am ou n t of
directly under the apex of the dom e. It is secured w ith 5–0 in creased project ion an d in frat ip augm en tat ion . In ad di-
PDS sut ure, keeping all kn ots aw ay from th e vestibular skin t ion to st abilizat ion , lateral crural an d but t ress graft s bev-
to prevent extrusion (Fig. 3.14). Oblique dom e sutures are eled to m eet th e sh ield graft sm ooth th e t ran sit ion s from
placed to at ten the dom es and orient the lateral crura w ith th e graft’s edges an d preven t graft visibilit y. Most pat ien t s
the caudal edge higher than the cephalic edge. th at un dergo placem en t of a sh ield graft w ith lateral cru-
Reposit ion ing of th e low er lateral cart ilages involves ral graft s do n ot n eed any oth er w ork don e on th e lateral
fu lly m obilizing th e lateral asp ect s of th e lateral cru ra. If cru ra, as th ey are deep to th e in uen ce of th e sh ield graft .
th ese cart ilages are large, th e lateral-m ost aspect m ay be A less aggressive altern at ive is a rect angu lar, h orizon t ally
h ar vested for soft t issu e cam ou age. Th e lateral cru ral st ru t orien ted t ip on lay graft secured w ith 6–0 Mon ocr yl sut ure
graft s are p erform ed as described p reviou sly, except for th e (Fig. 3.15). Variat ion in th e size an d p lacem en t of th e graft
lateral pockets design ed to correct asym m et r y of th e ala: a can set th e project ion , t ip w idth , suprat ip break, an d over-
n eu t ral or h orizon t al p ocket for th e low er alar lobu le an d all re n em en t of th e t ip . With in creasing am ou n ts of t ip
a d ow nw ard-orien ted p ocket for th e ret racted alar lobu le. augm en tat ion , th e n ost ril-to-colu m ellar rat io w ill m ove
In rep osit ion ing, any p lan n ed cep h alic t rim is redu ced, an d from 2:1 to 1:1.
a a
b b
Fig. 3.14 Lateral crural strut graft technique. (a) Lateral crura dis- Fig. 3.15 Shield graft versus horizontal onlay graft. (a) Shield
sected free. (b) Lateral crural strut grafts suture in position under- graft seen in surgeon’s view. (b) Horizontal onlay graft seen in sur-
neath lateral crura. geon’s view.
3 The Use of Cost al Cartilage for Dorsal Augm ent ation and Tip Grafting 39
After at ten ing the lateral crura, in creasing projection, Base Reduction
an d re n ing the tip, the surgeon replaces the dorsal graft and
redrapes the skin to assess the relationship bet w een projec- After closure of the nose, the nasal base w idth is assessed.
tion and the dorsal height. Once it is considered satisfactory, As a result of structured rhinoplast y w ith autologous costal
the dorsal graft can be secured into place for rigid xation. cartilage augm entation, particularly w ith lateral crural strut
grafts, the East Asian nose m ay require nasal base reduction
to balance the nose w ith the w idth of the new ly augm ented
Alar Batten and Alar Rim Grafts dorsum . This can be perform ed w ith techniques involving any
com bination of internal or external excision and base-cinch-
In th e East Asian n ose, w ith it s w ide air w ay an d th icker ing sutures. Caution is warranted, as sm all errors in perform -
lateral sidew alls, alar bat ten an d alar rim graft s are in fre- ing base reductions result in glaring deform ities. Unsightly
quen tly in dicated, because th e lobu les rarely pin ch or col- scars at the nasal base are di cult to correct. To im prove out-
lap se. Cost al car t ilage is an excellen t source m aterial sin ce com es, plan for an incision slightly adjacent to the alar-facial
it m ain tain s it s st rength even w h en car ved ver y th in . If or alar-vestibular junction. Avoid local anesthetics as they
cost al car t ilage is u sed for th ese grafts, a sm ooth t aper is can deform the tissue contours. Using a no. 11 blade, create
n ecessar y to preven t graft visibilit y.2 a slight bevel of the incisions to prom ote eversion of the skin
Alar bat ten graft s sh ou ld be placed in p recise p ockets edge. Avoid all cautery. Meticulously close the base reduction
orien ted along th e su pra-alar crease an d sut ured in to place. sites w ith a deep 5–0 PDS suture, 7–0 nylon vertical m attress
Th ese bat ten grafts are appropriate for in tern al valve col- sutures, and 6–0 fast-absorbing gut sim ple sutures.
lapse an d if th e lateral crura h ave been reposit ion ed w ith
lateral cru ral st rut graft s. Alar bat ten graft s are in dicated
for add ressing lateral w all de cien cy an d p in ch ing from Glabellar Augmentation
aggressive cep h alic t rim or oth er p reviou s surger y. Alar
bat ten graft s are rarely n eeded in Asian pat ien t s, as th eir To further balance the nose, it is im portant to evaluate the
air w ay ten ds to be relat ively large. East Asian face w ith lateral views. From this perspective, a
Alar rim grafts are p laced in precise pocket s along th e de cient glabella m ay be observed. This observation m ay be
m argin al in cision en d ing m edially beh in d th e t ip com p lex. m ade preoperatively and discussed w ith the patient through
Th ese graft s address extern al n asal valve collapse, pin ch ing digital im age m orphing software. The senior author perform s
of the t ip, an d irregular t ran sit ion s from th e t ip lobule to glabellar augm entation by an endoscopic technique. Attention
th e alar lobule. is directed at the forehead area, w here two hairline incisions
are m ade, and the endoscope is dropped dow n to the glabellar
region in a subperiosteal plane. A soft piece of septal cartilage
Closure covered w ith perichondrium is sutured on both sides w ith 5–0
PDS, keeping the suture tail long w ith needles attached. The
At this point, the surgeon needs to perform a m eticulous clo- graft is deposited through the scalp incision site. Then using
sure of the colum ellar incision to prevent the stigm ata of the 16-gauge needles, ports are created on the lateral aspects of
open rhinoplast y approach, a visible scar. Closure begins w ith the de cient glabella. The needles connected to the graft are
an interrupted 6–0 Monocryl suture in the m idline. This suture passed through 16-gauge needles and delivered externally.
aligns the soft tissue envelope and rem oves tension from the Sym m etry and positioning should be noted w ith the endo-
skin edge. Using a 7–0 nylon suture, seven interrupted vertical scope before t ying the anchoring sutures at the skin. The scalp
m attress sutures approxim ate and evert the inverted-V colu- incisions are closed w ith 5–0 PDS and 5–0 fast-absorbing gut.
m ellar incision. Between the nylon sutures, 6–0 fast-absorb- The anchoring sutures are cut in 7 days. Another option is to
ing gut suture is placed in a sim ple interrupted fashion. The use autologous fat augm entation of the glabella.
m arginal incision is closed w ith sim ple interrupted 5–0 chro-
m ic gut sutures, w hile observing the nostril m argin. If there is
inadequate vestibular lining. this stitch can lead to notching of
the nasal rim , in w hich case a com posite graft m ay be neces- ■ Postoperative Care
sary. The m ucoperichondrial aps are reapproxim ated w ith a
4–0 plain gut suture on a Keith needle in a running m attress All patien ts are seen on postoperative day 1. Vestibular
fashion, closing the septum . splints m ay be rem oved. The n ose is clean ed and antibiotic
Radio-opaque 0.25-m m septal splin ts (Reuter bivalve oin tm ent is applied. Patients undergoing costal cartilage
septal splin ts, Medtron ic, Jacksonville, Florida) are sutured grafting receive oral uoroquinolone and perform uoroqui-
in place if turbinate or septal w ork was perform ed to pre- nolone antibiotic nasal soaks in addition to a second-gen-
vent synechiae form ation. Lateral w all splints are used if lat- eration cephalosporin. The external cast, tape, lateral w all
eral crural strut grafts w ere placed w ith reposition ing of the splints, Kirschner w ire, and colum ellar sutures are rem oved
lateral crura. If there is any nostril asym m etry a vestibular in 7 days. If base reductions w ere perform ed, these sut ures
splint can be used interm it tently. Th e senior author does not are rem oved at 10 to 14 days postoperatively. A m ild narcotic
use any nasal packing. The nose is taped and an external cast pain m edication is provided, but an early transition to acet-
is applied. Antibiotic ointm ent is applied to all incisions. am in ophen is encouraged. Aspirin and n onsteroidal anti-
40 II Rhinoplast y
in am m ator y drugs are avoided postoperatively. Despite a but stressed that she preferred a “natural look.”. In her pre-
low level of discom fort, patients often refrain from taking operative com puter im aging we agreed on a m odest degree
deep inspirations to protect the costal cartilage donor site. of dorsal augm entation that would com plem ent a m oderate
Postoperatively, patien ts are en couraged to perform in cen - increase in nasal tip projection (Fig. 3.16). We also discussed
tive spirom etr y and am bulation to avoid atelectasis. chin augm entation to com plem ent her nasal projection and
other facial features. We harvested a 3.5-cm segm ent of her
sixth rib through a 1.1-cm chest incision. Perichondrium was
■ Key Technical Points harvested from the surface of the rib as well.
Th e r ib car t ilage w as car ved in to t h ree sep arate
segm en t s t h at w ere exam in ed for t h e p rop er ben d in g
1. The chest incision is m ade sm all to m inim ize the
(Fig. 3.17). Over several h ou rs a p recisely car ved cost al
visible scar; h ow ever, a surgeon sh ou ld con tin ue to
car t ilage d orsal graft w as fash ion ed an d obser ved for a
u se a larger in cision u ntil fam iliar w ith th e dissect ion.
ten d en cy to ben d . An exter n al rh in op last y ap p roach w as
2. By m ain t ain ing a p rotect ive cu of p erich on d riu m ,
u sed (Fig. 3.18) an d sp ecial care w as t aken to d issect a
th e cost al cart ilage h ar vest tech n ique sh ould
t igh t su bp er iosteal t u n n el along t h e m id lin e of h er n asal
en su re an in t act h ar vest site, avoiding violat ion of
d orsu m . Th e base of t h e n ose w as st abilized u sin g a cau dal
th e pleura. All n al cut s of th e cost al car t ilage are
sept al exten sion graft su t u red to t w o exten d ed sp read er
p erform ed w ith th e blun t en d of th e Freer elevator.
graft s t h at w ere p laced in to bilateral su bm u cosal t u n -
A lift ing m ot ion is ut ilized to protect th e un derlying
n els u n d er t h e u p p er lateral car t ilages. Th e d orsal graft
p erich on driu m an d pleura.
w as fash ion ed so t h at it h ad a sligh t con cave cu r vat u re
3. W h en open ing th e n ose, th e Joseph periosteal t h at w as or ien ted again st t h e n asal dorsu m . A st r ip of
elevator sh ould be used in a lim ited fash ion , p er ich on d riu m w as su t u red to t h e u n d ersu r face of t h e
p reser ving a t igh t dorsal p ocket , in an t icipat ion of a su p er ior p or t ion of t h e d orsal graft w it h 5–0 PDS su t u re.
d orsal augm en tat ion graft . A n ar row n e rasp w as u sed to rough en t h e n asal d orsu m
4. In th e set t ing of spreader grafts or splin t ing, by to create a p orou s bon e su r face t h at cou ld t h en in tegrate
opposing con cavit ies, th e surgeon can ut ilize th e w it h t h e p er ich on d r iu m an d x t h e dorsal graft to t h e
n at u ral cu r vat u re of th e costal cart ilage grafts. n asal bon es. Th e d orsal graft t sn uggly in to t h e su bp er i-
5. By keeping th e upper lateral cart ilages at t ach ed osteal t u n n el, xing t h e d orsal graft in to p osit ion . Th en
to th e dorsum , th e surgeon can u se subm ucosal a sh ield graft w as p rojected ~ 3 m m above t h e exist in g
spreader grafts an d does n ot n eed addit ion al t im e to d om es an d su t u red to t h e m ed ial cr u ra. Bilateral lateral
recon st ruct th e dorsu m . cr u ral graft s w ere su t u red to t h e p oster ior su r face of t h e
6. Th e dorsal graft is secured on ly after all t ip w ork is sh ield graft an d t h en su t u red to t h e lateral cr u ra. To p re -
com plete. ven t graft visibilit y p er ich on d r iu m w as su t u red on to t h e
lead ing edge of t h e sh ield graft . Th e colu m ellar in cision
7. Th e dorsal augm en tat ion graft requ ires rigid xat ion
w as closed u sin g a 6–0 Mon acr yl su bcu t an eou s su t u re
to preven t w arping. Th e su perior aspect of th e graft
an d 7–0 ver t ical m at t ress su t u res.
m u st be secu red w ith a t igh t p ocket , t ran sn asal
su t u re, or Kirsch n er w ire.
8. Tip projection m ay be achieved w ith a shield graft or
h orizontal onlay graft. The horizontal onlay graft is
less aggressive and w ill not change the infratip lobule.
9. W h en in creasing project ion , on e m ust con t rol for
rot at ion w ith a st able fou n dat ion . Septal exten sion
graft s precisely con t rol th ese variables.
10. Base redu ct ion s are tech n ically di cu lt w ith th e
p oten t ial for deform it y. Avoid con tour-altering local
an esth et ics an d cau ter y w h ile p erform ing base
redu ct ion s.
■ Case Studies
Case 1
This Asian patient presented for augm entation rhinoplast y Fig. 3.16 Preoperative computer im aging showing proposed
and requested to have her rib cartilage used for the augm enta- modest change in nasal dorsal height and tip projection. Chin aug-
tion. She was interested in a m odest degree of augm entation mentation was recommended as well.
3 The Use of Cost al Cartilage for Dorsal Augm ent ation and Tip Grafting 41
a b
Fig. 3.17 (a) A 3.5-cm segment of the sixth rib was harvested through a 1.1-cm chest incision. (b) Harvested costal cartilage was carved
into three separate segment s to allow selection of the best piece for the dorsal graft.
a b c
d e f
Fig. 3.18 (a) Bilateral spreader grafts were used to stabilize the caudal septal extension graft. The extension graft was placed to control
nasal tip projection and rotation. (b) Dorsal graft with slight bend with the concave side oriented inferiorly against the dorsum of the nose.
Perichondrium was sutured to the undersurface of the upper margin of the dorsal graft. (c) Dorsal graft with perichondrium sutured to
the undersurface of the superior end of the graft. (d) Shield graft sutured to the medial crura. The graft is projecting 3 mm above the
existing domes. (e) Bilateral lateral crural grafts sutured to the posterior surface of the shield graft to prevent over-rotation of the tip graft.
(f) Perichondrium sutured to the leading edge of the shield graft to minimize the likelihood of graft visibilit y.
42 II Rhinoplast y
a b c
d e f
g h
Case 2
Th is pat ien t presen ted for secon dar y rh in oplast y. Th e
pat ien t w as un h appy w ith h er dorsal im plan t , w h ich occa-
sion ally becam e in am ed. Sh e u n der w en t t w o p reviou s
su rgeries an d w ish ed to h ave h er im p lan t rem oved an d
replaced w ith h er ow n cart ilage. Sh e w an ted a low er radix
an d im p roved t ip con tou r. We dem on st rated h er p ro le
ch anges u sing com pu ter im aging (Fig. 3.20).
At th e t im e of su rger y w e n oted a large Gore-Tex dor-
sal im p lan t . Th e im plan t h ad t w o layers in th e radix area
Fig. 3.20 Preoperative computer imaging showing lower radix.
an d w as ver y di cu lt to rem ove (Fig. 3.21). A 4.5-cm seg-
m en t of cost al cart ilage w as h ar vested from h er righ t ch est
(Fig. 3.22). Th e p at ien t u n d er w en t revision rh in oplast y
(Fig. 3.23). Sh e h ad h ad a colu m ellar st ru t placed in a p revi-
ous surger y. We left th e st rut in place an d sut ured a costal
cart ilage sh ield graft to th e m edial cru ra. Th e sh ield graft
w as st abilized u sing a bu t t ress graft su t u red beh in d th e t ip
graft . Soft t issu e an d scar w ere su t u red along th e lateral
edges of th e t ip graft . A costal cart ilage dorsal graft w as
design ed to set a low er radix. Perich on driu m w as sut u red
to th e u n dersu rface of th e d orsal graft to aid in xat ion of
th e dorsal graft . Mult iple perforat ion s w ere m ade in th e
bony dorsum to allow m ore rapid in tegrat ion w ith th e peri-
ch on driu m on th e un dersu rface of th e dorsal graft . A large
space w as created w ith th e dissect ion of th e Gore-Tex dor-
sal im p lan t . To xate th e dorsal graft a th readed Kirsch n er
w ire w as placed th rough a sm all dorsal in cision , th rough
th e dorsal graft an d in to th e bony dorsum . A com posite Fig. 3.21 Gore-Tex dorsal graft rem oved. Note the double layer of
skin -cart ilage graft w as h ar vested from th e righ t cym ba Gore-Tex over the radix region and its extension into the glabellar.
con ch a. Th e com posite graft w as sut ured in to th e left m ar-
gin al in cision w h ere th ere w as a vest ibu lar skin de cien cy.
Th e Kirsch n er w ire aided xat ion of th e dorsal graft to th e
bony dorsum . Th e Kirsch n er w ire w as rem oved on th e sev-
en th postoperat ive day. Th e p at ien t did w ell an d sh e w as
h ap py w ith h er ou tcom e (Fig. 3.24).
a b c
d e f
g h
Fig. 3.23 (a) Shield graft sutured to medial crura. (b) But tress graft sutured behind leading edge of the shield graft. Soft tissue and scar
placed along edges of the shield graft for additional camou age. (c) Costal cartilage dorsal graft carved. (d) Perichondrium sutured to the
undersurface of the dorsal graft. (e) Kirschner wire advanced through a small incision over the nasal dorsum . (f) Composite skin-cartilage
graft harvested from right cymba concha. (g) Composite graft sutured into the left marginal incision. (h) Kirschner wire in position xing
the dorsal graft to the underlying bone.
3 The Use of Cost al Cartilage for Dorsal Augm ent ation and Tip Grafting 45
a b c
d e f
g h
Pearls
• For t ip surger y in East Asian s, project ion , rot at ion , • Th e sept al exten sion graft is a w orkh orse u sed to
an d volu m e are th e th ree m ost im p or tan t factors to m odify th e t ip sh ap e, an d it sh ou ld be su p ported by
con sider. a st rong cau dal sept u m or rein forced w ith bat ten or
• Sin ce in h eren t t ip support is w eak an d th e skin is exten ded sp reader grafts.
relat ively th ick in Asian s, t ip augm en t at ion is m ostly • W h en design ing th e sept al exten sion graft ,
ach ieved by car t ilage graft ing rath er th an su t u re project ion an d rot at ion are m odi ed by carefu lly
m odi cat ion tech n iqu es alon e. design ing th e sh ape of th e graft con sidering th e
• Pat ien t p referen ce, th e ch aracter of th e t ip, an d posit ion of th e n ew dom e.
su rgeon exp erien ce an d preferen ce are som e of th e • Ap p lying bon e as a septal exten sion graft or overly
factors to be con sidered in ch oosing th e app rop riate aggressive applicat ion of th e sept al exten sion graft
ap proach for t ip su rger y. sh ou ld be avoid ed to p reven t pain , h ard n ess, an d
• For th e t ypical Asian pat ien t , th e open approach discom for t at th e t ip.
gives bet ter an d m ore diverse opt ion s for m odifying • Even for relat ively th ick skin at th e n asal t ip, t ip
th e t ip sh ape, w h ile th e closed approach is e ect ive graft s n eed to be carefu lly beveled an d car ved to
in lim ited cases. keep from sh ow ing u p in th e long term .
• A cap graft w ith or w ith ou t a colu m ellar st ru t an d • To com plem en t m odi cat ion of th e t ip sh ape,
in terdom al sut u re th rough th e en d on asal or open ceph alic resect ion , th e sh ield graft , th e prem axillar y
ap proach p rovides an e ect ive in crease in t ip graft , th e lateral cru ral graft , an d th e alar rim graft
project ion an d rot at ion . are also u sed.
47
48 II Rhinoplast y
a b
Fig. 4.4 Colum ellar strut and interdomal suture through endona- Fig. 4.5 When performing this maneuver, start from the medial
sal approach for tip augmentation. After bilateral infradomal mar- crus going to the lateral crus, and then from the lateral crus mov-
ginal incisions extending to the lateral side of the columella, both ing to the medial crus. Care should be taken to maintain symme-
domes and medial crura are exposed. A columella strut is inserted try of the domes and to avoid excessive medialization of the lateral
after making a pocket bet ween the medial crura. Both domes and crus.
the strut are sutured together for stabilit y.
A septal exten sion graft is design ed w ith th e degree of xed to a port ion of th e cau dal sept u m . Th is is u sed in cases
t ip project ion an d rot at ion t aken in to con siderat ion . Low er w h ere on ly a m oderate am oun t of project ion is requ ired
lateral car t ilages are reposit ion ed an d su t u red to th e n ew ly an d w h ere th e septal cart ilage is relat ively th ick an d st rong.
form ed cau dal sept u m , resu lt ing in im m ediate t ip elevat ion In any t ype, th e graft can be rein forced u sing septal car t i-
an d rot at ion . Th is tech n iqu e is u sefu l in sh ort n ose cases or lage or bon e to preven t possible ben ding or buckling by th e
to in crease t ip project ion in pat ien t s w h o lack t ip suppor t , ten sion placed on th e graft .
sin ce st rong su p port of th e t ip can be ach ieved. How ever, it An en d-to-en d septal exten sion graft rein forced by
w ou ld be p ru den t n ot to overu se th e septal exten sion graft exten ded sp reader graft s h as dist in ct advan t age com p ared
w h en oth er m eth ods of in creasing t ip project ion are avail- w ith th e overlapping t ype: It avoids th icken ing or buck-
able (e.g., colu m ellar st ru t or cart ilage t ip graft), becau se ling of th e caudal sept um an d th us rarely causes n asal
th e sept al exten sion graft involves a m ore invasive proce- obst ruct ion .
d u re requ iring m ore t issu e dissect ion com p ared w ith oth er
m eth ods. On e draw back is decreased t ip elast icit y resu lt-
ing in a st i n asal t ip, w h ich , h ow ever, ten ds to im prove The Septal Extension Graft Technique
over t im e. An oth er d raw back is th at th e exten sion graft can
ben d w h en excessive ten sion is applied.5 Th is usually h ap - 1. For e ect ive execut ion , m ost sept al exten sion
p en s w h en th e cau dal sept um is w eak or th e reposit ion ed graft ing is perform ed via th e open approach . A large,
low er lateral car t ilage an d th e drap ing skin an d soft t issu e at piece of cart ilage is t ypically h ar vested from
exert too m u ch ten sion on th e n ew t ip . Th e su rgeon sh ou ld th e posterior n asal sept um . Th e sept al exten sion
be con scien t ious in in form ing th e pat ient of all th ese pos- graft is design ed con sidering th e n al sh ape an d
sibilit ies preoperat ively. stabilit y of th e t ip . For exam p le, to correct colu m ellar
ret ract ion , th e por t ion of th e sept al exten sion
graft correspon ding to th e colum ella is design ed to
Types of Septal Extension Grafts prot rude past th e sept u m , an d th e m edial crura of
th e low er lateral car t ilage are su t u red in a tongue-in -
Tw o di eren t t ypes of sept al exten sion graft s exist: th e groove fash ion to th e n ew cau dal sept um created by
overlap p ing t ype an d th e en d-to-en d t ype. Th e overlapp ing th e graft .
sept al exten sion graft can be divided in to variou s t ypes 2. W h en th e in h eren t septal support is st rong, a sept al
depen ding on th e car t ilage st rength an d in tegrit y of th e exten sion graft can be ap plied as an overlap p ing
caudal sept um , am oun t of available cart ilage, an d desired t yp e to th e cau dal sept u m (Fig. 4.6). Avoiding an
t ip sh ape. A com m on t ype is a sept al exten sion graft over- overly th ick cau dal sept u m by carefu l car ving is
lapp ing th e en t ire cau dal sept um an d exten ding to th e im p ort an t for a w ell-breath ing n ose. A sligh tly
an terior n asal sp in e. Du e to its in creased st abilit y it can cur ved graft can be used in an e ort to place th e en d
be used in m ajor t ip augm en tat ion . It can be placed an d of th e graft in th e m idlin e.
4 Nasal
Tip
Modi cation
in
Asians:
Augm ent ation
and Control 51
Rot ation
Fig. 4.7 An overlapping graft is xed on the left side of the cau-
dal septum. 5–0 or 4–0 PDS is used to securely x the graft onto
the caudal septum. Note that the septal mucosal dissection is done
3. After un ilateral dissect ion , un less in dicated entirely on the left side, but partially on the right side, just enough
oth er w ise, con t ralateral dissect ion is m in im ized on ly to secure the extension graft.
to th e exten t w h ere th e sept al exten sion graft can be
secu rely su t u red to th e cau dal sept u m (Fig. 4.7).
4. W h en th e cau dal sept um is w eak, rein forcem en t rein forcem en t can be obt ain ed by t ran s xion
is ach ieved in t w o w ays: First , th e posterior septal su t u ring of th e m em bran ou s sept u m to th e sept al
angle of th e cau dal sept u m is su t u re- xed to th e exten sion graft u sing 4–0 p lain gu t . If in dicated, a
an terior n asal sp in e. Secon d, th e septal exten sion cap graft or sh ield graft can be perform ed on th e
graft is supported using a spreader graft or bat ten n ew ly created dom e, to obt ain furth er re n em en t in
graft . Using th in bon e for bat ten ing pu rposes is t ip sh ape (Fig. 4.10).
n e, bu t u sing it as a sept al exten sion graft is n ot
advisable. If th e h ar vested car t ilage is big en ough ,
rein forcem en t an d exten sion can be ach ieved Other Useful Techniques to
sim u lt an eou sly by design ing th e graft as a bat ten Modify Tip Shape
graft prot ruding from th e cau dal sept um .
5. In th e en d-to-en d st yle, th e sept al exten sion graft Shield Graft
is st abilized at t w o or th ree poin t s: Th e posterior
sept al angle is st abilized to th e an terior n asal spin e, A sh ield graft p laced at th e an tero-in ferior part of th e n asal
u sing gu re-of-8 sut u res x th e sept al exten sion t ip (above th e m edial crus) can in crease t ip project ion
graft to th e en d of th e caudal sept um , an d th e septal as w ell as en h an ce de n it ion of th e su p rat ip an d in frat ip
exten sion graft is stabilized w ith a u n ilateral or breaks. Sept al car t ilage is com m on ly used, w ith rib cart i-
bilateral exten ded spreader graft (Fig. 4.8).6,7 lage used on occasion . Th e w idth of th e upper part of th e
6. Th e low er lateral cart ilage can be reposit ion ed by sh ield graft is d esign ed to be 6 to 8 m m in size, sim u lat-
su t u ring it to th e sept al exten sion graft u sing 5–0 ing th e t ip de n ing poin ts. Th e m argin s of th e graft are
PDS or 6–0 clear nylon to create th e n ew dom e t rim m ed. At least four st itch es to th e m edial crus are m ade
(Fig. 4.9). Addit ion al su t u res bet w een th e low er to m ain t ain stabilit y (Fig. 4.11). In th is case a bu t t ress graft
lateral car t ilage an d th e sept al exten sion graft sh ou ld be placed posterior to th e sh ield graft to preven t
are p erform ed to st rength en th e xat ion . Fu r th er t ilt ing of th e graft an d un in ten ded ceph alic rotat ion .8
52 II Rhinoplast y
Fig. 4.8 (a,b) An end-to-end t ype of septal extension graft is reinforced with a bilat-
eral extended spreader graft. In both t ypes, the graft shape is decided considering the
a amount of projection and rotation.
Fig. 4.9 Tip modi cation using a septal extension graft. Lower lat- Fig. 4.10 An additional onlay graft with conchal cartilage is used
eral cartilages are moved and xed to a new dome created by the for more projection or de nition.
septal extension graft.
Cephalic Resection of Low er Lateral m an euver does n ot cau se a dram at ic decrease in t ip vol-
Cartilage Lateral Crus u m e, w h ile in th in -skin n ed pat ien ts it can be an e ect ive
tech n iqu e. Th is procedu re can be don e eith er en don asally
W h en th e t ip looks too roun d or boxy du e to a w iden ed or w ith th e open approach . Th e resect ion sh ould leave at
in terdom al dist an ce of large low er lateral car t ilages (boxy least 7 to 8 m m of th e low er lateral car t ilages equally on
n asal t ip , bulbou s t ip), cep h alic resect ion of th e lateral crus both sides.9,10 Care m u st be t aken n ot to resect th e in term e-
an d convergen ce of th e in term ediate cru s can redu ce th e diate cru ra that form the t ip de n ing poin t s. Using a n o. 15
volu m e an d n arrow th e t ip . Th is m an euver also resu lts in blade, a par t ial-th ickn ess in cision is m ade to preven t injur y
sligh t cep h alic rotat ion of th e t ip du e to secon dar y scar to th e u n derlying m u cosa of th e low er lateral car t ilage. Th e
con t ract ion . In pat ien t s w h o h ave relat ively th ick skin , th is car t ilage is then dissected from th e m ucosa using iris scis-
4 Nasal
Tip
Modi cation
in
Asians:
Augm ent ation
and Control 53
Rot ation
Fig. 4.11 Shield graft (arrow) via the open approach. The shield
graft is placed and secured to at least four sites using 5–0 PDS
or 6–0 clear nylon. The edges are beveled and a but tress graft is
added for more stabilit y if necessary.
a b d
Fig. 4.14 Correction of alar-columellar disproportion. (a) Preoperative photo shows de cient nasal dorsum, hanging columella, and
slightly retracted alar rim . (b) Six months after surgery, the dorsum is well augmented and the ala and colum ella show a norm al relation-
ship. (c) After degloving, the lower lateral cartilage is round in shape due to lack of angulation bet ween the medial and lateral crura. (d) A
at piece designed from the septal cartilage is inserted in the dissected plane bet ween the lateral crus and vestibular skin. The intermedi-
ate crura are xed to the septal extension graft. The resulting change in the shape and angle formed by the intermediate and medial crura
can be appreciated.
In cases w here th e lateral crura are posit ioned along ics th at can be sh aped easily, such as Gore-Tex or Mersilen e
the longit udinal axis of the nose (“m alposit ion ed”), the t ip m esh , m ore com m on ly em p loyed . Rib car t ilage can p rovide
can look like a ball, cont ributing to an unnat ural look. The su cien t au tologou s graft ing m aterial. Th e p rem axillar y
appearan ce of th e t ip can be im proved by ch anging th e lat- area can be app roach ed after dissect ing bet w een th e m edial
eral crura from a vertically orien ted position to a m ore h ori- cru ra or th rough sublabial in cision . A pocket sligh tly larger
zontally oriented one. After the lateral crura are com pletely th an th e graft is m ade, follow ed by in ser t ion of th e graft
dissected o from the vestibular skin, a long st rut graft m aterial. Aggregates of sm all cart ilages can be p lu m p ed in
can be applied, extending past th e lateral crura. The lateral th e pocket , or a large piece of cart ilage is in serted an d xed
crus is then rotated caudally and xed tow ard the piriform to th e su rrou n d ing t issu e or an terior n asal sp in e to p re-
apert ure after dissection of th e soft t issue in th at area. Th is ven t slip ping d ow n or m igrat ion . It is im p or tan t to design
lateral crural repositioning m aneuver is w ell described an d th e graft to t th e cur vat ure an d sh ape of th e prem axilla.
used in Caucasian s, but it is not so e ective in Asians, w ho Diced car t ilage w rap ped w ith au tologou s fascia is an oth er
h ave relatively thick skin an d subcutan eous tissue. good opt ion . In case of an u n derdeveloped prem axilla w ith
poor t ip project ion , a prem axillar y graft in tegrated in to an
exten ded colu m ellar st ru t can be u sed.
Premaxillary Graft
In Asian s th e p rem axillar y area is com m on ly u n derde- Alar Rim Graft
velop ed, resu lt ing in ret ru sion of th e su bn asale, an acu te
n asolabial angle, an d colum ellar ret ract ion . Autologous Alar rim graft ing is a p rocedu re in w h ich a th in p iece of
(cart ilage, bon e) or art i cial (Gore-Tex, silicon e, Mersilen e) cart ilage graft is placed along th e alar rim st ar t ing from th e
graft s can be in ser ted n ear th e an terior n asal spin e or p re- n asal facet (soft t issue t riangle), to obtain a sm ooth t ran -
m a xilla, to im prove colu m ella ret ract ion an d to ach ieve a sit ion from th e t ip lobu le to th e alar lobu le. It rein forces
n at u ral elevat ion an d rot at ion of th e n asal base.11,13 th e alar m argin an d low ers th e alar rim sligh tly w h en alar
Au tologou s or syn th et ic grafts are in serted an terior to ret ract ion is presen t .14,15,16 In an open approach , soft t issue
th e m axilla an d just in ferior to th e an terior n asal spin e. A d issect ion along th e alar rim is started, begin n ing from th e
fair am ou n t of m aterial is u su ally n eeded, m aking syn th et- n asal facet u sing sh arp iris scissors. Dissect ion is p erform ed
4 Nasal
Tip
Modi cation
in
Asians:
Augm ent ation
and Control 55
Rot ation
close to th e alar rim m argin , t aking care n ot to m ake th e th e septal exten sion graft con sidering th e rot at ion an d pro-
p ocket too big. A th in , at p iece 2 to 3 m m in w idth an d 12 ject ion of th e t ip.
to 15 m m in length is design ed from th e h ar vested sept al
cart ilage.16 Th e graft is in ser ted in to th e pocket an d th e in let
is su t u red after bru ising th e t ip w ith Brow n -Adson forceps. Tip Asymmetry or Deviation
Tip asym m et r y or deviat ion is com m on w h en th e n at u ral
sh ape of th e t ip is m odi ed. Exact p osit ion ing of th e cau-
■ Key Technical Points dal sept um or septal exten sion graft in th e m idlin e is a key
elem en t to preven t th is com plicat ion . In addit ion , t ip on lay
1. An on lay cap graft th rough th e en don asal approach
graft s n eed exact an d sym m et ric p osit ion ing an d su t u ring.
is best ach ieved by adequate pocket dissect ion ,
In m any cases, a ver y m ild asym m et r y of th in , sm all low er
careful graft car ving, an d exact posit ion ing th rough
lateral cart ilage is easily cam ou aged by th ick n asal skin .
gu idan ce su t u re.
How ever, ever y e ort n eeds to be exerted in graft car ving
2. A com bin at ion of in terdom al sut ure, colum ellar an d p osit ion ing to avoid asym m et r y or t ilt ing.
st ru t , an d on lay t ip graft s th rough th e en don asal
ap proach gives a m in or to m oderate t ip
augm en t at ion w ith gen tle cep h alic rotat ion . Graft Show ing
3. A sept al exten sion graft is design ed w ith
con siderat ion of th e vector n eeded to augm en t or Graft sh ow ing is n ot in frequ en tly seen in th in -skin n ed
rot ate th e t ip . pat ien t s. Carefu l car ving an d avoiding overly aggressive
4. Th e overlapping t ype of sept al exten sion graft is elevat ion w ill preven t th is in m ost cases in m edium - to
cen tered in th e m idlin e by carefu l car ving an d th ick-skin n ed pat ien ts. How ever, in th e ver y th in -skin n ed
p osit ion ing of th e graft to avoid t ip deviat ion . pat ien t , even th is kin d of m easu re w ill even t ually en d up
w ith th e graft ing sh ow ing. Perich on drium , fascia, or soft
5. Th e en d-to-en d t ype of sept al exten sion graft is
t issue covering w ith ext rem e care on th e beveling of th e
p u t bet w een th e m edial crura an d align ed w ith
graft s h elp s to p reven t graft sh ow -u p .
th e caudal sept um in en d-to-en d fash ion w ith
gu re-of-8 su t u res. It is fu r th er rein forced w ith
exten ded sp reader graft s or th in bat ten graft s.
Pain or Discomfort
6. Various tip m odifying techniques including shield grafts,
cephalic resection, lateral crural grafts, prem axillary Pain or d iscom for t of th e t ip u su ally disap pears as t im e
grafts, and alar rim grafts, are properly m ixed w ith goes by, bu t occasion ally th is rem ain s con t in u ou sly long
septal extension grafts to further m odify the tip. after su rger y. Too m u ch st retch ing of th e t ip by overzeal-
ous project ion using a sept al exten sion graft , using a h ard
m aterial su ch as sept al bon e or Med por for a sept al exten -
a b c
Fig. 4.15 (a–c) Case 1. A slightly low dorsum and less than ideal tip projection are observed from the preoperative photos.
a b c
Fig. 4.17 (a–c) Case 1. Six months after surgery, the well-augmented dorsum and the tip are in balance.
a b c
Fig. 4.18 (a–c) Case 2. Preoperative photographs. Before surgery, a low dorsum with a poorly projected tip is evident.
58 II Rhinoplast y
a b c
d e f
Fig. 4.19 Case 2. Intraoperative photographs. (a) Rib cartilage harvest. (b) Septal extension graft using septal cartilage and reinforce-
ment with rib cartilage. (c) Repositioning of lower lateral cartilage. (d) Alar rim graft. After making an incision lateral to the nasal facet
and tunneling along the alar rim, a pre-designed piece of cartilage is inserted into the pocket. (e) Cap graft, lateral crural onlay graft, and
coverage with perichondrium. (f) Dorsal onlay graft with carved rib cartilage.
a b c
Fig. 4.20 (a–c) Case 2. Photos taken 1 year after surgery show a naturally augmented dorsum and the tip with good alar-columellar
relationship.
4 Nasal
Tip
Modi cation
in
Asians:
Augm ent ation
and Control 59
Rot ation
Pearls
• Th ree com m on feat u res of th e Asian h um p n ose • Am ong variou s tech n iqu es for addressing h u m p
are sm all size, low radix/low dorsu m , an d u n der- n ose, con ser vat ive h um pectom y of th e bony an d/or
projected t ip. cart ilagin ous h um p, follow ed by radix an d/or dorsal
• Managem ent strategy should be focused on achieving augm en tat ion is th e m ost com m on ly u sed m eth od.
an ideal n asal pro le and not on hum p rem oval. • In case of a large h u m p , com pon en t h u m p resect ion
• Obt ain ing a n at u ral brow t ip aesth et ic lin e in th e w ith recon st ruct ion of th e rh in ion using spreader
fron t al view is as im p ort an t as obt ain ing an ideal graft s is recom m en ded.
pro le in th e lateral view. • Com plicat ion s of h um p reduct ion in clude inverted-V
• Th e am oun t of h um p resect ion sh ould be deform it y, dorsal irregularit y, an d n asal obst ruct ion .
tailored based on th e predicted am oun t of dorsal Th ese can be preven ted by con ser vat ive h um p
augm en tat ion an d t ip p roject ion . rem oval and u se of spreader grafts or cam ou age
• Radix an d t ip augm en t at ion often m in im izes or graft s.
obviates th e n eed for h um p rem oval.
60
5 Hum p Resection 61
Fig. 5.1 Starting point of the nose in Asians. The ideal starting
point of the nose or the level of the nasion in Asians is considered
to be in bet ween the supratarsal crease and the midpupillary line.
Fig. 5.3 Thickness of the dorsal nasal skin. The dorsal nasal skin
is thickest in the nasion and thinnest in the rhinion, resulting in a
slight natural convexit y in the rhinion area.
b
a
c d
Fig. 5.6 Component hump reduction 1. (a) Visualization of the hump. (b) Upper lateral cartilages separated from the septum. (c) Reduc-
tion of the cartilaginous hump with a no. 15 blade. (d) Reduction of the bony hump with a Rubin osteotome.
a b c
Fig. 5.7 Component hump reduction 2. The upper lateral cartilages can be (a) trimmed with scissors or (b,c) used as autospreader aps.
5 Hum p Resection 65
Spreader Grafts
Sp reader graft s are p referably p osit ion ed bilaterally in
pat ien t s in w h om w e h ave resected substan t ial am oun ts of
dorsal sept u m in th e rh in ion area (Fig. 5.8). Th e reason s
for in corp orat ing spreader grafts after a h u m pectom y are
as follow s:
a b
c d
Fig. 5.9 Conservative humpectomy in a small Asian hump nose. (a) Visualization of the hump. (b,c) Bony humpectomy using osteotome
and rasp. Bony humpectomy reveals overlapping cartilaginous vault in the rhinion. (d) Reduction of the cartilaginous hump (dorsal septum
and upper lateral cartilage).
a b
c d
Fig. 5.10 Radix and dorsal augmentation. (a) Radix augmentation with crushed cartilage, (b) Radix and dorsal augmentation with ePTFE.
(c) Radix augmentation with periosteum. (d) Radix and dorsal augmentation with perichondrium.
5 Hum p Resection 67
1. Th e open approach
■ Case Studies 2. Septoplast y an d septal cart ilage h ar vest
3. Tip -plast y w ith colum ellar st rut an d cap graft
Case 1 4. Con ser vat ive en bloc resect ion of th e bony-
cart ilagin ous h um p w ith bony rasping
A 35-year-old fem ale p at ien t com p lain ed of a bu m p on
h er n ose (Fig. 5.11). Ch aracterist ics of h er n ose in clu ded 5. Radix augm en tat ion w ith bruised septal cart ilage
a m oderate h u m p w ith a low radix, a sligh tly u n der-p ro - The 1-year postoperat ive ph otos sh ow im proved brow
jected t ip , an d m oderately th ick skin . Operat ive tech n iqu es t ip aesth et ic lin es in th e fron t al view. Lateral an d oblique
w ere as follow s: view s sh ow a w ell-balan ced p ro le w ith sm ooth dorsu m
an d in creased t ip p roject ion an d rot at ion .
a b c
d e f
Fig. 5.11 Case 1. (a–c) Preoperative facial photographs of a 35-year-old female patient show a m oderate hump, low radix, and a slightly
under-projected nasal tip with moderate skin thickness. (d–f) Postoperative 1-year facial photographs show a balanced pro le with aug-
mentation of the radix and the tip.
5 Hum p Resection 69
a b c
d e f
Fig. 5.12 Case 2. (a–c) Preoperative facial photographs of a 23-year-old female patient show a generalized hump and slightly bulbous,
under-projected nasal tip with moderately thin skin. (d–f) Postoperative 1-year facial photographs show a balanced pro le with reduction
of the hump and the tip re ned. A straight nose with sm ooth brow tip aesthetic lines of adequate width is also noted in the frontal view.
5 Hum p Resection 71
Pearls
• Precise preoperat ive clin ical an alysis of extern al origin ates from th e in tegrit y of th e keyston e area,
an d in tern al n asal st ru ct u res is th e corn erston e of a rein forcem en t of th e L-st rut , an d a xat ion to th e
su ccessfu l correct ive rh in op last y. an terior n asal sp in e.
• It is essential to have a su cient preoperative • All ext rin sic an d in t rin sic deform ing forces sh ou ld
discussion bet ween the patient and the surgeon be evaluated an d relieved in t raoperat ively w ith
about the surgical options and w hat can be corrected. m et icu lou s m an ip u lat ion of each osteocart ilagin ou s
• Facial asym m et r y sh ould be th orough ly evaluated fram ew ork.
preoperat ively, an d th e pat ien t sh ould be in form ed • Bony deviat ion is corrected w ith accurate
of th e result s of th e evaluat ion . osteotom ies based on detailed evaluat ion of each
• Th e surgeon sh ou ld con sider cosm et ic im provem en t bony pyram id.
of th e deviated n ose as w ell as its fun ct ion al • Th e preferred tech n iqu es for correct ion of th e low er
restorat ion . t w o-th irds of a deviated n ose are use of a spreader
• Dorsal deform it ies frequ en tly accom pany a deviated graft an d septal exten sion graft .
sept u m , an d th e m ost im port an t step in correct ive • Deform ed osteocart ilagin ou s fram ew orks sh ou ld
rh in oplast y is to create a st raigh t sept um along th e be m an aged in a con ser vat ive m an n er to th e exten t
m idlin e. possible.
• Th e stabilit y of a recon st ructed n ose is determ in ed • Postop erat ive care an d follow -u p are as im p ort an t as
by th e st rength of th e st raigh ten ed sept um , w h ich th e surger y.
72
6 Correction of the Deviated, Twisted Nose 73
Fig. 6.1 Facial midline and brow tip aesthetic line. The brow tip
aesthetic line begins at the medial brow, curving inferiorly along
Common causes of facial the dorsal border, and gently blending with the tip-de ning point.
It should be parallel, uninterrupted, and symmetric.
asymmetry include :
• Di eren ce in facial w idth
• Asym m et ric eyebrow s Examination of the Internal Nose
• Orbit al level di eren ce
• O -cen ter an terior n asal spin e A p at ien t w ith a deviated n ose sh ou ld be assessed for th e
• Lateral p lacem en t of th e p iriform apert u re presen ce of n asal obst ruct ion . Th rough en doscopic exam i-
• Non h orizon tal alar base nat ion of th e n asal cavit y an d n asop h ar yn x, p aten cy of th e
extern al an d in tern al valves, sept al deviat ion , an in ferior
• Maxillar y or m an d ibu lar hyp er-/hyp op lasia
t urbin ate con dit ion , aden oid hypert rophy, an d any abn or-
• Malar prom in en ce or recession
m al n dings m u st be evalu ated preoperat ively.4 Th ese
a b
alterat ion s sh ou ld be som ew h at pred ict able p reop erat ively Surgical Planning
by several test s, such as acoust ic rh in om et r y an d paran asal
com puted tom ography. If th ere is anyth ing th at could cause Th e n ext step is plan n ing th e surgical procedure based on
n asal obst ru ct ion , it sh ou ld be m an aged d u ring correct ive clin ical an alysis. Th e surgical plan m ay con sist of correct ion
rh in op last y. of th e deform it y an d rein forcem en t of th e fram ew ork. Th e
ap prop riate ap p roach an d su rgical tech n iqu es sh ou ld be
determ in ed according to th e deform it ies of each an atom ic
Examination of the Nasal Skin and
elem en t . If use of a graft tech n ique is an t icipated, th e sur-
Soft Tissue Envelope geon sh ou ld kn ow th e m aterials p referred by th e pat ien t
before th e surger y.7 Pat ien t s m ust be in form ed abou t th e
Th e clin ical an alysis of extern al n asal deform it ies sh ould
pros an d con s of each graft m aterial, in cluding autologou s
in clu de an evalu at ion of th e skin –soft t issue envelope
(sept al, con ch al, or costal cart ilage), allograft (fascia lat a,
(SSTE). If th e pat ien t h as a th ick SSTE, it w ill t ake longer
alloderm ), an d ar t i cial m aterials (Gore-Tex, silicon e).8
for th e ed em a to su bside an d w ill disru pt th e postopera-
t ive aesth et ic outcom e.5 In con t rast , a th in SSTE is likely to
reveal sm all rem n an t deform it ies u n dern eath th e skin .
Patient Interview and Selection
Medical Photography On ce th e su rgeon h as develop ed a p lan , th ere sh ou ld be a
discu ssion w ith th e pat ien t about th e det ails of th e pro-
Stan dardized ph otograp h s are essen t ial in th e preop erat ive cedure an d expected surgical ou tcom e. Becau se th ere can
facial evalu at ion to con rm th e clin ical an alysis of th e n ose be discrepan cy in th e de n it ion of an opt im al outcom e
an d th e face. Fron tal, lateral, obliqu e, basal, an d bird ’s-eye bet w een th e perspect ives of th e surgeon an d th e pat ien t ,
view s are th e basic p h otograp h s th at sh ou ld be obt ain ed. th e surgeon sh ould explain th e result s of th e an alysis an d
Med ical p h otograp h s en able th e iden t i cat ion of im por- th e expected outcom e of surger y based on th e ph otograph s.
tan t facial n dings th at m ay h ave been m issed during Addit ion ally, th e su rgeon sh ou ld exp lain th e p oten t ial dif-
in it ial in spect ion an d allow for com parison of th e p ostop - feren ces bet w een surgical goals an d ult im ate outcom es.
erat ive ou tcom e an d p reop erat ive st at u s.6 Th e n al step of th e preoperat ive evalu at ion is pat ien t
Fu n dam en t al facial an alysis in clu des m easurem en t s select ion , an d th is is as im p ort an t as th e clin ical assess-
an d evalu at ion of p roport ion s of th e eyebrow s, m edial can - m en t . Pat ien ts w h o h ave a realist ic exp ectat ion for th e
th us, n asion , rh in ion , alar sidew all, alar facial ju n ct ion , col- su rger y an d an u n derst an ding of th e su rgical lim itat ion s
u m ella, colu m ellar-labial ju n ct ion , ph ilt ru m , m outh angle, are good su rgical can didates. Su rgeon s sh ou ld p ay part icu -
an d gn ath ion (Fig. 6.4). lar at ten t ion to detect poor surgical can didates w h o sh ow
6 Correction of the Deviated, Twisted Nose 75
Fig. 6.4 Facial analysis. The nasion, nasal tip, and philtrum
should all be along the midline. The distance from each
landmark on both sides to midline should also be the same.
Evaluation of facial asymmetry is very important in consulta-
Facial analysis
tion of deviated nose.
• Eyebrows
• Medial canthus
• Nasion/rhinion
• Alar side wall
• Alar facial junction
• Columella
• Columellar–labial junction
• Philtrum
• Mouth angle
• Gnathion
excessive con cern abou t m in or deform it ies or h ave u n real- lin e for surger y. Th e deviated n ose n eeds to be an alyzed
ist ic expect at ion s. according to each an atom ic dom ain (u p p er, m iddle, an d
low er th ird) an d reciprocal relat ion sh ips from a perspec-
t ive of align ing to th e m idlin e.
■ Surgical Techniques
Upper-Third Deviations
Choice of Approach
Deviat ion of th e u p per on e-th ird of th e n ose is cau sed
Th e ch oice bet w een en don asal an d extern al approach es by asym m et r y an d h um p of th e bony pyram ids. Th rough
depen ds on th e surgical plan an d th e surgeon’s preferen ce.6 m et icu lou s p alp at ion an d com pu ted tom ography, th e size,
Alth ough p reop erat ive clin ical an alysis m ay en able selec- sh ape, an d sym m et r y of each bony pyram id sh ou ld be
t ion of a part icular approach , pat ien t s w h o un dergo th e evaluated. In cases of m in or deform it ies, th e bony dorsu m
en don asal ap proach m u st be in form ed of th e p ossibilit y of can be corrected by a cam ou age or rasping tech n ique. A
conversion to an extern al approach for m ore com plete cor- pat ien t w h o h as on ly a deviated bony dorsum is likely to
rect ion . In gen eral, th e en don asal approach can be app lied have a h istor y of n asal t raum a or a h um ped bony pyra-
for cases w ith subtle deform it ies of th e u pp er or m iddle m id.12 Gen erally, m ost bony pyram idal deviat ion s en tail a
vau lt , an d for p at ien ts w ith keloid, w h o requ ire avoidan ce de ected m iddle th ird of th e n asal d orsu m .
of unpredict able con t ract ures associated w ith an open
ap proach .9 Meanw h ile, an extern al ap p roach is p referred Cam ou age
for th e m an agem en t of deviat ion of th e low er t w o-th ird s
an d severe asym m et ries of th e n asal bon e, an d som e cases Th is tech n ique can be applied to a pat ien t w h o h as a
requ ire m axim al exp osu re, m obilizat ion , an d resh aping. localized depression or asym m et r y of th e bony pyram id.
Th rough bilateral m argin al in cision s con n ected to a t ran s- Crush ed sept al cart ilage is th e preferred graft m aterial. Th e
colum ellar inverted-V in cision , com plete exposure of th e m aterial is p laced u n der a periosteal ap to redu ce m obilit y
n asal t ip an d m idvau lt in th e su praperich on drial plan e can an d visibilit y. Th e skin over th e bony dorsu m is relat ively
be ach ieved. To approach a bony pyram idal deform it y, an th in ; th erefore, the surgeon m ust be cer tain to con ceal th e
exten ded dissect ion in th e su bp eriosteal plan e is essen t ial. con tour of th e graft on th e skin .13
Rasping
Correction of Deviation
In som e cases w ith bony pyram idal deform it ies, rasp ing
Alth ough th ere h ave been variou s classi cat ion s for th e can be a conven ien t surgical m odalit y. If th e bony pyra-
deviated nose,3,4,10,11 th ey all originated from th e n eed for m id h as a sym m et ric arch bu t th e dorsal p ro le is devi-
stat ist ical an alysis of ou tcom es rath er th an a clin ical gu id e- ated or deform ed, th e rasp can be solely applied to correct
76 II Rhinoplast y
th e deform it ies. In m any cases, rasping is used to t rim th e ten t , an d double lateral (Fig. 6.5). Th ough osteotom ies are
dorsal con tou r before bony pyram idal recon st ruct ion of u sually perform ed un dern eath th e soft t issue envelop e, a
asym m et rical n asal bon es th rough osteotom ies. It sh ou ld percut an eous extern al approach can be used for lateral an d
be n oted th at rasping m ust be perform ed carefully w ith t ran sverse osteotom ies. Pun ct ure site visibilit y after percu-
con siderat ion of h ow th e bony pyram id w ill be posit ion ed tan eous osteotom y is n egligible.16 To produ ce an accurate
after th e recon st ru ct ion . fract u re lin e despite an atom ic di cu lt ies, th e t ip of th e
osteotom e sh ould alw ays be sh arp.
Osteotom y
Lateral Osteotomy
Th e osteotom y is on e of th e m ost essen t ial bu t di cu lt
tech n iqu es of correct ive rh in oplast y. It involves cut t ing th e Th e purpose of th e lateral osteotom y is to cu t th e n asal dor-
n asal pyram id bon es to correct a deviat ion . With out oste- su m from th e side w all. It en ables th e su rgeon to obtain
otom ies, th e deviated bony dorsu m can n ot be com p letely com plete m obilit y of th e n asal bon es an d th en reposi-
corrected. Th e osteotom y is a blin d procedure, w ith n o t ion th em on th e m idlin e. As sh ow n in Fig. 6.6, th e lateral
direct visualizat ion of cut t ing lin es; th erefore, it is ch al- osteotom y m akes a con t in uous cu r ved fract ure lin e on th e
lenging to learn . Th u s, surgeon s sh ould m ake an e ort to lateral asp ect of th e bony pyram id w ith an osteotom e an d
gain reliable an d reprodu cible su rgical skills. h am m er. En don asal osteotom y is frequen tly perform ed
To avoid un n ecessar y com plicat ion s, it is essen t ial to u sing th e vest ibular approach . First , a sm all lin ear in cision
h ave sou n d kn ow ledge of th e basic an atom y of th e bony is m ade w ith a n o. 15 blade on th e lateral en don asal w all at
dorsu m before perform ing an osteotom y. Th e bony dor- th e an terior m argin of th e in ferior t urbin ate. Th en iris scis-
su m is com p osed of th e fron t al bon e, n asal bon e, an d fron - sors are in serted to dissect th e soft t issu es in th e su bp eri-
tal process of th e m axilla; an d th ese st ruct ures are join ed osteal plan e along th e lateral rim of th e piriform aper t ure.
togeth er. Th e ch aracterist ics of th e bon e, especially ch anges Th e dissect ion on ly n eeds to be w ide en ough to in sert a
in th ickn ess, sh ou ld be un d erstood . Gen erally, th e n asal gu ard ed osteotom e (cu r ved or st raigh t). W h en determ in -
bon e is th icker in m en th an in w om en . It is th ickest at th e ing th e start poin t of a lateral osteotom y, Webster’s t riangle,
n asofron tal su t u re lin e (5 to 6 m m ) an d th en becom es pro- w h ich is a sm all t riangular port ion of th e fron t al process of
gressively th in n er tow ard th e low er m argin (2 to 3 m m ).14,15 th e m a xilla, sh ould be preser ved because th e in ferior t ur-
Th e lateral w all of th e bony dorsum con sist s of th e n asal bin ate in ser ts in to th is st ruct ure. Oth er w ise, th e in tern al
bon e an d th e fron tal process of th e m axilla, an d th e th ick- valve m ay be com p rom ised (Fig. 6.6). Th e t riangle can be
n ess of th e lateral p rocess is less th an 2.5 m m . preser ved by start ing th e osteotom y at th e sligh tly an tero-
Th ere are various t ypes of osteotom y, in cluding m edial su p erior p oin t of th e p iriform ap ert u re edge.17 Th rough
(m edial obliqu e, param edian ), lateral, t ran sverse, in term it- caut ious palpat ion of th e guard t ip, th e lateral osteotom y
2
1
1 Lateral osteotomy
2 Medial osteotomy (medial oblique)
3 Transverse osteotomy
4 Medial osteotomy (paramedian)
5 Intermediate osteotomy
6 Correction of the Deviated, Twisted Nose 77
eith er in t rin sic or ext rin sic. Release of ext rin sic forces is
essen t ial to correct th e cart ilagin ou s sept al deform it y, an d
th ese preven t surgical failure or recu rren ce.20 Ext rin sic
forces m ay origin ate from th e u p per lateral cart ilage, bony
sept u m , n asal spin e, septal m u cosa, low er lateral car t i-
lage, an d colu m ellar soft t issu e. Th rough elim in ation of th e
e ect s of ext rin sic forces on e by on e, a d eviated sept u m can
be st raigh ten ed. If th e freely m obilized sept um sh ow s any
d eform it y, in t rin sic deform ing forces m ust be add ressed
an d corrected. In t rin sic forces can be released by w eaken -
ing th e car t ilage or th rough rein forcem en t w ith su t ures
an d graft s.
Th e sept um sh ould be st raigh ten ed w h ile m axim iz-
ing residual dorsal n asal su pp ort . With th ese t w o goals
in m in d, th e deviated port ion of th e sept u m sh ou ld be
resected w h ile p reser ving at least an 8- to 10-m m dorsal
Fig. 6.7 L-strut of septal cartilage. It is important to preserve the
an d cau dal L-st ru t (Fig. 6.7).21 Th e resect ion can in clu de
L-strut with at least an 8- to 10-m m width to prevent saddle nose
th e m a xillar y crest , th e perpen dicular plate of th e eth m oid,
deformit y. The size of the L-strut depends on the strength and sti -
an d th e vom er. In th e keyston e area, th e L-st ru t sh ou ld ness of the remaining septal cartilage.
rem ain at t ach ed to th e perpen dicular plate. In addit ion , th e
at t ach m en t bet w een th e n asal spin e an d th e caudal port ion
of th e L-st rut sh ould be preser ved if possible. If th e cau dal
sept u m is su blu xated from th e m idlin e of th e n asal sp in e,
th e sept um n eeds an atom ic correct ion w ith separat ion Th rough m et iculous dissect ion of th e m idvault in th e
from th e n asal spin e an d low er lateral car t ilage, follow ed su p rap erich on drial p lan e, th e n asal dorsu m is exp osed
by xat ion using a gure-of-8 su t ure tech n ique (Fig. 6.8). en ough to be evalu ated . After in t raop erat ive evalu at ion of
Variou s su rgical tech n iqu es can be ap p lied for st raigh t- any dorsal deform it ies an d cau sat ive factors for each an a-
en ing th e sept u m , in clu d ing th e sw inging door tech n iqu e, tom ic com pon en t , th e bilateral su bp erich on d rial d issect ion
w edge resect ion , bat ten graft , sp reader graft , cu t t ing an d of the sept um is exten ded to th e dorsal sept u m an d across
su t u re tech n iqu e, an d scoring an d su t u re tech n iqu e.22,23,24,25,26 th e upper lateral cart ilage w h ile preser ving m ucoperich on -
In com plex cases, ext racorp oreal septop last y m ay be an drial in tegrit y. Th e dissect ion sh ould be w ide en ough to
e ect ive, safe, an d reliable tech n iqu e, especially for m ark- align th e sept u m to th e m idlin e. Next , th e dorsal sept u m is
edly t w isted n oses u n dergoing su rger y.27,28 released from th e upper lateral cart ilage, an d th is en ables
evalu at ion an d assessm en t of any in t rin sic deform it y of th e
Middle Third dorsal sept um . In th e presen ce of dorsal sept al deviat ion , a
un ilateral or bilateral spreader graft m ay be th e t reat m en t
After th e st raigh ten ed n asal sept u m h as been align ed in of choice (Fig. 6.9).
th e m idlin e, th e m idvault m u st be recon st ructed to ach ieve Th e spreader graft acts to x th e dorsal sept um in to a
an aesth et ic an d fu n ct ion al ou tcom e. Using variou s sept al st raigh t orien t at ion an d p reven t late ret u rn of th e defor-
su p p or t ing grafts an d p recise su t u re tech n iqu e, th e m id- m it y. In addit ion , th e graft s can m ain t ain or restore th e
dorsu m sh ould be rm ly st raigh ten ed. in tegrit y of th e in tern al n asal valves. Th e ideal graft m ate-
Fig. 6.8 Repositioning of the dislocated caudal septum . When the caudal septum is subluxated, it is frequently necessary to separate
the cartilaginous septum from the underlying bone. Then disarticulated cartilage should be xed to the anterior nasal spine using sutures.
6 Correction of the Deviated, Twisted Nose 79
Lower Third
As in th e m idvault , correct ion of low er-th ird deform it ies is
based on h ow to m ake a st raigh t an d st rong caudal sep -
t um . Deform ing forces from th e cart ilagin ous fram ew ork
of th e m idvault frequen tly a ect th e t ip; th erefore, a care-
fu l dissect ion is som et im es n eeded to det ach th e low er
lateral car t ilages from th e up per lateral cart ilage. If th e
caudal sept um is n ot in th e m idlin e, it sh ould be carefully
released from th e m axillar y crest an d an terior n asal spin e
an d a xed to th e m idlin e. Fu rth erm ore, if th ere is congen i-
tal deform it y or post t raum at ic ch ange of th e an terior n asal
spin e or m axillar y crest it self, th ese deform it ies sh ou ld be
preferen t ially corrected. Caudal deviat ion of th e sept um
can be e ect ively corrected w ith an exten ded spreader
graft or sept al bat ten graft u sing h ar vested car t ilagin ou s
Fig. 6.9 Spreader graft. After separation of the upper lateral carti-
an d bony sept u m .31
lage from the septal cartilage, a spreader graft is inserted and xed
Th e n ext step is to create a rm ver t ical st ru t in th e
using 4–0 PDS. This procedure is helpful in widening the air passage
as well as in cosmetic improvement of m iddle-third deviation. m idlin e. A sept al exten sion graft is u sefu l w h en th e t ip
is w eak or d eviated . It is e ect ive for obt ain ing a st raigh t
cau dal en d an d p rom in en t project ion . How ever, on e m u st
be carefu l to avoid fu n ct ion al n asal obst r u ct ion cau sed
rial is septal car t ilage, esp ecially th e p osteroin ferior p or- by th e th icken ed cau dal sept u m , an d th e p at ien t sh ou ld
t ion , w h ich h as th e m ost con sisten t w idth . Th e grafts are be in form ed of th e loss of exibilit y of t h e m em bran ou s
secu red w ith several 5–0 PDS m at t ress su t u res p arallel to sept u m . Th e en d of th e sept al exten sion graft sh ou ld be
th e dorsal sept u m . To decrease th e likelih ood of recurren ce, beveled an d is a xed to th e cau dal sept u m w ith m u lt i-
th e deviated sept al cart ilage can be cross-h atch ed before p le an ch oring su t u res. Th e sept al exten sion graft act s as
su t u ring. In th e case of ou t w ard bow ing of th e m idvau lt on a reliable st ru t n ot on ly for su p p or t ing th e low er lateral
th e convex side of th e dorsum , a bat ten graft can be placed car t ilages, bu t also to con t rol t ip p osit ion an d de n it ion
below the jun ct ion of th e sept um an d upper lateral car t i- (Fig. 6.11). Th e d egree of t ip p roject ion an d rot at ion , an d
lage. As sh ow n in Fig. 6.10, sligh t dorsal d eviat ion can be t h e colu m ellar pro le an d st rengt h can be deter m in ed by
st raigh ten ed th rough th e di eren t ial su t u re bet w een th e t h e size an d sh ape of t h e design ed graft an d th e p osit ion . A
u p p er lateral cart ilage an d septal d orsu m .29 Sim ilarly, th is m ore st able colu m ella recon st r u ct ion is obt ain ed th rough
su t u re tech n iqu e can be u sed to correct rem n an t deviat ion t ight xat ion of each of th e m iddle an d m edial cr u ra to th e
after a sp reader graft .30 septal exten sion graft .
a b
Fig. 6.10 Oblique suture to correct cartilaginous deviation. Compared with the horizontal suture, the di erentially oblique suture pro-
vides force to draw deviated septal cartilage to the midline. This technique can be used to correct the cartilaginous deviation (a) without
or (b) with a spreader graft.
80 II Rhinoplast y
5. In correct ion of th e t w isted n ose, st raigh ten ing an d year after su rger y; th erefore, th e pat ien t sh ou ld be given
rein forcem en t of th e n asal car t ilagin ou s sept um reassu ran ce. In som e cases w ith excessive scarring, local
are th e m ost im port an t p rocedu res. For th is, th e steroid (t riam cin olon e acetate) inject ion m ay be h elpfu l.
sept u m sh ou ld be released from ext rin sic d eform ing Su p er cial inject ion sh ou ld be avoided to preven t w h it ish
forces, w ith su bsequ en t assessm en t of th e in t rin sic pigm en t at ion . Of n ote, steroid inject ion can resu lt in sub -
d eform it ies, w h ile preser ving th e L-st rut . derm al at rophy w ith subsequen t u n desirable problem s,
6. The in tegrit y of th e keyston e area m ust be in cluding dorsal con tour deform it ies an d t ran slu cen cy of
m ain t ain ed an d th e cau dal en d of th e L-st ru t sh ou ld th e epiderm is.
be rm ly a xed to th e an terior n asal spin e using
a gu re-of-8 su t u re. If th e an terior n asal sp in e is
d isp laced, it sh ou ld be rep osit ion ed. Dorsal Irregularity/ Deviation
7. A spreader graft is a usefu l tool for sim ultan eous
In som e p at ien ts, dorsal deviat ion or irregu larit y can pres-
st raigh ten ing an d rein forcem en t of th e car t ilagin ou s
en t d u ring th e p ostoperat ive p eriod. Th e cau se an d degree
d orsu m .
of deform it ies sh ould be evaluated to determ in e w h eth er
8. Tip correct ion is based on a st raigh t an d st rong revision surger y is n eeded. Com m on causes of late bony
caudal sept u m as a reliable ver t ical st rut in th e deviat ion are listed below. Im m ediate postoperat ive devia-
m idlin e. t ion sh ould be reassessed as soon as possible, an d m in or
9. The a xat ion of low er lateral car t ilages sh ould be deform it ies in th e early postoperat ive period can be cor-
adju sted for ideal sym m et r y of each dom e at th e rected w ith m an ual pressure. If revision is required, it can
m idlin e. be don e 6 to 12 m on th s after th e prim ar y surger y.
10. The colum ellar in cision sh ould be repaired w ith
m et icu lou s su t u ring w ith ou t ten sion .
Causes of late deviation of the bony
pyramid include :
■ Complications and
Their Management • In com p lete osteotom ies: in com p lete con n ect ion
bet w een th e m edial an d lateral osteotom ies.
Mem or y of th e overlying soft t issu e can p u ll th e
Bleeding/ Hematoma n asal bon e to th e origin al posit ion .
• In com p lete correct ion of th e p osterior–su p erior
Sligh t postop erat ive oozing is com m on in th e rst 48 h ou rs
de ect ion of th e bony sept um .
after rh in op last y. Toilet gau ze d ressing is h elp fu l to redu ce
pat ien t discom fort , an d h ead elevat ion can reduce bleed-
• In su cien t correct ion of deform it ies of th e
cart ilagin ous low er t w o-th irds.
ing by decreasing ven ous pressu re. If bleeding persists, th e
su rgeon sh ou ld im m ediately evalu ate th e w ou n d. W h en
fu rth er n asal p acking is n ot en ough to con t rol bleeding, th e
su rgeon sh ou ld con sider tot al rem oval of p acking m ate-
rials an d reevalu at ion of th e n asal cavit y. A pat ien t w h o
com plain s of un con t rolled n asal pain sh ould be assessed
for sept al h em atom a. Regardless of locat ion , postoperat ive ■ Case Studies
h em atom as requ ire im m ediate drain age. An u n t reated sep -
tal h em atom a can result in devastat ing com plicat ion s, such Case 1
as sept al abscess an d p erforat ion . In ser t ion of a silast ic
drain in to th e drain age site of th e h em atom a h elps preven t A 22-year-old m an presen ted w ith a crooked n ose th at
recurren ce. had a C-sh aped deform it y of th e sept u m to th e righ t w ith
su bject ive n asal obst ru ct ion on th e righ t side. Th e brow t ip
aesth et ic lin es w ere asym m et ric, an d th e bony an d cart i-
Persistent Edema lagin ou s d orsu m w as o th e m idlin e (Fig. 6.12).
Th is case required correct ion s of both th e bony dorsum
Postop erat ive edem a u su ally occu rs w ith in th e rst 4 an d th e m idvau lt; th erefore, op en correct ive rh in oplast y
w eeks. Variou s m odalit ies are available to m in im ize edem a, w as perform ed. Th e au th or p refers to u se th e extern al
in clu ding cold com presses, h ead elevat ion , t aping, an d ap proach to correct th e low er t w o-th irds deviat ion , w h ich
perioperat ive steroids. Late edem a can be obser ved several usu ally n eeds a spreader graft or septal exten sion graft .
m on th s postop erat ively, an d it origin ates from ongoing scar Th rough th e extern al approach th e auth or can con den tly
rem odeling. Most late edem a is self-lim ited arou n d th e rst ap ply graft m aterials as w ell as evalu ate th e an atom ic
82 II Rhinoplast y
abn orm alit ies. In term s of order of procedu res, septoplast y In th is case, su rgical tech n iqu es in clu ded lateral an d
is carried ou t rst after elevat ion of th e skin soft t issu e m edial osteotom ies, release of th e cart ilagin ou s sept u m
envelop e. If th ere is a h u m p deform it y, rasp ing or h u m p ec- from th e u pp er lateral car t ilage, a left-sided sp read er graft ,
tom y is don e. Th e n ext step is to correct th e low er t w o- septoplast y, rep osit ion ing an d rein forcem en t of th e cau -
th irds deform it ies using graft ing an d sut ure tech n iques. dal sept al L-st rut w ith a gu re-of-8 su t ure an d colu m ellar
This is follow ed by t ip surger y, w h ich is m ain ly for cosm et ic st rut , ceph alic t rim of th e low er lateral car t ilage, an d in ter-
p u rposes. Medial an d lateral osteotom ies are usually don e dom al su t ure on th e t ip. Th e pat ien t w as sat is ed w ith th e
at th e en d of th e operat ion to avoid soft t issu e sw elling du r- fu n ct ion al an d aesth et ic ou tcom es after su rger y.
ing su rger y. In cases w ith a w ide alar base, its correct ion At 1 year after th e su rger y, th e dorsu m h ad a sym m et-
w ill be th e n al procedu re. ric con tou r w ith ou t any p ostop erat ive distor t ion .
a b
c d
Fig. 6.12 Case 1. (a,b) Preoperative frontal and bird’s-eye views show a C-shaped deviated bony and cartilaginous dorsum. (c,d) Postop-
erative photographs show a straightened nose.
http://e-surg.com
6 Correction of the Deviated, Twisted Nose 83
Fig. 6.12 (Continued) (e) Surgical diagram showing the techniques used.
http://e-surg.com
84 II Rhinoplast y
a b c
d e f
Fig. 6.13 Case 2. (a–c) Preoperative photographs show straight bony pyramid but deviated cartilaginous dorsum with mild hump. (d–f)
Postoperative photographs show well-aligned dorsum with reduced hump.
http://e-surg.com
6 Correction of the Deviated, Twisted Nose 85
http://e-surg.com
86 II Rhinoplast y
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2013;38(2):136–141 th e n asal sept u m in th e deviated n ose. Facial Plast Su rg
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Su rg Clin North Am 2012;24(1):95–107 21. Roh rich RJ, Gu n ter JP, Deu ber MA, Adam s W P Jr. Th e de-
5. Ch o GS, Kim JH, Yeo NK, Kim SH, Jang YJ. Nasal skin th ick- viated n ose: opt im izing results using a sim pli ed clas-
n ess m easured using com puted tom ography an d it s ef- si cat ion an d algorith m ic approach . Plast Recon st r Surg
fect on t ip su rger y outcom es. Otolar yngol Head Neck Surg 2002;110(6):1509–1523, discu ssion 1524–1525
2011;144(4):522–527 22. Jang YJ, Yeo NK, Wang JH. Cu t t ing an d su t u re tech n iqu e
6. Stepn ick D, Guyu ron B. Surgical t reat m en t of th e crooked of the caudal sept al cart ilage for th e m an agem en t of cau-
n ose. Clin Plast Su rg 2010;37(2):313–325 dal sept al deviat ion . Arch Otolar yngol Head Neck Su rg
7. Din i GM, Iurk LK, Ferreira MC, Ferreira LM. Graft s 2009;135(12):1256–1260
for st raigh ten ing deviated n oses. Plast Recon st r Surg 23. Pastorek NJ, Becker DG. Treat ing th e cau dal sept al de ec-
2011;128(5):529e–537e t ion . Arch Facial Plast Su rg 2000;2(3):217–220
8. Sh ipchan dler TZ, Papel ID. Th e crooked n ose. Facial Plast 24. Sh een JH. Spreader graft: a m eth od of recon st ru ct ing th e
Su rg 2011;27(2):203–212 roof of th e m iddle n asal vau lt follow ing rh in oplast y. Plast
9. Bagh eri SC, Khan HA, Jah angirn ia A, Rad SS, Mort azavi H. Recon st r Su rg 1984;73(2):230–239
An an alysis of 101 prim ar y cosm et ic rh in op last ies. J Oral 25. Roh rich RJ, Hollier LH. Use of sp reader graft s in th e exter-
Maxillofac Su rg 2012;70(4):902–909 n al approach to rh in oplast y. Clin Plast Surg 1996;23(2):
10. Jang YJ, Wang JH, Lee BJ. Classi cat ion of th e deviated 255–262
n ose an d it s t reat m en t . Arch Otolar yngol Head Neck Surg 26. Byrd HS, Salom on J, Flood J. Correct ion of th e crooked n ose.
2008;134(3):311–315 Plast Recon st r Su rg 1998;102(6):2148–2157
11. Boh lu li B, Moh aram n ejad N, Bayat M. Dorsal h u m p su rger y 27. Lee SB, Jang YJ. Treat m ent outcom es of ext racorporeal sep -
an d lateral osteotom y. Oral Maxillofac Surg Clin North Am toplast y com pared w ith in sit u sept al correct ion in rhino-
2012;24(1):75–86 plast y. JAMA Facial Plast Surg 2014;16(5):328–334
12. Higu era S, Lee EI, Cole P, Hollier LH Jr, St al S. Nasal t rau m a 28. Gu bisch W. Ext racorp oreal septoplast y for th e m ark-
an d th e deviated n ose. Plast Recon st r Surg 2007;120(7, edly deviated sept um . Arch Facial Plast Surg 2005;7(4):
Su p pl 2):64S–75S 218–226
13. Toriu m i DM. St ru ct u re ap proach in rh in op last y. Facial Plast 29. Pon t iu s AT, Leach JL Jr. New tech n iqu es for m an agem en t
Su rg Clin North Am 2005;13(1):93–113 of th e crooked n ose. Arch Facial Plast Surg 2004;6(4):
14. Harsh barger RJ, Su llivan PK. Th e opt im al m ed ial osteoto- 263–266
m y: a st u dy of n asal bon e th ickn ess an d fract u re p at tern s. 30. Guyu ron B, Beh m an d RA. Cau dal n asal deviat ion . Plast
Plast Recon st r Su rg 2001;108(7):2114–2119, discu ssion Recon st r Surg 2003;111(7):2449–2457, discussion 2458–
2120–2121 2459
15. Harsh barger RJ, Su llivan PK. Lateral n asal osteotom ies: im - 31. Byrd HS, An doch ick S, Copit S, Walton KG. Sept al exten sion
p licat ion s of bony th ickn ess on fract u re pat tern s. An n Plast graft s: a m eth od of con t rolling t ip project ion shape. Plast
Su rg 1999;42(4):365–370, discu ssion 370–371 Recon st r Su rg 1997;100(4):999–1010
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7 Correction of the Saddle Nose
Keng Lu Tan and Chae-Seo Rhee
Pearls
• Evalu at ion of th e degree of sept al su p p or t is th e dorsal depression . Subtotal sept al recon st ruct ion
m ost im p or tan t step in p reop erat ive p lan n ing in a w ith cost al car t ilage sh ou ld be adm in istered to
pat ien t w ith saddle n ose deform it y. Th is is becau se a correct th is saddle deform it y.
sadd le n ose is often du e to a dam aged car t ilagin ou s • Class 4 saddle n ose has severe loss of septal
sept u m . cart ilagin ous support w ith both bony an d
• Class 1 saddle n ose has good cart ilagin ous sept al cart ilagin ous dorsal depression , in w h ich case th e
su p p or t w ith a m in or su p ra-t ip dep ression . Th is can dorsal fram ew ork from th e radix to th e t ip n eeds to
be easily corrected by cosm et ic dorsal cam ou age. be tot ally recon st ructed w ith cost al cart ilage.
• Class 2 saddle n ose has m oderate loss of sept al • Correct ion frequen tly requires st raigh ten ing or
cart ilagin ous support w ith m oderate dorsal recon st it u t ing th e L-st ru t . A st able L-sh aped st rut
depression , w h ich can be m an aged by rein forcem en t of sept al car t ilage to th e n asal spin e is crucial to
an d recon st it u t ion of th e sept u m an d/or dorsu m . su p p or t th e u p per an d low er lateral cart ilages to
• Class 3 saddle n ose has severe loss of septal m a xim ize th e resu lts in creat ing a st raigh t an d
cart ilagin ous support w ith a m oderate to severe fu n ct ion al n ose.
87
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88 II Rhinoplast y
Fig. 7.2 The keystone area and saddle. (a) Quadrangular cartilage, as seen in the illustration,
forms the single most important support structure for the nasal dorsum. The area of overlap-
ping with the nasal bone and upper lateral cartilage, the keystone area, deserves particular
attention. (b) When the keystone area is interrupted, it causes instabilit y to the quadrangular b
cartilage and thus saddling of the nasal dorsum, with a resulting inverted-V deformit y.
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7 Correction of the Saddle Nose 89
a b
Fig. 7.3 Loss of support of the nasal septum causes distortion of the lateral cartilages. (a,b) Considerable loss of septal support causes
the upper and lower lateral cartilage to distort. (c) Saddling of middle vault, tip ptosis with cephalic rotation, and columellar retrusion will
develop.
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90 II Rhinoplast y
th e n asal septal vasculat u re w ill even t ually result in a large After extern al an d in tern al exam in at ion , discu ssion
sept al perforat ion , especially in th e cart ilagin ou s p or t ion , about th e p referred sou rces of graft s is m an dator y. Pat ien t s
an d collap se of th e dorsu m . Sim ilar assau lt to th e n asal sep - sh ould be given th e ch oice of au tologou s, h om ologou s, or
t um could be caused by prolonged use of oxym et azolin e syn th et ic graft s dep en d ing on th e circu m st an ces after th e
n asal sp ray or oth er vasocon st rict ive agen ts. pros an d con s of each opt ion h ave been discussed. Rib cage
view s cou ld be n ecessar y if rib cart ilage graft ing is p lan n ed .
Most p at ien t s w an t to correct th e both cosm et ic an d
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7 Correction of the Saddle Nose 91
a b
c d
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92 II Rhinoplast y
Class 3 Saddling
Su btot al recon st ru ct ion of th e n asal sept u m is recom -
m en ded . In th is d egree of sadd ling, on e w ill n d th e sept al
b
cart ilage n ot ju st w eak, bu t w ith part s of it m issing or w ith
volu m e, area, an d in tegrit y loss. Su btot al recon st ru ct ion of
Fig. 7.6 (a,b) The septal extension graft is the workhorse for sup-
th e sept um involves recon st it ut ing th e dorsal h eigh t of th e porting the caudal end of the septum. It can function to strengthen
n ose an d th e project ion an d rot at ion of th e t ip, by recon - and straighten the caudal septum , lift the medial crura of the lower
st ru ct ing th e L-st ru t . Th is m an euver often requ ires abu n - lateral cartilage, increase tip projection, and derotate the tip down-
dan t cost al car t ilage. The process begin s w ith fabricat ion of ward in the case of a rotated tip in a saddled nose.
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7 Correction of the Saddle Nose 93
Class 4 Saddling
A tot al dorsal recon st r u ct ion from t h e radix to t h e t ip is
n ecessar y w h en th ere is m ajor loss in t h e sept al st r u ct u re
an d p ossible loss of th e n asal pyram id bon es. Tot al recon -
st ru ct ion of t h e n asal bon e m ay requ ire a rep lacem en t
graft u sing cost al car t ilage. How ever, in cases of severe
sad d lin g w it h loss of n asal bon e, or if sept al recon st r u c-
t ion is im p ossible or n ot n eeded, a on e-piece dorsal on lay
graft an d exten d ed colu m ellar st r u t cou ld be u sed alter n a-
t ively. Th e exten ded colu m ellar st r u t sh ou ld be st abilized
rm ly to th e an terior n asal sp in e. Th e on e-p iece block of
dorsal on lay graft cou ld be design ed u sing cost al car t i-
lage. It is form ed in to a boat sh ap e. Th e can t ilever on lay
Fig. 7.7 Fabrication of the L-strut. The caudal septum is replaced graft sh ou ld id eally sp an t h e rad ix to th e low er lateral car-
with a at costal cartilage piece and supported with an extended
t ilages. A groove is m ade in th e cau dal en d of th e on lay
spreader graft. The L-strut should sit rmly on the anterior nasal
graft , w h ich is u n ited w ith t h e exten d ed colu m ellar st ru t
spine and not oat on top of it. Support should be provided by it to
the lower lateral cartilages and not the other way around. over th e an ter ior n asal sp in e (Fig. 7.8). Th is can su p p or t
th e n ose w ith ou t recon st ru ct ion of t h e sept u m . Up per an d
low er lateral car t ilages restore to th e st able colu m ellar
st ru t– d orsal graft . Last bu t n ot least , after th e restorat ion
of th e dorsal h eigh t an d t ip p roject ion , t h e n asal t ip n eeds
th e L-st rut using on e or t w o at an d st rong pieces of costal to be addressed m et icu lou sly, w h ich is described in a sep a-
cart ilage or sept al cart ilage. Th is cart ilage sh ould sit rm ly rate ch apter.5
on top of th e an terior n asal spin e, superiorly h eld rm ly by
th e bilateral spreader graft s (Fig. 7.7).
Oth er tech n iqu es th at can p rodu ce th e sam e st abilit y
are to car ve a th ick, st rong p iece of dorsal st ru t to in terlock ■ Key Technical Points
w ith a sh or ter but sim ilar sect ion of cart ilage at th e L-st rut .
1. Tech n iques for a saddle n ose correct ion var y
Th e L-st rut can be an ch ored to th e an terior n asal spin e
depen ding on th e degree of saddling. Proper
w ith 4–0 PDS by drilling a h ole th rough the n asal spin e
assessm en t of th e et iology an d d egree of sad dling
w ith a 1-m m drill bit or a 16-gauge n eedle; or sut ured to
form s th e basis for th e su rgical tech n iqu e u sed.
th e periosteum sn ugly using gure-of-8 sut uring at t w o
p oin t s, on e an terior an d on e posterior. The an terior n asal 2. Th e cam ou age graft is th e m ain tech n iqu e used for
spin e sh ou ld be ren dered st raigh t before th e an ch oring class 1 saddling. Careful design of th e skin pocket is
is don e. Th e L-st ru t sh ou ld be p laced rm ly before th e th e key to a su ccessful surger y in cam ou age graft s.
exten ded sp reader graft s are placed. 3. Class 2 saddling requires par t ial recon st it ut ion an d
Th e n ew dorsum th at th e spreader graft form s sh ould recon st ruct ion of th e sept um an d dorsum .
be st rong an d st raigh t , an d an overlap in to th e n asal bon e 4. Subtot al septal recon st ruct ion is required to address
is som et im es desirable to in crease graft st abilit y w h en th e a class 3 sad dling. More often th an n ot cost al
n asal bon e is stable en ough to en du re osteotom y. Th e t w o cart ilage is n eeded to recon st ru ct th e dorsal su ppor t
sides of th e u p p er lateral car t ilage sh ou ld be rm ly su t u red an d th e L-st ru t . Th ese t w o st ru ct u res w ill form th e
to th e spreader grafts using 5–0 PDS at t w o or th ree poin t s. pillars of n asal dorsal recon st ruct ion .
Sp ecial at ten t ion is to be p aid w ith regards to th e sym m e- 5. Th e recon st ructed caudal L-st ru t n eeds to be
t r y of th e upper lateral car t ilage w h en sut uring so as n ot to an ch ored rm ly to th e an terior n asal sp in e to
cause any iat rogenic deviat ion . preven t long-term sequaelae an d recurren ce of
On ce th e graft s are rm ly in p lace, th e m edial cru ra of sadd ling.
th e low er lateral cart ilages sh ould be sut ured to th e n ew
6. In th e class 4 saddling deform it y, tot al
L-st rut . Re n em en t can be ach ieved by adju st ing th e angles
recon st ruct ion is n eeded to restore n asal dorsal
of sut uring or by n al applicat ion of cam ou age grafts.
h eigh t from th e radix to th e t ip. Com bin ed bony an d
cart ilagin ous dorsal recon st ru ct ion n eeds h inging
w ith th e colum ellar st rut cau dally, bypassing th e
sept al su pp ort .
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94 II Rhinoplast y
a b
c d
Fig. 7.8 Total dorsal reconstruction bypassing septal support. The costal cartilage graft is carved to recreate the dorsum from the radix
to the tip and for bypassing the nasal septum support. (a) An extended colum ellar strut should be stabilized rm ly to the anterior nasal
spine. (b,c) Boat-shaped dorsal onlay graft carved from one piece of costal cartilage. An extended columellar strut is combined with the
onlay graft in tongue-in-groove fashion. The septum was partially replaced using carved costal cartilage. (d) The upper and lower lateral
cartilages are xed to the dorsal onlay graft.
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7 Correction of the Saddle Nose 95
a b c
Fig. 7.9 (a–c) Case 1. The patient had developed saddle nose after septoplast y. A middorsal depression is observed and the septum is too
weak to support an onlay cartilage graft. A dorsal onlay graft was carved from costal cartilage. An extended columellar strut was anchored
rmly onto the anterior nasal spine inferiorly and superiorly and extends into the groove created at the caudal end of the dorsal graft.
a b
Fig. 7.10 Case 1. Intraoperative photos. (a) Dorsal graft carved from the rib cartilage is hinged to the extended columellar strut.
(b) Lower lateral cartilages are reat tached to the new dome created by the grafts.
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96 II Rhinoplast y
a b c
Fig. 7.11 (a–c) Case 1. Six-month postoperative photos show improvement of saddle from three di erent views.
Case 2 rib cart ilage, an exten ded colu m ellar st ru t rein forced w ith
m in i bilateral exten d ed sp reader graft w as u sed for t ip an d
A 22-year-old m ale visited th e clin ic du e to a deform ed caudal support (Fig. 7.13). Lateral cru ral on lay graft s an d
n ose an d n asal obst ruct ion (Fig. 7.12). He h ad a n asal t ip onlay graft s w ere added for t ip con touring. A dorsal
t raum a h istor y in early ch ildh ood. On physical exam in a- on lay graft u sing car ved rib cart ilage w as u sed for dorsal
t ion , h e w as foun d to h ave saddling of th e low er t w o-th irds augm en tat ion .
of h is n ose; an un der-projected, sligh tly upt urn ed n asal Th ree years after surger y, a n orm al-looking n ose can be
t ip; an d hypert rophy of both t u rbin ates. Using au togen ous obser ved in all view s (Fig. 7.14).
a b c
Fig. 7.12 (a–c) Case 2. Preoperative photos show a t ypical severe saddle nose deform it y with middle vault collapse and tip ptosis with
slight cephalic rotation.
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7 Correction of the Saddle Nose 97
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98 II Rhinoplast y
a b c
Fig. 7.14 (a–c) Case 2. Three-year postoperative photos show well-augmented but smooth dorsum and more desirable tip projection
and rotation compared to preoperative status.
References
■ Conclusion
1. Young K, Row e-Jon es J. Current approach es to sept al saddle
Saddle n ose d eform it y correct ion can range from a p ro- n ose recon st ruct ion using autograft s. Curr Opin Otolar yn -
cedure as sim ple as applying a cam ou age graft to a tot al gol Head Neck Su rg 2011;19(4):276–282
n asal recon st ruct ion . Saddle n ose is a com m on problem 2. Kevin Bren n er JC. Saddle nose deform it y. In : Mu rphy M,
presen ted by Asian pat ien t s due to th e in h eren t low -pro le Azizzadeh B, Joh n son CM Jr, Nu m a W, eds. Master Tech -
n ose w ith a soft an d u n d er-developed n asal sept u m su s- n iques in Rh in oplast y. 1st ed. Saun ders; 2011:293–298
cept ible to in sult . As a result , th e volum e an d exten t of sad- 3. Durbec M, Disan t F. Saddle n ose: classi cat ion an d th era-
peut ic m an agem en t . Eu r An n Otorh in olar yngol Head Neck
dle n ose repairs in th e auth ors’ cen ters h ave provided th e
Dis 2014;131(2):99–106
oppor t un it y to gain m u ch experien ce an d re n e tech n iques
4. Tardy ME Jr, Schw art z M, Parras G. Saddle n ose deform i-
in h an dling saddle n ose. It sh ould be assessed m et icu lou sly
t y: autogen ous graft repair. Facial Plast Su rg 1989;6(2):
an d su rger y plan n ed w ith all even t u alit ies an t icipated to 121–134
en su re th e best ou tcom e. Th e best ou tcom e is w h en th e
5. Dan iel RK. Rhin oplast y: sept al saddle n ose deform it y
procedure is don e righ t th e rst t im e. Th at being said, m any an d com posite recon st ruct ion . Plast Recon st r Surg 2007;
of th e recon st ruct ion s for saddle n ose m ay n eed revision s 119(3):1029–1043
in variou s stages.
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8 Alar Base Modi cation
Ian Loh Chi Yuan and Hong Ryul Jin
Pearls
• Modi cat ion s to th e d orsu m an d n asal t ip w ill • It is param ou n t th at a cu r ved port ion of th e n ost ril
a ect th e alar base w id th , as w ell as th e deliberate be preser ved to avoid creat ing a teardrop n ost ril
creat ion of illu sion s, as a resu lt of object ive ch anges. during th e excision design .
• Alar base su rger y sh ou ld be p erform ed as th e n al • Con ser vat ism sh ould be obser ved during resect ion s,
procedure in th e rh in oplast y sequen ce. as correct ion of over-excision is ver y d i cu lt .
• Ap p ropriate design , sym m et r y, an d m et icu lou s • Com plicat ion s of alar base surger y in clude th e
soft t issu e h an dling are p aram ou n t in creat ing th e creat ion of a teardrop n ost ril, asym m et r y of th e
desired outcom e in alar base surger y. nost rils, an d various scar-related com plicat ion s,
• Th e m odi ed Weir excision is th e m ost com m on ly in cluding vest ibular sten osis w ith accom panying
em ployed d esign for East Asian s, w h o t ypically n eed nasal obst ruct ion .
redu ct ion of alar aring, n ost ril size, an d alar base • Most com p licat ion s are iat rogen ic an d can be
w idth . avoided w ith good design an d t issue h an dling.
• Th e use of a cin ch ing sut ure to m ain tain a ten sion - • Th e ben e ts of alar base surger y m ust be w eigh ed
free skin closu re is an im p ort an t p ar t of alar base again st th e poten t ial for com plicat ion s; th is is
su rger y. esp ecially t ru e for East Asian p eop les, w h ose skin is
m ore p ron e to scar-related com p licat ion s.
Th e poten t ial in dicat ion s for alar base surger y are (1)
■ Introduction in creased alar base w idth , (2) excessive aring of th e alar
side w alls, (3) large n ost rils, (4) th ick alar side w alls, (5)
Th e alar base describes th e port ion of th e n ose w h ere th e h ooded or h anging alar side w alls, an d (6) cleft n ose or n os-
alar side w all at t ach es to th e m idface. Modi cat ion to th is t ril asym m et r y.
area ch anges th e alar base w idth , th e degree of alar aring,
an d n ost ril sh ap e an d size. Eth n ic variat ion s in th e alar base
h ave been w ell described. Th e m ajorit y of East Asian n oses
(especially th ose of South east Asian origin ) can n ot con form ■ Patient Evaluation
to th e ideal an atom ic relat ion sh ip described in Cau casian s.
Th e alar base of th e East Asian n ose is w ider com pared w ith A carefu l an d det ailed h istor y sh ou ld be t aken du ring con -
th e European n ose, w ith a m arked ten den cy to are but n ot su ltat ion to id en t ify th e pat ien t’s con cern s. Exam in at ion
to as severe a d egree as th ose fou n d in African s or Sou th - of th e alar base sh ould focus on th e n ost ril shape, size,
east Asian s, in clu ding th ose of Filip in o, Malaysian , In d on e- an d sym m et r y; th e degree of alar aring; an d th e w idth
sian , an d Viet n am ese eth n icit y.1 of th e n asal base. Any pre-exist ing asym m et r y of th e n os-
The shape and extent of alar aring w ill depend on the t rils sh ould be n oted an d poin ted ou t to th e pat ien t , an d
sh ape and elasticit y of th e un derlying n asal cartilage, the corrected w h en ever possible during surger y; th is is also
connection bet w een the lateral crura and th e face, an d the im port an t to avoid any con cern s th at m ay h ave arisen iat-
prom inence of the nasal tip. In addition to the aring and rogen ically after surger y.
w ide alar base, other abnorm alities such as alar rim hang-
ing,2 retrusion of colum ella, w ide colum ellar base, and exces-
sively th ick alar rim should also be con sidered. Tech niques Physical Examination
to change th e alar sh ape are ch osen after assessing all these
param eters individually and judging com prehensively, con - On fron t al view, th e alar rim sh ou ld arc an d en d h igh er th an
sidering harm ony of the ala w ith the rest of the face. th e colum ella, giving a gull’s-w ing-in - igh t appearan ce.
Given th ese eth n ic variat ion s, it sh ou ld n ot be su rpris- Exaggerat ion of th e gull-in - igh t cur ve im plies ret ract ion
ing th at alar base su rger y is on e of th e m ost com m on ly of th e ala or depen den cy of th e in frat ip lobule. On lateral
requested p rocedu res du ring con su ltat ion for East Asian view, th e alar rim u su ally sit u ates 2 to 3 m m above th e
rh in op last y. nasal colum ella, creat ing a colum ellar sh ow. Th e lateral
99
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100 II Rhinoplast y
view is also th e best view for evaluat ing th e alar-colum el- of th e alar base, an d m ay m ake alar base surger y un n eces-
lar relat ion sh ip . W h en th e colu m ella is n ot seen , th is m ay sar y. In case of d ou bt , alar base excision s sh ou ld also be
in dicate a ret racted colu m ella or h anging ala. Norm ally, th e perform ed as a staged procedure, after th e pat ien t h as a
w idth of th e alar base is equal to the dist an ce bet w een th e ch an ce to evaluate th e e ect th at th ese oth er m odi cat ion s
m edial can th i. Th e th ickn ess an d aring of th e ala an d th e m ay h ave on th e alar base.
d egree of recu r vat ure of th e alar base in sert ion s sh ou ld
also be n oted. Ideally, th e n ose as seen from basal view
sh ou ld be an isosceles t riangle w ith a rou n d apex, sligh tly
Quality of Skin
bulging alar side w alls, an d n ost rils t ilted 30 to 45 degrees
Alar base su rger y is essen t ially a skin excision of th e alar
from th e m idlin e, w ith th e ap p earan ce of a p ear. Th e rat io
base region . Th e qualit y of th e pat ien t’s skin is an im por-
of th e colu m ella an d in frat ip lobule is 2:1, an d th e begin -
tan t determ in an t of th e surger y’s outcom e. Th e skin of th e
n ing of th e are of th e m edial cru ral foot p lates divides th e
alar base region is n at u rally th ick an d sebaceou s. In addi-
alar base in to h alves (Fig. 8.1).
t ion , East Asian skin is th icker an d m ore pigm en ted th an
Cau casian skin . Th ese factors p redisp ose th e East Asian
The E ect of Illusions on the pat ien t to hyper t roph ic scarring, keloid form at ion , an d
post-in am m ator y hyperpigm en t at ion w h en un dergoing
Nasal Base alar base su rger y.3
A p at ien t w ith th ick sebaceou s skin w h o gives a h is-
Alth ough alar base su rger y is frequ en tly requ ested as an
tor y of scar-related com p licat ion s sh ou ld be w arn ed of th e
isolated procedu re, th e pat ien t m ust be in form ed th at th e
possibilit y of th ese com plicat ion s w h en plan n ing alar base
ap pearan ce of th e alar base is a ected by m odi cat ion of
su rger y. An d m et icu lou s p ostop erat ive care sh ou ld be prac-
th e n asal t ip an d dorsu m , an d th at surger y to th is area can -
t iced to m in im ize such com plicat ion s.
n ot be con sidered in isolat ion . In creased n asal t ip projec-
t ion and dorsal augm en tat ion w ill both create an illusion of
decreased alar base w idth . Conversely, n arrow ing th e alar Function
base w ill create th e illusion of a broader n asal t ip. If su rger-
ies in th ese areas are also requ ired, th e pat ien t sh ould be Any st at ic an d dyn am ic collap se of th e extern al n asal valve
advised accordingly. m u st be n oted. Alar base su rger y th at redu ces th e size of
In cert ain cases, m odi cat ion of th e dorsu m an d t ip alon e th e vest ibular aper t ure can cau se extern al valve sten osis.
m ay su ce to create th e illu sion of decreased alar base Th e pat ien t sh ould be asked to in spire th rough th e n ose
w idth an d aring, m aking alar base surger y un n ecessar y. rapidly, an d any collapse of th e alar side w all sh ould be
It is im p erat ive th at th e pat ien t be in form ed th at m odi- noted. Pat ient s w ith sm all n ost rils sh ould h ave excision
cat ion s to th ese oth er areas in u en ce th e ch aracterist ics design s th at do n ot furth er reduce th e n ost ril apert ure;
a b c
Fig. 8.1 Ideal alar shape of East Asians. (a) Frontal view. (b) Lateral view. (c) Basal view.
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8 Alar
Base
Modi cation 101
Photographs
Proper ph oto docu m en t at ion u sing a prim e port rait len s
an d di u se ligh t ing is a clin ical an d m edico-legal requ ire-
m en t for rh in op last y. A fron t al view, p ro le view, an d basal
view are u sed in evalu at ing for alar base su rger y. Com p u ter
sim u lat ion can be p art icu larly u sefu l to illu st rate th e com -
plex relat ion sh ips bet w een dorsal length , t ip project ion , t ip
bulbosit y, an d alar base w idth , w ith th e pat ien t’s decision s
carefully docum en ted.
From th e fron tal view ph otograph , th e w idth of th e
n asal base can be evaluated; th is sh ould ideally lie just out-
side of th e m iddle h orizon t al fth of th e face in Orien tals.
Th e base can appear w ide from excessive aring or from a Fig. 8.2 De nition of alar aring. The aring is determined
large in ter-alar distan ce. Excision t arget ing th e righ t areas according to the degree of alar projection based on a vertical line
m u st be design ed to add ress th ese problem s. drawn at the alar-facial groove as seen from the basal view.
From th e basal view th e size of th e n ost rils an d degree
of aring can be object ively assessed. Ver t ical lin es pass-
ing th rough th e alar facial groove can be draw n in th e basal
view. Excess alar side w all lateral to th is lin e gives an objec- ap proach h as been perform ed, th e colu m ella in cision is
t ive m easu rem en t of th e degree of alar aring an d aids in closed w ith a few m on o lam ent sut ures to restore ten sion
plan n ing th e excision design (Fig. 8.2). to th e skin pocket . Th e n eed for alar base su rger y is th en
From th e lateral view, a lin e draw n th rough th e long assessed from th e basal view, fron tal view, an d pro le view
axis of th e n ost ril allow s th e su rgeon to evalu ate th e exten t as ou tlin ed earlier in th e ch apter.
of h anging alar deform it y an d th e am oun t of “lift” required Th e alar base region con sist s of th ick sebaceous skin
to correct alar h ooding.2 extern ally, h air-bearing vest ibu lar skin in tern ally, an d
bro-fat t y t issu e in bet w een . Th ere are n o car t ilagin ou s
st ru ct u res fou n d h ere. Th e ju n ct ion of th e alar side w all an d
lateral n asal sill form a n at ural cu r vat ure at th e in ferior lat-
■ Surgical Techniques eral asp ect of th e n ost ril, w h ich m u st be preser ved d u ring
any alar base su rger y to avoid creat ing a teardrop n ost ril.
Surgical Anatomy Th e jun ct ion bet w een th e alar side w all an d m idface
form s th e alar facial groove, an d w h en ever possible, th is
Alar base su rger y is perform ed as th e n al procedu re in sh ou ld be p reser ved. Leaving beh in d a 1-m m cu of soft
th e rh in oplast y sequen ce. Th is allow s th e su rgeon to fully t issue above th e alar facial groove w h en plan n ing th e in fe-
evalu ate th e e ect s from any m odi cat ion s to th e dorsu m rior in cision greatly facilitates closu re an d faster w ou n d
an d t ip on th e alar base (Fig. 8.3). If an op en rh in op last y healing.
a b
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8 Alar
Base
Modi cation 103
a b c
d e f
Fig. 8.5 A combined sill excision and wedge resection of ala. (a) Preoperative picture of a patient with under-projected tip and dorsum,
bulbous tip, and wide alar base. (b) The tip has been projected with the use of a columellar strut and cap grafts, and the dorsum has also
been augmented. An illusion of inter-alar distance narrowing has already been created through tip projection. The design for alar base
excision has been marked out. Note how a portion of the curved area of the nostril has been preserved to avoid the creation of a teardrop
nostril. Also note how a small strip of vertical skin has been preserved on the right to facilitate closure later. (c) The right wedge excision
has been performed. (d) The gure-of-8 suture has been passed from right to left through the deep premaxillary tissue. Note how the
needle has engaged the brofat t y tissue of the cut free edge of the alar side wall. (e) The direction of the needle is reversed and the needle
is passed back in a similar manner to catch the alar brofat t y tissue on the other side. (f) The suture is tied and the knot buried. The inci-
sions are closed with ne m ono lament sutures.
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104 II Rhinoplast y
a b
4. The superior extent of wedge sections should be kept excision design sh ou ld be p laced as m u ch as p ossible in
as inferior as possible in the alar facial groove. The skin th e alar-facial groove to ach ieve good cam ou age; a sm all
in this area is thick and sebaceous, and scar-related ver t ical cu of skin from th e ala can be preser ved to facili-
com plications here are conspicuous and unforgiving. tate closure. With expected scar con t ract ure, th is in cision
The lateral nasal artery also runs 4 m m superior to the sh ou ld even t u ally lie w ell cam ou aged in th e groove it self.
level of the nasal sill and should be preserved.4 In in st an ces w h ere th e in cision is m ade in th e groove
5. Ten sion sut ures ( gure-of-8) passed u n der th e directly, closure of th e n ear ver t ical alar side w all skin to
p rem axillar y soft t issue aid in ten sion -free closure th e h orizon t al m idface skin w ill be di cult . Th e ten uous
an d h ealing of th e in cision s. ep ith elializat ion of skin over th is righ t-angled closu re site
is often delayed an d w ill break dow n frequen tly w ith m in or
displacem en t , resu lt ing in poor w oun d h ealing, gran u la-
t ion , an d scarring (Fig. 8.8).
a b c
Fig. 8.7 Narrowing of columellar base. (a) Too-wide columellar base by divergent medial crura causes nasal obstruction. (b) After lateral
columellar incision and dissection, the divergent medial crura are exposed, excised, and cinched together. (c) Im mediately after surgery,
the columellar base looks narrower than before the surgery.
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Base
Modi cation 105
Nasal Obstruction
Aggressive reduct ion of th e alar base an d redu ct ion in
again st excessive u lt raviolet exp osu re to th e op erat ive site.
th e n ost ril size can resu lt in nasal obst ruct ion . Th e n ost ril
In t ralesion al steroid s can be ad m in istered if hyp er t rop h ic
form s th e an terior boun dar y of th e extern al n asal valve.
scarring d evelop s.
W h en th is aper t ure is excessively reduced in absolu te
term s, a st at ic extern al n asal valve obst ruct ion can result .
Teardrop Nostril A dyn am ic collap se can also resu lt if th e p at ien t h as p re-
exist ing w eak low er lateral car t ilages.
A teardrop nostril occurs w hen the curved portion of the nos- Excision design s that spare the vest ibular skin should be
tril is not preserved during alar base resection. This results used in patients w ho have sm all nostrils. Any pre-exist ing
in the alar side wall and nasal sill m eeting at an acute angle w eakn ess of th e low er lateral cart ilages sh ould also be iden -
after closure of the wedge excision. When seen from the ti ed preoperat ively and the patient inform ed of th e poten -
basal view, there is a loss of the norm al kidney bean shape of tial risk for nasal obst ruct ion after alar base surger y, w ith
the nostril, w ith the nostril resem bling a teardrop (Fig. 8.8). the option of rein forcing the low er lateral cart ilages w ith
The creat ion of a teardrop deform it y is best avoided bat ten grafts during the rh inoplast y o ered to the pat ient .5
w ith correct excision design , preser ving th e cur ved por t ion
of th e n ost ril.
■ Case Studies
Asymmetry
Case 1: Combined Nostril Sill and
Any p re-exist ing asym m et r y of th e n ost rils m u st be iden t i- Alar Wedge Resection
ed an d docu m en ted (Fig. 8.8). Correct ion of n ost ril asym -
m et r y is a tech n ically di cu lt p art of rh in op last ic su rger y. A 25-year-old w om an visited th e clin ic desiring rem oval of
It is im p or tan t to poin t th is out to th e pat ien t before sur- her n asal h um p an d re n em en t of h er nasal t ip (Fig. 8.9).
ger y. Asym m et r y in th e alar base can be corrected w ith Physical exam in at ion revealed a m ild reverse C-sh ap ed
n on -sym m et ric excision s. How ever, asym m et ries occur- dorsu m w ith a sm all h um p. Her n asal t ip w as bulbou s
ring h igh er in th e alar side w all, su ch as alar ret ract ion w ith insu cien t project ion an d h er n asal base w as w ide.
asym m et ries secon dar y to con tou r, n eed to be corrected Th ere w as n o sept al deviat ion , an d h er skin w as fair an d of
th rough m an ipu lat ion of th e low er lateral car t ilages, rim , m ediu m th ickn ess.
an d/or com posite graft s. Th ese sh ou ld be d iscu ssed w ith An open septorhinoplasty approach was taken and her
th e pat ien t beforeh an d. septal cartilage harvested. Osteotom ies were perform ed to
straighten her deviated dorsum w hile a caudal septal extension
graft was used to elevate her nasal tip. Soft tissue reduction of
Poor Harmony of Alar Base w ith the nasal tip was perform ed, w ith the excised m aterial used as
Nasal Dorsum and Tip a radix graft. Septal cartilage was used for dorsal augm entation.
Th ereafter, as par t of th e n al rh in oplast y sequen ce, a
Th e in t im ate relat ion sh ips bet w een th ese th ree areas h ave m odi ed Weir resect ion w as u sed to resect both th e alar
been elaborated earlier, an d a careful preoperat ive assess- side w all an d th e n asal sill to e ect redu ct ion in alar aring,
m en t is n ecessar y to avoid creat ing a dish arm on iou s- nost ril size, an d n asal base w idth .
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106 II Rhinoplast y
a b
a b
Postop erat ive p ict u res t aken 2 years later sh ow sign i - n ost r il asym m et r y w as n oted . En d oscopy revealed a r igh t -
can tly n arrow ed n asal t ip, alar base w idth , an d alar aring deviated n asal sept u m . Th e p at ien t ’s skin w as t h ick an d
(Fig. 8.10). In creased radix, dorsu m , an d t ip p roject ion is sebaceou s.
eviden t . Th e d orsal h um p h as been cam ou aged. An open septorh in oplast y approach w as un der taken
an d th e sept al car t ilage w as h ar vested . Osteotom ies w ere
used to st raigh ten th e bony dorsum . A colum ellar st ru t w as
Case 2: Combined Nostril Sill and used to in crease t ip project ion togeth er w ith t w o st acked
Alar Wedge Resection cap graft s to th e t ip. Stacked sept al cart ilage w as used to
augm en t th e dorsu m . Fin ally, a m odi ed Weir excision w as
An 18-year-old m an w as seen in t h e clin ic d esir ing re n e- used to excise th e sill an d alar side w alls to reduce aring,
m en t of t h e n asal t ip , cor rect ion of t h e d eviated n ose, an d alar base w idth , an d n ost ril size.
augm en t at ion of t h e n asal d orsu m (Fig. 8.11). Physical The 1-year postoperative photographs dem onstrate
exam in at ion revealed an u n d er-p rojected n asal d orsu m straightening and augm entation of the dorsum w ith increased
d eviated to t h e left . Th e n asal t ip w as boxy an d bu lbou s tip projection and tip re nem ent (Fig. 8.12). The alar base
w it h p oor p roject ion . Th e alar base ap p eared w id e an d w idth, nostril size, and alar aring have all been reduced.
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8 Alar
Base
Modi cation 107
a b
a b
References 3. Raw lings AV. Eth n ic skin t ypes: are there di eren ces in
skin st ruct ure an d fu nct ion ? In t J Cosm et Sci 2006;28(2):
1. Farkas LG, Hreczko TA, Deut sch CK. Object ive assessm en t 79–93
of st an dard n ost ril t ypes—a m orph om et ric st udy. An n Plast 4. Jung DH, Kim HJ, Koh KS, et al. Arterial supply of the nasal tip
Su rg 1983;11(5):381–389 in Asians. Laryngoscope 2000;110(2 Pt 1):308–311
2. Yap E. Im proving th e h anging ala. Facial Plast Surg 5. Ballert JA, Park SS. Fun ct ion al con siderat ion s in revision
2012;28(2):213–217 rh in oplast y. Facial Plast Surg 2008;24(3):348–357
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9 Aesthetic Rhinoplasty for Southeast Asians
Eduardo C. Yap
Pearls
• Th e bony-car t ilagin ous st ruct u re of South east Asian popu larly kn ow n as Gore-Tex) is preferred because it
n oses is gen erally sm all in all dim en sion s, result ing h eals by t issu e adh esion w ith n o capsu lar form at ion .
in a relat ive abun dan ce of skin an d soft t issu e. To It p rovides a m ore n at u ral look albeit w ith som e
ach ieve a long-last ing e ect , a st rong fram ew ork is un desirable poten t ial com plicat ion s such as
n eeded to cou n teract th e forces of w oun d h ealing deviat ion , visibilit y, an d in fect ion .
an d th e h eavy skin an d soft t issu e com p lex. • ePTFE in sh eet form or preform ed sh ou ld be lim ited
• Hanging ala of variou s d egrees is often n oted an d to a single piece if p ossible. St acking of sh eet s m ay
can be easily corrected via “sail” excision . Th is t rap con t am in an t s. Th e im plan t sh ould be rem oved
procedure also im proves colum ellar sh ow. from it s p ackage on ly w h en it is t im e for dorsal
• Th e sept al exten sion graft (SEG) is th e w orkh orse in augm en tat ion to avoid prolonged air exp osu re.
providing st urdy su pport to th e t ip. • ePTFE in sh eet form is p referred for a sh allow
• Th e SEG m ay be in adequate as su ppor t in som e radix w h ereas th e preform ed t ype is preferred for
cases. Addit ion al graft s can be used to support th e correct ing a deep radix.
SEG (e.g., exten ded spreader an d cau dal m argin • Th e im plan t sh ould be car ved to follow th e con tou r
exten sion graft s). Becau se of th e pau cit y of sept u m of th e n ose. Th e caudal en d of th e im plan t sh ould
th at can be h ar vested, folded con ch al cart ilage be sut ured to th e dom e to ach ieve a con t in uous
at t ach ed ben eath th e SEG is often u sed. st ru ct u re of th e dorsu m an d th e t ip .
• Tip -p last y is don e before dorsal augm en tat ion . After • A gap of space u su ally is left at th e ju n ct ion of
m odifying th e t ip as desired , th e dorsal graft is m ade th e upper cart ilage an d low er cart ilage after
to blen d th e n ew t ip an d th e radix. placem en t of th e im plan t . Th is space sh ould be lled
• Am ong syn th et ic produ cts for d orsal augm en tat ion w ith car t ilage to preven t postoperat ive su prat ip
m aterial, exp an ded p olytet ra u oroethylen e (ePTFE, depression .
108
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9 Aesthetic Rhinoplast y for Southeast Asians 109
Rh in oplast y rem ain s th e m ost com m on facial aesth et ic nique, th e face an d th e auricles are draped as a w h ole.
procedure don e in th e South east Asian region . Pat ien ts Lidocain e 2% w ith 1:100,000 adren alin e is used as local
sh ou ld determ in e th e righ t su rgeon for th em selves th rough an esth et ic. Cau t ion is advised tow ard th e safe dose of lido-
th orough con sultat ion w ith prospect ive su rgeon s. Prior to cain e w ith adren alin e, w h ich is 7.0 m g per kilogram of
discu ssing th e surgical plan , th e pat ien t sh ould alw ays be body w eigh t .
asked abou t th e im p rovem en t sough t for h is or h er n ose. Th e con ch al car t ilage is h ar vested eith er an teriorly,
Com puter sim ulat ion can be a dangerous tool because it if on ly a sm all am oun t of cym ba an d cavum con ch a is
m ay lead to fu t u re dissat isfact ion resu lt ing in argu m en ts needed, or posteriorly, if a bigger am oun t is n eeded. Th e
w ith th e surgeon . It sh ould be explain ed to th e pat ien t an terior in cision is d on e at th e p osterolateral p or t ion of th e
th at im provem en ts from th e su rger y largely depen d on cavum con ch a. Th e skin of th e cavum con ch a is dissected
th e exist ing st ruct ures. Th e aim of aesth et ic rh in oplas- above th e p erich on driu m an d elevated to th e cym ba con -
t ic surger y is to im prove th e curren t appearan ce, not to ch a. An in cision in th e cart ilage is th en m ade n ear th e skin
ach ieve p erfect ion . Th e m ajorit y of ou tcom es are good an d in cision site, leaving 2 m m of car t ilage ben eath . Dissect ion
fall w ith in p at ien ts’ an d su rgeon s’ exp ect at ion s. How ever, is th en perform ed at th e posterior side, m aking sure th at
th ere m ay be som e cases w h ere th e outcom e falls drast i- th e perich on drium is preser ved an d rem ain s at t ach ed to
cally sh ort of expectat ion s. Th is is often seen in n oses w ith th e car t ilage. Th e con ch al cart ilage h ar vested sh ould con -
m u lt iple aesth et ic de cien cies (e.g., sm all n ose, low bridge, tain perich on drium on both sides to preser ve th e st rength .
bulbous upt urn ed t ip, ret racted colu m ella, ret ru ded pre- It sh ou ld be soaked in n orm al salin e solu t ion at all t im es
m a xilla, h anging ala, an d w ide alar base). before being fash ion ed as graft s.
Th e pat ien t sh ould be aw are th at after th e rh in oplast y For th e p osterior ap p roach to con ch al cart ilage h ar vest ,
su rger y, th ere are a few p ossible react ion s to th e n ew n ose. an in cision is m ade bet w een th e su lcu s an d th e h elix. Dis-
Peop le w h o h ave frequ en t en cou n ter w ith th e p at ien t (e.g., sect ion is above th e p erich on driu m . Bleeders can be cau ter-
fam ily m em bers, o ce m ates, an d th e pat ien t h erself) m ay ized. To m axim ize th e h ar vest of cym ba an d cavum con ch a,
n d th e ch ange ver y obviou s. Th ose w h o see th e p at ien t t w o or th ree hypoderm ic n eedles are used to pierce an teri-
occasion ally (e.g., h igh sch ool an d college alum n i frien ds) orly at th e edge of th e con ch al car t ilage th rough an d th rough .
m ay n ot be able to n ot ice th e di eren ce; th ese p eop le w ill Th e car t ilage is th en in cised an d dissect ion is carried
gen erally com m en t th at th e p at ien t looks m ore beau t ifu l above th e p erich on driu m an teriorly, p reser ving 5 to 8 m m
th an before. People w h o h ad n ever m et th e pat ien t prior to of con ch al car t ilage n ear th e extern al auricular can al.
th e surger y m ay n ot even n ot ice th at th e pat ien t h as h ad Closu re of in cision s is a bit di eren t . For in cision s
su rger y don e on th e n ose. don e an teriorly at th e cavum th e donor defect sh ould h ave
Pat ien t s sh ould be in form ed of th e surger y in det ail 2 m m of con ch al cart ilage below th e site of skin in cision .
beforeh an d: exten t of th e surger y, durat ion of th e surger y, Th is w ill be h elpful because it w ill ser ve as a platform for
t yp e of an esth esia given , don or site, possible m orbid- skin w ou n d h ealing. Closu re w ith a sim p le in terru pted
it y after h ar vest , an d oth er per t in en t poin t s. Risks of th e su t u re is don e u sing nylon 5–0, in clu ding th e car t ilage to
operat ion sh ould be discussed th orough ly as w ell. Set t ing a avoid a crum pled look at th e in cision site. A bolster sut ure
realist ic su rgical goal is im port an t . Pat ien t s are advised to is also applied to avoid h em atom a form at ion . For a poste-
keep an old pict u re of th em selves close at h an d for t w o p u r- rior in cision , closu re is don e u sing nylon 5–0 vert ical m at-
poses: for iden t i cat ion an d to rem in d th em selves of th eir t ress sut ures. Som et im es th e h ar vest site of th e cym ba an d
previous appearan ce. Th eir n ew n oses sh ould be com pared cavum con ch a con t ract s, especially at th e big auricle; to
w ith th eir previous on es, n ot w ith oth er people’s n oses.1 avoid collapse an d con t ract ure, a st rip of cart ilage bet w een
th e cym ba an d cavum is preser ved.
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110 II Rhinoplast y
Th e irregular t riangular piece of skin t issue is sh aped like m ellar in cision at th e m edial cru ra is m ade beh in d th e skin
th e sail of a sailboat . Th e t w o sides are m arked at th e in n er m ou n d an d an terior to th e h air-bearing area. An oth er in ci-
alar rim m argin , an d a skin groove in th e lateral vest ibu le sion is m ade 2 to 3 m m cau dal to th e edge of th e low er
area is m arked by th e t ran sit ion of th in vibrissae to th ick lateral car t ilage. Th e m edial in cision an d th e caudal m ar-
vibrissae. Th e apex of th e t riangle is located at th e h igh est gin al in cision s are th en con n ected m ain t ain ing 2 to 3 m m
cur ve in th e “gull w ing” on the fron t al view. Th e alar rim of skin . Main t ain ing a 2- to 3-m m vest ibu lar skin allow an ce
skin is m ade to roll cep h alically as a ap, th u s lift ing th e en su res good coapt at ion du ring closing w ith su t u res.
w h ole alar rim . Th e defect is closed using nylon 6–0 sim ple Dissect ion of th e low er lateral cart ilage is ap p roach ed
in terru pted su t u res (Fig. 9.2).2 at th ree sites: rst at th e m edial crura, th en at th e low er
Th ere are som e in st an ces w h ere th e alar base is low er lateral car t ilage, an d n ally at th e dom e. A soft t issue dis-
th an th e colum ellar base. Th e alar lift su rger y sh ould sect ion is don e at th e m edial cru ra. Th e dissect ion of th e
be aggressive to lift th e alar base as w ell. Th is procedure low er lateral car t ilage is done above th e perich on drium . At
involves a radical “sail” excision by exten ding th e in cision th is t im e a t ran scolum m ellar in cision can be m ade an d th e
in feriorly an d posteriorly follow ing th e vest ibular groove. dom es are dissected aw ay from th e overlying skin an d soft
Th e design of the exten ded sail excision is act ually a sm all t issue envelope. Th e dissect ion of th e low er lateral car t ilage
t riangle in ferior to th e sail diagram ; it s apex is poin t ing is carried superiorly an d laterally up to th e scroll jun ct ion
in ferior-p osterior (Fig. 9.3). Closu re is don e via absorbable of th e u pper lateral car t ilage an d th e lateral en ds of th e
su t ure 6–0 sim p le in terru pted at th e sill area an d nylon 6–0 low er lateral cart ilage.
sim ple in terru pted at th e rim (Fig. 9.4). Th e dissect ion of th e dorsu m at th e area of th e upper
lateral cart ilage sh ou ld take place ben eath th e SMAS. Th is
is ach ieved by carefully applying blun t an d sh arp dissec-
The Approach t ion at th e dorsal sept um n ear th e an terior angle. On ce th e
plan e is iden t i ed at th e dorsal sept u m , a blun t dissect ion
Sin ce th e m ajorit y of South east Asian n oses n eed st ruc- is don e lateral-w ard un t il th e piriform open ing edge of th e
t ural m odi cat ion , an open approach is preferred for bet ter m a xillar y bon e is reach ed . At th is t im e th e low er lateral
visu alizat ion . A m argin al in cision is rst m ade. Th e colu - cart ilage sh ould be fully m obile for t ip reposit ion ing.
a b c
Fig. 9.2 Closure of the sail excision. (a) Markings for the triangle shaped “sail” are made. If there is a need for alar base surgery, the mark-
ings are made higher. (b) The defect after excision of skin and subcutaneous tissue. (c) Closure using nylon 6–0 starts at both ends. The
caudal side act s as a ap that coapts with the cephalic side and the base.
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9 Aesthetic Rhinoplast y for Southeast Asians 111
Fig. 9.3 Extended sail excision for correction of hanging alar rim
and alar base. The extended correction is done by designing a small
triangle posterior to the sail diagram and following the vestibu- a b
lar groove as a guide infero-posterior to the nasal sill. Removing
the vestibular skin with its subcutaneous tissues and suturing the Fig. 9.4 Extended sail excision. (a) Preoperative and (b) imme-
defect will result in maximum lift at the alar base. diately postoperative correction of hanging alar rim and alar base.
This maneuver is done as an initial step, with no other procedures
having been done yet. Note the instant lift of the alar base and bet-
ter alar-columellar relationship.
Th e upper dorsum com prises th e n asal bon es. Th e
plan e of dissect ion is subperiosteal. Use a sh arp periosteal
elevator, an d take care to avoid injur y to th e dorsal n asal
n er ve th at exit s 5 to 6 m m lateral to m idlin e bet w een th e A safe ap proach to sp lit th e m em bran ou s sept u m is fol-
n asal bon es an d u p per lateral cart ilage (Fig. 9.5). low ing th e geom et ric ru le of “t w o poin ts in a plan e deter-
m in e a lin e.” Poin t A is th e an terior angle of th e sept u m
an d p oin t B is th e foot p late. Th e “p lan e” is th e m em bran ou s
Membranous Septum Dissection: sept u m . After iden t ifying th e an terior angle of th e sept u m ,
Two Points in a Plane Determine a Line th e bers of th e opposing m edial crura are dissected via
blu nt dissect ion up to th e an terior n asal spine. Th is m an eu-
Th e m em bran ous sept um sh ould be open ed for access to ver exp oses th e foot p lates. A sh arp dissect ion of th e m em -
th e caudal edge of th e sept um . Th e dissect ion also frees th e branous sept um bet w een th e an terior angle of th e caudal
m edial cru ra an d foot p late for ten sion -free t ip reposit ion - sept u m (p oin t A) an d th e foot p late (p oin t B) is n ow p er-
ing an d colu m ellar sh ow. form ed u n t il on e reach es th e cau dal m argin of th e sept u m .3
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112 II Rhinoplast y
Fig. 9.8 The four-point suturing of the SEG and the folded conchal
Fig. 9.7 Manual stretching of the SSTE for simulation. In struc- cartilage for support of the SEG. The SEG should be xed with three
tural rhinoplast y where the nose is elongated, the thicker radix skin anterior sutures (dorsal, central, and caudal) and a loop-around
is pulled caudally when the SSTE is stretched to redrape the new structure to prevent deviation and tip t wisting. After the conchal
tip. The supra-tip bro-fat t y skin will appear more cephalic and the cartilage is scored on the concave side and folded, it is anchored
low radix will appear higher. bet ween the SEG and the caudal strut.
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114 II Rhinoplast y
ch ron ic pressure n ecrosis an d su bsequen t ext rusion . Th e Designing a Preformed ePTFE Implant
im p lan t sh ap es are gen erally classi ed as “I” or “L” sh apes.
The “I” sh ape im plan t exten ds from radix to th e t ip, w h ile Preform ed ePTFE im plan ts sh ould be rem oved from th e
th e “L” sh ape im plan t h as a st rut th at goes bet w een th e sterile p ackaging on ly w h en it is t im e for in sert ion . In sert-
m edial cru ra to th e an terior sp in e. Th e “L” sh ape m ain t ain s ing th e im plan t is a t rial-an d-error procedu re. First th e SSTE
th e t ip project ion an d preven t s superior m igrat ion of th e sh ou ld be redrap ed an d th e radix dow n to th e t ip sh ou ld
im p lan t; h ow ever, it is frequ en tly associated w ith t ip skin be palpated to determ in e th e ven t ral sh ape of th e im plan t .
p ressu re n ecrosis. Th e ven t ral side of th e im plan t is th en car ved accordingly.
Expan ded PTFE, on th e oth er h an d, h eals w ith adh esion Th e im plan t is rein serted an d th e length of th e im plan t is
an d d oes n ot form a cap su le. It closely adh eres to th e n asal ch ecked again st th e dom e. If th e im plan t is long, th en it is
bon e an d car t ilages, giving a m ore n at ural look. How ever, cut (Fig. 9.11).
in cases of long-st an ding react ion an d in fect ion it m ay be At ten t ion is th en d irected at th e n ew radix, su p rat ip,
d i cu lt to rem ove. Th e in ciden ce of ePTFE in fect ion varies w idth , an d rh in ion . Because th e rh in ion’s convexit y w ill be
w orldw ide, bu t if st rict sterilit y an d p rop er su rgical tech - at a di eren t site from th e st retch ed SSTE w h en redraped,
n iqu e are em p loyed, th e in ciden ce is low. care sh ould be t aken to avoid a h um p look of th e im plan t .
Cartilage as an im plan t is best for correction of sm all Th e rh in ion side of th e im plan t can be determ in ed in t w o
dorsal defects. Since the septal cartilage is m ainly used for w ays. On e w ay is to app ly extern al p ressu re to th e dorsu m
su pport, con ch al cartilage is u sed for th e dorsal graft. If m ore to p rodu ce a convexit y of th e im plan t; th e oth er w ay is by
volu m e is n eeded, bilateral h ar vest of con ch al cart ilage is using a Brow n -Adson forceps (on e jaw ben eath th e im p lan t
done. The cartilage is cut into 5- to 8-m m strips. Th e st rips to p alp ate th e bony-cart ilagin ou s ju n ct ion an d on e jaw
are scored on th e con cave side an d stacked using nylon or above th e im p lan t) an d m ake a p in ch m ark on ce th e bony-
PDS sut ures. Stacked con ch al cart ilage is e ective; h ow ever, cart ilagin ous jun ct ion is located (Fig. 9.12). Th e im p lan t is
the st rips resorb and m ay w arp over tim e. There m ay also be th en rem oved an d car vings are don e accordingly.13
irregu larities found w hen palpat ing the dorsum .13 Sin ce m ost t ips in rh in oplast y go dow n on long-term
Com paring th e ben e t s an d risks of th e th ree m ost follow -u p, it is recom m en ded th at th e cau dal en d of th e
com m on m aterials used for dorsal augm en t at ion , th e use im plan t be sut u red to th e dom e to allow th e w h ole un it of
of ePTFE is preferred because of its n at u ral look an d low th e dorsum to blen d w ell w ith th e t ip, even w ith long-term
risk of react ion an d ext ru sion . It com es preform ed an d in resorpt ion of th e t ip. Th e sut u ring also preven t s caudal
sh eet s. Alth ough ePTFE sh eet s can be stacked an d su t u red deviat ion of th e im plan t .
togeth er, it is recom m en ded th at a single p iece of im p lan t Th ere m ay be a space bet w een th e upper cart ilage an d
be used as m u ch as possible because of th e risk of con t am i- th e ven t ral side of th e im plan t . Th e space sh ou ld be oblit-
n an ts becom ing t rap p ed bet w een sh eet s du ring h an d ling. erated, p referably w ith car t ilage rath er th an a th in sh eet
Noses w ith a low radix n eed m ore augm en t at ion , so a of ePTFE because th e lat ter m ay cause ch ron ic pressu re at
preform im plan t is w ell suited w h ile a n ose w ith a sh al- th e m ucosa bet w een th e upper lateral cart ilage an d low er
low radix m ay just n eed a th in sh eet . In su t uring of sh eet s, lateral car t ilage, w ith subsequen t in fect ion (Fig. 9.13).
m on o lam en t su t u res sh ou ld be u sed. Avoid u sing absorb -
able braided su t u res to preven t im p u rit ies being in t ro-
duced an d em bedded in th e ePTFE m aterial.
Fig. 9.11 Preformed ePTFE implant. (a) The dorsal shape is ana-
lyzed to match the ventral side of the implant. (b) The ventral side
a is carved using a no. 10 surgical blade.
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9 Aesthetic Rhinoplast y for Southeast Asians 115
a b
c d
Fig. 9.12 Two ways to determine the rhinion. (a) External pressure on both ends will give a convexit y of the ePTFE. (b) A bet ter way is
inserting a Brown-Adson forceps up to the junction of the upper lateral cartilage and the nasal bone; the implant is pinched as a marker for
the rhinion. (c) The marks of the forceps teeth are noted and marked. (d) The marked area is carved out.
a b
Fig. 9.13 Gap bet ween ePTFE and upper lateral cartilage. (a) A space is often noted in the area of the upper lateral cartilage, especially
in a tip repositioned for projection. (b) The space can be lled up with cartilage. This is done to prevent collapse of the implant, causing
supratip depression.
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116 II Rhinoplast y
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118 II Rhinoplast y
Fig. 9.15 Case 1. Schematic drawing of the soft tissue correction and structural grafting. The main support graft is a SEG, which is fur-
ther supported with an extended spreader and folded conchal cartilage. Tip de nition grafts include shield, backstop, and crushed onlay
grafts. Medial and lateral osteotomies were done. A 3-mm ePTFE sheet was used for dorsal augmentation. Soft tissue correction includes
sail excision for alar lift and alar base surgery.
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120 II Rhinoplast y
a b
Fig. 9.18 Case 2. Schematic drawing of the soft tissue correction and structural grafting. The m ain support graft is a SEG, which is further
supported with a caudal margin extension graft. Tip de nition grafts include shield, backstop, and crushed onlay grafts. Medial and lateral
osteotomies were done. A 4-mm preformed ePTFE implant was used. Soft tissue corrections included a 5-mm sail excision for alar lift and
a 2-mm alar base resection.
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9 Aesthetic Rhinoplast y for Southeast Asians 121
a b
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10 Correction of the Short, Contracted Nose
Hong Ryul Jin
Pearls
• Repeated rh in oplast ies causing t rau m a to th e skin , is th e key st ruct u ral foun dat ion on w h ich th e low er
soft t issu e, an d car t ilages, im p lan t u se over th e lateral car t ilage can be reposit ion ed.
low er lateral cart ilage causing pressure n ecrosis, • An en d -to-en d t yp e septal exten sion graft h as th e
an d over-resect ion of car t ilages w ill en su e scar advan t ages of align ing th e cen ter in to m idlin e an d
con t ract u re w ith resultan t sh or t , con t racted n ose. avoiding caudal sept al deviat ion com pared w ith th e
• With every e ort m ade to correct the deform ity, often overlap p ing t yp e.
the postsurgical contracted, short nose cannot be • Various on lay grafts over th e reposit ion ed low er
elongated to a level equal to patient expectations. It is lateral car t ilage can h elp to length en or augm en t th e
crucial to have an adequate consultation before surgery. t ip.
• Th e st rategies for correct ing secon dar y sh or t n ose • A ch on drocu t an eou s com posite graft taken from
deform it y in clude skin envelope release th rough th e cym ba con ch a is often needed to ll th e gap
w ide un derm in ing, elongat ion an d derot at ion of bet w een th e length en ed skin envelope an d th e
th e t ip com pon en t , augm en t at ion of th e dorsum , vest ibu lar lin ing.
an d u se of com posite graft m aterial to ll th e gap • A staged operat ion or even a foreh ead ap w ill
bet w een th e elongated skin envelope an d th e be n ecessar y if th e skin sh ort age is severe in an
u n derlying vest ibular skin . ext rem ely con t racted or dest royed n ose.
• In m ost cases of sh ort n ose correct ion , cost al • Warping of th e rib car t ilage u sed as a dorsal on lay
cart ilage is n ecessar y for st ru ct ural suppor t an d graft can be m in im ized w ith prop er tech n iqu es
on lay graft ing. but is n ot com pletely avoidable. It can be corrected
• A sept al exten sion graft st rongly su pp or ted w ith w ith revision surger y after fu ll-blow n w arping h as
bilateral exten ded spreader grafts using rib cart ilage occurred.
122
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124 II Rhinoplast y
a b
Fig. 10.3 Illustrations showing key techniques used to correct short nose defor-
mit y. Septal extension grafts reinforced with extended spreader grafts and tip onlay
grafts are used to lengthen the nasal tip. (a) End-to-end t ype. (b) Overlapping t ype.
(c) Bilateral conchal composite grafts are applied when the elongated skin envelope
c and the vestibular lining cannot be primarily closed.
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10 Correction of the Short, Contracted Nose 125
is n ot as e ect ive for East Asian s, w h o h ave th icker skin . In toch on dral ju n ct ion is con rm ed by serial probing w ith a
m ost cases, th e st i an d in elast ic skin envelope an d de - 26-gauge n eedle. Marking is usually 1.5 to 2.0 cm in length
cien t vest ibular skin are th e m ost com m on ly en coun tered in th in -skin n ed pat ien ts an d 2.0 to 2.5 cm in th ick-skin n ed
lim it ing factors du ring th e low ering procedu re of th e alar pat ien t s. A local an esth et ic is in lt rated at th e in cision site.
rim . Th e au th or p refers to u se con ch al com posite graft s Ten m in utes after inject ion , th e skin an d subcut an eous t is-
from th e cym ba con ch a to ll th e gap bet w een th e elon - su e is in cised w ith a n o. 10 blade. Th e su bcu t an eou s fat is
gated skin envelope an d th e de cien t vest ibu lar m u cosa, at altern ately sep arated an d ret racted u sing Sen n ret ractors
th e sam e low ering th e alar m argin (Fig. 10.3c). un t il th e fascia an d th e extern al oblique m uscle layer are
Many Asian p at ien t s w an t t ip augm en t at ion even in a exp osed . Th e fascia is th en in cised an d th e m u scle bers
sit u at ion th at calls for th e correct ion of sh ort , con t racted sep arated w ith Kelly or m osqu ito forcep s. To adequ ately
n ose; h ow ever, it is n ot easy to get both an im p roved p ro- exp ose th e su rgical eld, th e m u scle layer is ret racted w ith
ject ion an d cau dal rot at ion of th e n asal t ip . W h en su cien t an Arm y-Navy ret ractor for bet ter visu alizat ion , in stead of
p roject ion is ach ieved, th e n ose is fou n d to be adversely cut t ing w ith a Bovie, to m in im ize postoperat ive pain . Th e
rot ated cep h alically. Conversely, correct ing th e sh ort n ose perich on drium an d th e rib are su cien tly exposed after
w ith on ly caudal rot at ion usually en ds in in su cien t t ip ret ract ing th e soft t issue an d m uscle.
p roject ion . Th u s, an adequate com prom ise bet w een aug- Tw o parallel in cision s are m ade on th e perich on drium
m en t at ion an d cau dal rot at ion of th e t ip n eed s to be fou n d. of th e rib along th e superior an d in ferior borders, leaving
th e cen t ral st rip of perich on drium on th e an terior surface
in t act . Follow ing th is, several cut s are m ade perpen dicu-
Graft Material Harvesting lar to th e longit udin al in cision to facilitate circum feren t ial
re ect ion of th e perich on drium , w h ich is th en dissected
In m ost cases, th e sept al car t ilage or con ch al car t ilage is from th e rib w ith a Freer elevator. Th e st raigh t p ort ion of
in su cien t an d costal car t ilage is used. Before deciding th e rib is often foun d to be of in su cien t length for dorsal
to u se cost al cart ilage, it is p ru den t to ch eck th e rib series im plan t at ion , n ecessitat ing exten sion of th e cart ilagin ous
for p ossible calci cat ion of th e cart ilage. Not in frequen tly, cut up to th e syn ch on drosis por t ion to obtain a longer piece
you ng fem ale pat ien t s h ave severe calci cat ion of th e cos- of cart ilage.
tal car t ilage.2 Calci cat ion m akes h ar vest ing an d car ving of Har vest ing is facilit ated if an an terior cu t is m ade at
th e car t ilage di cult . If th e cart ilage is tot ally calci ed, it is th e m edial en d of th e cart ilage before com plet ing th e dis-
ver y di cu lt to u se as graft m aterial. sect ion of th e posterior su rface of th e cost al car t ilage. Th e
The costal cart ilage graft is h ar vested m ostly from th e perich on drium of th e posterior surface of th e rib is dis-
sixth or th e seven th rib for u se in rh in op last y. In fem ale sected o as m u ch as p ossible w ith a cu r ved elevator. Th e
p at ien t s, th e in cision is placed just above th e in fram a- costoch on dral jun ct ion is iden t i ed visually or w ith th e
m m ar y crease for bet ter cosm esis (Fig. 10.4). In m ale help of a 26-gauge n eedle an d th e cart ilage cut is m ade.
p at ien t s, th e in cision is m ade directly over th e ch osen rib. Th ere is a great risk of injuring th e un derlying pleura if a
Th e proper car t ilage is located after palpat ion , an d th e cos- com plete cut is m ade using th e n o. 15 blade; th us, th e n al
cut is com pleted w ith th e Freer elevator to preven t su ch an
inju r y. After th e lateral cut , a sm all t w o-prong ret ractor is
used to pu ll up th e cost al cart ilage to expose th e posterior
su rface an d th e dissect ion is con t in u ed m edially. After com -
plete dissect ion of th e posterior perich on drium , th e cost al
cart ilage is separated at th e m edial cut an d delivered out .
A 3- to 4-cm length of cost al cart ilage is t ypically h ar-
vested . Th e cen t ral st rip of p erich on d riu m is dissected
an d preser ved for later u se. Th e h ar vested costal car t ilage
is soaked in w arm salin e to assess for an d in duce w arping
prior to car ving. Test ing for air leakage from th e pleura is
perform ed by lling th e dissect ion pocket w ith salin e an d
th en in it iat ing posit ive-pressure hyper ven t ilat ion . If n o air
leakage in th e form of bu bbles is eviden t , th e don or site is
packed w ith an t ibiot ic-soaked gauze un t il th e operat ion
is com pleted. Addit ion al cost al car t ilage can be h ar vested
during th e operat ion or th e cart ilage rem ain ing after graft-
Fig. 10.4 Harvest of rib cartilage. Rib cartilage is being removed ing can be rein serted an d preser ved un der th e m uscle layer
from the small, inframammary incision. The incision can be mini- for use in fut ure revision surger y. If air leakage is n oted, a
mized by exactly locating the costochondral junction by probing Nélaton cath eter is in serted at th e leakage site an d su t u red
the cartilage using a 26-gauge needle. in a pu rse-st ring m an n er. After t igh t closure of th e subcu -
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126 II Rhinoplast y
tan eous an d skin w oun d, th e Nélaton cath eter is rem oved augm en tat ion , th e p erip h er y of th e cost al car t ilage is sym -
w h ile sim ultan eously adm in istering in ten se posit ive-pres- m et rically cu t aw ay, leaving a cen t ral core of th e cart ilage.
su re hyp er ven t ilat ion . Th e cen t ral part of th e cart ilage is car ved w ith a n o. 10 scal-
Th e separated m uscles are t igh tly approxim ated to pel an d u sed as a dorsal im plan t . First , an appropriate sh ape
dim in ish postoperat ive pain an d th e w oun d is closed layer for th e dorsum is design ed. If a st raigh t piece of rib cart i-
by layer using 4–0 Vicr yl sut ures. No drain is in serted. Th e lage w ith su cien t length is har vested, th is is th e ideal sit -
skin m argin s are often bru ised w ith discolorat ion du e to uat ion . In m ost cases, a sligh tly cur ved cart ilage is obtain ed
excessive ret ract ion , an d th ese are t rim m ed an d su t u red an d a st rategic ap p roach an d design are n eeded to obtain a
w ith 6–0 nylon an d a com pressive dressing is applied. Th e st raigh t graft . After cu t t ing aw ay th e p erip h eral cart ilage
nylon su t ures are rem oved on th e seven th to ten th postop - according to th e design , th e cen t ral p ar t is scu lpted in to th e
erat ive day. Ordering a ch est X-ray to ch eck for p n eu m o- target sh ape (Fig. 10.5).
th orax im m ediately after th e operat ion is n ot obligator y Th e car t ilage is periodically soaked in physiologic
if th e su rgeon is con den t th at th ere w as n o air leakage salin e for 10 to 20 m in u tes at a t im e, an d th en brough t ou t
th rough th e h ar vest w oun d. If th e pat ien t presen t s w ith to con t in u e th e car ving w h ile w atch ing ou t carefu lly for
sign s an d sym ptom s of p n eu m oth orax follow ing su rger y, sign s of w arping. On ce w arping is eviden t , th e rem ain ing
th en a ch est X-ray is w arran ted. Rarely, a pn eum oth ora x periph eral con cave por t ion of th e cart ilage n eeds to be cut
can occu r even th ough th ere w as n o leakage during th e out . W h en th e im plan t is car ved in th is m an n er, postopera-
in t raop erat ive ch ecking. Mild pn eum oth orax can resolve t ive w arping can be m in im ized.6 It takes abou t an h ou r to
spon t an eou sly w ith a serial follow -u p of ch est X-ray; h ow - scu lpt ever y p iece of th e h ar vested car t ilage in th is m an -
ever, a ch est t ube is in ser ted to expan d th e collapsed lung n er to m in im ize th e risk of w arping. Th e com p leted, fu lly
in n on resolving or severe cases. car ved cart ilage graft h as rounded m argin al part s an d
progressively n arrow ed upper and low er part s, yielding a
can oe-like sh ape from th e fron tal view. W h en seen from
Carving of Costal Cartilage th e lateral view, it h as a sligh tly con cave side th at com es
in to con tact w ith th e n asal dorsum , an d a dorsal side th at
Har vested au tologou s costal cart ilage is design ed an d is sligh tly convex (Fig. 10.6). How ever, n ot w ith st an ding all
car ved in to various form s depen ding on th e purposes of th e th ese e ort s, ver y m in or w arping occur. Making several
graft: d orsu m augm en t at ion , rein forcem en t of th e sept u m cut s in th e graft fur th er m in im izes th e w arping, alth ough
in th e form of bat ten or septal exten sion graft s, exten ded th ese cut s m ay cause a poten t ial w arping deform it y later.
spreader graft s to rein force th e sept al exten sion graft , t ip A at , st raigh t p iece of car t ilage is n ecessar y for u se as
on lay grafts, or as a prem axillar y graft . a sept al exten sion graft an d exten ded sp reader graft . For
Cost al cart ilage con sists of a core an d periph eral th ese purposes, th e cart ilage is cu t an d car ved as a at
region s surrou n ding th e core; a balan ce an d stasis are piece an d soaked in w arm salin e to ch eck for any w arping
m ain t ain ed by th e in tern al st ress created by th e t w o com - before graft ing. To m in im ize w arping, th e car t ilage is cu t
pet ing region s.3 Cen t rally cu t pieces of car t ilage w arp longit udin ally or t angen t ially, leaving periph eral por t ion s
m ore qu ickly th an th e p erip h erally cu t p ieces; h ow ever, sym m et rically th ick on th e t w o sides of th e cen t ral p or t ion ,
th e periph erally cut cart ilage w arps at a greater rate th an w h ich coun teract s an d n egates the expected distor t ion on
th e cen t rally cut segm en t .4 Side-to-side w arp ing is m ore both sides (Fig. 10.7). Th is at , long piece of car t ilage is
clin ically eviden t du e to less soft t issue resist an ce in th is resist an t to w arping as long as the periph eral port ion s on
d im en sion .5 To prep are a n onw arp ing im p lan t for d orsal th e sides rem ain sym m et rical.
Fig. 10.5 Design for dorsal onlay graft. (a) A straight portion of the harvested rib cartilage
is selected and marked. (b) After excising the peripheral portion, a central portion remains
a for additional carving.
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Fig. 10.7 Carving of rib cartilage for a at, straight piece. The car-
tilage is cut and carved as a at piece by cut ting in the longitudinal
or tangential direction. Symmetric peripheral portions on the t wo
sides of the central portion counteract and negate the expected
Fig. 10.6 Final shape of dorsal onlay graft. The completed, carved
distortion on both sides.
cartilage graft has a canoe-like shape from the frontal view. When
seen from the lateral view, it has a slightly concave side that comes
into contact with the nasal dorsum, and a dorsal side that is slightly
convex. A perichondrium at tached to the cephalic side prevents
movement of the graft.
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128 II Rhinoplast y
a b c
Fig. 10.8 Elongation of the framework. (a) An overlapping t ype of septal extension graft is xed to the caudal septum. The septal exten-
sion graft is designed to reach the anterior nasal spine inferiorly and to extend the nasal tip anteriorly while rotating it caudally. It can be
xed to the anterior nasal spine for further stabilit y. (b,c) Bilateral extended spreader grafts are reinforcing the septal extension graft. 4–0
PDS sutures are used to x the grafts and reat tach the upper lateral cartilage to the graft complex.
a w eak lateral cru s, lateral cru ral on lay graft s are p laced t ion along th e alar rim is m ade begin n ing at th e n asal facet
to rein force it (Fig. 10.9b). If rot at ion an d p roject ion of using sh arp iris scissors. Dissect ion is perform ed close to
th e n asal t ip are excessively adjusted, th e alar m argin can th e alar rim m argin , w ith care t aken n ot to m ake th e pocket
ap pear u n n at u ral, sligh tly ret racted, or collapsed. too big. A th in , at piece, 2 to 3 m m in w idth an d 12 to 15
Alar rim graft s can be used to provide a sm ooth er n at u- m m in length , is design ed; th e m edial en d of th e graft is
ral con t in u at ion from th e n asal t ip to th e alar m argin an d to sligh tly bru ised u sing Brow n -Adson forcep s an d in serted
low er th e alar rim sligh tly (Fig. 10.9c). A soft t issu e d issec- in to th e pocket .
Fig. 10.9 Repositioning of lower lateral cartilages and additional tip grafts.
(a) Lower lateral cartilages are released from the upper lateral cartilage and
piriform aperture and repositioned on the new elongated nasal septum. (b)
Additional lengthening can be achieved with cap grafts and lateral crural
onlay grafts. (c) An alar rim graft is being introduced into the pocket made
c along the alar rim.
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■ Complications and
Their Management
Skin Damage
W h en th e skin envelope is st rongly adh eren t to th e un der-
lying scar t issue, in adver ten t skin dam age can occur du ring
th e dissect ion . Dorsal skin t igh tly adh ering to un derlying
scar t issu e is som et im es ext rem ely d i cu lt to dissect . Th e
torn skin n eeds to be carefu lly su t u red an d th e soft t issu e
or fascia un derlin ed for fur th er support .
■ Key Technical Points eter is in ser ted at th e leakage site an d su t u red in a pu rse-
st ring m an n er. After t igh t closu re of th e su bcu t an eou s
an d skin w ou n d, th e Nélaton cath eter is rem oved w ith
1. A su cien t am oun t of cart ilage is n eeded to build
sim u lt an eou s adm in ist rat ion of in ten se posit ive-p ressu re
a st able p latform to length en th e n ose. Usu ally, rib
hyper ven t ilat ion .
cart ilage h ar vest ing ser ves th is pu rpose.
2. Rib car t ilage car ving is st rategically t ailored
according to th e sites w h ere graft s are u sed. For Warping of Implanted Rib Cartilage
a dorsal on lay graft , th e cen ter of th e car t ilage is
u sed; tangen t ially cu t car t ilage is u sed for exten ded Warping m ay occu r after replacing th e dorsal alloplast ic
spreader grafts or sept al exten sion graft s. im plan t w ith rib car t ilage (Fig. 10.12). Even th ough th e
3. Wide un derm in ing of th e skin envelope is n ecessar y au th or takes all p reven t ive m easu res to p reven t w arp ing,
to redrape over th e length en ed platform . su ch as balan ced car ving u sing th e core of th e rib cart ilage,
4. An en d-to-en d t ype or overlapping t ype of septal repeated im m ersion an d ch ecking of cur vat ure, creat ion
exten sion graft to length en th e cau dal sept u m is a of a t igh t pocket for in sert ion , an d su t u re xat ion on th e
p latform to reposit ion th e low er lateral car t ilage. dorsum , it is st ill alm ost im possible to com pletely pre-
5. Th e sept al exten sion graft is design ed con sidering ven t w arping of cost al cart ilage. In su ch cases, th e au th or
th e rot at ion an d project ion of th e t ip an d n eeds to takes out th e cur ved rib graft an d car ves it st raigh t before
be st rongly supported w ith a bilateral exten ded rein ser t ing it in to place, w h ich solves th e problem in m ost
spreader graft . in st an ces. If th at is n ot possible, th e auth or dices th e cur ved
rib an d w rap s it in tem poralis fascia. In th e au th or’s exp eri-
6. Th e low er lateral cart ilage n eeds to be released
en ce, au togen ou s rib cart ilage is able to m ain tain it s origi-
from th e u p per lateral cart ilage an d scar t issu e for
n al volu m e even years after th e su rger y. Adding som e soft
rep osit ion ing to th e n ew dom e.
t issue such as th e m astoid periosteum w ill h elp to re n e
7. Th e n asion is m oved upw ard by adding a dorsal th e radix in th is case.
on lay graft in th e low dorsum . Addit ion al t ip
on lay grafts are used to add to caudal rot at ion an d
p roject ion of th e t ip. Movability of the Costal Cartilage
8. Th e lateral crural on lay graft an d alar rim graft h elp Onlay Graft
to low er an d suppor t th e alar rim .
9. A ch on drocut an eous com posite graft from th e Movem en t of a cost al cart ilage on lay graft after revision is
cym ba con ch a lls th e gap bet w een th e skin rare. Possible reason s for m igrat ion of th e im plan t in clu de a
envelop e an d de cien t vest ibu lar lin ing. large an d w ide pocket created during dissect ion to rem ove
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10 Correction of the Short, Contracted Nose 131
a b c
Fig. 10.12 Warping of dorsal onlay rib graft. (a) Warping developed after placement of dorsal onlay graft with autogenous rib cartilage.
(b) Six months after revision, the nose is straight. (c) In revision surgery, the dorsal onlay cartilage was removed in pieces. (d) The warped
portion was recarved and put together by wrapping with mastoid periosteum before reinsertion.
a large or st u bborn ly p lan ted allop last ic im p lan t arou n d th e it y or pain in th e n asal t ip. In m ost cases, th is discom for t
radix area; residu al cap su le after silicon e im p lan t rem oval; decreases w ith t im e; h ow ever, in som e cases th e graft
an d in app rop riate xat ion of th e cost al cart ilage, especially needs to be rem oved. Asym m et r y of th e n ost rils m ay occu r
at th e radix area. To preven t th is, com plete rem oval of th e w h en th e sept al exten sion graft is n ot exactly in th e m id-
u n derlying capsu le, rough en ing of th e radix w ith rasp , an d lin e or if t ip on lay graft s are n ot sym m et ric.
p erich on driu m applied on th e un dersurface of th e radix
skin above th e graft are n ecessar y. In rare cases, a K-w ire
xat ion of th e graft at th e radix p ar t is n eeded . ■ Case Studies
Case 1: Correction of Short Nose
Nasal Obstruction
Due to Contracture after Multiple
Ap p lying a too-th ick sept al exten sion graft , esp ecially th e Rhinoplasties
overlap p ing t ype, can m ake th e n ost ril in let sm all, cau s-
ing n asal obst ru ct ion . An en d-to-en d t ype sept al exten - A 28-year-old fem ale presen ted w ith sh ort n ose an d left
sion graft w ith a th in , at p iece of car t ilage can preven t nasal obst ru ct ion (Fig. 10.13). Sh e h ad u n dergon e fou r rh i-
th is com plicat ion . Also, beveling an d th in n ing th e exten ded noplast ies using Gore-Tex t w ice, silicon e on ce, an d autolo-
port ion of th e exten ded spreader graft bin ding to th e sept al gou s cost al car t ilage on ce over th e p ast 9 years, w ith th e
exten sion graft is im port an t to p reven t th icken ing of th e m ost recen t su rger y 2 years previou sly. Sh e h ad a t ypical
caudal sept um . If th e septal exten sion graft is w eak, th e post surgical sh or t , con t racted n ose w ith exaggerated n os-
caudal sept um m ay buckle, causing deviat ion an d n asal t ril sh ow in th e fron t al view an d severely ceph alic rotated
obst ruct ion . nasal t ip w ith low -set n asion in th e lateral view.
Her su rgical diagram sh ow s th at a sept al exten sion
graft , d orsal on lay graft , bilateral exten ded sp read er graft s,
Tip Problems lateral cru ral on lay graft s, sh ield graft , an d cap graft w ere
placed using irradiated h om ologous cost al cart ilage. Bilat-
Too m uch ten sion exerted on th e skin , especially w hen th e eral con ch al ch on drocu t an eou s com posite graft s w ere
sept al exten sion graft is m ade of sept al bon e or allop las- used to ll th e gap bet w een length en ed skin an d vest ibular
t ic m aterial such as Medpor, m ay cause pressure sen sit iv- lin ing.
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10 Correction of the Short, Contracted Nose 133
Case 2: Correction of Postsurgical Sh e u n der w en t a t w o-st age op erat ion : At rst revision ,
length en ing of th e n ose using autogen ou s rib cart ilage w as
Short Nose w ith Tw o -Stage Revisions t ried th rough an open approach . A sept al exten sion graft ,
dorsal on lay graft , bilateral exten ded spreader grafts, lat-
A 26-year-old fem ale visited th e clin ic com p lain ing of n asal eral cru ral on lay graft , an d t ip on lay grafts w ith a con ch al
deform it y (Fig. 10.15). Sh e h ad h ad th ree rh in oplast ies com posite graft w ere used. Th e secon d revision w as don e 1
before, w h ich in cluded silicon e dorsal augm en t at ion an d year after th e rst revision . At th e secon d revision , h er t ip
rem oval of th e silicon e im plan t . On physical exam in at ion , w as length en ed m ore u sing con ch al cart ilage on lay graft s
sh e h ad a st raigh t n ose, bu t th e d orsal h eigh t w as sh ort , on th e t ip th rough th e endon asal approach . On e year after
an d th ere w as excessive n ost ril sh ow from th e fron t al view. th e secon d revision , h er n asal sh ape im proved in both th e
Her t ip w as severely u pt u rn ed an d h ad skin dim p ling on fron t al an d lateral view s (Fig. 10.16).
th e t ip lobule.
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134 II Rhinoplast y
References 6. Adam s W P Jr, Rohrich RJ, Gunter JP, Clark CP, Robinson JB Jr.
The rate of warping in irradiated and nonirradiated hom o-
1. Na cy S, Baker SR. Length ening th e sh ort n ose. Arch Oto- graft rib cartilage: a controlled com parison and clinical im pli-
lar yngol Head Neck Su rg 1998;124(7):809–813 cations. Plast Reconstr Surg 1999;103(1):265–270
2. Sunw oo WS, Ch oi HG, Kim DW, Jin HR. Ch aracterist ics of 7. Park JH, Mangoba DC, Mun SJ, Kim DW, Jin HR. Length en -
rib cart ilage calci cat ion in Asian pat ien t s. JAMA Facial ing th e sh ort n ose in Asian s: key m an euvers an d su rgical
Plast Su rg 2014;16(2):102–106 results. JAMA Facial Plast Surg 2013;15(6):439–447
3. Fr y H. Nasal skelet al t raum a an d th e in terlocked st resses 8. Erol OO. Th e Turkish deligh t: a pliable graft for rh in oplast y.
of th e n asal sept al cart ilage. Br J Plast Surg 1967;20(2): Plast Recon st r Su rg 2000;105(6):2229–2241, discu ssion
146–158 2242–2243
4. Harris S, Pan Y, Peterson R, St al S, Spira M. Car t ilage 9. Daniel RK, Calvert JW. Diced cartilage grafts in rhinoplast y
w arping: an experim en t al m odel. Plast Recon st r Surg surgery. Plast Reconstr Surg 2004;113(7):2156–2171
1993;92(5):912–915 10. Dan iel RK. Graft s. In : Dan iel RK. Mastering Rh in op last y: A
5. Kim DW, Shah AR, Torium i DM. Con cen t ric an d eccen t ric Com preh en sive Atlas of Su rgical Tech n iqu e. New York, NY:
car ved cost al cart ilage: a com parison of w arp ing. Arch Fa- Springer; 2004:225–267
cial Plast Surg 2006;8(1):42–46
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11 Management of Alloplast-Related Complications
Eunsang Dhong
Pearls
• Th e perspect ive of using an alloplast ic im plan t in n ose deform it y. All con t racted t issu es, in clu d ing
com plicated septorh in oplast y is com pletely di eren t th e capsule, sh ould be rem oved to correct th is
from th at of u sing a sim p le dorsal augm en t at ion . deform it y.
Th e locat ion of th e pat ien t’s sellion is altered • Using Medp or (St r yker) as a sept al su p port or as a
follow ing im plan t at ion . It m igh t be h igh er or low er spreader graft becau se exten sion frequ en tly lead s to
th an th e origin al posit ion , an d it usually m igrates sept al p erforat ion .
ceph alically from th e origin al site. • Mu lt ilayered AlloDerm (LifeCell) m ay form avascu lar
• A long-st an ding im p lan t dest roys n ot on ly th e bony scar t issu e in th e cen ter.
dorsu m , but th e cart ilagin ous dorsum as w ell. • Sin ce an alloplast ic im plan t for rh in oplast y h as a
• The capsule surrounding a silicone im plant does not n ite lifespan , pat ien t s sh ou ld be in form ed abou t
dissolve even after the im plant is extracted. Therefore, th e lim ited ben e ts of using an alloplast ic im plan t .
if a patient undergoes m ultiple revisions, various • Placing an allop last ic im plan t over an op en roof
layers of the capsule can be seen during surgery. or dissected u pper lateral car t ilage from th e h igh
• A h ealthy capsu le can be reu sed w h ile it is at t ach ed sept u m m ay lead to disast rou s resu lts.
for th e su bst it ut ion of soft t issue in a secon dar y • Most im p lan t-related com plicat ion s resu lt from
rh in oplast y. a sh or t age of prop er soft t issu e coverage. In su ch
• Con t ract ure aroun d th e capsule m oves th e n asal t ip cases, im plan t s are often exposed to th e n asal cavit y
ceph alically, w ith th e pat ien t en ding up w ith a sh or t th rough a con cealed m u cosal lacerat ion .
135
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11 Managem ent of Alloplast -Related Com plications 137
a b
Fig. 11.2 Bone destruction after long-standing dorsal implanting. (a) The rhinion after 5 years’ presence of a silicone implant. (b)
Another patient with a silicone implant for 14 years.
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138 II Rhinoplast y
a b
Fig. 11.6 Septal perforation found after removal of intranasal Medpor. (a) Before removal of the Medpor in the left side of the nasal cav-
it y. (b) A huge defect at the high septum.
In th e n asal t ip area, rigid scar t issu e is frequ en tly un dern eath : an exposed n asal cavit y ben eath th e im p lan t
fou n d . In m ost cases, it is th e resu lt of m u lt ilayered Allo- or con cealed m ucosal lacerat ion after osteotom y of th e
Derm ap p licat ion . Th e cen t ral p ort ion of th e scar t issu e nasal bon e.
lacks vascu lar supply; h en ce, an avascu lar scar m ass form s
(Fig. 11.7).
Severe con t ract u re associated w ith im p lan t s is fre-
quen tly foun d in pat ien ts w h o u n der w en t com plicated ■ Surgical Techniques
sept al su rger y sim u ltan eou sly. Sept al su p port is u su ally
lost after su bm ucosal resect ion (SMR), an d the gravit y an d Correcting Noninfectious Conditions
ten sion from th e alloplast ic im plan t m ay be t roublesom e
over an op en roof or d issected ULC from th e h igh sept u m . Deviated Implant
Mu cocele is on e of th e frequ en t p ath ologic n dings resu lt-
ing from th is sit uat ion . Th is m ay be foun d in in t ran asal If th e p ocket is dissected w ider th an th e act u al size of th e
or ext ran asal areas (Fig. 11.8). Most of th e m u cocele m ay im plan t , th e im plan t h as a ten den cy to deviate to on e side
be related to th e sh or tage of proper soft t issue coverage of th e lateral n asal w all. Moreover, if th e im plan t is longer
a b
Fig. 11.7 Common nding in revision tip surgery. (a) Huge scar mass with conchal cartilage on the top of the tip. Underneath it m ultiple
layers of Alloderm were found. (b) After removal of allograft s, the LLCs underneath were destroyed to some extent.
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a b c
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140 II Rhinoplast y
a c d
Fig. 11.9 Implant calci cation. (a) Removed calci ed silicone implant and
entire capsules. (b) Double-layer dermal graft for the dorsum and cymba con-
cha for the tip. (c) Before the surgery. Transparent implant through the skin
with thinning and telangiectasia is noted. (d) After the surgery.
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11 Managem ent of Alloplast -Related Com plications 141
a c d
Fig. 11.10 Mucocele form ation after humpectomy with dorsal silicone implant.
(a) Preoperative X-ray reveals previous humpectomy (dot s) with migrated L-t ype
implant with thick scar. (b) Rem oved mucocele with thick capsules. (c) Before
the surgery. Short nose deformit y in patient with mucocele, who su ered from
relapsing edema and drainage of intranasal discharge. (d) After the surgery.
After total extirpation of previous alloplast s, dorsal augmentation with autograft
was performed (dermofat graft with concha cartilage graft).
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a c d
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11 Managem ent of Alloplast -Related Com plications 143
5. After capsule m an ipulat ion , re-drape th e skin ap. physiology of poor ciliar y clearan ce, con ch al hyper t rophy,
If th e skin ap is n ot m oving freely, m yotom y of th e an d disru pt ion of th e n asal m u cosal barrier. Long op erat ion
bilateral t ran sverse n asalis or bilateral subperiosteal t im e, n asal packing, w ide dissect ion , an d allo- an d auto-
d issect ion m ay be perform ed aroun d th e bony t ran splan tat ion are oth er in t raoperat ive factors th at pre-
pyram id. dispose pat ien ts to in fect ion .
6. If th e skin ap looks u n n at u ral du e to th e scar On e rep or t on th e correlat ion of septorh in op last y an d
ban d aroun d th e t ip, careful cross-h atch ing or bacterem ia revealed th at 15%of 53 cases of septoplast y an d
m orselizat ion of th e an terior cap su le m ay be septorh in oplast y sh ow ed bacterem ia postoperat ively, an d
p erform ed. 16.9% did so after rem oval of n asal packing.10 In an oth er
7. If th e t ripod of th e t ip is n ot elongated w ell after st u dy, it w as reported th at 3% of th e p at ien t s experien ced
th e posterior capsu lectom y, furth er dissect ion is bacterem ia after septoplast y an d 13% after septorh in o-
p erform ed. Th e sept um an d ULCs, caudal n asal bon e plast y.11 In th e perspect ive of su rgical con t am in at ion , rh i-
an d ULCs, an d ULCs an d LLCs (th e scroll area) are noplast y w ith ou t septal w ork m ay be categorized as a clean
d issected an d separated accordingly (Fig. 11.11a). su rger y, bu t septorh in op last y is categorized as a clean con -
tam in ated surger y.12
8. If th e t ip is not elongated even after all of th e
Regarding th e prophylact ic an t ibiot ic t reat m en t ,
e ort s listed, m et icu lou s vert ical scoring at th e
a st u dy of 100 cases of revision rh in op last y revealed 5
su bperich on driu m of th e m em bran ou s sept u m m ay
pat ien t s w ith severe in fect ion an d 9 pat ien t s w ith localized
be perform ed. How ever, th is sh ould be don e w ith
in fect ion . Th ese pat ien t s w ere n ot covered by prophylac-
caut ion as it is a ver y h azardous procedu re.
t ic an t ibiot ics. On th e oth er h an d, in th e t reated group 1
sh ow ed severe in fect ion an d 3 sh ow ed localized in fect ion .13
An t ibiot ic packing p roved to be e ect ive in d ecreasing th e
■ Infections in Septorhinoplasty colony t w o to seven t im es com pared w ith placebo packing
in a st udy of 110 cases of septoplast y.14
Th e in fect ion rate for rh in oplast y is reported as 1 to 4%, an d Th ere are debates on th e sen sit ivit y an d speci cit y of
th at of septoplast y bet w een 2 an d 7%. How ever, th e in fec- preoperat ive n asal sw abs. Th e auth or’s protocol depen ds on
t ion rate for septorh in oplast y varies from 2 to 14%, depend- th e result s of colon izat ion an d sen sit ivit y test in preparing
ing on w h eth er it is a prim ar y, secon dar y, or com plicated for com plicated septorh in op last y an d rh in op last y involving
septorh in oplast y.8 Com p licated septorh in op last y is su rger y alloplast ic im p lan t ing. Th e prim ar y ch oice of an t ibiot ics in
th at in cludes septal recon st ruct ion , osteotom y, subm uco- colon izing MSSA an d MSSE are rst- or secon d-gen erat ion
sal resect ion , an d free t ran sp lan tat ion th at resu lt s in long cephalosporin s an d Augm en t in (Beach am Ph arm aceu t i-
operat ion t im e. Most East Asian rh in oplast ies u sing allo- cals). In th e cases of MRSE, MRSA, an d Enterobacter, ap ply-
p last s fall in to th is categor y. ing suscept ible an t ibiot ics h as been con sidered a prim ar y
Perich on drit is an d sept al abscess are n ot rare in acute ch oice.
in fect ion . Th e m ajor con cern is th e cosm et ic ou tcom e after
th e dest ruct ion of th e rem ain ing septal L-st rut . Th e pat ien t
m ay com p lain of severe sadd le n ose deform it y an d sh ort
n ose deform it y. ■ Case Studies
Th e n orm al ora of th e n asal cavit y in clu des diph -
th eroids (Corynebacterium ), m icrococci (Staphylococcus Case 1
epiderm idis), Staphylococcus aureus, St reptococcus (α , β,
h em olyt ic), en terococci, yeast (Candida spp .), fu ngi, etc. In a 38-year-old fem ale, rh in oplast y u sing an L-t ype sili-
Th ey are n ot alw ays path ologic.9 con e im plan t h ad been perform ed 11 years previously
Meth icillin -resist an t Staphylococcus aureus (MRSA), (Fig. 11.12). Sh e com p lain ed of u pt u rn ed t ip an d sh ort
m eth icillin -su scept ible Staphylococcus epiderm idis (MSSE), nose. Th e operat ion w as perform ed an d in cluded low ering
an d Enterobacter sp p. are poten t ially in fect iou s n asal ora th e sellion , rem oving th e ent ire capsule, recon st ruct ion of
(PINF), an d th e rout in e prophylact ic an t ibiot ics are use- th e rem ain ing L-st rut using cost al cart ilage, project ing th e
less if th e colony sprou ts. Som e 20 to 60% of th e n orm al dorsal soft t issue pro le w ith fascia of th e rect u s abdom i-
populat ion are repor ted to h ave PINF in their n asal cavit ies. nis, an d project ing th e n asal t ip using cost al cart ilage
Th e predisposing factors of in fect ion are th e stat us of n asal (Fig. 11.13). Resu lt s are sh ow n in Fig. 11.14.
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b c
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11 Managem ent of Alloplast -Related Com plications 145
b c
a
Case 2 Case 3
In a 42-year-old fem ale, rhinoplast y using I-t ype silicone In a 25-year-old fem ale, rh in op last y u sing an I-t yp e silicon e
h ad been perform ed w ith a n asal tip onlay graft using con - im plan t an d an un kn ow n m aterial (presum ably AlloDerm )
ch al cart ilage 8 years previou sly. Sh e w as dissat is ed w ith w as p erform ed t w ice by th e sam e su rgeon ; 1 an d 3 years
the dorsal dem arcat ion of th e silicone im plant an d long nose previously (Fig. 11.16). Th e pat ien t su ered from relap s-
appearan ce. Th e operation in clu ded low ering th e sellion ing in am m at ion an d con sequ en t drain age of pus from
by ch anging th e silicon e im plan t an d sh orten ing th e n asal th e t ip. Th e form er surgeon h ad injected an cillar y ller to
length (Fig. 11.15). Addit ion al procedures w ere reu sing th e th e t ip, but th is resu lted in t ip deform it y. Th e pat ien t com -
posterior capsule to sm ooth out the dorsal dem arcation, plain ed of t ip deform it y an d h igh n asal dorsum . Mult ilay-
an d grafting of th e folded cym ba con ch a at th e caudal sep - ered capsu le w as rem oved an d th e radix w as redu ced . Th e
t um as a septal strut to project the nasal t ip and to elevate dorsal silicon e im plan t w as ch anged to a th in n er on e. Tip -
the subnasale using cavum con cha at the dorsum . Folded plast y using th e cym ba an d cavum con ch a w as perform ed
Gore-Tex w as in serted to augm ent the alar crease jun ction. (Fig. 11.17). Resu lt s are sh ow n in Fig. 11.18.
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146 II Rhinoplast y
c d
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11 Managem ent of Alloplast -Related Com plications 147
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148 II Rhinoplast y
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III
Blepharoplasty
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12 Double -Eyelid Surgery: Nonincisional Suture
Techniques
Jin Joo Hong and Hae Won Yang
Pearls
• Th e pat tern of skin fold form at ion in th e open ing th e edge of th e skin fold, an d th e t ru e lid m argin
ph ase of th e u pper eyelid is ch aracterist ic of th e w ith th e eyelash es are join ed togeth er m edially.
East Asian in dividual. In a double eyelid, th e upper • Th e m iddle port ion of th e double fold sh ould be
border of th e eye con sist s of t w o outlin es, as if th e su cien tly h igh er th an th e m ed ial an d lateral
u pp er eyelid w ere com posed of dual layers. port ion s in th e closed state to preven t st raigh ten ing
• The creation of an arti cial connection of skin (anterior of th e dou ble fold w h en th e eyes are open .
lam ella) and levator (posterior lam ella) at a higher level • After p reop erat ive design , ve p u n ct u res or sm all
is the m ain feature of the double-eyelid procedure. slit s sh ou ld be m ade w ith a n eedle or n o. 11 blade.
• Non in cision al su t u re ligat ion creates a fold w ith ou t A 7–0 n on absorbable su t u re is p assed th rough th e
dissect ion . It is a sim ple, n on invasive, an d e cien t skin to th e u pp er m argin of th e t arsu s an d ret u rn ed
tech n iqu e to m ake a double fold, but it h as also th rough th e sam e site of th e t arsu s to th e skin . Th en
m any con t rain dicat ion s. For exam p le, revision th e lid skin is xed on th e t arsal plate.
bleph aroplast y is perform ed to reduce th e h eigh t • W h en rem oving th e septal fat , th e posit ion of th e
of th e fold, especially after a previou s in cision al fat m u st be con sidered . Th e sept al fat m oves to an
bleph aroplast y. upper an d lateral area in th e supin e posit ion .
• Th e n on in cision al su t ure tech n iqu e n eeds to be • For Mü ller m uscle t u cking, 7–0 nylon th read is
m odi ed con sidering variou s factors su ch as pu y in t roduced th rough th e skin to th e upper m argin of
eyelid, w eak levator fun ct ion , an d exoph th alm os. For th e t arsu s. Th e sut ure is passed th rough th e tarsus
a p u y eyelid, th e sept al fat sh ou ld be rem oved as to th e poin t of th e conju n ct iva n ear th e su p erior
m u ch as possible, an d th e n ew crease lin e design ed forn ix an d ret urn ed th rough th e sam e poin t on th e
to be as low as p ossible. Too h igh a fold m ay h in der conjun ct iva to th e t arsus, t ucking th e Mü ller m uscle.
th e full open ing of th e apert u re an d yield open ing Th e sut ure exit s th rough th e t arsus to th e skin an d is
discom for t , especially in a subclin ical or clin ical kn ot ted to t igh ten th e th read.
ptot ic eyelid. If exoph th alm os is prom in en t , th e lin e • W h en th e sut ure passes th rough th e t arsus, th e
of th e crease sh ould be low ered m ore th an usual to su t u re m ay ap p ear on th e conju n ct ival side, w h ich
avoid an excessively h igh fold. can in duce a foreign body sen sat ion an d severe pain .
• Th e lid m argin m ay be closed (“in side fold”) or If th e p at ien t com p lain s of a foreign body sen sat ion ,
open (“out side fold”) at th e m edial en d according to th e eyelid is everted an d th e t arsal plate is carefully
w h eth er or n ot th e t w o upper ou tlin es of th e eye, scru t in ized.
151
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152 III Blepharoplast y
a b
t u re (dou ble eyelid) togeth er. In a double eyelid, th e upper an atom y, th e inver ted t riangle-sh ap ed u pp er eyelid h as a
border of th e eye con sist s of t w o outlin es as if th e upper th ick u pper por t ion w ith th ree dist in ctly separated lam el-
eyelid w ere com p osed of du al layers (Fig. 12.1). lae an d a th in distal lid m argin in w h ich th e an terior an d
In con t rast , th e single eyelid h as on ly on e bord er, posterior lam ellae are at ten uated an d con den sed rm ly
because th e skin fold is form ed below th e lid m argin . Th e togeth er (th e skin , orbicu laris ocu li m u scle, an d tarsu s).
edge of th e skin fold h id es th e real lid m argin an d p u sh es Th e in ter ven ing orbit al sept um an d orbit al fat (m iddle
th e eyelash es from above in th e open ing ph ase (Fig. 12.2). lam ellae) exten d on ly to th e fusion lin e, w h ich can be iden -
Com pared w ith th e double eyelid, th e palpebral apert ure t i ed as a skin crease on th e outer surface. Th e con den sed
is redu ced by th e low er skin fold. Th e single-lin ed upper dist al lid m argin is at t ach ed to th e levator m ech an ism
border is a un ique feat u re of East Asian in dividuals (Korean , (levator ap on eu rosis, su p erior levator palp ebralis m u scle,
Ch in ese, Japan ese, an d Mongolian ), w h ile th e dou ble lin e is an d Mü ller m u scle) an d act ively ret ract s at th e begin n ing
th e m ost prom in en t eyelid fold pat tern in Caucasian , Afri- of th e open ing ph ase (Fig. 12.3). Meanw h ile, th e an terior
can Am erican , an d South Asian in dividuals. an d m iddle lam ellae above th e fu sion lin e (t ran sverse
skin crease) are p assively fold ed according to th e op en ing
m ovem en t .
Anatomy of the Upper Eyelid With th e su p erior levator p alpebralis m u scle con t ract-
ing, th e distal lid m argin (red-colored surface) directly con -
Th e upper eyelid is a layered st ruct ure, divided in to th e nected to th e levator m ech an ism begin s to ret ract upw ard ,
an terior, m idd le, an d posterior lam ellae. Th e an terior leaving th e upper an terior lam ella (above th e fusion lin e,
lam ella is com posed of th e skin an d u n derlying orbicularis green - an d blu e-colored su rface) st at ic in sit u . As th e
oculi m uscle. Th e posterior lam ella con sist s of th e tarsus degree of open ing in creases, th e an terior lam ella ju st above
an d u n d erlying conju n ct iva. Th e m iddle lam ella con sists of th e crease is passively lifted from its distal en d (green -
th e orbit al sept u m an d fat separat ing th e orbit al con ten t s colored surface). At th is level, th e t ran sverse skin crease
from th e p resept al st ru ct u res.2 In th e sagit t al sect ion al becom es prom in en t an d is folded furth er as open ing pro-
a b
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12 Double-Eyelid
Surgery:
Nonincisional
Suture
Techniques 153
Fig. 12.4 Single and double eyelid. The most important anatomic di erence bet ween a single and double eyelid is the level at which the
fusion bet ween the anterior and posterior lamellae occurs, and thus the level at which the anterior skin is folded. The pat tern of the skin
fold in the opening phase determines the shape of the eye. (a) In a single eyelid of an Asian, the skin fold is formed at a lower level and the
folding skin hides the real lid margin and eyelashes as well as the upper part of the palpebral aperture. (b) In contrast, the skin fold of a
double eyelid lies at the upper level and the fold edge is formed far above the eyelashes.
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154 III Blepharoplast y
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12 Double-Eyelid
Surgery:
Nonincisional
Suture
Techniques 155
a b c
Fig. 12.5 Di erent shapes of lid margin. (a) The shape of the lid margin is determined by the edge of the fold and the distal border of
the lid. If the middle portion of the lid margin is too wide, the shape of the eye looks too round or oval-shaped. (b) If the middle portion
of the lid margin is too narrow, the eye appears as though it is frowning. (c) The upper and lower sides of the lid margin should be parallel
or gradually grow farther apart.
a b c
Fig. 12.6 Three t ypes of double fold. (a,b) The lid margin may be closed (“inside” fold)
or open (“outside” fold) at the medial end according to whether or not the t wo upper
outlines of the eye, the edge of the skin fold and the true lid margin with the eyelashes,
join together medially. (c) In the “in/out” or “neutral” fold, the m edial side is open with a
small gap, but the height of the lid margin is gradually increasing laterally. (d) Design of
d the outside fold (red), in/out or neutral fold (yellow), and inside fold (blue).
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156 III Blepharoplast y
of sut ure m aterial is im port an t . Frequen tly u sed nylon ven t st raigh ten ing of th e d ou ble fold w h en th e eyes open .
(p olyam ide, 7–0 nylon ) is a n on absorbable, m on o lam en t If th e p at ien t h as th in eyelid skin an d good levator fu n c-
su t u re m aterial. Alth ough a m on o lam en t nylon su t u re h as t ion , a h igh er double fold is possible. On th e con t rar y, if th e
a great m em or y to ret u rn to its p reviou s sh ape an d a p ro- pat ien t h as th ick eyelid skin an d poor levator fu n ct ion , it is
clivit y for kn ot slippage, it h as a low in fect ion rate. Un dyed bet ter to m ake th e double fold lin e low er because it ten ds
t ran slucen t nylon is preferred for a n on in cision sut ure liga- to look u n n at u ral if a h igh er fold is m ade in su ch a p at ien t .
t ion procedu re, because un dyed nylon h as a greater ten sile Th e ve m arkings vert ical to th e double fold lin e in terrupt
st rength th an th e dyed form , w h ich in clu d es im p u rit ies. an d divide th is lin e in to fou r areas (Fig. 12.7). Th e m edial
How ever, t ran slu cen t su t u re m aterial is h ard to n d in a en d sh ou ld be at or im m ediately lateral to th e u pp er en d of
revision procedu re.5,6 th e epican th al fold. Th e lateral en d sh ould be at th e lateral
en d of th e p alp ebral ssu re.
Th is surgical procedure is usually perform ed un der
Choice of Needle local an esth esia using 2% lidocain e m ixed w ith 1/100,000
ep in ep h rin e an d m ild in t raven ou s sedat ion . For skin an es-
Needle ch oice d ep en ds on th e an t icip ated locat ion of th e th esia, sh allow in sert ion of a 26-gauge n eedle in to th e sub -
su t u re loop in th e eyelid t issu e. Con n ect ing loop (s) can be derm al layer is perform ed, because if th e n eedle is in ser ted
m ade by p erforat ing th e fu ll th ickn ess of th e lid or by p ar- deep, bleeding an d sw elling m ay occur an d th e su rgeon
t ial t agging of th e lid skin to th e tarsus. For a perforat ion m ay n ot be able to predict th e ou tcom e of su rger y. Th e
procedure, a long, circu lar n eedle is conven ien t (24 m m conjun ct iva is also an esth et ized w ith lidocain e inject ion .
rou n d ⅜ circu lar n eedle w ith 7–0 w h ite nylon ). How ever, A 0.5% op h th alm ic solu t ion of p rop aracain e hyd roch loride
a sm aller n eed le is p referred for th e p ar t ial tagging proce- is used to an esth et ize th e corn ea. A plast ic corn ea protec-
dure. A t riangu lar cut t ing n eedle can dam age large vessels, tor can be u sed to p rotect th e eyeball. Th e su rgical step s
so a rou n d or rectangu lar cu t t ing n eed le is ch osen . of th e n on in cision al sut ure tech n ique for a double-eyelid
operat ion are sh ow n in Fig. 12.8. Du ring local an esth esia,
th e poin t s previously m arked w ith gen t ian violet are pun c-
■ Surgical Techniques t ured w ith th e 26-gauge n eedle. Th ese tem porar y m ark-
ings can in dicate th e en t ran ces an d exit s of th e 7–0 nylon
Nonincisional Suture Technique of a su t u re. In stead of a pu n ct u re, a sm all st ab in cision can be
Double -Eyelid Operation m ade w ith a n o. 11 blade.
If th e orbit al sept al fat volu m e is ver y bu lky an d th e
It is bet ter to design a dou ble eyelid w ith th e clien t in an upper eyelid appears pu y, sept al fat rem oval can be p er-
u prigh t p osit ion because th e sh ape of th e eyes an d th e form ed th rough a sm all in cision on th e lateral port ion of
double fold can ch ange in a supin e posit ion . Th e surgeon th e dou ble fold. W h ile h olding th e sept um w ith tooth ed
can bet ter predict th e surgical outcom e for th e pat ien t in forceps, a sm all in cision is m ade on the sept um w ith sh arp
an u p righ t posit ion . scissors, an d th e sept al fat is ext racted w ith sm ooth forcep s.
Th ere are th ree classi cat ion s for th e start ing poin t of
th e double fold. An in side fold is on e in w h ich th e double
fold lin e st ar t s below th e epican th al fold. It ten ds to be m ore
n at u ral bu t th e eyes can look sm aller th an w ith oth er form s
of fold. An out side fold is on e in w h ich th e double fold lin e
start s above th e epican th al fold. Th e eyes look bigger th an
w ith an in side fold, but th e appearan ce m ay be un n at ural. A
n eu t ral fold or in /ou t fold is a t ype of out side fold in w h ich
th e st art ing poin t is low er th an it is for th e classical out side
fold . It looks n at ural an d th e eyes look bigger; m any Asian
clien ts prefer th is fold (Fig. 12.6d).7
Th e preoperat ive design of th e double fold lin e sh ould
be m arked w ith a sh arp surgical m arking pen along th e
n at ural cu r vat u re of th e eyelid skin . Gen erally, th e m ean
h eigh t of a dou ble fold is 6 to 8 m m from th e eyelash , an d
th e h eigh t ranges from 4 to 10 m m . Th e range of tarsal
w idth in Asian in dividu als is usu ally 6 to 8 m m , so a sut ure Fig. 12.7 Preoperative design of the nonincisional suture tech-
th at pen et rates th e skin can be xed on th e t arsal plate.8 nique. The m idportion of the fold should be higher than the medial
Th e m iddle port ion of th e fold sh ould be h igh er th an and lateral portions in the closed state to prevent straightening of
th e m edial an d lateral por t ion s in th e closed st ate, to pre- the double fold when the eyes open.
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12 Double-Eyelid
Surgery:
Nonincisional
Suture
Techniques 157
a b c
d e f
Fig. 12.8 Surgical procedures for the nonincisional suture technique. (a) After local anesthesia using 2% lidocaine mixed with 1/100,000
epinephrine and mild intravenous sedation, the points previously marked with gentian violet are punctured with a no. 26G needle. These
temporary tat toos can be the entrance and exit points for 7–0 nylon sutures. (b) Septal fat removal can be done through a small incision on
the lateral portion of the double fold. (c) The suture is passed through the skin to the upper margin of the tarsus. As the suture is passed,
the upper eyelid is everted with wide sm ooth forceps or other forceps for the tarsus. (d) The suture needle is returned through the same
site at the tarsus to the skin. (e) The suture is passed through the subdermal layer to the next puncture of the skin. (f) The same procedure
is repeated on the following punctures.
Th e ext racted fat is coagu lated w ith an elect rical coagulator of the skin side exceeds that of the conjunct ival side, the
an d th en cu t . Met icu lou s coagu lat ion is n ecessar y becau se double fold w ill be deeper an d the eyelashes w ill be everted.
th ere are sm all vessels w ith in th e sept um . If th e skin side is shorter th an the conjun ctival side, the skin
A 7–0 m on o lam en t n on absorbable sut ure w ith a below the double fold w ill sag. After the sut ure exits th e
t apered 24-m m ⅜c n eedle is used. A roun d n eedle sut ure hole of the skin again , it is passed th rough th e subderm al
is u sed becau se an angled n eedle m ay cu t th e nylon acci- layer to the n ext skin punct ure, w ith the procedure repeated
d en t ally. Th e su t ure is passed th rough th e skin to th e upper on each punct ure. The sequence of the procedure can be
m argin of th e t arsu s an d ret u rn ed th rough th e sam e site ch anged. Nu m bering skin en tr y poin ts as 1 th rough 5 from
of th e tarsus to th e skin . Th en th e lid skin is xed on th e m edial to lateral, th e au th ors proceed in th e order 5–3–1–
t arsal plate. 2–4–5. W h en the septal fat is rem oved, the order proceeds
W hen th e sut ure is being passed, the upper eyelid is as 4–5–3–1–2–4 (Fig. 12.9). Th e en ds of th e sut u res are t ied
everted w ith a w ide sm ooth forceps, or another t ype of at the lateral posit ion and the kn ot is buried w ithin the sub-
forceps for th e tarsus. Th ere are m any t ypes of forceps for derm al layer. The kn ot can be placed in any locat ion, but
h an dling th e tarsu s. To pen etrate th e tarsus in th e sh ortest the cent ral area is avoided because the knots can be visible
distance, the needle should be vert ical to the tarsus. If the there. The skin incision is closed w ith nylon 7–0, or m ay not
n eedle is n ot vert ical to th e tarsus, th e soft tissue ben eath need to be closed w hen th e incision is ver y sm all.
the skin can be xed to th e tarsus an d unw anted dim pling The patient opens his/her eyes and the surgeon checks the
w ill develop. The distance from the eyelid m argin to the shape of the double fold and the sym m etry of both eyes. An
h ole in th e skin side sh ou ld be sim ilar to th e distan ce from ice bag is applied to the periorbital area for 2 days to reduce
the eyelid m argin to the conjunct ival ent rance. If the length swelling. The skin stitches are rem oved 3 to 5 days later.
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158 III Blepharoplast y
Fig. 12.9 Typical sequence of needle passes in the nonincisional suture technique. Numbering skin entry points as 1 through 5 from
medial to lateral, the authors proceed in the order 5–3–1–2–4–5. The ends of the sutures are tied at the lateral position and the knot is
buried within the subdermal layer.
Transconjunctival Müller Tucking 2. W h en rem oving th e sept al fat , th e posit ion of th e fat
m u st be con sid ered . Th e sept al fat m oves to an u pp er
In th e u n ilateral or bilateral m ild ptosis case, t ran sconju n c- an d lateral area in th e su p in e p osit ion .
t ival Mü ller t ucking can be don e w ith th e double-eyelid 3. During th e sut ure pass th rough th e t arsu s, an
operat ion (Fig. 12.10). Th e preop erat ive design of th e dou - u nw an ted kn ot can be m ade on th e conju n ct ival side
ble fold lin e sh ould be perform ed along th e n at ural skin th at can in du ce a foreign -body sen sat ion an d severe
crease. Th e locat ion s of Mü ller t u cking sut ures are m arked pain . If th e pat ien t com plain s of th e sen sat ion of
on th e vert ical lin e of th e m edial an d lateral lim bi. Th e sur- a foreign body, th e eyelid is everted an d th e t arsal
gical p rocedu re is u su ally perform ed u n der local an esth esia plate is obser ved rst .
u sing 2% lidocain e m ixed w ith 1/100,000 epin ep h rin e an d 4. For t ran sconju n t ival Mü ller t ucking, an assist an t
m ild in t raven ou s sedat ion . Sm all in cision s are m ade w ith sh ou ld pu ll th e t ract ion su t u re an d pu sh th e eyelid
a n eed le or n o. 11 blade on p oin t s th at th e n eedle w ou ld in th e opposite direct ion w ith a cot ton sw ab to m ake
pen et rate. Ever t ing th e u pper lid, a t ract ion sut ure is m ade th e procedu re easier to perform .
on th e upper m argin of th e t arsus w ith nylon 5–0.
5. It is best if th e poin t of th e conjun ct iva at w h ich th e
For Mü ller m uscle t ucking, 7–0 nylon th read is in t ro-
su t u re exit s is n ear th e su p erior forn ix.
duced th rough th e skin to th e upper m argin of th e t arsus.
Th e sut ure is passed th rough th e t arsus to th e poin t of th e
conjun ct iva n ear th e superior forn ix an d ret u rn ed th rough
th e sam e poin t on th e conjun ct iva to th e tarsus, t ucking th e ■ Complications and
Mü ller m u scle. Th e su t u re exit s th rough th e t arsu s to th e Their Management
skin an d is kn ot ted to t igh ten th e th read. Th e sam e p roce-
dure sh ou ld be perform ed at oth er sites of Mü ller m u scle Relapse
t ucking, an d th en th e t ract ion sut ure is rem oved. Next , th e
com m on procedu re for th e dou ble fold is perform ed. Th e Becau se th ere is n o t issue adh esion bet w een th e an terior
kn ots of th e th reads sh ould be buried w ith in th e skin so an d p osterior lam ellae of th e u pp er eyelid, u n like th e case
th at th ey are n ot exposed.9,10 in an in cision al bleph aroplast y tech n ique, the con n ect ion
bet w een th e t w o st ruct ures depen ds on ly on th e sut ure
loop in a n on in cision al tech n ique. A sut u re loop in evit ably
■ Key Technical Points loses it s h old on t issues over th e postoperat ive m on th s an d
th e am oun t of t issu e h eld by each loop gradually reduces
1. In th e design of th e double fold, th e h eigh t of over t im e. Hen ce, th e xat ion bet w een th e t w o lam ellae
th e m iddle por t ion of th e dou ble fold sh ould be loosen s, even w ith a t igh t relat ion sh ip at th e begin n ing.
su cien tly h igh er th an th e m ed ial an d lateral Alth ough m oderate loosen ing is a n orm al, n at u ral drift
p ort ion s in the closed state to preven t st raigh ten ing tow ard an equ ilibriu m , excessive loosen ing e aces th e skin
of th e dou ble fold w h en th e eyes are open . fold or m akes m u lt iple skin folds in oth er creases (relap se).
Th is relapse is th e m ain draw back of th e n on in cision sut ure
ligat ion bleph aroplast y tech n ique. Various au th ors h ave
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12 Double-Eyelid
Surgery:
Nonincisional
Suture
Techniques 159
a b c
d e
Fig. 12.10 Transconjunctival Müller tucking. (a) Preoperative design for transconjunctival Müller tucking. The points 2 and 4 are for Mül-
ler tucking suture. The points 1, 3, 5, and 6 are for the double fold procedure. (b) A traction suture is located on the upper margin of the
tarsus. (c) The suture is passed through the skin to the upper m argin of the tarsus. (d) The Müller tucking suture is passed through the
tarsus to a point of the conjunctiva near the superior fornix. The surgeon’s assistant should pull the traction suture and push the eyelid in
the opposite direction using a cot ton swab to facilitate the procedure. (e) The Müller tucking suture returns through the same point of the
conjunctiva to the tarsus to tuck the Müller muscles.
rep or ted th eir ow n relapse rates, bu t th ese are n ot clin ically th e crease becom es gradually deeper as th e globe exposure
m ean ingfu l. In pat ien t s w ith u n favorable feat u res (e.g., w iden s. Becau se th e fold h angs over th e skin crease, a lin -
th ose w ith pu y eyelids), th e rate of fold relapse in creases. ear sh adow of th e fold ap pears parallel to th e crease an d
Th e m ost com m on cause of relapse is a sut ure loop fold . At th is t im e, u n less th e crease is parallel to th e relaxed
h olding t issu e w ith less brou s com p on en t s. Th eoret ically, skin ten sion lin e (RSTL), m u lt ip le part ial obliqu e folds can
th e surgeon sh ould dist ribute th e ten sion of each loop be created, disrupt ing th e con t in uit y of th is fold sh adow.
even ly, an d in clu de m ore brou s t issu e in each loop as a Unw an ted obliqu e folds n ear the crease during th e open ing
su p port ing st ru ct u re. An oth er cau se of relapse is w eakn ess m ovem en t dim in ish th e n at u ral look of th e dou ble-eyelid
of th e su t ure m aterial. Pure nylon is t ran slucen t an d ver y crease. Th e crease sh ould be design ed perfectly parallel to
exten sible, bu t colored nylon m ixed w ith p igm en t loses its th e RSTL in any case.
exten sibilit y an d breaks easily. How ever, a sim p le su t u re Alth ough th e irregularit y of th e skin folds can be
m aterial problem occu rs in frequ en tly.11,12,13 prom in en t at th e site of th e sut ure loop in th e im m ediate
postoperat ive period due to local pin ch ed t issu e, th e skin
can recoil an d th e irregularit y fades aw ay w ith in 3 m on th s.
Irregular Fold How ever, dim p ling in an area of scar t issu e can n ot easily
fade aw ay becau se scar t issu e h as less recoiling pow er. In
Fold form at ion of th e upper lid skin during eye op en ing addit ion , a scar in th e skin p reven t s even fold form at ion ,
from th e closing p h ase p roceed s dyn am ically an d gradu - so th e scar sh ou ld be located below th e skin fold ing crease
ally. At th e begin n ing of th e op en ing, th e skin fold along (Fig. 12.11).
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160 III Blepharoplast y
a b c
Fig. 12.12 Tension eversion. (a) Lid margin skin tension should be adequate and considered in the design at the beginning of the proce-
dure. An abrupt di erence in skin thickness along the crease looks unnatural and arti cial. (b) In addition, the eyelashes might be everted
to a large extent, and the hidden conjunctival mucosa might appear abnormal. (c) The prospective crease would be lowered and would
undulate into an unnatural curve.
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12 Double-Eyelid
Surgery:
Nonincisional
Suture
Techniques 161
a a
b b
Fig. 12.13 Case 1. Nonincision suture ligation for double fold for- Fig. 12.14 Case 2. Transconjunctival Müller tucking. (a) A 35-year-
mation. (a) This 25-year-old female patient with a low and asym - old female patient with ptosis of the left eyelid and asymmetric
metric double fold wanted a neutral or outside fold and a higher double fold. She had an incisional double-eyelid operation 1 month
double fold. (b) Six months after septal fat removal and nonincision previously. (b) Two weeks after transconjunctival Müller tucking on
suture ligation, she has a sym metric and higher double fold. the left side only, the ptosis of the left side and asymm etry of the
double fold have resolved.
References pylene im plants used for augm entation of fascial repair in a rat
m odel. Gynecol Obstet Invest 2007;63(3):155–162
1. Zide BM, ed. Surgical An atom y aroun d th e Orbit: Th e Sys- 8. Ch o IC, Eed. The Art of Bleph aroplast y. Seou l, Korea: Koon -
tem of Zon es. Ph iladelph ia, PA: Lip pin cot t , William s & ja; 2013
Wilkin s; 2006 9. Wong JK. A m eth od in creat ion of th e superior palpebral
2. Most SP, Mobley SR, Larrabee WF Jr. Anatomy of the eyelids. fold in Asian s u sing a con t in uous buried tarsal st itch
Facial Plast Surg Clin North Am 2005;13(4):487–492, v (CBTS). Facial Plast Su rg Clin North Am 2007;15(3):
3. Fralick FB. An atom y an d physiology of th e eyelid. Tran s Am 337–342, vi
Acad Op h th alm ol Otolar yngol 1962;66:575–581 10. Park JW. Non -in cision t ran sconju n ct ival Mu ller t u cking in
4. Reid RR, Said HK, Yu M, Hain es GK III, Few JW. Revisit ing bleph aroplast y. Arch Aesth Plast Surg. 2012;18:31–34
u pper eyelid an atom y: in t roduct ion of th e sept al exten - 11. Ah n YJ. Cases of m ild ptosis correct ion w ith su t u re-m eth -
sion . Plast Recon st r Surg 2006;117(1):65–66, discussion od. Arch Aesth Plast Surg. 2012;18:15–20
71–72 12. Hom m a K, Mu tou Y, Mu tou H, Ezoe K, Fujit a T. In t raderm al
5. Moy RL, Lee A, Zalka A. Com m only used suture m aterials in skin st itch bleph aroplast y for orien t als: does it disappear? Aes-
surgery. Am Fam Physician 1991;44(6):2123–2128 th et ic Plast Su rg 2000;24(4):289–291
6. Lober CW, Fenske NA. Sut ure m aterials for closing th e 13. Ko RY, Baek RM, Oh KS, Lim JH. Com plicat ion of n on -in -
skin an d subcut aneous t issu es. Aesth et ic Plast Su rg 1986; cision Orien t al bleph aroplast y: is disappearan ce of th e lid
10(4):245–248 crease a fearful com plicat ion ? J Korean Soc Plast Reconst r
7. Spelzini F, Konstantinovic ML, Guelinckx I, et al. Tensile Surg 2000;27:199–203
strength and host response towards silk and type I polypro-
http://e-surg.com
13 Double -Eyelid Surgery: Incisional Techniques
Jae Woo Jang
Pearls
• Th e East Asian upper eyelid h as several dist in ct 3-m m pret arsal sh ow, 20 to 30% of th e length of th e
an atom ic ch aracterist ics, in clu ding a low, poorly in terpalpebral ssure, is opt im al in East Asian s.
de n ed, or absen t eyelid crease; n arrow palpebral • Th e h eigh t an d sh ape of th e eyelid crease sh ould
ssu re; an d ep ican th al fold. be in dividualized depen ding on a pat ien t’s eyelid
• Th e goal of upper bleph aroplast y for th e Asian ssu re or ep ican th al fold . Th e favorite t yp es of eyelid
pat ien t is to m ake eyes fresh , you th ful, an d creases are th e in side crease an d out side crease—
at t ract ive w h ile m ain t ain ing th eir eth n ic appearan ce fan t yp e or m ixed t ype—in East Asian s, esp ecially
by surgically creat ing a suprat arsal crease. Korean s.
• Th e in dicat ion s for th e in cision al tech n iqu e are • Proper rem oval of th e orbicularis m uscle an d orbit al
redu n dan t skin , bulky eyelids due to soft t issu e an d fat is n ecessar y to create a m ore secu re eyelid crease.
fat , disapp earan ce of th e eyelid crease after su t u re Som et im es ret ro-orbicu laris orbital fat (ROOF)
or par t ial in cision al tech n ique, an d reoperat ion rem oval is required depen ding on th e pu n ess of
due to various com plicat ion s after eyelid crease th e in dividual’s eyelid.
su rger y. Scarring is n ot a p roblem if th e tech n iqu e is • Ap p ropriately design ed d ou ble-eyelid h eigh t an d
delicately perform ed. proper xat ion resu lt in a n at ural an d aesth et ically
• Th e eyelid crease h eigh t in East Asian s is 6 to 8 pleasing double eyelid.
m m in fem ales an d sligh tly low er in m ales. A 2- to
162
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13 Double-Eyelid
Surgery:
Incisional
Techniques 163
cally h ave an eyelid crease, but Asian eyelids can be catego- th at pat ien t s recover m ore quickly w ith n o scarring, w h ile
rized in to th ree t yp es: single eyelid, low eyelid crease, an d th e disadvan tages in clu de th e in abilit y to rem ove pre-apo-
d ou ble eyelid. neurot ic fat an d soft t issue, w h ich leads to th e disappear-
The causes of an absen t or low er crease in an Asian an ce of th e dou ble fold.
u pp er eyelid in clu de th e follow ing: (1) Th e orbital sept u m Th e in dicat ion s for th e in cision al tech n ique are (1)
fu ses to th e levator ap on eu rosis below th e su perior t arsal redu n dan t skin , (2) bulky eyelid due to soft t issue an d fat ,
border. (2) Preapon eurot ic fat pad prot rusion an d a th ick (3) disappearan ce of th e eyelid crease after th e use of a
su bcu tan eou s fat layer preven t levator bers from exten d- non in cision al sut ure tech n ique or par t ial in cision al tech -
ing tow ard th e skin n ear th e su p erior t arsal border. (3) Th e nique, an d (4) an addit ion al operat ion due to various com -
p rim ar y in sert ion of th e levator apon eu rosis in to th e orbi- plicat ion s after eyelid crease surger y (Fig. 13.2).
cularis m uscle an d in to th e upper eyelid skin occurs closer Th e m ajor disadvan tage to th e in cision al tech n ique is
to th e eyelid m argin in Asian s (Fig. 13.1).6,7 Asian single th e long recover y t im e (usually 1 w eek is required to reduce
eyelids h ave m ore prom in en t subcut an eous and ret ro-orbi- postoperat ive sw elling an d edem a). Scarring is n ot a prob -
cularis fat in th e suprat arsal region . Several com pon en t s, lem w h en th e procedure is perform ed precisely an d deli-
su ch as a su bm u scu laris bro-adip ose t issu e layer an d a cately. Th e in cision lin e is m ore prom in ent w ith th e part ial
low er-posit ion ed t ran sverse ligam en t , h ave been iden t i ed in cision tech n ique com pared w ith th e in cision al tech n iqu e
an d are fou n d exclu sively in th e Asian eye. because th ere is an apparen t abrupt en ding w ith th e m ore
Th e prim ar y goal of double-eyelid su rger y is n ot sim - lim ited in cision al m eth od.8
ply to create a suprat arsal crease but to create a crease th at
is con sisten t w ith th e n at ural con gurat ion presen t in th e
gen eral East Asian p op u lat ion . ■ Patient Evaluation
Most pat ien t s d esire p erm an en t an d n at u ral-looking eyelid
■ When Should the Incisional creases. At th e in it ial con sult at ion , th e pat ien t’s goals an d
Technique for Double -Eyelid exp ectat ion s sh ou ld be iden t i ed. Th e eyelid crease h eigh t
usually depen ds on th e in terpalpebral ssure size an d tar-
Surgery Be Performed? sal p late h eigh t . Th e prop er eyelid crease h eigh t in East
Asian s is 6 to 8 m m in fem ales an d sligh tly low er in m ales.
Th e t ypes of double-eyelid surger y in clude th e sim ple Th e rst step is to sim ulate th e est im ated eyelid crease
su t u re tech n iqu e, th e part ial in cision al tech n iqu e, an d in fron t of th e m irror by push ing th e eyelid skin w ith
th e in cision al tech n ique. Th e ch oice of tech n ique is based devices such as a forceps, a lacrim al probe, a paperclip, or a
on pat ien t preferen ce, skin qualit y, an d th e volum e of fat w ooden cot ton -t ip ped app licator; th e di eren t sh ap es an d
t issue in th e upper eyelid. Th ere are advan t ages an d dis- w idth s of th e eyelid crease can be created an d visualized
advan t ages to th e in cision al tech n iqu e an d n on in cision al using th ese tools. Th e h eigh t an d sh ape of th e eyelid crease
tech n iqu es. Th e advan tages of n on in cision al tech n iques are requ ired for a n at ural look sh ould be decided via discus-
sion w ith p at ien t . Sh ou ld th e p at ien t requ est a h eigh t an d
sh ape th at d o n ot m atch th e eyelid sh ap e, a m ore th or-
ough explan at ion w ill be required to assist in th e decision
m aking p rocess. Som e p at ien t s m ay n ot fu lly express th eir
desires, w h ich can m ake th ese cases ver y di cult to m an -
age. As m en t ion ed previously, m ost Asian s w an t a crease
th at is con sisten t w ith th ose th at occur n at urally in th e
popu lat ion .
a b
Fig. 13.1 Di erences in upper eyelid anatomy bet ween (a) East
Asians and (b) Caucasians. In Asians, the orbital septum fuses with
the levator aponeurosis below the superior tarsal border. The pro- Fig. 13.2 A t ypical indication for the incisional technique for eye-
truded pre-aponeurotic fat and thick subcutaneous fat layer disturb lid crease surgery. The eyelids show pu ness, skin laxit y, and an
extension from the levator aponeurotic bers toward the skin. epicanthal fold in a 25-year-old woman.
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164 III Blepharoplast y
Ptosis of the upper eyelid is assessed by m easuring the w ith a n at ural crease h ave eith er a n asally t apered crease
palpebral ssure w idth and m argin re ex distance 1 (MRD1, or a parallel crease, as described in various repor t s. Ch en
from th e ligh t re ex on th e pat ien t’s corn ea to th e cen t ral noted th at inside fold an d out side fold are less ap p rop riate
upper eyelid m argin). Lash ptosis or dow nw ard angulat ion term s; h ow ever, in Korean populat ion s, th e in side crease is
of the lashes ow ing to relaxat ion of the anterior lam ella of w ell m atch ed w ith th e n asally tapered crease, bu t th e p ar-
the eyelid should also be noted and corrected during upper allel crease does n ot exactly m atch th e ou t side fold.2 Th ere-
lid blepharoplast y.9 Early m yasth en ia gravis sym ptom s are fore, in th is ch apter, th e au th or w ill u se th e term s inside
sim ilar to th ose of ptosis an d require a di eren tial diagn osis. crease an d out side crease in stead of nasally tapered crease
Periorbit al fat is im port ant for bleph aroplast y, espe- an d parallel crease.
cially w h en subbrow fat (ret ro-orbicularis orbital fat , or
1. Inside crease. A n at u ral, low er crease th at converges
ROOF) is dist ributed up to th e orbital sept u m level an d fu ll-
tow ard th e m edial can th us an d run s parallel across
n ess in th e u p p er eyelid can be seen ; th is is dist ingu ish able
th e ciliar y m argin , over th e cen t ral port ion , and
from orbit al fat h ern iat ion .7 Th e orbital fat of th e u p p er eye-
ares aw ay from th e ciliar y m argin as it app roach es
lid is divided in to t w o groups: cen t ral an d m edial. Cen t ral
th e lateral can th us (fan t ype) (Fig. 13.3a).
orbit al fat h as a yellow, but ter color, w h ile m edial orbit al
fat is w h it ish in color an d is com posed of sm aller lobu les. 2. Out side crease. Th e crease ru n s fairly p arallel to th e
Blep h arop last y m ay be adapted according to th e qual- lash m argin from th e m edial can th us to th e lateral
it y of th e eyelid skin . Th e surgeon w ill con sider eyelid skin can th us. Th e ou tside crease is divided in to th ree
th ickn ess (th in or th ick), dehydrat ion of th e skin , an d th e t yp es: (a) fan t yp e, (b) fan -p arallel or m ixed t yp e
loss of elast ic an d collagen bers, depen ding on th e degree (th e eyelid crease gradually ares aw ay from the
of aging. With a greater degree of aging, bleph aroplast y for lid m argin tow ard th e cen ter port ion an d th en run s
th ick eyelid skin requires that th e skin in cision be m ade at parallel to th e ciliar y m argin tow ard th e lateral
a low er level an d th e procedu re n ot involve excessive skin can th us), an d (c) parallel t ype (th e crease run s at th e
rem oval. sam e w idth from th e m edial to th e lateral can th u s)
Before su rger y, th e pat ien t’s eyebrow shape an d posi- (Fig. 13.3b,c).
t ion , th e appearance of th e eyelids an d degree of sagging, Usu ally an in side crease becom es a fan t yp e an d an ou t-
an d th e degree of fat bu lging sh ou ld be recorded u sing side crease becom es a fan , fan -parallel, or p arallel t yp e.
pain t ings or ph otograph s. Th ese records can also play an In gen eral, th ere is a greater ten den cy to create an in side
im port an t role in resolving any com plain ts or con icts th at crease th an an out side crease in pat ien ts w ith a st rong
m ay occu r follow ing su rger y. m edial ep ican th al fold. Th e in side fold is con sid ered to be
m ore n at u ral an d con ser vat ive, w h ereas th e ou t side fold is
con sidered to be m ore m odern an d outgoing. Alth ough th e
■ What Is the Favorite Type h igh er ou t side-crease eye w as on ce t ren dy, it is u n n at u ral-,
of Double Fold in Asians art i cial-, an d Western -looking (Fig. 13.4), East Asian s,
esp ecially Korean s, p refer th e in side crease an d ou tsid e
in Relation to the Medial crease fan t ype or out side crease m ixed t ype. Moreover, it
Epicanthal Fold? is n ow un com m on for East Asian s to ch oose a sem ilun ar
crease like th at of Caucasian s.
Th e sh ape of an eyelid crease can be ch aracterized as It is reported th at ep ican th al folds are fou n d in 50 to
n asally t ap ered, parallel, or sem ilun ar. Asians rarely h ave 80% of Sou th Korean s. Due to th e epican th al fold, in 70% of
a sem ilu n ar sh ap e, w h ich is com m on in Cau casian s. Asian s eyelids th e caru n cle an d lacrim al lake are n ot overtly vis-
a b c
Fig. 13.3 Variations of East Asian creases. (a) Inside crease. (b) Outside crease, fan t ype. (c) Outside crease, parallel t ype.
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13 Double-Eyelid
Surgery:
Incisional
Techniques 165
Fig. 13.4 The higher outside crease. The high outside creases
may look cool, but they also look unnatural, arti cial, and Western.
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166 III Blepharoplast y
Supratarsal crease
Pretarsal show
(width of double eyelid)
Fig. 13.6 Pretarsal show. (a) The width of the eyelid crease during eye opening.
(b) The pretarsal show depends on m anaging the amount of skin excised using the
incisional technique: height of incision line (x) = 6–8 mm; pretarsal show (y) = 2
mm ; amount of skin excision is z × 2. b
is u su ally m arked in a leveled or are con gu rat ion . Th e taken to inject the anesthet ic solut ion only in the super cial
m arkings on th e opp osite eye sh ou ld be design ed to be as area of th e orbicu laris oculi m u scle to avoid th e occu rren ce
sym m et rical as p ossible. of a hem atom a due to m uscle injur y. To avoid bleeding, light
pressure is applied to th e area w h ere th e needle en ters th e
skin . Th e su rgeon takes care to adm in ister th e an esth et ic
Anesthesia solution th rough out th e proposed lesion of in cised skin .
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13 Double-Eyelid
Surgery:
Incisional
Techniques 167
a b
If p ret arsal soft t issu e is abu n dan t , it s rem oval is n eces- fat p ad , t h e orbit al sept u m is in cised m ed ially. Th e color of
sar y to create ad equ ate ad h esion s. Care sh ou ld be t aken n ot t h e p rot r u d ing fat is m ore w h it ish t h an t h at of t h e cen t ral
to in cise th e tarsu s u pp er m argin to preven t dam age to th e fat p ad . W h en rem ovin g t h e n asal fat p ad , care is t aken n ot
term in al in terdigit at ion of th e levator apon eurosis w h en to dam age t h e ar ter ies t h at are r u n n ing m ed ially, or t h e
excising th e p retarsal soft t issu e. Excessive rem oval of p re- ar ter ies sh ou ld be cau ter ized in advan ce to avoid bleed -
tarsal soft t issue m ay result in t igh t adh esion bet w een th e in g. Su p p lem en t ar y local an est h esia inject ion is n eed ed
skin an d t arsu s, w h ich m ay lead to a st at ic dou ble-eyelid for p ain con t rol before rem ovin g t h e n asal fat p ad . It is
crease. If th ere is n ot su cien t pret arsal soft t issue in th e im p or t an t to rem ove t h e sam e am ou n t of fat p ad from
h igh eyelid crease, an ad dit ion al op erat ion su rger y from a each eye.
h igh to low crease is ver y di cu lt an d t ricky. Som et im es lateral-h alf ROOF rem oval is n ecessar y in
pat ien t s w ith th ick redun dan t t issues even after rem oving
th e pre-apon eu rot ic fat (Fig. 13.9c). Care sh ou ld be t aken
Removal of Orbital Fat and ROOF not to rem ove th e ROOF th at is close to th e m uscle.
Excessive rem oval of fat or th e pret arsal orbicularis
The orbital sept um can easily be distinguished from th e m u scle along th e low er in cision lin e can cau se m u lt iple
prot ruded pre-aponeurotic fat by pressing th e eyeball gen - folds in you ng pat ien t s after th e in cision al eyelid crease
tly w hen the eyes are closed. The upper eyelid should be su rger y. Th e su rgeon m ay t ap e th e fold or inject absorbable
ret racted t ightly anteriorly and slightly dow nw ard w hile ller in m in or cases (Fig. 13.10).
forceps apply counter-t ract ion to tense the orbital sept um .
The exposed orbital sept um is pen etrated by the tip of the
scissors or Colorado n eedle to create a w in dow an d th e pre- Low er-Positioned Transverse
apon eurotic fat is exposed th rough th e open ing (Fig. 13.9a). Ligament
The orbital sept um is divided m edially and laterally w ith
scissors or by cau ter y to expose th e levator apon eurosis an d The low er-positioned t ransverse ligam ent (LPTL) is the
pre-apon eurotic fat . Yellow ish central pre-aponeurot ic fat is oth er tran sverse ligam en t in th e upper eyelid, w ith less elas-
obser ved w hen the orbital sept um is open ed. ticit y th an W hitnall’s ligam ent. It origin ates from the ante-
Th e fat p ad is grasp ed w it h a h em ost at an d excised rior su rface of th e t roch lea, exten ds in ferolaterally tow ard
across a closed h em ost at . Bleed in g is con t rolled to t h e en d the w hite lin e, and is re ected onto the orbital sept um ,
of t h e excised fat p ad by en su r ing t h at t h e h em ost at is inserting into the lateral orbital rim . The LPTL is th ought to
n ot loosen ed . Th e clam p is loosen ed on ly after ad equ ate prevent eyelid opening, and severing this ligam ent allow s
h em ost asis. If a CO2 laser is u sed , t h e fat p ad is excised furth er excu rsion of th e u pper eyelid an d is recom m en ded
w it h ou t t h e h em ost at (Fig. 13.9b). To rem ove t h e m ed ial w h en perform ing eyelid crease surger y (Fig. 13.11).12,13
a b c
Fig. 13.9 Opening of the septum and fat removal. (a) Tenting of the orbital septum during opening is necessary for preventing damage
to the levator aponeurosis. After opening the septum, the glistening levator aponeurosis is seen under the orbital fat. (b) Orbital fat is
removed with a CO2 laser. (c) Descended ROOF can be removed if desired.
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168 III Blepharoplast y
a b
Fig. 13.10 Triple fold. (a) The triple fold occurred after eyelid crease surgery due to excessive orbicularis muscle excision. (b) The triple
fold was managed by hyaluronic acid ller.
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13 Double-Eyelid
Surgery:
Incisional
Techniques 169
Skin Suture
carr y out full ptosis correct ion , it is bet ter n ot to m ake an
After xation of the eyelid crease, the eyelid skin suture is eyelid crease. Oth er w ise, th e eyelid crease m ay be ver y h igh
perform ed w ith a ne suture after con rm ation of complete or fain t , giving th e appearan ce of sleepy eyes, w h ich is n ot
hem ostasis. In Korea, the interrupted or continuous suture w ith aesth et ically accept able. Fu ll ptosis correct ion is m an da-
6–0 nylon or 6–0 fast-absorbing sutures are com m only used. tor y before eyelid crease su rger y (Fig. 13.15).
The skin of Asians is di erent from that of Caucasians, w ith the
form er requiring a greater num ber of sutures (Fig. 13.14).
■ Key Technical Points
Levator Advancement or Ptosis 1. In gen eral, a h igh -set crease m akes an ou tside crease,
Correction w h ereas a m oderate- to low -set crease m akes an
in side crease. Th e sh ape of th e eyelid crease also
In East Asia, w hen a patient w ith norm al levator function and depen ds on th e epican th al fold; th ere is a greater
w ithout pathologic ptosis desires the appearance of a larger ten den cy to create an in side crease in pat ien t s
eye, levator aponeurosis advancem ent or levator aponeurosis w ith an epican th al fold. Th e creat ion of out side
plication are com m only perform ed sim ultaneously during crease fan -t ype or m ixed-t ype lids requires th e
double-eyelid surgery.1 However, the e ect of plication of the m odi cat ion or rem oval of th e ep ican th al fold .
levator is not predictable and disappears at long-term follow - 2. Th e pret arsal sh ow in East Asian s is opt im al at 2 to
up. After dissection of the levator aponeurosis, the am ount of 3 m m or 20 to 30% of th e in terpalpebral ssu re. Th e
aponeurosis advancem ent is decided by observing the eyelid am ou n t of redu n dan t skin excision depen ds on th e
level and degree of sym m etry in the seated position. pre-determ in ed pret arsal sh ow.
In asym m et ric or u n ilateral ptosis, th e h eigh t of th e 3. Appropriately design ed eyelid crease h eigh t an d
eyelid crease sh ou ld be a lit tle less th an th at for a n orm al proper xat ion result in a n at ural an d aesth et ically
eyelid. In bilateral ptosis, th e h eigh t of th e eyelid crease is pleasing double eyelid.
1 or 2 m m less th an the n orm al 6 to 8 m m .5 If you do n ot
a b
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170 III Blepharoplast y
Their Management h igh fold , if th ere is en ough rem ain ing skin , t h e su rgeon
w ill decide th e n ew crease h eigh t an d th en excise t h e
skin toget h er w ith th e p reviou s in cision lin e. How ever, if
Asymmetry th ere is n ot en ough skin , a fu ll-th ickn ess skin graft cou ld
be n eeded. Du r ing th e operat ion , su rgeon s ten d to avoid
A com m on ly occu rring com p licat ion after dou ble-eyelid m aking t h e h igh crease at t h e sam e level as is p revalen t in
su rger y is asym m et r y, w h ich is cau sed by design fau lt , Western pract ice becau se correct ion su rger y from a h igh
asym m et ric skin resect ion , asym m et ric fat rem oval, di er- to a low crease is m ore com plex an d th e su rgical resu lt s
en t xat ion h eigh t of levator ap on eu rosis or t arsu s to create are som et im es u n d esirable. An ad d it ion al op erat ion to
a dou ble-eyelid crease, or di eren ces in adh esion bet w een cor rect a h igh ou t side crease to a low ou t side crease or
su bcu tan eou s t issu e an d levator ap on eu rosis. Th erefore, a in side crease is ver y di cu lt .
su rgeon m u st alw ays keep in m in d th e variou s factors th at
m ay cau se asym m et r y du ring th e op erat ion .
■ Case Studies
Disappearance of the Eyelid Crease
Case 1: Correction from the Short
Th e fading or disappearan ce of th e eyelid crease is caused Inside Crease to the Outside Crease
by in correctly xed su t ures from th e subderm al t issu e
below th e skin in cision to th e levator apon eu rosis or tarsus, A 22-year-old w om an visited th e au th or’s clin ic for eyelid
or by u n stable xat ion du e to postoperat ive h em atom a. crease surger y (Fig. 13.16a). Sh e w an ted an ou t side crease.
Th is con dit ion is m ore com m on w ith sut ure tech n iques Sh e h ad a low an d sh or t in side crease in both eyes. In ci-
th an w ith th e in cision al tech n ique. If th e pat ien t h as pre- sion al blep h arop last y w ith m edial epican th op last y w as
viou sly u n d ergon e th e n on in cision al m eth od, th e su rgeon perform ed. After eyelid crease surger y, th e in side crease
can perform th e n on in cision al m eth od again or th e in ci- ch anged to an ou tside crease (Fig. 13.16b).
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13 Double-Eyelid
Surgery:
Incisional
Techniques 171
a b
Fig. 13.16 Case 1. From the short inside crease to the outside crease with the incisional technique. (a) The preoperative photo revealed a
short inside fold in both eyes. (b) The patient had an outside fold after the incisional technique with medial epicanthoplast y.
Case 2: Correction from High Crease w an ted to h ave a low er eyelid crease. First , th e au th or
rem oved all of th e buried sut ure m aterials th at could pre-
to Low Crease ven t or redu ce th e adh esion . After 3 m on th s, th e righ t eyelid
crease disappeared an d th e left h igh eyelid crease rem ain ed
A 22-year-old w om an visited th e au th or’s clin ic becau se
(Fig. 13.17b). Good, n at u ral-looking in side creases w ere
of eyelid creases th at w ere too h igh (Fig. 13.17a). Sh e h ad
m ade in an add it ion al operat ion u sing th e in cision al tech -
u n dergon e eyelid crease su rger y via th e n on in cision al
nique after 6 m on th s (Fig. 13.17c).
tech n iqu e 4 w eeks previously. Sh e w as ver y un h appy an d
a b
Fig. 13.17 Case 2. From the high crease to the low crease with the
incisional technique. (a) The high eyelid creases were made after
nonincisional eyelid crease surgery. (b) The right eyelid crease disap-
peared and the left high eyelid crease still remained 3 months after
removal of buried suture materials. (c) Good, natural-appearing
inside creases were created after an additional operation with the
c
incisional technique.
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172 III Blepharoplast y
References 8. Lam SM, Karam AM. Suprat arsal crease creat ion in th e
Asian u p p er eyelid . Facial Plast Su rg Clin Nor th Am 2010;
1. Lee CK, Ah n ST, Kim N. Asian upper lid bleph aroplast y sur- 18(1):43–47
ger y. Clin Plast Su rg 2013;40(1):167–178 9. Lee TE, Lee JM, Lee H, Park M, Kim KH, Baek S. Lash pto-
2. Ch en W PD, Park JDJ. Asian upper lid bleph aroplast y: an sis an d associated factors in Asian s. An n Plast Surg
u pdate on indicat ion s an d tech n iqu e. Facial Plast Surg 2010;65(4):407–410
2013;29(1):26–31 10. Park JI, Toru m i DM. Dou ble eyelid op erat ion : orbicu laris-
3. Kang DH, Koo SH, Ch oi JH, Park SH. Laser bleph aroplast y levator xat ion tech n iqu e. In : Park JI, Toru m i DM, eds.
for m aking dou ble eyelids in Asian s. Plast Recon st r Surg Asian Facial Cosm et ic Su rger y. Ph iladelp h ia, PA: Elsevier
2001;107(7):1884–1889 Saun ders; 2007:49–59
4. Scaw n R, Josh i N, Kim YD. Upper lid blepharoplast y in 11. Flow ers RS. Asian blep h arop last y. Aesth et Su rg J 2002;
Asian eyes. Facial Plast Su rg 2010;26(2):86–92 22(6):558–568
5. Park DH, Kim CW, Shim JS. Strategies for sim ultaneous double 12. Kakizaki H, Malh ot ra R, Selva D. Up per eyelid an atom y: an
eyelid blepharoplast y in Asian patients w ith congenital bleph- u pdate. An n Plast Surg 2009;63(3):336–343
aroptosis. Aesthetic Plast Surg 2008;32(1):66–71 13. Ban M, Mat su o K, Ban R, Yu zu rih a S, Kan eko A. Develop ed
6. Jeong S, Lem ke BN, Dort zbach RK, Park YG, Kang HK. Th e low er-posit ion ed t ran sverse ligam en t rest rict s eyelid
Asian u p per eyelid: an an atom ical st u dy w ith com parison opening an d folding an d determ in es Japan ese as being
to th e Cau casian eyelid . Arch Op h th alm ol 1999;117(7): w ith or w ith out visible superior palpebral crease. Ep last y
907–912 2013;13:e37
7. Saonanon P. Update on Asian eyelid anatom y and clinical rel- 14. Wong JK. Aesth et ic su rger y in Asian s. Cu rr Op in Otolar yn -
evance. Curr Opin Ophthalm ol 2014;25(5):436–442 gol Head Neck Su rg 2009;17(4):279–286
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14 Aging -Related Upper Blepharoplasty
Hokyung Choung and Namju Kim
Pearls
• Un derstan ding an atom ic di eren ces an d • Many aged p eop le w h o w an t blep h arop last y m ay
involu t ion al ch anges in th e eyelids of East Asian s, have bleph aroptosis of som e degree but m ay
w h ich are speci c to age an d gen der, is th e key to not be aw are of it becau se it is con cealed by th e
ach ieving opt im al resu lt s. derm atoch alasis.
• Too m uch is as unw elcom e as too lit tle. Th e t ren d • If the patient com plains of ocular irritation sym ptom s,
in Asian aging-related bleph aroplast y is tow ard problem s w ith tear secretion such as dry eye syndrom e
con ser vat ive excision of skin an d fat , m aking a could be present. The surgeon should m ake the patient
n at u ral-looking, low -posit ioned dou ble eyelid (or understand that ocular irritation m ay be aggravated
n ot m aking an art i cial double eyelid). after blepharoplasty and that such problem s need to be
• It is im port an t to h ave a realist ic u n derstan ding m anaged before blepharoplasty.
of th e outcom e of bleph aroplast y th rough an • Th e m ost di cult cases of aging-related
in -depth d iscussion bet w een th e surgeon an d th e bleph aroplast y in Asian s involve pat ien ts w h o h ad
pat ien t before su rger y. Th e goal of aging-related un dergon e previous bleph aroplast y w ith excessive
bleph aroplast y is to restore th e in dividual’s skin an d fat rem oval, w ith a ver y h igh -posit ion ed
you th fu l ap p earan ce w h ile ret ain ing th e eth n ic double-eyelid crease. In th ese cases, au tologous fat
ch aracterist ics. Th is is especially t rue in th e case of or ller inject ion along th e brow an d upper eyelid
t reat ing th e Asian upper eyelid. com plex is m ore h elpfu l in im proving th e cosm et ic
• Th e upper crease is usually low or absen t in th e outcom e th an a bleph aroplast y.
Asian eyelid. Sligh tly folded upper eyelid skin over • Th e lacrim al glan d is located laterally just beh in d
th e double-eyelid crease, or a low double-eyelid th e orbit al rim , an d n orm ally it is n ot seen during
crease (e.g., 3–4 m m in h eigh t) looks m ore n at ural bleph aroplast y. With aging it prolapses, w h ich
an d blen ds w ell. Usu ally, a dou ble-eyelid crease over m igh t be m istaken for lateral fat p rolapse, especially
7 to 8 m m in h eigh t looks ver y un n at ural in Asian s, in Asian pat ien t s w h o have th ick skin over the
even in fem ale pat ien t s. lacrim al glan d.
• Brow ptosis usually occurs after m iddle age, an d • Com plicat ion s after aging-related bleph aroplast y are
derm atoch alasis an d bleph aroptosis m ay appear usually th e result of excessive skin or fat resect ion ,
accen t u ated d u e to brow ptosis. Th erefore, th e lack of h em ostasis, an in adequate preoperat ive
su rgeon m u st recogn ize brow ptosis before assessm en t , or careless postop erat ive m an agem en t .
su rger y an d decide w h eth er to p erform a brow Ever y e or t sh ou ld be m ade to m in im ize or preven t
lift in advan ce or do it in conjun ct ion w ith th e com plicat ion s du ring or after bleph aroplast y by
bleph aroplast y. recogn izing kn ow n risk factors an d paying careful
at ten t ion during an d after surger y.
173
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174 III Blepharoplast y
th e t ren d th ese days in Asian aging-related bleph aroplast y ptosis resu lt s from st retch ing or w eaken ing of th e levator
is tow ard con ser vat ive excision of skin an d fat , giving a n at- palp ebralis du e to involu t ion al ch ange or disin ser t ion of
u ral-looking, low -posit ion ed double eyelid an d n ot creat ing th e levator apon eu rosis from th e t arsal plate. It cau ses
an art i cial-app earing dou ble eyelid. Now adays m ost aging n ot on ly cosm et ic p roblem s bu t also visu al d iscom for t
Asian pat ien t s w an t to restore th eir youth ful appearan ce su ch as obscu rin g th e view. Alt h ough th e su p erior visu al
but at th e sam e t im e ret ain th eir eth n ic characterist ics, n ot eld is p rim arily involved , m any p at ien t s com p lain of d if-
Western ize th eir eyelids, th rough bleph aroplast y su rger y. cu lt y w it h read ing becau se th e ptosis is aggravated w it h
Periorbit al ch anges w ith aging in clude derm atoch ala- dow n -gazing. Park et al rep or ted th at Korean s age 50 years
sis, crow ’s feet , an d p eriorbit al fat p rolap se, an d th ese lead or older sh ow ed a ver y h igh frequ en cy (54.9%) of pto-
to ch anges in eyelid con tou r. Th e goal of blep h arop last y in sis, an d as th e age in creases, t h e frequ en cy of ptosis also
aging p at ien t s is to correct th ese processes an d to allow th e in creases.5 Th e exam in er sh ou ld n ote t h e p at ien t’s h ead
pat ien t to look younger. Bleph aroplast y in elderly people p osit ion , ch in -u p p osit ion , or brow p osit ion to d etect th e
is m ostly in cisional bleph aroplast y. To im prove th e perior- p resen ce of ptosis.
bital w rin kles or superior h ollow n ess, ller or bot ulin um Pat ien ts often involu n tarily at tem pt to com pen sate for
toxin inject ion s m ay follow. Periorbit al ch ange w ith aging derm atochalasis by ch ron ic u se of th e fron t alis m uscle an d
is a dyn am ic process involving th e aging of facial t issu e an d th is can lead to h igh -posit ion ed eyebrow an d deep (prom i-
bony st ruct ures, an d several ch anges are com m on . Epider- n en t) t ran sverse fu rrow s in th e foreh ead (Fig. 14.1). Un like
m al th in n ing an d decreased collagen cau se th e skin to lose oth er areas of th e body, w h ere th ere is descen t of soft t is-
it s elast icit y. Loss of fat , coupled w ith gravit y an d m uscle su es, th ere m ay be p aradoxical elevat ion of eyebrow s w ith
pull, leads to w rin kling an d th e form at ion of dyn am ic aging, especially th e m edial an d m idbrow. So th e clin ician
lin es. Th e aging process h as also been sh ow n to a ect facial sh ou ld t r y to determ in e th e eyebrow m orp h ology an d
bon es. Mult iple st udies suggest that bon e aging of th e orbit posit ion of th e in dividu al pat ien t an d select ively elevate th e
an d m idface occu r p rim arily du e to con t ract ion an d m or- lateral brow to h ave a rejuven at ing e ect on th e upper th ird
ph ologic ch anges. Th is loss of bony volum e an d projec- of th e fem ale face.6
t ion m ay con t ribute to th e aged appearan ce. Th e e or t to On th e oth er h an d, brow ptosis frequ en tly accom p an ies
u n derst an d each pat ien t’s in dividual involut ion al ch anges, derm atoch alasis, an d th e pat ien t can be over-diagn osed as
w h ich are speci c to age an d gen der, is m an dator y. Th ere- h aving ver y severe droop ing of th e u pp er eyelid skin an d
fore, id en t ifying th e pat ien t’s person al n eeds an d select ing excessive excision of skin w ith su bsequ en t fu rth er drag-
th e righ t t reat m en t accordingly is crucial for ach ieving th e ging of th e eyebrow dow nw ard. Th erefore, th e exam in er
best outcom e both for th e clin ician an d for th e pat ien t .3 sh ould ch eck for any h istor y of facial n er ve p alsy in case
The eyelid is im portant not on ly in its funct ional of unilateral brow ptosis (Fig. 14.2). Seo an d Ah n an alyzed
aspects such as tear distribut ion from blin king, but also in th e m orph ologic ch anges of th e eyelid according to gen der
its cosm etic aspects because it greatly a ects other people’s am ong di eren t age grou ps in Korean s an d rep or ted th at
im pressions by de ning one’s facial characteristics. The th e degree of brow ptosis sh ow ed a st at ist ically sign i can t
drooped brow an d eyelid skin can obscure one’s view and in crease from th e seven th decade of life in m en an d from
look heavy, and lateral eyelid skin can be folded and thus th e sixth decade in w om en . In part icu lar, th e lateral brow
cause eczem a.4 Th e eyelid becom es pu y due to the pro- drooped m ore th an th e cen ter brow. Th e lateral h ood w idth
lapse of orbital fat from the loosening of the orbital sept um . of the eyelid sh ow ed a st at ist ically sign i can t in crease from
Blep h aroptosis refers to d roop ing or in frat ran sp osi- th e seven th decade of life in m en an d from th e sixth decade
t ion of th e u p per lid. Th e m ost com m on t ype of acqu ired in w om en .7
a b
Fig. 14.1 Typical pat tern of blepharoptosis in an aged female. Blepharoptosis caused elevated eyebrow by compensation and this
resulted in forehead creases.
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14 Aging-Related Upper Blepharoplast y 175
Fig. 14.3 Typical presentation of involutional blepharoptosis. Fig. 14.4 Method of measuring margin-re ex distance (MRD).
Patients with involutional blepharoptosis frequently show high- MRD is measured by the distance from the upper eyelid margin to
located multiple creases and hollow superior sulcus. the corneal light re ex in the primary position.
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176 III Blepharoplast y
a b
c d
Fig. 14.5 Di erentiation bet ween dermatochalasis and blepharoptosis. (a) Young male patient who worried about right blepharoptosis.
(b) After curling up redundant skin, margin-re ex distances were symmetric and there was no real blepharoptosis. (c) Older female patient
complained of “drooped skin” of the right upper eyelid. It looks like there is dermatochalasis in her right eye. (d) However, after curling
up the right upper eyelid skin, margin-re ex distance was smaller than on the left side. This patient had both right upper blepharoptosis
and dermatochalasis.
m u scle is n ot presen t in th e lateral brow area. Droop ing of in advan ce or in conjun ct ion w ith th e bleph aroplast y. Th e
th e brow is called brow ptosis. Brow ptosis occurs usually m edical h istor y m u st be ch ecked for facial n er ve palsy in
after m iddle age, an d derm atoch alasis an d blep h aroptosis cases of un ilateral brow ptosis or m ore prom in en t droop -
m ay app ear accen t u ated du e to brow ptosis. Th e su rgeon ing of th e un ilateral u pper eyelid skin . If brow ptosis w as
m u st recogn ize th e brow ptosis accom p anying d erm a- overlooked , iat rogen ic p ostop erat ive lagop h th alm os can
toch alasis as a cont ribut ing factor in th e pat ien t’s aged result from th e resect ion of too m uch skin an d m uscle.
ap pearan ce before su rger y. In th e p resen ce of brow ptosis, Th erefore, to get good result s, th e brow lift h as to precede
th e su rgeon m u st decide w h eth er to perform a brow lift bleph aroplast y.
a b
Fig. 14.6 Method of measuring the levator function. It was de ned as the movement of the upper eyelid margin in millimeters from (a)
down-gaze to (b) up-gaze while xating the brow with the examiner’s ngers.
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14 Aging-Related Upper Blepharoplast y 177
Upper Eyelid Crease fat p ocket to exte n d late rally an d cove r t h e an t e r ior
asp e ct of t h e lacr im al glan d . In a p reviou s st u d y b ase d on
Th e u p p e r eyelid crease is m a d e by at t a ch m e n t of t h e Korean age d p e op le, t h e eyelid fat w as m ost p rot r u d e d at
levat or a p on e u rosis ext e n d in g t h rou gh t h e orb icu la r is t h e ce n t ral low e r p ar t .7
in t o t h e skin . Th e u p p e r eyelid crea se is h igh e r in fe m a les
t h a n in m a les. Th e u p p e r eyelid crea se is u su a lly low
or a bse n t in t h e Asian eyelid . Th e ave rage Asia n eyelid
Corneal Protection Mechanism
crea se is 2 m m low e r com p a re d w it h Cau casia n s,1 2 w it h
Ocu lar m ot ilit y an d Bell’s ph en om en on sh ou ld be ch ecked
a h e igh t of 6 t o 8 m m in fe m ales an d 4 t o 6 m m in m a les.
carefully before surger y. Con rm th at th e eyelid is com -
Asym m et r ic h e igh t or m u lt ip le d ou b le - lid crea ses m ay
pletely closed w ith a blin k. Poor Bell’s ph en om en on can
refle ct st ret ch in g or d isin se r t ion of t h e levat or a p on e u -
cause exposure kerat it is or corn eal ulcer postoperat ively.
rosis. Th e d ou b le - eyelid cre ase it self is u su a lly elevat e d
Bell’s ph en om en on m ust be n orm al.
w it h involu t ion al ch a n ges, b u t t h e ove rlyin g d e r m at o -
ch a la sis m ay con cea l t h at , esp e cially in t h e Asia n eld e rly.
High d u p licat e d eyelid crea ses m ay in d icat e d isin se r t ion Tear Secretion
of t h e levat or a p on e u rosis.
Th e Asian pat ien t w ith a double-eyelid crease created If t h e p at ie n t com p lain s of ocu la r ir r it at ion sym p t om s, it
during previous surger y is t reated in th e sam e w ay as th e is likely t h at t h e p at ie n t h a s a p rob le m w it h t ea r se cre -
pat ien t w ith a n at ural crease. But th e m ost di cult com - t ion su ch as d r y eye syn d rom e. Te ar film b rea ku p t im e,
plicat ion in aging-related bleph aroplast y in Asian s is a t h e p rese n ce of lagop h t h alm os, an d sym p t om s or sign s
ver y h igh -p osit ion ed dou ble-eyelid crease in th e pat ien t of d r yn ess sh ou ld also be a ssesse d p re op e rat ively. Dr y-
w h o un der w en t excessive skin an d fat rem oval at a young n ess can b e aggravat e d aft e r su r ge r y, esp e cia lly in t h e
age, an d w h o is aging n ow. Th ese pat ien t s h ave lit tle skin eld e rly p at ie n t . Th e su rge on w h o is n ot fam iliar w it h
rem ain ing to resect an d m ay h ave som e adh esion s w ith t h ose ocu la r exa m in at ion s ca n con su lt an op h t h a lm olo -
u n derlying t issu es. Th erefore, rem oving m ore skin or lift ing gist t o ch e ck t h e p rese n ce an d seve r it y of d r y eye. Also,
th e brow can m ake an un n at ural eyelid crease n ot iceable. If t h e p at ie n t sh ou ld b e n ot ifie d t h at h is or h e r sym p t om s
th e pat ien t h as som e drooping skin over th e eyelid crease, w ill n ot im p rove a n d m ay eve n b e aggravat e d a ft e r
m aking th e “visible” eyelid crease look n at u ral an d n ot too ble p h a rop la st y. So if t h e p at ie n t com p la in s of seve re
h igh , it is bet ter n ot to do su rger y an d ju st leave it as it is. sym p t om s of d r y eye, t h e su r ge on sh ou ld m ake t h e
In stead, au tologou s fat or ller inject ion along th e brow an d p at ie n t u n d e r st an d t h at ocu lar ir r it at ion m ay b e aggra -
u pp er eyelid com p lex m ay be h elpfu l in im proving cosm e- vat e d a ft e r b le p h a rop la st y. Aft e r a t h orou gh d iscu s-
sis. On ly th e p at ien t w ith p rofou n d bleph aroptosis n eeds sion of t h e r isk fa ct ors, a d e cision sh ou ld b e m ad e on
to u n dergo correct ive su rger y by levator advan cem en t or w h et h e r t o p roce e d w it h t h e b le p h a rop last y p roce d u re
by resect ion to elevate th e eyelid an d to m ake th e visible as p la n n e d or n ot .
eyelid crease look sm aller.
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178 III Blepharoplast y
Anesthesia
pat ien t s do n ot w an t an art i cial-looking crease, th e in ci-
Blep h arop last y can be perform ed un der gen eral, seda-
sion lin e can be m arked ver y close to th e eyelid m argin . If
t ive, or local an esth esia, bu t local an esth esia is preferable.
th e pat ien t h as lateral h ooding of th e skin , th e in cision m ay
Recen tly, m on itored an esth esia care (MAC) h as been gain -
be exten ded to th e lateral can th al area, but n o m ore th an 1
ing pop u larit y in bleph aroplast y. MAC is a plan n ed proce-
cm from th e lateral can th al angle. Th is design is in ten ded to
dure during w h ich th e pat ien t un dergoes local an esth esia
excise m ore lateral skin th an skin from th e m edial or cen -
togeth er w ith sedat ion an d an algesia. Pat ien t s u n dergoing
t ral side.
con sciou s sedat ion are able to an sw er to orders appropri-
Using sm ooth forceps, th e redu n dan t skin is grasp ed
ately an d h ave th e eyelid h eigh t an d con tou r ch ecked in
an d m arked. Lid ocain e m ixed w ith epin ep h rin e (1:100,000)
th e sit t ing posit ion during surger y. Tw o percen t lidocain e
is injected subcut an eously along th e previous m arking lin e.
m ixed w ith epin eph rin e (1:100,000) is u su ally u sed as th e
Th e in cision is m ade w ith a n o. 15 or 15T Bard-Parker blade
local an esth et ic. Local an esth esia is to be injected slow ly
or scissors Recen tly CO2 lasers an d radiofrequen cy w aves
to redu ce pain du ring inject ion an d sh ou ld n ot be injected
have been used to m in im ize bleeding.
in to th e m u scle layer to avoid bleeding. After th e local an es-
th esia inject ion , ligh t com pression is applied to preven t
pressure an d to dist ribute th e an esth et ic drug even ly to th e
Redundant Skin Excision
su rgical eld.
Th e skin an d orbicu laris m u scle are in cised an d dissected
from th e sept u m (Fig. 14.8). Th e skin an d orbicu laris are
Designing the Eyelid Crease and excised in on e layer. Th is skin -m u scle excision tech n iqu e
Skin Excision causes less bleeding an d m akes it easy to protect th e orbit al
sept u m . Care sh ou ld be taken n ot to cau se inju r y to th e
The m ost im portant step in blepharoplast y is design- orbit al sept um , w h ich is a w h it ish m em bran ous st ruct ure.
ing, w hich is deciding the am ount of skin and m uscle to
be excised. It is im portant that the sam e am ount of skin
bet w een the brow an d eyelid fold be kept in both eyes, rather
than rem oving sym m etrical am ounts of skin (Fig. 14.7).
After design ing th e eyelid crease lin e w ith th e pat ien t
in th e su p in e posit ion , th e pat ien t is t urn ed to th e sit t ing
posit ion . Th e surgeon grasps th e skin an d decides h ow
m u ch of th e redu n dan t skin is to be excised w h ile th e
pat ien t is asked to open an d close th e eye. W h en grasping
th e skin to excise, developm en t of a 1-m m lagoph th alm os
or sligh t eversion of th e eyelash is proper. Caut ion sh ou ld
be t aken to leave at least 15 m m of skin bet w een th e eye-
brow an d double-eyelid fold. In case of design ing a double
lid, care sh ou ld be taken to en sure a sym m et ric h eigh t . Th e
in cision lin e is m arked at 4 to 7 m m from th e eyelid m argin Fig. 14.8 Skin and orbicularis muscle were incised along previous
an d is recom m en ded n ot to exceed 10 m m . In cases w h ere marking and dissected from the septum.
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14 Aging-Related Upper Blepharoplast y 179
a b
c d
Fig. 14.9 (a–d) The orbital septum was opened and orbital fat was identi ed. Orbital fat was grasped, cut, and cauterized using mono-
polar cautery.
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180 III Blepharoplast y
Fig. 14.10 A crease was made using tarsal xation suture: sutures Fig. 14.11 Skin was closed using a continuous running suture.
are applied through the skin, epitarsal tissue, and the skin of the
opposite side.
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14 Aging-Related Upper Blepharoplast y 181
Asymmetric or Unnatural Eyelid m osqu ito forceps sh ou ld be m ain tain ed, an d after releasing
the clam p, hem ostasis of the rem aining fat edge should be
Contour secured. Hem orrh age from th e orbital fat can cause retro-
bulbar hem orrhage and opt ic ner ve com pression, leading to
Severe derm atochalasis can obscure pre-existing eyelid
visu al im pairm en t . If retrobu lbar orbital h em orrh age cau s-
asym m etry, and m any patients do not realize this before sur-
ing visual im pairm ent is suspected, the w ound should be
geons point it out to them . In these patients, cautious design
opened up im m ediately, the bleeding focus should be found
is m andatory to m aintain sym m etric skin and fat, instead of
an d coagulated, an d th e drain sh ou ld be left for som e tim e.
rem oving a sym m etrical am ount of skin and fat. Surgeons
should also pay attention to the position of the eyebrow,
because asym m etric eyebrow can cause postoperative asym - Exposure Keratopathy
m etry or under-correction. Aging-related blepharoplast y is
usually perform ed in conjunction w ith levator aponeurosis Upper eyelid bleph aroplast y can a ect th e blin king fun c-
m anipulation, and xation sutures bet ween the levator apo- t ion , an d in elderly pat ien t s dr yn ess m ay be aggravated.
neurosis and the tarsal plate can lead to an asym m etric or Th erefore, it is im port an t to evaluate tear breaku p t im e an d
unnatural contour. To prevent this com plication the xation Bell’s ph en om en on before m aking th e decision in favor of
should be carefully placed. bleph aroplast y. Proper explan at ion an d m an agem ent of
th e dr y eye syn drom e is m an dator y.
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182 III Blepharoplast y
a b
Fig. 14.12 Case 1. Blepharoplast y making a natural eyelid crease. (a) A 65-year-old man has a droopy eyelid skin that causes visual eld
impairment and lateral canthal eczema. (b) After the excision of the droopy skin with low-sit ting eyelid crease formation, he could see
more comfortably and the eczema at the lateral canthal angle disappeared.
a b
Fig. 14.13 Case 2. Blepharoplast y without creation of an eyelid crease. (a) A 59-year-old man who has droopy eyelid skin with lateral
canthal eczema. (b) After the skin and m uscle excision but without creation of an eyelid fold.
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14 Aging-Related Upper Blepharoplast y 183
Case 3 m ore cheerful appearance. The operative plan was to rem ove
the droopy skin beyond the lateral canthal angle and create an
A 72-year-old Asian wom an wanted to have droopy lateral eyelid crease at 6 m m from the eyelid m argin w ith tarsal xa-
skin rem oved and to im prove skin eczem a (Fig. 14.14a). The tion using nonabsorbable sutures. Additionally, levator apo-
preoperative picture showed asym m etry of the brow and neurosis advancem ent was planned to raise the eyelid level.
m ore skin drooping over the right upper eyelid, w hich was After bleph aroplast y w ith levator advan cem en t sh e
not noticed by the patient before consultation w ith the sur- could see m ore com fort ably, an d th e eczem a of th e lat-
geon. After thorough discussion, the authors found that she eral can th al angle an d brow asym m et r y also im p roved
also wanted a distinct but natural crease and a younger and (Fig. 14.14b).
a b
Fig. 14.14 Case 3. Blepharoplast y with creation of a noticeable eyelid crease. (a) A 72-year-old Asian woman wanted to remove droopy
lateral skin, improve skin eczema, and have a distinct but natural crease and a younger, cheerful appearance. During the surgery, droopy skin
was removed beyond the lateral canthal angle, an eyelid crease was made at 6 mm from the eyelid margin, and levator aponeurosis advance-
ment was performed. (b) After surgery, she could see more comfortably and the eczema of the lateral canthal angle and brow asymmetry
also improved.
Pearls
• Cosm et ic epican th oplast y releases th e epican th al de cien t skin on th e in n er part of th e low er eyelid to
fold an d m odi es th e m ed ial corn er of th e p alpebral decrease th e risk of par t ial ect ropion .
ssu re, th u s revealing m ore of th e m edial p ort ion of • Th e t w o m ost frequen t com plicat ion s of
th e eye an d decreasing th e in terepican th al distan ce. ep ican th op last y are scarring an d th e aggravat ion
• Th e lacrim al carun cle can be t riangu lar, roun d, of th e epican th u s inversus. Th ese risks can be
or h ook-sh aped, an d th ese variat ion s n eed redu ced by design ing th e skin in cision s along th e
to be con sidered in select ing an ap proach for relaxed skin ten sion lin es an d avoiding a con n ect ion
ep ican th op last y. bet w een th e epican th oplast y an d bleph aroplast y
• W h en m odifying th e can th u s for aesth et ic reason s, in cision s.
a con ser vat ive ap p roach is recom m en ded becau se • In aesth et ic lateral can th oplast y, n ot on ly h orizon t al
an over-corrected epican th u s is ext rem ely di cu lt palpebral exten sion but also proper posterior
to revise. deepen ing is im port an t to m ain t ain a proper con t act
• Righ t an d left lacrim al caru n cles h ave di eren t bet w een th e eyeball an d palpebral conjun ct iva.
scales of grow th an d direct ion , w h ich n eeds • Com bin ed lateral can th oplast y an d low ering of
con siderat ion in th e design of epican th oplast y. low er eyelid slan t w ill m ake th e eyes look m ild
• W h en a double-fold operat ion is com bin ed w ith an d big. Mongolian slan t low ering can be d on e by
ep ican th op last y, redu n dan t skin from th e u pp er ap su t u ring bet w een th e t arsu s an d cap su lopalp ebral
of th e dou ble eyelid sh ould be rotated tow ard th e fascia.
184
15 Epicanthoplast y and Aesthetic Lateral Canthoplast y 185
Patient Evaluation
It is im p ort an t to m easu re th e in terep ican th al d ist an ce an d
th e am oun t of exposed lacrim al carun cle. Pat ien t s w ith
ext rem e ep ican th al fold an d w ide in terep ican th al dis-
tan ce can realize a dram at ic ben e t from th is procedu re.
A pat ien t can in sp ect th e ch anges after epican th op last y
by nger t ract ion of th e in n er can th us. Un der-correct ion
is safer th an over-correct ion becau se an u n der-corrected a b
ep ican th al fold can be revised m u ch m ore easily th an an
over-corrected ep ican th al fold.
Of th e fou r t yp es of ep ican th al folds, epican th u s t ar-
salis is m ost com m on in East Asian s. Not all epican th al
fold s requ ire correct ion , an d ep ican th u s t arsalis allow s for
c d
a b c
Fig. 15.3 Classi cation of epicanthal folds as proposed by John-
Fig. 15.2 Three shapes of lacrimal caruncle. (a) Triangular shape. son. (a) Epicanthus supraciliaris. (b) Epicanthus palpebralis. (c) Epi-
(b) Round shape. (c) Hook shape. canthus tarsalis. (d) Epicanthus inversus.
186 III Blepharoplast y
a b
c d
Fig. 15.4 The reverse Fuente's design. (a,b) The triangular ap from the inner upper part of the epicanthal fold is rotated toward the
incision site of the lower eyelid to hide the scar. (c) A 19-year-old girl wanting epicanthoplast y and double-eyelid surgery. Medial epican-
thoplast y with reverse Fuente’s design and incisional double-eyelid surgery were performed. (d) After surgery, more exposed caruncle
with double eyelids makes the eyes more beautiful.
th e dog-ear sh ould be resected as close to th e upper cilia 3. Can th e t ran sverse in cision be placed in a n onvisible
as possible. If th e skin is in su cien t on th e lid m argin of area or along a relaxed skin ten sion lin e?
th e m edial carun cle, th e dog-ear port ion of th e upper ap 4. Is it possible to leave a skin bridge bet w een th e
sh ou ld be p reser ved an d t u rn ed in to a t riangu lar ap to ep ican th op last y in cision an d th e dou ble-eyelid
be rot ated in to th e in n er por t ion of th e n ew can th otom y in cision ?
st ru ct u re (Fig. 15.5). An oth er p ossibilit y is to release th e 5. Of th e appropriate operat ive tech n iques, w h ich am I
ban d-sh aped epican th us inversus on th e low er par t of th e m ost com for t able w ith ?
ep ican th al fold by rot at ing th e ap m ad e by th e dog-ear
an d advan cing th e t riangu lar ap p erp en dicu larly to th e
ep ican th u s inversu s. Simple Skin Excision
Sim ple skin excision is not com plicated an d can be per-
Surgical Techniques form ed even by inexperienced surgeons. Alth ough skin-only
excision can be suitable for som e cases, excessive tension in
Th ere is n o single tech n ique th at can address th e fu ll spec- the low er ap is a con cern an d can result in postoperative
t rum of epican th al folds, an d th e surgeon m ust rely on a set scarring. To decrease ten sion , th e soft t issue m u st be dis-
of tech n iques th at are applicable to speci c t ypes of epican - sected an d th e perpen dicular accessor y ber m ust be tran -
th al folds. Most epican th oplast y tech n iques are variat ion s sected. Th is m eth od is n ot com m on ly perform ed n ow adays.
an d com bin at ion s of a few fu n dam en t al con cept s: sim ple
skin excision , V-Y advan cem en t , Z-plast y, an d W-p last y.
Th e follow ing ve quest ion s m ust be an sw ered before th e V-Y Advancement Methods
ap prop riate ep ican th op last y tech n iqu e can be ch osen .
Th ere are several kn ow n variat ion s of V-Y advan cem en t .
1. How w ill I m an age th e skin redun dan cy an d Th e Roveda m eth od involves advan cem en t of th e n asal side
d e cien cy? skin an d rem oval of th e rem ain ing skin from th e top an d
2. How w ill I con t rol th e exten t of carun cle exposure? bot tom to preven t dog-ear. Uch ida m odi ed th e Roveda
15 Epicanthoplast y and Aesthetic Lateral Canthoplast y 187
x
x' z
m eth od, bu t th e Uch ida design w as too close to th e lacrim al Skin Redraping Method
carun cle to preven t n ot iceable scars. Th e Uch ida m eth od
h as been fu rth er m odi ed to th e p ericiliar y ep ican th al fold An oth er frequen tly u sed epican th oplast y tech n iqu e is th e
in cision m eth od, w h ich involves a large V-sh ap ed in cision skin redraping m eth od. It can be perform ed sim ultan eously
follow ed by dissect ion an d excision of th e su rrou n ding skin w ith the double-eyelid fold operation. The skin redraping
to com pletely h ide th e scar (Fig. 15.6).4 design w as origin ally rectilinear but the design needs to be
m odi ed from a rect ilin ear lin e to a roun d or sligh tly trian -
gular lin e. Th is m odi cation can preven t ectropion at th e
Z-Plasty Flap m edial side of th e low er eyelid (Fig. 15.8). W h en epican th o-
plast y is perform ed w ith out the double-eyelid fold opera-
Th is is a frequen tly used tech n ique w ith m any variat ion s to
tion , th e t riangular ap should be placed as close to the
allow for exibilit y in th e locat ion an d size of th e t w o skin
ciliar y line as possible. In addition, the incision should be
ap s. Fu en te’s design in corporates h alf of a Z-p last y, w h ich
extended to allow adequate resection of the redun dant skin.
takes th e t riangular ap from th e low er part of th e epican -
Un derdeveloped lacrim al caru n cle cases are ext rem ely
th al fold an d t ran sfers it to th e m iddle par t , an d exten ds th e
ch allenging to address. In such pat ien t s, th e m edial can th al
double-eyelid fold in cision lin e tow ard the in n er upper part .
ten don requires plicat ion to reveal m ore of th e m edial cor-
Th is m eth od is recom m en ded for pat ien t s w ith a pre-exist-
ner of th e eye. Th e can th al ten don can be secured th rough a
ing dou ble-eyelid fold . How ever, resect ion of redun dan t
hole drilled th rough th e n asal bon e u sing eith er m et al w ire
skin is n ecessar y, if th e tech n iqu e is p erform ed sim u lt an e-
or th ick nylon su t u re.5
ously w ith th e double-fold lin e operat ion (Fig. 15.7).
Park’s m eth od is a m odi cat ion of Fuen te’s m eth od an d
incorporates partial resect ion of redun dant skin bet w een
the double-eyelid fold lin e and the epicanthoplast y site. This ■ Complications and
m eth od rotates skin from th e low er epican th al fold to th e Their Management
m iddle portion . Th e redu n dan t skin in th e upper epican th al
fold is resected. This procedure is suitable for patients w h o Th e t w o m ost frequen t com plicat ion s of epican th oplast y
h ave th e redundant skin in th e low er epican thal fold w ith are scar an d th e aggravat ion of th e epican th u s inversu s.
h igh ten sion in th e m iddle portion. The tech n ique is also Th e risk of th ese com plicat ion s can be reduced by design -
useful in addressing th e dog-ear from the redundan t skin ing th e skin in cision s along th e relaxed skin ten sion lin es
along th e u pper bleph aroplast y in cision lin e. an d avoiding a con n ect ion bet w een th e epican th op last y
Th e reverse design of Fuen te’s m eth od can be used an d blep h arop last y in cision s. It is bet ter to sep arate ep ic-
for p at ien ts w ith redu n dan t skin on th e u pp er part of th e an th op last y an d blep h arop last y in cision lin es becau se th e
ep ican th al fold an d lack of skin on th e low er p art . In su ch m ovem en t of th e u pp er eyelid can t ran sm it ten sion from
cases, th e t riangular ap sh ould be m ade on th e u pper th e upper bleph aroplast y in cision to th e epican th oplast y
in n er part an d rot ated dow nw ard (Fig. 15.4). If less th an 1 in cision in case th ese t w o in cision s are con t in uou s. Rota-
m m of lacrim al caru n cle is visible, th en th e t riangu lar ap t ion of th e redu n dan t upper skin to th e low er por t ion of th e
from th e u p p er p ar t of th e epican th al fold is rotated in to ep ican th u s redu ces th e ten sion ect ropion . Iat rogen ic ep i-
th e m edial can th otom y site (Fig. 15.5). can th u s inversus is aggravated by perpen dicular ten sion ,
188 III Blepharoplast y
w x y z
x'
x'
w x y
Wu’s square-flap m ethod z
th e n al sh apes of th e epican th al fold an d m edial can th al preven t s back-cut scars an d avoids th e relapse of excessive
angle. To preven t u n n ecessar y recon st ru ct ive su rgeries, exp osu re of th e lacrim al caru n cle (Fig. 15.10).
p at ien t s sh ould be provid ed w ith su cien t explan at ion s Even after recon st ru ct ive epican th op last y, recu rren ce
abou t h ow th e t w o lacrim al caru n cles h ave d i eren t scales of skin exten sion an d asym m et r y of th e eyes m ay develop.
of grow th an d direct ion . Th us, it is st rongly recom m en ded th at th e surgeon in form
Hyp ert rop h ic scar is t reated w ith t riam cin olon e injec- pat ien t s about th e possibilit y of developing m icro di er-
t ion , but th e t riam cin olon e m ust be diluted four t im es en ce bet w een th e left an d th e righ t , th e p ossibilit y of ad di-
m ore th an th e u su al dose. Oth er w ise, th ere cou ld be som e t ion al operat ion s, an d th e lim it s of th ese operat ion s before
visible w h ite pow ders appearing th rough t ran slucen t skin su rger y.2
for a long p eriod . With ou t dilu t ion of th e t riam cin olon e,
d erm is at rop hy an d telangiect asia m ay develop .
■ Aesthetic Lateral Canthoplasty
Reconstructive Epicanthoplasty Gen erally, lateral can th oplast y refers to all of th e su rgeries
t ran sform ing th e lateral can th u s. Notably, a lot of Western
If the interepicanthal distance is less than 3 cm , then the eyes st u dies h ave com m on ly in t rodu ced lateral can th op last y as
look too close together. In addition, if m ore than 5 m m of a su rgical m eth od th at correct s can th al laxit y or low er lid
lacrim al caruncle is exposed on both sides, it could cause an m alp osit ion an d relieves aging-related sign s on th e low er
uncom fortable look. Besides excessive exposure of the lacri- eyelid an d m idface. “Lateral can th u s exten sion ” surger y
m al caruncle, there could be som e prom inent epicanthoplasty perform ed for Asian s as a cosm et ic procedure is also con -
scarring. Reconstructive epicanthoplasty reduces and conceals sidered lateral can th op last y. How ever, to be p recise, lateral
this scarring and changes the unnatural parallel fold (outfold) can th oplast y is an expan sion of th e lateral can th us an d a
into a m ore favorable natural-shaped epicanthal fold. resh aping of th e lateral can th al area in clu ding th e angle of
A fu n dam en t al w orkh orse for recon st ruct ive epican - lateral can th us. Sin ce th e eyeball is sph erical in sh ape, th e
th oplast y is th e V-Y advan cem en t ap. Mostly, th e epi- palpebra is a th ree-dim en sion al st ru ct ure. For cosm et ic lat-
can th u s inversus appears arou n d th e low er par t of th e eral can th op last y, n ot on ly h orizon t al p alpebral exten sion ,
ep ican th u s du e to p erp en dicu lar ten sion of th e u pp er part . but also proper posterior deepen ing sh ould be perform ed
On e m eth od to t reat su ch a con dit ion cou ld be a back-cu t so th at a p roper con t act bet w een eyeball an d palp ebral
skin in cision in th e low er p art of th e ep ican th u s (Fig. 15.9). conjun ct iva can be m ain t ain ed.6
An oth er m eth od is to m ake a long, in feriorly directed
V- ap in th e V-Y advan cem en t ap d esign to p reven t ep i-
can th us inversus. Th e low er in cision of th e V- ap start s Patient Evaluation
from th e m ore lateral sid e of th e back-cu t site an d passes
parallel to th e low er cilia an d exten ds to th e m edial side. As w ith ever y cosm et ic eyelid su rger y, it is n ecessar y to
In stead of th e back-cu t design , th e V- ap is rot ated an d ch eck th e pat ien t’s eye con dit ion before u n dergoing lateral
lls th e skin de cien cy. By th is V- ap rot at ion , th e su rgeon can th oplast y. Con siderat ion s in th e select ion of good can -
a b c
Surgical Techniques
Western literat ure h as detailed th e surgical m eth ods for
exp an sion of th e lateral can th u s an d h orizon t al exp an -
sion of th e p alpebral ssu re. Becau se lateral can th oplast y
a b h as been in t roduced as a t reat m en t for bleph aroph im osis
an d recon st ru ct ive su rger y, som e su rgical m eth ods are
n ot su it able for Asian s w h o w an t th is su rger y for cosm et ic
im provem en t on ly.
a b
Fig. 15.11 Von Ammon’s method for lateral canthoplast y. (a) After a lateral canthal incision, the conjunctiva is undermined. (b) The
conjunctiva is pulled out and sutured to the skin edges. Double-armed sutures are passed through the conjunctiva, brought out lateral to
the canthus, and tied over a peg.
15 Epicanthoplast y and Aesthetic Lateral Canthoplast y 191
a b c
Fig. 15.12 Blaskovics’ method for lateral canthoplast y. (a) The lateral canthus is incised as a V shape and a skin ap is made. (b) The skin
ap is elevated and the transverse incision is made. (c) The wedge-shaped incision site on the lower lid is closed. The upper eyelid lateral
skin ap is trim med and sutured.
the upper and lateral part of the upper eyelid (Fig. 15.12c). can th oplast y is perform ed on pat ien ts w ith Mongolian
Because this surgical m ethod uses skin tension only in the slan t , th e lateral can th u s w ill n ot seem to be exten d ed
lateral canthus, the e ect of expansion is not dram atic. en ough an d th e eyes w ill look m ore slan ted. Com bin ing
low ering of th e slan t w ith lateral can th op last y w ill m ake
th e eyes look bigger an d m ilder at th e sam e t im e an d
Fox’s Method en h an ce pat ien t sat isfact ion . How ever, th ese procedu res
sh ou ld be ap plied on ly to th e p at ien ts w h o h ave eyes w ith
To apply Fox’s m eth od, select a desired lateral exten sion steep Mongolian slan t .
poin t ~ 4 m m aw ay from th e in digen ous lateral can th us
(Fig. 15.13a). Split on e-qu ar ter of th e lateral p art of th e
u pp er an d low er eyelids bet w een th e an terior an d p oste-
rior lam ellae. Exten d th e sp lit u pp er palp ebral lin e 4 m m
m ore follow ing th e exten sion lin e of th e u p p er p alpebral
border. Con n ect th e th ree poin t s of x, y, z an d elevate th e
ap (Fig. 15.13b,c). Pu ll y to x an d su t u re th em . Elevate th e
low er eyelid ap con sidering x′ as th e vertex an d p u ll x′ to z
an d su t u re th em . Elevate a conju n ct ival ap of ap prop riate
x y
size from th e lateral an d su t u re to th e skin (Fig. 15.13d,e ). x'
z
a
Shin’s Method xz
xz
In Sh in ’s m et h od , 2 m m of t h e u p p e r cr u s a n d 3 m m yx'
x' y
of t h e low e r cr u s of t h e lid m a r gin are elevat e d for a d
rot at ion fla p (Fig. 1 5 .1 4 a,b). Th e elevat e d fla p is u se d b
for low lat e ral lid ext e n sion . Th e lat e ral e n d of t h e ele -
vat e d flap is su t u re d t o t h e p e r iost e u m w it h n ylon 6 – 0
xz
t o ext e n d t h e lat e ra l can t h u s lat e ra lly a n d d ow nw ard
(Fig. 1 5 .1 4 c). Close all t h e in cision s of t h e lat e ral can - yx' y
t h u s a n d t h e conju n ct iva (Fig. 1 5 .1 4 d). Eve n t u ally, t h e e
lat e ra l can t h u s w ill b e ext e n d e d lat e ra lly a n d d ow n - c
w a rd . Th is p roce d u re is relat ively sim p le a n d com p lica -
t ion s a re n ot fre qu e n t ; h ow eve r, t h e lat e ra l ca n t h u s w ill
Fig. 15.13 Fox’s method of lateral canthoplast y. (a) Find a desired
b e low e re d in eve r y p at ie n t . lateral extension point y ~ 4 mm away from the indigenous lateral
canthus. Split one-quarter of the lateral part of the upper and lower
eyelids bet ween the anterior and posterior lam ellae. Extend the
Lateral Canthoplasty Combined w ith split upper palpebral line 4 m m more following the extension line
of the upper palpebral border. (b,c) Connect the three point s of x,
Mongolian Slant Low ering y, z and elevate the ap. Pull z to x and suture them. (d,e) Elevate
the lower eyelid ap considering x′ as vertex, and pull x′ to y and
East Asian s are m ore likely to h ave u pw ard-slan ted eyes suture them. Elevate a conjunctival ap of appropriate size from the
com pared w ith European s. In dividuals w h o h ave Mongol- lateral end of the conjunctiva toward the m edial side and suture the
oid slan t m ay give th e im pression of being angr y. If lateral the end of the ap to y.
192 III Blepharoplast y
Palpebral
conjunctiva
2 mm
Cornea
3 mm
5 mm
b c
Lateral can th al exten sion w ith low ering of th e Mongo- 5. Penet rate th e CPF using nylon 7–0 an d th en
lian slan t is possible if a t riangu lar ap can be m ade on th e pen et rate th e area you w ish to low er on th e low er
u pp er, lateral par t of th e lateral can th u s as in Sh in’s m eth od border of th e tarsus from side to side, an d su t ure
of lateral can th oplast y. Usu ally, it is n ot easy to m ake th e th em .8,11 Th e xat ion locat ion can be ch anged
t riangular ap in revision cases due to scar. Even in prim ar y d epen ding on th e am oun t of desired lid low ering.
su rger y, it is h ard to m ake th e t riangu lar ap if th e distan ce Usu ally, t w o areas of th e CPF are xed on th e tarsal
bet w een th e lid m argin an d cilia is too close or if th e cilia plate (Fig. 15.16).
are located in th is area. 6. Sut ure the in cision site of th e u pper eyelid m argin
Use th e follow ing tech n iqu e: exp osed by can th otom y an d x th e lateral en d of
1. According to th e slope bet w een th e lateral part of th e low er eyelid to th e periosteum of th e lateral
th e upper eyelid an d th e lateral can th us, perform an orbit al rim using nylon 6–0. En sure th at a n ew lateral
obliqu e can th otom y st ar t ing from th e lateral can th u s can th u s is form ed as desired.
an d exten ding laterally an d in feriorly. Th e length 7. To rem ove th e dog-ear skin surroun ding th e lateral
of th e in cision is usually 4 to 5 m m , alth ough it can can th u s, m ake th e m in im ual in cision follow ing th e
be longer or sh orter based on th e desired exten ded cilia on th e low er eyelid, resect th e rem ain ing skin ,
length (Fig. 15.15). an d close th e w ou n d.12,13
2. In cise th e conjun ct iva less th an 1 cm at 1–2 m m
low er par t of th e tarsal plate of th e low er eyelid.
Du ring th e p rocedu re, coagu late th e visible vessels. Postoperative Care
3. Make a dissect ion bet w een th e orbicularis ocu li
Du e to th e n at u re of th e lateral can th al area, th e dressing of
m u scle an d th e orbit al sept u m to secu re a clear view,
a lateral can th op last y is d i cu lt . App lying oin t m en t to th e
an d m ake a m in im al in cision of th e orbital sept u m
su rgical site is en ough as p ostop erat ive care. St itch rem oval
so th at th e lateral orbital fat can be exp osed.
is perform ed on p ostop erat ive day 7 or 8.
4. W h ile an assist an t t akes th e exposed orbit al fat
d ow nw ard, n d th e capsulop alpebral fascia (CPF) at
th e rear of th e exposed orbit al fat an d grab it w ith
th e forceps.
15 Epicanthoplast y and Aesthetic Lateral Canthoplast y 193
a b
Cant hotom y
Lowering
c d
Fig. 15.15 Cosmetic lateral canthoplast y and Mongolian slant lowering. (a) The area of lateral scleral expansion is triangular and colored
pink. (b) Following the slope of the upper eyelid, a lateral oblique canthotomy with preseptal dissection is performed. The lateral part of
the lower eyelid tarsal plate is xed to the capsulopalpebral fascia (CPF) in t wo sites, using nylon 7–0. (c) Fix the lateral end of lower eyelid
to the periosteum of lateral orbital rim using nylon 6–0. The slope of palpebral ssure becomes less steep (from pink to red line). (d) The
lateral canthus is extended laterally and downward exposing more sclera.
IO IO
3.1
3.1 TM TM
5.4
5.4
CPF CPF
OS OS
Lid
lowering
Fig. 15.16 Mongolian slant lowering. (a) Open the lateral orbital septum and reach the capsulopalpebral fascia (CPF) using the transcon-
junctival preseptal approach (blue line). (b) Suture the CPF and lower border of the tarsus with nylon 7–0 to lower the lower eyelid (red line).
194 III Blepharoplast y
a b
Fig. 15.17 Case 1. Before (a) and after (b) epicanthal fold reconstruction. A 24-year-old woman with noticeable depressed scar after
medial epicanthoplast y had epicanthal reconstruction with V-Y advancement and a rotation ap. After surgery, caruncle exposure
decreased and the intercanthal area looks natural without noticeable scar.
Case 2: Lateral Canthoplasty w ith Mongolian slan t ing (Fig. 15.18a). Ep ican th oplast y w as
perform ed w ith Z-plast y (reverse Fuen te’s design ). Double-
Mongoloid Slant Low ering eyelid surger y w as p erform ed u sing th e in cision al m eth od.
A lateral can th al exp an sion w ith Mongoloid slan t low ering
A 26-year-old w om an w an ted to m ake h er eyes m ore beau - w as also d on e. After su rger y, th e caru n cle is m ore visible
t iful. A physical exam sh ow ed sm all eyes w ith an invis- an d h er eyes look bigger an d m ild er th an before su rger y
ible caru n cle by th e ep ican th al fold, n o double fold, an d (Fig. 15.18b).
a b
Fig. 15.18 Case 2. Lateral canthoplast y and Mongoloid slant lowering. (a) A 26-year-old woman with epicanthal fold, no double fold,
and Mongolian slanting had an epicanthoplast y, double-eyelid surgery, and lateral canthoplast y with Mongoloid slant lowering. (b) After
surgery, the caruncle is more visible and her eyes look bigger and milder than before surgery.
15 Epicanthoplast y and Aesthetic Lateral Canthoplast y 195
References 8. Hw ang K, Ch oi HG, Nam YS, Kim DJ. An atom y of arcu ate
exp an sion of cap su lop alpebral fascia. J Cran iofac Su rg
1. Ch o IC, ed. Th e Art of Bleph aroplast y. Seoul: Koonja; 2013 2010;21(1):239–242
2. Baek BS, Park DH, Nah ai F. Cosm et ic an d Recon st ruct ive 9. Fox SA. Op h th alm ic Plast ic Su rger y. 5th ed. New York, NY:
Ocu loplast ic Su rger y. 3rd ed . Seou l: Koonja; 2009:29 Gru n e & St rat ton ; 1976:223–225
3. Kao YS, Lin CH, Fang RH. Epican th oplast y w ith m odi ed 10. Von Am m on FA. Klin ish edarstellu ngen der angeh oren en
Y-V advan cem en t p rocedu re. Plast Recon st r Su rg 1998; kran kh eiten u n d bildlu ngsfh ler des m en sch lich en der aug-
102(6):1835–1841 es u n d der augen lider. Berlin , Germ any: G. Reim er; 1841:6
4. Sh in YH, Hw ang PJ, Hw ang K. V-Y an d rot at ion ap for 11. Hw ang K, Kim DJ, Hw ang SH, Ch ung IH. Th e relat ionsh ip of
recon st ruct ion of th e ep ican th al fold. J Cran iofac Su rg capsu lop alp ebral fascia w ith orbit al sept u m of th e low er
2012;23(4):e278–e280 eyelid: an an atom ic st udy un der m agn i cat ion . J Cran iofac
5. Oh YW, Seul CH, Yoo W M. Medial epican th oplast y us- Surg 2006;17(6):1118–1120
ing th e skin redrap ing m eth od . Plast Recon st r Su rg 12. Park DH. Anthropom etric analysis of the slant of palpebral
2007;119(2):703–710 ssures. Plast Reconstr Surg 2007;119(5):1624–1626
6. Sh in YH, Hw ang K. Cosm et ic lateral can th oplast y. Aesth et ic 13. Hiroh i T, Yoshim ura K. Vertical enlargem ent of th e palpebral
Plast Su rg 2004;28(5):317–320 aperture by static shortening of the anterior and posterior
7. Baek BS, Park DH, Nah ai F. Cosm et ic an d Recon st ruct ive lam ellae of th e lower eyelid: a cosm etic option for Asian
Ocu loplast ic Su rger y. 3rd ed . Seou l: Koonja; 2009:300 eyelids. Plast Recon str Surg 2011;127(1):396–406
16 Low er Blepharoplasty
Yoon-Duck Kim and Kyung In Woo
Pearls
• Th e surgical procedure of low er bleph aroplast y • Th e surgeon m ust assess th e degree of low er eyelid
evolved from fat an d skin excision in to volum e laxit y w ith a sn ap -back test or a lid dist ract ion
en h an cem en t . A cu stom ized app roach con sid ering test an d m ust perform a h orizon tal lid t igh ten ing
each pat ien t’s low er eyelid con gu rat ion is essen t ial procedure if th e laxit y is sign i can t en ough to a ect
to th e su ccess of su rger y. postoperat ive low er lid ret ract ion .
• Su rgeon s m u st discu ss w h at th ey can or can n ot do • Du ring th e fat red ist ribu t ion procedu re, ocu lar
w ith pat ien t s. Fin e or dyn am ic w rin kles, local skin m ovem en t sh ou ld n ot be rest ricted on a fat
pigm en t at ion , or skin scars can n ot be addressed an ch oring su t u re. If th ere is m ovem en t rest rict ion ,
w ith low er bleph aroplast y, an d th is sh ould be release th e sut ure, perform fur th er dissect ion , an d
ackn ow ledged to th e p at ien ts w h o w an t low er con rm th at m ovem en t is n ot h in dered by a re-
bleph aroplast y. xat ion su t u re.
• Th e surgeon sh ou ld ch oose an approach : • Proper h em ost asis is n eeded during orbit al fat
t ran sconjun ct ival versus t ran scut an eous. A resect ion to avoid th e disast rous com plicat ion
t ran sconjun ct ival approach is ideal for pat ien t s of orbit al h em orrh age. Tract ion on th e fat t issue
w h o sh ow fat prolapse w ith out skin or eyelid laxit y. sh ou ld be m in im ized to avoid h em orrh age from th e
A t ran sconju n ct ival ap p roach is also app licable deeper orbit , an d a clam p -cut-cauter y tech n ique is
for th ose w h o don’t w an t a skin scar, w h o are recom m en ded for resect ion of th e m edial fat p ocket
u n dergoing reoperat ion for fat prolapse, or w h o h ave h arboring relat ively large-bored blood vessels.
a ten den cy to d evelop hyp erp igm en tat ion on a skin • Th e skin excision sh ould be con ser vat ive to avoid
in cision site. low er eyelid ret ract ion during t ran scu t an eou s
• Th e surgeon m ust decide h ow m uch orbit al fat bleph aroplast y. It is h elpful to h ave th e pat ien t open
is to be rem oved or redist ributed. If tear t rough h is or h er m ou th an d look up w h en th e skin excision
depression is eviden t relat ive to fat prolapse, am ou n t is m easu red w ith a drap ing m eth od, to
fat redist ribu t ion is recom m en ded to avoid a m in im ize skin over-resect ion .
postoperat ive h ollow appearan ce. Gen tle pressure • Postop erat ive cau t ion sh ou ld be st ressed to th e
to th e globe is h elp fu l in deciding w h eth er or h ow pat ien t to preven t orbit al h em orrh age. Cold
m u ch fat excision is n eeded becau se lying dow n on com pression is recom m en ded for 48 h ours, an d
a su rgical t able does n ot sim u late th e con dit ion s of avoidan ce of h ead dow n posit ion ing an d of physical
sit t ing u p . exert ion sh ou ld be em p h asized.
196
16 Lower Blepharoplast y 197
fat p rolapse. After th e volu m e de at ion con cept w as in t ro- sion w as th e m ost sign i can t con tribu ting factor, follow ed
d u ced in th e in terpret at ion of th e aging process, aesth et ic by orbital fat prolapse, loss of skin elast icit y, eyelid uid,
ap proach es to p at ien ts h ave been m odi ed t rem en dou sly. orbicularis prom inence, and t riangular m alar m ound. In an
In th e h istorical view of su rgical m an agem en t of th e an alysis of low er eyelid aging in an Asian populat ion , Asian s
low er eyelid aging process, th e protot yp e procedu re w as sh ow ed a ten den cy tow ard less con t ribut ion of tear trough
orbit al fat excision w ith a t ran scut an eous approach . Low er defect and m ore con tribut ion of fat prolapse to eyelid bags
lid t igh ten ing p rocedures w ere developed to preven t or com pared w ith Caucasian pat ien ts.13 The periocular aging
t reat eyelid m alposit ion , w h ich w as th e m ost com m on changes can be assessed by analyzing th ese categories.
com plicat ion of th e conven t ion al tech n ique.6,7,8 Th e t ran s-
conjun ct ival approach subsequen tly becam e popu lar in
bleph aroplast y, as it could preven t postoperat ive eyelid Tear Trough Depression and
ret ract ion an d leave n o visible scar w h ile providing w id e Palpebromalar Groove
exposu re.9 Sin ce th e t ran sconju n ct ival app roach w as ap p li-
cable on ly to pat ien t s w h o did n ot n eed skin excision , th e Tear t rough depression occurs at th e in ferom edial aspect of
con com itan t skin pin ch tech n iqu e w as used to address th e th e low er eyelid. With aging, th is deform it y is seen m ore
excess skin in t ran sconju n ct ival blep h arop last y. prom in en tly (Fig. 16.1). Tear t rough dep ression is kn ow n
How ever, for p at ien ts w h o h ad p seu doh ern iat ion of th e to be ch aracterized by loss of su bcu t an eou s fat an d skin
fat an d tear t rough depression , rem oving low er eyelid fat th ickn ess along w ith th e in ferom edial orbit al rim , w h ich
can create a con cave con tour deform it y of th e low er eyelids is accen t uated by fat prolapse an d ch eek descen t .14 In a
an d cau se a h ollow ap pearan ce.10 In addit ion , deep en ing m icroscopic st u dy com p aring th e you ng an d th e aged, th e
of th e superior sulcu s h as been n oted after th e orbit al fat elderly in d ividuals sh ow ed sign i can t t issu e at rop hy in
rem oval p rocedu re.11 Th erefore, volu m e en h an cem en t h as variou s layers, m alar fat at rop hy an d d escen t , an d orbit al
becom e an im por t an t issue in rejuven at ion of the low er eye- fat bu lging.15
lid . Con sequen tly, a custom ized app roach to each p at ien t is To correct tear t rough depression , various tech n iques
essen t ial; th e sp eci c con gu rat ion of each pat ien t n eeds h ave been t ried, in clu d ing fat redrap ing blep h aroplast y,
to be assessed an d addressed.12 variou s inject ion s, an d tear t rough im p lan ts of variou s
design s. Fat inject ion is n ot a recom m en ded procedure for
th is region becau se injected fat ten ds to leave sm all, rm
■ Patient Evaluation n odules of fat an d scarring, an d p rovides irregu larit y an d
sh adow s. Filler inject ion su ch as hyalu ron ic acid gel is
Goldberg et al analyzed the con gurat ion of aging low er in creasing in th is region an d get s favorable result s; h ow -
eyelids in patien ts seeking aesth et ic surger y an d revealed ever, repeated inject ion s are n eeded.16
an atom ic factors con t ributing to eyelid bags.12 They assessed The volum e change in the tear trough area was addressed
patients in six anatom ic categories; tear trough depres- by Ham ra w ith fat preservation blepharoplasty, w hich corre-
a b d
Fig. 16.1 Aging changes in the lower eyelid. (a) Orbital fat prolapse is prominent. Tear trough depression (black arrows) and palpebroma-
lar groove (open arrows) are noted. (b) Negative vector con guration with pseudoherniation of fat. Malar depression is noted (arrowhead).
(c,d) Oblique line (arrow) is accentuated with facial expression due to prom inent orbicularis oculi muscle.
198 III Blepharoplast y
sponded to an epoch in lower blepharoplasty.10 Since then, sev- Even th ough th e p resen tat ion of eyelid u id w as fou n d
eral m odi cations have been introduced. The procedure can be to be ver y rare in a Korean st u dy, it sh ou ld be on e of th e dif-
perform ed transconjunctivally or transcutaneously, and the fat feren t ial diagn oses of fat p rolap se in Asian p eop le.13
can be transposed subperiosteally or supraperiosteally.4,17,18,19,20
To address th e palpebrom alar groove, an orbit al rim
depression of th e cen t ral to lateral region , orbital ret ain ing Orbicularis Prominence
ligam en t release is an im port an t step th at can be com bin ed
w ith suborbicularis oculi fat (SOOF) elevat ion or th e orbi- Orbicu laris ocu li p rom in en ce also con t ribu tes to low er eye-
cularis t igh ten ing procedure.15,19 lid aging feat ures, w ith st at ic an d dyn am ic w rin kles. Hori-
Sin ce Asian pat ien ts h ave relat ively th icker skin an d zon t al or oblique lin es accen t uated w ith facial expression s
su bcu tan eou s t issu e at th e tear t rough or palp ebrom alar can be n ot iced in m any pat ien ts, an d m ay be m ore com m on
region , th e fat resect ion p rocedure alon e can ach ieve a in Asian p at ien t s (Fig. 16.1c,d).13,24
good cosm et ic ou tcom e in selected cases.21 Orbicu laris prom in en ce can be dealt w ith by th e orbi-
cularis oculi suspen sion procedure in bleph aroplast y.
w on’t be n ecessar y. If th e eyelid goes back after blin king, th e subconjun ct ival space an d fat pockets. Make a conju n c-
h orizon tal t igh ten ing p rocedures such as orbicu laris ocu li t ival in cision 3 to 4 m m below th e in ferior m argin of th e
su sp en sion m igh t be n eeded. If th e eyelid does n ot go back tarsus (Fig. 16.2), an d proceed to dissect tow ard th e in fe-
even after blin king, a lateral t arsal st rip p rocedure is rec- rior orbital rim u n t il th e orbit al fat p ocket s are exp osed
om m en ded to avoid eyelid ret ract ion after bleph aroplast y. (Fig. 16.3). With th is ap p roach , th ere is n o scar form at ion
With a dist ract ion test (for w ard t ract ion test), m edial on th e orbit al sept um because th e sept um is n ot violated.
an d lateral can th al ligam en t an d eyelid laxit y can be Th is ret rosept al t ran sconjun ct ival approach can avoid th e
assessed. If th e eyelid can be p u lled over 8 m m from th e com m on com plicat ion s of low er lid bleph aroplast y su ch as
corn ea w ith for w ard t ract ion of th e eyelid, a h orizon t al eyelid ret ract ion an d scleral sh ow.
t igh ten ing procedu re is recom m en ded. A preseptal t ran sconjun ct ival low er bleph aroplast y is
also p erform ed by som e su rgeon s: a conju n ct ival in cision
is m ade below th e tarsu s, dissect ion th en proceeds in feri-
Surgical Considerations in orly, an d a presept al space is assessed. Th e orbital sept um is
Asian Patients open ed to expose th e orbital fat . Propon en ts of th e presep -
tal approach suggest th at th e scar form at ion on th e sept um
For pat ien t s requiring low er eyelid bleph aroplast y, sign i - m ay bolster again st th e pseu do-h ern iat ion postoperat ively.
can t factors in th e aging process in each pat ien t sh ould be No sign i can t di eren ce in eyelid p osit ion bet w een p re-
assessed an d suggest ive su rgical m eth ods discu ssed w ith an d ret ro-sept al ap proach es h as been rep or ted.27,28
th e pat ien t .25
If a p at ien t sh ow s fairly good skin ton e, sim p le fat exci-
sion w ith th e t ran sconju n ct ival app roach is th e rst ch oice
for prim ar y eyelid bags.21,25 If a pat ien t h as redun dan t skin
an d w rin kles w ith ou t sign i can t laxit y of th e eyelid, t ran s-
conjun ct ival fat rem oval w ith pin ch skin excision or t ran s-
cut an eous fat excision bleph aroplast y can be perform ed.24
Th e orbicularis m u scle t igh ten ing procedure can be added
to t ran scu t an eou s bleph aroplast y for th ose w h o sh ow
m oderate eyelid la xit y.
If a pat ien t h as a tear t rough d ep ression an d m idface
sagging resu lt ing in sign i can t volu m e dep let ion at th e
in ferom edial orbit al rim , fat t ran sposit ion bleph aroplast y
is n eeded t ran sconju n ct ivally or t ran scu t an eously.26 If th e
p at ien t sh ow s sign i can t palpebrom alar groove, orbicu -
laris ret ain ing ligam en t release an d orbicu laris susp en sion
an d/or SOOF lift are recom m en ded.
Ph otograp h s sh ou ld be t aken p reop erat ively w ith eye- Fig. 16.2 Surgical procedure for transconjunctival fat resection
lid closed an d open an d w ith th e p at ien t looking up an d and skin resection with the pinch technique. Conjunctiva is incised
d ow n . Th ese p h otos are for legal protect ion or in case of 3 to 4 mm below the tarsus (arrowheads).
p ostop erat ive p at ien t dissat isfact ion .
■ Surgical Techniques
Transconjunctival Fat Excision
Blepharoplasty
With th e t ran sconju n ct ival ap p roach , th e in tegrit y of th e
orbicularis m uscle an d th e orbit al sept u m can be m ain -
tain ed. Equal exposu re to th e fat pads is provided w ith th e
t ran scut an eous approach , an d th e skin pin ch tech n ique is
allow ed for redu n dan t skin .
Conjunctival Incision
Before su rger y, assess th e am ou n t of prolapsed orbit al fat Fig. 16.3 Capsulopalpebral fascia and conjunctiva are pulled with
from each com p ar t m en t w h ile th e p at ien t sit s u p . Wait 15 forceps and the lower eyelid is retracted with a Desmarres retractor
m in u tes for h em ost asis after local an esth et ic inject ion in to to expose orbital fat.
200 III Blepharoplast y
Fig. 16.4 Gentle pressure to the eyeball facilitates fat extrusion. Fig. 16.5 Inferior oblique muscle (arrow) is identi ed with dissec-
Fascial tissue bet ween t wo fat pockets is visible (arrow). tion bet ween t wo fat pockets.
a b
Fig. 16.6 (a) Medial fat pedicle is clamped with a hemostat. (b) The pedicle is excised and the cut end is cauterized for hemostasis.
16 Lower Blepharoplast y 201
in terru ptedly w ith 6–0 plain gut or 7–0 Vicr yl (Eth icon ) in Transcutaneous Approach
a bu ried fash ion so as n ot to irrit ate th e eyeball.
The t ranscutaneous approach can be used w hen there is
extensive skin excess, m alar bags, or festoon form at ion.
Pinch Skin Excision
W hen concurrent lid tightening procedures are planned, the
transcutaneous approach is preferred by m any surgeons.28
For th e pat ien t s w h o h ave redun dan t skin after t ran s-
After local an esth et ic is injected, a su bciliar y skin in ci-
conjun ct ival bleph aroplast y, th e excessive skin can be
sion is m ade 1 m m below th e lash lin e (Fig. 16.9). Sin ce a
addressed u sing th e pin ch tech n iqu e skin excision w h ile
su rgical scar over 10 m m lateral to th e lateral can th u s can
preser ving th e orbicularis m uscle.29 Th is tech n iqu e is suited
be not iceable, th e lateral exten sion sh ou ld be m in im ized to
to Asian pat ien t s at risk for pigm entar y ch anges w ith laser
an am ou n t ju st su itable to rem ove th e redu n dan t skin an d
or ch em ical peel resu rfacing.
orbicularis m uscle. Th e lateral por t ion of th e in cision t akes
Using t w o n e Brow n -Ad son forcep s, th e excess skin is
a h orizon tal or dow nw ardly in clin ed path to th e w rin kle
rm ly p in ch ed, creat ing a skin fold from th e lateral can th u s
lin es, keeping a m in im u m of 5 m m distan ce from th e upper
exten ding m edially (Fig. 16.7). Th e fold form s a m axim u m
skin in cision lin e to avoid w ebbing in case u pp er blep h a-
h eigh t below th e lateral can th u s, an d is t ap ered m edially
roplast y is con com it an tly perform ed. Th en , a skin -m u scle
an d laterally. Th rough ou t th is p in ch ing procedu re, th e p osi-
ap is raised an d dissected from th e orbit al sept u m u sing
t ion of th e low er eyelid sh ould n ot be draw n dow nw ard. If
blu nt an d sh arp dissect ion (Fig. 16.10). Th e th ree com p ar t-
th e eyelid posit ion is ch anged, th e am oun t of skin pin ch ed
m en t s of orbital fat are su bsequ en tly exp osed by in cising
sh ou ld be red u ced. St raigh t scissors are u sed to excise th e
th e sept um (Fig. 16.11). Th e orbit al fat is in lt rated w ith
skin fold, leaving th e orbicu laris m u scle in tact (Fig. 16.8).
th e anesth et ic solu t ion an d rem oved u p to th e am oun t
After h em ostasis, th e skin is closed con t in uously w ith a
w h ere gen tle globe pressu re sh ow s th e an terior surface of
6–0 fast-absorbing plain gut or a 7–0 nylon sut ure.
th e fat to be th e sam e as th e in ferior orbital rim level.
A sm all am ou n t of low er lid pretarsal skin can th en be
Postoperative Care judiciously excised. It is recom m en ded th at th e su rgeon
h ave th e pat ien t look u p an d open th e m ou th w h ile d eter-
For postoperat ive care, cold com pression is recom m en ded m in ing th e am ou n t of resect ion to avoid over-resect ion
for 24 to 48 h ou rs to con st rict blood vessels sh ow ing (Fig. 16.12).
in creased perm eabilit y from su rger y. Pat ien t s sh ou ld take Buried closure w ith a 6–0 absorbable sut ure is n eeded
a rest w ith th e h ead elevated an d sh ou ld ch eck th eir vision at the lateral can th al region to align th e skin -m u scle aps
for 24 h ou rs by self-exam . Th ereafter, w arm com pression an d to lessen skin ten sion . Skin m argin s are th en closed
is recom m en ded to decrease edem a an d bruising because con tin uou sly w ith a 7–0 nylon su t ure; m et iculous closure
vascu lar perm eabilit y recovers at th at m om en t . An t ibiot ic is requ ired for th e lateral por t ion to m in im ize scar form a-
eye drops w ith cort icosteroid are adm in ist rated for 1 w eek. t ion. Th e su t u res are rem oved 4 to 5 days after surger y.
Fig. 16.7 Excess skin is rmly pinched to create a skin fold from Fig. 16.8 Straight scissors are used to excise the skin fold.
the lateral canthus to the medial side.
202 III Blepharoplast y
Fig. 16.9 Transcutaneous lower eyelid blepharoplast y. Skin inci- Fig. 16.10 A skin muscle ap is raised and dissected.
sion is made with a no.15 B-P blade.
Fig. 16.11 The fat pocket is excised with a monopolar cautery. Fig. 16.12 Excessive skin is excised judiciously while the patient
is looking up.
Fat preser vat ion bleph aroplast y is ben e cial, especially for A su bp eriosteal app roach is claim ed to provide easier dis-
th ose w h o h ave n egat ive vector an d tear t rough depression . sect ion in th e su bp eriosteal p lan e, w ith less ch an ce of
Ham ra origin ally described a sept al reset p roced u re for fat- bleeding an d bet ter con tour after fat t ran sposit ion com -
preser ving bleph aroplast y, w h ich h as been m odi ed.10,20 pared w ith th e supraperiosteal approach .17
For th e fat t ran sposit ion procedure, su rgical dissect ion After reach ing th e in ferior orbit al rim , a periosteal in ci-
proceeds to th e in ferior orbit al rim after conjun ct ival or sion is m ade w ith a m on op olar cau ter y. Su bp eriosteal dis-
t ran scut an eous in cision , an d the orbit al sept um is open ed section is th en p erform ed below th e in fraorbit al rim an d
in feriorly. Th e m edial an d cen t ral fat pocket s are to be lateral to th e poin t w h ere fat t ran sfer is n eeded. If excess
t ran sposed over th e orbital rim , an d usually a lateral pocket fat is p resen t , p art ial resect ion is p erform ed to im p rove
n eeds to be resected. After fat t ran sp osit ion , com plete sep - con touring. Sin ce orbital fat is con n ected w ith th e orbit al
tal release is recom m en ded to preven t sept al teth ering.19 fascial system –related ocu lar m ot ilit y system , care sh ou ld
Th ere are t w o approach es to fat t ran sposit ion . be t aken n ot to cause any rest rict ion in fash ion ing fat ped-
16 Lower Blepharoplast y 203
icles. A forced du ct ion test sh ould be adm in istered before (Fig. 16.14). Du e to th e su p er cial p lan e of dissect ion ,
t ran sposit ion to verify th at th ere is n o ext raocular m ot il- orbit al fat can be m ore apparen t or lum py after surger y.
it y abn orm alit y. Th en t w o m at t ress percu tan eous 4–0 or Th is sh or t-term h arden ing of th e t ran sposed fat resolves
5–0 sut ures are n eeded to secure th e fat pedicles in feriorly. w ith t im e an d in t ralesion al steroid inject ion .
Con rm ing th e adequacy of e acem en t of th e tear t rough
by th e t ran sposed fat , th e sut ures are t ied over bolsters. Th e
su t u res an d bolsters are rem oved in 1 w eek. SOOF Lifting
Th is procedure is ver y useful for palpebrom alar groove
Supraperiosteal Transposition correct ion . A palpebrom alar groove is exacerbated by th e
descen t an d decreased volum e of th e m alar fat pads an d
A ben e t of th e su praperiosteal approach is easier an es- SOOF. Th erefore, th e SOOF lift p roced u re along w ith an
thesia an d dissect ion com pared w ith the subperiosteal orbicularis-retain ing ligam en t release tech n ique can ll th e
approach becau se subperiosteal dissection along th e orbital defect .19,27
rim is n ot easy.18
For the supraperiosteal approach , dissect ion is per-
form ed dow n to the inferior orbital rim after t ran scon - Orbicularis-Retaining Ligament Release
ju n ct ival or transcu tan eou s incision . Then careful blunt and Orbitomalar Suspension
dissection is com pleted in the plane of th e suborbicularis
oculi fat (SOOF) to a level 8 to 12 m m below the orbital After reach ing th e in ferior orbital rim , th e orbicu laris-
rim (Fig. 16.13). Preser vation of th e zygom at ic bran ch of retain ing ligam en t is released; th e at t ach m en t s of th e
the facial n er ve during dissection is essent ial; the critical orbicularis-retain ing ligam en t are liberated in feriorly an d
zone is a circle w ith a diam eter of 1 cm located 2.5 cm aw ay laterally w ith blun t dissect ion an d cut t ing cauter y in th e
from th e lateral can th us at an angle of 30 degree.30 If the preperiosteal plan e. Th e origin of the orbicularis-retain ing
dissection is don e too far in feriorly, orbicularis den er vation ligam en t an d SOOF can be su spen ded w ith a 5–0 Prolen e
an d ect ropion m igh t resu lt .18 Th e vascularit y of th is plan e (Eth icon ) sut ure to th e su perior-m ost par t of th e lateral
necessitates proper hem ostasis; in fact, it is claim ed th at orbit al rim . Th ey can also be su spen ded to th e superolat-
this m ay cont ribute to in creased sur vival of the fat pedicle.18 eral orbit al rim of th e lateral orbital w all via th e u pp er eye-
Each fat pocket is open ed, an d th e fat is allow ed to lid bleph arop last y in cision in case u pper blep h aroplast y is
prolapse over th e in ferior orbit al rim . Part ial fat excision perform ed sim ult an eously. More su t ure resuspen sion is
is d on e as n ecessar y. On e or t w o m at t ress 5–0 sut ures are perform ed to th e presept al orbicularis in case sign i can t
ap plied to th e fat p edicle an d p eriosteu m or SOOF p ocket orbicularis laxit y is fou n d.19
Fig. 16.13 Surgical procedures of fat repositioning blepharo- Fig. 16.14 The fat pedicle is transposed and xed to the
plast y. A blunt dissection is made below the orbital rim. periosteum.
204 III Blepharoplast y
Ectropion
■ Complications and
Their Management Ect ropion can occur tem porarily du e to low er eyelid sw ell-
ing in case of eyelid laxit y, or perm an en tly w ith th e an terior
Com plicat ion s of low er bleph aroplast y sh ould be preven ted lam ellar sh or tage from excessive skin excision (Fig. 16.15).
during surger y an d t reated properly if th ey occur. Th e m ost Ju diciou s skin excision du ring su rger y is essen t ial as a p re-
frequ en t com p licat ion resu lt ing from low er blep h aroplast y ven t ive m easu re.
is eyelid m alposit ion , alth ough m ore seriou s com plicat ion s If ectropion occurs a few days after surgery w ith in am -
su ch as visu al loss h ave been rep or ted. m atory signs, upward eyelid taping and an intrafat pad steroid
injection can lessen the condition, reducing the postsurgical
in am m ation reaction. If ectropion persists, watchful waiting
Eyelid Retraction w ith m assaging and use of steroid ointm ent is recom m ended
for 3 to 6 m onths before surgical correction is perform ed.
Eyelid ret ract ion can resu lt from several factors related to Horizon t al eyelid t igh ten ing procedu res are n eeded if
low er bleph arop last y. Pat ien t s w h o h ave n egat ive vector low er eyelid laxit y is sign i can t . A SOOF lift or skin graft
con gurat ion are predisposed to eyelid ret ract ion , an d loss can be applied to an terior lam ellar length en ing. Th e SOOF
of orbicularis m uscle fun ct ion from surgical in ter ven t ion lift procedure sh ould be t ried prim arily, if possible, because
also con t ribu tes to th e eyelid posit ion . Fu rth erm ore, m id - a skin graft m ay leave cosm et ic blem ish an d u n accept able
dle eyelid lam ellar sh orten ing an d t igh ten ing from surger y scarring in th e Asian p op u lat ion .
also a ect low er eyelid p osit ion .32,33
As t im e elapses after surger y, eyelid sw elling an d
in am m at ion su bside an d orbicularis ton e is gain ed. Th ere- Asymmetric or Lumpy Appearance
fore, su p port ive care is im p or t an t in th e early postoperat ive
period, in cluding eyelid taping, steroid inject ion , an d th e Fault y est im at ion of fat prolapse preoperat ively or im proper
use of an an t i-in am m ator y agen t . debu lking of fat pads during su rger y m ay resu lt in an asym -
If th e ret raction is associated w ith sign i cant m iddle m et ric ap pearan ce bet w een th e t w o eyelids. Residu al fat
lam ellar shortening and tightening, surgical inter vent ion prolapse can be corrected w ith furth er resect ion after 6 to
is unavoidable. Forced upw ard t raction testing to see if the 8 w eeks, w h ile a sun ken appearan ce can be revised w ith a
eyelid can be elevated w ith a surgeon’s nger is im portan t to fat graft from th e con t ralateral fat p ad or elsew h ere.
evalu ate th e tigh t ness in th e m iddle lam ella. In case m iddle A prom in en t lateral fat pad m ay be foun d after t ran s-
lam ellar con tract ure is evident , m iddle lam ellar release and conjun ct ival bleph aroplast y for pat ien t s w h o h ave exces-
a spacer graft to relieve th e vertical tigh t n ess are n eeded. sive fat p rot ru sion in th e lateral fat p ad. Reresect ion
For a m iddle lam ellar spacer, hard palate, ear cartilage, or a th rough a n ew, sm all skin in cision at th e lateral can th al
cellular derm is (AlloDerm , LifeCell) is frequently used. area m ay relieve th e lu m py ap p earan ce.
a b
Fig. 16.15 Ectropion complicated lower blepharoplast y on the left eye. (a) SOOF lift and lateral tarsal strip were performed to correct
anterior lam ellar shortage and horizontal laxit y. (b) Three months after surgery.
206 III Blepharoplast y
a b
Fig. 16.16 Case 1. Transcutaneous blepharoplast y with the orbicularis oculi suspension procedure was done in a 62-year-old female.
(a) Preoperative photo showing prominent orbicularis (arrow). (b) One year after surgery.
Case 2
A 58-year-old fem ale p at ien t sh ow ed tear t rough dep res-
sion , p alp ebrom alar groove, an d m ild orbicu laris p rom i-
n en ce. Each com pon en t w as addressed. Fat reposit ion ing,
orbitom alar ligam en t release an d SOOF lift to th e upper
part of th e lateral orbit al w all, an d orbicularis m uscle
resuspen sion w ere perform ed (Fig. 16.17).
a b
Fig. 16.17 Case 2. A 58-year-old female patient with a negative vector con guration. Fat repositioning, SOOF lift, and orbicularis m uscle
anchoring with the transcutaneous approach were performed. (a) Before the surgery. (b) One year after the surgery. A skin wrinkle line is
moved upward with this procedure (arrows).
208 III Blepharoplast y
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16 Lower Blepharoplast y 209
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17 Correction of Ptosis
Woong Chul Choi and Juwan Park
Pearls
• Margin -re ex d ist an ce 1 (MRD1, distan ce from th e • Th e burden factors such as redun dan t skin,
corn eal ligh t re ex to th e upper lid m argin ) in a orbicularis m u scle, an d fat sh ould be addressed
sit t ing p osit ion is th e m ost im p or tan t param eter for because th ey can aggravate th e ptosis or cause
ptosis evaluat ion . su bclin ical ptosis.
• Histor y, levator fu n ct ion test , an d m easu rem en t of • St ru ct u ral w eakn ess an d th e pretarsal fat pad are
lid lag on dow n -gaze help di eren t iate bet w een m ore easily seen in th e m edial part am ong eld erly
ap on eu rot ic an d congen ital ptosis. East Asian s, an d an e or t to overcom e th ose factors
• Levator fu n ct ion is th e m ost im port an t p aram eter is required for bet ter resu lt s.
in determ in ing th e su rgical m eth od (levator • Addit ion al p rocedu res to form a lid crease after
advan cem en t , fron t alis sling, etc.) an d th e m ost ptosis correct ion are usually required for a du rable
reliable predictor of surgical respon se. lid crease form at ion in Asian pat ien t s.
• Mild ptosis w ith good levator fu n ct ion can be • Met icu lou s h em ostasis an d in t raop erat ive
t reated w ith conju n ct ivo-Mü llerectom y. cooling are h elpfu l in im proving th e accuracy of
• Bilateral su rger y is m ore likely to be predict able an d in t raoperat ive adjust m en t .
reliable th an un ilateral surger y, especially in elderly • Asym m et r y after ptosis repair can be xed in th e
pat ien t s or pat ien t s w ith poor levator fun ct ion . early postop erat ive p eriod of a w eek or so.
210
17 Correction of Ptosis 211
a b c
Fig. 17.1 Congenital ptosis. This 13-year-old boy who has (a) right congenital ptosis (b) shows poor levator function on up-gaze and
(c) lid lag on down-gaze.
Diagnosis of Ptosis
It is im p or t an t to m easu re t h e MRD an d levator fu n ct ion
to obt ain p rop er evalu at ion s. MRD1 is kn ow n to be t h e
m ost p red ict able m easu rem en t for p tosis evalu at ion .34
MRD1 m u st be exam in ed w it h t h e p at ien t in a p r im ar y
p osit ion w it h n o excessive u se of t h e fron t alis m u scle or
orbicu lar is m u scle. For an accu rate exam , a ligh t sou rce (a
p en ligh t or ash ) m u st be p osit ion ed at t h e sam e h e igh t
as t h e p at ien t ’s eyes. MRD1 is t h e d ist an ce from t h e cor-
n eal ligh t re ex to t h e u p p er eyelid m argin , n ot t h e h an g-
Fig. 17.2 Aponeurotic ptosis. This 65-year-old female has apo-
in g skin m argin . If t h e h an gin g u p p er lid skin is cover in g
neurotic ptosis of the right eye and shows right eyebrow elevation,
multiple lid creases, and a deep superior sulcus. t h e u p p er lid m argin of a p at ien t w it h d e r m atoch alasis,
t h e skin sh ou ld be ge n t ly p u lled u p an d t h e lid m argin
sh ou ld be obser ved d u r in g t h e exam . MRD2 (d ist an ce
from t h e cor n eal ligh t re ex to t h e low e r lid m argin )
d ep en d s on t h e p osit ion of t h e low er lid . Th e su m of t h ese
t w o is t h e in ter p alp ebral ssu re (IPF).
Sin ce Asian s often h ave m ed ial ep ican t h al fold s, Th e levator fu n ct ion is d eter m in ed by m easu r ing
m ed ial ep ican t h op last y can be p er for m ed at t h e sam e t h e excu rsion of t h e eyelid m argin , or t h e tot al d ist an ce
t im e as t h e ptosis su rger y. It is essen t ial to t ake p h otos t raveled by t h e lid m argin from dow n -gaze to u p -gaze.
before t h e su rger y for d ocu m en t at ion , review, ed u ca- A n or m al levator fu n ct ion is ~ 15 m m . Levator excu rsion
t ion , an d m edicolegal p u r p oses. Pat ien t s n or m ally d o n ot is con sid ered to be p oor w h en t h e d ist an ce is less t h an
rem em ber t h eir p reop erat ive feat u res. By com p ar in g t h e 4 m m , m oderate w h en t h e d ist an ce is bet w een 5 an d 10
p reop erat ive an d p ostop erat ive p h otos, t h e resu lt s of t h e m m , an d good w h en t h e d ist an ce is above 10 m m . To p re-
su rger y can be object ively an alyzed an d evalu ated . Th is ven t fron t alis recr u it m en t d u r in g t h ese m easu rem en t s,
h elp s to est ablish t r u st bet w een t h e p at ien t an d t h e su r- it is advisable to eit h er h ave t h e foreh ead lean in g on a
geon . W h en t h e p at ien t com p lain s, review t h e p h otos; if su p p or t bar or u sin g on e’s h an d s to h old t h e foreh ead .
som et h in g is fou n d lackin g, d iscu ss it w it h t h e p at ien t an d By u sin g a r u ler at t ach ed to t h e sid e bar of t h e slit lam p ,
con sid er p er for m ing a revision su rger y for bet ter resu lt s. t h e valu es of MRD1, IPF, levator fu n ct ion , an d lid lag are
If a p at ien t d oes n ot w an t p h otos to be t aken before t h e record ed in d et ail (Fig. 17.3). Usin g t h ese kin d of reliable
su rger y, t h e op erat ion sh ou ld be recon sid ered . Ph otos are record s to object ively exp ress p at ien t s’ st at u s often bu ild s
t aken w h ile t h e p at ien t is looking ah ead , u p , an d d ow n . To p at ien t s’ t r u st .
ch eck t h e con dit ion s of t h e eyelash es, ad d it ion al lateral Th e m ost com m on clin ical ptosis occurs from st retch -
view p h otos sh ou ld be t aken . If t h ere are any im p or t an t ing an d deh iscen ce of th e levator apon eurosis. Typical apo-
or u n iqu e occu r ren ces du r ing t h e su rger y, in t raop erat ive n eu rot ic ptosis is fou n d in cases of frequ en t eye ru bbing
p h otos sh ou ld be t aken as w ell. To evalu ate t h e p rogress due to atopy or w earing con t act len ses for a long t im e, an d
of t h e su rger y, p h otos are t aken 1 w eek, 1 m on t h , an d 3 sen ile ch anges du e to aging. Sim ilar cases can be fou n d in
m on t h s after t h e su rger y. pat ien t s after oph th alm ic surger y, t raum a, or frequen t lid
17 Correction of Ptosis 213
a b
Fig. 17.3 Measuring MRD1, MRD2, IPF, and levator function. (a) Precise measurements of levator function using a ruler at tached to the
slit lamp. (b) The blue line is MRD1, and the yellow line is MRD2. The sum of these t wo is IPF.
sw elling.35,36 Gen eral clin ical ch aracterist ics of apon eurot ic in sit uat ion s of ptosis ow ing to apon eurot ic deh iscen ce.37
ptosis in clude Levator fu n ct ion in p at ien t s w ith ap on eu rot ic ptosis is
good in gen eral. How ever, if th e levator apon eu rosis tot ally
• Eyebrow elevat ion of th e a ected eye det ach es from th e t arsal plate, th e levator fun ct ion w ill
• Deep su p erior su lcu s be ver y poor.38 Th is is especially t rue for elderly pat ien t s
• High er or m u lt ip le lid creases w h o h ave h ad oph th alm ic surger y several t im es an d w h ose
• Lid drooping levator apon eurosis is often totally det ach ed from th e tar-
• Good levator fu n ct ion sal plate (Fig. 17.4).
Most apon eu rot ic ptosis resu lts from aging an d is com -
Th e lid crease h eigh t is th e dist an ce bet w een th e lid m argin m on ly detected in elderly pat ien t s. On th e oth er h an d, con -
an d th e crease form ed by th e at t ach m en t of levator ap o- gen ital ptosis is th e m ost com m on t yp e in ch ild ren . Un like
n eu rosis bers to th e su bcu t an eou s t issu e. Th is can var y ap on eu rot ic ptosis, congen ital ptosis sh ow s poor to fair
am ong races an d by sex. Lid crease h eigh t m ay in crease levator fu n ct ion an d lid lag on dow n -gaze due to th e loss of
a b c
Fig. 17.4 (a–c) Poor levator function in aponeurotic ptosis. This 72-year-old
female shows very poor levator function on upward gaze and severe lid drooping
on downward gaze. (d) Operative dissection shows a total detachment of the
d levator aponeurosis from the tarsal plate.
214 III Blepharoplast y
levator m u scle elast icit y. In som e cases, in com plete lid clo- rin e is in st illed in cases of m ild ptosis w ith good levator
su re (lagop h th alm os) is also presen t . Th e h istologic n d - fu n ct ion . On ce th e eyelid goes u p to a n orm al p osit ion , it
ing of congen it al ptosis is dyst rophy of th e st riate m u scle is regarded to be a good can didate for a conjun ct ivo-Mü l-
bers.39 Som e pat ien t s w ith m ild congen ital ptosis are n ot lerectom y. Th is m eth od is advan t ageous for pat ien ts w h o
d iagn osed t ill adu lth ood. n eed u n ilateral surger y an d do n ot w an t skin excision or
any ch an ce of get t ing a skin scar.
Incision
Th e surgeon uses th e ngers to st retch th e eyelid out w ard
an d in cises th e skin in on e sm ooth step u sing a Bard-Parker Fig. 17.9 Injection of local anesthetic subcutaneously with a
(Aspen Su rgical) n o. 15 kn ife, to avoid a zigzag in cision . 30-gauge needle from the lateral side.
17 Correction of Ptosis 217
Fig. 17.10 Removal of the orbicularis muscle strand with West- Fig. 17.11 After removal of the orbicularis muscle, the orbital
cot t scissors. septum is revealed.
n eu rosis. Th e n ext st ru ct u re ben eath th e orbit al sept u m is If the surgeon needs m ore levator advancem ent, then
th e pre-apon eurot ic fat . If th ere is di cult y in n ding th e the aponeurosis can be further delam inated up to the level
fat , th e eyeball can be gen tly p ressed w ith a nger from th e of W hit nall’s ligam ent. The Mü ller m uscle tends to bleed, so
low er eyelid. Th en th e fat w ill bu lge out . Th e surgeon n eeds you sh ou ld coagulate th e vessels carefully to preven t bleed-
to rem ove on ly th e fat th at n at urally com es out at th is t im e ing before dissection (Fig. 17.14). If cauter y of th e Mü ller
(Fig. 17.12). A deep su p erior su lcu s w ill resolve after th e m uscle is con ducted w ith a corn eal protector in place, it w ill
ptosis correct ion becau se th e eyebrow s w ill go dow n after not cause inadvertent th erm al dam age to the cornea. Alter-
th e surger y, except in cases of severe fat de cien cy. Sau - nat ively, th e surgeon should pull the eyelid up w ith forceps
sage deform it y, w h ich m igh t occu r after th e su rger y, can to distan ce it from th e corn ea before u sing th e cauter y.
be preven ted by rem oving th e pretarsal orbicularis m uscle.
Th is procedure sh ould especially be perform ed on Asian s,
w h o h ave ver y th ick eyelids. After th e su rgeon lift s th e Fixation of Levator-Müller
ap on eu rosis, w h ich is loosely at t ach ed to th e an terior tar- Muscle Flap
sal su rface, an d delam in ates it u sing scissors in an u pw ard
d irect ion up to th e su perior tarsal border, th e p eriph eral W h en perform ing a levator advan cem en t , th e su rgeon
p alp ebral arcad e can be obser ved, w h ich run s on th e Mü l- sh ou ld sep arate th e levator ap on eu rosis rst from th e tar-
ler m u scle (Fig. 17.13). sal plate, an d th en from th e Mü ller m u scle w ith Westcot t
Fig. 17.12 After opening of the septum, bulging fat is clamped Fig. 17.13 Dissecting the levator aponeurosis up to the superior
with a hemostat and resected. border of the tarsal plate after lifting the levator aponeurosis that is
loosely at tached to the tarsal plate.
218 III Blepharoplast y
low, eyelash ect ropion w ill occur. If th e sut ure is placed too
h igh , en t ropion w ill occur.
A sh allow xat ion to th e t arsal plate m ay result in easy
loosen ing or u n der-correct ion . Th erefore, w h en sut uring to
th e t arsal plate, it is bet ter to an ch or w ith levator apon eu-
rosis 3 to 4 m m in w idth . If th e sut ure is p assed th rough th e
tarsal plates too deeply, it m ay pen et rate th e t arsal plates. It
can be ch ecked w h eth er th e n eedle h as passed th rough th e
tarsal plate or n ot by evert ing th e eyelid during th e surger y
(Fig. 17.17).
Fig. 17.15 A needle is passed through the levator aponeurosis at Fig. 17.16 The levator is sutured to the tarsal plate not super -
the part medial to the pupil. cially, but deeply, and tied with mat tress suture.
17 Correction of Ptosis 219
Fig. 17.17 Check whether the needle has passed through the tar-
sal plate by everting the lid.
Levator Resection
Th e di eren ce bet w een levator resect ion an d levator
advan cem en t is a vert ical in cision of th e m ed ial an d lateral ing from m edial to tem p oral an d th en exit ing th rough
h orn s to release an d advan ce th e levator m u scle m ore. Th e th e tem poral skin st ab in cision . Tie th e sut u re en ds, an d
su rgeon sh ou ld rem ove rem n an t s of th e levator ap on eu ro- rem ove th e st itch es in a w eek.
sis at th is t im e.
Frontalis Sling
Conjunctivo -Müllerectomy
Fron t alis sling is a ver y e ect ive surger y for revision cases
Th e sim plicit y an d predict abilit y of th is procedure m ake it after m u lt ip le levator su rgeries or in cases sh ow ing p oor
at t ract ive. Th is tech n iqu e is preferred in m ild ptosis cor- levator fu n ct ion below 4 m m (Fig. 17.19). Th ere are diverse
rect ion .27,52,53 If th e eyelid rises to th e level of th e opposite, sling m aterials su ch as au tologou s fascia lata, preser ved
n orm al eyelid after th e in st illat ion of 2.5% or 10% p h enyl- fascia lat a, silicon e rod, Su pram id (S. Jackson ), exp an d ed
ep h rin e eye drop s an d sh ow s good fu n ct ion of th e levator polytet ra u oroethylen e (ePTFE, or Gore-Tex [W. L. Gore]),
m u scle, good p ostop erat ive resu lts w ith th is tech n iqu e can an d oth ers. Th e au th ors p refer th e single rh om boid sling
be expected. In con t rast to levator su rger y, w h ich requires a m eth od w ith ePTFE su t u res (Gore-Tex CV-3).
skin in cision , th is tech n iqu e w ill n ot leave an extern al scar. Th e surgeon in cises th e skin 3 to 5 m m above th e lid
In addit ion , a relat ively p recise resu lt can be p redicted . m argin , exp oses th e t arsal p lates, an d p asses th e Gore-Tex
Inject 1 m L of 2% lidocain e in to th e su bconju n ct ival space su t u re h orizon tally th rough th e tarsal plate ~ 3 m m in ferior
an d 0.5 m L in to th e lateral th ird of th e u p p er eyelid. Ever t to th e su p erior t arsal border. Th e n eedle sh ou ld be passed
th e u pper eyelid, an d th en m ark th e am oun t of conjun ct iva un der th e an terior surface of th e t arsal plate deep en ough
to be excised. Hold th e conju n ct iva w ith a Pu t term an clam p to p reven t loosen ing of th e su t u re. How ever, if th e su t u re
or t w o h em ost at s. is passed too deeply, th e n eedle w ill pen et rate th e t arsal
Make a st ab in cision th rough th e skin tem p orally. Pass conjun ct iva. Th erefore, th e upper eyelids sh ou ld be everted
a 6–0 nylon su t u re th rough th e st ab in cision an d w eave a to ch eck w h eth er th e sling m aterial is exp osed or n ot . Th e
con t in uou s su t u re 1 m m below th e clam p from tem poral sling m aterial p assed th rough th e tarsal p late is xated
to m ed ial. Rem ove th e clam p after cu t t ing below it , th en w ith 6–0 nylon sut ures at th e m edial an d tem poral sites.
su t u re th e cu t st u m p by con t in u ing th e su t u re, n ow w eav- Th is preven t s loosen ing after th e surger y.
220 III Blepharoplast y
■ Postoperative Care
An t ibiot ic oin t m en t is app lied to th e in cision after th e su r-
ger y an d an ice p ack is h eld to th e closed eyelid for 20 to
b 30 m inu tes in th e recover y room . If th e am oun t of levator
advan cem en t is large or th e pat ien t h as severe lagoph th al-
Fig. 17.19 Frontalis sling to correct ptosis. (a) This 35-year-old m os du e to a fron t alis sling, ar t i cial tears an d lu brican t
woman has had t wo previous ptosis surgeries and still has ptosis. oin t m en t are ben e cial. Th e surgeon sh ould advise th e
(b) Postoperative photo shows correction of ptosis after use of pat ien t to apply art i cial tears frequen tly an d lift up th e
bilateral ePTFE (Gore-Tex CV-3) frontalis slings. low er eyelid to dist ribu te th e tears even ly on to th e corn ea
during th e day, as w ell as put t ing th e oin t m en t in to th e
eyes before sleep.
Th e pat ien t is advised to use a plast ic eye sh ield to pre-
ven t ru bbing of th e eyes by th e h an d s du ring sleep. St itch es
Th e surgeon creates m edial, cen t ral, an d tem poral slit are n orm ally rem oved 6 to 7 days after th e su rger y, an d an
in cision s above th e eyebrow. Using a Wrigh t n eedle, each an t ibiot ic oin t m en t is ap plied for an ad dit ion al 3 to 4 days
en d of th e sling m aterial from th e tarsal p late is passed follow ing th e rem oval of th e st itch es.
deeply in fron t of th e foreh ead periosteu m th rough th e
m edial an d tem poral brow in cision s. Th en th e en d s are
passed th rough th e cen t ral brow in cision . Th e upper eye- ■ Complications and
lid in cision is closed w ith 6–0 nylon before t ying th e sling
m aterial at th e cen t ral brow in cision . Th e sling m aterial is
Their Management
t ied at th e cen t ral brow incision an d st itch kn ots using 5–0
Vicr yl su t ures are used to preven t loosen ing. Th e skin in ci- Over-correction and
sion above th e eyebrow is closed w ith deep 6–0 nylon or Under-correction
Prolen e sut ures so th at th e sling m aterial is n ot exposed.
Over-correct ion is m ore com m on in pat ien t s w ith good
levator fu n ct ion , in revision cases, an d in post t raum at ic
■ Key Technical Points ptosis. Postoperat ive dow nw ard t ract ion m assage w ill eas-
ily overcom e a m ild over-correct ion (less th an 1 m m ). If th e
1. On e-sm ooth -step skin in cision is recom m en ded to eyelid is sligh tly over-corrected postop erat ively, st retch ing
avoid creat ing a zigzag in cision . th e upper lid dow nw ard in th e early postoperat ive period
2. Excise the orbicularis m uscle in an oblique superior w ill correct such a m ild over-correct ion .
direction to prevent indeterm inate aponeurosis injury. Un der-correct ion can occur in cases of poor leva-
tor fu n ct ion . Possible reason s for u n der-correct ion are
3. To n d th e fat , gen tly push th e eyeball by pressing
im proper xat ion of th e levator-Mü ller m uscle ap on to
th e low er eyelid w ith th e ngers.
th e tarsal plate an d loosen ing of sut ure kn ot s. Perform ing
4. Iden t ify th e levator apon eurosis un der th e a revision at 1 w eek after levator advan cem en t is recom -
p reapon eu rot ic fat . m en ded if th e eyelid is 1.0 m m above or below th e target
5. Hold th e levator apon eurosis, w h ich is loosely h eigh t , or if th ere is asym m et r y bet w een th e t w o eyelids of
at t ach ed to th e t arsal plate an d dissect it u p to th e 1.0 m m or m ore (Fig. 17.20).
su p erior border of th e t arsal p late.
17 Correction of Ptosis 221
Keratitis
Th e causes of kerat it is after ptosis surger y are corn eal
exp osu re an d p oor corn eal p rotect ive m ech an ism s (dr y eye
syn drom e, facial n er ve palsy, poor or absen t Bell’s p h en om -
en on ). Lu brican t s sh ou ld be prescribed an d Frost su t u res
a can be perform ed to lift up th e low er lid.
Conjunctival Prolapse
Conjunctival prolapse can be seen in cases of signi cant leva-
tor advan cem en t. It is caused by dam age to th e suspensory
ligam ent in the superior fornix. If it does not im prove w ith
b pressure patching, partial conjunctival resection is needed.
a b
Fig. 17.21 Case 1. (a) A 27-year-old male with a tired look and prominent forehead wrinkles with brow elevation due to bilateral blepha-
roptosis and lash ptosis. (b) After levator advancement and lash correction, he does not use his forehead muscle any more and feels
comfortable.
a b
Fig. 17.22 Case 2. (a) A 25-year-old female with congenital ptosis. She has a history of ptosis correction at 9 years old. (b) After levator
advancement of the right eye and bilateral upper blepharoplast y, the right, droopy lid improved, inferior scleral show resolved, and both
eyebrows are down.
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224 III Blepharoplast y
43. Bodian M. Lip droop follow ing con t ralateral ptosis repair. 49. Morris CL, Morris W R, Flem ing JC. A h istological an alysis
Arch Oph th alm ol 1982;100(7):1122–1124 of th e Mü llerectom y: rede n ing it s m echan ism in ptosis
44. Lyon DB, Gon n ering RS, Dort zbach RK, Lem ke BN. Un ilat- repair. Plast Recon st r Surg 2011;127(6):2333–2341
eral ptosis an d eye dom in an ce. Op h th al Plast Recon st r Surg 50. Jang SY, Ch in S, Jang JW. Ten years’ exp erien ce w ith u n i-
1993;9(4):237–240 lateral conju n ct ival Mu llerectom y in th e Asian eyelid. Plast
45. Worley MW, Gal O, An derson RL, al Hariri A. Eye dom in an ce Recon st r Su rg 2014;133(4):879–886
and Hering’s law e ect on bilateral blepharotosis repair. 51. Steinkogler FJ, Kuchar A, Huber E, Arocker-Met t inger E.
Ophthal Plast Reconstr Surg 2013;29(6):437–439 Gore-Tex soft-tissue patch fron talis su spen sion tech n iqu e
46. Erb MH, Kersten RC, Yip CC, Hudak D, Kulw in DR, McCul- in congenital ptosis and in blepharoph im osis-ptosis syn -
ley TJ. E ect of u n ilateral blep h aroptosis repair on con - drom e. Plast Recon st r Su rg 1993;92(6):1057–1060
t ralateral eyelid posit ion . Op h th al Plast Recon st r Su rg 52. Karesh JW. Polytet ra u oroethylen e as a graft m aterial
2004;20(6):418–422 in oph th alm ic plast ic an d recon st ru ct ive su rger y. An ex-
47. Malik KJ, Lee MS, Park DJJ, Harrison AR. Lash ptosis in con - perim en t al an d clin ical st u dy. Op h th al Plast Recon st r Surg
gen it al and acqu ired blep h aroptosis. Arch Oph th alm ol 1987;3(3):179–185
2007;125(12):1613–1615 53. Bajaj MS, Sast r y SS, Gh ose S, Beth aria SM, Pu sh ker N.
48. Lee TE, Lee JM, Lee H, Park M, Kim KH, Baek S. Lash pto- Evalu at ion of polytet ra u oroethylen e su t u re for fron t alis
sis an d associated factors in Asian s. An n Plast Su rg 2010; suspen sion as com pared to polybut ylate-coated braid-
65(4):407–410 ed polyester. Clin Experim en t Oph th alm ol 2004;32(4):
415–419
18 Management of Double -Eyelid Surgery
Complications
In-chang Cho and Aram Harijan
Pearls
• Ident ify an d nd w ays to avoid th e origin al m istake. • Th e secon d goal is th e preven t ion of fur th er
Oth erw ise, secon dar y an d tert iar y operat ion s w ill com plicat ion s.
only com pound th e problem from the rst operat ion. • Th e th ird goal is to create th e desired eyelid sh ape,
• Railroad scar from d elayed rem oval of st itch es in cluding n ew crease h eigh t an d fold depth .
sh ou ld n ever h ap p en . • Th e problem beh in d pretarsal fulln ess is in
• Mech an ical resistan ce to fold ing of th e eyelid skin th e h eigh t (n ot th e volum e) of th e pretarsal
varies from pat ien t to pat ien t . Th is resist an ce is com par t m en t . Rath er th an rem oving soft t issue, th e
evaluated by obser ving h ow long a tem p orar y crease h igh crease sh ould be replaced w ith a low er on e.
stays after u sing a bougie. • It is t h e su rgeon ’s job to h elp t h e p at ien t
• Deeper folds u su ally accom p any h igh creases, bu t u n d erst an d t h at t h ere is n o w ay to rem ove an
crease h eigh t is n ot th e sam e as fold depth . eyelid crease an d m ake t h e eyes look like t h eir
• In secon dar y eyelid operat ion s, th e rst goal sh ou ld or igin al for m s. A bet ter solu t ion is to low er t h e
be decon st ruct ion of layers th rough release of crease to t h e eyelid m argin an d to bu r y t h e in cision
adh esion an d sep arat ion of app rop riate p lan es. scar w it h in t h e fold .
225
226 III Blepharoplast y
■ Surgical Techniques
Scar
Eyelid skin d oes n ot d evelop hypert roph ic resp on se in m ost
cases. W h en hypert roph ic respon se is obser ved after an
eyelid operat ion, th e fu n dam en t al problem could be th e
pat ien t’s ten den cy to develop hypert roph ic scar. In m any
in st an ces, h ow ever, th e problem is n ot w ith th e pat ien t but
w ith th e surgeon w h o perform ed th e in dex operat ion .
Th e m ost com m on tech n ical m ist ake is a lack of un der-
stan ding of th e d ist ribu t ion of th e su p erior-p osterior force
Fig. 18.1 On opening the eyes, the lower ap is dislocated as it
vector of th e levator m u scle. If th is vector is u n equ ally
is pulled inward by the xation suture there. For prevention, skin
dist ributed to th e low er ap, it is possible to dislocate th e
sutures must be done closely to su ciently bite the tarsal plate.
low er ap from th e u pp er ap (Fig. 18.1). Th is occu rs m ore
frequ en tly in th e lateral p or t ion of th e u p per eyelid becau se
th e apon eurosis is deeper in th e t issue. To m in im ize such a
risk, th e su rgeon m u st en su re th at th e u pw ard p u ll of th e
levator is t ran sferred to th e t arsu s—n ot th e skin —via a su -
cien t n um ber of bites of th e plate. In younger pat ien t s, skin
excision s do n ot h ave to be exten ded along th e fu ll length
of th e eyelid to create a crease of desirable length ; a sh orter
in cision design is usu ally su cien t . A less tech n ical bu t
st ill com m on m ist ake is leaving su t u res in for m ore th an
5 days; epith elial t un n els form aroun d sut ures on ly 7 days
after op erat ion . Railroad t rack scars from delayed su t u re
rem oval are u n accept able. Eyelid scars are m ore n ot iceable
Fig. 18.2 Depressed scars from excessive removal of orbicularis
w h en th ey are depressed. Such scars result from exces- muscle. Depression is seen beneath the fold from removal of orbi-
sive rem oval of th e orbicu laris m u scle, con n ect ive t issu e cularis muscle.
(Fig. 18.2), or deep fold (Fig. 18.3).3,4
An eyelid scar revision m u st obey th e w ou n d h eal-
ing prin ciples th at govern all aspect s of surgical care. Th e
operat ion m ust be asept ically possible. Both surgeon an d
in st ru m en t m ust be at rau m at ic w ith respect to th e eyelid
t issues. All layers—n ot just skin —sh ould be approxim ated
w ith as lit tle ten sion as possible.
Excision an d re-approxim at ion of th e skin does n oth -
ing to address scars th at are depressed. Th e m issing layer
of orbicu laris oculi m ust be recon st ructed by un derm in -
ing an d advan cing th e m u scle edges from both u pper an d
low er aps. Su ch un derm in ing is also ben e cial if th e
problem is th at th e skin adjacen t to th e pre-exist ing scar is
inverted. W h en approp riate, u n derm in ing of th e skin aps Fig. 18.3 Depressed crease line from ectropion. The lower ap is
sign i can tly m it igates th e ten sion p laced directly across stretched upward.
th e derm is (Fig. 18.4). Sim p le con t in u ou s su t u re can p lace
diagon al ten sion across th e w oun d. An in terlocking con t in -
u ou s su t u re w ill m ain t ain an even perpen dicular ten sion .
In clu sion cysts resu lt from a p rolonged foreign body
react ion to th e su t u re placed bet w een th e up per an d low er Loss of Fold
skin ap s or from sebaceou s glan d act ivit y. Th ese cyst s
m ay d evelop over w eeks to m on th s after an op erat ion an d All su rgically created eyelid creases at ten u ate du ring th e
sh ould be excised if th ey do n ot resolve sp on t an eou sly rst few m on th s. Th is ch ange m igh t be m in im al, or th e fold
(Fig. 18.5). In clu sion cyst s are best avoid ed by u sing th e m igh t disap p ear altogeth er. Th e degree to w h ich a p ostop -
orbicularis m uscle—n ot th e derm is it self—as th e an ch oring erat ive fold soften s is d eterm in ed by p at ien t ch aracterist ics
point for th e su t u res. an d su rgical tech n iqu e.
18 Managem ent of Double-Eyelid Surgery Com plications 227
Adhesion
Deep Folds or Ectropion
Deep folds an d ect ropion are cau sed by creases th at w ere
xated too h igh on th e eyelid. Th is p laces an u n du e u pw ard
ten sion on th e low er ap an d ever t s th e eyelid m argin . A Fig. 18.6 Correction of a shallow crease. Release the previous
adhesion at the pretarsal area. Since elasticit y is compromised from
pat ien t often com plain s about th e un in ten ded im pres-
brous change and a relapse is common, xate at a higher point
sion of aggression conveyed by th e ever ted eyelids. Th e
than usual.
depressed scar is visible w h en th e eyes are closed. Th e
pat ien t m ay also com plain of a t ugging sen sat ion in th e
eyelids. Th e palp ebral ssu re m ay becom e larger. Th e skin
ju st su perior to th e fold ten ds to bu lge.
High xat ion s in adverten tly in crease th e p alpebral s- Th ere are th ree approach es to correct a low fold. Th e
su re becau se th e levator ap on eu rosis is p licated w h en th e rst is an open blep h aroplast y by w h ich th e skin an d orbi-
low er ap is xed at a h igh p oin t on th e levator apon eu ro- cularis m uscle are excised above th e previous crease. Th e
sis. In case of severe ect rop ion , th e conju n ct iva is exposed . secon d ap p roach is to create a m ech an ically overriding
Th e m ucocut an eous jun ct ion becom es kerat in ized, leading crease above th e previous on e. Th e th ird com bin es soft t is-
to dr y eye syn drom e. su e excision an d m ech an ical xat ion above th e prior crease
Th e rst step in correct ing th e deep fold is to release (Fig. 18.8).4
th e adh esion s an d re-approxim ate th e layers at a low er Th e rst approach (open bleph aroplast y) can in corpo-
poin t along th e eyelid. If th is part of th e operat ion does n ot rate scar revision an d allow s for excision of redun dan t skin
resolve th e ect ropion , th e low er ap m ust be un derm in ed in old er pat ien t s. How ever, th e su rgeon m ust leave en ough
an d redrap ed over th e t arsal p late to d ecrease th e ever t ing eyelid skin to m in im ize th e risk of postbleph aroplast y brow
force of th e ad h esion in th e low er ap. Th e secon d por t ion ptosis. In pat ien ts w ith out sign i can t redun dan cy of eyelid
of th e operat ion is to preven t th e form at ion of t riple folds. skin , excision of th e orbicu laris m u scle above th e old crease
Th e surgeon m ust t ake care n ot to allow re-adh esion by is m ore im port an t th an excision of th e skin . Maxim u m ele-
in t roducing th e orbit al fat in to th e sp ace bet w een th e apo- vat ion of th e eyebrow s sh ou ld resu lt in 80 to 90% elevat ion
n eurosis an d orbicularis m uscle. of the upper eyelid m argin in pat ien t s w ith an appropri-
Deep crease is often accom p an ied by a h igh fold, an d ate am ou n t of skin excised. Th is is an im p or tan t par t of th e
th e operat ion s to correct th ese t w o feat ures are ver y sim i- preoperat ive an d in t raoperat ive guidelin e on est im at ing
lar. Th e on ly sign i can t di eren ce bet w een th e t w o correc- h ow m u ch of th e u p per eyelid skin is redu n dan t .
t ion m eth ods is th at th e locat ion of th e previou s crease is Th e secon d approach (t arsal xat ion ) allow s con sider-
m ain t ain ed in cases of d eep crease w ith ou t h igh fold, th e able elevat ion of th e fold crease bu t w ill create an addit ion al
n ew crease is design ed low er th an th e previou s crease, an d scar, if secon dar y in cision s are n ecessar y. Th is ap p roach
th e skin in bet w een is excised in cases of h igh fold alon e.
Correct ion of deep crease w ill be described again along
w ith correct ion of h igh fold in th e follow ing sect ion .
Low Crease
In a crease th at is too low, ver y lit tle skin w ill sh ow bet w een
th e eyelid m argin an d th e crease. Th is is usu ally a problem
of th e act ual crease design being too low, but a sh allow
fold can som et im es give th e appearan ce of a low crease
(Fig. 18.7). Red u n dan cy of skin can also m ake a crease
ap pear low er th an it really is. Fig. 18.7 Low fold due to a shallow crease.
18 Managem ent of Double-Eyelid Surgery Com plications 229
Soft tissue
Skin and
New line excision
OOM excision
New line
Previous
incision
line
a b c
Fig. 18.8 Methods of raising low fold. (a) The skin and orbicularis oculi m uscle (OOM) are removed around the previous incision line.
(b) A new crease is made above the previous incision line, by a buried suture method or a short incision method. (c) Combination of a and
b methods; excision of soft tissue is performed above the previous incision line.
is m ore ap prop riate for pat ien t s w h o h ave in con spicuous th at failed to address th e m ech an ical et iology beh in d th e
scars from th e rst op erat ion an d w ish for th e eyelid fold ptosis (Fig. 18.9).
to be h igh er. If th e previous fold is st rongly de n ed (i.e., too High creases can be obser ved w ith deep, n orm al, or
d eep ), th en a sim ple m ech an ical xat ion m ay resu lt in m ul- sh allow fold depth s. Th e m ost com m on form is a fold th at is
t iple eyelid folds. To m in im ize such risk, th e low er ap can both high an d deep, w h ich is often accom pan ied by ect ro-
be un derm in ed th rough a sm all in cision w in dow. Th is can pion . At t im es, pat ien t s m igh t h ave folds of var ying depth
sign i can tly at ten u ate th e p rim ar y fold to a fain t ap pear- (e.g., a fold th at is sh allow on th e m edial side but deep over
an ce. Pat ien t s sh ou ld be w arn ed of th e p oten t ial for p ret ar- th e pupils).4
sal fu lln ess from th e scar t issu e after th e in it ial op erat ion .
Th e com bin ed approach of open bleph aroplast y an d
m ech an ical xat ion is reser ved for p at ien ts w ith ver y low
Correction of High Creases
folds an d great redu n dan cy of skin .
Like oth er com plicat ion s, h igh creases sh ould be corrected
according to th e cau se. Gen erally, th e secon dar y op erat ion
High Crease in corporates an op en bleph aroplast y w ith skin excision .
Th e u pper m argin of th is excision is along th e fold th at is
In m any East Asian cu lt u res, h igh eyelid crease is associated to be revised, an d th e low er m argin m arks th e n ew crease
w ith an aggressive or an tagon ist ic person alit y. High creases heigh t . If th e skin lacks redun dan cy an d lagop h th alm os
are u su ally accom pan ied by deep folds, an d p at ien ts com - is expected, skin is n ot resected. Rath er, a low er in cision
plain of u n n at ural appearan ce, depressed scar, an d exces- can be used to u n derm in e th e upper ap an d release th e
sive eversion of th e eyelash es. Pat ien t s m ay also com plain high fold th rough eith er th e pre-apon eurot ic layer or p re-
abou t pretarsal fu lln ess th at h as n ot im proved w ith t im e. sept al layer. Releasing th e fold th rough th e p re-apon eu rot ic
Sligh t bleph aroptosis can be seen in p at ien t s w ith an ad h e- layer m in im izes th e risk of re-adh esion becau se it is in th e
sion bet w een th e skin an d levator ap on eu rosis th at p re- deeper layer. In pat ien t s w ith bleph aroptosis, th is deeper
ven t s recu rsion of th e levator m u scle. dissect ion plan e is a n at ural ch oice, as it allow s th e opera-
tor to access th e levator m ech an ism . For th e sam e reason ,
how ever, th is plan e of dissect ion can injure th e levator
Causes ap on eu rosis an d resu lt in postoperat ive blep h aroptosis. In
con t rast , releasing th rough th e pre-sept al layer m in im izes
High creases can be cau sed by h igh -p osit ion ed skin crease th is risk but is associated w ith in creased risk for t riple fold
design , h igh xat ion , excessive skin excision , un in ten ded form at ion .
adh esion , blep h aroptosis, or su n ken eyelid . Am ong th ese, Deep folds respon d bet ter to dissection of th e upper ap
h igh crease design from th e in it ial operat ion is th e m ost through the deeper plane. How ever, a deep fold m ay rem ain,
com m on . Fixat ion of th e low er ap to a h igh poin t can even w ith adequate release ben eath th e upper ap. In su ch
result in h igh folds w ith ect ropion . Th e problem can also sit uation s, th e low er ap m igh t also con t ribute to fold depth
result from excessive skin resect ion , w h ich leaves in su - an d sh ould be released from th e un derlying tissue. Th e
cien t skin to cover th e crease. Pat ien ts w ith bleph aropto- low er ap should then be xed at the desired height . This
sis ten d to develop h igh folds after an eyelid fold operat ion also addresses th e problem of ect ropion , if presen t .
230 III Blepharoplast y
a b
c d
Fig. 18.9 Causes of high fold. (a) High incision line. (b) High fold from ectropion. (c) High fold from blepharoptosis. (d) High fold from
sunken eyelid.
High creases w ith n eu t ral fold depth can be ad dressed prim ar y an d secon dar y operat ion s, w h ere th e low er crease
by sim ple open bleph aroplast y, as described previou sly. is th e desired crease an d th e h igh er crease reappeared at
Sh allow eyelid folds are corrected in a sim ilar m an n er to th e site of th e in it ial operat ion . Even after com plete adh e-
n eu t ral folds, by op en blep h arop last y. Even w ith a com - siolysis, th e p osterior lam ella can re-adh ere to th e an terior
p lete loss of fold, h ow ever, th e low er ap can st ill h ave lam ella. Th e problem s of t riple folds are so com m on th at it
severe adh esion s an d requ ire ad h esiolysis. If n o su ch adh e- is discussed as a dist in ct topic in a later part of th is ch apter.
sion s are p resen t , th e low er ap sh ou ld h ave en ough laxit y To preven t th ese secon dar y com plicat ion s, th e sur-
to allow adequate xat ion at th e desired h eigh t .1 geon m u st m ain tain su cien t t issu e volu m e, th orough ly
free th e adh ered t issu e p lan es, an d m ake e ort s to p reven t
re-adh esion . To accom plish th ese goals, it is im port an t to
Failures after Correction of High Crease abide by th e follow ing gu idelin es:
Th e t w o m ajor problem s th at occur after h igh fold correc- 1. Resect on ly th e skin an d leave th e scar t issue to
t ion are ect ropion an d m ult iple folds. Failu re rates for h igh rein force th e u pper ap (Fig. 18.10).
fold correct ion can be un accept ably h igh for su rgeon s w h o 2. If the upper ap lacks su cient soft tissue bulk, the
do n ot grasp th e fun dam en tal prin ciple beh in d second- orbital fat along w ith the septum can be lowered
ar y op erat ion s: th at u nw an ted adh esion is th e en em y. Th e to add volum e to the upper ap and also provide
prim ar y reason of failure in revising th e h igh lid crease is a gliding m em brane bet ween the orbicularis oculi
an in com p lete release of th e t issu e arou n d th e old eyelid and the levator aponeurosis. This latter function of
crease. Th e failure m ay also be caused by re-adh esion of th e interposition ap is extrem ely im portant in preventing
t issue th at w as adequ ately freed. re-adhesion of separated elem ents (Fig. 18.11).
In com p lete lysis of adh esion s or re-adh esion m ay resu lt 3. In th e sam e m an n er, th e orbicularis m uscle can be
in ect ropion w ith an eyelid crease th at appears to ch ange u sed as an in terp osit ion ap (Fig. 18.12).
h eigh t w ith m ovem en t . With th e eyes closed, th e crease 4. If th ere is in su cien t orbital fat or orbicu laris
w ill appear low ered, as in ten ded. How ever, th e sam e crease m u scle, a con n ect ive t issu e ap can be elevated for
does n ot appear low ered w h en th e eyes are open because rein forcem en t . Derm ofat graft , fat graft , or m icrofat
th e skin is expan ded an d bun ch ed from th e ever ted eyelid. inject ion deep to th e orbicularis oculi are possible
Mu lt ip le eyelid creases can form after correct ion altern at ive solu t ion s an d are also e ect ive in
of h igh creases. In such post secon dar y bleph aroplast y low ering th e risk of re-adh esion .
pat ien t s, each crease represen ts th e xat ion s perform ed in
18 Managem ent of Double-Eyelid Surgery Com plications 231
a b c
Fig. 18.10 Correction of high fold. (a) Resection of skin down to the newly created lower
crease. Resect only the skin, without resecting any scar tissue. (b) Adhesiolysis at the pre-
aponeurotic layer. (c) Con rm complete adhesiolysis by holding the upper skin ap. If ever-
sion remains, undermine the lower ap. (d) Fixate the lower ap at a lower point and close
d the skin.
a b
8. Excessive skin excision w ill result in th e low er crease Partially High Crease or
being pulled up tow ard th e eyebrow s, result ing in Undesirable Curvature
eversion . To preven t th is, th e low er ap can be xed
by secu ring it to a par t ial purch ase in th e t arsal plate A com m on m ist ake in correct ing a part ially h igh crease is to
during closure. Th is is e ect ive in coun teract ing th e part ially address th e problem . For exam ple, a part ial revi-
upw ard pull from th e t igh t eyelid skin (Fig. 18.15). sion of on ly th e m ed ial side w ill in t rodu ce a kin k to th e cu r-
9. Skin de ciency can be partially o set by un derm ining vat u re of th e crease su ch th at th e ou ter p or t ion w ill ap pear
a 2-m m m argin of skin in the upper ap. h igh er th an th e m edial port ion . Th is could also in t rodu ce a
t riple fold appearan ce along th e m edial side.
Part ially h igh creases sh ould be repaired using th e sam e
prin ciples as h igh crease correct ion : skin excision , lysis of
adh esion s, an d xat ion . Th e n ew crease sh ou ld be allow ed
to p ar t ially overlap th e cou rse of th e p reviou s crease.
Pretarsal Fullness
Com m on ly obser ved w ith h igh creases, pretarsal fulln ess is
also described as “sau sage eyelid” am ong Korean p at ien t s.
It refers to th e u nw an ted soft t issu e p roject ion in th e area
over th e tarsal p late in p ostbleph arop last y eyelids. Preop -
erat ive factors th at p redict pretarsal fu lln ess in clu de th ick
eyelid skin an d orbicularis m uscle. Pat ien t s w ith th ese fea-
t ures sh ou ld receive eyelid folds th at are design ed low er
th an usual to coun teract th is propen sit y.
Pretarsal fulln ess in creases in propor t ion to th e
squ are of th e h eigh t of th e p ret arsal soft t issu e com part-
Fig. 18.15 To prevent eversion in eyelids with de cient skin, x m en t , w h ich im plies th at sm all ch anges in h eigh t can
the lower ap to the tarsal plate by biting through the tarsal plate resu lt in great ch anges in th e volum e of th is com par t m en t
partially during skin closure. (Fig. 18.16). For exam p le, an eyelid crease th at ch anges
h eigh t from 4 to 3 m m w h en open ing th e eye w ill h ave a
volu m e redu ct ion close to 50% (9/16).
18 Managem ent of Double-Eyelid Surgery Com plications 233
a
b
c
Previous
fixation level
New fixation level
a b c
Fig. 18.22 Correction or prevention of triple fold. (a) If the release of the upper ap bet ween the levator aponeurosis and the orbital
septum is not su cient to correct the triple fold, the space bet ween the postorbicularis fascia and the orbital septum should be dissected
extensively and superiorly for additional separation of outer and inner elements. (b) Re-adhesion can be prevented by inferior displace-
ment of well-organized septum and orbital fat bet ween the orbicularis oculi and the levator aponeurosis. (c) The postorbicularis fascia and
muscle are lowered from the previous site of adhesion and anchored to the tarsal plate.
236 III Blepharoplast y
An oth er m eth od to p reven t re-adh esion is to create a w ill en sure th at th e levator m uscle is w ell w ithin the orbital
roll w ith th e skin an d orbicu laris ocu li m u scle of th e u pper rim an d w ill decrease th e w eigh t bu rden on th e m u scle.
ap . Th e m eth od is to pass th e n eedle th rough th e skin Inject ing fat in to th e orbicu laris ocu li m u scle can be
an d orbicu laris ocu li ju st ben eath th e crease, th en th rough e ect ive for a t rip le fold cau sed by an adh esion w ith in a
th e orbicularis oculi an d skin of th e upper ap, creat ing a su p er cial layer. In m ost cases, h ow ever, th is can n ot be rec-
sligh tly bu n ch ed kin d of roll (Fig. 18.13). om m en ded becau se of th e problem w ith surface irregulari-
Postop erat ive blep h aroptosis can coexist w ith m u lt iple t ies. Fat can be injected ben eath th e orbital sept u m if th e
creases. In such cases, early correct ive operat ion for ptosis sept u m can be visu alized by an in cision . Th e graft su r vival
is e ect ive in separat ing th e an terior and posterior layers, rate is relat ively h igh , w ith m in im al risk of surface irregu-
w h ich w ere previously adh ered.5 larit y or lum p form at ion w ith closed eyelid s. It is, h ow ever,
n ot a w idely pract iced tech n ique an d m ay rep resen t a ch al-
lenge in term s of tech n ical kn ow h ow.
Sunken Eyelid/Primary Triple Fold
Su n ken eyelid s occu r from de cien cy of orbit al fat or soft Blepharoptosis
t issue an d rarely from adh esion bet w een super cial an d
deep st ruct ures. For th is reason , prim ar y t riple fold an d In th e im m ediate postop erat ive p eriod, m ild to m oder-
su n ken eyelids can be th ough t of as a single clin ical en t it y. ate blep h aroptosis m ay sim p ly be due to edem a, w h ich
As su ch , t reat m en t for sun ken eyelid is sim ilar to t reat m en t is t ran sien t an d w ill disap pear. If a m oderate to severe
for p rim ar y t rip le fold. bleph aroptosis does n ot recede w ith edem a, th e surgeon
The lost volum e of soft t issue can be replenished by m u st su spect inju r y of th e levator apon eu rosis as a cau se
fat injection , derm ofat graft , or grafting of oth er soft tis- (Fig. 18.25).
su es such as m u scle fascia (Fig. 18.23 an d Fig. 18.24). Fat
inject ion to th e subcutan eous layer or oculi m uscle layer
can create irregularit y in text ure. Microfat inject ion in the
deeper plane bet w een the orbicularis oculi m uscle and the
sept um redu ces th e poten tial for surface irregularit y. How -
ever, inject ing into th e deeper layer h as the poten tial for
levator m uscle injur y, w hich w ould result in bleph aroptosis.
Injection in to the ROOF can also cause blepharoptosis from
the added w eight, although this is usually t ransient . Never-
theless, th e risk of this com plication can be m inim ized by
inject ing the fat just above the periosteum w hile the upper a
eyelid is pulled upw ard and th e eyes are w ide open . This
■ Case Studies
Case 1: Triple Fold and Ptosis
A 49-year-old fem ale h ad u n d ergon e a dou ble fold op era-
t ion 11 years previously, w h ich resu lted in t riple fold of
th e righ t upper eyelid 3 m on th s after th e in it ial operat ion .
Recen tly, th e pat ien t h ad un dergon e u pper bleph aroplast y a
to address th e t rip le fold bu t exp erien ced im m ediate post-
operat ive ptosis w ith persisten t t riple fold an d eccen t ric
crease. On exam in at ion , th e pat ien t w as foun d to h ave a
ptot ic u pper eyelid w ith part ial pupil coverage on th e righ t
side (Fig. 18.26a). Th e di eren ce in MRDs w as 2 m m .
Th e pat ien t con sen ted an d un der w en t an open u pper
bleph aroplast y w ith ptosis correct ion of th e righ t eye. Th e
t riple fold w as addressed as described previously, w ith
adh esiolysis an d in terp osit ion of fat bet w een th e an terior b
an d p osterior lam ellae. A bu lky su bcu tan eou s roll w as cre-
ated w ith th e orbicularis oculi m uscle to in crease fold resis- Fig. 18.26 Case 1. Revision of triple fold and ptosis. (a) A 49-year-
tan ce above th e n ew ly establish ed crease. Th e upper ap old female patient presented with eccentric crease and ptosis of the
right upper eyelid after revision upper blepharoplast y. The patient
w as sp lin ted w ith Du oDERM to preven t inw ard folding of
underwent adhesiolysis and interposition of septal fat bet ween the
th e skin . A postoperat ive ph otograph at 6 m on th dem on - anterior and posterior lamellae. A bulky subcutaneous roll was cre-
st rates resolu t ion of th e t rip le fold w ith acceptable sym - ated with orbicularis oculi muscle to increase fold resistance above
m et r y of th e u p per eyelid m argin s (Fig. 18.26b). the newly established crease. (b) Postoperative photograph at 6
months demonstrates resolution of the triple fold with acceptable
symmetry of upper eyelid margins.
Case 2: Triple Fold and Deep Fold
A 46-year-old fem ale w ith a h istor y of m u lt ip le u p per an d
low er bleph aroplast ies presen ted w ith variou s com plica-
t ion s. Her h istor y is m ost relevan t for th e double-eyelid
operat ion 3 m on th s prior, w ith a h igh crease in th e righ t
eye as th e m ajor com plicat ion . Th e pat ien t un der w en t an
u n successfu l revision , an d presen ted 2 w eeks after w ard.
On exam in at ion , th e righ t eyelid w as n ot able for m u lt ip le
creases an d ptosis. Th e left eyelid fold w as deep an d sh ow ed
a sligh tly ect ropic feat u re (Fig. 18.27a). a
The recom m en dat ion w as to correct th e im m ediate
fu n ct ion al p roblem in th e righ t eyelid an d to address th e
deep fold in th e left eye at a later t im e. Du ring th e in t raop -
erat ive explorat ion of th e righ t lid, th e levator ap on eu ro-
sis w as fou n d n ot to be in con t in u it y w ith th e tarsal plate.
Th e adh esion s respon sible for m ult iple creases w ere lysed,
an d th e m edial sept al fat w as m obilized an d in terp osed
bet w een th e an terior an d posterior layers. Th e upper ap
w as sp lin ted w ith Du oDERM CGF u pon skin closu re. Th e b
outcom e w as sat isfactor y. Th e ptosis w as corrected, an d th e
m ajorit y of ext ran eou s folds did n ot reap p ear. Six m on th s Fig. 18.27 Case 2. Revision of triple fold and deep fold. (a) A
later, th e pat ien t un der w en t a su ccessfu l bleph aroplast y of 46-year-old female patient presented with a high, triple fold with
ptosis in the right eye and deep, slightly ectropic left eyelid after
th e left eyelid, w ith resolut ion of th e deep fold an d ect ro-
multiple upper and lower blepharoplasties. In the right eye, the
pion (Fig. 18.27b). adhesions were lysed and the medial septal fat was mobilized and
interposed bet ween the anterior and posterior layers. Correction
of deep fold and ectropion of the left eye was done 6 months after
right eye surgery. (b) Six-month postoperative view shows resolu-
tion of the preoperative problems.
18 Managem ent of Double-Eyelid Surgery Com plications 239
References
■ Conclusion
1. Kim YW, Park HJ, Kim S. Secondary correction of unsatisfac-
Com plicat ion s after bleph aroplast y are too n um erous an d tory bleph aroplast y: rem oving m ultilam inated septal struc-
varied to allow a com p reh en sive discu ssion w ith in th is t ures and grafting of preaponeurotic fat. Plast Reconstr Surg
ch apter, but th e basic prin ciples of recon st ruct ive surger y 2000;106(6):1399–1404, discussion 1405–1406
are app licable to a m ajorit y of th ese com p licat ion s. Th e 2. Ch en W P. Th e con cept of a glide zon e as it relates to upper
rst p rin cip le is to u n derst an d th e n orm al an d abn orm al lid crease, lid fold, an d ap p licat ion in u p per blep h arop last y.
Plast Recon st r Su rg 2007;119(1):379–386
fu n ct ion an d an atom y of th e eyelid. Th e secon d prin ciple
3. Kim YW, Park HJ, Kim S. Revision of un favorable double
is to u n do, or decon st ru ct , th e postoperat ive t issu e ch anges
eyelid operat ion by reposit ion ing of preapon eurot ic fat . J
causing th e com plicat ion . Th e th ird prin ciple is to redo th e
Korean Soc Plast Recon st r Su rg 2000;27(2):99–104
in it ial op erat ion w ith out m aking th e sam e m ist ake.
4. Ch o IC. Th e Art of Bleph aroplast y. Seou l, South Korea:
Koonja Pu blish ing; 2013:84–124
5. Lew DH, Kang JH, Ch o IC. Surgical correct ion of m ult iple
u pper eyelid folds in East Asian s. Plast Recon st r Surg
2011;127(3):1323–1331
6. Ch ang SH, Ch en W P, Ch o IC, Ah n TJ. Com preh en sive review
of Asian cosm et ic upper eyelid oculoplast ic surger y: Asian
bleph aroplast y an d th e like. Arch Aesth et ic Plast Surg
2014;20(3):129–139
IV
Facial Bone Surgery
19 Zygoma Reduction
Sanghoon Park and Jihyuck Lee
Pearls
• The aim of zygom a reduction is to reduce the w idth con sidered. Cau t ion sh ou ld be taken for pat ient s
of the cheekbone, thus changing the boxy at facial w ith a long face, as th ere is a risk for th e face to
shape into a three-dim ensional contour and achieving ap pear longer after th e su rger y.
a sm ooth, fem inine facial line. • Reduct ion m alarplast y can be perform ed solely or in
• Bizygom at ic w idth an d volu m e an d th e posit ion com bin at ion w ith m an dible reduct ion , gen ioplast y,
of th e zygom at ic body are th e key variables to be or foreh ead augm en tat ion .
evaluated, an d th e am ou n t of body ostectom y is • Soft t issu e p lays a great role in redu ct ion
determ in ed during th e surger y. m alarp last y. In p at ien ts w ith abu n dan t ch eek fat , th e
• Th e zygom at ic body an d arch are usually m oved slim m ing e ect is less obviou s an d ch eek drooping
m edially, posteriorly, an d som et im es su periorly is m ore probable.
during th e surger y; th e poin t of m axim al m alar • Th e follow ing ve factors are con sidered h igh risk
project ion is m arked an d it s n ew posit ion carefu lly for skin an d soft t issue sagging: (1) over 40 years of
plan n ed. age, (2) abu n dan t ch eek fat , (3) th in skin an d skin
• In zygom a red u ct ion overall facial sh ap e, in clu ding laxit y, (4) class II m an dible or ill-de n ed m an dible
m an dible p rom in en ce an d facial h eigh t , sh ou ld be n eck line, (5) deep n asolabial fold or jow l.
243
244 IV Facial Bone Surgery
■ Patient Evaluation
Direct physical exam in at ion is th e key p rocess to evalu -
ate th e pat ien t’s problem s an d establish a surgical p lan .
Clin ical ph otos are n ecessar y, as is radiologic exam in at ion
in cluding fron t al view, lateral view, subm en tover tex view,
an d Waters’ view. A com p u ted tom ograp hy (CT) scan w ith
3D view is also essen t ial to evaluate th e sh ape of th e zygo-
m at ic com plex.
Th e volum e an d posit ion of th e zygom at ic body, an d
a b th e bizygom at ic w idth are key variables to be con sidered.
Th e volum e of th e zygom at ic body determ in es th e am oun t
Fig. 19.1 Bony facial morphology at the level of the cheekbone
in axial section. Compare the (a) dolicocephalic Caucasian face and of ostectom y requ ired during th e su rger y. If th e volum e is
the (b) brachycephalic Asian face. large, a w ider resect ion of th e zygom at ic body sh ou ld be
plan n ed. How ever, over-zealous reduct ion results in a at
or de cien t look. Th erefore, keeping an adequ ate volum e of
th e zygom at ic body in th e an tero-posterior dim en sion an d
t ran sverse plan e is essen t ial.
Th e posit ion of th e zygom at ic body is m easured both at
2. Ch ange a boxy at facial sh ape in to a th ree- it s m ost lateral m argin and in it s m axim al project ion . Th e
dim en sion al con tour. Even if facial w idth is reduced, outer m argin of th e zygom at ic body is obser ved in conjun c-
th e face can st ill appear squ are.1 Asian faces h ave t ion w ith tem ple an d ch eek. To n arrow th e an terior m id-
a brachyfacial ch aracterist ic w ith a at su borbit al facial w id th , th e lateral m argin of th e ch eekbon e sh ou ld
area. W h en view ed from below, th e lack of m alar
project ion result s in th e suborbit al area an d
zygom at ic arch form ing a 90-degree angle th at len ds
a boxy app earan ce. In th is case, th e face ap p ears
at an d t w o-dim en sion al, an d even w ider th an it
ap pears from th e fron t . Th erefore, ch anges in th e
sh ape an d p osit ion of th e zygom at ic body are n eeded
to create a m idface fu lln ess th at ap pears m ore th ree-
dim en sion al an d youth ful.
3. At t ain a sm ooth facial lin e th at looks m ore fem in in e
an d you ng. An angu lar face lin e n eeds to be m ade
soft . In th e case w h ere th e ch eekbon es prot ru de
out w ardly, th e facial lin e con n ect ing th e tem ple-
zygom a-ch eek-m an dible angle con st it u tes a ver y
convoluted lin e (Fig. 19.2). In th e case of Western ers,
prom in en ce of th e zygom at ic body is a sym bol of
beaut y an d you th fuln ess. How ever, for Asian s this
prom in en ce result s in an obst in ate an d m asculin e
look, w h ich gives a n egat ive im pression . High
ch eekbon es are n ot an ideal look in Asian cu lt ures;
th erefore, reduct ion is n eeded to m ake th e face soft
an d fem in in e. For th ose over th e age of 35, facial
soft t issu e decreases an d skin start s to droop ; m alar
em in en ce looks even m ore pron ou n ced an d cau ses
grooves in th e ch eek an d tem ple, gradu ally resu lt ing Fig. 19.2 Anterior and posterior facial contour lines. The anterior
in a t ired an d aged look. Fat inject ion s to su ch h ollow facial contour line connects the temple, zygomatic body, cheek,
and mandible body (red line), while the posterior facial contour line
areas can be an easy opt ion , bu t th e resu lt is n ot
connects the temple, zygomatic arch, m andible angle, and chin
predict able or perm an en t . Zygom at ic reduct ion is a
(blue line). If the anterior contour line is too convoluted, the patient
good opt ion for th e m idd le-aged w om an w h o desires gives a “strong,” “o ensive,” “old,” “tired,” “m asculine” impression.
a you th fu l, soft , an d fem in in e facial con tou r. The posterior contour line re ects the facial width and facial size.
19 Zygom a Reduction 245
be t rim m ed or m oved inw ard. If th e outer m argin of th e On ce th e su rgical variables for th e zygom at ic body are
ch eekbon e is placed w ide, th e am oun t of n arrow ing an d evaluated, th e bizygom at ic w idth is m easured, an d th e
m edializat ion sh ou ld be m axim ized an d ostectom y sh ou ld requ ired am ou n t of arch m edializat ion , w h ich is crit ical in
be com bin ed. th e reduct ion of posterior facial w idth , sh ould be decided.
The poin t of m axim al m alar project ion (MMP) is the Th e posterior basal por t ion of th e arch , w h ich is posterior
point w here the outer contour of the zygom atic com plex to th e osteotom y, can n ot be m edialized an d sh ou ld be care-
prot rudes m ost in the basal three-quarters view. If the fu lly sh aved to p reven t visible step . Too m u ch arch redu c-
reduction of th e zygom atic body is perform ed by sh aving, or t ion w ith th e rem ain ing zygom at ic body w ill resu lt in a at ,
the osteotom y is placed lateral to the MMP, this point stays boxy face. To avoid th is outcom e an d create a full m idface
u n ch anged w h ile th e outer m argin of th e zygom at ic body con tour, th e redu ct ion of th e zygom at ic body an d arch
is n arrow ed, result ing in an unn at u ral, box-sh aped cheek- sh ou ld be coordin ated an d balan ced.
bone. As stated before, the purpose of reduction m alar- Th ere are m any variables th at n eed con siderat ion dur-
plast y is not resection of th e projection ; therefore, adequate ing surger y, an d th ese sh ould be decided by th e above-
projection and posit ion of the MMP is the key postopera- m en t ion ed evalu at ion . Variables of th e zygom at ic body are
t ive result. The point of MMP is m arked and the surgeon (1) am oun t of ostectom y, (2) am oun t of m edializat ion , (3)
decides w here to m ove this point three-dim ension ally. The am ou n t of setback, an d (4) su p erior or in ferior posit ion -
am oun ts of m edial reposition ing an d ostectom y are closely ing. Variables of th e zygom at ic arch are th e am oun t of arch
related to th e reduct ion of anterior facial w idth . m edializat ion an d th e sh aving qu an t it y of th e p osterior
Th e ideal posit ion of th e MMP m ay var y am ong dif- area of th e ar t icu lar t u bercle.
feren t eth n icit ies; h ow ever, th e follow ing are t w o sim p le Facial soft t issu e is an im port an t aesth et ic com pon en t
m eth ods of determ in ing th e ideal posit ion of th e MMP in zygom a redu ct ion an d sh ou ld be con sid ered before an d
(Fig. 19.3). during th e surger y. If th e pat ien t h as th in fair skin w ith
m in im al ch eek fat , th e ch anges after bon e su rger y w ill be
1. Hinderer analysis. Th e MMP is determ in ed at th e
obvious an d th e ch an ce of soft t issu e drooping is m in im al.
p oin t of in tersect ion of t w o lin es, w h ere th e rst
Th is pat ien t is a good can didate for zygom a reduct ion .
lin e con n ect s th e lateral can th u s an d th e oral
How ever, bony step , especially arou n d th e orbit , m ay be
com m issure, an d th e secon d lin e con n ect s th e n asal
visible an d th e p late m ay be palp able th rough th e th in skin .
alar base an d th e t ragu s lin e. Th e n ew locat ion is a
Su rgeon s sh ou ld t ake ext ra e or t to en su re a sm ooth t ran -
p oin t p laced in ju xt ap osit ion to th e crossed lin es in
sit ion bet w een bony osteotom y. If th e p at ien t h as abu n -
th e upper outer quadran t .2
dan t ch eek soft t issu e, or th ick skin , th ere is a h igh risk of
2. W ilk inson analysis. A lin e is d rop p ed vert ically ch eek drooping. Th e pat ien t sh ould be in form ed about th e
d ow nw ard from th e lateral can th u s to th e in ferior possibilit y of ch eek drooping an d appropriate adjun ct ive
border of th e m an dible. Th e MMP is located at on e- m easu res, in clu d ing liposu ct ion or lift ing p rocedu res. If th e
th ird th e dist an ce from th e lateral can th us to th e pat ien t h as a th ick m alar fat pad, th e zygom at ic body sh ould
angle of th e m an dible.3 be sligh tly over-corrected to preven t un der-correct ion .
a b
Fig. 19.3 Determ ining the ideal position of the maximal malar projection (MMP). (a) Hinderer analysis. (b) Wilkinson analysis.
246 IV Facial Bone Surgery
the zygom at ico-m axillar y but t ress. Great at tent ion m ust be
paid to avoid injur y to the orbital contents or infraorbital
ner ve. A second, parallel lin e is draw n lateral to the rst line
to represen t th e st rip of bon e to be resected, allow ing in set
of th e fragm ent .12 The distan ce of the second lin e from th e
rst lin e depen ds on th e patien t’s preferen ce an d th e w idth
of the zygom at ic body. A w ider parallel osteotom y can be
m ade for greater reduction ; h ow ever, th e usual w idth of th e
strip at th e au th ors’ h ospital is ~ 3 to 5 m m . Th e sh ort lim b
of the osteotom y m ust be high enough to avoid th e den tal
roots. Carefu l dissect ion is required in the zygom at ic-pter y-
goid space to preven t inju r y to th e vessel, w h ich m ay lead to
profuse bleeding and postoperat ive bruising.
Mu lt ip le ret ractors are p laced an d th e cu ts are m ade
w ith a reciprocat ing saw st ar t ing from th e su perior lateral
Fig. 19.5 Design of bone cuts in malar reduction. An inverted lim b of th e osteotom y. Superior m edial lim b an d n ally
L-shaped osteotomy line is marked over the malar eminence. A sec- in ferior t ran sverse cut s are m ade, an d th e in ter ven ing bon e
ond, parallel line is drawn lateral to the rst line to represent the fragm en t is rem oved .
strip of bone to be resected. A posterior bone cut is made ~ 2 to 3
cm anterior to the tragus.
Posterior Osteotomy
Up on exp osin g t h e p oster ior p ar t of t h e zygom at ic arch ,
As th e in t raoral approach is th e m ost w idely used t h e cou rse of t h e fron t al bran ch of t h e facial n e r ve an d
m eth od th ese days, zygom a redu ct ion via th e in t raoral t h e zygom at ic arch is m arked on t h e skin . A ~ 1-cm ve r t i-
ap proach w ith an L-sh ap ed osteotom y is th e m ost p re- cal in cision is m ad e w it h in t h e sid ebu r n ,12 2 to 3 cm an te-
ferred m eth od to correct facial im balan ce in pat ien t s w ith r ior to t h e t ragu s. Th is in cision sh ou ld lie p oster ior to t h e
prom in en t zygom at ic body and arch . cou rse of t h e n er ve. Th e arch is id en t i ed after t h e d is-
sect ion of t h e p er iosteu m , an d n e elevators are p assed
over t h e top an d beh in d t h e arch an d as far p oster iorly as
Anesthesia and Approach p ossible to en su re t h at t h e oste otom y is st ill an te r ior to
t h e tem p orom an d ibu lar join t . A recip rocat in g saw is u sed
All patien ts are given gen eral an esth esia. Orotrach eal in t u- to m ake t h is ver t ical oste otom y. W h en t h e p oste r ior oste-
bation is preferred at the auth ors’ hospital, but nasotracheal otom y is com p leted , t h e zygom at ic segm e n t sh ou ld be
int ubation can be used. A ~ 3-cm labiobuccal vestibular inci- fre e to m ove w h ile rem ain in g at t ach ed to t h e m asseter.
sion is m ade on each side of th e m axilla.7 Th rough th is in ci- Ad d it ion al bon e d ist al to t h e osteotom y m ay be bu r re d if
sion , th e soft t issues are elevated su periorly an d laterally at n ecessar y.12
the subperiosteal plane. Dissect ion is lim ited to the area of
the zygom at ic body, th e anterior w all of the m axillar y sinus,
an d th e lateral an d in ferior orbital rim . As th e dissect ion Fixation
exten ds superolaterally over th e m alar em in en ce, a portion
of the origin of the zygom at ic m ajor an d zygom at ic-cuta- Th e osteotom ized body an d arch are posit ion ed posteriorly
neou s ligam ents m ay be partially divided from the bony an d m edially as a resu lt of th e osteotom y, an d th e in ter ven -
su rface. ing segm en t is rem oved. According to the pat ien t’s desired
outcom e an d preoperat ive plan n ing, th e th ree-dim en sion al
locat ion of th e segm en t is determ in ed w h ile good con t act
Anterior Osteotomy of bony surfaces is m ain t ain ed. Six-h ole m in iplates w ith
screw s are placed to x th e an terior port ion of th e segm en t ,
An inverted L-sh aped osteotom y lin e is m arked over th e an d t w o- or th ree-h ole m in ip lates w ith screw s are u sed to
m alar em in en ce (Fig. 19.5). Th is lin e gen erally exten ds x th e zygom at ic arch (Fig. 19.6). Posit ion ing of th e osteot-
m edially from th e lateral border of th e orbital rim to just om ized segm en t is th e m ost crit ical step for postoperat ive
below the in fraorbital foram en. Be careful not to start the resu lt s, an d th e n al segm en t posit ion is adjusted based on
osteotom y too low from w here the arch changes from a pre-exist ing asym m et r y an d in t raoperat ive appearan ce to
vert ical to a h orizon tal direct ion , w h ich m ay result in in suf- ach ieve th e desired n al ou tcom e. An id en t ical p rocedu re
cien t volum e reduct ion in th e zygom atic body. Th e sh ort is th en p erform ed on th e con t ralateral side. Stan dard tech -
lim b of the osteotom y th en t urns at about a 90° angle tow ard niqu es are used to close th e in t raoral an d skin in cision s.
248 IV Facial Bone Surgery
Fixation Nonunion
Alth ough xat ion m ay n ot be essen t ial in m alar red u ct ion Nonunion is a source of under-correction and cheek drooping,
u sing th e in -fract u re m eth od, rigid xat ion is n ecessar y and is one of the reasons for unidenti ed pain in long-term
w h en on e or m ore osteotom ies are con ducted. On ly rigid follow -up. Though radiology can reveal breakage of xation
xat ion to both th e zygom at ic body an d arch can gu aran - m aterial and separation of bony segm ents, exam inations m ay
tee precise reposit ion ing an d st abilit y. If rigid xat ion is at tim es be unable to detect de nite signs of m alunion. Partial
n ot u sed after osteotom y, u n der-correct ion , asym m et r y, or separation of bone, especially in the supero-lateral position
relapse after surger y can occu r. It is a seriou s sh or tcom ing of the orbital rim , is often found but is not considered non -
th at surgeon s are un able to con t rol th e exact degree an d union if one-third of the bone is healed in continuit y. Possible
posit ion of m ovem en t , especially in th e eld of aesth et ic causes of nonunion are excessive resection of bone, unstable
su rger y. Rigid xat ion is also crit ical to preven t n on u n ion xation, excessive m ovem ent (e.g., w hen chew ing), m uscle
an d p ostop erat ive p ain . pull, and traum a in the im m ediate postoperative period. Con-
As th e m asseter m uscle fun ct ion s as a depressor an d servative treatm ent can be tried initially to relieve pain and
a m edial rot ator for th e zygom at ic segm en t after oste- cam ou age soft tissue depression. Soft tissue depression can
otom y, th ree-p oin t xat ion is n ecessar y for th e zygom at ic be corrected w ith fat injections, although frequent relapse
body, orbital rim an d zygom at ic arch to preven t th ree- can occur. In cases of repeated relapse after fat injection,
dim en sion al rot at ion . How ever, xat ion in th e orbit al rim onlay Medpor (Stryker) insertion to create continuit y over
requ ires addit ion al in cision . To avoid addit ion al in cision the gap is an option. Indications for m ajor surgery include a
an d xat ion in th e orbit al rim , th e au th ors recom m en d severe recurrent pain, and aesthetic problem s such as obvi-
u sing dou ble-squ are m idplate in th e zygom at ic com plex as ous bony gap, asym m etry, and sagging of the m alar com plex.
a ver y sim p le an d easy m eth od to p reven t rot at ion w h ile Repositioning of the zygom a com plex is ideal, though very
m in im izing th e in cision s. di cult if bone loss is extensive, and additional bone graft or
alloplastic m aterial m ay be necessary.
■ Complications and
Infraorbital Nerve Injury and
Their Management Paresthesia
Sagging of Soft Tissue Du ring zygom at ic redu ct ion , inju ries to th e orbit , orbit al
con ten ts, in fraorbit al n er ve, an d tem poral bon e are possi-
As re d u ct ion m alar p last y involves re d u ct ion of bon e as
ble. To preven t injur y to th ese st ru ct ures, th e surgeon m u st
w ell as t ran sp osit ion , saggin g of soft t issu e m igh t be
be carefu l and acutely aw are at all t im es regarding th e loca-
in evit able an d n e e d s to b e ad d resse d d u r in g t h e p ro -
t ion of th e saw.12 Excessive pull by ret ractors are a com -
ce d u re. Previou sly, an in fe r iorly p osit ion e d zygom at ic
m on sou rce of paresth esia after su rger y. Plate an d screw s
com p lex or m obile bon e segm e n t w as a m ajor cau se of
m ay cau se th e paresth esia if th ey are placed too close to th e
soft t issu e saggin g. Th is com p licat ion can be p reve n t e d
in fraorbit al foram en .
by r igid xat ion .
Wid e dissect ion an d excess soft t issu e are poten t ial
reason s for sagging of soft t issue. Min im izing th e dissect ion Trismus
an d preser ving th e origin of th e m asseter m u scle in th e
zygom at ic body can m in im ize unw an ted soft t issue prob - Com pression of th e tem poralis m u scle due to inw ard
lem s. Th e st at us of soft t issue also plays a role in soft t issue m ovem en t of th e zygom at ic arch can cau se t rism u s. It w ill
sagging. High -risk factors for skin an d soft t issu e sagging im prove w ith in 1 to 2 m on th s after surger y, an d m outh
in clu de (1) age over 40 years, (2) abun dan t ch eek fat , (3) open ing exercises are h elpful to relieve th ose sym ptom s.
th in skin an d skin laxit y, (4) class II m an dible or ill-de n ed
m an dible n eck lin e, an d (5) p red isp osing deep n asolabial
fold or jow l. In th ese h igh -risk groups of p at ien t s, p reopera- Asymmetry
t ive explan at ion s about th e possibilit y of ch eek drooping
are n ecessar y, an d sp ecial at ten t ion sh ou ld be paid before As m ost pat ien ts w h o com plain of asym m et r y postopera-
an d du ring th e p rocedu re to t r y to overcom e th is com p lica- t ively already h ad asym m et r y prior to surger y, a careful
t ion . Midface lift , th read lift , buccal fat rem oval, an d para- an d th orough p reop erat ive exam in at ion is crit ical, follow ed
n asal augm en t at ion are h elpfu l adju n ct ive p rocedures an d by com m u n icat ion regarding th e possibilit y of asym m et r y
can be com bin ed or perform ed separately. an d lim itat ion s of su rger y.
250 IV Facial Bone Surgery
Under-correction
■ Case Studies
From th e pat ien t’s aesth et ic poin t of view, th e m ost com -
m on com p lain t after zygom at ic redu ct ion is u n der-cor- Case 1: Zygoma Reduction
rect ion . In adequate reduct ion of th e zygom at ic body or
in ap propriate posit ion ing of th e m axim u m m alar pro- A 32-year-old w om an com plain ed of p rom in en t zygom a
ject ion is a com m on cau se for dissat isfact ion . Th erefore, an d w ide m idface (Fig. 19.7). An inverted L-sh aped ostec-
proper pat ien t select ion is required an d pat ien ts’ expect a- tom y w ith a 5-m m redu ct ion of each zygom a w as con du cted
t ion s sh ould be realist ically addressed an d adjusted. to redu ce th e p rot ru sion of h er zygom a. Th e p osterior p ar t
of th e zygom at ic arch w as divided w ith com plete ostec-
tom y. After th e osteotom ized zygom a w as sh ifted m edially
(5 m m ) an d posteriorly (3 m m ), it w as xed w ith m in i-
plates an d screw s. Th e body of th e zygom a w as xed w ith a
double-bridged plate to provide st abilit y again st th e torque
from th e m asseter m u scle. Th e arch of th e zygom a w as
xed w ith a p re-ben ding p late to ach ieve an accu rate p osi-
t ion as w ell as st abilit y (Fig. 19.8). Th e m alar p rom in en ce
an d m idfacial w idth w ere redu ced m arkedly at 12 m on th s
postoperat ively (Fig. 19.9).
a b
Fig. 19.8 Case 1. (a) Preoperative and (b) postoperative radiographic showing posteromedial repositioning of the zygoma.
Case 2: Combined Zygoma Reduction (Fig. 19.11). After com p lete ostectom y w as app lied to th e
an terior an d posterior p ar t of th e zygom a, th e zygom a
and Mandible Contouring w as rep osit ion ed p osteriorly an d m edially. Narrow ing
gen iop last y an d con com itan t m an dible con tou ring su rger y
A 28-year-old w om an com plain ed of m alar prot ru sion an d w ere p erform ed to correct h er squ are low er face. Fou r teen
prom in en t m an dibular angle (Fig. 19.10). Sh e u n der w en t m on th s after th e op erat ion , th e p at ien t’s facial con tou r
redu ct ion m alarplast y an d m an dible con touring su rger y ap pears soft an d slen d er (Fig. 19.12).
a b c
Fig. 19.10 Case 2. Preoperative (a) frontal, (b) oblique, and (c) basal photographs. Zygoma reduction and mandible narrowing surgery
were done simultaneously.
a b
Fig. 19.11 Case 2. Three-dimensional CT images: (a) preoperative and (b) 8 months postoperative
19 Zygom a Reduction 253
a b c
Pearls
• “Angle reduct ion ” is th e old n am e for th is procedure • Th e in ferior alveolar n er ve is th e m ost im port an t
an d rep resen t s a m ajor m iscon cept ion regard ing st ru ct u re d u ring m an dible redu ct ion , an d it sh ou ld
w h at th e su rger y is for. Th e pu rpose of m an dible be carefu lly exam in ed preoperat ively in pan oram ic
redu ct ion is to m ake th e low er face appear slim in view as w ell as in a com p u ted tom ograp hy (CT)
th e fron tal view an d to ach ieve a sm ooth con tour in scan . It is t yp ically located at least 20 m m aw ay from
th e lateral view. Ch anging th e m an dibu lar plan e an d th e upper border of th e m an dible, w h ich sh ould be
con touring th e w h ole low er border of th e m an dible kept in m in d w h en design ing an d con du ct ing th e
are crit ical step s. On th e oth er h an d, angle red u ct ion osteotom y. Th e m ost com m on cause of paresth esia
w ith rem oval of t riangular bon e w ill in evit ably leave is n ot a direct cut bu t a blu n t inju r y to th e n er ve
an u n n at u ral low er con tou r of m an dible w ith a by ret ractors com ing out of th e m en tal foram en .
secon dar y angle. Osteotom y sh ou ld be con du cted at least 3 m m aw ay
• Becau se sh ap ing th e lateral con tour of th e m an dible from th e m en tal foram en .
alon e m ay resu lt in m in im al im p rovem en t in th e • Th e in cid en ce of m ajor in t raop erat ive h em or rh age
fron t al view, su rgical tech n iqu es to red u ce th e w idth h as d ecreased d u e to advan ces in su rgical
of th e low er face via bu rring or ostectom y of th e tech n iqu e an d t h e u se of a hyp oten sive an est h et ic
lateral cortex sh ou ld u su ally also be don e. p rotocol. If t h e ret rom an d ibu lar vein or t h e
• Th e ch in plays an im port an t role in creat ing a facial ar ter y is tor n d u r in g a p roced u re, ad equ ate
beaut iful facial lin e an d overall con tour; th erefore, h em ost asis w it h elect rocau ter y m ay n ot be
gen iop last y sh ou ld be con sidered in con t in u it y w ith easy, an d t h is m ay lead to excessive blood loss.
m an dible redu ct ion . Ap p licat ion of h em ost at ic su bst an ces an d exter n al
• Th e relat ion sh ip bet w een th e m axilla an d th e m an u al com p ression for m ore t h an 30 m in u tes can
m an dible in p ro le view sh ou ld be obser ved. In h elp to stop t h e bleed in g.
class II, or class III pro le, orthogn ath ic surger y • Follow ing th e com plet ion of surger y, th e soft t issu es
is rst con sidered. How ever, in pat ien t s w ith of th e ch eek an d th e n eck sh ould be ch ecked for any
m ild deform it y, or in pat ien t s w h o do n ot w an t sign s of bleed ing or sw elling. Any sign of sw elling or
or th ogn ath ic su rger y, m an dible reduct ion sh ould bleeding n ear th e th roat is a serious com plicat ion
be plan n ed to preven t th e exist ing problem s from an d sh ou ld be t reated im m ed iately as it m ay cau se
deteriorat ing. breath ing problem s.
254
20 Mandible Reduction 255
a b c
Fig. 20.1 Mandible reduction surgery has evolved from (a) simple resection of the angular portion to (b) contouring of the total man-
dible shape as the desire for a slim and small face has increased. Recently, (c) narrowing genioplast y was introduced to achieve a slim and
oval-shaped jaw using the conventional surgical method.
256 IV Facial Bone Surgery
Fig. 20.2 The shapes of the lower face in the frontal view are diverse. Because the chin should be designed based on the individual
patient’s preference, this classi cation system helps patients to compare the shapes of the chin and consult with the surgeon in detail.
sh ow m ild to m oderate in crease in bigon ial dist an ce du e to be iden t i ed. Th e ideal gon ial angle is w ith in th e range of
lateral aring of the m an dible angle. How ever, th e rem ain - 105 to 115 degrees, an d th e MP-SN angle is 30 to 40 degrees.
ing th ird sh ow s tot al m an dibu lar hyper t rophy an d accen t u- After m easu ring an d u n derst an ding th e accu rate balan ce of
ated square con tour of th e w h ole low er face. th e upper an d m idface, th e am ou n t of reduct ion , length en -
Th e sh ape an d w idth of th e low er face in th e fron t al ing, an d ver t ical/h orizon tal advan cem en t or ret rusion (set-
view can be classi ed as in Fig. 20.2. Th e p ro le as w ell as back) of th e m an dible in th e an terior-posterior direct ion
th e h eigh t of th e ch in sh ould be t aken in to con siderat ion . w ill be determ in ed.
Th e stat us of soft t issue in cluding m uscle an d fat sh ould be
con sidered as w ell.
Transverse Plane
Frontal Plane
Using th e PA cep h alogram an d 3D CT, th e degree of p ro-
t rusion or aring of th e m an dible angle, sym m et r y, con -
vexit y of th e body, deviat ion , an d sh ap e of th e ch in sh ou ld
be exam in ed. Th e am oun t of n arrow ing an d lateralizat ion
(con sidering th e degree of asym m et r y), an d th e am ou n t
of angle an d in ferior border resect ion are determ in ed
after ch ecking th e cou rse of th e in ferior alveolar n er ve. A
pan oram ic view is h elpful in determ in ing th e am oun t of
ostectom y of th e m an dibular angle an d body, as w ell as th e
posit ion of its ostectom y lin e.
Sagittal Plane
Fig. 20.3 Analysis of the transverse plane. The exact region and
Using th e lateral ceph alogram , th e gon ial angle, th e m an - amount of sagit tal resection can be determined by thorough eval-
dibular plan e–sellar n asion angle (MP-SN angle), an d th e uation of the angle of divergence and convexit y of the mandible
ver t ical an d an terior-p osterior p osit ion of th e ch in sh ou ld from this view.
20 Mandible Reduction 257
a b
Fig. 20.4 Types of ostectomy for m andible reduction. (a) Curved ostectomy with an oscillating saw. (b) Tangential ostectomy with a
reciprocating saw (lateral cortex ostectomy).
20 Mandible Reduction 259
a b c
d e
Fig. 20.5 Operative procedures. (a) The incision line is designed. (b) Subperiosteal elevation with periosteal elevator. The lateral aspect
of the mandibular body is exposed. (c) The desired level of the osteotomy line is marked on the bone with a marking pencil. The marked
line is checked by using dental mirrors. (d) A long curved ostectomy is performed. A 110-degree oscillating saw is used for the ostectomy.
(e) Dividing the at tachment of muscle to the medial part of the mandible. A large elevator or Bovie electrocautery is used to divide any
remaining medial pterygoid muscle bers from the medial surface of the osteotomized segment.
oral cavit y an d th e teeth are brush ed w ith dilute 5. Using a specialized angle ret ractor, th e m an dibular
aqu eou s bet adin e solu t ion . Th e op erat ive eld is angle is h ooked, an d th e desired level of th e
d raped to assist w ith in t raoperat ive evalu at ion of osteotom y lin e is m arked on th e bon e w ith a
sym m et r y. Su rger y is p erform ed in th e in t raoral area m arking p en cil. Th e m arked lin e is th en ch ecked
in a dark eld; h en ce, w earing a h eadligh t is h elpful w ith den tal m irrors.
in perform ing th e surgical p rocedu re. 6. Usually, a long curved ostectomy is perform ed. A
3. A rubber open er is placed bet w een th e upper an d 110-degree oscillating saw is used for the ostectomy.
th e low er teeth . Th e in cision lin e is design ed using a We use a set of oscillating saws of di erent lengths.
gen t ian violet solu t ion . A bu ccal vest ibu lar in cision If the ostectomy is done w ith full thickness, the bone
d esign is m ade from th e ram us exten ding an teriorly segm ent m oves freely. When patients request angle
to th e rst m olar or secon d prem olar w h ile leaving reduction, the authors em ploy the curved ostectomy
a 7- to 8-m m m u cosal cu . Th is m u cosal cu h elps technique, and for a V-line face, a long curved ostectomy
to close th e sut ure in an easy m an n er. Th e operat ive technique w ith narrow ing genioplasty is perform ed.
eld is in lt rated w ith 0.25% lidocain e w ith 7. After th e ostectom y, th e at t ach m en t of m uscle to th e
1:200,000 dilu ted epin eph rin e solut ion . m edial p art of th e m an d ible u su ally rem ain s. A large
4. Th rough a subperiosteal elevat ion w ith th e elevator or Bovie elect rocauter y is used to divide
p eriosteal elevator, th e lateral aspect of th e any rem ain ing m edial pter ygoid m u scle bers from
m an dibu lar body is exp osed. Th e d issect ion th e m edial su rface of th e osteotom ized segm en t ,
con t in ues superiorly along th e vert ical ram us allow ing it s rem oval.
to adequately expose th e area of resect ion . Th e 8. Fin ally, a h igh -speed bur is used to rem ove any
m asseter bers are st ripp ed from th e low er border addit ion al bon e from th e lateral cor tex an d to m ake
of th e body, angle, an d posterior border of th e ram u s a sm ooth t ran sit ion . Th is p rocedu re preven t s th e
w ith an angle st ripper to secure a good operat ive ch an ce of secon dar y angle.
eld. Su bp eriosteal dissect ion p reven ts bleeding 9. An iden t ical procedu re is perform ed on th e
from th e m asseter m u scle. Du ring th e dissect ion th e con t ralateral side. Here any preoperat ive asym m et r y
m en t al n er ve, th e m argin al m an dibu lar bran ch of in th e degree of angle prom in en ce sh ou ld be t aken
th e facial n er ve, th e ret rom an dibular vein , an d th e in to accoun t an d a relat ively greater or lesser am ou n t
facial arter y sh ou ld be p rotected. of m an dibular bon e resected.
260 IV Facial Bone Surgery
10. Th e bilateral w oun ds are irrigated by salin e an d determ in ed preoperat ively, depen ding on the w idth of ch in
h em ostasis secu red. Th e w ou n ds are closed in an d th e pat ien t’s desire. Th e t w o segm en t s are app roxi-
t w o layers (periosteu m an d m ucosa) w ith a 4–0 m ated cen t rally an d xed w ith m icrop lates an d screw s.
absorbable su t u re. Bilateral su ct ion d rain s are left in Advan cem en t of th e t w o segm en t s is also possible if cor-
p lace overn igh t . Com p ression w ith a facial ban dage rect ion of th e pro le is required. Th e resect ion of th e cen -
is u sed . t ral st rip ranges from 6 to 12 m m .
b
Fig. 20.8 Case 1. Bone fragments resected by ostectomy.
Fig. 20.9 Case 1. Cephalograms (a) before and (b) after the surgery.
20 Mandible Reduction 263
a b
a b
c d
Fig. 20.15 Case 3. Three-dimensional CT scans (a,b) before and (c,d) after the surgery.
20 Mandible Reduction 267
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21 Aesthetic Orthognathic Surgery
Seong Yik Han and Kar Su Tan
Pearls
• Orth ogn ath ic su rger y is a du al-p ronged op erat ion su rger y, an d th u s avoid a p ain fu l detou r to a t rial of
th at ful lls both fun ct ion al an d aesth et ic goals or th odon t ics th at produ ce n o ben e t .
th rough reposit ion ing of th e m a xilla an d/or • Tem porom an dibular join t posit ion ing sh ould be
m an dible via orth odon t ic an d su rgical m an ip u lat ion . assessed rst as th e con dylar posit ion is th e key
Fu n ct ion al restorat ion sh ould take preceden ce over referen ce poin t of th e m an dible. Mast icator y m uscle
aesth et ic con siderat ion s. fu n ct ion an d facial n er ve fu n ct ion sh ou ld also be
• Th e psych ological im pact of orth ogn ath ic surger y ch ecked before t reat m en t .
sh ou ld be em p h asized in th e preoperat ive • High sagit t al su praforam in al osteotom y is su perior
evalu at ion . It is recom m en ded th at sign i can t oth ers to sagit t al sp lit ram u s osteotom y n ot on ly becau se it
at ten d th e p reoperat ive discussion w ith th e p at ien t . requ ires a sh or ter operat ing t im e, h as less bleeding
• Un derstan ding of m alocclusion is im port an t for ten den cy, an d is less invasive, but also because it h as
proper fun ct ion al reh abilit at ion . How ever, restoring th e low est risk of in ferior alveolar n er ve injur y.
n orm al occlu sion does n ot n ecessarily en sure a good • Adequ ate soft t issu e p rotect ion , m et icu lou s
aesth et ic ou tcom e. h em ostasis, rigid xat ion , prop er preoperat ive
• Pure or th odon t ic com pen sat ion t reat m en t is plan n ing, an d good su rgical skills are th e key ten ets
som et im es abou t m oving th e teeth in th e opp osite for a successful facial bon e surger y.
direct ion to th e surgical m ovem en t . Hen ce, it • “Aged appearance” can result from the relaxed m idfacial
is im port an t for th e orth odon t ist to be able to soft tissue follow ing LeFort I or bim axillary surgery, and
recogn ize w h ich pat ien ts w ill even t ually require m ay require additional aesthetic procedures.
268
21 Aesthetic Orthognathic Surgery 269
Blair (1907) Perthes (1924) Schuchardt (1954) Trauner & Obwegeser Obwegeser & Dal Pont
Schlössm ann (1922) (1975) (1958)
Fig. 21.1 The development of the mandibular ramus osteotomy technique. Blair, Schlössmann, and Perthes perform ed osteotomy via
the external oral approach, Schuchardt and Obwegeser used the intraoral approach, and Perthes (1924) is known to be the rst to perform
a sagit tal osteotomy on the ascending ramus. The intraoral sagit tal spit ramus osteotomy was rst performed by Obwegeser (1953), and
Dal Pont modi ed Obwegeser’s procedure to enlarge the contacting surfaces.
to n orm al occlusion is th e overriding priorit y of all or th og- Th e m odern in terpret at ion of Angle’s classi cat ion is
n ath ic su rgeries. It is th erefore of u t m ost im p or tan ce th at con n ed m ain ly to th e an terior-posterior relat ion s (on th e
th e su rgeon rst be w ell in form ed on w h at con st it u tes n or- sagit t al plan e), om it t ing in form at ion on th e ver t ical an d
m al occlu sion . In n orm al occlu sion , th e m esiobu ccal cu sp t ransverse plan es. In pract ice, th e ideal occlu sion can be
of th e upper rst m olar is received in th e groove bet w een described as h aving (1) class I m olar an d can in e relat ion -
th e m esial an d dist al buccal cusps of th e low er rst m olar. sh ip; (2) n o crow ding, n o sp acing, n o rotat ion ; (3) overjet
An teriorly, th e upper can in e sh ould occlu de bet w een th e ~ 2 to 4 m m ; (4) correct crow n angu lat ion an d in clin at ion ;
low er can in e an d rst prem olar. Angle classi ed th e m aloc- (5) at an d sligh t upw ard cu r ve of Spee; an d (6) upper an d
clusion in to th ree classes w ith respect to th e den tal align - low er m idlin es th at are in align m en t . Malocclu sion sh ould
m en t an d in terrelat ion sh ip of m axillar y an d m an dibu lar be an alyzed w ith respect to in t ra-arch an d in ter-arch
arch es an d bon es (den to-skelet al) (Fig. 21.2).4 Class I m al- problem s. In t ra-arch problem s are related to in dividual
occlusion is de n ed as h aving a n orm al m olar occlusion teeth—sagit t ally an d vert ically rot ated, or t ran sposit ion ed.
bet w een th e upper rst an d low er rst m olars but prob - In ter-arch p roblem s are related to th e in term axillar y p rob -
lem s w ith th e oth er teeth , su ch as rot at ion or m alp osit ion - lem s, w h ich occur on th ree plan es: (1) class II or III m aloc-
ing. Class II m alocclu sion involves cases w h ere th e low er clusion s in th e sagit t al plan e; (2) cross-bite, scissor bite, or
rst m olar is occlu ded dist al to th e u pp er rst m olar. Th is m idlin e sh ift in th e t ran sverse plan e; an d (3) deep bite or
is su bdivided in to t w o division s: Division 1 is w h ere th e open bite in th e vert ical plan e.
u pp er in cisors are proclin ed, in creasing th e overjet; divi-
sion 2 is for cases w ith ret roclin ed in cisors, w ith redu ced
overjet . Class III m alocclu sion describes th e low er rst ■ Patient Evaluation
m olar as being occlu ded m esial to th e u p p er rst m olar.
Accord ing to Angle’s classi cat ion , it w as fou n d th at class The goal of consultation is to determ ine w hat a patient
I is th e m ost com m on occlu sion pat tern across all races. wants (chief com plaints) an d h is or her concerns regard-
How ever, Japan ese p erson s w ere fou n d to h ave a sign i - ing function and aesthetics. Past m edical and dental history
can tly greater percen t age of class II relat ionsh ips (15%), (especially orthodontic treatm ent) is particularly im portant.
w h ile class III relat ion sh ips are h igh est am ong th e Ch in ese The psychological state of the patient should also be evalu-
p opu lat ion (34%).6 ated during the inter view. If the patient appears to have
270 IV Facial Bone Surgery
a b c
Fig. 21.2 Angle’s classi cation of malocclusion. (a) Class I malocclusion. (b) Class II malocclusion. Mandible is in a retruded position
compared with the maxilla. (c) Class III malocclusion. Protrusion of the mandible with mesial occlusion of the lower teeth is observed.
obsessive-com pulsive tendencies, extra care should be taken facial h eigh t is th e dist an ce bet w een th e soft t issu e n asion
before the surgery. The psychological im pact of orthogna- an d m en ton . Th e facial w idth is de n ed by th e bizygom at ic
thic surgery should be discussed w ith the patient before w idth —th e distan ce bet w een th e outerm ost poin t s of th e
surger y. It is recom m en ded that signi cant others, including soft t issu e zygom at ic arch . Th e bitem poral w idth an d bigo-
fam ily m em bers, also at ten d the preoperative discussion . In n ial w idth sh ou ld ap proxim ate 80 to 85% an d 70 to 75% of
bim axillary protrusion patients, w ho have the greatest risk th e bizygom at ic w idth , respect ively (refer to Fig. 19.4).
of postoperative “aged face,” it is w ise to w arn them about Lip p roject ion is also a d eterm in ing factor of facial aes-
the possibilit y of additional aesthetic procedures because of th et ics. Asian s usu ally h ave dist in ct ive ch aracterist ics of
the increased skin redundancy after surgery. th e lip due to a com bin at ion of th ickn ess, bim axillar y pro-
Docu m en t at ion of any tem p orom an d ibu lar join t (TMJ) t rusion , an d labioversion of th e upper an d low er in cisors.
sym ptom s su ch as clickin g, deviat ion on m ou t h op en ing, Th e ideal upper lip sh ould be balan ced w ith th e n ose an d
an d associated h eadach es sh ou ld be record ed . In p ar t icu - ch eek, an d th e low er lip sh ould be sligh tly posterior to th e
lar, p re-exist in g TMJ dysfu n ct ion p r ior to su rger y sh ou ld u pp er lip. Th e am oun t of teeth exp osu re depen ds on th e
be ad d ressed before or t h od on t ic t reat m en t , as t h e con - ver t ical h eigh t of th e m axilla. W h en both lip s are in repose,
dylar p osit ion is t h e key referen ce p oin t of t h e m an d ible. th e verm illion of th e low er lip sh ould be ~ 25 to 30% m ore
Th e range of m ot ion an d any d eviat ion on m ou t h op en - exp osed com p ared w ith th e u p p er lip. Th is is esp ecially
in g sh ou ld be carefu lly d ocu m en ted . Mast icator y m u scle im port an t for or th ogn ath ic surger y for a cleft lip -palate
fu n ct ion an d facial n er ve fu n ct ion sh ou ld also be ch ecked pat ien t . W h en sm iling, th e in cisors sh ould be at least th ree-
before t reat m en t . quar ters exposed yet n ot exceed 2 m m of gingival sh ow. A
Harm ony an d sym m et r y are th e key factors determ in - gu m m y sm ile, or excessive gingival sh ow du ring sm iling, is
ing facial aesth et ics, even th ough it sh ou ld be recogn ized n ot a reliable in dicator of th e adequ acy of m axillar y h eigh t .
th at w h at de n es a beaut iful face can di er according to Fin ally, facial sym m et r y can be assessed based on several
sociocu lt u ral factors. In th e fron tal view, th e face can be relat ion sh ips, involving th e m idsagit t al plan e th rough th e
d ivid ed equ ally in to th e up per th ird (t rich ion to glabella), n asal t ip, m idlin e of th e u pper an d low er in cisors, m idlin e
m iddle th ird (glabella to su bn asale), an d low er th ird (su b - of th e sym physis of th e ch in , an d th e gon ion posit ion of
n asale to m en ton ) (Fig. 21.3a). Ver t ically th e fron t al p lan e eith er sid e. Dyn am ic sym m et r y can be assessed by obser v-
is com posed of equal fth s (rule of fth s) (Fig. 21.3b). ing th e level of th e oral com m issures an d teeth exposure
Th e cen t ral fth is th e dist an ce bet w een th e m edial on sm iling. Occlusal plan e can t ing sh ould also be assessed.
can th i (w h ich is equivalen t to th e alar base w idth ). Th e Cephalom et ric analysis is crucial for ident ifying the
outer t w o- fth s is th e dist an ce bet w een th e outer can th i patient’s skeletal and den tal problem s for correct ive surgical
an d th e ou term ost p oin t of th e ear. A vert ical lin e from planning and postoperative assessm en t. Standard reference
eith er ou ter can th u s in d icates th e ideal vert ical p osi- points on a cephalom et ric X-ray im age and basic propor-
t ion of th e gon ion (m an dibu lar angle) on both sides. Th e tion s are show n in Fig. 21.4 and Fig. 21.5. Ceph alom etric
facial h eigh t-to-w id th rat io (facial in dex) is opt im al w h en data an alysis reveals that there exists som e disparit y in
it app roach es 1.35:1 for m ales an d 1.3:1 for fem ales. Th e certain param et ric values bet w een Asian s and Caucasians
21 Aesthetic Orthognathic Surgery 271
Tr
1/3
G'
1/3
Sn 1/3
1/3
2/3
Me'
Fig. 21.3 Aesthetic facial division on frontal view. (a) The face can be divided equally into the upper third (trichion to glabella), middle
third (glabella to subnasale), and lower third (subnasale to menton). (b) Vertically, the face is divided into equal fths (rule of fths).
G'
N
S N'
Por
Or
Ar Pr
ANS
UIA A Sn
PNS
A'
Ls
LIE
UIE
Go
Li
LIA B B'
Pog
Gn Pg'
Me
a M' b
Fig. 21.4 (a,b) The skeletal, dental, and soft tissue reference points in cephalometry (see Table 21.1 for key).
272 IV Facial Bone Surgery
N
N
S
ANS A
E line
B
a Me b
1/2
Sn Fig. 21.5 Basic proportions, angles, and lines in cephalom etric anal-
ysis of the face. (a) The nasion (N)–anterior nasal spine (ANS)/ante-
1/3 rior nasal spine (ANS)–menton (Me) ratio is the most frequently used
1/2
St parameter to assess the adequacy of the vertical height of the chin.
1/2 (b) The “esthetic line” (E-line, Ricket t s line) is drawn from the nasal tip
Li
(pronasale) to the soft tissue pogonion (Pog′) to evaluate lip position.
2/3 1/2 (c) The ideal ratio of the distances Sn–St:St–Me′ is 1:2 and that of the
distances Sn–Li:Li–Me′ is 1:1. S, sella; Me′, soft tissue menton; St, sto-
mion; A, A point, subspinale; B, B point, submentale; G, glabella; Sn,
c Me'
subnasale; and Li, Labrale inferior.
PNS Posteror nasal spine Most posterior point on hard palate contour
G′ Soft tissue glabella Median point bet ween eyebrows (most anterior point of forehead)
A′ Soft tissue A point Deepest point bet ween subnasale and upper lip
Ls (UL) Labialis superior (upper lip) Most anterior point of upper lip
Li (LL) Labialis inferior (lower lip) Most anterior point of lower lip
B′ Soft tissue B point Deepest point bet ween lower lip and chin
Pog′ Soft tissue pogonion Most prom inent point of soft tissue chin
Bimaxillary protrusion ASO + genioplast y or upper ASO and lower SSRO + genioplast y
Abbreviations: ASO, anterior segmental osteotomy; BVSRO, bilateral vertical sagittal ramus osteotomy; SSRO, sagittal split ramus osteotomy.
21 Aesthetic Orthognathic Surgery 275
a b
c
276 IV Facial Bone Surgery
a b c
Fig. 21.8 High sagit tal supraforaminal osteotomy (HSSO). (a) The incision line is 25 to 30 mm long and follows the anterior border of
the ramus. A simple lateral retractor (width 20 mm) is applied to protect the lateral and posterior surface during the osteotomy. (b) The
osteotomy on the lateral cortical surface is ~ 10 to 15 mm lower than the medial osteotomy on the ascending ramus. (c) Osteosynthesis
is performed using a maxiplate with four screws on each plate.
21 Aesthetic Orthognathic Surgery 277
b
a
d e f
Fig. 21.10 Le Fort I osteotomy. (a) Osteotomy starts at the lateral wall of the piriform fossa and ends at the maxillary tuberosit y (red line).
(b) The lower part of the nasal septal cartilage and vomer is detached from the maxilla and palatine bone using an osteotome. (c) The
pterygoid plate is separated from the maxilla with a curved pterygoid osteotome. (d) The m axilla is down-fractured. (e) Four L-shaped,
four-hole miniplates are applied on each side of the piriform rim and lateral but tress. (f) A cinch suture is applied at the alar base before
wound closure to prevent splaying of the alar base.
sm all in terin cisal angle. In dicat ion s for an terior segm en tal th e labial side an d to th e coron al m idlin e of th e h ard palate
osteotom y (ASO) for pat ien ts w ith bim axillar y prot rusion on th e palat al surface. Ext ract ion of both upper an d low er
in clude rst p rem olars follow s (Fig. 21.11b).
Th e prem olar socket m arks th e osteotom y lin e an d
1. Prot rusion of m axillar y teeth an d bon e, causing
th e am oun t of posterior setback of th e an terior segm en t .
sign i can t facial deform it y
Th e bon e spicu les at th e edges are sm ooth ed to allow for
2. Orth odon t ically un t reat able prot ru sion , such as proper bon e con tact during osteosyn th esis later. Care m ust
an kylosed teeth , root resorpt ion , or im m ovable/ be taken n ot to injure th e can in e an d secon d prem olar by
slow -m oving tooth d u e to th ick bon e stock keep ing th e in ter ven ing socket w all in t act . Th e osteotom y
3. An terior open bite n ot t reatable w ith orth odon t ic lin es are m arked on th is prem olar socket w ith a pen cil,
t reat m en t alon e keep ing a distan ce of at least 5 m m p osteriorly an d 3 to 4
4. Un aesth et ic sm all ch in w ith lip excess m m in feriorly from th e an terior teeth root s, an d ru n par-
allel to th e n asal oor. Th e bu ccal an d p alatal bony w all
First , segm en t al osteotom y of th e m axilla is perform ed. at th e ext racted socket is rem oved prim arily w ith a bon e
On th e labial side, th e m argin al gingival in cision ru n s from rongeur. Using a sm all roun d bu r, th e au th ors u sually m ake
th e secon d prem olar of on e side to th at of th e oth er side. sm all port s along th e p lan n ed osteotom y lin e an d in lt rate
Th e palat al m argin al gingival in cision is sh or ter, from th e ep in ep h rin e an d lidocain e in to th e m arrow p rior to per-
can in e to th e rst prem olar on each side (Fig. 21.11a). Th is form ing th e osteotom y. Th e au th ors start by deepen ing a
in cision can p reser ve th e vascular su pply to th e bon e sin ce groove along th e p lan n ed osteotom y lin e w ith a 3.8-m m
th ere are n o m ucosal in cision s. On ce th e in cision is m ade, roun d bur (Fig. 21.11c). Th e diam eter of th e bu r is deter-
th e periosteum is elevated to th e an terior n asal spin e on m in ed by th e am ou n t of sh orten ing requ ired. Altern at ively,
21 Aesthetic Orthognathic Surgery 279
Fig. 21.11 Anterior segmental osteotomy (ASO). (a) The palatal marginal gingival inci-
sion is made from the canine to the rst premolar on each side of the maxilla and m andible.
(b) Extraction of both upper and lower rst premolars follows. (c) Osteotomy is performed
by burring out a groove along the planned osteotomy line. (d) The segment is mobilized
and a splint fabricated preoperatively is used as a guide to achieve the desired occlusion.
b c d
a recip rocat ing saw can be u sed. Bleed ing from th e in cisive Double Jaw Surgery
foram en d u ring drilling is con t rolled by bon e w ax easily.
Th e m axillar y sin u s can be en coun tered as th e groove is Dou ble jaw su rger y is also called t w o-jaw su rger y or bim ax-
d eep en ed . Th e sin us m ucosa is kept in t act an d lifted o th e illar y surger y. Dou ble jaw surgeries sh ould be lim ited to
bon e in stead of being cut th rough . pat ien t s in w h om (1) th e am oun t of m an dibu lar setback
On ce th e osteotom y is com pleted, th e segm en t is m obi- requ ired is m ore th an 14 m m (in th ese cases, m an dibular
lized an d th e preoperat ively fabricated splin t is used as a osteotom y alon e is in su cien t to ach ieve n orm al occlusion ,
gu ide to ach ieve th e d esired occlu sion (Fig. 21.11d). Th e an d w ill likely h ave a h igh relap se or com p licat ion rate), (2)
can in e an d secon d prem olar teeth are ligated w ith w ires sign i can t open bite or seriou s bim axillar y p rot ru sion in
on both sides an d IMF is don e. Th e occlusion is ch ecked class III m alocclu sion is presen t , or (3) h orizon tal occlusal
before osteosyn th esis w ith four-h ole, L-sh aped m in iplates can t ing can n ot be adequately corrected or th odon t ically.
an d screw s. After rigid xat ion is ach ieved, th e sp lin t is Th e m axilla an d m an dible are osteotom ized an d m obi-
rem oved an d th e m argin al gingival in cision is closed w ith lized as described previously in th e sam e set t ing. Opera-
in terden tal su t u res. t ion begin s w ith a Le Fort I m axillar y osteotom y an d th e
Segm en tal osteotom y of th e m an d ible is ver y sim ilar m a xilla is d ow n -fract u red . Next th e m axilla is align ed w ith
to th at of th e m axilla. A m argin al gingival in cision is m ade th e h elp of a prefabricated splin t an d xed w ith m in iplates
from th e secon d p rem olar of on e side to th at of th e oth er an d screw s. Man dibu lar osteotom y w ith SSRO or HSSO is
side (Fig. 21.11a). Su bperiosteal dissect ion p roceed s along perform ed n ext an d align ed an d xed in a sim ilar m an -
th e ch in an d body of th e m an dible. Th e osteotom y lin e is ner. Th e n ew occlu sion is plan n ed p reoperat ively an d t w o
m arked an d th e rst p rem olars are ext racted on both sides. splin t s are n ecessar y: On e is u sed as an in term ed iate sp lin t
Th e bon e is cut in a sim ilar m an n er as described per viously after m a xillar y osteotom y to t th e m ovable m axilla to th e
to create th e an terior segm en t (Fig. 21.11c). Th e splin t is un t reated m an dible, an d th e oth er is for after th e m an dibu -
ap plied n ext to get th e desired align m en t an d occlu sion . lar osteotom y, to be u sed as th e n al splin t .
IMF w ith orth odon t ic ru bber elast ics is don e, follow ed by
osteosyn th esis w ith 4-h ole st raigh t plates ben t for proper
t an d adapt at ion . In terru pted in terden t al p ap illar y su t u res
are u sed to close th e in cision an d a silast ic d rain is in serted . ■ Postoperative Care
For ASO, th e p refabricated occlusion splin t s are used
p u rely to gu ide th e plan n ed an terior occlusion an d th en Day surger y is possible after postoperat ive m on itoring for
rem oved p rior to ext ubat ion . Postoperat ive IMF is n ot ~ 4 to 5 h ou rs. Th e n ext visit is on p ostop erat ive day 3, for
requ ired, an d th e p at ien t is allow ed to open h is or her rem oving th e silast ic drain an d dressing th e w ou n d. On
m ou th im m ediately. postoperat ive day 4 or 5, IMF is released an d t w o m iddle
280 IV Facial Bone Surgery
ring elast ics are u sed on each sid e to en able th e pat ien t to
start early m obilizat ion of th e TMJ w ith sligh t m ou th op en - ■ Complications and
ing. On p ostoperat ive day 7 or 8, th e splin t is rem oved an d
th e orth odon t ist begin s postoperat ive or th odon t ic t reat-
Their Management
m en t . Th e su t u res are u su ally rem oved on postoperat ive
day 10.
Common Complications Follow ing
An t ibiot ics an d an algesics are prescribed in liquid Facial Bone Surgery
form . Th e pat ien t is advised to alw ays carr y arou n d a p air
of sm all scissors to cut o th e ru bber elast ics in case of an Bleeding du ring SSRO occurs m ain ly from th e bon e m arrow
em ergen cy. of th e ram us an d body of th e m an dible. Nut rien t ar teries
from adjacen t soft t issu e also con t ribu te to th e bleeding.
Th ese are m ostly self-lim it ing an d n on -life-th reaten ing.
■ Key Technical Points Severe bleed ing, h ow ever, can resu lt from inju r y to th e in fe-
rior alveolar ar ter y du ring elevat ion of th e periosteu m o
1. Prior to elevat ing th e lingual periosteu m of th e th e lingual cor tex. Hen ce, th e ut m ost care sh ould alw ays be
ascen d ing ram u s, in lt rat ion of epin eph rin e an d taken w h en dissect ing n ear th e lingual cor tex, an d proper
lidocain e is h elpful to avoid acciden t al ru pt ure of soft t issu e p rotect ion w ith broad elevators sh ou ld alw ays
n u t rien t vessels em erging from th e bony foram en . be em ployed to avoid such m ish aps. If severe bleeding is
en cou n tered, p acking th e lingu al t u n n el w ith ep in ep h rin e-
2. During periosteal elevat ion for lingu al cortex
soaked gau ze an d app lying direct digit al pressu re over th e
osteotom y, keep th e dissect ion area n arrow to avoid
m an dibu lar foram en rem ain s th e m ost reliable w ay to slow
dam age to th e vessel an d n er ve from th e m an dibular
th e bleeding. Th e pressure sh ould be sust ain ed for ~ 5 to 10
foram en .
m in u tes. After th e bleeding h as ceased, th e packing is kept
3. For accurate ram us split t ing, create several guide in sit u w h ile th e oth er side is prepared. Th e osteotom ies
h oles in th e m edu lla, dow n to th e posterior border m ay p roceed as per u su al if th ere is n o rebleeding. Su rgicel
w ith a 1.8-m m roun d bur. Ram u s split t ing is or brin glue can be applied to th e bleeding area after lin -
com pleted by join ing th ese guide ch an n els w ith a gu al cor t ical osteotom ies.
2-m m ch isel. If m assive bleed ing resu lts from facial ar ter y inju r y
4. Rigid xat ion after p recise redu ct ion is key to during SSRO, th e bleeding site sh ould be packed w ith epi-
sh orten IMF an d bon e h ealing t im e, an d pain less n eph rin e gau ze w ith digital com p ression . A 2–0 or 3–0
h ealing. h em ostat ic su t u re can be app lied over th e bleeding area.
5. Th e operator’s nger sh ould be placed on th e During Le Fort I osteotom ies, the vessels at risk are th e
pter ygoid ham ulu s during th e osteotom y at th e descending palatine arter y, the m axillar y artery, and the
pter ygom axillar y jun ct ion to preven t injur y to th e pterygoid plexus.13,14 The descending palatine artery in the
m a xillar y arter y an d pter ygoid plexu s. retrom axillar y region is particularly vulnerable during sepa-
6. After m axillar y bon e su rger y, a cin ch sut ure is ration of the m axilla from the pterygoid process or dow n-
ap plied at th e alar base before w ou n d closu re to fract uring of the m axillary segm ent because th is process is
p reven t splaying of th e alar base. not visualized directly. Thus, placem ent of the osteotom e at
7. During ASO, care sh ould be t aken n ot to injure its inferior aspect by palpation is critical to avoid vessel injury
th e can in e an d secon d prem olar by keeping th e w ithin the pterygopalatine fossa.14,15 Som etim es delayed
in ter ven ing socket w all in t act after ext ract ion of th e secondary h em orrhage (days 1–2 or 7–9) can arise from th e
u pp er rst p rem olars. Th e bon e sp icu les at th e edges t uberosit y area. Although the am ount of bleeding is m od-
are sm ooth ed to allow p rop er bony con t act du ring erate, it should be m anaged prom ptly as it can poten tially
osteosyn th esis. develop into airw ay obstruction. Bleeding from the nasal
oor an d sin us m ucosa can be con trolled spontaneously.
8. Th e osteotom y lin es sh ould be kept at least 5 m m
Infection is uncom m on follow ing orthognathic surgery;
aw ay from th e an terior teeth root s so as n ot to
the reported incidence is less than 1%.16,17 Nonetheless, if
d isru pt th e vascular su pply to th e tooth .
infection occurs, it is usually associated w ith the m andibu-
lar osteotom y. Follow ing SSRO procedures, m assive irriga-
tion to rem ove bony dust and chips is required.14 Em pirical
antibiotics are routinely prescribed for 7 days after surgery. If
localized infection occurs around the screws, then it is recom -
m ended that they be rem oved. Postoperative pain is usually
m inim al and is easily controlled w ith analgesics such as acet-
am inophen. Severe TMJ pain can occur on the third or fourth
postoperative day and m ay require loosening of the IMF.
21 Aesthetic Orthognathic Surgery 281
a b
Fig. 21.12 Partial necrosis of bone segment. (a) The X-ray shows that partial necrosis of
the bone segment developed 10 days after surgery. (b) The anterior maxillary bone was
recovered, but root resorption rem ained.
a b
Fig. 21.13 Case 1. Mandibular prognathism with long face. (a,b) Preoperative photo-
graphs. (c,d) Preoperative cephalometry and panoram ic view. d
21 Aesthetic Orthognathic Surgery 283
a b
Fig. 21.14 Case 1. (a,b) Two years postoperative photographs. (c,d) Two years postopera-
tive cephalometry and panoramic view. d
Case 2: Mandibular Prognathism t ion ), leveling of upper an d low er teeth , tooth align m en t to
restore th e rotat ion s, an d crow ding teeth .
w ith Long Face Becau se t h e p at ien t refu sed d ou ble jaw su rger y,
A you ng m ale pat ien t visited for relat ive ret ru sion of th e HSSO an d gen iop last y w ere t h e on ly opt ion s at t h e t im e
u pp er jaw an d p rot ru sive low er jaw (Fig. 21.15). He sh ow ed of t reat m en t p lan n ing. Sin ce t h e ver t ical im p act ion of t h e
an excessive low er facial th ird , a h igh ly con cave facial p ro- u p p er p oster ior teet h w as n ot p ossible w it h or t h od on -
le, a long an d p rot ru sive ch in , an d a long face w ith ou t a t ic t reat m en t on ly, en dodon t ic p roced u res on t h e u p p er
labiom en tal fold. In fun ct ion al assessm en t , h e w as desig- m olars on each sid e, follow in g p rost h od on t ic t reat m en t ,
n ated as a classi cat ion of class III m alocclu sion skelet al w as ad opted ad d it ion ally. On gen iop last y, t h e am ou n t
t yp e w ith accom p anying m ast icator y di cu lt y an d TMJ of ch in red u ct ion w as 13.5 m m , an d t h e d ist al segm en t
fu n ct ion al derangem en t . Preop erat ive orth od on t ic t reat- w as m oved 3.5 m m backw ard . Con sid erin g t h e p ostop -
m en t w as adm in istered for in t ru sion of m axillar y p osterior erat ive relap se, m an d ibu lar set back w as over cor rected
m olars, arrangem en t of m axillar y an d m an dibu lar den t al 3 m m . After 3 years, t h e occlu sion w as n or m alized, bu t
arch discrep an cy w ith p alatal exp an sion , decom p en sat ion 1 m m an ter ior d isp lacem en t of t h e m an d ible w as n oted
of upper an d low er teeth (adjust m en t of teeth in clin a- (Fig. 21.16).
284 IV Facial Bone Surgery
a b
Fig. 21.15 Case 2. Mandibular prognathism with long face. (a,b) Preoperative photo-
graphs. (c,d) Preoperative cephalometry and panoram ic view. d
a b
Fig. 21.16 Case 2. (a,b) Three years postoperative photographs. (c,d) Three years post-
operative cephalometry and panoram ic view. d
21 Aesthetic Orthognathic Surgery 285
Pearls
• Gen ioplast y has n o e ect on occlusion an d can thus • Th e ideal ch in posit ion varies am ong in dividuals,
be considered a w holly aesthet ic procedure aim ed an d is determ in ed by taking in to con siderat ion both
at m odifying the form and appearance of th e bony th e h ard an d soft t issue ceph alom et r y referen ce
m en t um . poin t s.
• Gen iop last y is m ost com m on ly don e as an • Gen ioplast y can be perform ed in t w o w ays:
adju n ct ive p rocedu re of an terior segm en tal (1) osseou s gen ioplast y an d (2) augm en tat ion
osteotom y, angle redu ct ion surger y, m an dibular gen iop last y u sing im p lan ts. Th e au th ors p refer
sh aving, zygom at ic su rger y, an d rh in oplast y to osseous gen ioplast y because it provides a m ore
yield syn ergist ic e ects in m aking an aesth et ically reliable outcom e.
pleasing face. • Osseou s gen iop last y is don e in t raorally u n der
• Proper evaluat ion an d docum en tat ion in th e form gen eral an esth esia. Horizon t al bon e cu t s are m ade
of facial ph otography, sim ulat ion m odeling, an d bicort ically w ith an oscillat ing saw, t aking care
radiograp h ic invest igat ion s (pan oram ic view, lateral n ot to injure th e m en tal n er ve, an d th e m obilized
an d p osterior-an terior [PA] cep h alogram , an d/or 3D segm en t is xed w ith pre-ben t m in iplates.
com puted tom ography [CT] scan ) are im perat ive • Alth ough gen iop last y is a relat ively safe operat ion
prior to surger y. w ith ver y low com plicat ion rates, m en t al n er ve
• Th e object ive is to ach ieve facial h arm ony th rough inju r y, m alun ion /n on u n ion , irregularit y of bon e
su rgically m odifying th e m en t u m an d m an dibu lar su rface, lip droop ing or skin dim p ling, ch in ptosis,
sym p hyseal areas, recreat ing ap p ropriate facial an d asym m et r y m ay develop .
propor t ion s an d sym m et r y of th e low er th ird of
th e face.
286
22 Genioplast y 287
a b
Fig. 22.1 Early genioplast y techniques. (a) Anterior sliding advancement genioplast y was rst described by O. Hofer in 1942. It was
performed via an extraoral submental approach. (b) Genioplast y surgery described by Obwegeser. This sliding advancement genioplast y
was performed intraorally, xed with perimandibular Supramid thread on each side over an acrylic dental splint.
288 IV Facial Bone Surgery
Table 22.1 Important norms of chin position by cephalometric analysis (adapted from Dr. SN Ahn 4)
N–ANS (mm) 52.9 ±2.7 (45% from N–Me) 52.4 ±3.0 (45% from N–Me)
ANS–Me (mm ) 65.9 ±4.5 (55–56% from N–Me) 63.3 ±5.5 (54–55% from N–Me)
G–Sn:Sn–Me′ 1:1
Sn–St:St–Me′ 1:2
a
See Chapter 21, Table 21.1 for a guide to variables.
p at ien t’s desires an d exp ect at ion s. Th e param eters dis- m en ton (see Ch apter 21, Fig. 21.5), an d (4) th e con cept of
cussed usually in clude (1) th e volu m e an d sh ape of th e ch in th e “zero-m eridian ” (Gon zalez-Uloa, 1962).
(sm all/large, broad/n arrow, sh arp/oval), (2) posit ion ing of Th e “esth et ic” lin e, or E-lin e, can be draw n from th e
th e ch in t ip on th e sagit t al plan e (prot rusion or ret ru sion ), n asal t ip (pron asale) to th e soft t issue pogon ion (Pog′)
(3) vert ical h eigh t of th e ch in (length ening/sh or ten ing), to evalu ate lip p osit ion (Fig. 22.2). Th e m ean dist an ce of
an d (4) sym m et r y (in all th ree plan es). th e upper lip to th e E-lin e is 0.41 m m in Asian s an d 4.72
Occasion ally, th e su rgeon m ay en cou n ter a pat ien t h av- m m in Cau casian s; w h ile th e m ean d ist an ces for th e low er
ing good ch in sh ape, p osit ion , h eigh t , an d sym m et r y but lip are 1.27 m m an d 3.14 m m for Asian s an d Caucasian s,
w h o requests su rger y. In th is sit u at ion , th e surgeon n eeds resp ect ively.4 Using th ese m easu rem en t s, th e p osit ion of
to con sider th e p at ien t ju diciou sly. th e pogon ion can be ext rapolated. On e pitfall to n ote is th at
Th e pat ien t’s occlusion is also exam in ed during th e th is m eth od relies h eavily on th e pat ien t’s h aving a n or-
con su ltat ion . Th is is especially crucial in pat ien t s w h o h ave m ally p rojected pron asale (n asal t ip ). Usu ally th e pron asale
h ad p reviou s orth odon t ic t reat m en t or jaw surgeries. Gen - is in adequately projected in Asian s; th u s, u sing th is poin t as
erally, sim ple gen iop last y alon e is su cien t for a pat ien t a referen ce in su ch p at ien ts can lead to an erron eou s con -
w ith n orm al class I occlusion . How ever, it w ill n ot su ce clusion in iden t ifying a ret ruded pogon ion posit ion .
for p rop er aesth et ic correct ion for pat ien t s w ith class II or Th e rule of th irds is also applied in th e an alysis of facial
III occlu sion s. In th is case, orth odon t ic t reat m en t or su r- p ropor t ion s. Th e face is divided in to th ree equ al vert ical
ger y (su ch as an terior segm en t al osteotom y or sagit tal split sect ion s: Th e p ort ion from th e t rich ion (Tr) to th e glabella
ram u s osteotom y) sh ould precede gen ioplast y to correct form s th e u pper th ird, from th e glabella to th e su bn asale
m alocclu sion . th e m iddle third, an d from th e su bn asale to th e m en ton th e
low er th ird (see Ch apter 21, Fig. 21.3a). Asian s are kn ow n
to h ave a longer low er th ird th an Caucasian s by ~ 2 to 3%.
■ Patient Assessment Th is m eth od of propor t ion al an alysis m ay be used to deter-
m in e th e ideal p osit ion of th e soft t issu e m en ton (Me′)
For preoperat ive assessm en t , an alysis of facial ph oto- (Fig. 22.3a). In addit ion , fu rth er an alysis of th e low er th ird
graph s, in clu ding fron tal, 45 degrees obliqu e, lateral, basal, can be m ade by st udying th e posit ion s of th e subn asale
an d h elicopter view s, an d sm iling an d pou t ing view s, is th e (Sn ), stom ion (St), low er lip (LL), an d soft t issue m en ton .
rst step . It is cru cial to obt ain sm iling an d pou t ing p h oto- Th e rat io of th e dist an ces Sn –St:St–Me′ is 1:2, an d th at of
graph s sin ce som e problem s, su ch as skin dim p ling, m ay th e dist an ces Sn –LL:LL–Me′ is 1:1 (Fig. 22.3b). In p at ien t s
ap pear on ly du ring p ou t ing or sm iling. w ith sm all chin s, th e Sn –LL:LL–Me′ rat io w ill be m ore th an
To determ in e th e ideal soft t issue vert ical dim en sion of 1. Using th ese rat ios of th e low er facial th ird, th e opt im al
th e low er th ird of th e face, various referen ces m ay be used, p osit ion of the soft t issue m en ton can be calculated.
su ch as (1) th e Ricket ts lin e (E-lin e), (2) th e ru le of th irds, Th e con cept of zero-m eridian w as described by Gon -
(3) soft t issue division s from th e su bn asale (Sn ) to th e soft zalez-Ulloa in 1962.8 From th e soft t issue N poin t , a lin e
t issue m en ton (Me′) an d from th e glabella to th e soft t issu e p erp en dicu lar to th e Fran kfort h orizon t al lin e (FH lin e), th e
22 Genioplast y 289
Fig. 22.2 Esthetic line (E-line, lin e from th e upper rim of th e extern al auditor y can al to
Ricket ts’ line). The “esthetic” line, th e low er rim of th e orbit , is draw n . Th is is kn ow n as th e
or “E-line,” is drawn from the nasal zero-m eridian . Th e soft t issu e pogon ion is located along
tip (pronasale, Pn) to the soft tis-
th e zero-m eridian (Fig. 22.3c).
sue pogonion (Pog′) to evaluate lip
Im aging an alysis in clu ding X-ray (p an oram ic view,
position.
Ceph alo PA, Ceph alo Lat) or 3D CT scan is also a n ecessit y.
In th e p lan n ing of th e ideal p osit ion of th e ch in t ip (Me or
Pog), it is u sefu l to bear in m in d th at p roport ion is m ore
Pn
im port an t th an th e act ual length . Lateral cep h alom et r y
is perh aps th e single m ost in form at ive tool in assessing
an d d eterm in ing th e posit ion of th e ch in . Th e an terior-
posterior ch in project ion (Pog) is determ in ed on th e sag-
UL to E line it tal plan e by locat ing it bet w een th e SNA an d SNB lin es.
Th e n asion (N)–an terior n asal spin e (ANS)/an terior n asal
LL to E line spin e (ANS)–m en ton (Me) rat io is th e m ost frequ en tly u sed
param eter to assess th e adequacy of th e ver t ical h eigh t of
th e ch in (Fig. 22.4). Th ese p aram eters are th e n orm s for
Pog'
referen ce; h ow ever, depen ding on th e pat ien t’s preferen ce,
th e n al ch in posit ion m ay be adjusted to w ith in 6% of th is
referen ce gure safely.
a b
Fig. 22.6 Operative incisions for osseous genioplast y. (a) Labial
a
mucosal incision. (b) Marginal gingival incision.
Fig. 22.7 Bony marking for genioplast y. The midline of the chin
is marked with a small round bur or saw. Marking the horizontal
cut ting line is done with a pencil or marking pen as designed. A
long groove is created at the t wo ends of the planned osteotomy to
prevent slippage during sawing.
c
Irregularity of Bone Surface an d it s p rop er re-at t ach m en t d u ring su rger y are essen t ial.
W h en it is u sed, revision surger y is aim ed at re-an ch oring
Irregu larit y of th e in ferior border of th e m an dible is a th e m en t alis m uscle to th e in cisive fossa, an d to repose th e
com m on com plicat ion , par t icu larly in vert ical ch in h eigh t dragged periosteum an d ch in pad superiorly.
redu ct ion surgeries. After m aking parallel h orizon t al oste-
otom ies, th e m iddle segm en t is rem oved; th e cau dal seg-
m en t is th en p laced to th e m ain m an dibu lar body. At th e
Asymmetry
lateral en ds of th e bon e edges, a t riangular bony prot u ber-
Asym m et r y m ost frequ en tly results from errors in plan -
an ce w ill be p rod u ced du e to th e m isalign ed m an dibu lar
n ing an d/or surgical execu t ion . Correct ive gen ioplast y for
lin e (Fig. 22.10).
asym m et ric ch in s sh ou ld be p lan n ed m et icu lou sly. Failu re
If th is p rot u beran ce is n ot sh aved o du ring th e su rger y,
to m ark th e m idlin e p rior to perform ing th e osteotom y w ill
pat ien t s w ill com plain of irregu larit y an d som et im es pain
lead to asym m et r y. Also, it m ust be kept in m in d th at th e
at th e m an dibular border. It m ay also be seen in aggressive
m agn it u de of soft t issu e m ovem en t correspon ds to on ly 75
n arrow ing of th e ch in t ip. In th is case u sing ar t i cial bon e
to 90% of th e m agn it u de of bony t ran slat ion s. For exam p le,
w ith BMP can h elp sm ooth out th e steps.
if th e bon e segm en t is m oved 5 m m t ran sversely, th e cor-
resp on ding soft t issu e posit ion w ill on ly m ove bet w een
Lip Drooping, Chin Ptosis, and 3.75 an d 4.75 m m . Th erefore, in correct ion of th e asym -
m et ric ch in , over-correct ion of th e bon e is often requ ired
Skin Dimpling to ach ieve soft t issu e sym m et r y. On ce it is establish ed th at
th ere is postoperat ive asym m et r y as a resu lt of m alposi-
Ch in ptosis is de n ed as th e drooping of ch in soft t issue
t ion ing, revision is advised w ith in 2 w eeks.
over th e in ferior border of th e m an dible. Lip droop ing is
de n ed as low er-posit ion ed lip w ith dim pled skin during
lip closure. Ch in ptosis an d lip droop ing are due to prob -
lem s w ith th e m en talis an d depressor m u scles of th e low er
Allograft-Related Complications:
lip. Th e m en talis m uscle origin ates from th e in cisive fossa Chin Drooping, Distortion,
of th e m an dible an d in sert s in to th e derm is of th e ch in skin . Irregular Skin
It h as t w o fu n ct ion s: (1) to su pp ort , elevate, an d prot ru de
th e low er lip; an d (2) elevat ion an d w rin kling of th e skin Ch in drooping an d distort ion occu r after im plan tat ion of
of th e ch in . Failure to re-at tach th e m en t alis m uscle after an allograft su ch as silicon e or Gore-Tex. Th ere is invari-
division an d m uscular brosis after in fect ion or rem oval of ably erosion of th e cort ical ch in bon e by in ser ted im p lan ts,
a large im p lan t are kn ow n to be th e m ain cau ses of th is an d in som e p at ien t s th is is cou p led w ith an osteop hyt ic
ph en om en on .9 Pat ien t s h aving a h istor y of ch in im plan t react ion along th e p erim eter of th e im plan t , creat ing a cra-
su rger y h ave a h igh er risk of exacerbat ion of ch in ptosis ter-like bony defect (Fig. 22.11). Occasion ally th is erosion
after revision osseou s gen iop last y for th is reason . Th u s, it can exten d th rough th e an terior alveolar bon e to reach th e
is im port an t to obt ain preoperat ive ph otograph s for docu- root s of th e fron t al teeth .
m en t at ion . To preven t th e aesth et ic an d fu n ct ion al com pli- A peau d’orange appearan ce of th e ch in is an oth er
cat ion s m en t ion ed previously, preser vat ion of th e m en t alis frequ en tly en cou n tered p roblem follow ing ch in im p lan ts,
a b
Fig. 22.10 (a,b) Treatment of bony irregularit y after osseous genioplast y. Triangular bony irregularities at both lateral ends following
vertical or sagit tal reduction genioplast y. This bony edge needs to be removed to prevent postoperative inconvenience. It is usually located
near the mental foramen, and thus extra caution should be taken during the removal.
22 Genioplast y 295
a b
Fig. 22.11 Osteolytic crater on chin bone by alloplastic chin implant. (a) Identi cation of previously inserted Gore-Tex chin implant. (b)
Crater-like erosion of the chin bone near the root of anterior teeth is observed during removal of the chin implant.
esp ecially Gore-Tex. Th is m ay be du e to disru pted m u scle f. Low er an d u p p er lip p rot ru sion : u p per lip to
bers failing to re-align an d re-at t ach to th e cort ical bon e E-lin e, 3.7 m m (m ean –1.02); low er lip to E-lin e,
su rface du e to th e presen ce of th e in terp osit ion ed im plan t . 7.2 m m (m ean 2.03)
An oth er possibilit y m ay be im plan t m igrat ion . Th ese allo-
p last ic im plan t s h ave also been fou n d to adh ere to over-
lying m u scle bers an d derm is, result ing in skin th in n ing Treatment Plan
over t im e. Care sh ou ld be t aken in perform ing revision
su rger y in su ch cases, as p erforat ion of th e skin can occu r 1. Con ser vat ive tem porom an dibular join t (TMJ)
d u ring im plan t rem oval. t reat m en t w ith an occlusal stabilizing applian ce.
Th e aim is to set up th e opt im al an d stable con dylar
posit ion
■ Case Studies 2. Orth odon t ic t reat m en t: teeth align m en t for an terior
crow ding, leveling of den tal arch es, in t rusion of
Case 1 u pp er posterior m olars.
3. Operat ion : an terior segm en tal osteotom y (ASO) of
A 23-year-old wom an presents w ith a bim axillary protrusion m a xilla, sagit t al sp lit ram u s osteotom y (SSRO) of
and a severely retruded sm all chin (Fig. 22.12 and Fig. 22.13). m an dible, gen iop last y.
c d
22 Genioplast y 297
b c
298 IV Facial Bone Surgery
a b
c
d e
f
Fig. 22.14 Case 2. Pre- and postoperative photos and cephalogram. (a,b) Preoperative facial photographs show slightly protruding lips
with retruded chin. (d,e) Postoperative photographs show increased chin projection and improved lip position. (c,f) Pre- and postopera-
tive lateral cephalograms.
300 IV Facial Bone Surgery
References 5. Hw ang HS, Kim WS, McNam ara JA Jr. Ethn ic di eren ces in
th e soft t issu e pro le of Korean an d Eu rop ean -Am erican
1. Aufrich t G. Com bin ed n asal plast ic an d ch in plast ic: correc- adult s w ith n orm al occlusions an d w ell-balan ced faces.
t ion of m icrogen ia by osteocart ilagin ou s t ran sp lan t from Angle Orth od 2002;72(1):72–80
large h u m p n ose. Am J Su rg 1934;25:292 6. Ioi H, Nakat a S, Nakasim a A, Coun t s AL. Com parison of
2. Hofer O. Operat ion del Progn ath ie un d Microgen ie: Die ceph alom et ric n orm s bet w een Jap an ese an d Cau casian
Op erat ive Beh an d lu ng d er alveolaren Ret rakt ion des Un - adult s in antero-posterior an d vert ical dim en sion . Eur J
terkiefers u n d ih re Anw en du ngsm oglich keit fu r Prog- Or th od 2007;29(5):493–499
n ath ie un d Mikrgen ie. Dt sch Zah n Mun d Kieferh eilk 7. Ricket t s RM. Esth et ics, environ m en t , an d th e law of lip re-
1942;9:121–132 lat ion . Am J Orth od 1968;54(4):272–289
3. Obw egeser H. Surgical procedures to correct m an dibu- 8. Gon zalez-Ulloa M. Quan t it at ive prin ciples in cosm et ic sur-
lar p rogn ath ism an d resh ap ing of th e ch in . In : Trau n er R, ger y of th e face (pro leplast y). Plast Reconst r Surg Tran s-
Obw egeser H, eds. Th e su rgical correct ion of m an dibu lar plan t Bu ll 1962;29:186–198
p rogn ath ism an d ret rogn ath ia w ith con siderat ion of gen io- 9. Zide BM, McCarthy J. Th e m en talis m uscle: an essen t ial
p last y. Oral Su rg Oral Med Oral Path ol 1957;10:677–689 com p on en t of ch in an d low er lip posit ion . Plast Recon st r
4. Ah n SN. Keph alom et risch e Vergleich st udie von skelet t alen Surg 1989;83(3):413–420
u n d Weich teil Param etern zw eier eth nisch er Gruppen .
Doctoral Dissert at ion . Kieferorth op aedie, ZMK Klin ik, Un i-
versit at Ham bu rg; 1995
V
Facial Skin and Hair Rejuvenation
23 Management Strategies for the Aging Asian Face :
Philosophy and Evolution
Samuel M. Lam
Pearls
• Th e prin cipal m an ifestat ion of aging for m ost • Typically, low er facial rejuven at ion for th e East
East Asian s (an d all oth er peoples for th at m at ter) Asian is n ot n ecessar y un t il m uch later in life w h en
is volum e loss. Ju diciou s volu m izat ion u sing fat com pared w ith the Caucasian . Neurom odulators can
graft ing an d/or llers can p rovide w on derfu l be used in th e plat ysm a to reverse early aging an d
rejuven at ion th at is n at ural an d im pactful. to delay th e n eed for a facelift . A ch in im p lan t can
• Hair restorat ion can be a vit al com p on en t to global be an im port an t adjun ct to im prove th e sh ape of
facial rejuven at ion an d can p rovide an im p or tan t th e Asian face as w ell as to en h an ce a facelift result .
fram e to th e u p per face to m ake it ap p ear m ore Lipocon touring of th e n eck sh ou ld be don e sh arply
you th fu l an d at t ract ive. w ith scissors in a con ser vat ive fash ion un der direct
• Th e aging Asian eyelid is a com plicated su bject . vision rath er th an w ith a su ct ion can n u la.
Th e t reat m en t algorith m is based on w h ich t ype of • Man agem en t of th e skin sh ou ld be an in tegral
eyelid a pat ien t possesses: a n at u ral eyelid crease, part of ever y con sult at ion an d st rategy for global
an eyelid w ith ou t a crease, or an eyelid w ith a rejuven at ion . How ever, it is advisable to alw ays
previously surgically created crease. be m ore con ser vat ive w h en it com es to ablat ive
tech n iqu es ow ing to th e in creased risk an d t im e of
convalescen ce for th e Asian pat ien t .
303
304 V Facial Skin and Hair Rejuvenation
su re can act u ally be w orse for aging th an sm oking or oth er w h en lling an Asian face n ot to do so as robustly in m any
n icot in e u se, an d th at su n an d n icot in e togeth er can be n eg- cases as for th e ver y gaun t faces th at are often seen in oth er
at ively syn ergist ic. Fu rth er, Asian s w h o rem ain in Asia t yp i- races. In fact , lling areas aroun d th e periorbital an d ch in
cally h ave h ealth ier diets th an th ose Asian s w h o m igrate to region s can m ake a face act u ally appear slim m er if don e in
th e West , w h ich can fur th er m ain tain th eir youth fu l m ien . a ju diciou s fash ion (Fig. 23.1). A fu r th er w ord of cau t ion is
All bet s are o w h en th e Asian decides to t ravel to th e West th at in m any Korean faces, lling th e m alar region can be
to set tle an d th en adopts Western h abits of sun bath ing deem ed m asculin izing sin ce it can squ are o a w ide face;
an d con su m pt ion of processed an d h eavily adip ose-laden in fact , m any Korean s pay to h ave th eir m alar bon es sur-
foods. Never th eless, th e gen et ic n at u re of th e Asian skin gically redu ced an d collap sed inw ard. Th is cu lt u ral sen si-
t yp e can p rovide relat ive protect ion again st aging d esp ite t ivit y sh ould be verbally addressed an d h eeded to avoid a
th e adopt ion of such adverse lifest yle ch anges. m iscalcu lated ou tcom e.
Th ere are t w o prin cipal m ech an ism s for volu m izing a
face, fat graft ing (a su rgical m odalit y) an d inject able ll-
■ Volume Loss and ers (an in -o ce procedu re). Fat graft ing is ver y e ect ive
a b a b
scar form at ion th an Cau casian s, at t im es a th icker scar m ay th e crease to be too h igh an d th ereby ren der th e appear-
d evelop in th e don or area. Fu rth er, because th e don or h air an ce u n n at u ral in m y op in ion . Sim ilarly, brow lift ing can
is ver y dark black an d ver y st raigh t , th e w h ite lin e of a scar m ake a su prat arsal crease too h igh in an Asian , esp ecially
can be m ore visible th an in m any oth er races. Th ese con sid- if p erform ed in conju n ct ion w ith eyelid skin rem oval. Con -
erat ion s are m ean t to ser ve on ly as gu idelin es for a p hysi- versely, fat graft ing an d llers m ain tain or low er th e eyelid
cian w h o is in terested in perform ing a h air t ran splan t in an crease. Accordingly, if skin is rem oved or a brow lift per-
Asian pat ien t , an d are n ot in ten ded to frigh ten or m islead form ed, I alm ost alw ays use som e level of lling to bring
eith er a prosp ect ive su rgeon or p at ien t . th e eyelid crease h eigh t back dow n as n eeded (Fig. 23.6).
Recen tly, th ere h as been a rise in th e use of regen era- On e oth er p oin t th at sh ou ld be st ressed is th at an eye-
t ive m edicin e tech n iqu es th at I like to refer to as “fert ilizers” lid crease, un fort un ately, is not an all-or-n on e proposi-
sin ce th ese adju n ct ive m easu res h elp t ran sp lan ted h airs t ion . Th ere are par t ial creases, an d a pat ien t can h ave a fu ll
grow m uch bet ter, faster, an d m ore con sisten tly. Th e don or crease on on e side an d a part ial crease on th e oth er side.
scar can be h elp ed w ith th ese p rodu ct s as w ell. Th e th ree Typically, th e side w ith th e par t ial crease h as a n arrow er
m ajor p rodu ct s th at w e u se are Mat riStem (ACell), p latelet- palpebral apert ure th at resem bles t rue ptosis. W h en I
rich p lasm a (PRP), an d aden osin e t rip h osp h ate (ATP). It lies speak of an Asian born w ith an eyelid crease, I am speaking
beyon d th e scope of th is ch apter to discuss h ow an d w hy on ly of Asian s w h o h ave 100%com plete full creases bilater-
each of th ese p rodu ct s is u sed . Su ce it to say th at I believe ally. Part ial creases of any degree really beh ave abou t th e
th ese produ cts are in dispen sable for ever y h air t ran splan t sam e as n o creases at all an d sh ou ld be p laced in to th at cat-
p rocedu re th at I p erform an d can be ver y h elpfu l to ach ieve egor y, w h ich I w ill discu ss n ext .
bet ter outcom es w h eth er th e pat ien t is Asian or n ot . Th e tem ptat ion w ith th e Asian w h o is born w ith out a
crease is sim ply to perform a st an dard bleph aroplast y in
w h ich eyelid skin is rem oved an d n o xat ion is perform ed
■ Aging Asian Eyelids and to create a crease. Sin ce th ere is n o crease, w h ere does th e
Brow s, and Eyelid Rejuvenation su rgeon m ake th e in cision ? Th ere is n o good an sw er. I h ave
not iced th at w h en on e sim ply rem oves th e skin in th ese
pat ien t s, th ere is n o discern ible result , th at is, n o im prove-
I h ave w rit ten abou t th is topic before in oth er textbooks,
m en t . In stead, a visible scar m ay becom e ap p aren t sin ce
an d I believe I h ave com e to a good u n derstan ding of h ow
th e skin can n ot fold over a crease th at doesn’t exist . If th e
to h elp a su rgeon t r ying to m an age th e com plex top ic of
su rgeon con cu rren tly t ries to rem ove fat from th e p ost sep -
th e aging Asian eyelid. I h ave divided th e aging Asian eye-
lid in to th ree categories: Asian s born w ith a n at u ral supra-
tarsal eyelid crease, Asian s w h o do n ot h ave a crease, an d
Asian s w h o h ave h ad a previou sly surgically created crease.
By ap proach ing an Asian p at ien t in th is fash ion , th e su r-
a b
geon sh ou ld be able to n avigate th is issu e safely to develop
th e best outcom es for a part icular in dividu al.
Let u s begin w ith Asian s w h o are born w ith a n at u ral
eyelid crease. Th ese in dividu als are perh ap s th e easiest
categor y to m an age. Becau se of th e crease, th eir eyelid
beh aves alm ost iden t ically to a Caucasian on e, an d accord-
ingly th e sam e opt ion s are available. If th e eyelid skin h angs
over th e ciliar y m argin , I recom m en d a con ser vat ive u p p er
bleph aroplast y, rem oving skin on ly. I alm ost alw ays recom -
m en d ad ding som e kin d of volu m e to th e u p per eyelid an d
brow sim ult an eously or in a st aged procedure. As I h ave
th orough ly discu ssed, de at ion of th e brow an d upper eye-
lid is th e p rin cipal m ech an ism by w h ich aging occurs in all
races. Th erefore, I believe th at eyelid skin rem oval is on ly
a su pp ort to re-in at ion of th e eyelid an d brow. Fu r th er,
I believe th at brow lift ing is u n n ecessar y an d det rim en - Fig. 23.6 A Chinese patient who has ptosis on her right side and
what appears to be too high a supratarsal crease even though she
tal. On e caveat is w orth issuing h ere: I rem ove skin on ly
has never had a previous eyelid surgery. The height of her crease
w h en it appears to be h anging at or over th e ciliar y m ar-
is high most likely from volume loss as well as acquired ptosis. She
gin . If th ere is st ill a ver y visible dist an ce of 1 to 3 m m of had full facial fat grafting that improved her eyelid position and
exp osed su p ratarsal crease w h en th e p at ien t h as h is or h er contour, thereby rejuvenating her upper eyelid. She also underwent
eyes op en on for w ard gaze, th en I do n ot recom m en d any a transconjunctival blepharoplast y. (a) Before the surgery. (b) After
addit ion al skin rem oval becau se su ch rem oval w ou ld cau se the surgery.
308 V Facial Skin and Hair Rejuvenation
The nal categor y is the Asian patient w ho has had a pre- as a preven t ive m easu re again st recu rren ce an d as a rst
viously surgically created crease. You could potentially treat at tem pt to see h ow m uch im provem en t can be h ad sh or t
this patient just like an individual born w ith a natural crease. of surger y. Th ere really is n o di eren ce in m y facelift tech -
However, the reason this is a separate category has a lot to niqu es for an Asian n eck an d a Caucasian n eck. I t ypically
do w ith how high the previous crease w as m ade and how use sh or t in cision s th at on ly circum scribe th e ears an d do
long ago. Back in the 1980s, a procedure know n as West- not exten d in to th e h air-bearing area, along w ith an in ci-
ern ization w as in vogue, in w hich a lot of skin and fat w as sion in th e su bm en t al region , w h ich I believe can be u n iver-
rem oved and a high crease created. Over tim e, as the patient sally accept able n o m at ter th e race. Becau se th e Asian skin
ages, the skin around the crease continues to de ate, m aking is th icker an d m ore elast ic th an th at of m any fairer-skin n ed
the crease look m uch sm aller than it w as originally. How - races, often I do n ot rem ove a lot of skin during th e su rger y,
ever, this low er crease cannot be treated as a norm ally low but th at is n ot th e poin t of a facelift anyw ay.
crease. The reason for this is that if skin is further rem oved An oth er procedu re th at can be ver y h elpful for m any
from this patient, the previously abn orm ally high crease w ill Asian s, w h eth er a facelift is perform ed or n ot , is an allo-
ret urn and the patient m ay experience lagophthalm os. The plast ic ch in im plan t . (I use th e exten ded an atom ic Con -
way th at the physician can determ ine if th e crease w as m ade form im plan t m an ufact u red by Im plan tech .) Many Asian s
too high is sim ply to lift up th e eyelid skin and look at w h ere have a ret ruded ch in along th e in ferior border as w ell as
the crease w as fashioned. Just by doing this sim ple m aneu- prem axillar y de cien cy. Adding a ch in im plan t can provide
ver during the consultation, the surgeon can easily deter- im proved skelet al project ion an d ren der th e face less fu ll
m ine if th e crease w as m ade very h igh and the eyelid tissue an d rou n d in asp ect . In add it ion , I believe a ch in im plan t
excavated (i.e., already excessively rem oved). Another option in an Asian can be h elpful in im proving a facelift resu lt for
is just to look at the patient. With previous surgery the eyelid th ree reason s. First , th e n eck length is in creased, m aking
w ill look som ew hat unnatural but it m ay not be apparent th e n eck appear im proved w ith out th e n eed to perform a
w hy to the surgeon since the crease height can be relatively lift ing procedure in m any cases of early t issue descen t . Sec-
low. The reason for this is that the crease prim arily consists on d, th e ch in im plan t can provide a fulcrum aroun d w h ich
of thick brow skin that has been folded over, m aking the eye- th e lift ing of th e t issues is im proved, as w ou ld be th e case
lid look deep set and bizarre. I believe that the only w ay to in any in dividual w ith w eaker skeletal support . Fin ally, th e
im prove this situation is w ith volum ization using either fat ch in im plan t can disrupt th e m an dibular ligam en t , a retain -
grafting or llers. I w ould contend that any oth er m eth od ing st ruct u re th at lim it s th e abilit y to lift th e t issues e ec-
would com prom ise the desired outcom e by return ing the t ively. William Bin der, w h o lect ures on th e subject , believes
patient to the m ore unnat ural state of m any years ago. th at th e perm an en t in terposit ion of th e ch in im plan t w ill
bet ter m ain tain th e posit ion of th e jaw lin e sin ce th e m an -
dibular ligam en t n ever re-adh eres.
As far as neck adiposit y is con cerned, for the younger or
■ Low er Facial Aging and older pat ient I prefer to open the neck t issues sharply w ith
Rejuvenation scissors an d th en select ively rem ove ju st th e righ t am ou n t of
adipose tissue, taking care to leave en ough fat on top of th e
Fort u n ately, for m any Asian s th e low er face does n ot age plat ysm a that plat ysm al dehiscen ce does not show up after-
as m u ch as in Cau casian s. Th eir th icker an d solar-resist an t w ard if a facelift is n ot being sim u ltan eously perform ed. I
skin h elps th em to keep th eir n eck posit ion bet ter for a believe that judicious an d selective rem oval of pre-plat ys-
m u ch longer p eriod th an for Cau casian s. How ever, aging m al adipose tissue w ith ou t a con curren t rhyt idectom y can
st ill w ill sh ow u p in th e Asian , even th ough it m ay do so be undertaken in som e Asian s even into their 50s, unlike in
a decade or t w o later th an in oth er races. A preven t at ive fair-skin n ed in dividuals, in w h om I gen erally am con cern ed
m an euver th at I u se in all races to delay th e n eed for a face- about doing so after ~ 40 to 45 years of age for fear th at th e
lift is rout in e applicat ion of n eu rotoxin to th e p lat ysm al plat ysm al bands w ill becom e m ore eviden t if no con curren t
bands (using ~ 10 to 15 un it s of bot ulin um toxin ). Pat rick tighten ing procedure is undertaken. I alm ost never perform
Trevidic, from Paris, Fran ce, h as presen ted convin cing evi- liposuction using a cannula anym ore because I believe that
den ce th at in dividuals w h o h ad st rokes m any years prior it overskeletonizes a neck that can already be skeletonized
su er n o n eck aging on th e a ected/st roked side. I h ave in appearance from aging. Accordingly, m y liposuct ion
seen clin ical evid en ce of ongoing im p rovem en t in th e n eck m ach in e gen erally sits in th e corn er of m y operat ing room
w ith con t in uous n eurotoxin used to ret urn th e n eck to a collect ing dust. A com bin at ion of judicious lipocon touring,
m ore you th fu l st ate. Obviou sly, if th e n eck h as already ch in augm en tation , an d rhyt idectom y often can provide far
con siderably advan ced in aging, it w ill be di cult to ele- bet ter results th an any one procedure alone, but obviously
vate th e n eck t issu e w ith ou t a form al rhyt idectom y. Even m ust be un dertaken in th e righ t can didate w h o w ould ben -
in th ese cases, I like o ering n eurom odu lator t reat m en t s e t from all th ree of th ese treat m en t st rategies.
310 V Facial Skin and Hair Rejuvenation
Pearls
• Reducing th e in it ial excessive expect at ion s of th e • Using an ideal grip tech n iqu e is im port an t in
pat ien t by adequate coun seling is im port an t . in creasing sur vival an d redu cing th e com plicat ion s
• Th e st ruct u ral an d fun ct ion al relat ion sh ip of of fat graft ing.
th e aging an d soft t issue fou n dat ion s un der th e • Fat inject ion s m ust alw ays be perform ed as th e
in u en ce of gravit y sh ould be con sidered to avoid an syringe or can n u la is being d raw n back to p reven t
u n n at u ral facial con tou r after fat graft ing. vascu lar occlu sion .
• Fat graft ing ach ieves volum et ric lift ing by • W h en inject ing fat in to th e foreh ead area, th e
st rength en ing soft t issu e fou n dat ion s an d restoring su rgeon is st rongly recom m en d ed to inject
volu m e de cien cy. bot ulin um toxin before th e procedu re for bet ter fat
• Com m on fat h ar vest ing sites are th e abdom en an d su r vival, w ith th e except ion of pat ien t s w h o h ave
lateral th igh , follow ed by th e m edial th igh an d an k. eyelid ptosis.
• Fat graft ing of th e face sh ould be perform ed • Fat inject ion is n ot a procedure w ith ou t
sequ en t ially from th e p ostero-su p erior to th e com plicat ion s. Serious com plicat ion s such as
an tero-in ferior area an d from th e deep layer to th e in fect ion an d vascular occlu sion alw ays n eed both
su p er cial layer. th e surgeon’s an d th e pat ien t’s at ten t ion .
• Pressing or m assaging after fat inject ion m ust be
avoided sin ce it can dam age m at ure adipocytes.
Separation of Aspirates
After h arvesting, th e fat aspirate is centrifuged at 1,200 g
b
for 3 m in utes.6 Free oil should be rem oved by holding the
syringe diagonally and pouring the oil out. Th e contam in ated Fig. 24.2 Separation and transfer of fat. (a) Lipo-aspirate before
portion can be absorbed or w iped by m oist gauze w ith ster- the centrifugation (left), fractionated lipo-aspirate after centrifuga-
ile saline. After elim inating the free oil, the low er fraction, tion, separated into three layers (supranatant oil layer, middle real
w hich contains blood and t um escent solution, is discharged fat layer, and infranatant layer, which is composed of blood, tissue
an d th e puri ed fat is then transferred from the 10-m L Luer uid, tumescent solution, and puri ed fat after removing suprana-
lock syringe to a 1.0-m L disposable syringe (Fig. 24.2). tant and infranatant layers (right). (b) Direction of fat transfer from
10-mL Luer lock syringe to 1.0-mL Luer slip disposable syringe.
Fat Injection
Region al in lt rat ion of an esth esia w ith a 1% lidocain e w ith
ep in ep h rin e (1:100,000) m ixt u re is injected in to th e en t r y
site of fat inject ion for sen sor y n er ve block. Th e su p raor-
ce
Zone I
n
e
Line 1
n
io
1
Line 2 3 Zone II
ing, pain , an d vascu lar em bolizat ion in th e tem ple, orbital,
buccal, an d pre-auricular area. Line 3 8
2
To ach ieve a successful outcom e in fat inject ion , appro- 13 9 5
Line 4 10 6 Zo n e
priate design an d sequen t ial inject ion are im port an t . Th e 14 4 III
20 11
au th or in t rod u ced th e sequ en t ial au tologou s fat inject ion 17 7
g
15
in
g
12
h
18
s
system ic ap proach . 16 Zo n e IV
f
w
o
in n
19
g
o t io
21
p
c
d ir e
ro
Zo n e
V
Low er Face Regions)
For SAFI, four lin es divide th e lateral face in to ve zon es Fig. 24.3 Four SAFI lines and possible areas for injection. The four
(Fig. 24.3). Each zon e h as several areas for fat graft ing. Th e SAFI lines that divide the face into ve zones are (1) Line 1, con-
areas n u m bered 1, 3, 6, 9, 11, 13, 14, 15, 17, 18, 19, an d 21 necting the temporal hairline and the anterior auricular border; (2)
Line 2, connecting the orbital ligament, the posterior border of the
are th e areas w h ere m ost of th e pat ien t s w an t fat graft ing.
orbital process of the zygoma, the zygomatic retaining ligament,
Th e oth er n um bered areas are th e sites w h ere th e physi-
and the posterior border of the super cial masseter muscle; (3)
cian sh ould inject fat for providing st rong skelet al support , Line 3, connecting the zygomatico-maxillary suture, the anterior
st rength en ing th e soft t issu e fou n dat ion , an d p reven t ing inferior prominence of the maxilla, and the anterior border of the
gravit at ion al descen t . Th e p lacem en t an d injectable vol- super cial m asseter muscle; (4) Line 4, connecting the nasolabial
u m e of each SAFI area are described in Table 24.1. fold and the labio-m andibular fold.
314 V Facial Skin and Hair Rejuvenation
Table 24.1 Areas, placement, and volume of fat grafting in the face
I 1 Temporal scalp area within Augm ent and strengthen The space bet ween super cial 2.0–3.0
5 cm from the hairline soft tissue foundations temporal fascia (STF) and
deep temporal fascia (DTF),
2 Sideburn and its posterior subcutaneous super cial fat layer, 1.0–2.0
temporal area and inferior temporal septum
II 3 Temporal hollow Strengthen soft tissue Orbital ligament and inferior 2.0–4.0
foundations temporal septum
4 Pre-auricular area Augmentation Sub-SMAS and super cial fat layer 2.0–3.0
(Super cial temporal fat pad)
5 Zygom atic arch Strengthen soft tissue Zygom atic retaining ligam ent 0.5–1.5
foundations
6 Lateral cheek depression Augmentation Deep lateral cheek fat, SMAS, and 1.0–2.0
subcutaneous super cial fat layer
7 Parotid gland area Augm entation Subcutaneous super cial fat layer 1.0–2.0
III 8 Lateral canthal area Augm entation On the periosteum and under the 0.5–1.0
orbicularis oculi muscle
9 Palpebro-malar groove Strong skeletal support Under the orbital retaining 0.5–1.5
(lateral trough deform it y) and augmentation ligament, on the periosteum of
anterior area to arcuate m arginalis,
above the orbital retaining
ligament, and SOOF
Fig. 24.4 sh ow s th e locat ion of en t r y sites, inject able Fat injection is perform ed in a system at ic m anner: (1) in
areas, an d advan cing direct ion s for th e can n u la in perform - the sequence of zones I, II, III, IV, and V; (2) from the postero-
ing SAFI. Th e arrow s from each en t r y site in dicate th e d irec- su perior area to th e an tero-in ferior area w ith in th e sam e
t ion s an d approach able areas for th e can n u la. How ever, th e zone (Fig. 24.3); an d (3) in th e sequen ce of deep, m iddle,
select ion of th e en t r y sites d ep en ds on th e st at u s of th e an d super cial layer w ith in an area or its subarea (Fig. 24.5).
pat ien t s an d th e preferred post ure or conven ien ce of th e For exam ple, th e subm alar h ollow is divided in to t w o
physician . su bareas (an terior an d lateral) becau se th is area is relat ively
24 Facial Fat Grafting 315
IV 13 Tear trough deformit y Strong skeletal support On the periosteum of the inferior 1.0–2.0
and augm entation orbital rim, under orbital retaining
and bucco-maxillary ligam ent,
SOOF, and preorbital subcutaneous
super cial fat layer
14 Midcheek furrow Strong skeletal support Bucco-maxillary ligam ents, above 2.0–4.0
and augm entation the periosteum and under the lip
levator muscles (deep medial cheek
fat, a part of SOOF), and super cial
medial cheek fat.
20 Pre-maxillary and upper Strong skeletal support On the periosteum of the piriform 1.0–2.0
lip area and augm entation area and deep fat
Abbreviations: DTF, deep temporal fascia; SMAS, super cial musculoaponeurotic system ; SOOF, suborbicularis oculi fat; STF, super cial
temporal fascia.
*Volume: Injectable fat (mL/one side of face)
w ide an d h as a h igh risk of sagging due to th e w eak soft t is- sion , inject ion in to th e w h ole layer of th e d ep ressed area
su e fou n dat ion . Fat is sequ en t ially injected in to th e su pra- is n ecessar y.
p eriosteal layer of th e zygom a an d m axilla for in creasing
skelet al su p p or t , in to th e m asseteric cu tan eou s ligam en t
for st rength en ing th e soft t issu e fou n dat ion , an d in to th e Forehead Region
at roph ied bu ccal fat p ad for in creasing fu lln ess (Fig. 24.6).
Th e n asolabial fold con sists of t w o part s: th e lateral Th e foreh ead also can be divided in to ve zon es based on
bulging caused by volum e-depleted pseu do-ptosis an d th e th e st ru ct ures related to th e m orphology an d aging of th e
m edial dep ression cau sed by th e loss of volu m e. To correct foreh ead . Fat is injected in th e sequen ce of zon es I, II, III,
th e lateral bulging, fat is injected to th e m alar, m idch eek IV, an d V as sh ow n in Fig. 24.7. W h en p erform ing foreh ead
fu rrow, an d su bm alar area. To correct th e m edial depres- fat graft ing, fat sh ou ld be rst injected in to area above th e
316 V Facial Skin and Hair Rejuvenation
B
B
B
o
o
o
n
n
n
e
e
e
a
Skin
Skin
1
1 5 5
8 8 2
B
2 6 10 10 6
o
n
B
9 9 3
e
o
3 7
n
7
e
4 4
Fig. 24.4 Possible entry sites and directions of injection. The Fig. 24.5 Sequential depth of fat injection. (a) As the fat is
arrows from each entry site indicate the directions of injection and injected closer to the underlying skeleton, the e ect of the sup-
approachable areas for the cannula. porting skeleton is stronger and the chance of gravitational descent
is less. (b) As the fat is injected more into the deep level, the pos-
sibilit y of injected fat descending inferiorly becomes less.
Upper
Lower depressed
depressed area
area
Skin a
Retaining ligament
Muscle
Fig. 24.6 Sequential fat injection in t wo abut ting areas of the face. When
injecting t wo depressed areas that are abut ting (a), fat should be injected into
the upper depressed area rst followed by the lower area, including soft tissue
and retaining ligament (b). This technique helps to decrease the volume of c
injected fat in lower areas and skin becomes more tense. Eventually, it can also
prevent soft tissue sagging induced by gravitational descent. Injecting fat in
the reverse order (c) is not recommended.
24 Facial Fat Grafting 317
areas. App roach ing zon es I to III is also easy from en t r y site
Zone I B. Zon e IV in cludes th e m ost depressed area in th e fore-
head. If deep h orizon tal foreh ead w rin kles are presen t in
Zone II zon e IV, en t r y at site C along th e w rin kles is selected.
Irregu larit ies an d lu m ps occu r frequ en tly in foreh ead
fat graft ing. Mold ing th e irregu lar areas is often perform ed
Zone III
for a sm ooth an d even su rface, bu t it is n ot usually recom -
m en ded . Ad dit ion ally, it is st rongly recom m en ded to inject
Zone IV bot ulin um toxin before th e procedure for bet ter fat sur-
vival, except in pat ien t s w h o h ave eyelid ptosis. Th e bou n d-
aries of th e zon es an d th e am ou n ts of fat to be injected are
Zone V
described in Table 24.2.
Table 24.2 The boundary of SAFI zones, purposes, placement, and volume of fat grafting in the forehead
II Upper third of forehead Anterior projection and Subgaleal space, super cial fat layer 1–2
natural lateral contour
III Middle third of forehead Anterior projection and Subgaleal space, super cial fat layer 1–3
natural frontal em inence
IV Lower third of forehead Strong skeletal support Supraperiosteal layer or subgaleal space, 2–4
intramuscular, galeal fat pad, super cial fat layer
V Brow area below zone IV Volum e recovery and Supraperiosteal layer or subgaleal space, 1–2
strong skeletal support glabella fat pad, brow fat pad (ROOF),
super cial fat layer
Fig. 24.8 Baton grip technique for fat grafting. The barrel of the
syringe is positioned bet ween the tip of the thum b and the distal
interphalangeal joint of the index nger. The rest of the plunger is
positioned in the junction bet ween the hypothenar eminence and
the medial side of the palm . Other ngers hold the barrel of syringe
as if they were grabbing an egg. (a) Lateral view of the exion state.
(b) Lateral view of the extension state.
3. Tu m escen t solut ion sh ould n ot be injected sudden ly any lu m p an d bu m p st ill exist s, excision is recom m en d e d .
in a h uge volum e w ith h igh pressu re; th is could Th ese com p licat ion s can be p reven te d if an ad e qu ate vol-
cause th e developm en t of a lake in th e t issu e, w h ich u m e of fat is p laced at t h e op t im al laye r u sin g a p recision
could lead to in su cien t an d un even liposuct ion . syr in ge gr ip tech n iqu e.
4. The baton grip tech n ique of using th e syringe in fat
inject ion h elps to in crease th e sur vival of grafted fat
an d to decrease com p licat ion s. Asymmetry and Hyper- and
5. W h en correct ing tear t rough deform it y, th e en d Hypo -Correction
p oin t of fat graft ing is a st at us th at is sligh tly un der-
corrected in th e supin e posit ion . Occasion ally, som e p at ien ts com p lain of asym m et r y im m e-
diately after fat graft ing. Edem a or in appropriate correc-
6. In foreh ead fat graft ing, fat is injected in to th e
t ion is th e m ost com m on cau se of asym m et r y. Th is can be
area above th e fron t al h airlin e ben eath th e galea
im proved w ith adju st m en t of volum e by perform ing eith er
ap on eu rosis an d fron t alis m u scle to t igh ten th e
liposuct ion or addit ion al fat graft ing at least 1 m on th after
fron t alis m u scle an d th u s h elp to redu ce p hysical
th e procedu re.
st ress on th e grafted fat .
7. Inject ing bot ulin um toxin before graft ing in creases
th e sur vival of grafted fat in th e foreh ead. Migration and Gravitational Descent
Early m igrat ion is m ain ly caused by direct pressure on th e
■ Complications and in lt rated site or act ive m ovem en t of th e m im ic m u scle. It
m igh t be im p roved by m olding w ith gen tle d igit al pressu re
Their Management or preven ted by pret reat m en t w ith bot ulin um toxin . Late
m igrat ion u su ally occu rs in th e areas of th e n asolabial folds,
Edema, Bruising, or Hematoma ch eeks, an d jow ls an d is caused by gravit at ion al descen t
due to th e w eigh t of th e injected fat . Th e prin ciple of correc-
Edem a or persisten t edem a (longer th an 2 w eeks) m ay t ion is to do proper liposuct ion of th e descen t area rst an d
occur due to t issue dam age during pre-t un n eling an d injec- th en do volum et ric fat graft ing in to th e depressed area. But
t ion , hypo-osm olarit y due to th e t um escen t uid, an d sev- som et im es facelift su rger y is n ecessar y for p at ien t s w h o
eral oth er system ic diseases. To avoid or m in im ize edem a, have severe laxit y of skin . It is suggested th at applicat ion of
adequ ate tap ing is m ost im p ort an t . Prolonged edem a th e SAFI tech n ique an d pret reat m en t w ith bot u lin u m toxin
sh ou ld n ot be con fu sed w ith hyp er-correct ion , h em atom a, are reliable ap proach es to p reven t th ese com p licat ion s.
in am m at ion , or factors due to system ic diseases. Gen er-
ally, a m edical device th at accelerates lym p h at ic circu lat ion
can be h elpfu l to reduce edem a. Resorption of Fat
Th e m ajor cause of bruising or h em atom a is vascu lar or
m u scu lar dam age cau sed by th e can n u la du ring inject ion . A Resorpt ion of grafted fat is th e m ost seriou s com m on com -
precise inject ion grip tech n ique sh ould be applied, an d th e plain t by pat ien t s. Many environ m en t al an d tech n ical fac-
bleeding ten den cy of th e pat ien t sh ould be ch ecked before tors are related to th e su r vival rate of injected fat . To redu ce
th e procedu re. th is com plicat ion , applying ADSC, pret reat m en t w ith bot-
ulinu m toxin , even placem en t of fat using th e baton grip,
cessat ion of sm oking, postoperat ive lim it at ion of facial an i-
Irregularity, Lump, and Bump m at ion , an d on e or t w o session s of addit ion al fat graft ing
are requ ired .
Th e occu r ren ce of ir regu lar it y, lu m p , an d bu m p u su ally
d ep en d s on t h e p hysician ’s gr ip tech n iqu e, exp er ien ce,
an d aest h et ic se n se. Mold in g of t h e ir regu lar areas is Hyperpigmentation and Scar
ofte n p e r for m ed for a sm oot h an d even su r face d u r in g
t h e p roced u re, alt h ough it s e ect is lim ite d . If t h e lu m p is Hyperp igm en t at ion is frequ en tly fou n d in th e orbit al an d
seen or felt d u r in g or w it h in 2 w eeks afte r t h e p roced u re, periorbit al area w ith bruising after fat graft ing. Th e sur-
it sh ou ld be rem oved p rop erly w it h lip olysis-assisted or geon sh ou ld app ly su n block cream an d p rescribe 2 to 4%
m an u al lip osu ct ion . Also, if any ir regu lar it y is se en afte r hydroqu in on e cream on e or t w o t im es per day if it becom es
rem oval of t h e lu m p , it is advisable to cor rect it im m e- w orse. In th e pat ien t w ith sen sit ive skin , h alf-st rength
d iately w it h ad d it ion al fat graft in g. Som et im es, t w o or hydroqu in on e cream is applied. Th e applicat ion of in ten se
t h re e inject ion s of cat abolic steroid solu t ion can h elp to pulsed ligh t an d Q-sw itch Nd: YAG laser m igh t also be
red u ce t h e size of lu m p an d bu m p . Desp ite all at tem p t s, if helpfu l to im prove hyperpigm en tat ion . Dam age of approxi-
320 V Facial Skin and Hair Rejuvenation
Acneiform Eruption
Acn eiform eru pt ion is cau sed by excessive oil form at ion
from dest royed fat cells after fat graft ing. It frequ en tly
develops in pat ien ts w ith oily skin an d previous acn e h is-
a
tor y. It can be im p roved by adequ ate clean sing of th e face
an d adm in ist rat ion of drugs for ~ 7 days.
Vascular Embolization
or surroun ding bran ch es of an ar ter y w h en fat is acciden tly
Alth ough th e occu rren ces of vascu lar occlu sion from fat injected in to th e ar ter y. If a large am oun t of fat is injected
graft ing h ave sign i can tly decreased w ith th e u se of th e in to th e ar ter y w ith h igh pressure, th e fat can be re u xed
blu n t can n ula, it st ill exists. It is kn ow n to occur frequen tly in to th e in tern al carot id ar ter y. Even t ually, a seriou s com -
after facial fat graft ing at th e region s of th e glabella, n asola- plicat ion su ch as st roke m ay occur.15,16 Blin dn ess occurs
bial folds, n ose, an d tem poral area (Fig. 24.11). con cu rren tly w ith sudden orbit al or periorbit al pain du ring
Region al com p licat ion s such as skin n ecrosis 13 an d or im m ediately after th e fat graft ing. No in st an ces of visual
blin dn ess 14,15 can be cau sed by occlu sion of an en d bran ch restorat ion h ave been reported after fat graft ing–in du ced
24 Facial Fat Grafting 321
blin dn ess, but sym ptom s of brain in farct ion h ave partly accom pan ied by volu m e redu ct ion of th e tem p oral, m alar
resolved in a few cases as t im e passed.14,15,16,17 an d su bm alar areas, an d th e lateral ch eek. Six m on th s after
On th e oth er h an d, if th e fat is injected in to th e vein , fat graft ing, th e overall facial con tou r ch anged to an oval
it goes th rough th e h ear t an d th en blocks th e pu lm on ar y or reversed t riangle sh ape, an d asym m et r y sign i cantly
arter y. Su dden sw eat ing, dyspn ea, an d t achyp n ea can be im proved in th e fron t al view (Fig. 24.13). Th is su ccessfu l
m an ifested as t ypical sym ptom s of n on th rom bot ic pu lm o- volu m e red ist ribu t ion m ade th e face look lifted n at u rally in
n ar y em bolism du ring fat graft ing.18 th e postero-superior direct ion also. Th e m ost rem arkable
It app ears th at th e m obilit y of th e vessel is sign i can tly ch ange is th e ogee cur ve in th e m idface. Th e com pletely
redu ced after th e rst fat graft ing du e to brosis an d fu ll- isolated ogee cur ve becam e con n ected an d roun d by th e
n ess of th e in lt rated area. Th u s, in spite of u sing th e blu n t an terior p roject ion th rough fat graft ing.
can nula, th e vessels m ay h ave a m u ch h igh er ch an ce of
being pen et rated w ith re-inject ion of th e previou s in lt ra-
t ion site th an w ith th e prim ar y fat inject ion . Even w h en
th e fat is injected for th e rst t im e, fulln ess due to over-
correct ion can also reduce th e m obilit y of th e vessels, th u s a b
in creasing th e p ossibilit y of pen et rat ion .
Th ese serious com plicat ion s can be preven ted by avoid-
ing over-correct ion an d u sing a cau t iou s ap proach in th e
secon d an d th ird session s of fat graft ing. It is im port an t to
inject fat n ot w h en th e can n u la is pu sh ed ah ead, bu t w h en
th e can n ula is being draw n back. Avoid inject ing fat parallel
to th e cou rse of a vessel an d u se ep in ep h rin e for con st rict-
ing vessels. Add it ion ally, em ergen cy care m u st alw ays be
ready an d th e p at ien t m ust be t ran sferred im m ediately to
th e secon dar y or tert iar y care cen ter for fu rth er appropri-
ate treat m en t w h en vascu lar occlu sion occu rs.
Complications of the Donor Site Fig. 24.12 Case 1. Whole face volume recovery with fat grafting.
(a,b) The patient before the procedure (unpowdered state).
Severe com p licat ion s from lip osu ct ion occu r rarely sin ce
on ly a relat ively sm all am oun t of fat is n eeded for facial
fat graft ing. Th e possible com p licat ion s from lip osu ct ion
in clu de depression or irregu larit y, bleeding an d h em atom a,
brosis, hyp erp igm en tat ion , p aresth esia an d p ain , in am -
a b
m at ion , serom a, scar, n ecrosis, fat em bolism , th rom boem -
bolism , an d toxic sh ock syn drom e.
■ Case Studies
Case 1: Whole Face Fat Grafting
A 30-year-old w om an w an ted to im prove h er angu lar face
(Fig. 24.12). Sh e h ad dark circles w ith in fraorbit al h ollow s,
deep n asolabial folds, volu m e de cien cies of th e lateral
ch eek, tem poral h ollow s, an d a at foreh ead. A tot al of
65 m L of puri ed fat w as u sed for inject ion in to th e face
an d foreh ead. A p reop erat ive view sh ow s a long, rect an -
gu lar, asym m et ric face w ith a sagging ap p earan ce d u e to Fig. 24.13 Case 1. (a,b) Six m onths after the procedure (unpow-
th e developm en t of n asolabial folds an d jow ls, w h ich is dered state).
322 V Facial Skin and Hair Rejuvenation
Case 2: Low er Lid Rejuvenation Using th e m alar, palpebro-m alar groove, tear t rough deform it y,
an d m idch eek fu rrow to in crease skeletal su p port an d to
Fat Graft restore volum e de cien cy. Postop erat ively, th e lid-ch eek
jun ct ion w as sign i can tly sh orten ed, an d in fraorbital h ol-
A 33-year-old w om an com plain ed of orbit al fat p rot ru sion low n ess an d deep m idch eek fu rrow im proved rem arkably
an d tear t rough deform it y (Fig. 24.14). Using th e baton (Fig. 24.15). In creased skelet al su pp ort an d restorat ion of
grip tech n iqu e, ~ 15 m L of p u ri ed fat w as injected to soft t issu e m ade th e fat p rot ru sion less p rom in en t .
Fig. 24.14 Case 2. Skeletal supporting and volume recovering e ect Fig. 24.15 Case 2. The patient 18 months after the procedure.
of SAFI on lower lid rejuvenation. The patient before the procedure. The lid-cheek junction was signi cantly shortened and infraorbital
hollowness and deep midcheek furrow rem arkably improved after
fat injection.
Fig. 24.16 Case 3. Forehead fat grafting and pretreatment with bot-
ulinum toxin. The patient before the procedure (unpowdered state).
a b
Fig. 24.17 Case 3. (a) Five months after the rst procedure (unpowdered state). A second procedure was performed at this time. (b) Five
years after the rst procedure, and 4 years and 7 months after the second procedure (powdered state).
24 Facial Fat Grafting 323
References 10. Beeson WH, Slam a TG, Beeler RT, Rachel JD, Picerno NA.
Group A streptococcal fasciitis after subm ental tum escent
1. Fourn ier PF. Fat graft ing: m y techn iqu e. Derm atol Surg liposuction. Arch Facial Plast Surg 2001;3(4):277–279
2000;26(12):1117–1128 Com m en t in Derm atol Surg 11. Galea LA, Nicklin S. Mycobacterium abscessus infection
2003;29:898 com plicating hand rejuvenation w ith structural fat grafting.
2. Am ar RE. [Adipocyte m icroin lt rat ion in th e face or t issue J Plast Reconstr Aesthet Surg 2009;62(2):e15–e16
rest ruct u rat ion w ith fat t issu e graft .] An n Ch ir Plast Esth et 12. Villan i F, Caviggioli F, Gian n asi S, Klinger M, Klinger F. Cu r-
1999;44(6):593–608 ren t applicat ion s an d safet y of au tologous fat grafts: a re-
3. LaTren t a GS. Atlas of Aesth et ic Face an d Neck Surger y. 1st port of th e ASPS Fat Graft Task Force. Plast Recon st r Surg
ed. Ph iladelph ia, PA: Sau n ders, Elsevier; 2004:52–59 2010;125(2):758–759, auth or reply 759
4. Yoshim ura K, Sato K, Aoi N, Kurita M, Hirohi T, Harii K. Cell- 13. Dan esh -Meyer HV, Savin o PJ, Sergot t RC. Case rep ort s an d
assisted lipotransfer for cosm etic breast augm entation: sup - sm all case series: ocular an d cerebral isch em ia follow ing
portive use of adipose-derived stem /strom al cells. Aesthetic facial inject ion of autologous fat . Arch Oph th alm ol 2001;
Plast Surg 2008;32(1):48–55, discussion 56–57 119(5):777–778
5. Kuh bier JW, Weyan d B, Radtke C, Vogt PM, Kasper C, Re- 14. Teim ou rian B. Blin dn ess follow ing fat inject ion s. Plast Re-
im ers K. Isolat ion , ch aracterizat ion , di eren t iat ion , an d ap - con st r Su rg 1988;82(2):361
p licat ion of adipose-d erived stem cells. Adv Bioch em Eng 15. Dreizen NG, Fram m L. Su dden u n ilateral visu al loss after
Biotech n ol 2010;123:55–105 autologous fat inject ion in to th e glabellar area. Am J Oph -
6. Colem an SR. St ruct ural Fat Graft ing. St Louis, MO: Qualit y th alm ol 1989;107(1):85–87
Medical Pu blish ing; 2004:55–73 16. Th au n at O, Th aler F, Loirat P, Decroix JP, Bou lin A. Cerebral
7. Cer velli V, Palla L, Pascali M, De Angelis B, Curcio BC, Gen - fat em bolism in duced by facial fat inject ion . Plast Recon st r
t ile P. Au tologou s p latelet-rich plasm a m ixed w ith p u ri ed Surg 2004;113(7):2235–2236
fat graft in aesth et ic plast ic surger y. Aesth et ic Plast Surg 17. Yoon SS, Ch ang DI, Ch u ng KC. Acu te fat al st roke im m edi-
2009;33(5):716–721 ately follow ing au tologou s fat inject ion in to th e face. Neu -
8. Abu zen i PZ, Alexan der RW. En h ancem en t of au tologou s rology 2003;61(8):1151–1152
fat t ran splan t at ion w ith platelet rich plasm a. Am J Cosm et 18. Jiang X, Liu DL, Ch en B. Midd le tem p oral vein : a fatal h az-
Surg 2001;18:59–70 ard in inject ion cosm et ic surger y for tem ple augm ent at ion .
9. Niech ajev I. Lip en h an cem ent: surgical altern at ives an d JAMA Facial Plast Surg 2014;16(3):227–229
h istologic aspect s. Plast Recon st r Surg 2000;105(3):
1173–1183, discussion 1184–1187
25 Endoscopic Forehead and Brow Lift
Tee Sin Lee and Stephen S. Park
Pearls
• Th e aging upper on e-th ird of th e face is assessed as a scalp , foreh ead, an d brow com p lex; an d xat ion of
u n it , an d all aesth et ic u n it s are in terrelated. th e com plex at th e desired h eigh t .
• Th e aging brow can h ave a dram at ic im pact on • W h en a com bin ed approach to dealing w ith th e
gen eral facial exp ression , creat ing a t ired or fat igu ed brow s an d eyelids is plan n ed, EFBL is don e rst to
ap pearan ce. set th e h eigh t of th e eyebrow s an d determ in e th e
• Ptosis of th e aging brow can sim ulate am ou n t of skin to be excised .
derm atoch alasis of th e upper eyelid. • Th e advan t ages of EFBL over th e coron al approach
• Th e approach es to foreh ead an d brow lift can be are cam ou aged in cision s, sh orter recover y t im e,
divided in to open an d en doscopic. Open approach es an d less risk of alop ecia an d scalp n u m bn ess.
in clu de t ran s-bleph aroplast y, direct , m idforeh ead, • Th e disadvan t ages of EFBL are th at th e h airlin e
t rich ophyt ic, an d coron al. can be raised, redun dan t foreh ead skin can n ot
• Th e prin ciples of en doscopic foreh ead an d brow lift be excised, less con t rol in asym m et rical brow s,
(EFBL) are th e m aking of sm aller, w ell-cam ou aged in creased cost du e to m ore soph ist icated
in cision s; m axim al release of m u scu lar an d in st ru m en t s being used, an d learn ing cur ve.
periosteal at tach m en t s; ceph alic rot at ion of th e • EFBL h as been sh ow n to be e ect ive w ith last ing
outcom es. Di eren t xat ion m eth ods are available.
324
25 Endoscopic Forehead and Brow Lift 325
Fig. 25.3 Cadaveric dissection demonstrating temporal anatomy. Fig. 25.4 Intraoperative endoscopic view of the sentinel vein
A: Temporoparietal fascia on the ap side. B: Deep temporalis fascia (asterisk) seen traversing bet ween the temporoparietal fascia
demonstrating the glistening white fascia. C: A small window cre- (above) and deep temporalis fascia (below).
ated in the deep temporalis fascia to demonstrate the temporalis
muscle. Bet ween A and B: loose areolar tissue and plane of surgical
dissection.
Aging Process
As w e age, th e brow un dergoes descen t due to gravit at ion al
forces an d loss of skin elast icit y. Th e m edial brow h eigh t
is m ain tain ed by th e balan ce bet w een brow elevator (fron -
talis) an d depressors (corrugator supercilii an d procerus).
How ever, as th e fron t alis stop s at th e tem p oral fu sion lin e,
th e lateral brow receives u n opposed depression from th e
lateral par t of th e orbicularis ocu li du e to lack of fron t alis
act ion . Hen ce, th e lateral brow d escen ds earlier an d m ore
severely th an th e m edial brow.
Fig. 25.6 Conjoint fascia and brow m uscles. A: Conjoint fascia. B:
Orbital retaining ligament. The conjoint fascia requires complete As t h e lateral brow descen ds, it creates h ooding of th e
transection from the vertex to the orbit. This is approached from lateral p ar t of th e eyelid, w h ich m ay cau se obst ru ct ion of
lateral to medial (direction shown in C), and then released anterior th e visu al eld. Ptot ic brow s can por t ray th e ap pearan ce of
to posterior (as in direction D). anger, sad n ess, w orr y, an d w earin ess d esp ite th e absen ce
of em ot ion al in ten t or cau sat ive p hysical con dit ion .
Foreh ead an d glabellar rhyt ids develop as a result of
rep eated m u scu lar con t ract ion during facial expression
an d also th e p rocess of aging, w h ich produ ces skin th in n ing
an d loss in elast icit y.
■ Considerations
Brow Aesthetics
a b
Before assessing th e pat ien t , th e surgeon n eeds to kn ow
w h at th e ideal brow posit ion an d sh ape are, an d also to
u n derst an d th e p roblem th at is being addressed. Th e ideal
brow posit ion an d sh ape var y w ith sex, age, race, cult ure,
an d fash ion t ren d s. Hen ce, it is im port an t to u n derst an d
th e pat ien t’s n eeds an d con cern s before em barking on sur-
ger y. Th ere is n o on e st an dard su rger y for all p at ien ts.
Th e brow can be an alyzed in term s of its sh ape, posi-
t ion , m obilit y, an d sym m et r y w ith th e con t ralateral side.
Th e m edial brow sh ou ld begin at a ver t ical lin e draw n from
th e alar facial crease to th e m edial can th us, an d at ~ 1 cm
above th e m edial can th u s (Fig. 25.7). It sh ou ld p rogress
laterally in a clu b -like con gurat ion , gradu ally t apering
tow ard it s lateral en d. It sh ou ld ascen d su periorly to th e
ap ex an d th en t u rn in feriorly. Th e lateral brow sh ou ld en d
at an obliqu e lin e from th e alar facial crease to th e base of
th e lateral can th us. Th e h igh est poin t , or apex, of th e brow
sh ou ld be at th e lateral lim bu s. How ever, som e believe th at
th is h igh poin t sh ould be m ore lateral th an th e lateral lim - Fig. 25.7 Ideal brow position. The medial brow should begin at a
vertical line drawn from the alar facial crease to the medial canthus.
bus an d closer to th e lateral can th us. Fin ally, th e m edial an d
The lateral brow should end at an oblique line from the alar facial
lateral en ds sh ou ld lie at abou t th e sam e h orizon t al plan e.
crease to the base of the lateral canthus. The highest point of the
Th e sh ape of th e brow can be described as at , arch ing, brow should be at the lateral limbus (a) or some believe that it should
dow nw ard slan t ing, or upw ard slan t ing. Most im port an t , be more lateral, closer to the lateral canthus (b). Finally, the medial
th e brow s on th e t w o sides sh ould be in sym m et r y. and lateral ends should lie at about the same horizontal plane.
328 V Facial Skin and Hair Rejuvenation
propor t ion an d h arm ony, in cluding th e aging process of th e am ou n t of redu n dan t u p p er lid skin is determ in ed by
low er face. After rejuven at ion of th e upper face, th e low er pin ch ing an d th en m arking w ith a skin m arker. Th e
jow ls an d m arion et te lin es w ill appear m ore dram at ic in am ou n t of skin to be resected sh ou ld be ju st en ough
con t rast . Th e face can be in dish arm ony. to evert th e lid lash es to 90 degrees bu t n ot cau se
It is crit ical to give pat ien t s a m irror du ring th e con - lagoph th alm os.
su ltat ion for th em to poin t ou t th eir exact con cern s. You 6. Presence of eyelid ptosis: It is ext rem ely im port an t
can th en use th e m irror to con rm w h at th ey desire an d to assess for eyelid ptosis, as it can be th e m ajor
also to dem on st rate w h at you can ach ieve for th em . It is con t ribu tor to th e t ired appearan ce an d visual eld
im port an t for th e su rgeon an d pat ien t to h ave sim ilar goals de cit . Th e m argin al re ex dist an ce can be used. Th e
an d exp ectat ion s. ptosis m ay secon darily give rise to an asym m et ric,
Th e exam in at ion sh ould st ar t from top to bot tom . relat ive, u n ilateral brow ptosis as th e ip silateral
1. Hairlin e: Th e h airlin e is im p or t an t as it d eter m in es fron t alis at tem pts to com pen sate an d elevates th e
t h e st ar t in g p oin t of t h e u p p er face an d can be brow. Moreover, a st an dard brow lift w ill n ot correct
altered d u r in g a brow lift . If t h e h airlin e is h igh , th e com pen sator y brow asym m et r y.
it m akes t h e foreh ead ap p ear lon ger, an d fu r t h er 7. Absence of Bell’s phenom enon and lagophthalm os:
elevat ion m ay be u n d esirable. Conversely, a low Any baselin e lagoph th alm os sh ou ld be d etected
h airlin e le n d s it self w ell to a brow lift p roce d u re. A as it w ill likely be exacerbated follow ing EFBL an d
reced in g h airlin e is a m ajor factor in d eter m in in g u pp er bleph aroplast y. Bell’s ph en om en on is a
t h e p rop er su rgical opt ion sin ce scar exp osu re in n orm al p rotect ive m ech an ism for th e corn ea an d
t h e fu t u re is clearly a p roble m . Even w om en , as sh ou ld be p resen t , especially if a sm all am ou n t of
t h ey age, can sh ow sign s of t h in n in g h air in t h e lagoph th alm os occurs postoperat ively.
fron t al area. 8. Low er t w o-thirds of the face: Again , th e rest of th e
2. Height and shape of forehead: Th e h eigh t an d sh ape face sh ou ld be assessed to en su re facial h arm ony. If
of th e foreh ead determ in es if th e EFBL m eth od can sign i can t aging co-exist s in th is region of th e face,
be used. If th e foreh ead is too long an d convex, th e th e discrepan cy can be m ore dram at ic follow ing
en doscop ic in st ru m en t s m ay n ot be able to reach th e su rger y.
su p raorbit al rim an d arcu s m argin alis adequ ately,
m aking th e p rocedu re tech n ically ver y d i cu lt . A
at ter foreh ead w ith a relat ively low h airlin e is ideal
for EFBL.
Methods and Patient Selection
3. Forehead and glabellar rhyt ids: Foreh ead an d Th ere are m any m eth ods to elevate th e foreh ead an d brow ;
glabellar rhyt ids are assessed to determ in e if th ey th ese can be divided in to open an d en doscopic approach es.
are dyn am ic or st at ic. Mu scu lar hyp eract ivit y is n ot Th e various in cision s available for di eren t t ypes of brow
un com m on , an d e ort s to relax th e m uscles are lift are sh ow n in Fig. 25.8. Th e open app roach es in clu de
requ ired to bring th e brow s back to th eir n at u ral
posit ion . Th is is an im port an t step before assessing 1. Coron al approach
th e act ual posit ion of th e brow s an d th e am oun t of 2. Modi ed coron al ap p roach
redu n dan t u pper lid skin . a. Trich op hyt ic
4. Posit ion, shape, and sym m et ry of eyebrow s: Th e b. Pret rich ophyt ic
d esired h eigh t an d sh ap e of t h e brow is d eter m in ed 3. Direct brow lift
w it h t h e p at ie n t in fron t of a m ir ror. It can be
4. In direct brow lift or m idforeh ead brow lift
d iscu ssed in on ly gen eral ter m s, or a p recise
calcu lat ion can be m easu red . Th e foreh ead is rst 5. Tran s-bleph aroplast y brow lift
rela xed an d brow s are elevated to t h e d esired Th e m ain disadvan tage of th e open tech n ique is th e prob -
p osit ion an d sh ap e. A skin m arker is t h en p laced lem w ith th e surgical scar an d n um bn ess from t ran sect ion
at t h e ap ex of t h e brow at t h e d esire d h e igh t . of th e supraorbit al an d suprat roch lear n er ves. Th e scar
Next , t h e brow is released an d t h e skin m arker is can be too visible or result in alopecia along th e in cision .
allow ed to slid e u p on to t h e skin of t h e foreh ead . Going across th e sku ll or h airlin e causes scalp hypoesth e-
Th e d ist an ce m arked is t h e am ou n t of brow sia, w h ich can be discon cert ing to som e p at ien ts. Alth ough
elevat ion requ ired . Th e sam e is t h e n d on e on t h e th e t ran s-bleph aroplast y approach avoids th e m ajor issue
con t ralate ral sid e. Any baselin e asym m et r y sh ou ld of th e surgical scar, it does n ot allow a great deal of lift an d
also be p oin te d ou t . sh ou ld be regarded m ore as a brow st abilizer th an as an
5. Am ount of redundant upper eyelid sk in: With th e elevator. Th e en doscopic ap proach rem edied th ese issu es
brow s h eld at th e desired h eigh t by an assist an t , th e an d h as becom e th e tech n iqu e of ch oice for m ost su rgeon s.
330 V Facial Skin and Hair Rejuvenation
Fig. 25.8 Incisions available for di erent t ypes of brow lift. a, cor-
onal; b, trichophytic; c, pre-trichophytic; d, indirect brow or mid- Preoperative Preparation
forehead; e, direct brow; f, trans-blepharoplast y.
Preoperat ive ph otograph s sh ould be taken w ith th e pat ien t
in th e up righ t posit ion an d w ith ou t any m akeup. Skin
m arkings sh ou ld also be don e in th e u prigh t posit ion an d
Th e en doscopic approach does h ave som e disadvan - th e am oun t of brow elevat ion recorded. Th e course of th e
tages an d lim itat ion s, an d h en ce pat ien t select ion is im por- fron t al bran ch of th e facial n er ve, th e su praorbit al n otch /
tan t . It s advan t ages in clude foram en , an d su prat roch lear n otch can be m arked out on
th e skin .
• Redu ct ion in length of in cision s
• Well-cam ou aged in cision s
• Less edem a an d sw elling Incisions
• Less blood loss an d su rgical t rau m a
• Faster recover y EFBL can be don e u n der eith er gen eral an esth esia or con -
• Less scalp paresth esia sciou s sedat ion . On e percen t xylocain e w ith 1:100,000
ep in ep h rin e is u sed to in lt rate th e p lan n ed in cision s.
Disadvan t ages in clu de
Tu m escen ce solut ion can be used to inject in th e sub -
• Learn ing cu r ve periosteal plan e at th e foreh ead an d scalp to facilit ate th e
• Raised h airlin e dissect ion .
• In creased cost d u e to in st ru m en t s an d m on itor Scalp in cision s can var y. Gen erally, ve or six in cision s
• Poten t ial com p licat ion s from im p lan ts are u sed (Fig. 25.10). On e (or t w o) m idlin e an d t w o m ore
a b c
Fig. 25.12 Temporal xation for temporal lift during a cadaveric dissection. (a) The rst bite of the suture, securing the temporoparietal
fascia at the distal ap. (b) The second bite of the suture, taking the deep temporalis fascia at the proximal ap. (c) Sutures tied to achieve
temporal lift.
on w h ich n o o cial con sen sus exist s. Fixat ion is th rough 4 m m is con sidered a safe depth as deep drilling m ay result
each of th e fron t al scalp in cision s. On e m u st be m in dfu l of in cerebrospin al uid leak. Th e safest area to drill is along a
th e sagit t al sin us if a bon e drilling tech n iqu e is used. parasagit tal lin e at th e m idpu pil or lateral lim bus lin e an d
just an terior to th e coron al sut ure. Hen ce, th is can be safely
No Fixation don e at th e lateral in cision s. Drilling of th e bon e in th e m id-
lin e of th e calvarium sh ould be avoided as it h as a risk of
Som e h ave advocated th at th e release an d m obilizat ion of inju ring th e sagit t al sin us, w h ich is foun d in th e m idlin e
th e foreh ead an d brow com plex is th e m ost crucial part of th e in n er skull. Nu m erous ven ous lakes can also be fre-
of EFBL, ren dering th e xat ion un n ecessar y. Troilius 13 quen tly foun d in th e m idlin e. Fixat ion sh ould also n ever be
rep orted in h is 20 su bp eriosteal en doscopic brow lift don e over th e squam ous port ion of th e tem poral bon e as it
w h ere th e surgeon does n ot use scalp xat ion at all, relying is th e th in n est port ion of th e tem poral bon e.
on ly on ch anging th e balan ce of m uscle vectors aroun d th e Th e locat ion at w h ich to place th e screw is determ in ed
eyebrow s. He con clu ded th at good resu lt s can be ach ieved by th e am oun t of lift desired. Th is sh ould h ave been m ea-
w ith out scalp xat ion if n ot m ore th an 4 m m of elevat ion su red p reop erat ively w h en assessing th e p at ien t . On e
is requ ired. cen t im eter sh ou ld be added to th is m easu rem en t to com -
pen sate for th e distan ce bet w een screw an d brow an d for
Fixation w ith Fibrin Glue som e descen t in th e u p righ t p osit ion . Th is dist an ce is th en
m easu red from th e m arking on th e sku ll bon e m ade at th e
Fixat ion can be ach ieve d w it h t issu e sealan t or br in glu e. lateral in cision ceph alically to determ in e th e placem en t of
After t h e brow h as been elevated to t h e d esire d p osit ion , th e screw.
br in glu e is sp rayed u n d er n eat h t h e raised ap t h rough Th e screw s used can be perm an en t or resorbable.
t h e t w o lateral in cision s an d t h e ap is h eld d ow n for 5 Resorbable screw s are th readless screw s m ade of poly-L-
m in u tes. Th is m et h od o e rs t h e ad d it ion al advan t age of lact ic acid th at w ill dissolve in 12 to 24 m on th s. Th ey are
obliterat in g t h e p oten t ial d ead sp ace bet w ee n t h e sku ll gen erally ~ 2 m m in d iam eter, an d th ey h ave a low p ro le
bon e an d foreh ead ap in ad d it ion to t h e xat ion of t is- an d h en ce n ot easily p alp able th rough th e scalp. Th ey are
su e. Th is p reve n t s h e m atom a an d se rom a for m at ion , in ser ted w ith an aid of a carrier in to a bur h ole created by
an d h e n ce n egates t h e u se of d rain s p ostop erat ively. In a a 4-m m self-lim it ing drill. Th e screw ts in w ith a t igh t
rep or t of 80 p at ien t s, t issu e glu e w as sh ow n to be e e c- frict ion grip , an d th e p resen ce of a cen t ral t u n n el allow s
t ive an d safe in m ain t ain in g brow p osit ion d u r in g EFBL an ch oring su t u res to pass th rough . In th is case th e m ea-
for u p to 1 year.14 su rem en t is m ade from th e cau dal border of th e in cision
ceph alically to determ in e th e placem en t . On ce th e screw s
Fixation w ith Monocortical Screw s are in , 2–0 p olypropylen e or p olydioxan on e can be u sed
to secu re th e cau dal border of th e lateral in cision , t aking
A m ore rigid form of xat ion u ses m on ocort ical screw s as th e su bderm al t issues an d galea apon eurot ica to th e screw
th e poin t of an ch or. Th is requires drilling in to th e outer (Fig. 25.13).
table of th e calvarium . In a st udy by Harirch ian et al,15 th e Th e advan t age of using th e resorbable screw s is th at
average skull th ickn ess for m ales w as foun d to be 5.96 th ey o er a st rong an ch oring poin t to suspen d th e brow s.
m m versu s 6.16 m m in fem ales, w ith th e cran ial th ick- How ever, th e d isadvan tages are th e in creased cost of th e
n ess in creasing m edially an d p osteriorly. Th ey reported n o im plan t , im plan t palpabilit y, in fect ion , an d risk of cerebro-
relat ion sh ip bet w een age an d sku ll th ickn ess. In gen eral, spin al u id leak w h en drilling th e calvariu m .
334 V Facial Skin and Hair Rejuvenation
b c d
Fig. 25.13 Fixation with monocortical screws and sutures. (a) Monocortical screw. (b) Monocortical hole drilled in the skull bone. The
amount of brow lift is determined by the distance of the hole drilled from the caudal border of the incision. (c) Placem ent of monocortical
screw into the hole. (d) Sutures secured bet ween the screw and the caudal margin of the incision, resulting in desired brow lift.
Altern at ively, longer t it an iu m screw s can be u sed. h oles are created at 45 degrees, m ade ~ 4 m m apart . Th ey
How ever, th ey p rot ru de from th e sku ll an d requ ire rem oval can be orien ted h orizon t ally or vert ically to th e brow s.
in 2 w eeks. In th is m eth od, th e am ou n t of lift requ ired is Altern at ively, a bon e t u n n el gu idan ce device (Brow lift Bon e
m easu red from th e cep h alic border of th e lateral in cision Bridge System , Medt ron ic Xom ed, Jacksonville, Florida) can
ceph alically. As th e scalp is rotated superoposteriorly to be used to create th e bon e t u n n el. On ce th e t un n el is cre-
ach ieve th e desired elevat ion , th e screw is in serted an d ated, a device design ed to pu ll a sut ure th rough th e bon e
skin st ap les are p laced cau dal to th e screw to m ain tain th e t un n el is used to engage th e sut ure. Eith er 2–0 polypropyl-
elevat ion (Fig. 25.14).16 en e or p olydioxan on e can be u sed for an ch oring in a sim ilar
fash ion as for th e resorbable screw s. Fig. 25.16 sh ow s th e
Fixation w ith Cortical Bone Tunnels resu lt s for a pat ien t w h o un der w en t EFBL u sing th e cor t ical
bon e t u n n el xat ion m eth od.
An oth er xat ion m eth od, d escribed by McKin n ey et al,17 is Th e advan tages of th is m eth od are it s low cost an d th ere
by creat ing cort ical bon e t u n n els in th e calvarium to allow is n o risk of im plan t p alpabilit y. Cor t ical t u n n el su t ure xa-
an ch oring (Fig. 25.15). Th e bon e bridge is created w ith a t ion h as been sh ow n to be sim ple, st able, an d reproducible
1.1-m m bur w ith a safet y guard of 4 m m . Tw o opposing bur in m ain t ain ing brow posit ion in EFBL w ith low m orbidit y.18
Jon es et al19 com p ared t w o xat ion m eth od s, brin glu e
versu s p olydioxan on e su t u res t ied th rough bon e t u n n els,
in h is review of 538 pat ien t s. He foun d th at xat ion w ith
p olydioxan one sut ures t ied th rough bon e t un n els produ ces
a sign i can tly m ore st able resu lt th an brin glu e alon e,
w ith out greater risk.
a b c
d e
Fig. 25.15 Fixation with cortical bone tunnels. (a) Bone tunnel guid-
ance device (Browlift Bone Bridge System, Medtronic Xomed, Jackson-
ville, Florida) and drill. (b) Demonstrating the engagement of drill in
the guidance device. (c) Using the guidance device to create cortical
bone tunnel. (d) A device designed to pull suture through the bone
tunnel is used to engage the suture. (e) Successful engagement of
suture in the bone tunnel. (f) Needle introduced to engage the caudal
margin of the lateral incision. (g ) Sutures are then tied to achieve the
f g desired brow lift.
a b
Fig. 25.16 A 45-year-old female who had endoscopic forehead lift, lower blepharoplast y, rhinoplast y, rhytidectomy, and fat injection of
upper and lower face. (a) Before the surgery. (b) Two months after the surgery. (Courtesy of Dr. In-Sang Kim.)
336 V Facial Skin and Hair Rejuvenation
a b d
c
Fig. 25.17 Fixation with Endotine Forehead device. (a) Endotine Forehead device with multiple tines shown. (b) Placement of the device
in a monocortical hole created in the skull bone. (c) Lifting of the forehead superiorly to achieve the desired brow lift and redraping the
ap over the device. (d) Finger pressure applied over the device to ensure adequate penetration of the periosteum by the tines so that the
brow can be held at the desired position.
Tw o m on ocor t ical w ells are created w ith a drill can be m ore accu rately determ in ed. Th is w ill allow a m ore
equ ip ped w ith th e En dot in e drill bit an d sleeve at th e cau - con ser vat ive bleph aroplast y, reducing th e risk of lagoph -
dal m argin s of th e lateral in cision s. Th e En dot in e Foreh ead th alm os postoperat ively. If th e upper eyelid skin is rem oved
d evice is th en in serted w ith th e aid of an in sert ion device rst , th e correct brow lift m ay resu lt in lagop h th alm os.
in to th e w ell. On ce th e device is rm ly xated, th e foreh ead
an d scalp can be lifted an d red raped over th e t in es an d be
h eld at th e desired p osit ion . Digital p ressu re over th e t in es ■ Postoperative Care
is n ecessar y to en sure adequ ate p en et rat ion of th e perios-
teu m by th e t in es. Th e sym m et r y an d h eigh t of th e brow s Th e pat ien t is advised to sleep w ith h ead elevated 30
are ch ecked . If th e h eigh t is in adequ ate or if th ere is any degrees to m in im ize sw elling an d bru ising. Fur th erm ore,
asym m et r y, th e ap can be released from th e device an d ice packs to th e exposed areas an d eyes can h elp m in im ize
redraped again to ach ieve th e desired ou tcom e. edem a. Th e p at ien t sh ou ld n ot engage in any vigorou s exer-
Th e advan t age of using th is device is th at th e im plan t cise or act ivit y for 1 w eek.
resorbs. In add it ion , th e En dot in e Foreh ead device provides
m u lt iple poin t s of con t act w ith th e elevated t issu e an d can
th eoret ically create a w ider dist ribut ion of h olding st rength ■ Botulinum Toxin
th at does n ot rely on a single sut u re.5 It also elim in ates th e
con cern of un due ten sion on th e scalp in cision . Bot u lin u m toxin can ser ve as an adju n ct to EFBL. Inject ion
Th ere is st ill a risk of im plan t extrusion an d in fect ion . in to th e p roceru s an d corrugators ser ves to elevate th e
Th e device m ay be palpable or ten der, an d it in creases th e m edial brow, an d som e su bst it u te th is tech n iqu e for sec-
cost of th e su rger y. t ion ing of th e m uscles. Bot ulin um toxin injected in to th e
brow depressors preoperat ively can also facilitate th e reat-
tach m en t of th e brow s in th e elevated posit ion during th e
Closure and Dressing h ealing process.
Wound Problems
Th e in cision s m ay h eal w ith hypert roph ic scars or keloids,
■ Complications and esp ecially if closed u n der ten sion . In t ralesion al steroids or
Their Management scar revision m ay be requ ired .
Seroma or Hematoma
Implant Problems
Serom a an d h em atom a can occu r in th e p oten t ial space of
Th e screw s an d En dot in e devices m ay cause discom fort an d
th e foreh ead an d scalp. Th is risk is m in im ized by careful
irrit at ion to th e pat ien t . Rarely are th ey palpable or visible.
dissect ion in th e correct plan e, h em ost asis at th e in cision s,
an d u se of a rm p ressu re d ressing over th e foreh ead. Fibrin
sealan t can fu rth er redu ce th e risk of bleed ing.
Alopecia
Th e scalp in cision sites can h ave alopecia. Th is occurs m ost
Edema and Ecchymosis
often if closed u n der ten sion , if cauter y w as used on h air
follicles, or if gross m ism atch of skin edges exist s.
Th ere w ill in evit ably be som e edem a an d ecchym osis
w ith in th e rst 48 h ou rs. EFBL m ay involve less edem a th an
th e open coron al an d t rich ophyt ic approach es.
Raising Hairline
Th is is n ot a com plicat ion as m uch as a con sequen ce of
Infection
EFBL. For th is reason , p at ien t s w ith a pre-exist ing h igh
hairlin e are n ot ideal can didates for th is t ype of brow lift .
Woun d site in fect ion is ver y un com m on due to th e robust
blood supply of th e scalp. Postoperat ive an t ibiot ics are usu-
ally n ot n ecessar y.
Over- and Under-Correction
Over- an d u n der-correct ion are p ossible ou tcom es.
Nerve Injury
Un der-correct ion can be im proved w ith a revision or bot-
ulinu m toxin inject ion in the brow depressors. Over-cor-
Th e fron t al bran ch of th e facial n er ve can be injured dur-
rect ion , w ith th e un desirable resultan t facial expression , is
ing th e tem poral dissect ion . It can also be injured by th er-
ext rem ely d i cu lt to reverse.
m al inju r y w h en at tem pt s at arrest ing bleeding from th e
sen t in el vein are d on e w ith elect rocau ter y. Th e n er ve can
also be st retch ed du ring th e dissect ion , resu lt ing in tem p o-
rar y n eu rop raxia. If th is occu rs, th e n er ve m ay take several
Relapse
m on th s to recover.
As th e pat ien t con t in ues to age, th e brow s w ill again
Th e sen sor y ner ves, su praorbit al, an d suprat roch lear
descen d. Longevit y varies according to m any variables,
n er ves, can be inju red du ring th e subperiosteal dissect ion
in cluding skin elast icit y, sun exposure, sm oking, an d pos-
n ear th e su praorbit al rim , an d th is w ill resu lt in p araesth e-
sibly th e xat ion m eth od u sed.
sia in th e foreh ead an d scalp areas.
t ive e d e m a, sh or te r re cove r y t im es, an d , m ost im p or t an t , 9. Sclafan i AP, Fozo MS, Rom o T III, McCorm ick SA. St rength
less ve r tex n u m b n ess h as le d to it s w id e acce p t an ce an d an d h istological characterist ics of periosteal xat ion to
p op u lar it y. Th e key factors in EFBL are w id e u n d e r m in - bon e after elevat ion . Arch Facial Plast Surg 2003;5(1):
63–66
in g in t h e cor re ct p lan e, com p lete p e r iost eal release, an d
e e ct ive xat ion . Carefu l scu lpt in g of t h e brow sh ap e is 10. Kim JC, Craw ford Dow n s J, Azu ola ME, Devon Grah am H III.
Tim e scale for periosteal readh esion after brow lift . Lar yn -
im p e rat ive to creat e an aest h et ic an d n at u ral-ap p ear in g
goscope 2004;114(1):50–55
exp ression .
11. Kriet JD, Yang CY, Wang TD, Cook TA. Evalu at ion of p eri-
cran ial skull adh eren ce during h ealing in th e rabbit m odel.
Arch Facial Plast Su rg 2003;5(1):67–69
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logic com p arison of p eriosteal re xat ion after en doscop ic 20. Ch ow dh u r y S, Malh ot ra R, Sm ith R, Arn stein P. Pat ien t an d
versu s bicoron al lift . Plast Recon st r Su rg 2000;105(3): su rgeon experien ce w ith th e En dot in e Foreh ead d evice
1111–1117, discussion 1118–1119 for brow an d foreh ead lift . Oph th al Plast Recon st r Surg
2007;23(5):358–362
26 Facial Rejuvenation Using Energy Devices
Un-Cheol Yeo
Pearls
• Collagen den at urat ion is on e of th e m ech an ism s for • In lt rat ive radiofrequ en cy (RF) can t arget di eren t
n on ablat ive rejuven at ion laser t reat m en t . depth s by ch anging th e length s of th e n eedles, th u s
• Cooling during n on ablat ive facial rejuven at ion is facilitat ing m u lt ilayer th erapy.
ver y im p or tan t for th e skin of East Asian s. • In ten se p u lsed ligh t (IPL) is ver y u sefu l for t yp e I
• En ergy devices th at do n ot use ligh t m ay be safer rejuven at ion . Bu t it sh ou ld be used w ith caut ion
in Asian skin . Pigm en t at ion in th e epiderm is of as it h as a large spot size an d com plicat ion s can be
Asian skin h in ders e ect ive deliver y of ligh t in to catast roph ic.
th e derm is an d causes com plicat ion s su ch as • Am ong th e t yp es of fract ion al laser t reat m en t ,
hyperpigm en t at ion . En ergy devices th at do n ot use su p er cial t reat m en t lasers su ch as th e th u liu m
ligh t h ave n o in teract ion w ith epiderm al m elan in . fract ion al laser give im m ediate e ect ive resu lts.
• En ergy device em ission s oth er th an ligh t can bypass Becau se it target s th e su rface, th e ch anges are
ep id erm al m elan in t issu e, bu t Asian skin react s readily visible. Th is ph en om en on doesn’t im ply th at
im m ediately to in am m at ion caused by skin dam age sh allow t reat m en t is bet ter th an deep t reat m en t .
an d m ay develop hyperpigm en t at ion even w h en a • To reverse aging beyon d th e depth of th e skin , h igh -
ligh t sou rce is n ot u sed for rejuven at ion . in ten sit y focused ult rasoun d (HIFU), in lt rat ive
• Dep en d ing on th e n at u re of th e en ergy device, RF w ith long n eed les, or in terst it ial lasers can be
su rgeon s can target d i eren t depth s for ap plied.
rejuven at ion . Som et im es m ult ilayer th erapy is • HIFU w as origin ally in t rod u ced to t igh ten th e
possible w ith th e com bin ed u se of th ese devices. su p er cial m u scu lo-apon eu rot ic system (SMAS) an d
m ay dest roy fat w h en d elivered to th e fat layer. Th is
can be used ver y e ect ively for ch ubby ch eeks.
339
340 V Facial Skin and Hair Rejuvenation
Most lasers for NAR u se w ater as a ch rom op h ore to Concept of Type I and Type II
gen erate h eat in th e skin . Wavelength s bet w een 1,300 an d
1,600 n m are used for th is purpose. With in th is range, th e
Rejuvenation
w avelength th at h as h igh absorpt ion to w ater can pen et rate
For t ype I rejuven at ion of Asian skin , IPL, Q-sw itch ed lasers,
th e skin m ore sh allow ly th an th e w avelength th at h as low
ch em ical peeling, an d m edical skin care, in clu ding vitam in
absorpt ion to w ater. Using th ese ch aracterist ics, app rop ri-
C ion toph oresis, can be used. Alth ough m edical skin care
ate w avelength s can be ch osen to h eat th e exact depth of
requ ires long-term t reat m en t , it is safest an d ver y usefu l
th e skin . Fract ion al t reat m en t , a non ablat ive t ype, also uses
w h en com bin ed w ith oth er t reat m en t . Vit am in C ion toph o-
a w avelength bet w een 1300 an d 1600 n m , an d determ in es
resis is often u sed before an d after laser t reat m en t . Pat ien t s
it s depth of p en et rat ion according to th e w avelength . Th e
w ith sen sit ive skin can get t ype I rejuven at ion safely w ith
key m ech an ism of NAR is collagen den at u rat ion , w h ich
IPL as op p osed to ch em ical p eeling. Norm al skin t reated
result s in regen erat ion of n ew collagen . Gen erally, collagen
w ith ch em ical peeling m ay respon d posit ively, sh ow ing
exposed for m ore th an 1 secon d to 60°C sh ow ed den at ur-
im provem en t in both pigm en tat ion an d w rin kling. Th e
at ion . Bu t w h en it w as exposed to a tem perat ure less th an
Q-sw itch ed laser is th e stan dard laser for p igm en tat ion
50°C, act ivated h eat sh ock protein (HSP) in creases th e col-
problem s. It t arget s speci c lesion s an d h as a sm all t reat -
lagen syn th esis rath er th an den at u rat ion .1,2 In th e case of
m en t beam size, w h ereas IPL h as a ver y big spot size.
dye laser t reat m en t , collagen bers sh ow ed ch anges after
For type II rejuvenation aim ed at improving the appear-
2 w eeks an d in creased collagen bers appeared after 4
ance of w rinkles, various kinds of lasers and energy devices
w eeks. After 5 w eeks, an in creased n u m ber of broblast s
can be applied. To reverse epiderm al aging, ablative or nonab-
w as con sp icu ou s.3 A ligh t-em it t ing diode (LED) w as also
lative fractional lasers and in ltrative fractional RF can be used.
able to dem on st rate in creased act ivit y of broblast w ith -
In Asian skin, the ablative lasers are subject to com plications
out collagen den at urat ion .4 CO2 lasers, dye lasers, an d NAR
such as hyperpigm entation, and so the nonablative fractional
t reat m en t s are also kn ow n to increase m at rix m etallopro-
laser is safer. For derm al reform , LED, pulsed dye laser, NAR and
tein ases (MMPs), w h ich rem ove ph oto-dam aged collagen s
fractional lasers, and in ltrative fractional RF can be used. In l-
an d resu lt in th e act ivat ion of broblast s, th u s con t ribu t ing
trative fractional RF bypasses the epiderm is w ith cold penetra-
to th e reversal of th e aging process.5,6 Collagen syn th esis
tion needling, so it could be a good option for Asian skin, w hich
w as app aren t in 1 to 2 m on th s an d th e resu lt p ersisted u p
easily develops hyperpigm entation. The sam e factor renders RF
to 1 year.7 On th e oth er h an d, th e e ect of t reat m en t w ith
useful for patients w ho have sensitive skin. Reduction of fat vol-
ablat ive fract ion al CO2 laser w as m ain tain ed from 3 m on th s
um e in the subcutaneous fat and tightening of SMAS are pos-
to u p to 2 years.8,9 Th is im p lies th at ablat ive laser is m ore
sible w ith m onopolar RF, HIFU, and interstitial lasers.
e ect ive an d th e e ect is longer-last ing com p ared w ith th e
n on ablat ive laser in term s of collagen syn th esis.
Commonly Used Devices in
Principles of Ablative Rejuvenation Facial Rejuvenation
Beyon d t issu e ablat ion , sh ort-pu lsed, h igh -en ergy, rapidly Devices u sed in facial rejuven at ion can be d ivid ed in to fou r
scan n ed CO2 lasers are able to t igh ten th e skin by m ean s grou p s based on en ergy sou rce: ligh t , radiofrequ en cy, u lt ra-
of t w o m echan ism s: con t rolled in st an t an eous h eat ing an d sou n d, an d p n eu m at ic. Ligh t-based devices in clu d e th e dye
w ou n d h ealing.10 Precise h eat ing of collagen lead s to im m e- laser, IPL, Nd:YAG laser, m idin frared laser, fract ion al laser,
diate con t ract ion an d visible skin t igh ten ing from dest ru c- an d in terst it ial laser. Rad iofrequ en cy d evices are divided
t ion of th e hydrogen bon ds w ith in th e collagen t riple h elix in to m on opolar, bipolar, an d in lt rat ive t ypes using th e
w ith out dest roying th e collagen m olecule. Th e ideal tem - elect rical curren t th rough a t reat m en t t ip. Recen tly, ult ra-
perat u re h as been sh ow n to be 63°C. As tem perat u re rises, sou n d an d m icrojet inject ion by p n eu m at ic com pression
m ore an d m ore cross-lin k bon ds are broken u n t il d en a- are being u sed as n on invasive m eth ods.
t urat ion an d loss of st ruct ure occur. Den at ured collagen
slough s in th e rst few days after th e procedu re w ith fu ll
re-epith elializat ion w ith in 1 w eek. Over th e en suing 3 to ■ Rejuvenation by Light Devices
6 m on th s, th is process st im ulates n ew collagen deposit ion
an d broblast p roliferat ion . Th e w ou n d h ealing respon se Dye Laser
in du ces con t ract ion th rough broplasia. Th is ablat ive frac-
t ion al t reat m en t h as a h igh er risk of com plicat ion s, but th e The pulsed dye laser uses the w avelength of 585 to 595
e ect of t reat m en t is su perior. Modern fract ion al ablat ive n m . It targets hem oglobin in th e capillaries of th e derm is,
tech n ology allow s for ablat ion of a por t ion of th e epiderm is indirectly stim ulat ing th e derm is. The convent ion al pulse
w h ile leaving adjacen t , un t reated skin to act as a reser voir durat ion of 0.45 m s produced purpura, but low -energy
for h ealing, resu lt ing in a sh or ter d ow n t im e an d low er risk treatm ent w ith an NLite laser (Clem son Eye) w ith pulse
for com plicat ion s. durat ion of 0.35 m s sh ow ed e ectiveness w ith no purpura.11
26 Facial Rejuvenation Using Energy Devices 341
Intense Pulsed Light m asked by oth er p igm en t at ion problem s. Sin ce IPL t reat-
m en t u ses a ver y large sp ot size com p ared w ith lasers, it
In ten se p u lsed ligh t , or IPL, is broadban d ligh t , as op posed is su itable for obscu ring th e dyspigm en tat ion in th e w h ole
to a a laser, th at em it s ligh t w ith a single w avelength . Th e face an d ach ieving gen eral im provem en t (Fig. 26.1).
spect ral d ist ribu t ion is bet w een 550 an d 1200 n m . Variou s Dep en d ing on th e site of th e face, h ow ever, th e opt im al
w avelength s in teract w ith variou s ch rom op h ores in th e set t ing can var y dram at ically. Areas su ch as th e foreh ead,
skin , an d gen erally longer w avelength s p en et rate deep er. m an dibu lar lin e, an d zygom a sh ou ld be t reated cau t iou sly.
Becau se broadban d ligh t h as d iverse e ect s on th e skin , Th ese areas overlying th e facial bon es are pron e to er y-
select ivit y tow ard a cert ain t arget is low com p ared w ith th em a an d pain . Th e foreh ead sh ould be t reated w ith a u -
laser. Th ere are various kin ds of IPL w ith di eren t spect ral en ce at least 2 J/cm 2 low er th an th e set t ings u sed to t reat
dist ribut ion s, spot sizes, etc. The param eter sh ow n on th e th e ch eek. During IPL t reat m en t , cooling gel is useful to
com puter screen , h ow ever, m ay n ot be th e real IPL beam preven t form at ion of air space bet w een th e t reat m en t t ip
param eter. Th erefore, using th e sam e param eter bet w een an d skin su rface. Filling th e sp ace w ith gel can h elp p ropa-
di eren t IPL devices is un reliable an d sh ould be avoided. gate ligh t even ly in to th e skin . Th e gel can also h elp to cool
dow n th e t reat m en t t ip, w h ich becom es h ot w ith con t in u-
ous ring of IPL. Depen ding on th e th ickn ess of th e gel, th e
Type I Rejuvenation w ith IPL at ten uat ion of ligh t can be ch anged. More th an 10%at ten u -
at ion is expected w ith th e use of gel. Hen ce, it’s essen t ial
Treat ing a vascu lar lesion w ith IPL risks h eat ing m elan in to kn ow th e th ickn ess of th e gel app lied. It is m ore likely
pigm en t s at th e sam e t im e due to th e broad spect rum of to n d cu r ved areas su ch as th e n ose an d foreh ead bet ter
th e ligh t . W h en using IPL to t reat vascular lesion s, blisters covered by th e gel. W h en th e assum pt ion is th at th e gel is
an d cru st s are seen before th e develop m en t of p u rp u ra. too th ick an d th e param eter is adju sted to com p en sate for
Blisters an d cru st s are m an ifest at ion s of ep iderm al h eat th e at ten uat ion by the gel, overly h igh uen ce m ay be deliv-
dam age. Mult iple pulses of IPL can gen erate h eat aroun d ered. If th e at ten u at ion is n ot as expected , th is m ay becom e
th e vessels. Th erefore, epiderm is m ust be given t im e to cool dangerous to th e pat ien t . It is th erefore safer to set th e
dow n . Th is can be ach ieved by allow ing a longer th erm al param eter w ith th e assum pt ion th at th e layer of gel is th in .
relaxat ion t im e th an th e in ter val bet w een subpulses of IPL. Som e operators m ay at tem pt to pu sh th e cr yst al closer to
As for t reat m en t of pigm en t at ion , IPL h as a long pulse th e skin surface. Th is w ou ld n ot in crease th e uen ce deliv-
durat ion , w h ich leads to m ild ch anges after t reat m en t . ered to th e skin , th ough any p ossible com p licat ion w ou ld
It h eat s u p an d p rod u ces m ild ch anges in a m elan ocyt ic be n egligible. In any case, th e th ickn ess of th e gel sh ou ld be
lesion w ith out m elan osom al dest ru ct ion . By select ing th e kept con stan t at all t im es.
ap prop riate lter, th e opt im al set t ing for each skin ph oto- Im m ed iately after irrad iat ion , th e p igm en ted lesion
t yp e can be ach ieved. W h en IPL is u sed for th e t reat m en t m ay becom e darker, w h ich in dicates adequ ate t reat m en t .
of m elasm a, special adjust m en t of th e param eters is n eces- Th e t reat m en t en d poin t sh ould be con t rolled carefully.
sar y. Th e p aram eter u sed for th e t reat m en t of m elasm a is Im m ed iately after IPL irradiat ion , th e skin sh ow s m ild
low er com pared w ith oth er pigm en t at ion problem s. In ad- er yth em a. Th at is gen erally regarded as a t reat m en t en d
ver ten t h igh u en ce irradiat ion on m elasm a can lead to poin t . W h en th e redness is di u sed, it is n e; but th e sit u -
aggravat ion of th is con dit ion . Th is ph en om en on t yp ically at ion is dangerous if th e redn ess is in ten se an d sh ow s th e
m an ifest s in th e case of invisible m elasm a or m ild m elasm a m ark of th e t reat m en t t ip . Th is ill-de n ed er yth em a u su-
a b c
Fig. 26.1 IPL treatment for freckles. (a) Before treatment. (b) Immediately after treatment with IPL. The freckles became darker and the
treated area shows di use erythema, which indicates a treatment end point. (c) Ten days after treatment freckles are e ectively removed,
and the skin appears bright.
342 V Facial Skin and Hair Rejuvenation
Fractional Lasers
an d avoid s th e app earan ce of scar. Th e Mosaic fract ion al
CO2 lasers h ave been used for a long t im e for resurfacing laser,14,15 w h ich u ses th e sam e tech n ology as th e Fraxel, h as
but are com prom ised by long dow n t im e. To overcom e th is been in troduced in South Korea an d is w idely u sed. Th is
d em erit , th e Er:YAG laser w as in t roduced. It h as less dow n t reat m ent m eth od delivers NAR in a fract ion al w ay w ith out
t im e, but is also less e ect ive th an th e CO2 laser. On e tech - cooling.
n iqu e to circu m ven t th is p roblem w as to deliver th e en ergy
in a fract ion al w ay. Fract ion al t reat m en t targets a port ion of
th e en t ire skin . Fract ion al t reat m en t spares n orm al, un in - Ablative Fractional Laser
jured t issu e in bet w een irradiated colum n s of coagulat ion ,
to ser ve as a regen erat ion sou rce du ring th e regen erat ion After th e adven t of n on ablat ive fract ion al lasers su ch as
period. Advan tages of fract ion al t reat m ent are less dow n th e Fraxel, curiosit y regarding th e usage of th e CO2 laser
t im e an d relat ively h igh e cacy. Th e depth of t reat m en t or Er:YAG laser in a fract ion al w ay su rged. In ablat ive frac-
depen ds on th e laser being used. t ion al laser t reat m en t , th e tem perat ure of th e core of th e
coagulat ion colum n is over 100°C. Th is m ean s vaporizat ion
of w ater an d evaporat ion of skin . As th e w ater vaporizes, it
Nonablative Fractional Laser rem oves th e t issue th at h arbors w ater in to th e air, produc-
ing a real h ole in th e skin . Th is ablat ive fract ion al t reatm en t
Th e Fraxel fract ion al laser irradiates w ith 1,550-n m -w ave- causes m ore dow n t im e an d h eigh ten s th e risk of com plica-
length ligh t an d scan s th e skin w ith t iny dot s (80 to 180 t ion s, bu t th e e ect of t reat m en t is superior (Fig. 26.5).
µm ). Th ese dot s form n um erous (375 to 4,000 per square
cen t im eter) m icroth erm al zon es (MTZs). A MTZ is a col-
u m n -sh aped coagulat ion zon e from th e skin su rface to th e Thulium Fractional Laser
derm is. Sixt y m in utes after applicat ion of th e topical an es-
th et ics, th e Fraxel laser scan s th e skin m u lt iple t im es an d Th e th ulium fract ion al laser, w ith a 1,927-n m w avelength ,
covers ~ 10 to 20% of th e skin su rface. Th e n on irradiated, has a w ater absorpt ion coe cien t bet w een th ose of th e CO2
h ealthy skin part icipates in regen erat ion an d th e recover y laser an d th e n on ablat ive fract ion al laser, such as th e Fraxel
is ver y easy. Th e proced ure causes sw elling for 1 to 3 days. or th e Mosaic (Lut ron ic). In oth er w ords, its ch aracterist ics
Th e er yth em a after t reat m en t su bsides w ith in 3 to 7 days posit ion it bet w een ablat ive fract ion al an d n on ablat ive
in 85% of th e pat ien t s. It m ay last u p to 3 w eeks in som e fract ion al laser t ream en t . Becau se of th is, th e th u liu m frac-
pat ien t s. Th is t reat m en t is repeated biw eekly to m on th ly, t ion al laser can provide eith er t ype of t reat m en t depen ding
u su ally for th ree to ve session s. Un like oth er form s of on th e param eter.
NAR, th is fract ion al t reat m en t can m odify th e epiderm is Fract ion al laser t reat m en t using th ulium h as h igh
an d su p er cial derm is safely. Th is t reat m en t to th e su per- absorpt ion by w ater com p ared w ith n on ablat ive fract ion al
cial port ion of th e skin im p roves w rin kles an d elast icit y lasers, so it s pen et rat ion in to th e skin is ver y sh allow bu t
344 V Facial Skin and Hair Rejuvenation
a
w ith draw n . It is aim ed at dam aging th e un dersurface of th e
derm is for rem odeling an d regen erat ion . In terst it ial laser
t reat m en t not on ly can safely be u sed for lipolysis but also
can be u sed in com bin at ion w ith liposu ct ion . After in ter-
st it ial laser t reat m en t , it is easier to do liposu ct ion as th e
fat t issu e h as already been d est royed part ially by th e laser.
A w avelength of 1,927 n m is th e latest t reat m en t opt ion
available as an altern at ive for lipolysis an d derm al rem od-
eling (Fig. 26.6). After in terst it ial t reat m en t w ith a 1,927-
n m laser for subderm al rem odeling, an in creased am oun t
of collagen in th e t argeted derm is can be n oted (Fig. 26.7).
In terst it ial t reat m en t bypasses th e epiderm is an d is associ-
ated w ith less risk for hyperp igm en t at ion , w h ich m akes it
b
u sefu l for Asian skin .
■ Rejuvenation by
Radiofrequency Devices
Radiofrequ en cy (RF) d evices u t ilize elect ricit y in th e fre-
quen cy range 3 kHz to 300 MHz to ach ieve skin rejuven a-
t ion . W h en th e elect rical curren t goes th rough th e skin , it
creates frict ion w ith in th e t issue. Th is frict ion causes h eat-
ing. Th e h eated t issue is a good m edia for elect ric curren t
Fig. 26.5 Facial rejuvenation using the Edge ablative fractional because t issu es w ith h igh er tem perat ure h ave low er im ped-
laser (Jeisys Co., South Korea). (a) Before treatment. Periorbital an ce. Th e RF cu rren t follow s th e less resist an t p ath w ay.
wrinkles and infraorbital fat bulging are observed. (b) After four RF devices h ave m on opolar an d bipolar t reat m en t t ips.
treatments with the Edge (30 mJ, 30 W, 300 dots/cm 2 used for Recen tly, in sulated n eedles h ave been used for RF. After
each treatment), improvement of periorbital wrinkles and removal m u lt iple in su lated n eedles are in ser ted in to th e skin ,
of infraorbital fat bulging can be seen.
µa , cm –1
12
th e react ion is in ten se. As a result , it is used for w rin kle 2300–2400
redu ct ion . Th e ch anges cau sed by th u liu m fract ion al t reat-
m en t are m ostly su p er cial an d th u s are easily recog- 1927
n ized by obser vers. Becau se of th e in ten se dam age th at
1759
occurs in th e epiderm is, th e th ulium fract ion al laser can
6 1724
also be a good m odalit y for p igm en tat ion problem s. Th u s,
th ulium fract ion al lasers can be used in t ype I an d t ype II 425
1424
0
500 1500 2500 nm
Th e laser t reat m en ts for skin rejuven at ion discu ssed so far
u se on ly extern al irradiat ion w ith laser beam s. Now a n ew
m eth od is available th at involves in sert ing opt ical ber in to Fig. 26.6 Optical properties of the subcutaneous adipose tis-
th e skin an d h aving th e irradiat ion don e un der th e skin sue in the spectral range 400 to 2,500 nm. Spectral dependence
of the absorption coe cient of the subcutaneous adipose tissue
su rface. It is called in terst it ial laser. Som e exam ples are
calculated from the experimental data by the inverse adding-dou-
Sm artlipo (Cyn osu re), a 1,064-n m laser, an d Accu scu lpt
bling method. The vertical lines indicate the standard deviation.
(Lut ron ic), w ith a 1,444-n m w avelength ; both w avelength s The arrows and numerals indicate the absorption band m axima.
are absorbed by fat t issu e. Opt ical ber is in serted in to th e (Adapted with permission from Bashkatov AN, Genina A, Kochubey
fat layer an d u sed for lip olysis. After in sert ion th e opt ic VI, et al. Optical properties of the subcutaneous adipose tissue
ber is orien ted u pw ard w h ile it irradiates an d is grad u ally spectral range 400–2500 nm. Opt Spectrosc 2005;99:836–842.)
26 Facial Rejuvenation Using Energy Devices 345
a
Th e m et h od relies on t h e d eliver y of con cen t rated u lt ra-
sou n d en ergy from t h e u lt rasou n d t ran sd u cer. Th e HIFU
m et h od is n ot on ly u sed for lysin g fat in t h e body bu t also
for t arget in g t h e SMAS in t h e face. Ult h era w as t h e rst
d evice claim ing to t arget t h e SMAS u n d er t h e skin . HIFU
d elivers u lt rasou n d en ergy to t h e SMAS an d d en at u res
collagen an d st im u lates regen erat ion . Ult h era u ses 4-, 7-,
an d 10-Mh z t ran sd u cers an d t arget s a sp ot 4.5 m m , 3.0
b m m , or 1.5 m m from t h e skin su r face w it h t h e resp ect ive
t ran sd u cers. Th e focu sed coagu lat ion area is called t h e
t h er m al coagu lat ion zon e (TCZ). After 12 w eeks t h e TCZ
is rep laced by n ew collagen syn t h esis.20,21,22 Th e sh ap e of
t h e TCZ is an “inver ted con e” or cylin d er, an d t h e size is
~ 1 m m . TCZs are m ad e fract ion ally in lin e by t h e scan n er
of t h e t ran sd u cer. Th is is called t h e “t reat m en t lin e.” Each
Fig. 26.8 Periorbital rejuvenation by in ltrative fractional RF t reat m en t lin e is 2.5 cm an d is com p osed of 17 to 23 TCZs;
(Intracel, Jeisys Co., South Korea). (a) Before rejuvenation. (b) The t h e in ter val bet w een TCZs in t h e lin e is 1.1 to 1.5 m m .
full face was treated with one pass (bipolar, level 2, needle 1.5 mm), Even t h ough it is rep or ted t h at a 4-MHz, 4.5-m m t ran s-
and additional treatments in the periorbital area used t wo or three d u cer h as a TCZ at t h e 4.5 m m d ept h , t h e d ept h of t h e TCZ
passes (bipolar, level 2, needle 0.8 mm or 1.5 mm). Sixt y days after
w ill d i er dep en d ing on w h et h er it is p h an tom , fat t is-
treatment the patient shows improved periorbital wrinkles. (Cour-
tesy of Dr. Takashi Takahashi, Tokyo, Japan.)
su e, skin , d e-ep it h elialized skin , etc. W h en HIFU t raverses
low -im p edan ce t issu e su ch as fat , it resu lt s in a d eep TCZ.
W h en HIFU t raverses h igh -im p edan ce t issu e su ch as skin ,
it for m s TCZ at a sh allow d ept h . Th e d ept h of TCZ is n ot
xed accord in g to t h e t ran sd u cer. Th u s, it sh ou ld be t aken
in to accou n t w h en clin ically ap p lied . W h en w e t reat t h e
Th e in lt rat ing n eedles can also t arget an d dest roy seba-
t h in -skin n ed p at ien t w it h HIFU, t h e TCZ m ay be deep er
ceous glan ds an d im prove acn e problem s. Repor ts suggest
t h an exp ected , becau se t h in skin w ill n ot absorb HIFU
th at it is e ect ive for act ive acn e.19 In lt rat ive fract ion al RF
m u ch . On t h e ot h er h an d , w h en w e t reat t h ick-skin n ed
can be used w ith a com bin at ion of di eren t n eedle length s
p at ien t s w it h HIFU, too m u ch en ergy m ay be absorbed in
in on e session . Th is result s in m u ltilayer t reat m en t .
it s early p rop agat ion , for m in g t h e TCZ at a sh allow d ept h .
Th ese factors sh ou ld be con sid ered in t h e t reat m en t p ro -
tocol (Table 26.1).
■ Rejuvenation by High-Intensity Good can didates for this procedure are those w ho have
Focused Ultrasound a fat t y ch eek. Th ey m ay be satis ed w ith th e shru n ken ch eek
after HIFU treat m en t. Conversely, th ose w ith a th in ch eek
Th e h igh -in ten sit y focu sed u lt rasou n d (HIFU) d evice w ould com plain about a sun ken ch eek appearan ce after
em it s u lt rasou n d , w h ich p en et rates t h rough skin an d HIFU t reatm en t . Som et im es focal depression is obser ved
focu ses t h e sign al on a sm all p oin t below t h e skin su r face. after HIFU t reatm en t , w h ich is regarded as fat atrophy.
Table 26.1 Types of cartridges that should be used for targeting di erent HIFU penetration depths in various
conditions
Thin skin and fat Thin skin, normal fat Normal skin and fat Thick skin and fat
■ Rejuvenation by a
Pneumatic Devices
Skin rejuven at ion tech n ology u sing pn eu m at ic en ergy is a
n on invasive p rocedure delivering m icro-jet u id in to th e
derm al or subderm al layer w ith out th e use of a n eedle.14,15
Micro-jet u id is broken dow n in to m icro-bu bbles in skin
t issue an d spreads th rough th e derm is even ly, form ing a
vor tex an d accelerat ing collagen boost ing in collagen -rich
derm al t issu e by h igh pressure. Th is can be used for facial
lift ing, scar t reat m en t (acn e scars, su rgical scars, an d keloid
b
scars), w rin kles, etc. Variou s u id s can be u sed, su ch as
salin e solu t ion , dilu ted n on -cross-lin king hyalu ron ic acid
(HA) solut ion, 20% glu cose solut ion , an d poly-deoxy ribo-
n u cleot ide (PDRN) accord ing to th e sp eci c requ irem en ts.
W h en using a pn eum at ic energy–based device, su cien t
pressure an d speed are n eeded. How ever, th e pressure an d
volu m e of u id sh ou ld be adju sted to variou s skin con di-
t ion s su ch as th ickn ess, elast icit y, exibilit y, an d st rength .
An im m ediate skin rejuvenation e ect is achieved by ll-
ing the em pt y space bet ween skin tissue cavities w ith m icro-
bubbles and perform ing skin tightening by physical injection.
Facial w rinkles caused by collapse of skin tissue can be c
im proved by injection of diluted non-cross-linking HA solu-
tion into the appropriate skin structure. Right after injection,
the injection site w ill appear like a balloon w ith bleaching
seen. This w ill rem ain from m inutes to hours depending on
the t ype and viscosit y of uid injected. As the injected uid is
absorbed, the bleaching balloon form ed at the injection site
subsides slow ly and occasionally rem ains erythem atous.
A prolonged skin rejuven at ion e ect is n ow possible
due to dam aged skin t issue regen erat ion w ith n ew colla-
gen syn th esis. Du e to th e n ew collagen syn th esis, p at ien ts
can feel con t in uous skin ch anges such as im provem en t Fig. 26.9 Neck wrinkle treatment with Innojector (Amorepaci c
of skin text ure an d th e facial con tou rs. Th ese ch anges are Co., South Korea). (a) Before treatment of neck transverse line. (b)
m an ifested th ree m on th s after th e t reat m en t . Th ree to ve Single treatment using needle-less tip (150 µL saline per shot, pres-
t reat m en t s biw eekly can resu lt in aesth et ic im provem en t sure level 3, distance bet ween injection sites ~ 1.0 cm). Swelling is
(Fig. 26.9). observed immediately after injection. (c) One m onth after treat-
ment. (Courtesy of Dr. Beom -Joon Kim, Seoul, South Korea.)
References
1. Desm et t re T, Maurage CA, Mordon S. Heat sh ock protein pro lom etric, histologic, ultrastructural, and biochem ical
hyperexpression on ch orioret in al layers after t ran spu- evaluations and com parison of three di erent treatm ent set-
p illar y th erm oth erapy. Invest Oph th alm ol Vis Sci 2001; tings. J Photochem Photobiol B 2007;88(1):51–67
42(12):2976–2980 5. Orringer JS, Kang S, Joh n son TM, et al. Con n ect ive t is-
2. Souil E, Capon A, Mordon S, Din h -Xuan AT, Polla BS, Bach - su e rem odeling in du ced by carbon dioxide laser resu r-
elet M. Treat m en t w ith 815-nm diode laser in duces long- facing of p h otodam aged h u m an skin . Arch Derm atol
last ing expression of 72-kDa h eat sh ock p rotein in n orm al 2004;140(11):1326–1332
rat skin . Br J Derm atol 2001;144(2):260–266 6. Orringer JS, Voorhees JJ, Ham ilton T, et al. Derm al m at rix
3. Om i T, Kaw an a S, Sato S, Hon da M. Ult rast ruct ural ch anges rem odeling after n on ablat ive laser th erapy. J Am Acad Der-
elicited by a n on -ablat ive w rin kle redu ct ion laser. Lasers m atol 2005;53(5):775–782
Surg Med 2003;32(1):46–49 7. Dain ich i T, Ueda S, Fu m im ori T, Kir yu H, Hash im oto T.
4. Lee SY, Park KH, Choi JW, et al. A prospective, random ized, Skin t igh ten ing e ect using fract ion al laser t reat m en t II:
placebo-controlled, double-blinded, and split-face clinical a p ilot an im al st u dy on skin rem odeling. Derm atol Su rg
study on LED phototherapy for skin rejuvenation: clinical, 2010;36(1):71–75
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8. Ort iz AE, Trem ain e AM, Zach ar y CB. Long-term e - 16. Lee HS, Lee DH, Won CH, et al. Fract ion al rejuven at ion u s-
cacy of a fract ion al resu rfacing device. Lasers Su rg Med ing a n ovel bip olar radiofrequ en cy system in Asian skin .
2010;42(2):168–170 Derm atol Su rg 2011;37(11):1611–1619
9. Man u skiat t i W, Fit zpat rick RE, Gold m an MP. Long-term 17. Seo KY, Yoon MS, Kim DH, Lee HJ. Skin rejuven at ion by
e ect iven ess an d side e ect s of carbon dioxide laser re- m icron eedle fract ion al radiofrequ en cy t reat m en t in Asian
su rfacing for p h otoaged facial skin . J Am Acad Derm atol skin : clin ical an d h istological an alysis. Lasers Surg Med
1999;40(3):401–411 2012;44(8):631–636
10. Ort iz AE, Goldm an MP, Fit zpat rick RE. Ablat ive CO2 lasers 18. Kim JE, Lee HW, Kim JK, et al. Object ive evalu at ion of th e
for skin t igh ten ing: t radit ion al versus fract ion al. Derm atol clin ical e cacy of fract ion al rad iofrequ en cy t reat m en t for
Su rg 2014;40(Su pp l 12):S147–S151 acn e scars an d en larged pores in Asian skin . Derm atol Surg
11. Bjerring P, Clem en t M, Heicken d or L, Egevist H, Kiern an 2014;40(9):988–995
M. Select ive n on -ablat ive w rin kle red u ct ion by laser. J Cu - 19. Lee KR, Lee EG, Lee HJ, Yoon MS. Assessm en t of t reat m en t
t an Laser Th er 2000;2(1):9–15 e cacy an d sebosu ppressive e ect of fract ion al radiofre-
12. Goldberg DJ, W h it w or th J. Laser skin resu rfacing w ith th e quency m icron eedle on acn e vulgaris. Lasers Surg Med
Q-sw itch ed Nd :YAG laser. Derm atol Su rg 1997;23(10): 2013;45(10):639–647
903–906, discu ssion 906–907 20. W h ite W M, Makin IR, Barth e PG, Slayton MH, Gliklich RE.
13. Schm ults CD, Phelps R, Goldberg DJ. Nonablative facial rem od- Select ive creat ion of th erm al injur y zon es in th e su per -
eling: erythem a reduction and histologic evidence of new col- cial m usculoapon eurot ic system using inten se ult rasoun d
lagen form ation using a 300-m icrosecond 1064-nm Nd:YAG th erapy: a n ew t arget for n on invasive facial rejuven at ion .
laser. Arch Derm atol 2004;140(11):1373–1376 Arch Facial Plast Su rg 2007;9(1):22–29
14. Mit ragot ri S. Cu rren t st at u s an d fu t u re prosp ects of n ee- 21. W h ite W M, Makin IR, Slayton MH, Barth e PG, Gliklich R.
d le-free liqu id jet injectors. Nat Rev Drug Discov 2006; Select ive t ran scu t an eou s deliver y of en ergy to porcin e soft
5(7):543–548 t issu es u sing In ten se Ult rasou n d (IUS). Lasers Su rg Med
2008;40(2):67–75
15. Baxter J, Mit ragot ri S. Need le-free liqu id jet inject ion s:
m ech an ism s an d app licat ion s. Exp ert Rev Med Devices 22. Lau bach HJ, Makin IR, Barth e PG, Slayton MH, Man stein D.
2006;3(5):565–574 In ten se focused ult rasoun d: evaluat ion of a n ew t reat m en t
m odalit y for precise m icrocoagu lat ion w ith in th e skin .
Derm atol Su rg 2008;34(5):727–734
27 Hair Transplantation in East Asians
Sungjoo (Tommy) Hwang
Pearls
• Th e East Asian sku ll ten ds to be rou n der in • Ap p lying th e vibrator an d ice p ack du ring local
circum feren ce an d to h ave a larger an d w ider an esth esia can be ver y h elp fu l in redu cing p ain .
foreh ead com pared w ith it s Cau casian coun terp ar t , Allow ing th e pat ien t to grasp th e assistan t’s h an d or
w h ich result s in roun ded fron totem poral angles an d arm can also h elp to m in im ize th e react ion to p ain .
a at ter h airlin e. • Vit am in E, om ega-3, an d h erbal m edicat ion s sh ould
• Asian s h ave few er h airs an d a low er m ult i-h air be avoided for at least t w o w eeks prior to surger y to
follicular u n it (FU) cou n t th an Caucasian s. Th e redu ce bleeding during h air t ran splan t at ion .
follicle length from epid erm is to derm al papilla is • Preoperat ive oral diazepam m ay lim it th e in ciden ce
longer an d th e average h air sh aft diam eter is th icker. of syn cope an d fain t ing. Taking a break an d
• Asian s are pron e to keloid an d hyper t roph ic con su m ing cookies an d juice w ould be h elpful to th e
scarring, w h ich is m ore com m on in you nger p at ien t s pat ien t in redu cing discom for t during th e h ours-
due to th eir h igh er rate of collagen syn th esis. long op erat ion .
• Even after p at ien t s receive h air t ran splan t at ion , • Follicular u n it ext ract ion (FUE) sh ould be perform ed
th e loss of exist ing h air con t in ues as t im e goes on . w ith care in Asian s because of th eir idiopath ic
Th erefore, addit ion al m edical t reat m en t is n ecessar y t issue brosis, low er FU den sit y an d h air-graft rat io,
to p reven t or lim it fu rth er h air loss. h igh h air-skin color con t rast , an d a h igh er risk of
• “Depth -con t rolled t ran sp lan t at ion ” according to t ran sect ion du e to th eir longer h air follicle.
graft length can h elp to yield a su p erior resu lt an d • Several factors sh ou ld be evalu ated du ring
h elp to m in im ize com p licat ion s su ch as folliculit is, con su ltat ion . Th ese in clu de th e age of th e pat ien t ,
pit t ing, an d poor sur vival. don or den sit y, don or h air th ickn ess, exten t of h air
loss, an d th e pat ien t’s exp ect at ion s.
Hair t ran sp lan tat ion am ong East Asian s an d Cau casian s
■ Introduction is sim ilar in m any asp ects, but th ere are several di eren ces
th at m ust be discussed.
In h air t ran splan t at ion , th e term Asian en com passes in di-
vidu als from a w ide area located geograp h ically from w h at
European s call th e Middle East to th e Far East . Eth n ic groups
h ave di eren t h air an d facial ch aracterist ics depen ding on
■ Characteristics of the
th eir coun t r y of origin . In th is ch apter, th e w ord Asian w ill Asian Scalp and Hair
m ain ly be u sed in referen ce to th e p eop les of East Asia, su ch
as th e Korean s, Japan ese, an d Han Ch in ese. Shape and Hairline
Historically, Asians have been concern ed less about m ale
pat tern hair loss (MPHL) than Caucasians. This is m ainly Th e sh ape of th e Asian skull appears roun der in circu m fer-
because MPHL was associated w ith w ealth, the w isdom due en ce th an th e u su ally ovoid Cau casian sku ll. Th e foreh ead
to age, and the upper classes.1,2 In today’s societ y, Asians are area of th e Asian sku ll also ten ds to be larger an d w ider
becom ing m ore concerned about their external features and th an it s Cau casian coun terpart (Fig. 27.1). Th ese di er-
appearan ce th an they h ave been in the past. For exam ple, it en ces resu lt in rou n ded fron to-tem p oral angles an d a h ead
is becom ing m ore di cult for Korean m ales w ith a Norw ood th at is at ter across th e h airlin e in East Asian s.3
t ype IV or greater level of baldness to get m arried or obtain Clin ical con sultat ion s w ith Asian m ales h ave fou n d
em ploym ent because th ese individuals look older than th eir th at m ost prefer a low, st raigh t h airlin e w ith a roun ded
actual age. This can lead to feelings of insecurit y and sh am e. fron totem p oral angle. Su rgeon s occasion ally recom m en d a
To overcom e this, m ore and m ore Asians are becom ing inter- fron t al recession to p at ien ts for a bet ter cosm et ic resu lt , as
ested in hair transplantation surger y. it is som et im es n ecessar y to m odify th e pat ien t’s desired
349
350 V Facial Skin and Hair Rejuvenation
2. Donor densit y: Th e h air d en sit y of th e p at ien t’s don or screen ed for th ese p roblem s, an d old w ou n d s sh ou ld
area sh ou ld be evalu ated u sing a den sitom eter.15 Th is be exam in ed. Pat ien ts w ith a person al h istor y of
procedure assesses th e n um ber of single-, t w o-, an d keloid scar form at ion are n ot good can didates for
th ree-h air FUs th at w ill be obtain ed from th e donor h air restorat ion surger y, w h ile th ose w ith a fam ily
area. Korean s h ave an average of 130 h airs p er squ are h istor y of keloid scarring, or a person al h istor y of
m eter on th e occipit al scalp . Greater h air n u m ber hypert roph ic scarring, sh ould be cau t ion ed on th e
w ith h igh er den sit y ten ds to h ave 2- an d 3- h air FU, in creased risk of abn orm al h ealing.
resu lt ing in a bet ter outcom e after th e t ran splan t . If
th e den sit y is m uch low er th an average in pat ient s
w ith severe h air loss, h air t ran splan t at ion sh ould
be avoided because th e pat ien t w ill n ot be sat is ed
w ith th e result s. ■ Surgical Techniques
3. Hair thick ness: Th icker h airs on th e don or site resu lt
in greater volum e an d bet ter cosm esis after th e Preparation on the Day of Surgery
t ran splan t . It is h elpful, th erefore, to m easure th e
th ickn ess of th e h air during th e con sult at ion . If th e W h en th e pat ien t arrives for surger y, the auth or begin s
h air th ickn ess is less th an 60 m m , th e ou tcom e of th e by t aking preoperat ive ph otograph s. If a pat ien t h as h igh
h air t ran sp lan t at ion w ill n ot be as good an d pat ien t s blood pressure, th is can lead to excessive bleeding during
usually w ill n ot be able to ach ieve th e exp ected su rger y. Tran sien t h igh blood pressu re m ay be cau sed by
fu lln ess. em ot ion al st ress, so p reop erat ive sedat ives su ch as diaze-
pam an d/or sublingual n ifedipin e are useful in reducing or
4. Pat ient’s expectat ions: Pat ien ts w ith early m ale-
n orm alizing th e pat ien t’s blood p ressure. Assistan t s sh ou ld
pat tern h air loss ten d to h ave h igh er expect at ions,
sh am p oo th e scalp before d on or h ar vest ing to redu ce th e
resu lt ing in low er pat ien t sat isfact ion . Also,
bacterial colony cou n ts in th e scalp, th us h elping to preven t
th e progression of alopecia an d th e sur vival of
or reduce in fect ion s th at m ay be associated w ith surger y.
t ran splan ted h airs can resu lt in u n usu al an d
un accept able h air pat tern s. In con t rast , advan ced
m ale-pat tern h air loss pat ien t s ten d to h ave low er Hairline Design
exp ectat ion s, resu lt ing in h igh er sat isfact ion . It is
ver y im p or tan t to assess th e p at ien t’s exp ect at ion s Th e sh ape of th e scalp is gen erally roun d an d w ide am ong
from th e su rger y. Un realist ic expect at ion s w ill resu lt East Asian s. Th e h airlin e design in East Asian s sh ou ld be
in u n h appy p at ien ts. It is im por tan t to adjust th e a w ide arc w ith less cen t ral convexit y, an d fron totem p o-
pat ien t’s expectat ion s prior to th e surger y, an d it is ral recession sh ou ld be less p rom in en t com pared w ith th e
w ise to delay th e su rger y if th e expectat ion s do not Cau casian’s rou n d, convex h airlin e.3
ch ange. Th e design of th e fron tal h airlin e is m ade using st an -
5. Scalp laxit y: A th ick an d im m obile scalp is described dard dist an ces an d an atom ical lan dm arks. Th e prin ciple of
as “t igh t scalp,” an d it can be di cu lt to close th e th ree equal dist an ces is th e balan ce bet w een ch in an d n asal
don or site w oun d if th e w idth is greater th an 1 cm . It t ip, nasal t ip an d glabella, an d glabella an d m idfron tal poin t
is safer to operate m ult iple t im es w ith sm all w idth s of the h airlin e. In gen eral, th e distan ce bet w een th e glabella
in cases of t igh t scalp sin ce a w idth of 1.5 cm can an d th e m idfron t al p oin t of th e h airlin e ranges from 6.5 to
resu lt in n ecrosis an d severe scarring. With t igh t 8.5 cm .16 A 7.0 to 7.5 cm h airlin e w orks w ell in th e m ajor-
scalp , th e w id th sh ou ld be sm all an d th e n u m ber it y of pat ien t s, an d th is is w h ere th e auth or places m ost
of h ar vested h air follicles low er th an usu al, or else h airlin es. W h en design ing th e h airlin e it is im port an t to
sat isfact ion w ith th e ou tcom e of t ran sp lan t at ion also rem em ber th e h airlin e con sists of th e fron t al h airlin e an d
w ill be low. Th erefore, a scalp th at is too t igh t is a tem ples. Th e fron t al h airlin e h as to balan ce w ith th e tem -
con t rain dicat ion for h air t ran splan t at ion . ples to ach ieve a balan ced, n at ural look. If th e tem ples are
6. Past history and fam ily history regarding scarring: receded an d h air t ran splan t at ion on th e tem ple area is n ot
East Asian s are gen et ically suscept ible to abn orm al in dicated becau se of in su cien t don or h air, th en a h igh er
don or area scarring, w h ich a ect s th eir suitabilit y h airlin e, w ith an u p slop e, w ill create balan ce.
for h air t ran splan t at ion . In part icular, th ey are Gen erally, in pat ien ts w ith m ild h air loss an d bet ter
pron e to keloid scarring, w h ich occurs w h en the don or h air on average, placing th e fron t al h airlin e at 7 to 8
brou s t issu e exp an ds beyon d th e bou n daries of th e cm is safe. If th e pat ien t does n ot object , th e auth or gen er-
in cision al scar, an d hypert roph ic scarring, w h ich ally prefers to design in a sm all am ou n t of u pslope, th u s
is ch aracterized by exuberan t brous grow th th at m aking it easier to t ie th e top h airlin e to th e tem p les w ith -
does n ot cross th e w oun d m argin . Th ese problem s out h aving it exten d too far in to th e tem ple area. Younger
occur m ore com m on ly in younger pat ien t s, due to pat ien t s w ill often push for a low er h airlin e or a dow n -
th eir h igh er rates of collagen syn th esis. Du ring the slop ing (juven ile) h airlin e. On an ad u lt Asian th is design
con su ltat ion , East Asian pat ien t s sh ould be carefully looks odd, is di cu lt to correct , an d sh ou ld be avoided.
27 Hair Transplant ation in East Asians 353
Hair sh afts of East Asian s are coarse, dark, an d st raigh t . Donor Harvesting
It is u su ally n ot easy to m ake a soft an d n at u ral-looking
h airlin e in East Asian p at ien t s. Th erefore, Asian s requ ire
Strip Surgery
m ore single-h air u n it s to create a n at u ral-looking h airlin e.
Th e au th or prefers to place a m in im u m of 400 single-h air
St rip h ar vest ing is perform ed by th e m ajorit y of h air resto-
FUs at th e fron tal h airlin e.
rat ion su rgeon s th rough out th e w orld. ISHRS 2013 cen sus
Th e rout in e th at th e auth or uses to create th e h airlin e is
resu lt s sh ow ed 68%for st rip h ar vest ing com pared w ith 32%
sim p le an d is as follow s (Fig. 27.2):
for follicular un it ext ract ion .17
1. Note th e distan ce bet w een th e ch in an d n asal t ip, La xit y of scalp can be assessed easily by m oving th e
bet w een th e n asal t ip an d glabella, an d bet w een scalp vert ically w h ile h olding h airs from th e don or site. It
th e righ t an d left tem ples. Using th e referen ce, can be classi ed in to hyperelast ic, n orm al, an d t igh t scalp.
m ark a sh ort h orizon t al lin e 6.5 to 8.5 cm above th e Th ere are oth er m eth ods to m easure th e scalp laxit y: May-
m idbrow level. er’s scalp elast icit y scale 18 an d Moh ebi’s la xom eter.19 Th ere
2. Mark a poin t on th is lin e dividing th e face in to equal are di eren t op in ion s abou t ideal w idth s for d on or sites.
left an d righ t h alves. Th is can be don e easily by Th e opt im al w idth of th e don or st rip in Asian s is 1.5 cm
h old ing th e m arking pen over th e n ose an d bisect ing or less.1,2,6 It can be di cult to close using a 1-cm w idth in
th e face in to equal h alves. pat ien t s w ith a t igh t scalp, so it is advisable to m in im ize
w idth s. It can be easy to close a hyperelast ic scalp w ith
3. From th is m idpoin t draw th e top h airlin e laterally,
w idth s of m ore th an 2 cm ; h ow ever, excess scarring can
keep ing it on a h orizon t al p lan e or a sligh t u pslop e
result from th e st retch -back ph en om en on .20 Th erefore, it is
w h en view ed from th e fron t .
advisable to in cise w ith in a 1.5-cm w idth in p at ien t s w ith
4. Ch eck from th e fron t to m ake su re th e t w o sides hyperelast ic scalp. Wide scars ten d to occur m ore readily
are even an d from th e side to see if th e lin e th at h as in younger pat ien ts sin ce th e rate of collagen syn th esis is
been draw n balan ces th e exist ing tem ples. If th e greater. In you ng p at ien ts, th erefore, a long an d n arrow
fron t al h airlin e looks low w h en view ed from th e don or st rip is safer th an a sh or t , w ide st rip.
sides, you w ill h ave to m ove th e top lin es u p sligh tly On ce th is is determ in ed, th e h air is t rim m ed in th e
an d red raw th e top lin e w ith a sligh t u p slope. don or area, w h ich is located in th e m idocciput , exten ding
5. Th e st raigh t lin e looks un n at ural. Add a zigzag sligh tly in to th e tem p oral region . Th e h air is t rim m ed to
pat tern lin e on th e st raigh t h airlin e an d im plan t th e ~ 2 m m in length w h en em ploying th e Western m eth od,
single-h air FUs on th e zigzag lin e to m ake a n at u ral- an d 5 to 10 m m in length for th e im plan ter tech n iqu e.21
ap pearing h airlin e. Som e doctors p refer to u se th e t u m escen t tech n iqu e to
an esth et ize th e d on or area, w h ile oth ers favor a bu ered
solu t ion of 1% lidocain e w ith 1:100,000 epin ep h rin e w ith -
out t um escen ce.2 Allow ing th e pat ien t to h old th e assis-
tan t’s h an d or arm during local an esth esia can also h elp to
sooth e th e p ain . Ap p lying an ice p ack an d vibrator n ear th e
inject ion site during local an esth esia can be ver y h elpful
to red u ce p ain (Fig. 27.3).22 Pat t ing th e p at ien t’s back is a
useful m eth od to m ake th e pat ien t feel com for table during
don or h ar vest ing, especially in th e pron e posit ion .
To m inim ize the num ber of t ransected follicles, the
incision should be parallel to the direct ion of the hair fol-
licles. This is im portant because the length of hair follicles is
greater in Asian s th an in Caucasian s, an d th u s th e probabil-
it y of t ransect ion is higher am ong Asian s. For th is reason,
the single-blade knife technique is safer for m aking an inci-
sion th an th e m u lt i-blade kn ife tech n ique. More accurate
incision al m eth ods include the open technique suggested
by Path om van ich : Four skin h ooks an d t w o assistan ts are
required to gain m ore exposure and to potent ially cut
faster.6 He m in im ized th e follicular t ran sect ion at 1%or less.
In addit ion , bleeding n eeds to be con t rolled com p letely
before w ou n d closure. Arterial bleeding n eeds to be con -
t rolled w ith a h em ostat . Sm aller vessels can be con t rolled
Fig. 27.2 Hairline design in Asian male with male-pat tern hair
loss. A new hairline is designed considering the vertical and hori- w ith a h em ost at , bu t a larger vessel n eeds ligat ion w ith 4–0
zontal facial harmony. A zigzag pat tern is more natural-looking Vicr yl (Eth icon ). It is recom m en ded th at th e surgeon avoid
than a straight line. or reduce th e degree of elect ro-cauterizat ion to con t rol
354 V Facial Skin and Hair Rejuvenation
sm all p ercen t age of pat ien t s w ill develop sign i can t scar-
ring, u su ally d u e to gen et ic di eren ces in skin t ype.
Recipient Site
In Asian countries, both the im planter and Western tech -
niques of im plantation are used. The m ain di erence
Fig. 27.7 A deeply transplanted graft may cause folliculitis on bet w een these techniques is that w ith the Western tech-
the recipient site. nique, m ost of the recipient site incisions are prem ade by
the doctor, and grafts are planted later by the assistant nurse.
As a variation of this, the doctor m akes a ne slit and im m e-
diately places the FU in sit u. The im planter techniques w ere
rst developed in Korea in the 1990s and are w idely used
oped a board for graft length m easurem en t . As sh ow n in there but are not as popular in other countries. Historically,
Fig. 27.8, a fu rrow on th e board is m ade an d th e en d of th e Mr. Paek, a Korean m edical assistan t, developed an in stru-
graft is p laced on th e ledge of th e fu rrow ; th en in dividu al m ent for eyebrow h air transplan tation for a patient w ith
h air follicles are grou ped by length . Using th is device, th e m adarosis in the 1960s.41 Then Choi m odi ed this instru-
au th or’s assistan ts w ere able to m easu re th e length s m ore m ent an d developed th e Choi im planter in th e 1990s.21 Many
e cien tly an d redu ce th e t im e of m easu rem en t . With th e t ypes of im planters have since been m anufactured. This is
“depth -con t rolled t ran sp lan tat ion ” tech n iqu e, th e au th or w hy the im planter technique is so popular in Korea, and it
h as redu ced or preven ted follicu lit is, cyst , an d pit t ing in has recently becom e m ore popular in Western countries.
m ost of h is p erson al cases.34 The im planter is shaped like a pencil w ith a hollow nee-
Con t rol of th e tem perat ure an d preven t ion of desic- dle at the tip. There are four sizes (0.6, 0.8, 1.0, an d 1.2 m m )
cat ion is im por t an t . Com m on ly used solut ion s are ch illed that correspon d to one-, t w o-, and three-h air follicular unit
n orm al salin e or lact ate Ringer, an d graft s sh ou ld be grafts (Fig. 27.9). A single graft is placed in side th e hollow
im m ersed in th e solut ion but ju st put on w et gau ze.36 Stor- en d of each device. Th e sh arp en d of th e device can then be
age of prepared graft s on gau ze or Telfa pads (Ken dall) can injected into the recipient site, w here it sim ultaneously cre-
in crease th e in tegrit y of th e h air graft s as com pared w ith ates a slit and inserts the graft in side the slit . On w ithdraw al
su bm erged p reser vat ion . Su r vival of p reser ved h air graft s of the needle, the graft is left inside the in cision site.2
Fig. 27.8 Hwang’s board for graft length measurement. The Fig. 27.9 Various t ypes of implanters. The sizes of an implanter’s’
length of each follicle was measured on Hwang’s board; 3- to 4-mm, needles (0.8, 1.0, and 1.2 m m from left to right) correspond to
4- to 5-mm , 5- to 6-mm, and 6- to 7-mm grafts were grouped. one-, t wo-, and three-hair follicular unit grafts.
27 Hair Transplant ation in East Asians 357
th e scalp as easily an d th e low er-den sit y areas becom e less • With th is t yp e of den sit y gradien t , com bing th e h air
obvious. A proper den sit y gradien t an d layering are crit ical from th e parted side an d fron t p rodu ces a “layering
elem en t s in th e aesth et ics of h air restorat ion in East Asian s. e ect ,” m aking th e h air ap p ear fu ller.
a b c
Fig. 27.12 Revision of linear scar using W-plast y. (a) Scar on the donor site. (b) W-plast y postop. (c) Six m onths postoperative.
Com plicat ion s on th e t ran splan ted site var y from m ild to
severe p ru rit u s. Som e of th ese can be secon dar y to n er ve Folliculitis
dam age, crust s, folliculit is, or seborrh eic derm at it is. Mild
prurit us can be con t rolled w ith topical steroids, but severe Hair follicles tran splanted too deeply can cause in am m a-
cases m ay require oral an t ih ist am in es. Scalp prurit us usu- tion. The reported incidence rate varies from 1 to 20%. Also,
ally disap p ears in a cou ple of w eeks. increased sebum production and inappropriate w ashing of
360 V Facial Skin and Hair Rejuvenation
the hair can result in secondary folliculitis, w hich can be pre- inject ion or surger y. Sin ce pat ien t s lie on th e bed for m any
vented by appropriate w ash ing using sh am poos. Topical ste- h ours during th e t ran sp lan t , th e auth or recom m en ds per-
roids can relieve sym ptom s, but oral antibiotics are required form ing leg exercises for 1 m in ute before sit t ing on th e bed
for severe cases. Transplanting to the appropriate depth is to p reven t p ost u ral hyp oten sion . Taking a break an d eat ing
the m ost im portant factor to prevent this. The author largely cookies an d juice can be h elpful to reduce th e pat ien t’s dis-
prevented folliculitis after transplantation w ith use of the com for t during th e hours-long operat ion .16
depth-controlled transplantation (DCT) technique.34
Hiccups
Pitting
Th e cause an d physiology of h iccups are n ot know n . It is
Pit t ing resu lt s from th e t ran splan t being seated too deeply. specu lated th at th is occu rs du e to con du ct ion of st im u li
Th is can be preven ted w ith th e DCT tech n ique. from dam aged n er ves on th e don or site to th e p h ren ic
n er ve.52 Hiccu p s u su ally occu r w ith in 6 to 24 h ou rs an d
can last up to 2 days before spon tan eously resolving. Ch lor-
Poor Survival and Loss of p rom azin e 50 m g t w ice daily is kn ow n to h elp ease th e d is-
Transplanted Hair com fort caused by con t in uou s h iccu ps.
13. Avram M, Rogers N. Con tem p orar y h air t ran sp lan t at ion .
■ Conclusion Derm atol Su rg 2009;35(11):1705–1719
14. Makh eja AN, Bailey JM. An t ip latelet con st it u en t s of garlic
Hair t ran splan t at ion for East Asian s p resen t s several an d onion . Agen t s Act ion s 1990;29(3–4):360–363
ch allenges seldom seen in Caucasian s. Th ese in clude an 15. Bern stein R, Rassm an W. Den sitom eter an d video-m icros-
in creased risk of scarring, a lim ited n u m ber of don or h airs, copy. Hair Tran sp lan t Foru m In t 2007;17(2):49–51
h igh skin /h air color con t rast , low er h air den sit y, an d a 16. Path om van ich D, Im agaw a K, eds. Hair Restorat ion Su rger y
u n ique fron t al h airlin e. In spite of th ese ch allenges, w ith in Asian s. New York, NY: Sp ringer; 2010:37–39, 91–93,
th e select ion of good can didates an d use of appropriate 105, 125–129, 133–140
operat ive tech n iques, excellen t results can be produced in 17. Leon ard R, Ch arles G, Dorin R, et al. In tern at ion al Societ y of
Asian s. Hair t ran splan t at ion tech n iques sh ould alw ays be Hair Restorat ion Surger y. 2013 Pract ice Cen sus Resu lt s
adju sted depen ding on th e in dividu al being t reated. Hair 18. Mayer M, Pau ls T. Scalp elast icit y scale. Hair Tran sp lan t Fo-
ch aracterist ics, h ead sh ape, h air an d skin color, an d oth er ru m In t 2005;15:122–123
feat u res speci c to Asian s n ecessit ate cer tain m odi cat ion s 19. Moh ebi P, Pak J, Rassm an W. How to assess scalp laxit y.
Hair Transplan t Foru m In t 2008;18:161, 167
in h air t ran splan t at ion procedures an d t reat m en t s.
20. Bern stein RM, Rassm an W R. Th e scalp laxit y p aradox. Hair
Tran splan t Forum In t 2002;12:9–10
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h air t ran splan ter. J Derm atol Surg On col 1992;18(11):
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591–595, 892–897 brat ion and m ovem ent . J Neu rol Neurosu rg Psych iat r y
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1995;3:119–132
26. Kim D. Plan n ing o in ferior edge in th e Frech et an d
5. Bern stein RM, Rassm an W R. Follicular t ran splan t at ion . Rose t rich op hyt ic closu res. Hair Tran splan t Forum In t
Pat ien t evaluat ion an d surgical plan n ing. Derm atol Surg 2008;18(6):211
1997;23(9):771–784, discussion 801–805
27. Rassm an W R, Bern stein RM, McClellan R, Jon es R, Worton
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7. Arn old J. 6th ann u al m eet ing of th e In tern at ion al Societ y 28. Harris JA. Follicu lar u n it ext ract ion : th e SAFE system . Hair
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1998;6:4
29. On da M, Igaw a HH, In ou e K, Tan in o R. Novel tech n iqu e
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su rger y on t reat m en t of m ale baldn ess. Jp n J Aesth et Plast pow ered pu n ch ing device. Derm atol Su rg 2008;34(12):
Surg 1997;19:99–117 1683–1688
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Elsevier Sau n d ers; 2006:149–156 date: p rocedu ral tech n iqu es, in n ovat ion s, an d app licat ion s.
10. Kau fm an KD, Roton da J, Sh ah AK, Meeh an AG. Long-term Derm atol Clin 2013;31(1):141–153
t reat m en t w ith n asterid e 1 m g decreases th e likelih ood 31. Kim C, Kim H, Kim D. Follicu lar u n it t ran splan t at ion : com -
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gen et ic alopecia (m ale pat tern h air loss). Eu r J Derm atol Arch Aesth et ic Plast Su rg 2014;20(1):61–64
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32. Lim m er B. Bob Lim m er d oes it all on e h air at a t im e. Hair
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(5-year) m u lt in at ion al experien ce w ith n asteride 1 m g
33. Keen e SA, Gibson GH. New cost-e ect ive, ergon om ic w ay
in th e t reat m en t of m en w ith an drogen et ic alopecia. Eu r J
to m agn ify d on or h air du ring follicu lar u n it graft dissec-
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34. Hw ang S. In t ra-pat ien t graft length d i eren ces in u en c-
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ing depth con t rolled in cision s. Hair Tran sp lan t Foru m In t
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28 Aesthetic Laser Hair Removal for the Asian Face
Wooseok Koh
Pearls
• Wom en of all races seek h air rem oval because • An 800- to 810-n m diode laser (e.g., Ligh t Sh eer XC,
visible h air on th e face is aesth et ically u n desirable, Lum en is) w ith pulse durat ion of 3 to 30 m s an d
darken s th e skin , an d in terferes w ith m akeup an en ergy den sit y of 23 to 40 J/cm 2 can be u sed
ap plicat ion . Men seek h air rem oval for a clean er for facial h air rem oval. Th e ch an ces of obt ain ing a
ap pearan ce, to avoid th e in conven ien ce of daily p osit ive outcom e dw in dle w ith a pulse durat ion
sh aving, an d to avoid skin dam age from sh aving an d exceeding 30 m s for Asian m ale facial h air rem oval.
follicu lit is. • Usu ally, slow t reat m en t w ith h igh er u en ce is m ore
• A n arrow foreh ead is on e of th e m ajor in d icat ion s for e ect ive in facial h air rem oval. Low ering th e skin
laser facial h air rem oval in Korea. More t radit ion ally tem perat ure before t reat m en t is ver y im por tan t to
m in ded Korean s an d Ch in ese believe th at a redu ce th e side e ect s of laser h air rem oval.
sm all foreh ead is aesth et ically u n desirable; th is • In ad dit ion to decreased facial h air, an aesth et ic
con t ribu tes to th e popu larit y of facial h air rem oval. im provem en t of skin in cluding brigh ter an d soft
• You ng w om en in Korea d esire m en w ith a h airless skin ton e, im provem en t of follicu lit is/acn e, an d
face; th is h as sign i can tly in creased th eir in terest in decreased hyperpigm en t at ion associated w ith
laser facial h air rem oval. sh aving can be ach ieved w ith facial laser h air
• Many factors are involved in th e su ccess of laser rem oval.
facial h air rem oval; am ong th em , a doctor’s • A n ew foreh ead h airlin e n eeds to be design ed
kn ow ledge from experien ce perform ing th e con sidering th e pat ien t’s w ish es, gen der, an d facial
procedure is m ost im por tan t . outlin e. Act ively guiding th e pat ien t in regards to th e
• Con sult at ion before th e t reat m en t is ver y im port an t opt im al design an d e cacy is im port an t because
in set t ing reason able goals for facial laser h air pat ien t s ten d to ch oose an excessively h igh or low
rem oval, especially if it involves w iden ing th e h airlin e. Th e design ing of th e foreh ead h airlin e is n ot
foreh ead . design ing a beaut iful h airlin e, bu t redesign ing on e-
th ird of th e n at ural facial outlin e.
364
28 Aesthetic Laser Hair Rem oval for the Asian Face 365
■ Mechanisms of Laser Hair laser h air rem oval is st ill un clear, even th ough th e p roce-
dure w as developed 20 years ago.
Removal
Th e rst h air rem oval laser w as based on th e con cept of ■ Factors That Improve the
“select ive p h ototh erm olysis.”1,23 Years later, th is con cept
w as exp an ded as th e “exten ded th eor y of select ive p h oto- E cacy of Permanent Hair
th erm olysis.”24 According to th ese th eories, th e m ain ch ro- Removal
m op h ore is eu m elan in in th e h air sh aft an d h air bu lb. Heat
from laser absorpt ion in th e m elan in p igm en ts of th e h air Many factors, in clu ding u en ce, p u lse du rat ion , w ave-
follicle di u ses ou t to dam age th e h air follicle, in terfering length , spot size, an d t reat m en t in ter val, a ect th e suc-
w ith regen eration of th e visible term in al h air. Recently, cess of laser h air rem oval.25 In addit ion , th e kn ow ledge an d
low - uen ce, h igh -frequen cy lasers h ave been foun d to pro- exp erien ce of th e p hysician in u en ce th e resu lt s. Opt im al
duce result s sim ilar to th ose of h igh -pow er, low -frequen cy factors th at im prove th e su ccess rate are as follow s:
lasers.15,16,17
1. Proper w avelength: 755 nm or 800 to 810 nm 26,27,28,29,30
To rem ove h air perm an en tly, th e targets sh ould be cells
th at are biologically n ecessar y for regen erat ion of th e h air 2. Proper pulse durat ion : 20 to 80 m s (from person al
follicles. Based on th is hyp oth esis, th e biological targets exp erien ce)
sh ould be eith er th e h air stem cell (Fig. 28.1) or p ap illa cell, 3. Proper uen ce: as h igh as possible w ith out causing
or both .22 How ever, alth ough th is hypoth esis is plausible, adverse e ects 6,31
n o data su p p or t ing th is h ave been p u blish ed. Dam age to 4. Proper spot size: as large as possible, if applicable 32,33
366 V Facial Skin and Hair Rejuvenation
Technique E ects
I u se a p u lse du rat ion of 30 to 50 m s, becau se m ost h airs Aesthetic Im provem ent and Skin Brightening
h ave th ick sh aft s. I set th e u en ce based on th e curren t skin
color, as w ith fem ale facial h air rem oval. Accord ing to m y su bject ive assessm en t , th e facial skin
ap pears to im p rove in m ost Asian m ale p at ien ts after laser
1. I set th e u en ce as h igh as p ossible. I start th e h air rem oval, alth ough th e im p rovem en t h as n ot been sci-
t reat m en t at 30 m s an d 24 to 35 J/cm 2 w h en u sing an en t i cally m easu red. Th e p at ien t s th em selves feel th at th eir
800-n m Ligh t Sh eer XC. skin h as im p roved after t reat m en t , an d m ost of th e gen eral
2. Avoid overlap of irradiat ion , but do n ot om it any popu lat ion also see an im provem en t in th e “before” an d
t arget area during t reat m en t . Caut ion is n eeded, as “after” ph otograph s of pat ien t s (Fig. 28.4). Fu rth er research
rep eated irradiat ion of th e sam e area m ay lead to is n eeded to clarify w h eth er th is im provem en t is du e to th e
scarring an d oth er seriou s adverse e ects. ap pearan ce of less h air or to th e w h iten ing or rejuven at ing
3. I use on ly a con t act-t ype skin cooling system . e ect s of th e laser.56
Rem oving den se an d th ick h airs w ith a h igh
u en ce can cau se n on sp eci c d erm al dam age, an d Reduced Hyperpigm ent ation
p rotect ing deeper layers w ith con t act cooling h elps
p reven t adverse e ect s. To allow su cien t cooling, Many Asian m en seeking laser h air rem oval p resen t w ith
in crease th e con t act t im e of th e cooling system from hyperpigm en t at ion of th e skin . Post in am m ator y hyper-
0.5 to 1 secon d in areas w ith th ick an d den se h airs. pigm en t at ion is suspected to arise from sh aving-related
4. Frequ en tly ch eck for h airs adh ering to th e t ip of th e skin dam age, follicu lit is, or aftersh ave-related d erm at it is.
con tact-t ype h an dpiece. Asian m en , w h o h ave th icker facial h air, apply m ore pres-
su re to th e skin du ring sh aving th an do Cau casian s; h en ce,
5. Var y th e u en ce u n d er th e n ose an d on th e ch in ,
th ey are m ore likely to experien ce skin irrit at ion . Asian skin
ch eeks, an d sideburn s, depen ding on th e den sit y
is also m ore su scept ible to p ost in am m ator y hyp erpig-
an d th ickn ess of th e h air sh aft s. Use a relat ively low
m en t at ion .57 E ect ive h air rem oval redu ces th e frequ en cy
u en ce for den ser an d th icker h air sh aft s.
of sh aving and skin irritat ion during sh aving. Th is result s in
a grad u al im provem en t of hyp erp igm en tat ion (Fig. 28.5).
Im provem ent of Folliculitis and Acne Th e follow ing tech n iqu es are u sed to create an irregular
hairlin e (Fig. 28.7):
I see con sisten t an d rep eated ou tcom es of im p roved follicu -
1. Use di eren t u en ces du ring t reat m en t .
lit is or acn e after laser facial h air rem oval in Korean m en , as
h ave oth ers.58 After th ree or fou r t reat m en t s, th e frequ en cy 2. Com bin e various w avelength s an d pulse durat ion s
of shaving decreases, an d sh aving-related folliculit is an d during t reat m en t .
acn e im p rove. In som e cases, follicu lit is an d acn e of th e 3. To avoid form ing a dist in ct lin e, do n ot set a lin ear
areas n ot t reated by laser also sh ow im p rovem en t , bu t th e boun dar y for laser irradiat ion .
reason s are n ot u n derstood (Fig. 28.6). I believe th at th e
t yp e of sh aving cream m ay p lay a role an d sh ou ld be inves-
t igated fur th er.59 Technique
The hairline generally includes som e thick hairs, w hereas
Forehead Widening in East Asians the forehead surface is covered w ith ne hairs. Therefore, the
param eters should be set di erently for the two areas. As
Excess hairs of the forehead are rem oved to im prove the fore- explained previously, the wavelength, uence, and pulse dura-
head shape in patients w ith a narrow forehead, wom en w ith tion should be varied to avoid form ing a distinct line at the hair-
a m asculine forehead shape, or m en w ith a fem inine forehead line. The frequency of treatm ent di ers between individuals,
shape. For Koreans and Chinese, hairline correction to w iden but at least six treatm ents are typically needed.
the forehead is a com m on aesthetic procedure because a
1. For th e rst t reat m en t , test variou s u en ces (e.g.,
narrow forehead is considered unat tractive. The goals of
Ligh t Sh eer XC, 10–28 J/cm 2 ) an d spot sizes (e.g., 5–12
this treatm ent are to expand the forehead area, im prove the
m m ), an d u se at least t w o w avelength s (e.g., 800 n m
physiognom ic balance of the face, and create a fem inine or
an d 1,064 n m ).
m asculine forehead shape, depending on the gender.
2. Adjust th e t reat m en t in ter val (8 to 10 w eeks) based
on th e degree of h air rem oval desired.
Forehead Hairline Design
Laser spot
Th e n al design sh ould be con rm ed th rough m ult iple con -
su ltat ion s (an average of t w o or th ree). Pat ien t s n eed su f-
cien t t im e to th in k over th e opt im al design w h ile looking
12 m m 9 mm 5 mm 7 mm 10 m m 12 m m
in th e m irror. Th e doctor sh ou ld lead th e design ph ase but
sh ou ld ask for pat ien t s’ op in ion s, begin n ing w ith th e sec-
on d t reat m en t . Th is h elps to in crease pat ien t sat isfact ion . Treatment diagram
Hairlin e d esign is based on th e follow ing factors:
risks w h ile keeping clin ical e cacy. Lasers Surg Med 36. Nelson JS, Majaron B, Kelly KM. Act ive skin cooling in con -
2012;44(4):277–281 jun ct ion w ith laser derm atologic surger y. Sem in Cut an
18. Fern an dez AA, Fran ça K, Ch acon AH, Nouri K. From in t ra- Med Su rg 2000;19(4):253–266
zors to lasers: a t im elin e of h air rem oval m eth ods. J Cosm et 37. Ram R, Rosen bach A. E ect s of am bien t room tem p erat u re
Derm atol 2013;12(2):153–162 on cold air cooling during laser h air rem oval. J Cosm et Der-
19. Wim m ersh o MB, Sch erer K, Loren z S, Lan dthaler M, Ho- m atol 2007;6(3):203–206
h en leut n er U. Hair rem oval using a 5-m sec long-pulsed 38. Klavuhn KG, Green D. Im portance of cutaneous cooling dur-
ru by laser. Derm atol Su rg 2000;26(3):205–210 ing ph ototherm al epilat ion : theoret ical and pract ical con -
20. Vogt A, Mc Elw ee KJ, Blum e-Peyt avi U. Biology of th e h air siderat ion s. Lasers Surg Med 2002;31(2):97–105
follicle. In : Blum e-Peyt avi U, Tost i A, W h it ing DA, Trueb R, 39. Goldberg DJ. E ect of tem p erat u re-con t rolled cooling on
eds. Hair Grow th an d Disorders. Leipzig, Germ any: Spring- ligh t-based skin t reat m en t s. J Cosm et Laser Th er 2006;
er; 2008:8–9 8(3):155–156
21. Koh W, Hw ang J. New clinical applicat ion of laser h air re- 40. Moren o-Arias GA, Castelo-Bran co C, Ferran d o J. Side-
m oval; w iden ing of n arrow foreh ead. Lasers Su rg Med e ect s after IPL ph otodep ilat ion . Derm atol Su rg 2002;
2003;32S15:67 28(12):1131–1134
22. Ibrah im i OA, Avram MM, Han ke CW, Kilm er SL, An der- 41. Bern stein EF. Hair grow th in du ced by d iode laser t reat-
son RR. Laser h air rem oval. Derm atol Th er 2011;24(1): m en t . Derm atol Su rg 2005;31(5):584–586
94–107 42. Noh S, Koh WS, Lim HW, et al. Tool to visu alize an d evalu -
23. An derson RR, Parrish JA. Select ive ph ototh erm olysis: pre- ate op erator p ro cien cy in laser h air-rem oval t reat m en t s.
cise m icrosurger y by select ive absorpt ion of pulsed radia- Biom ed Eng On lin e 2014;13:40
t ion . Scien ce 1983;220(4596):524–527 43. Bou zari N, Tabat abai H, Abbasi Z, Firooz A, Dow lat i Y. Hair
24. Alt sh uler GB, An derson RR, Man stein D, Zen zie HH, rem oval u sing an 800-n m diode laser: com parison at dif-
Sm irn ov MZ. Exten ded th eor y of select ive p h ototh erm oly- feren t t reat m en t in ter vals of 45, 60, an d 90 days. In t J Der-
sis. Lasers Su rg Med 2001;29(5):416–432 m atol 2005;44(1):50–53
25. Koh W. Laser hair rem oval. In : Park S, Yeo U, eds. Laser Der- 44. Lan da N, Corron s N, Zabalza I, Azp iazu JL. Urt icaria in d u ced
m atology Plast ic Su rger y. Seou l: Koonja; 2014:253–275 by laser ep ilat ion : a clin ical an d h istop ath ological st u dy
26. Sadighha A, Mohaghegh Zahed G. Meta-analysis of hair re- w ith extended follow -up in 36 pat ien t s. Lasers Surg Med
m oval laser trials. Lasers Med Sci 2009;24(1):21–25 2012;44(5):384–389
27. Erem ia S, Li CY, Um ar SH, New m an N. Laser h air rem oval: 45. Helou J, Maatou k I, Mou t ran R, Obeid G. Fox-Fordyce-like
long-term resu lt s w ith a 755 n m alexan drite laser. Derm a- disease follow ing laser h air rem oval appearing on all t reat-
tol Su rg 2001;27(11):920–924 ed areas. Lasers Med Sci 2013;28(4):1205–1207
28. Han drick C, Alster TS. Com parison of long-pulsed diode 46. Bech ara FG, Georgas D, San d M, et al. E ect s of a long-
an d long-pulsed alexan drite lasers for h air rem oval: a pulsed 800-n m d iode laser on axillar y hyp erh idrosis: a
long-term clin ical an d h istologic st u dy. Derm atol Su rg ran dom ized con t rolled h alf-side com p arison st u dy. Der-
2001;27(7):622–626 m atol Surg 2012;38(5):736–740
29. Bouzari N, Tabatabai H, Abbasi Z, Firooz A, Dow lat i Y. Laser 47. Desai S, Mah m ou d BH, Bh at ia AC, Ham zavi IH. Paradoxical
h air rem oval: com parison of long-pu lsed Nd:YAG, long- hypert rich osis after laser th erapy: a review. Derm atol Surg
p u lsed alexan drite, an d long-pu lsed diode lasers. Derm atol 2010;36(3):291–298
Su rg 2004;30(4 Pt 1):498–502 48. Willey A, Torron tegu i J, Azp iazu J, Lan da N. Hair st im u la-
30. Li R, Zhou Z, Gold MH. An e cacy com parison of hair rem oval t ion follow ing laser an d in ten se p u lsed ligh t p h oto-epila-
utilizing a diode laser and an Nd:YAG laser system in Chinese t ion : review of 543 cases an d w ays to m an age it . Lasers
wom en. J Cosm et Laser Ther 2010;12(5):213–217 Surg Med 2007;39(4):297–301
31. Polderm an MC, Pavel S, le Cessie S, Grevelin k JM, van Leeu- 49. Dosh i SN, Levy ML, Marku s R. Koebn erizat ion of react ive
w en RL. E cacy, tolerabilit y, an d safet y of a long-p u lsed perforat ing collagen osis in du ced by laser h air rem oval. La-
ru by laser system in th e rem oval of u nw an ted h air. Derm a- sers Surg Med 2003;32(3):177–179
tol Su rg 2000;26(3):240–243 50. Moreno-Arias GA, Cam ps-Fresneda A. Long-lasting hypopig-
32. Nou ri K, Ch en H, Sagh ari S, Ricot t i CA Jr. Com paring 18- m entation induced by long-pulsed alexandrite laser photo-
versu s 12-m m sp ot size in h air rem oval u sing a Gen tle- epilation . Derm atol Surg 2003;29(4):420–422
LASE 755-n m alexan drite laser. Derm atol Su rg 2004;30(4 51. Weisberg NK, Green bau m SS. Pigm en t ar y ch anges af-
Pt 1):494–497 ter alexan drite laser h air rem oval. Derm atol Su rg 2003;
33. Bäum ler W, Sch erer K, Abels C, Ne S, Lan dth aler M, 29(4):415–419
Szeim ies RM. Th e e ect of di eren t sp ot sizes on th e ef- 52. Lan igan SW. In cid en ce of sid e e ect s after laser h air re-
cacy of hair rem oval u sing a long-pulsed diode laser. Der- m oval. J Am Acad Derm atol 2003;49(5):882–886
m atol Surg 2002;28(2):118–121 53. Brilakis HS, Hollan d EJ. Diode-laser-in du ced cat aract an d
34. Alt sh uler GB, Zen zie HH, Erofeev AV, Sm irn ov MZ, An der- iris at rop hy as a com p licat ion of eyelid h air rem oval. Am J
son RR, Dierickx C. Con t act cooling of th e skin . Phys Med Op h th alm ol 2004;137(4):762–763
Biol 1999;44(4):1003–1023 54. Davou di SM, Beh n ia F, Gorou h i F, et al. Com p arison of long-
35. Zen zie HH, Alt sh uler GB, Sm irn ov MZ, An derson RR. Evalu - pulsed alexan drite an d Nd:YAG lasers, in dividu ally an d in
at ion of cooling m eth ods for laser derm atology. Lasers Su rg com bin at ion , for leg h air redu ct ion : an assessor-blin d ed,
Med 2000;26(2):130–144 ran dom ized t rial w ith 18 m on th s of follow -u p . Arch Der-
m atol 2008;144(10):1323–1327
374 V Facial Skin and Hair Rejuvenation
55. Lou W W, Qu in t an a AT, Geron em u s RG, Grossm an MC. Pro - t reat m en t opt ion s in skin of color. J Clin Aesth et Derm atol
sp ect ive st u dy of h air red u ct ion by diode laser (800 n m ) 2010;3(7):20–31
w ith long-term follow -u p. Derm atol Su rg 2000;26(5): 58. Manuskiatti W, Dierickx CC, González S, et al. Laser hair re-
428–432 m oval a ects sebaceous glands and sebum excretion: a pilot
56. Dang Y, Liu B, Liu L, et al. Th e 800-n m diod e laser irrad ia- study. J Am Acad Derm atol 1999;41(2 Pt 1):176–180
t ion in d u ces skin collagen syn th esis by st im u lat ing TGF-β/ 59. de Groot AC. Con t act allergy to cosm et ics: cau sat ive ingre-
Sm ad sign aling p ath w ay. Lasers Med Sci 2011;26(6): dien t s. Con tact Derm at 1987;17(1):26–34
837–843
60. Uyar B, Saklam az A. E ect s of th e 755-n m alexan d rite la-
57. Davis EC, Callen der VD. Post in am m ator y hyp erpigm en ta- ser on n e dark facial h air: review of 90 cases. J Derm atol
t ion : a review of th e epidem iology, clin ical feat u res, an d 2012;39(5):430–432
VI
Minimally Invasive Facial Plastic Surgery
29 Aesthetic Facial Use of Botulinum Toxin in East Asians
Kyle Seo
Pearls
• Th e t reat m en t st rategy beh in d bot ulin um toxin • Most p hysician s u se clin ical equ ivalen ce at
t yp e A (BTA) in East Asian s, regarding dosages an d a conversion rat io of 1:1 for aesth et ic u se of
inject ion p oin ts, sh ou ld be based on th e follow ing on abot ulin um toxin A an d oth er BTA product s, except
con siderat ion s: th e pat ien t’s m uscle m ass, m uscle abobot u lin u m toxin A, for w h ich th e conversion rat io
sh ape, an d p at tern of m u scle act ivit y; eth n ic is believed to be 1:2.5 for on abot ulin um toxin A to
di eren ces bet w een East Asian s an d Caucasian s; abobot u lin u m toxin A.
an d aesth et ic ap prop riaten ess in th e con text of th e • Th e m ain target of BTA w h en resh aping a square jaw
pat ien t’s overall facial st ruct ure. is th e low er cen t ral belly of th e m asseter m u scle.
• Com pared w ith Caucasian s, East Asian s h ave Deep inject ion , su cien t to tou ch th e m an d ibu lar
relat ively w ide, roun d, an d at faces. Th e use of bon e, is ver y im por tan t to avoid em barrassing
BTA for th e t reat m en t of m asseter hyp ert rop hy an d facial expression (e.g., an u n n at u ral asym m et ric
en larged parot id glan d, in w h ich a squ are-sh ap ed sm ile cau sed by su p er cial inject ion w eaken ing th e
face can be sm ooth ed by d ecreasing th e facial w idth rizoriu s in th e an terior p art of th e m asseter). Fou r
an d ach ieving a “V” sh ap e in th e fron t p ro le, is to six inject ion poin t s (IPs) w ith 5 U p er inject ion
popu lar am ong East Asian s for th is reason . site are recom m en ded dep en ding on th e p at ien t’s
• BTA inject ion for th e p u rposes of w iden ing th e m u scle volu m e.
palpebral apert u re (i.e., th e eye open ing) by inject ion • Inje ct ion of BTA in to an en larged or p rot r u d in g
of th e low er eyelid is con t rain dicated in East Asian s p arot id glan d can red u ce t h e w id t h of t h e low er
because it m ay rem ove th e pret arsal bulge. How ever, face by blockin g t h e act ion of acet ylch olin e as
East Asian s do con sider th e w iden ed palpebral a n eu rot ran sm it te r in t h e salivar y glan d s. Dee p
ap er t u re a h allm ark of fem ale beau t y (kn ow n as th e in t raglan d u lar inject ion at t h e m ost p rot r u d in g
“ch arm ing roll”). p ar t of t h e p arot id glan d arou n d t h e m an d ibu lar
• Eyebrow “sh aping” w ith BTA, pop u lar in Cau casian s, an gle is requ ire d w it h ve or six IPs an d 5 U p e r
is also n ot recom m en ded for East Asian s because inject ion site.
prom in en tly arch ed brow s m ay look especially • The use of m ultiple intraderm al injections of BTA
u n n at u ral in an Asian face, w h ich is relat ively w ide. (intraderm al BTA), under various nam es such as
• Asian s gen erally ten d to h ave a sm aller m ass, an d “m esobotox,” “derm atoxin,” and “m icrotoxin,” has
less hyp erdyn am ic act ivit y, of facial m uscle th an been w idely adopted in Asia. The treatm ent is used
Cau casian s. Th erefore, low er doses of BTA m ay not only to reduce dynam ic facial w rinkles but also
be required in East Asian pat ien t s com pared w ith to reduce static w rinkles and pore size. An additional
Cau casian s. Gen erally, in Asian s an in it ial d ose of 3 action is creating the so-called perceived lifted e ect
to 6 U is recom m en d ed for foreh ead h orizon tal lin es or pseudolift. Thus, intraderm al BTA can be considered
an d 10 U for glabellar frow n lin es. to produce a full range of anti-aging e ects.
377
378 VI Minim ally Invasive Facial Plastic Surgery
indications of BTA, thereby providing som e practical sugges- n ot on ly from gen et ic d i eren ces 11 bu t also from cult ural
tions for the aesthetic use of BTA in East Asians. d i eren ces, sin ce Asian s ten d to u se th eir facial expression
m u scles less th an do Cau casian s.12 Moreover, Asian s h ave
been described as developing few er age-related w rin kles
■ Patient Evaluation th an Caucasian s. Th is m ay be because, in com parison w ith
Cau casian s, Asian s h ave a th icker d erm is,13 in creased fat
Each pat ient should be exam ined individually. Individual- above an d deep to th e su per cial m u scu lar ap on eu rot ic
ized assessm ent and treat m ent are necessar y because there system , an d den ser fat an d brou s con n ect ion s bet w een
is sign i cant variabilit y am ong individuals w ithin the sam e th e super cial m uscu lar apon eurot ic system an d deep
East Asian populat ion in the shape and function of m any (p arot idom asseteric) fascia.14 Th erefore, low er doses of BTA
target m uscles. Dosages and IPs should be based on the sub- m ay be requ ired in East Asian p at ien ts th an in Cau casian s.
ject’s m u scle m ass, m uscle sh ape, pat tern of m uscle act iv-
it y, and judgm ent of w hat is aesth etically appropriate in the
con text of th e in dividual patien t’s overall facial st ruct ure.
How ever som e crit ical eth n ic di eren ces bet w een East
■ Procedural Techniques
Asians and Caucasians should be kept in m in d in developing
a treatm en t st rategy for East Asian s u sing BTA.
Commercial Products of
Botulinum Toxin Type A
Di erences in Aesthetic Ideals Com m ercially available BTA produ cts in Asia are on a-
bot ulin um toxin A (Botox/Vistabel, Allergan In c., Ir vin e,
Com pared w ith Caucasian s, East Asian s h ave a relat ively Californ ia), abobot u lin u m toxin A (Dysp or t , Ip sen , Bou logn e-
w ide, rou n d, an d at face. For th is reason , East Asian s con - Billan cour t , Fran ce/Medicis/Valean t , Bridgew ater, NJ; also
sider a sm aller, n arrow er, an d m ore th ree-dim en sion al face licen sed as Azzalure to Galderm a, Lausan n e, Sw it zerlan d),
to be m ore at t ract ive, an d m ay w ish to ach ieve th is ideal an d in cobot u lin u m toxin A (Xeom in /Xeom een /Bocou t u re/
u sing bot u lin um toxin . On e of th e m ost t yp ical exam ples XEOMIN Cosm et ic); bot u lin u m toxin t ype A (150 kDa) free
of th is is t reat m en t for m asseter hypert rophy using bot u li- from com plexing p rotein s (Merz Ph arm aceu t icals Gm bH,
n u m toxin , w h ich is n ot popu lar in Western cou n t ries even Fran kfurt , Germ any). Oth er BTA product s th at h ave been
th ough it w as rst developed in Western cou n t ries m ore ap proved for u se in Asia are Neu ron ox (Medytox In c., Seou l,
th an 20 years ago.2 Th is n ovel t reat m en t w ith BTA h elp s Sou th Korea; also m arketed as Bot u lift , Cu n ox, Meditoxin ,
th ose East Asian s w ith a square-looking face to ach ieve a an d Siax), Prosign e (CBTX-A; Lan zh ou Biological Produ cts
d ecreased facial w idth an d a “V” sh ape to the face in fron t In st it u te, Lan zh ou , Ch in a) an d Regen ox (Hugel Ph arm a,
p ro le as w ell. In a sim ilar con text , bot u lin u m toxin t reat- Sou th Korea; also m arketed as Bot u lax an d Zen tox).
m en t for th e p arot id glan d is gain ing p op u larit y am ong An oth er Korean toxin , Nabot a (Daew oong Ph arm aceu t ical
East Asian s as a w ay of decreasing facial w idth . Co. Ltd., Seoul, South Korea), is licen sed an d un der invest i-
BTA inject ion for w id en ing th e p alp ebral ap ert u re (th e gat ion in th e Un ited States an d Eu rop e as Evosyal (Alph aeon
eye open ing) is an oth er t ypical exam p le of th e di eren ce Corp., New por t Beach , Californ ia).
in t reat m en t ap proach es bet w een Asian s an d Caucasian s. In each p rodu ct labeling, th e m an u fact u rer states th at
BTA inject ion can rem ove th e p ret arsal bu lge an d sligh tly dosage u n it s are n ot in terch angeable becau se di eren t
low er th e in ferior ciliar y m argin to w iden th e palpebral assays are u sed to m easu re th e poten cy of di eren t bot u -
ap er t u re.10 How ever, it is im port an t n ot to dim in ish th e lin um toxin t ype A p roduct s. How ever, several con sen sus
pret arsal m uscu lar bulge in East Asian s, w h o con sider it papers an d clin ical st udies suppor t clin ical equivalen ce at a
a h allm ark of fem ale beau t y (th e “ch arm ing roll”). Th ey conversion rat io of 1:1 for aesth et ic use of on abot ulin um -
m ay also believe th at th e “ch arm ing roll” brings th e opt ical toxin A an d oth er BTA p rod u ct s except abobot u lin u m -
illu sion of a “big eye” (like double-eyelid surger y does in toxin A.5,8,15,16 Variou s dose conversion rat ios h ave been
Asian s w ith in h eren tly sm aller eyes). Th e roll can even be suggested for on abot u lin u m toxin A an d abobot u lin u m tox-
en h an ced by th e inject ion of hyalu ron ic acid ller. In su ch a in A. Based on available dat a an d clin ical experien ce, m ost
con text , BTA inject ion for w iden ing th e palpebral apert u re p hysician s apply a rat io for on abot ulin u m toxin A to abob -
is th erefore a con t rain dicat ion in East Asian s. ot ulin um toxin A of 1:2.5 for aesth et ic u se.17,18
by patients from th e injection of BTA w ithout in uencing because eyebrow ptosis is a fairly em barrassing side
the potency of BTA.19,20 Various volum es of n orm al saline e ect from th e aesth et ic view p oin t in Asian s, w h o
have been used for the reconstitution of BTA pow der, from h ave a w ider distan ce bet w een th e eyebrow an d th e
1 to 10 m L, w ith 2.5 m L and 3.3 m L being popular dilutions, palpebral ssu re com pared w ith Caucasian s. Typical
w ith respective concentrations of 4 U/0.1 m L and 3 U/0.1 m L. at-risk pat ien ts for eyebrow ptosis are older people
Variou s resu lt s h ave been suggested for th e e ect of (i.e., in th eir 50s an d above); th ese p at ien t s requ ire a
refrigerator storage on th e poten cy of BTA follow ing th e low in it ial dose from 2 to 3 U.
recon st it u t ion of BTA. Based on available dat a an d clin ical 2. Many Asian s require low er doses of BTA sin ce Asian s
exp erien ce, h ow ever, m ost p hysician s store th e recon st i- h ave a sm aller m uscle m ass an d less hyperdyn am ic
t uted BTA in th e refrigerator for up to 4 w eeks.21,22,23 act ivit y th an Cau casian s.
a b
Fig. 29.2 Injection points and dose of BTA for forehead horizontal lines. (a) Injection points and dose of BTA for t wo rows with six to seven
IPs. (b) Alternatives include three rows of injections for people with a high forehead. (Used with perm ission from Seo KK. Botulinum Toxin
for Asians [in Korean]. Seoul: Seoul Medical Books & Publishing; 2014.)
Intram usclular injection into four IPs should be used (2 U in Lateral Canthal Rhytides
two IPs in the procerus and 4 U in two IPs in the m edial part of
the corrugator) (Fig. 29.4a). The standard Caucasian pattern for
(Crow ’s-Feet)
glabellar frow n lines requires an additional 1 to 2 U at the m id-
Th e t arget m uscle is th e orbicu laris oculi (Fig. 29.5). Con -
pupillary line for the lateral part of the corrugator (Fig. 29.4b).
siderat ion p oin ts are as follow s:
Occasion ally, an addit ion al inject ion of 1 U at th e lateral
can th al lin e im m ediately above th e eyebrow is n ecessar y 1. It is im port an t to preser ve th e expression lin es at
for th ose pat ien t s w ith a hyp eract ive orbicu laris ocu li. th e lateral can th al lin es to som e exten t to m ain t ain a
To avoid ptosis, on e of th e m ost serious an d u n com for t- n at u ral look.
able adverse e ects of BTA, t ake th e IP for th e corrugator 2. It is also im port an t , prior to inject ion , to dist inguish
h ead above th e bony orbit al rim by palp at ing th e bony rim , bet w een orbicu laris act ivit y an d zygom at icu s
an d th en inject it slow ly w ith a n on dom in an t nger, com - act ivit y as th e cau se of w rin kles arou n d th e lateral
p ressing th e bony orbit al rim so as to p reven t th e spread of can th al area. Horizon t al lin es un der th e eyes an d
BTA in to th e orbit al p ar t below. descen ding lin es at th e lateral m alar area are cau sed
29 Aesthetic Facial Use of Botulinum Toxin in East Asians 381
a b
Fig. 29.4 Injection points and dose of BTA for glabellar frown lines. (a) Intramusclular injection into four IPs should be used (2 U in t wo
IPs in the procerus, and 4 U in t wo IPs in the medial part of the corrugator). (b) The standard Caucasian pat tern for glabellar frown lines
requires an additional 1 to 2 U at the midpupillary line for the lateral part of the corrugator. (Used with permission from Seo KK. Botulinum
Toxin for Asians [in Korean]. Seoul: Seoul Medical Books & Publishing; 2014.)
by zygom at icus act ivit y an d, con sequ en tly, are n ot ing vessels. At least th ree IPs w ith 2 to 3 U per IP sh ould be
in dicat ion s for BTA. Th is sh ould be com m u n icated used, w ith an opt ion al on e or t w o IPs, dep en ding on th e
in advan ce to pat ien ts prior to t reat m en t so th at w rin kle pat tern (Fig. 29.6).
expect at ion s are ap p ropriate.
3. Follow ing BTA for crow ’s-feet , Asian s w ith
p rom in en t zygom a an d abu n dan t prem alar fat above Eyebrow s (Brow Lifting and Shaping )
th e n asojugal groove ten d to readily sh ow m ore
p rom in en ce of th e lateral m alar area, w h ich Asian s Th e t arget m u scles are brow depressors (corrugators,
gen erally h ate. In th ese p at ien t s, inject ion at a low er procerus, orbicularis ocu li). Con siderat ion poin ts are as
p ar t is un n ecessar y; altern at ively, a low er dose (i.e., follow s:
on ly 0.5 U of BTA) is required.
1. It is im port an t to preser ve or ach ieve a n at u ral
To avoid bruising, subderm al inject ion tech n ique is useful eyebrow posit ion becau se eyebrow s ten d to droop
for th is t reat m en t area as th e area h as abu n dan t u n d erly- w ith aging in Asian s.
382 VI Minim ally Invasive Facial Plastic Surgery
Infraorbital Wrinkles
The target m uscle is the lower part of the orbicularis oculi,
preseptal and orbital part. Consideration points are as follows:
Fig. 29.6 Injection points and dose of BTA for lateral canthal rhyt-
ides. At least three IPs should be used with an optional additional
Infraorbital Eye Opening
one or t wo IPs (purple) above and/or below these depending on the
wrinkle pat tern. (Used with permission from Seo KK. Botulinum Th e t arget m uscle is th e orbicu laris oculi, pretarsal part .
Toxin for Asians [in Korean]. Seoul: Seoul Medical Books & Publish- Con siderat ion poin ts are as follow s: BTA inject ion w ou ld
ing; 2014.) rem ove th e pret arsal bulge an d sligh tly low er th e in ferior
Nasal Tip Lifting Fig. 29.8 Injection point and dose of BTA for an infraorbital eye
opening. One point per eye 1 to 2 mm below the inferior ciliary mar-
Th e t arget m u scles are th e depressor sept i n asi an d n asalis gin in the midpupillary line is su cient. A dose of 2 U per eye is rec-
(an d som et im es th e levator labii su perioris alaequ e n asi). ommended. (Used with permission from Seo KK. Botulinum Toxin for
Asians [in Korean]. Seoul: Seoul Medical Books & Publishing; 2014.)
Con siderat ion poin t s are as follow s:
a b
Fig. 29.9 Injection points and dose of BTA for nasal tip lifting. One injection with 4 U at the subnasale (nasolabial junction) deep into the
nasal spine is recommended, combined with treatment for the nasalis with 4 U at t wo IPs. (a) Frontal view. (b) Lateral view. (Used with
permission from Seo KK. Botulinum Toxin for Asians [in Korean]. Seoul: Seoul Medical Books & Publishing; 2014.)
384 VI Minim ally Invasive Facial Plastic Surgery
Bunny Lines
Th e target m uscles are th e levator labii su perioris alequae
n asi an d n asalis. Con siderat ion poin ts are as follow s: Cen -
t ral ver t ical bun ny lin es are caused by th e n asalis, an d can
be dim in ish ed com pletely w ith BTA. How ever, bun ny lin es
lateral to th e dorsu m of th e n ose, w h ich are produced by
th e levator labii su perioris alaeque n asi an d th e m edial
band of th e orbicularis oculi, can n ot be en t irely im proved,
sin ce com pletely p aralyzing th e levator labii su perioris
alaequ e n asi is n ot recom m en ded.
As w ith all subject s, keeping th e IPs m edial to th e n aso-
facial groove can avoid in adver ten t com p lete p aralysis of
th e levator labii superioris alaeque n asi. Th ree IPs w ith 2 U
per IP are recom m en ded (Fig. 29.10).
Gummy Smile
Th e t arget m uscle is th e levator labii superioris alaeque
n asi. Con siderat ion poin t s are as follow s:
Fig. 29.10 Injection points and dose of BTA for bunny lines. Three
1. Th e m ech an ism for th is in dicat ion is w eaken ing of IPs with 2 U per IP are recommnended. (Used with permission from
hyperact ivit y of th e elevator m uscles of th e upper Seo KK. Botulinum Toxin for Asians [in Korean]. Seoul: Seoul Medi-
lip to im prove excessive gingival display (“gum m y cal Books & Publishing; 2014.)
sm ile”).
2. It is im port an t to inject BTA on ly in to th e levator labii
su p erioris alaequ e n asi becau se p aralysis of oth er lip
levator m uscles result s in a w eird-looking sm ile.
3. Bot u lin u m toxin inject ion sh ould be perform ed
caut iously in Asian pat ien t s w ith a long ph ilt rum
an d p rot ru ding u p per lip , becau se th is m ay lead to
elongat ion of th e ph ilt rum .
Perioral Rhytides
Th e target m uscle is th e orbicularis oris. Con siderat ion
poin t s are as follow s:
At least t w o IPs p er side on th e u p per lip verm illion border bot ulin um toxin sh ould be injected in to th e low er
are recom m en ded. Occasion ally th is m ay be exten d ed to part of th e depressor angu li oris to avoid th e
in clu de t w o to four poin t s on th e low er lip . A dose of 1 U poten t ial for in adver ten t di usion in to oth er m u scles
p er IP is recom m en ded (Fig. 29.12). resp on sible for m ovem en t of th e corn er of th e
m ou th .
Mouth Corner Elevation Su bderm al inject ion can be p erform ed to avoid in adverten t
di usion in to th e depressor labii in ferioris. On e IP w ith a
(Marionette Lines) dose of 2 to 4 U in th e low er on e-th ird of th e depressor
angu li oris is recom m en d ed (Fig. 29.13).
Th e t arget m uscle is th e depressor anguli oris. Con sider-
at ion p oin t s are as follow s:
a b
Fig. 29.12 Injection points and dose of BTA for perioral rhytides. (a) At least t wo IPs per side with 1 U per IP on the upper lip vermillion
border are recommended. (b) Occasionally this may be extended to include t wo to four points on the lower lip. (Used with permission
from Seo KK. Botulinum Toxin for Asians [in Korean]. Seoul: Seoul Medical Books & Publishing; 2014.)
386 VI Minim ally Invasive Facial Plastic Surgery
Fig. 29.14 Injection points and dose of BTA for cobblestone chin.
Intram uscular injection with 4 U into t wo IPs 1 cm apart from the
Fig. 29.13 Injection point and dose of BTA for mouth corner ele- central line at the lower border of the chin is recommended. Two
vation (marionet te line). One IP with a dose of 2 to 4 U in the lower more injections with 2 U per IP above these are required subder-
one-third of the depressor anguli oris is recommended. (Used with mally. (Used with permission from Seo KK. Botulinum Toxin for
permission from Seo KK. Botulinum Toxin for Asians [in Korean]. Asians [in Korean]. Seoul: Seoul Medical Books & Publishing; 2014.)
Seoul: Seoul Medical Books & Publishing; 2014.)
1. BTA inject ion for th e plat ysm a is used to reduce 1. Th e m ain ben e t from th is n ovel in dicat ion for BTA
p lat ysm al ban ds. Decu ssat ion of th e plat ysm al ban d inject ion is to en h an ce the sh ape of th e low er face by
is m ore frequ en t in Asian s th an in Cau casian s.28 m odifying th e squ are jaw com m on in Asian s. Anyon e
Hen ce, th e so-called gobbler n eck deform it y is rarely can ach ieve a reduced facial con tour to som e exten t
fou n d in Asian s. by reducing th e th ickn ess of th e m asseter m uscle
2. BTA inject ion to th e plat ysm a m ay result in a provided th ey h ave su cien t m u scle volu m e.
d ecrease in rest ing m uscle ton e, w h ich brings about 2. Th e m ech an ism of act ion of BTA in th e t reat m en t
th e pseudo-lift ing e ect ach ieved by th e m ech an ism of square jaw is a t ype of disuse m uscular at rophy.
of bot ulin um rebalan cing. Th erefore, th is t reat m en t result s in a t im e lag in
both th e on set an d peak of act ion th at di ers from
In t ram u scu lar inject ion along th e p lat ysm a ban d from th e
conven t ion al t reat m en t s for w rin kles, w h ere th e
in ser t ion area aroun d th e jaw lin e to th e origin at ing area
on set of act ion begin s after just 2 to 3 days an d th e
n ear th e clavicle is p erform ed w ith IPs 2 cm ap art . A dose
peak e ect is reached 1 to 2 w eeks post inject ion .
of 2 to 4 U per IP, an d n o m ore th an 80 U in on e session , is
In clin ical p ract ice, th e e ect of BTA u sed in th e
recom m en ded (Fig. 29.15).
m asseter h as an on set t im e of 2 w eeks post inject ion ,
a b
Fig. 29.15 (a,b) Injection points and dose of BTA for plat ysmal band. Intramuscular injection with a dose of 2 to 4 U per IP along the
plat ysma band from the insertion area around the jaw line to the originating area near the clavicle is performed with IPs 2 cm apart.
29 Aesthetic Facial Use of Botulinum Toxin in East Asians 387
an d th e p eak e ect develops at 2 to 3 m on th s 7. In dividuals w ith a pre-exist ing sun ken ch eek sh ould
post inject ion .3,29 be in form ed in advan ce of th e risk of aggravat ion
3. Six m on th s later, th e m uscle volum e w ill usu ally of th e sun ken ch eek w ith th e disappearan ce of th e
h ave ret u rn ed to som e exten t , an d by 10 to 12 m u scle volu m e follow ing th is p rocedu re.
m on th s p ost inject ion , th e m u scle volu m e can be 8. Pat ien t s in th eir 40s an d above w ith a pre-exist ing
ap proach ing it s previou s st ate. Th is is becau se sagging jow l gen erally sh ow aggravat ion of th e
m u scle at rop hy is reversible, w ith recover y occu rring sagging follow ing th is p roced u re.
after 3 to 6 m on th s. How ever, th e d u rat ion of th e 9. Mild tem p orar y m u scle w eakn ess, su ch as di cu lt y
e ect is variable an d depen ds on th e in dividu al’s ch ew ing, w ill occur after BTA inject ion s in a
p erson al h abit s, such as bru xism , u n con sciou s jaw propor t ion of su bjects. How ever, th is gen erally
clen ch ing, an d excessive ch ew ing. Th ere h ave also passes an d ch ew ing ret urn s to n orm al forcefuln ess
been m any report s th at th e e ects of BTA in th e w ith in 3 m on th s.32
t reat m en t of m asseteric hypert rophy can last for
m ore th an 1 or 2 years, even after on ly on e session of The lower central belly of the m asseter m uscle is the m ain target
inject ion s.30 Th is exten ded du rat ion of th e e ect of when reshaping a square jaw using botulinum toxin. Deep injec-
BTA is p art icu larly n oted in th ose su bjects w h o h ave tion su cient to touch the m andibular bone, rather than injec-
th e acquired form of m asseteric hyper t rophy, as long tion at a m edium depth, is very important. Super cial injection
as th ey avoid eat ing tough foods an d do n ot h ave th e can weaken the rizorhius attached super cially to the anterior
h abit of jaw clen ch ing. part of m asseter, causing an em barrassing change of facial
expression (e.g., an asym m etric, unnatural sm ile). To reduce the
4. A person w ith a square jaw in th e fron t view th at
risk of adverse change of facial expression w hen treating m as-
is m ain ly due to th e m asseter m u scle is th e best
seteric hypertrophy, physicians should start by injecting at least
can didate for this n ovel in dicat ion for t reat m en t .
1 cm inside the anterior m argin of the m asseter m uscle in addi-
5. Factors th at con t ribu te to m asseteric hypert rophy tion to deep injection.
in clu de jaw clen ch ing an d bru xism , an d th e h abit ual For th e cosm et ic p urpose of resh aping a low er facial
ch ew ing of gu m or dried, h ard food.31 On e-sided con tour, th e low er part of th e m asseter m uscle un der th e
ch ew ing can lead to asym m et ric m asseteric im agin ar y lin e con n ect ing th e t ragu s to th e m ou th corn er
hypert rophy. is th e m ain t arget . A safe an d e ect ive inject ion zon e for
6. Fem ales w ith a prom in en t zygom a tend to w ish squ are jaw can be delin eated by th e u p per m argin being
th e zygom a to n ot appear even m ore prom in en t; an im agin ar y lin e con n ect ing th e t ragu s to th e m ou th cor-
th erefore, reduct ion of th e low er par t of th e ner, th e low er m argin as th e m an dibu lar bony border, an d
m asseter, rath er th an th e w h ole m u scle, is m ost th e an terior an d posterior m argin s as th e an terior an d pos-
ap prop riate. terior borders of each m asseter m uscle. IPs are located at
388 VI Minim ally Invasive Facial Plastic Surgery
least 1 cm in side from th e bord er, to avoid unw an ted di u - Intradermal Botulinum Toxin
sion of BTA in to oth er facial m u scles.
Fou r to six IPs of 5 U are recom m en ded dep en ding on Con siderat ion poin t s are as follow s:
th e m uscle volum e (Fig. 29.17).
1. Mult iple in t raderm al inject ion s of BTA (in t raderm al
BTA) h ave been w idely adopted in Asia, u n der
Reduction of the Parotid Gland variou s n am es su ch as “m esobotox,” “d erm atoxin ,”
an d “m icrotoxin .” Th e t reat m en t is ap plied w ith
Th e t arget is th e parot id glan d. Con siderat ion poin t s are as th e expect at ion of n ot on ly redu cing dyn am ic facial
follow s: w rin kles bu t also reducing stat ic w rin kles an d pore
sizes, as w ell as creat ing th e so-called perceived
1. En larged parot id glan ds can con t ribute to a
lifted e ect or pseudolift— even th ough act u al lift ing
squ are-sh aped low er face app earan ce. Becau se
e ect s h ave n ot been object ively veri ed. Th erefore,
acet ylch olin e, th e n eu rot ran sm it ter in th e salivar y
in t raderm al BTA can be con sidered to produce a full
glan ds, can be blocked by BTA, inject ion of BTA in to
range of an t i-aging e ect s.
th e parot id glan d can resu lt in at rophy of th e parot id
glan d in h u m an s.33 In deed, inject ion of BTA in to an 2. Th e sam e dyn am ic w rin kle reduct ion th at is
en larged or p rot ru ding parot id glan d can redu ce th e delivered by th e conven t ion al in t ram uscular
w idth of th e low er face. inject ion of BTA can also be ach ieved by di usion
of BTA in to un derlying facial expression m u scles,
2. Inject ing BTA in to th e parot id glan d seldom result s
because BTA spreads in a th ree-dim en sion al
in a dr y m ou th as 71% of salivar y produ ct ion com es
m an n er from th e derm is an d becau se several
from th e su bm an d ibu lar glan d.34
facial expression m u scles also h ave in t racu t an eou s
Th e m ost prot ruding part of th e parot id glan d aroun d th e in ser t ion s.
m an dibu lar angle is th e m ost e ect ive inject ion site. Deep 3. Th e hypoth esized e ects of th e im provem en t of
in t raglan du lar inject ion is requ ired . Five to six IPs w ith 5 stat ic w rin kles an d t igh ten ing of p ores, w h ich
U p er inject ion site are recom m en ded dep en d ing on th e im p art s a sh in e an d a t igh ter look to th e skin ,
parot id glan d volum e (Fig. 29.18). involves derm al edem a resu lt ing from th e t ran sien t
a b
Fig. 29.17 Injection points and dose of BTA for square jaw. Depending on the muscle volum e, IP numbers can vary. (a) Four IPs. (b) Six
IPs. (Used with permission from Seo KK. Botulinum Toxin for Asians [in Korean]. Seoul: Seoul Medical Books & Publishing; 2014.)
29 Aesthetic Facial Use of Botulinum Toxin in East Asians 389
Com bin ing m ult iple in t raderm al inject ion s w ith th e con -
ven t ion al in t ram u scu lar inject ion is u su ally recom m en ded.
Conven t ion al in t ram u scular inject ion s can be u sed for
Fig. 29.18 Injection points and dose of BTA for enlarged parotid sup p lem en t at ion in areas w ith deep m u scles su ch as th e
gland. Five to six IPs with 5 U per injection site are recommended corrugator, m en t alis, an d m asseter. Areas for in t raderm al
depending on the parotid gland volume. (Used with permission inject ion are th e foreh ead, ch eek, an d an terior m alar area
from Seo KK. Botulinum Toxin for Asians [in Korean]. Seoul: Seoul
(Fig. 29.19).
Medical Books & Publishing; 2014.)
■ Complications and
Their Management
an d m ild lym p h at ic in su cien cy in du ced by
u n derlying m u scu lar paralysis. Derm al edem a m igh t To date, th ere is n o e ect ive an t idote for BTA. Th erefore,
im prove th e n e st at ic w rin kles an d dilated pores. on ce it is adm in istered, th ere is n o w ay to reverse an adverse
4. In som e an ecdotal repor t s, in t raderm al BTA h as been e ect of BTA for at least 2 to 3 m on th s. Adverse e ect s are
described as reducing sebum product ion an d pore th erefore best preven ted. Hen ce, a screen ing assessm en t of
prom in en ce.35,36,37 Acet ylch olin e receptors h ave been risky pat ien t s is m ost im p or tan t , an d a carefu l an d m et icu -
rep orted to be presen t in sebaceou s glan ds,38 an d a lou s inject ion tech n iqu e is also recom m en ded. Com p lica-
p ossible e ect of BTA is to redu ce th e act ivit y of th e t ion s of BTA an d speci c in dicat ion s for BTA t reat m en t h ave
sebaceou s glan d an d th e p ore size, th u s im p roving already been described in depth in th e previou s sect ion s.
a b
Fig. 29.19 Injection points and dose of BTA for intradermal BTA. The white dots indicate intradermal injection sites and the gray dots
indicate intramuscular injection sites. (a) Frontal view. (b) Lateral view. (Used with permission from Seo KK. Botulinum Toxin for Asians [in
Korean]. Seoul: Seoul Medical Books & Publishing; 2014.)
390 VI Minim ally Invasive Facial Plastic Surgery
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1278–1284 23. Liu A, Carru th ers A, Coh en JL, et al. Recom m en dat ion s
8. Loren c ZP, Ken kel JM, Fagien S, et al. Con sen su s pan el’s as- an d curren t pract ices for th e recon st it ut ion an d storage of
sessm en t an d recom m en dat ion s on th e use of 3 bot ulin um bot ulin um toxin t ype A. J Am Acad Derm atol 2012;67(3):
toxin t yp e A prod u ct s in facial aesth et ics. Aesth et Su rg J 373–378
2013;33(1, Suppl):35S–40S 24. Hu ilgol SC, Carru th ers A, Carru th ers JD. Raising eye-
9. Ahn BK, Kim YS, Kim HJ, Rho NK, Kim HS. Consensus recom - brow s w ith bot ulin um toxin . Derm atol Surg 1999;25(5):
m endations on the aesthetic usage of botulinum toxin t ype 373–375, discussion 376
A in Asians. Derm atol Surg 2013;39(12):1843–1860 25. Sundaram H, Kiripolsky M. Nonsurgical rejuvenation of the up-
10. Flyn n TC, Carru th ers JA, Carru th ers JA. Bot u lin u m -A per eyelid and brow. Clin Plast Surg 2013;40(1):55–76
toxin t reat m en t of th e low er eyelid im p roves in fraorbit al 26. Su n daram H, Carru th ers J, eds. Th e glabella an d cen t ral
rhyt ides an d w iden s th e eye. Derm atol Su rg 2001;27(8): Brow. In : Carru th ers J, Carru th ers A, eds. Procedu res in
703–708 Cosm et ic Derm atology: Soft Tissu e Augm en t at ion . 3rd ed.
11. Yang HM, Kim HJ. Anatom ical st udy of the corrugator super- New York, NY: Elsevier Saun ders; 2013:88–99
cilii m uscle and its clinical im plication w ith bot ulinum toxin 27. Hu KS, Yang SJ, Kw ak HH, et al. Locat ion of th e m od iolou s
A injection. Surg Radiol Anat 2013;35(9):817–821 an d th e m orph ologic variat ion s of th e risorius an d zygo-
12. Tzou CH, Giovan oli P, Plon er M, Frey M. Are th ere eth n ic m at icus m ajor m uscle related to th e facial expression in
d i eren ces of facial m ovem en t s bet w een Eu ropean s an d Korean s. Korean J Phys An th rop ol 2005;18:1–11
Asian s? Br J Plast Su rg 2005;58(2):183–195 28. Kim HJ, Hu KS, Kang MK, Hw ang K, Ch u ng IH. Decu ssa-
13. Lee Y, Hw ang K. Skin th ickn ess of Korean ad u lt s. Su rg Ra- t ion p at tern s of th e p lat ysm a in Korean s. Br J Plast Su rg
d iol An at 2002;24(3-4):183–189 2001;54(5):400–402
14. Sykes JM. Man agem en t of th e aging face in th e Asian p a- 29. Yu CC, Ch en PK, Ch en YR. Bot u lin u m toxin A for low er fa-
t ien t . Facial Plast Su rg Clin North Am 2007;15(3):353–360, cial con touring: a prospect ive st udy. Aesth et ic Plast Surg
vi–vii 2007;31(5):445–451, discussion 452–453
15. Pou lain B, Trevidic P, Clave M, et al. Clin ical equ ivalen ce 30. Kim NH, Ch u ng JH, Park RH, Park JB. Th e u se of bot u lin u m
of conven t ion al on abot ulin um toxin A (900 kDa) an d in - toxin t ype A in aesth et ic m an d ibu lar con tou ring. Plast Re-
cobot u lin u m toxin A (n eu rotoxin free from com plex- con st r Su rg 2005;115(3):919–930
ing p rotein s—150 kDa): 2012 m u lt idisciplin ar y Fren ch 31. Man d el L, Th arakan M. Treat m en t of u n ilateral m asseter-
con sen su s in aesth et ics. J Drugs Derm atol 2013;12(12): ic hyp ert rophy w ith bot u lin u m toxin : case rep ort . J Oral
1434–1446 Maxillofac Su rg 1999;57(8):1017–1019
29 Aesthetic Facial Use of Botulinum Toxin in East Asians 391
32. Kim KS, Byu n YS, Kim YJ, Kim ST. Mu scle w eakn ess after in t raderm al inject ion of bot ulin um toxin t ype A. Int J Der-
rep eated inject ion of bot u lin u m toxin t yp e A evaluated m atol 2008;47(12):1287–1294
according to bite force m easurem en t of h um an m asseter 36. Rose AE, Goldberg DJ. Safet y an d e cacy of in t rad erm al
m u scle. Derm atol Su rg 2009;35(12):1902–1906 inject ion of bot u lin um toxin for th e t reat m en t of oily skin .
33. Bae GY, Yu n e YM, Seo K, Hw ang SI. Bot u lin u m toxin in - Derm atol Surg 2013;39(3 Pt 1):443–448
ject ion for salivar y glan d en largem en t evalu ated u s- 37. Sh ah AR. Use of in t raderm al bot u lin u m toxin to redu ce
ing com p u ted tom ograp h ic volu m et r y. Derm atol Su rg sebu m p rodu ct ion an d facial p ore size. J Drugs Derm atol
2013;39(9):1404–1407 2008;7(9):847–850
34. Flin t P, Haugh ey B, Lu n d V. Physiology of th e salivar y glan ds. 38. Ku rzen H, Wessler I, Kirkpat rick CJ, Kaw ash im a K, Gran d o
In : Cum m ings CW, Fredrickson JM, Harker LA, Krau se CJ, SA. Th e n on -n euron al ch olin ergic system of h um an skin .
Sch u ller DE, eds. Otolar yngology—Head an d Neck Surger y. Horm Met ab Res 2007;39(2):125–135
Vol 2, 5th ed. St Lou is, MO: Mosby Elsevier; 2010
39. Li ZJ, Park SB, Soh n KC, et al. Regu lat ion of lip id prod u ct ion
35. Ch ang SP, Tsai HH, Ch en W Y, Lee W R, Ch en PL, Tsai TH. Th e by acet ylch olin e sign alling in h um an sebaceous glan ds. J
w rin kles sooth ing e ect on th e m iddle an d low er face by Derm atol Sci 2013;72(2):116–122
30 Facial Contouring Using Fillers
Jongseo Kim
Pearls
• Con touring or augm en t at ion of th e facial skeleton n odu le form at ion an d color ch ange. In th is case, it is
w ith llers is on e of th e m ost su btle bu t pow erful bet ter to inject a sm all am oun t m ult iple t im es or u se
n on surgical t reat m en t s. soft ller by can u la.
• An E-plan e, w h ich is a lin e draw n from th e t ip of th e • Th e foreh ead, tem ple, ch eek, ch in , n ose, n asolabial
n ose to th e t ip of th e ch in , is an im port an t gu idelin e fold, an d jaw lin e are com m on ller inject ion sites
for con tou ring th e lateral pro le. In th e fron t al view, for facial con touring.
a h eart-sh ap ed face is th e p referred facial con tou r. • For foreh ead con touring, 1.5 to 3.0 m L of ller is
• To t reat n e w rin kles, volum e replacem en t ju st injected u n der th e m uscle layer using th e radial
u n der th e derm is w ith soft ller th at h as low er fan n ing tech n iqu e th rough on e en t r y p oin t m idw ay
elast icit y is e ect ive. bet w een th e eyebrow s.
• For st ruct ural facial con touring, a larger volum e of • Com m only used llers for nasal augm entation are
ller is requ ired in m ost cases. Hard ller gels su ch CaHA ller, Rest ylane (Galderm a), and Perlane (Merz).
as CaHA ller, PCL ller, an d p ar t icle t yp e HA ller Subm uscular injection using the linear threading
are p referred. technique and subcutaneous injection using the serial
• W h en a pat ien t is n ot su re about th e proper ller puncture technique are usually com bined.
t yp e an d it s e ect at in it ial con su ltat ion , use of • In aged p at ien t s, m ore exten sive volu m et ric
n orm al salin e or HA ller is recom m en ded. If th e replacem en t is n eeded an d oth er, con com it an t
pat ien t is sat is ed w ith th e result s of ller inject ion lift ing procedures su ch as ult rasoun d lift ing or
but w an t s to avoid repeated inject ion s, long st an ding su rgical face lift ing w ou ld be h elpfu l.
ller can be app lied. • Hydro lift ing, in w h ich hyalu ron ic acid is directly
• Sp ecial cau t ion sh ou ld be taken w h en inject ing ller injected in to th e derm is layer of th e skin , is usefu l in
in to th in -skin areas su ch as th e eyelid, periorbit , an d people w h o h ave serious dr y skin or w h o w an t m ore
n e w rin kles on th e ch eek area becau se of p ossible elast ic an d hydrated skin .
392
30 Facial Contouring Using Fillers 393
W h ile th e E-plan e is a guidelin e for con touring th e dures. Aspirin or Coum adin (Bristol-Myers Squibb) n eeds
facial pro le, a h eart sh ap e is con sidered th e preferred to be stop p ed before th e procedu re to p reven t bleeding an d
facial con tou r by Asian s in th e fron t al view. It is ch aracter- bruising. Any pat ien t s w ith im m un ologic diseases such
ized by h igh er an d fuller ch eeks, raised n asal p ro le, an d as lu pu s or scleroderm a sh ou ld take ext ra precau t ion s as
sm aller ch in con t ribu t ing to a sm ooth facial convexit y. Tra- people w ith facial soft t issue at rophy can h ave problem s.
dit ion ally, it is con sidered ideal w h en th e rat io bet w een th e Th e con sult at ion an d assessm en t sh ould in clude th e
upp er, m id-, an d low er face is equal or represen ted as 1:1:1. follow ing:
Recen tly, h ow ever, th e “baby face,” in w h ich th e low er face
1. Discu ssion of th e pat ien t’s expectat ion s (durat ion of
part’s rat io is a lit tle sh or t of 0.8, h as been receiving at ten -
llers, inject ion am ou n t of llers, p at ien t’s aim an d
t ion in th e rejuven at ion of th e Asian face.
purpose)
Derm al llers can be an opt ion for t reat m en t of rhyt id es
as w ell as for facial scu lpt ing. Un d erst an d ing th e aging pro- 2. Medical an d surgical h istor y, m edical con dit ion s, an d
cess is crucial to at t ain opt im al resu lt s w ith facial rejuven a- drug allergies
t ion by ller inject ion . Facial aging is th e result of decreased 3. Radiologic assessm en t (com puted tom ography [CT]
th ickn ess an d elast icit y of th e skin , absorpt ion of fat , an d scan s or facial X-rays)
resorpt ion of th e bony skeleton . In addit ion , decreased 4. Preoperat ive an d postoperat ive ph otography for
adh eren ce bet w een th e skin an d su bcu t an eou s t issu e, m u s- evalu at ion an d com p arison
cle alterat ion , an d sagging of soft t issues are presen t . Th us, 5. Com puter-assisted sim ulat ion if available
ju st t igh tly ret ract ing th e facial skin th rough su rgical in ter-
ven t ion m ay be in ap prop riate in som e p at ien ts becau se it In m ost cases, bot u lin u m toxin an d inject able llers are
can produce an un n at ural-looking appearan ce. Replen ish - in ext ricably lin ked. Con com itan t bot ulin um toxin inject ion
ing facial volu m e an d lling n e w rin kles w ith injectable is ben e cial as it preven t s unw an ted m igrat ion of injected
llers w ou ld be a bet ter ap proach in th ese pat ien t s. ller by rest rict ing excessive m u scle m ovem en t , an d also
Recen tly, facial rejuven at ion using th e hydro lling ch anges facial sh ape favorably.5 Th erefore, it is essen t ial to
e ect of hyalu ron ic acid (HA) ller h as been em p loyed for h elp th e p at ien t u n derst an d th e ben e t s of com bin ed bot u -
im p rovem en t of skin text ure. Sin ce th e con cen t rat ion of HA lin um toxin inject ion .
in skin decreases w ith aging, th e skin’s elast icit y an d abilit y
to h old w ater are decreased, leading to an in creased ten -
d en cy tow ard w rin kling an d skin laxit y, part icularly in th e ■ Filler Materials
facial skin . Becau se of th eir hydroph ilic n at u re, HA llers
p lay a role as a derm al reser voir of hyd rat ion , by d raw ing A w ide variet y of ller m aterials are cu rren tly avail-
w ater in to th e ext racellu lar m at rix in th e d erm is, resu lt ing able, w ith a seem ingly en dless ow of n ew an d em erging
in hydrat ion in th e derm is an d im provem en t of skin surface product s. Table 30.1 sh ow s detailed in form at ion on ller
rough n ess an d n e w rin kles. m aterials cu rren tly available. Am ong th ese llers, th e best
an d th e safest p rodu ct s are hyalu ron ic acid (HA) llers.
Th ere are t w o t ypes of HA in term s of rh eology or it s par-
■ Patient Consultation t icle sh ape: On e is biph asic HA ller (Rest ylan e) an d th e
oth er is m on op h asic HA ller (Juved erm , Belotero). With a
Du ring con su ltat ion , th e p at ien t w ill be in form ed of th e m on op h asic HA ller su ch as Juved erm , it is easy to inject
poten t ial risks w ith th e ller inject ion . A detailed m edical w ith out lum ps or irregu larit y, but it is h ard to use w h en
h istor y sh ou ld be t aken , in cluding prior inject ion proce- con touring to form a sh ape w ith a n arrow base an d t all
h eigh t . With a biph asic HA ller su ch as Rest ylan e, it is easy Selecting Needles
to lay bricks (“brickw ork”) in to a form w ith a n arrow base
an d t all h eigh t , bu t th ere is a h igh risk of lu m p s or irreg- Derm al llers m ay be injected u sing eith er a sh arp n eedle
u larit y. Molding is m u ch m ore d i cu lt w ith biph asic HA or a blun t-t ip m icrocan n u la (Fig. 30.1). A blu n t-t ip m icro-
llers bu t th ey can last longer an d are m ore du rable th an can n ula (also called a sm ooth -t ip m icrocan n ula or a blun t-
th e m on oph asic HA llers. Over t im e, th e injected HA gel n eedle can n u la) is a sm all t u be (18- to 30-gauge), w ith an
is slow ly absorbed in to th e su rrou nd ing t issu es an d disap - edge th at is n ot sh arp , design ed for th e at rau m at ic su bder-
p ears by a p rocess called isovolum et ric degradat ion . m al inject ion of llers. Depen ding on th e in n er diam eter,
Sim ilar to HA-based prod uct s, calcium hydroxylapa- it can be used eith er for fat t ran sfer, or for th e inject ion of
t ite (CaHA, Radiesse, Merz) is also relat ively in ert , is ver y llers su ch as HA, PCL, PLLA, CaHA, etc.
safe, an d requ ires n o skin test ing prior to inject ion . In com - Each physician h as speci c preferen ces for inject ion
parison to HA-based llers, h ow ever, CaHA is n ot recom - in st rum en t s depen ding on th e t ype of procedu re being per-
m en ded for th e t reat m en t of ver y su per cial w rin kles an d form ed. For exam ple, n eedles m ay be preferred for delicate
creases. CaHA is m ore com m on ly used to augm en t deep correct ion of lin es an d w rin kles, w h ile can n ulas m ay be
creases an d folds as w ell as con touring th e ch eek, ch in , preferred for volum e correct ion . Needles h ave th e advan -
an d foreh ead. Ap proxim ately 9 m on th s after an inject ion , tages of ext rem e precision of m ovem en t , th e possibilit y of
CaHA begin s to u n dergo gradu al en zym at ic digest ion , w ith deep in t raderm al inject ion , an d conven ien ce w h en sm aller
com plete disappearan ce of th e aesth et ic e ect bet w een 12 inject ion volum e is required. Disadvan t ages in clu de pain ,
an d 18 m on th s. From th e au th or’s exp erien ce, th e volu m e bruising, an d possible vessel lacerat ion . Can n ulas cause
st art s to decrease w ith in 1 m on th after CaHA inject ion . less t raum a, pain , an d bru ising an d allow a large area to be
Poly-L-lact ic acid (PLLA; Sculpt ra, Derm ik Laboratories) t reated at th e ch osen inject ion depth . Speci c t rain ing is
an d p oly-cap rolacton e (PCL; Ellan se, AQTIS Medical) w ork required to m aster the tech n iques of inject ion , an d th is is
by providing a delayed long-last ing volum izing e ect .6 con sidered a disadvan t age.
How ever, m u lt ip le t reat m en t s (t w o or th ree session s) are Usually a 50-m m -length, 27-gauge needle is used for the
n eeded to ach ieve com plete correct ion . Act u ally, Scu lpt ra is injection of Restylane. The author prefers a 70-m m 23-gauge
n ot a volu m izing ller, bu t a st im u lator. Th e augm en t at ion m icrocannula since it can also be used to inject Ellanse,
or con touring e ect s of Sculpt ra are n ot predictable eith er; Restylane Sub-Q (large-particle HA), and m onophasic HA llers
th erefore, it is n ot recom m en ded for con touring purposes. such as Juvederm and Teosyal (Teoxane Laboratories) as well.
■ Procedural Techniques
Anesthesia
Th e topical an esth et ic is n ot adequate; h en ce, it is recom -
m en ded th at th e su rgeon block th e n er ve locally or u se
t um escen t solut ion for an esth esia before ller inject ion .
Th e auth or prefers both . Epin eph rin e in th e an esth et ic solu -
t ion h elps to reduce bruising an d prolong th e an esth et ic
e ect for a few h ou rs. Lidocain e (m ixed w ith ep in ep h rin e)
is u sed for local n er ve block. For a m idface local block, th e
n eedle can be placed th rough an in t raoral app roach just
above th e can in e arou n d th e in fraorbit al n er ve area. Th e
m icro–n er ve block tech n iqu e can be u sefu l for an inject ion a
of th e lip area. For th e m icro–n er ve block tech n ique, sm all
aliqu ot s of an esth et ic solu t ion are injected along th e m u co-
sal bord er of th e lip n ear th e gingival su lcu s. Micro-blocks
h ave th e advan t age of n ot producing a deep region al an es-
th esia. How ever, th is tech n ique m ay t ake longer to perform
an d th e poten t ial for in com p lete an esth esia is greater. Th e b
au th or p refers t u m escen t solu t ion , w h ich is p repared by
m ixing 100 m L of n orm al salin e w ith 20 m L of 2%lidocain e Fig. 30.1 Needles for ller injection. (a) Sharp needle with 1-mL
an d 1 m L of 1:100,000 ep in ep h rin e. ller syringe. (b) Blunt-tip micro cannula.
30 Facial Contouring Using Fillers 395
a b
Linear Threading, or Tunneling Th e inject ion area is draw n w ith a pen cil an d th e in ser-
t ion poin t s are selected in th e cen ter of th e area to be aug-
Lin ear th reading is a tech n iqu e in w h ich th e n eedle is m en ted . After bolu s inject ion u n der th e fascia, m olding is
in ser ted in to th e skin an d th e ller is deposited in a lin ear ap plied by sim p le com p ression on th e injected area. Th is
fash ion along th e t rack as th e n eed le is slow ly w ith draw n . m eth od is com m on ly u sed in tem p oral depression . Assess-
Becau se th is creates essen t ially a t u n n el of ller, th is is also m en t is easy becau se it is n ot n ecessar y to pre-inject w ith
com m on ly called th e t un n eling tech n ique. Applied w ith a lidocain e solut ion in th is tech n ique.
can n ula, th is is th e m ost frequen tly u sed tech n ique for th e
augm en tat ion of th e n ose (Fig. 30.2a).
Serial Puncture
a b
Serial pu n ct u re involves m u lt iple inject ion s posit ion ed
adjacen tly along th e length of th e w rin kle or crease. Th is
tech n iqu e m akes m any “ch ocolate Kisses”–like st ruct ures
on th e n ose (Fig. 30.2b). It is im p erat ive th at th ese injec-
t ion s rem ain su cien tly close to form a relat ively sm ooth ,
con t in uou s lin e of augm en t at ion (Fig. 30.3). In cases w h ere
th ere is a n ot iceable separat ion bet w een th e inject ion sites,
post t reat m en t m assage m ay h elp blen d th e ller.
Fanning Technique
Th e fan n ing tech n iqu e is perform ed for augm en t at ion of
a w id e area su ch as th e foreh ead , m alar, an d jow l region s
(Fig. 30.4). Radial fan n ing is an exten sion of th e lin ear
th reading tech n ique.7 Th e ller is deposited in a lin ear lin e
as th e n eedle is w ith d raw n w ith a fan sh ap e m ovem en t .
Before th e n eedle is act u ally rem oved from th e skin , it Fig. 30.3 Correction of mild hump nose with ller. (a) Pro le view
is redirected an d advan ced along a n ew radial lin e. Mu l- shows a mild hump nose. (b) After injection of 0.5 m L of Rest ylane
t iple st rokes w ill be n eeded to preven t irregularit y after using a 29-gauge sharp needle with serial puncture (“Kisses”) tech-
inject ion . nique, the pro le became smooth.
396 VI Minim ally Invasive Facial Plastic Surgery
1 2 3
5
1. Skin
2. Subcutaneous tissue
3. Musculo-aponeurotic layer
4. Retaining ligaments and space
5. Periosteum and deep fascia
3
45
1 2
Fig. 30.5 Soft tissue layer of the face. There are ve tissue layers
on the face composed of skin, subcutaneous tissue, aponeurosis,
loose connective tissue, and periosteum , which are collectively
Facial Contouring called SCALP.
Forehead
Th ere are ve layers on th e foreh ead, com posed of skin ,
su bcu tan eou s t issu e, ap on eu rosis, loose con n ect ive t is- or subcut an eous t issues because th e bon e can be a guide
su e, an d p eriosteu m , collect ively called SCALP (Fig. 30.5).8 to con t rol th e inject ion depth .9 For con touring of th e Asian
W h en inject ing llers to th e foreh ead, th e t arget layer dif- foreh ead , CaHA an d PCL llers are p referred an d 3 m L is
fers according to th e pu rp ose of ller inject ion . To t reat u sed for th e rst session . Molding im m ediately after ller
w rin kles, injectable llers can be in t roduced to th e derm al inject ion is easy an d essen t ial because it is h ard to m old
an d th e su bderm al layers. How ever, to ch ange th e foreh ead after th e ller h as set tled dow n . For m olding, a roller is
con tour, a deeper inject ion in to th e supraperiosteum an d u sed in th is region .
su bm u scu lar layer is p referred . In ller inject ion , a deep
inject ion h as a low er risk of lu m ps an d irregularit ies. To
preven t m igrat ion of ller gels, bot ulin um toxin is injected Temple
togeth er w ith th e ller in m ost cases.
W h en using a blun t n eedle, th e en t r y poin ts sh ould The tem poral fossa is a critical area for volum e restoration
be m ade before an inject ion . Th e auth or prefers to m ake of the aging face.7 Tem ple contouring is also perform ed for
on e en t r y poin t m idw ay bet w een th e eyebrow s.9 Occasion - patients w ho h ave a big m alar bone. The tem poral fossa is
ally, th e au th or m akes on e en t r y p oin t at th e cen ter of th e a sh allow depression on th e side of th e skull bou n ded by
foreh ead (Fig. 30.6) sin ce th e m idlin e ap proach is safer by the tem poral lines and term inat ing above the level of th e
avoiding dam age to th e blood vessels. Som e doctors prefer zygom atic arch (Fig. 30.7). To con rm inject ion depth dur-
to m ake t w o en t r y poin ts on each side of th e eyebrow, but ing ller inject ion w ith a cann ula, a blunt needle can be
th is is n ot safe due to risk of inju r y to th e supraorbit al n er ve passed through the zygom at ic arch . If the cannula goes
an d blood vessels. Also, th e en t r y p oin t s on th e eyebrow through under the zygom at ic arch , it m eans that the can -
h ave a h igh risk of bacterial con t am in at ion from h air folli- nula is posit ioned under a deep tem poral fascia or m u scle
cles of th e eyebrow s. For foreh ead con touring, 1.5 to 3.0 m L layer. If the cannula is blocked again st the zygom atic arch,
of ller is injected using th e radial fan n ing tech nique. Th e it is posit ioned bet w een the deep and super cial tem po-
fan n ing m eth od is ap p ropriate for placem en t of th e prod- ral fasciae. To contour or augm ent the tem poral fossa, it is
u ct in th e su praperiosteal layer in stead of th e su bderm is essen t ial to inject th e ller into various layers according to
30 Facial Contouring Using Fillers 397
c d
ch eek, th e auth or prefers a t ran scut an eou s approach w ith because it is n ot a par t icle-t ype HA gel. To inject Juvederm
a can n u la after m aking an en t r y poin t 1 cm lateral from th e or Teosyal, 23 gauge is recom m en ded. Th e inject ion is don e
corn er of th e m outh . Th ere is less risk of in fect ion an d bio- at th e sup ra-periosteal layer, subm u scular layer, or both .
lm creat ion w ith t ran scu t an eou s inject ion . Besides, u sing For a m ajor augm en tat ion , th e auth or prefers t w o-layer
a can n u la is tech n ically less d em an ding, easier to teach , inject ion s (Fig. 30.10), rst in to th e su bm u scu lar layer w ith
an d h as less risk of in fraorbit al n er ve inju r y an d vascu lar th e lin ear th reading tech n ique an d th en in to th e subcu ta-
inju r y com p ared w ith n eedle inject ion . W h en perform ing a neous layer w ith th e serial p un ct ure tech n ique.
t ran soral approach , th e use of an t ibiot ics is recom m en ded Th e auth or prefers th e serial pun ct ure tech n ique
to preven t bio lm form at ion as th ere is a risk of con t am i- using HA ller (especially Rest ylan e lidocain e), Ca ller
n at ion w h en th e can n u la is m oving for w ard an d backw ard (Radiesse), an d PCL ller (Ellan se) for n asal augm en tat ion .
th rough th e en t r y poin t . An oth er approach is to place th e Th e usual am oun t of inject ion is ~ 0.5 m L in Asian s. How -
m on op h asic an d less refract ive HA in th e su bderm al p lan e. ever, in som e cases up to 1 m L is adm in istered by adding
an oth er 0.5 m L a m on th later. Avoid u sing m ore th an 1 m L
Tear Trough in on e session to p reven t m igrat ion of th e ller m aterials.
Th e angles of inject ion ch ange according to th e sh ape
For t reat ing th e tear t rough , th e lin ear th reading or serial of th e n ose. Th e auth or prefers to inject rst at 10 to 20
pun ct ure tech n ique is used w ith a 30-gauge sh arp n eedle degrees along th e ver t ical a xis an d th en ch ange th e angle to
or can n ula. Tem porar y, long-last ing, or perm an en t llers 90 degrees. Th en m ult iple “Kisses” inject ion s are applied,
can be used e ect ively to augm en t th e un derlying soft t is- esp ecially on th e d orsu m an d th e colu m ella area.
su e. In p at ien t s w ith th in n er skin , h ow ever, ller can create On follow -u p , m old ing of th e n ose area can be p er-
a lu m p or Tyn dall e ect , resu lt ing in a m ore aggravated tear form ed to reduce irregularit y an d deviat ion . Molding is
t rough . Th e au th or prefers to use Belotero am ong HA llers don e im m ediately after inject ion if a visible con tour irregu -
to t reat tear t rough becau se th e Tyn dall e ect is less. larit y is n oted becau se it is h ard to m old a few w eeks later.
Pre-inject ion of lidocaine, w hich is called the “Baiser A gen tle p in ch -an d -roll tech n iqu e is u sed. A cold com press
Voler” tech nique,15 is needed to cont rol pain and ecchy- is h elpfu l on th e rst day to m in im ize sw elling an d ecchy-
m osis. It is often h elpfu l to keep th e patien t in an uprigh t m osis. Special care sh ou ld be t aken to avoid u n du e p res-
posit ion during the procedure to accurately visualize the su re th at cou ld cau se u nw an ted d isp lacem en t of th e ller.
ongoing contouring process. The needle is inserted from lat-
eral to m edial just in ferior to th e deepest m argin of th e tear
t rough. The plane of injection is supra-periosteal to m axi-
m ize th e soft tissue cush ion ing of th e ller below th e tear
t rough ligam ent . W hen using a cannula, touching the tear
a b
t rough ligam ent can be a guide to an appropriate plane. On
average 0.5 m L of ller is placed on each side, depending on
the degree of rejuvenat ion desired.
Nose
Nose augm en tat ion by ller inject ion can be don e for cos-
m et ic p u rposes an d for correct ion of st ru ct u ral abn orm ali-
t ies. Sim ple dorsal augm en tat ion , in creasing t ip project ion ,
h u m p or deviated n ose correct ion , an d n ost ril reduct ion
are com m on in d icat ion s for n ose con tou ring u sing ller.
Inject able llers are also qu ite u sefu l in pat ien t s w h o h ave
already u n dergon e rh in op last y an d n oted p ersisten t post-
operat ive con tour irregularit ies or depression s. Th is sim ple
inject ion m eth od h as gain ed in creasing pop ularit y an d is
often referred to as m edical rh in oplast y.
Th e lin ear th reading tech n ique w ith a blu n t can n ula is Fig. 30.10 Nasal dorsal augmentation using ller. (a) Before injec-
th e m ost frequen tly used tech n ique for n asal augm en t at ion tion. After making an entry point at the nasal tip with a 23-gauge
needle, a 50-mm , 27-gauge cannula was inserted through the
to p reven t em bolism an d blin dn ess, alth ough even w ith a
entry point to the nasion (bet ween the medial canthi) under the
blu n t n eedle, blin dn ess can occu r in rare cases. Can n ulas muscle layer. Rest ylane ller (0.8 mL) was injected while withdraw-
of 23, 25, an d 27 gauge can be u sed. Th e auth or prefers ing the cannula in a single motion from the nasion to the tip. For
23-gauge for CaHA ller an d 27-gauge for Rest ylan e or Per- further augmentation, subcutaneous injection using the serial
lan e. It is h ard to inject Juvederm w ith a 27-gauge can n ula puncture technique was added. (b) After injection.
400 VI Minim ally Invasive Facial Plastic Surgery
Nasolabial Folds
Nasolabial folds are form ed bet w een th e n ose an d lips,
an d a dyn am ic fold occu rs w h en rep et it ive m ovem en t of
th e facial m u scles creates a skin crease. W h eth er th e ller
w ou ld be injected at th e d erm al, su bcu tan eou s, or su p ra-
periosteal level is determ in ed by th e an atom y of th e fold.
For inject ion , eith er th e lin ear or fan n ing tech n ique is used Fig. 30.11 Determination of the depth of injection in the nasola-
bial fold. The dynamic fold formed by repetitive movement of the
(Fig. 30.11).
facial muscles is corrected by injection into the derm is layer. In case
Fillers injected in t h e d erm al layer in a lat t ice p at tern
the cause is innate under-development in the upper jaw bone, it is
give p ersisten ce an d a n at u ral e ect to sm iling. For injec- best to inject into the supra-periosteal layer.
t ion in th e derm is layer or low er, m olding is n eeded, bu t
m old ing is n ot n ecessar y w it h inject ion in th e su p ra-p eri-
osteal layer. W h en t h e prim ar y cau se is th e u n der-devel-
opm en t of th e u pp er jaw bon e, it is best to inject in to th e
su p ra-p eriosteal layer.16,17 In Asian s, th e n asolabial folds layer for a ller p lacem en t is th e su bm u cosa just above th e
are often created by a w eaken ed u p p er jaw an d t h e ller orbicularis oris m uscle. In m any cases, a layered dist ribu-
is injected ju st above th e p eriosteu m of th e u p p er jaw to t ion h elps to provide fu ller, m ore un iform en h an cem en t .
create volu m e. W h en a n asolabial fold is cau sed by ch ange For in creased verm illion de n it ion , th e n eedle is carefully
of locat ion of th e m alar fat p ad, it is recom m en ded th at in ser ted w ith in th e p oten t ial space bet w een th e red an d
t h e inject ion be m ade to th e su bderm al layer of both th e w h ite lips. W h en don e properly, inject ion of th e ller can
n asolabial fold an d th e n asojugal groove (tear t rough ) to be seen to plum p out th e verm illion border even w ith out
get lift an d p roject ion . advan cem en t of th e n eedle. If th is is n ot th e case, th e n ee-
dle sh ould be reposit ion ed un t il th ere is low resist an ce to
ow. Many you nger pat ien t s w ill also ben e t from a vol-
Lips u m e en h an cem en t along th e ph ilt ral colum n s. Th is usu -
ally involves a m idderm is ller inject ion w ith in th e base of
Lip augm en tat ion by ller is a sim ple procedure to im prove each colu m n , w h ich h elps to fu r th er ou tlin e an d d e n e th e
th e appearan ce of th e lips an d to m ake a h arm on ious lips. A tot al of 1 to 2 m L is usually su cien t to ach ieve th e
relat ion sh ip w ith th e n ose an d th e ch in by in creasing th e desired size an d sh ape.
fu lln ess of th e lips. Th e aging p at ien t t yp ically requ ires su b - For lip augm en tat ion , HA gels are com m on ly used .
m u cosal inject ion along th e en t ire length of th e lip rath er Oth er ller gels, su ch as PCL an d CaHA llers, are n ot p re-
th an ju st th e cen t ral port ion . Som e pract it ion ers prefer to ferred on th e lips sin ce w h ite n odules are visible an d pal-
address th is by inject ing th e in divid u al lin es sep arately. pable. Moreover, PCL an d CaHA ller gels can m igrate after
Care sh ou ld be t aken n ot to create u nw an ted ver t ical ridges an inject ion on th e lip s by st rong m u scle m ovem en t . Colla-
or beading due to in adverten t over correct ion of th e der- gen ller h as a risk of cau sing redn ess an d im m u n e-related
m is. Precise correct ion of th ese th in su p er cial lin es is h ard problem s an d is n ot used at presen t for lip con touring, but
to ach ieve by deep derm al inject ion . A bet ter altern at ive is som e allo-t ran sp lan t at ion of h u m an derm is (su ch as Allo-
to sim p ly add m ore volu m e d u ring th e verm illion inject ion , derm , LifeCell) is used for lip augm en t at ion .
w h ich ten ds to st retch th e vert ical lip lines as they exten d
from th e m u cosal lip, resu lt ing in decreased visibilit y.
An oth er opt ion is to u se on ly collagen -based tem porar y Chin
llers for inject ion of th e in d ividu al lin es becau se collagen
is bet ter su ited for su per cial derm al p lacem en t . In Asia, con tou ring th e ch in along w ith n ose augm en tat ion
Lip en h an cem en t in th e you nger p op u lat ion involves is a popular procedure because m any Asian s h ave sm all
st raigh tfor w ard volu m e en h an cem en t . Most of th ese ch in s. Derm a llers can be a t reat m en t opt ion for a sm all
pat ien t s requ ire volu m e en h an cem en t on ly along th e cen - ch in correct ion in stead of surger y or graft im plan tat ion .
t ral th ree- fth s of th e lip. Inject ion is t ypically don e w ith Inject ion of ller w ith a sh arp n eedle is th e sim p lest
th e lin ear th reading or serial pun ct ure tech n iqu e, proceed- m eth od for ch in augm en t at ion (Fig. 30.12). Th is procedu re
ing from m edial to lateral. Along th e red lip , the targeted can be perform ed w ith in 1 m in ute. For th is sim ple injec-
30 Facial Contouring Using Fillers 401
a b Jaw
Age-associated volum e loss is kn ow n to play an im port an t
role in th e st ru ct ural ch anges of th e low er face lin e. In th e
low er face, th is m an ifest s as drooping of th e corn ers of
th e m outh an d jow l, leading to a loss of th e oval jaw lin e
of youth . Jaw lin e resh aping by volum e replacem en t h as
th erefore becom e an in dispen sable com pon en t of m odern
facial rejuven at ion an d con tou ring.
Jowl Contouring
CaHA, PCL gel, or h ard HA gels can be injected in to th e fol-
low ing locat ion s.21 To correct th e roun d sh ape of th e low er
jaw lin e, CaHA or PCL ller sh ou ld be placed at th e deep
derm is u sing a 70-m m , 23-gauge can n ula. Inject ion s can
be delivered using th e fan n ing tech n ique (Fig. 30.14). Th e
ch oice of inject ion depth w ill depen d on w h eth er a n eedle
or can n ula is used an d also on th e th ickn ess of the der-
Fig. 30.12 Chin augmentation using ller. (a) Before the proce-
dure. (b) Immediately after injection of 1.5 mL of Radiesse. m is. Recom m en ded in sert ion p oin t s are at th e m an dibu lar
angle an d p rejow l su lcu s. Pat ien ts w h o h ave severe sag-
ging on th e low er face lin e m ay n ot ach ieve th e ben e t s
w ith derm al ller procedures on ly. Th e m ajorit y of doc-
tors advocate u se of injectable llers in su bject s w h o are
w ait ing for su rger y, or in th ose w h o do n ot w an t su rger y
t ion , Rest ylan e m ixed w ith lidocain e can be used w ith a
or in w h om surger y is con t rain dicated, an d as a pow erful
29-gauge n eedle. Th is sh arp n eedle is in cluded in th e box
adju n ct in augm en t ing or com p lem en t ing a su rgical resu lt .
w ith th e ller. Juvederm also can be used for ch in con -
Cogged th read in ser t ion or h igh -in ten sit y focused u lt ra-
touring u sing th e sam e m eth od. Th ese HA llers can be
sou n d (HIFU) can be p erform ed for con tou ring th e low er
injected in to th e su bderm al layer, alth ough su pra-p erios-
face for th ese in dividu als in stead of u sing inject ion llers. It
teal or su bm uscular inject ion is preferred. In t ram u scular
is bet ter to com bine ller inject ion w ith th ese procedures.
inject ion sh ou ld be avoided because of discom for t in th e
m en t alis m u scle du ring facial expression . W h en m aking a
h eart lin e ch in , th e p rocedu re m u st be don e even ly from
Marionet te Lines
th e upper layer of th e periosteum to th e subderm al layer
Volu m e en h an cem en t of m arion et te lin es is u su ally don e
bet w een th e ch in’s cen t ral lin e an d th e m en talis m us-
w ith on e of th e th ree inject ion tech n iques m en t ion ed pre-
cle.18,19,20 Th e injected p rodu ct can easily m ove to th e low er
viou sly. Nearly all categories of llers can be safely u sed
part of th e ch in because th ere is n o barrier t issue w ith in
th e subcut an eous fat layer below th e ch in . To be success-
fu l, th e n on inject ing h an d sh ou ld be u sed as a barrier or
gu ide w h en inject ing to en su re th e p rodu ct rem ain s w h ere
it is in ten d ed . Th e blu n t n eedle tech n ique is p referred for
inject ion of CaHA an d PCL ller. For a can n u la m eth od, t w o
en t r y p oin t s are u sed in th e p re-jow l su lcu s area of th e
low er border (Fig. 30.13).
Prior to m arking th e en t r y poin t s, a sm all am oun t of
lidocain e is injected, follow ed by th e in sert ion of a sh arp
23-gauge n eedle or a 70-m m , 23-gauge can n ula. To reduce
pain during th e procedure, t um escen t solut ion can be
injected p rior to CaHA an d PCL ller inject ion th rough th e
sam e can n u la. Pat ien t s sh ou ld be n ot i ed th at th e am ou n t
of augm en t at ion by CaHA an d PCL ller w ill be reduced 1
m on th after th e inject ion . Mu scle relaxan ts su ch as Botox
(Allergan ), Dysport (Galderm a), an d Xeom in (Merz) are
also u sed con com itan tly to soften th e ch in (preven t ing a Fig. 30.13 Contouring of the lower face line by llers. Entry points
cobbleston e appearan ce) an d to im prove th e con tour. and fanning technique of injection for rejuvenation of jaw lines.
402 VI Minim ally Invasive Facial Plastic Surgery
a b c d
Fig. 30.14 Lower face contouring using ller. (a) Before the procedure. Sagging skin and underlying bone resorption contribute to forma-
tion of the jowl with aging. (b) Immediately after an injection to the lower jawline with Ellanse M. (c) One month after injection. (d) After
t wo sessions of injections for the lower jawline.
for th is pu rp ose. Th e inject ion layer is a com bin at ion of llers.22 Par t icle-t ype S-HA can im prove skin text ure as
th e deep derm al an d subcut an eous plan es. In m any cases, w ell as skin rough n ess.
th ere is n ot on ly a deep lin e exten ding from th e com m is- Before th e t reat m en t , a 9% lidocain e topical an esth et ic
su re, bu t also a loss of volu m e in th e su rrou n ding area. In cream is applied to th e inject ion area an d covered w ith
th ese cases, a cross-h atch ing tech n ique can be used to add plast ic w rap for 40 m in utes. Pat ien t s can be injected w ith
m ore volu m e. Dist ribu t ion of th e ller often en d s u p follow - 1m L of S-HA (Rest ylan e Vit al, Belotero Soft , Belotero Basic,
ing th e sh ap e of an inverted t riangle w ith th e lateral m ar- Juvederm Vobella) th at is divided in to 1,000 sh ot s u sing
gin based on th e d eep est m arion et te lin e. Prejow l su lcu s th e injector (Derm aQueen , Woorhi Medical Group or Vit al
en h an cem en t by exten ding th e ller inject ion dow n to th e Injector). Th is d evice h as ve n eed les an d th e dist ribu t ion
low er m an dibu lar border is often an adju n ct to m arion et te of th e m icrodroplet inject ion s provides a m ore regular area
lin e correct ion . In th in -skin n ed pat ien t s, longer-last ing an d of coverage th an m an ual inject ion . Part icle-t ype S-HA or
p erm an en t llers can be placed over th e periosteum w ith biph asic (Rest ylan e Vit al), m on oph asic (Juvederm Vobella),
a h igh er safet y m argin . Du e to disp lacem en t of th e jow l or polyph asic (Belotero Basic) llers can be injected in to th e
w h en su pin e, it is recom m en ded th at pat ien t s be injected derm is. Th e inject ion depth can be con t rolled by a touch
in th e u p righ t posit ion for m ore accurate correct ion . Th e pan el on th e injector (0–2 m m ). Th e recom m en ded injec-
ller is dist ribu ted along th e low er m argin of th e m an dible t ion depth is about 1 m m . Th is m eth od w as inven ted by th e
an d in som e cases ju st below th e m an d ibu lar border if th e au th or an d w as n am ed th e “Reteen age m eth od .”23 Because
jow ling is severe. Th is inject ion exten ds from th e an terior th ere is a bevel in th e t ip of th e n eedle, th e act ual depth
m argin of th e jow l tow ard th e m idlin e of th e ch in to h elp of th e inject ion w ill be less th an 1 m m . During th is proce-
restore a m ore you th fu l t ran sit ion bet w een th ese poin ts. dure, th e inject ion depth sh ou ld be reduced if subst an t ial
Bet w een th e m arion et te lin es an d p rejow l su lcu s, a tot al bleeding is n oted, w h ich m ean s th e inject ion pen et rated
volu m e of 2 to 3 m L of ller is com m on ly u sed to ach ieve th e subderm al plexus. After th e inject ion s, cold com pres-
adequ ate correct ion . sion is p erform ed to spread th e S-HA an d to redu ce pain
an d ecchym osis.
3. Becau se t um escen t solut ion can in terfere w ith th e To prevent intra-arterial ller injection, the needle tip
d eterm in at ion of th e prop er volu m e of ller to be should always be kept in the m idline and never placed paral-
injected in to th e su bderm al tem p le region , th e lel to the dorsal nasal artery. If side wall injection is inevitable
volu m e e ect of t u m escen t solu t ion sh ou ld alw ays due to correction of a deviated nose, the needle tip should be
be con sidered. m oved obliquely after m idline injection. Severe pain during
4. In t ram uscular inject ion during ch in augm en t at ion the procedure and geographic pale skin color change are clues
sh ou ld be avoided becau se of m en talis m u scle of arterial injection. But skin necrosis by venous congestion
d iscom for t during facial expression . is m ore com m on and occurs w hen a large volum e of ller is
5. The linear threading technique w ith a cannula is the injected into the supratip area. To avoid this, a sm all am ount of
m ost frequently used technique for nasal augm entation ller should be injected to the deep layer. If a vascular problem
to prevent arterial em bolism and blindness. is suspected, stop the injection and aspirate the injected ller
to reduce volum e. Hyaluronidase injection and hyperbaric
6. HA gels are com m on ly preferred for lip
oxygen therapy m ust be applied as soon as possible. Antibiot-
augm en tat ion . Oth er ller gels, su ch as PCL an d
ics should be adm inistrated to prevent secondary infection.24
CaHA ller, are n ot ap prop riate in m ost cases du e to
Th e m idface region h as a relat ively loose subcut an e-
visible an d palpable w h ite n odules.
ous fat plan e, an d th ere can be pressu re-in duced m igra-
7. Due to displacem en t of th e jow l w h en supin e, th e t ion of th e ller. Th e auth or does n ot recom m en d rm
p hysician is advised to inject pat ien t s in th e u prigh t m assages w ith in 3 w eeks after inject ion , an d it is bet ter
p osit ion for m ore accurate correct ion . to inject ller w ith h igh er coh esiven ess to p reven t m igra-
t ions. Malar edem a can arise from inject ion s w ith HA, Juve-
deram , or Rest ylan e Vit al, as th ese llers h ave th e pow er
■ Complications and to at t ract w ater. Malar edem a can p ersist as long as a few
Their Management m on th s after an inject ion . Low er eyelid edem a also can
develop after ch eek con touring. During con touring of th e
Irregularit y, asym m etr y, and un even shape are com m on ch eek or tear t rough correct ion , a ller can be in ciden tally
com plicat ion s after ller injection regardless of region . injected in to th e orbital fat th rough th e orbit al sept u m ,
These com plications can be prevented by choosing the w h ich causes a prolonged edem a on th e low er eyelid. A
appropriate t ype of ller according to inject ion layers an d large am ou n t of ller in to th e subderm al layer of th e low er
postoperat ive m olding. Retouching is recom m ended 1 to 3 eyelid can also m ake a prolonged edem a. Th erefore, w h en
m on th s after th e rst injection if th ese com plicat ion s occur. inject ing th e subderm al layer on th e low er eyelid to t reat
Region-related speci c com plicat ion s are m ent ioned later.
Su p raorbit al n er ve dam age can be avoided by u sing
th e m idlin e on e-en t r y-poin t tech n ique. Inject ing CaHA an d
PCL w ith t um escen t solut ion to reduce pain h as th e pos-
sibilit y of u n dergoing su dden volu m e loss after 1 m on th ,
w h ich sh ould be explain ed to pat ien ts before th e proce-
dure. Bruising or skin n ecrosis by ar terial em bolism is rela-
t ively rare in th e foreh ead region .
In contouring of the tem ple, irregularit y is the m ost com -
m on after a fanning technique injection into a subderm al
layer and m igration m ay occur after the self-pistol technique
into a deep layer. Pain and hem atom a are com m on com plica-
tions after an intram uscular injection (self-pistol technique).
To prevent intra-arterial injection, a negative pressure test
(regurgitation) should be done before injecting ller.
In con tou ring of th e n ose, blin d n ess is th e m ost seri-
ous an d irreversible com plicat ion , alth ough it is rare. It can
occur w h en ller is injected in to th e dorsal n asal arter y,
su p rat roch lear ar ter y, or angu lar ar ter y arou n d th e n asal
an d p eriorbit al region . Th ese arteries an astom ose w ith th e
oph th alm ic ar ter y. To preven t th is, th e n eedle sh ould be Fig. 30.15 Skin necrosis after nasal ller injection. Nasal skin
kept in th e m idlin e an d m oved back an d forth con t in u ou sly necrosis with crust formation developed in a 25-year-old woman
during inject ion . Skin n ecrosis is th e secon d m ost serious who had a nasal HA ller injection 1 month previously. She was
com plicat ion (Fig. 30.15). In t ra-ar terial em bolizat ion or treated with hyaluronidase and hyperbaric oxygen therapy, but the
ven ou s congest ion can lead to th is problem . necrosis progressed.
404 VI Minim ally Invasive Facial Plastic Surgery
References
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m an agem en t of facial aging. Clin In ter v Aging 2008;
3(1):153–159
Fig. 30.16 Course of lateral nasal artery at the alar groove. To
2. McCurdy JA, Lam SM, eds. Cosm et ic Surger y of th e Asian
prevent intra-arterial injection in nasolabial fold correction, avoid
Face. New York, NY: Th iem e Medical Pu blish ing; 2011
injecting above the alar groove because the lateral nasal artery runs
3. Ricket t s RM, ed. Orth odont ic Diagn osis an d Plan n ing: 4 mm above the alar groove.
Th eir Roles in Preven t ive an d Reh abilit at ive Dent ist r y. Vol.
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lat ion . Am J Orth od 1968;54(4):272–289
5. Carruth ers JD, Glogau RG, Blit zer A; Facial Aesth et ics Con - 15. Kim JA, Van Abel D. Neocollagen esis in h u m an t issu e in -
sen sus Group Facu lt y. Advan ces in facial rejuven at ion : jected w ith a polycaprolacton e-based derm al ller. J Cos-
bot ulin um toxin t ype a, hyaluron ic acid derm al llers, m et Laser Th er 2015;17(2):99–101
an d com bin at ion th erapies—con sen sus recom m en da- 16. Em re IE, Cakm ak O. Ageing face, an over view —aet iol-
t ion s. Plast Recon st r Su rg 2008;121(5, Su p pl):5S–30S, qu iz ogy, assessm en t an d m an agem en t . Otorh in olar yngologist .
31S–36S 2013;6(1):160–166
6. Mikos AG, Th orsen AJ, Czer w on ka LA, et al. Preparat ion 17. Zim bler MS, Kokoska MS, Th om as JR. An atom y an d p ath o-
an d ch aracterizat ion of poly (L-lact ic acid) foam s. Polym er physiology of facial aging. Facial Plast Su rg Clin Nor th Am
1994;35(5):1068–1077 2001;9(2):179–187, vii
7. Buck DW II, Alam M, Kim JY. Inject able llers for fa- 18. Colem an SR, Grover R. Th e an atom y of th e aging face: vol-
cial rejuven at ion : a review. J Plast Recon st r Aesth et Surg um e loss an d ch anges in 3-dim en sion al topography. Aes-
2009;62(1):11–18 th et Su rg J 2006;26(1S):S4–S9
8. Men delson BC, Mu za ar AR, Adam s W P Jr. Surgical an at- 19. Roh rich RJ, Pessa JE. Th e fat com p art m en t s of th e face:
om y of th e m idch eek an d m alar m ou nds. Plast Recon st r anatom y and clin ical im plicat ion s for cosm et ic surger y.
Surg 2002;110(3):885–896, discu ssion 897–911 Plast Recon st r Su rg 2007;119(7):2219–2227, discu ssion
9. Kim JA. Clin ical experien ce w ith Ca ller in o -label u se in 2228–2231
foreh ead, n eck fold, n ose an d tear t rough . Paper presen ted 20. Hu r MS, Kim HJ, Ch oi BY, Hu KS, Kim HJ, Lee KS. Morph ol-
at: 2014 join t m eet ing of Aesth et ics Asia an d th e 1st Aes- ogy of th e m en t alis m u scle an d it s relat ion sh ip w ith th e
th et ic an d An t i-Aging Med icin e Asian Congress; Septem - orbicularis oris an d in cisivus labii inferioris m uscles. J Cra-
ber 25–27, 2014; Singpore, Marin a Bay San ds n iofac Su rg 2013;24(2):602–604
10. Sh aw RB Jr, Kat zel EB, Kolt z PF, et al. Aging of th e facial skel- 21. Dallara JM, Basp eyras M, Bu i P, Cart ier H, Ch aravel MH,
eton : aesthet ic im plicat ions an d rejuven at ion st rategies. Du m as L. Calciu m hydroxylap at ite for jaw lin e rejuven a-
Plast Recon st r Su rg 2011;127(1):374–383 t ion : con sen su s recom m en dat ion s. J Cosm et Derm atol
11. Rich ard MJ, Morris C, Deen BF, Gray L, Woodw ard JA. An al- 2014;13(1):3–14
ysis of th e an atom ic ch anges of th e aging facial skeleton u s- 22. Mat arasso SL, Carru th ers JD, Jew ell ML; Rest ylan e Con -
ing com p u ter-assisted tom ograp hy. Oph th al Plast Recon st r sen su s Grou p . Con sen su s recom m en dat ion s for soft-t is-
Surg 2009;25(5):382–386 su e augm en t at ion w ith n on an im al st abilized hyalu ron ic
12. Zadoo VP, Pessa JE. Biological arch es an d ch anges to th e acid (Rest ylan e). Plast Recon st r Surg 2006;117(3 Su ppl):
cu r vilin ear form of th e aging m axilla. Plast Recon st r Su rg 3S–34S; discussion 35S–43S
2000;106(2):460–466, discussion 467–468 23. Kim AJ. E ect of injection depth and volum e of stabilized
13. Pessa JE, Desvigne LD, Lam bros VS, Nim erick J, Sugunan B, Za- hyaluronic acid in hum an derm is on skin texture, hydration,
doo VP. Changes in ocular globe-to-orbital rim position w ith and thickness. Arch Aesthet Plast Surg 2014;20(2):97–103
age: im plications for aesthetic blepharoplast y of the lower 24. Colem an SR. Avoidance of arterial occlusion from injection of
eyelids. Aesthetic Plast Surg 1999;23(5):337–342 soft tissue llers. Aesthet Surg J 2002;22(6):555–557
14. Dou al JM, Ferri J, Lau de M. Th e in u en ce of sen escen ce on 25. Roh rich RJ, Rios JL, Fagien S. Role of n ew llers in facial
cran iofacial an d cer vical m orph ology in h um an s. Surg Ra- rejuven at ion : a caut ious ou tlook. Plast Recon st r Surg
d iol An at 1997;19(3):175–183 2003;112(7):1899–1902
31 Management of Facial Filler Injection
Complications
Hyoung Jin Moon and Jong Sook Yi
Pearls
• Skin th ickn ess varies across di eren t an atom ic n ew m an euver th at can redu ce orbital com p licat ion s
region s. Sin ce th e eyelids, periorbit al area, an d by in creasing in t ralum in al pressure.
n asal dorsu m are kn ow n to h ave a ver y th in derm is, • Severe pain an d blan ch ing of th e skin are w arn ing
special care sh ou ld be t aken w h ile inject ing in to sign s of in t ravascu lar inject ion of ller an d requ ire
th ese region s n ot to create lum pin ess, n odules, or em ergen t m easu res. Th ese in clu de stopp ing
gran u lom as. inject ion , aspirat ing as m u ch injected ller as
• Th e glabellar an d n asolabial region s are regarded as possible, an d inject ing a h igh dose of hyaluron idase
h igh -risk facial u n it s in w h ich su rger y can lead to in case of hyaluron ic acid ller.
seriou s vascu lar com p licat ion s. • Low -m olecu lar-w eigh t h eparin , h ot p acks an d soft
• Fillers sh ou ld be placed in th e app ropriate layer of m assage, 2% n it roglycerin p aste p atch , an d inject ion
skin . Too su per cially injected llers can resu lt in of prostaglan din E1 are addit ion al m easu res to
un even n ess an d visibilit y. Too deeply injected llers en h an ce vasodilat ion an d in h ibit ion of p latelet
can be un der e ect ive at ch anging sh apes. aggregat ion in case of vascular occlusion by ller.
• Given th at m ost faces are sligh tly asym m et ric, it is • On ce esch ar h as form ed, ap prop riate w et dressing
im p ort an t to visually ch eck w h eth er th e t w o sides of is required w ith an t ibiot ics to preven t secon dar y
th e face are sym m et ric during inject ion . in fect ion . St art ing hyperbaric oxygen th erapy also
• Massage is gen erally su cien t to at ten an d h elps to im prove h ealing.
disperse excessive, super cial, or un aesth et ically • W h en addressing an in ter ven t ion to com plicated
placed ller causing visibilit y. cases such as skin n ecrosis, m ore con ser vat ive an d
• Bilateral com pression an d releasing of th e su perior less invasive t reat m en t sh ould be at tem pted before
n asal corn er of th e orbit al rim s du ring inject ion is a recom m en ding a radical solut ion .
405
406 VI Minim ally Invasive Facial Plastic Surgery
that can be associated w ith serious com plications, includ- sit u at ion , it is best to at tem pt an altern at ive t reat m en t or
ing em boli and resulting necrosis because their m ain arter- product , or sim ply n ot to t reat at all. To set u p an accurate
ies, the supratrochlear artery and the angular lateral nasal t reat m en t plan , th e physician sh ould ask about th e on set
artery, respectively, are vulnerable to em bolism by ller an d progress of sym ptom s an d sign s. Gen erally, t ran sien t
(Fig. 31.1).2,3,4 Augm enting the chin w ith heavy llers can sw elling or ten dern ess can be seen 24 to 72 h ou rs after
potentially lead to vascular com prom ise if too m uch of the inject ion becau se of th e p hysical im posit ion an d su bse-
product is injected at once by com pressing the blood vessels. quen t volu m e displacem en t on th e skin from an im plan t .2
It is n ot clear w h ich t ype of inject ion tech n iqu e, th e Th ese adverse e ect s w ill dim in ish over a relat ively sh ort
m u lt iple serial pu n ct u re or th e lin ear th reading tech n iqu e, period of t im e. But if th ere is an irregularit y due to a sem i-
causes few er com plicat ion s. Th e m ult iple pun ct ure tech - perm an en t or perm an en t ller, it w ill require som e form of
n iqu e m akes it easier to con t rol p lacem en t bu t can lead in ter ven t ion . W h en th e physician determ in es it is n eces-
to un even n ess. Th e lin ear th reading tech n ique ten ds to sar y to do som e kin d of in ter ven t ion , th e p at ien t n eeds to
requ ire m ore exp erien ce, an d can resu lt in over-inject ion be in form ed th at th e t reat m en t plan m ay require m u lt iple
to a given area. Th e fan n ing tech n iqu e h as been repor ted session s, w h eth er it is a sm all com plicat ion or a devast at-
to in crease the likelih ood of bleeding even in experien ced ing on e. A discu ssion regarding th e poten t ial for any per-
h an ds.2,5 Ult im ately, th e p ract it ion er can u t ilize th ese tech - m an en t scars from th ese in ter ven t ion s sh ou ld be in clu ded
n iqu es to su p p lem en t th e w eakn esses of on e an oth er. in th e in it ial con su lt at ion . Th is step is really im port an t in
m ain t ain ing a good doctor-pat ien t relat ion sh ip sin ce th e
pat ien t is usually in a ver y an xious st ate. More con ser va-
Early Onset
Minor Form
Bruising is a com m on com plication of ller injections, and
it is caused by vascular dam age from a needle. All patients
sh ould be in form ed not to take blood th in ners such as aspirin
1 w eek before the procedure. During the procedure, pierc-
ing of m uscular layers m ust be m inim ized. The injection
site should be cleaned w ith an alcohol sw ab, and the pro-
cedure should be perform ed in a room w ith adequate light- Fig. 31.2 Cannula for ller injection. For safet y reasons, facial ller
ing. Im m ediately applying an ice pack to the injection site injection is best done using a thin, blunt cannula instead of a sharp
m ay help to m inim ize bruising. Special needles or cann ulae needle.
can be used to m inim ize vascular injury as w ell (Fig. 31.2).
If bleeding occurs during the procedure, the injection site
sh ould be covered w ith gauze and pressed for several m in -
utes to prevent hem atom a form ation. Usually bruising is Th e facial arter y t akes a tort u ous course along th e n aso-
on ly tem porary and does not a ect the n al therapeutic labial crease (Fig. 31.3), w h ere it becom es en dangered by
e ect. It can darken in the days follow ing the injection, but an inject ion in ten ded to soften an d redu ce th e p rom in en t
w ill gradually disappear after 10 days in m ost cases.6 n asolabial fold . Th e fron t al bran ch of th e su p er cial tem -
Occasion ally, th ere m ay be hyp ersen sit ivit y to th e ller poral arter y gives o descen ding bran ch es to an astom oses
ingred ien t s. Th e m ain sym ptom s are pain an d er yth em a, w ith th e supraorbit al an d th e suprat roch lear ar teries from
accom pan ied by pru rit u s an d fever.7 In th e vast m ajorit y th e oph th alm ic arter y. To preven t com plicat ion s, a sm all-
of pat ien t s, fort un ately, th ese sym ptom s resolve in 2 to 3 bore n eedle t ip is recom m en ded w ith sm aller syringes,
days as th e cau sat ive su bst an ce disappears. In severe cases, preferably 0.5 to 1 m L, so th at less pressure is required on
adm in istering cor t icosteroid p rodu ct s an d w arm com pres-
sion m ay h elp alleviate th e sym ptom s. V-beam laser t reat-
m en t can be u sed for persisten t er yth em a.8
Major Form
Th e serious com plicat ion s th at occur after ller inject ion
are blin dn ess an d derm al n ecrosis. Vascu lar com prom ise
can be largely divided in to in t ra- an d ext ravascular causes.
In t ra-ar terial inject ion of ller is rare bu t can be disast rou s.
Ext ravascu lar causes in clude extern al ven ous com pres-
sion d u e to excessive volu m e of inject ion , an d edem a an d
in am m ator y respon se cau sed by a com pon en t of th e ller.
Intra-arterial Embolism
In t ra-ar terial em bolism h as a relat ively low in ciden ce,
but its con sequen ces are devastat ing. Blin dn ess follow ing
cosm et ic ller inject ion is th e m ost serious com plicat ion .
Most cases of ocu lar com plicat ion s occu r du ring m u lt ip le-
site inject ion s, bu t som e facial u n its dist ingu ish ed by th e
fat com p ar t m en ts an d th e ret ain ing ligam en t s m ay h ave a
h igh er risk com p ared w ith oth ers.9,10,11 Th e n asolabial an d
th e fron totem poral un its are kn ow n to be danger zon es
due to large-core cutan eous arteries suscept ible to acci-
dent al can n ulat ion , the facial an d th e super cial tem poral Fig. 31.3 The tortuous course of the facial artery. The facial
arteries.12 You ng p at ien t s m ay h ave h igh er risk of blin d- artery runs along the nasolabial crease and anastomoses with the
n ess because h ealthy skin h as abu n dan t cu t an eou s ar terial descending nasal artery. The t wo facial arteries communicate with
an astom oses. each other in the nasal supratip region.
408 VI Minim ally Invasive Facial Plastic Surgery
th e plunger. Th e n eedle t ip sh ould be m oved back an d for th If th e p at ien t com plain s of su dden ocu lar p ain or visu al
con t in uously during inject ion sin ce m ost com plicat ion s loss, h ow ever, inject ion m ust cease im m ediately. An oph -
occur w h ile inject ing ller m aterials in th e st at ic state w ith th alm ologist sh ould be con tacted for m easu rem en t of
h igh pressu re. Previou sly t rau m at ized areas, su ch as a blu n t visual acu it y an d fu n d oscopy.
t raum a site or bleph aroplast y site, sh ou ld be avoided. Dur- Th e goal of t reat m en t is rapid restorat ion of perfusion
ing ller inject ion at th e tem ple area, th e n eedle t ip can be to th e ret in a an d opt ic n er ve h ead . Ret robu lbar inject ion
d eviated su p er cially from th e deep inject ion plan e by a of 2 to 4 m L (150 to 200 U/m L) of hyaluron idase is recom -
bony cur ve of th e fron t al bon e an d en coun ter th e fron t al m en ded w ith in 60 to 90 m in u tes.13 Th is m igh t be th e single
bran ch of th e super cial tem poral arter y. Th us, special care m ost e ect ive opt ion to dissolve th e in t raorbital in t ravas-
sh ou ld be taken n ot to lose th e ap p ropriate p lan e. Recen tly, cular hyalu ron an in a t im e-sen sit ive m an n er.14 Ocu lar m as-
eviden ce h as em erged of persisten t an astom oses bet w een sage (rep eated, in creasing pressu re ap p lied to th e globe for
th e oph th alm ic arter y an d th e facial ar terial system at th e 10- to 15-secon d in ter vals over 3 to 5 m in utes) m ay low er
su p erior n asal corn er of th e orbital rim .12 Based on th is in t raocu lar pressu re an d in crease ar teriolar ow, poten -
kn ow ledge, th e auth or h as in t rodu ced an e ect ive safet y t ially m oving th e ret in al vascular em bolus periph erally.15
m an euver th at bilaterally com p resses th e su p erior n asal In t raven ou s m an n itol an d diu ret ics (500 m g of acet azol-
corn ers of th e orbit al rim s during th e inject ion m om en t am id e) m ay in crease ret in al blood ow an d rapidly redu ce
an d releases th em soon after w ard . Th is tech n iqu e creates a in t raocular pressure. Topical an d in t raven ous an t ibiot-
tem porar y collapse of th e an astom ot ic pathw ays using th e ics an d subsequ en t adm in ist rat ion of h igh -dose cor t ico-
h an d of an assist an t (Fig. 31.4). steroid (m ethylp redn isolon e 1 g/day in t raven ou sly for 3
W h en an assist an t is u n available, an altern at ive m eth od days, an d dose tapering w ith oral adm in ist rat ion ) can be
is to com press th e t issue on th e course of th e core arter y at tem pted.15,16 In fact , n o safe, feasible, an d reliable t reat-
bet w een th e inject ion site an d th e eye w h ile st retch ing m en t exists for iat rogen ic ret in al em bolism . Non eth eless,
th e skin for an inject ion procedure u sing th e n on dom in an t th erapy sh ou ld th eoret ically be applied as soon as possible
h an d. Th is m eth od cou ld in crease th e lu m in al pressu re to in crease th e ch an ce of recover y.
en ough to block any ller th at w as acciden tally injected Inject ion rh in oplast y is also th e m ain p roced u re th at
in to th e m ain arter y u n d ern eath from t raveling to th e globe. can in du ce in tra-ar terial em bolism by inject ing th e dorsal
Th e target areas for com pression are th e oral com m issure, n asal ar ter y directly. Th e dorsal n asal ar ter y, as it s n am e
u pp er n asolabial fold, alar crease, side of th e n ose, m ed ial suggest s, ru n s along th e dorsu m of th e n ose, ~ 3 m m aw ay
can th us, superior n asal orbit al rim , an d glabella. With th e from th e m id lin e (Fig. 31.5). It is a fairly im m obile blood
in dex an d long ngers cou n teract ing w ith th e th um b, th e vessel xed to th e su rrou n ding t issu e, an d th e n eed le t ip
inject ion areas can be st retch ed an d im m obilized. can be in ser ted safely if it is in ser ted in parallel w ith th e
a b
Fig. 31.4 Anastomotic channel blockage by compression. Blocking the anastomotic channel bet ween the ophthalmic artery and the
other facial arterial system prevents blindness by embolism. Orbital rims at the superior nasal corners are compressed using the index and
long ngers during ller injection at the (a) nasolabial area and (b) superciliary ridge.
31 Managem ent of Facial Filler Injection Com plications 409
Infraorbital a.
Lateral nasal a.
Septal branch
Angular a.
Superior labial a.
Facial a.
blood vessel. Th e dorsal n asal arter y an astom oses w ith th e n eedle t ip sh ould m ove to th e side. Becau se th e dor-
th e oph th alm ic, in frat roch lear, an d angular arteries, an d a sal n asal ar ter y is located in th e su p er cial fat t y layer an d
w idespread em bolism th rough th e con n ected blood vessels SMAS, th e inject ion sh ou ld be in to th e deep fat t y layer to
m an ifest s as skin n ecrosis in a geograp h ic p at tern . preven t em bolizat ion to th e dorsal n asal ar ter y. Aspirat-
If arterial inject ion is su sp ected, h ow ever, p rom pt ing th e n eedle before inject ion an d inject ing ller w h ile
m an agem en t sh ou ld be don e accord ing to th e t reat m en t w ith draw ing th e n eedle are t ips for safe inject ion . Using a
p rotocol of in t ra-arterial em bolism . On ce ller is injected blu n t can n ula also h elps to preven t in ciden tal pun ct ure of
in to th e ar terial bloodst ream , th e pat ien t exp erien ces th e vessel an d is recom m en ded to physician s w h o are n ot
severe p ain im m ediately, an d m ay com p lain of a sen sa- fam iliar w ith th e inject ion tech n iqu e.
t ion of som eth ing spreading ou t from th e inject ion site. If the patient com plains of severe pain and blanching of
Th e area su pplied by th e blood vessel w h ere ller em bo- the skin is observed along the area of the blood vessel dur-
lism h as occu rred becom es pale du e to isch em ia. Th e isch - ing the ller procedure, the injection should im m ediately
em ic area develops edem a w ith in several h ou rs, an d soon stop and as m uch ller should be aspirated as possible. If
ap pears m ot tled an d p u rplish d u e to ven ou s congest ion as hyaluronic ller has been injected, injection of hyaluronidase
a rebou n d p h en om en on . After ~ 24 h ou rs, m u lt ip le u lcer- to the lesion is recom m ended (Fig. 31.8). The optim al tim e
at ive lesion s accom p an ied by esch ar an d er yth em a, w ors- of hyaluronidase injection in case of vascular com plications
en ing over t im e, resu lt in d esqu am at ion of th e t issu e w ith in has not been determ ined yet, but it is w ise to use high doses
several days (Fig. 31.6).3,4 Th ese large areas of n ecrosis h eal of hyaluronidase (at least 200 U) as early as possible. Som e
an d redu ce over t im e, even t u ally leading to scar form at ion experts recom m end dilution w ith saline to increase disper-
w ith con t ract ion of t issue (Fig. 31.7). sion or lidocaine to aid vasodilation. Additional hyaluronidase
To preven t th is com plicat ion du ring n asal augm en t a- should be injected if im provem ent is not seen w ithin 60 m in-
t ion w ith llers, th e n eedle t ip m ust alw ays be located in utes.17 According to an experim ental study, the degradation
th e m idlin e to avoid inject ing in to th e dorsal n asal ar ter y. ratio of cross-linked HA w ith 100 IU of hyaluronidase after
If ller h as to be injected in to th e sid e of th e n asal dorsu m , 24 hours was 50%, and it depended on the am ount of hyal-
for exam ple, for correct ion of a d eviated n ose, th e n eedle uronidase.18,19 Recently, there has been som e evidence that if
sh ou ld n ever m ove in parallel w ith th e direct ion of th e hyaluronidase is injected subcutaneously, it w ill di use into
blood vessel. After in sert ing th e n eedle in to th e m idlin e, the obstructed vessels and degrade the HA ller to prevent
410 VI Minim ally Invasive Facial Plastic Surgery
a b c d
Fig. 31.6 Intra-arterial embolism by ller injection. The ischemic area develops edema within several hours, and soon a purplish, mot tled
area appears due to venous congestion occurring as a rebound phenomenon. After ~ 24 hours, multiple ulcerative lesions accompanied by
eschar and erythema appear and worsen over time, resulting in desquamation and ulceration of the tissue within several days. (a) Before
injection. (b) Four hours after injection. (c) One day after injection. (d) Three days after injection.
im pending necrosis caused by intra-arterially injected HA e ective by the action of vasodilation and inhibition of plate-
ller.17 Low -m olecular-weight heparin therapy can decrease let aggregation. A regim en of 10 m g a day for 3 to 7 days is
throm bosis and em bolism , but it m ay be di cult to obtain recom m ended. Appropriate dressing should be applied once
and adm inister in an outpatient clinic setting. It is very im por- desquam ation and pustule form ation occur after a day. The
tant to supply enough oxygen to the area of ischem ia. For this physician should adm inister appropriate antibiotics to pre-
purpose, hot packs, soft m assage, and 2% nitroglycerin paste vent secondary infection, apply wet dressing for faster wound
can be applied for vasodilation. Injection of prostaglandin E1 is healing, and continue to adm inister antibiotics.2,3,4
a b c
Fig. 31.7 Skin contracture after nasal ller injection. (a) Treatment was delayed after intra-arterial ller injection, and necrosis pro -
gressed even with hyperbaric oxygen chamber treatment. (b,c) Two months later, the size of the necrotic area has decreased, but her right
alar area shows slight contracture.
31 Managem ent of Facial Filler Injection Com plications 411
a b
Start ing hyperbaric oxygen th erapy is also h elpful. It pack sh ould be applied to th e a ected area. Th e skin sh ould
is kn ow n to im p rove n eovascu larizat ion an d post isch em ic be pu n ct ured at th e site of ller inject ion an d squeezed to
t issue sur vival by elevat ing cellu lar oxygen levels. Th e pro- rem ove ller. If hyaluron ic acid–t ype ller w as u sed, inject
tocol di ers am ong pract it ion ers, bu t th e auth ors recom - hyaluron idase rst an d th en t r y rem oving injected ller.
m en d 90 m in u tes of t reat m en t t w ice per day for 7 to 30 Adm in ister an t ibiot ics an d p rostaglan din E1 as m en t ion ed
days w ith 100% oxygen at 0.2 MPa. This yields a m ore th an previously. Tw o percen t n it roglycerin paste can be applied
20% in crease in ar terial blood oxygen con ten t .20 for vasodilat ion . Hyperbaric oxygen th erapy is also recom -
m en ded. Un like in t ra-arterial em bolism , ven ou s com p res-
Venous Congestion sion can be resolved w ith ou t sequ elae if t reated p roperly
in it ially. How ever, if th e in it ial t reat m en t w as n ot provided
Derm al n ecrosis du e to ven ou s com pression from exces- or w as in appropriate, it progresses to derm al n ecrosis due
sive ller volu m e is m ore com m on th an derm al n ecrosis to ven ou s congest ion , and after a day th e skin t u rn s dark
by direct in t ra-arterial inject ion . In it ially, both th e vein an d violet . W h en th is h appen s, th e physician sh ou ld apply
arter y su pp lying th e injected site are com p ressed by th e a w et dressing for faster w ou n d h ealing an d con t in u e to
excess ller volu m e, so th e p at ien t feels severe p ain an d th e adm in ister an t ibiot ics.4,6
skin in th at area becom es p ale. Un like arterial com p ression , Aft e r t h e act ive w ou n d st age, n e crot ic a rea s ch a n ge
w h ich can be reperfu sed by h igh lling pressu re an d col- in t o ch ron ic st age w it h re m ain in g scar s. Scar s w ill n eve r
lateral circulat ion , ven ou s congest ion often persist s. In th is d isap p ea r b u t can b e re d u ce d . Th e Fra xel Xe n a la se r
case, th e pat ien t con t in ues to feel dull pain an d th e skin (Solt a Me d ica l), p lat elet - r ich p lasm a (PRP), st e m cell fat
darken s w ith t im e. Th e skin t urn s dark violet after 24 h ours graft in g, d iam on d p e elin g, a n d car boxy t h e rapy can b e
an d desqu am at ion or p u st u les can be obser ved. De n it ive ad d resse d w h e n t h e sca rs b e com e p e r m a n e n t . Su r gica l
sign s of derm al n ecrosis su ch as esch ar form at ion occu r t reat m e n t of scar t issu e can b e at t e m p t e d if seve re skin
gradu ally, an d th e skin recovers th rough th e w ou n d h eal- d efor m it y re m a in s re gard less of t h ese m ea su res. Sin ce
ing p rocess (Fig. 31.9).1–4 su rgica l t reat m e n t h a s t h e r isk of m akin g a n ew sca r, a
Th e skin color an d pain sh ould be closely m on itored t h orou gh d iscu ssion sh ou ld t a ke p lace w it h t h e p at ie n t
w h ile inject ing a sm all am ou n t at a t im e. before t h e su r ge r y. Accord in g t o t h e size an d locat ion
If vascu lar com pression is su spected from blan ch ing of of t h e w ou n d an d t h e p refe re n ce of t h e su r ge on , a local
th e injected area righ t after inject ion , th e inject ion sh ould rot at ion a l fla p , n a sola b ial flap , or foreh ea d flap ca n b e
be stopped im m ediately, an d su cien t m assage an d a h ot u se d .
412 VI Minim ally Invasive Facial Plastic Surgery
a b
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(Rest ylan e) ller for facial rhyt ids: lesson s learn ed from
th ese can be due to eith er gran ulom a or n odule form a-
Am erican Societ y of Op h th alm ic Plast ic an d Recon st ru c-
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m g/m L) sin ce it can resu lt in adjacen t skin at rophy.2 Nod - 1616–1625
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Th e t reat m en t is hyaluron idase inject ion , if th e used ller 2008;28(3):335–347
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m on bacteria, su ch as m ycobacteria.22 Fluct uan t n odules
7. Mat arasso SL, Her w ick R. Hypersen sit ivit y react ion to n o-
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an d drain age or dressing ch anges u su ally fail to eradicate
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an t ibiot ic th erapy. Su ccessfu l t reat m en t requ ires aggres- 26(2):135–137
sive debridem en t of all in fected su bcu tan eou s t issu es an d 9. Alam M, Dover JS. Man agem en t of com plicat ion s an d se-
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skin graft ing. Surg 2007;120(6, Su ppl):98S–105S
Migrat ion of llers can occu r u p to several years after 10. Gierlo M, Stöh ring C, Bu der T, Wiltfang J. Th e su bcu t an e-
th e inject ion . Sem i-perm an en t an d perm an en t im plan t s ous fat com part m en t s in relat ion to aesth et ically im por-
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gical rem oval are t reat m en t opt ion s for m igrated llers.
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Index
Note: Page nu m bers follow ed by f an d t in dicate gures an d tables, respect ively.
415
416 Index
augm en tat ion rhin oplast y bleph aroplast y, 7f, 307, 307f. See – fat t ran sposit ion , 199, 202–203 – evalu at ion , 175, 176f
(cont inued) also double-eyelid su rger y –– com plicat ions of, 206 – involut ion al
– silicon e im plant s for (cont inued) – aging-related (upper), 173–183, –– subperiosteal, 202–203 –– clin ical presen tat ion of, 175,
–– ext rusion of, 23 328 –– supraperiosteal, 203, 203f 175f
–– in fect ion w ith , 23, 24, 25f –– an esth esia for, 178 – goals of, 173–174 –– an d deep superior sulcus,
–– in sert ion of, 19, 19f –– asym m et r y after, 181 – low er, 196–209 175, 175f
–– key tech nical poin ts in , 21–22 –– bleph aroptosis an d, 175, 176f –– in Asian pat ien ts, surgical – pat ien t evaluat ion , 211–214
–– pearls, 13 –– brow posit ion an d, 175–176 con siderat ion s, 199 – versu s ptosis, 174, 175f
–– periosteal pocket for, 17–18, –– case st udies, 182–183, –– asym m et r y after, 205 – upper eyelid fu nct ion in, 153
18f 182f–183f –– case st udies, 206–207, 207f blindn ess
–– p rep arat ion of, 16–17, 16f, –– com plicat ions of, 180–181 –– com plicat ions of, 205–206 – fat graft em bolizat ion an d, 320
17f –– corneal protect ion m ech an ism –– conjun ct ival ch em osis after, – after ller inject ion , 10, 403
–– splin t ing, 21 an d, 177 206 –– preven t ion of, 407–408, 408f
– skin ap elevat ion, 17, 17f –– deep superior sulcus an d, –– diplopia after, 206 blood, as ller, propert ies of, 393t
– skin m arking for, 15–16, 16f 175, 175f –– ect ropion after, 205, 205f bot ulinum toxin
– spreader graft placem en t in , –– derm atoch alasis an d, 175, –– eyelid ret ract ion after, 205 – as adjun ct to en doscopic
32–33, 33f, 40, 41f 176f –– globe posit ion an d, 198 foreh ead an d brow lift , 336
– stacked on lay graft for, 19–20, –– eyelid crease design in , 178 –– h orizont al laxit y correct ion – aesth et ic facial use of, 377–391
20f –– eyelid crease form at ion in , procedures, 204 –– inject ion levels, 379
– surgical tech niques for, 28–39 179, 180f –– in ferior orbital rim an d, 197f, –– landm arks for, 379
– t ip contouring in , 37–39, 38f –– eyelid w rin kles an d, 177 198 –– pat ien t evaluat ion for, 378
– an d t ip -to-sept um h eigh t –– fat rem oval in , 179, 179f, 181 –– key tech n ical poin ts in , 204 –– pearls, 377
di erence w ith lateral crural –– goals of, 173–174 –– an d lateral tarsal st rip – for brow lift ing an d shaping,
in clin at ion , varian t techn ique –– key tech n ical poin ts in , 180 procedure, 204 336, 381–382
for, 21, 21f –– lacrim al gland injur y in , 181 –– low er eyelid laxit y an d, – for bu nny lin es, 384, 384f
– un i ed graft an d im plan t hybrid –– lacrim al gland posit ion an d, 198–199 – for cobbleston e ch in , 385, 386f
in sert ion in , 20 177 –– an d m in im ally invasive lateral – com m ercial form ulat ion s, 378
– varian t techn iques for, 20–21 –– lagoph th alm os after, 181 can th oplast y, 204 – com plicat ion s of, 389
– vert ical lin e for, 16, 16f –– levator fu nct ion an d, 175, –– n egat ive vector anatom y an d, – for crow ’s-feet , 380–381, 381f,
– w ing graft placem en t in , 20, 20f 175f, 176f 197f, 198, 207, 207f 382f
autoim m un e disease, an d saddle –– an d nat ural eyelid crease –– an d orbicu laris oculi – dilut ion of, 378–379
n ose, 89 creat ion , 182, 182f suspension, 204, 206, 207f – dosage of, 378
autologous grafts, 8–9 –– an d not iceable eyelid crease –– orbicularis-retain ing ligam ent – for forehead an d glabellar
creat ion , 183, 183f release and orbitom alar rhyt idosis, 328
B –– orbit al fat prolapse an d, 177 suspension in , 203 – for forehead h orizon t al lin es,
backstop graft , in aesth et ic –– an d orbit al h em orrhage, 181 –– an d orbit al h em orrh age, 206 379, 379f, 380f
rh inoplast y for South east –– pat ien t dissat isfact ion w ith , –– pat ien t evaluat ion for, – for glabellar frow n lin es,
Asian s, 113 180 197–199 379–380, 380f
beaut y –– pat ien t evaluat ion for, –– pearls, 196 – for gum m y sm ile, 384, 384f
– Asian ideal of, 5 175–178 –– w ith pin ch skin excision , 199, – for infraorbital eye open ing,
– cult ural beliefs about , 5 –– pearls, 173 201, 201f 382–383, 383f
– Eurocen t ric, 5 –– postoperat ive care, 180 –– posit ive vector an atom y an d, – for infraorbital w rin kles, 382,
– Korean de nit ion of, in uence –– skin closure, 179, 180f 198 382f
of, 5 –– skin excision in , 178, 178f, 181 –– postoperat ive care, 201 – int raderm al inject ion, 388–389,
Bell’s ph enom enon , preoperat ive –– skin text ure and thickn ess –– an d prom in en t lateral fat 389f
evaluat ion, 177, 181, 214, 329 an d, 178 pad, 205 – for m arion et te lines, 385, 386f
Belotero. See hyaluronic acid –– an d su perior sulcus, 181 –– an d SOOF lift , 198, 199, 203, – for m asseter m uscle
bigonial dist an ce, 254, 270, 271f –– tear secret ion and, 177 207, 207f hypert rophy, 386–388, 387f,
– increased, 255–256 –– tech n iques for, 178–179 –– surgical tech n iques for, 388f
– reduct ion of, 255 –– too-h igh double-lid fold after, 199–204 – for m outh corn er elevat ion ,
bilateral vert ical sagit t al ram us 181 –– t ransconju nct ival approach, 385, 386f
osteotom y, m an dibular, 274t –– t ren ds in , 173–174 197, 199 – for n asal t ip lift ing, 383, 383f
bim axillar y advan cem ent/ –– under-correct ion in, 180 –– t ransconju nct ival fat excision – for parot id glan d reduct ion,
reduct ion, 9, 295, 296f–297f, –– unn at ural eyelid con tou r procedure, 199–201, 199f, 388, 389f
298, 299f after, 181 200f – for perioral rhyt ids, 384–385,
bim axillar y prot rusion , an terior –– upper eyelid crease an d, 177 –– t ranscu tan eous approach , 197, 385f
segm en tal osteotom y for, 274t, –– w ith out eyelid crease creat ion, 199, 201, 202f – for plat ysm al ban ds, 386, 386f
277–279, 279f 182, 182f – upper – for squ are jaw, 386–388, 387f,
– an d gen ioplast y, 286, 295, – Asian , 162. See also double- –– an d en doscopic foreh ead an d 388f
296f–297f, 298, 299f eyelid su rger y brow lift , 336 – storage of, 378–379
bim axillar y surger y. See anterior – com plicat ion s of, 225–239 –– skin -on ly, 304f breast augm en tat ion , an d cost al
segm en tal osteotom y; double – dem an d for, am ong East asian s, blepharoptosis, 162, 174, 174f cart ilage h ar vest , 28–29, 29f
jaw surger y 196 – cau ses of, 210 brow lift . See also en doscopic
bitem poral w idth, 270, 271f – an d epicanth oplast y, com bin ed, – correct ion , 153, 154 foreh ead an d brow lift
bizygom at ic w idth, 244–246 8 – versu s derm atoch alasis, 175, – w ith augm en tat ion rh in oplast y,
Blaskovics’ m eth od, for aesthet ic – fat preser vat ion m eth od, 176f 15
lateral can th oplast y, 190–191, 197–198, 202–203 – after double-eyelid surger y, – an d blepharoplast y, 176
191f –– in dicat ion s for, 198 236–237, 237f – botulinum toxin for, 336, 381–382
Index 417
– incision s for, 329, 330f – de n it ion of, 257 – edem a after – h ar vest of, 125–126, 125f
– indicat ion s for, 15 – drooping/distor t ion , after –– late (persisten t), 81 –– an atom ical con siderat ion s in ,
brow t ip aesthet ic line, 72–73, 73f gen ioplast y, 294 –– m anagem en t of, 81 29, 29f
bruising – ideal, ch aracterist ics of, 286 – en don asal approach for, 75 –– in cision for, 28–29, 29f
– facial fat graft ing an d, 319 – on lay augm en tat ion, h istorical – extern al approach for, 75 –– an d pn eum oth orax, 130
– ller inject ion an d, 407 perspect ive on , 287 – key tech n ical poin ts in , 80–81 –– an d scar, 28, 29f, 31
bun ny lin es, bot ulin um toxin for, – peau d’orange on , after – n asal sept al st raighten ing in, –– tech niqu e for, 28–31, 30f, 40,
384, 384f gen ioplast y, 294–295 77–78, 78f 41f, 43, 44f
BVSRO. See bilateral vert ical – in plann ing for low er facial – osteotom y in , 76–77 – for n asal dorsal augm en tat ion ,
sagit t al ram us osteotom y contouring, 257 – pat ien t select ion , 74–75 8, 26–46, 30f, 41f, 43, 44f
– posit ion , ceph alom et ric an alysis – pearls, 72 –– pearls, 26
C of, 287, 288t, 289, 290f, 295, – postoperat ive m an agem en t, 80 – n asal dorsal onlay graft
calci cat ion, of alloplast ic 297f – preoperat ive pat ien t in ter view –– m ovabilit y of, 130–131
im plan ts, 22 – psychosocial sign i can ce of, 286 for, 74 –– w arping of, 130, 131f
calcium hydroxylapat ite, 394, 405 – ptosis, after gen ioplast y, 294 – for saddle n ose, 87–98 – for n asal t ip graft ing, 26–46,
– propert ies of, 393t – resect ion, in low er facial –– pearls, 87 30f, 41f
cart ilage con touring, 257 – sept al exten sion graft in , 79–80, –– pearls, 26
– auricular, advan tages of, 24 ch in im plan t , 9 80f – problem s w ith , 13
– autologous, for nasal t ip cobbleston e ch in , bot ulinu m toxin – for sh ort con t racted nose, coun seling, preoperat ive, for
augm en tat ion , 13 for, 385, 386f 122–134, 141–142, 142f rh in oplast y, 27–28
– con ch al cocain e abuse, and saddle n ose, –– case st udies, 131–133, CPT. See Com fort Pulse
–– in corrective rhinoplast y for 89–90 132f–133f Tech n ology
short contracted nose, 124f, 125 collagen , inject ion, depth of, 405 –– closure, 129 Crohn’s disease, an d saddle
–– har vest of, 17, 109 colum ella –– com plicat ion s of, 130–131 n ose, 89
– costal. See cost al cart ilage – Asian , 26, 27f –– com posite graft for, 124f, 125, crow ’s-feet
– as dorsal im plan t , 114 – lengthen ing aps for, 9 129, 130f – bot ulin um toxin for, 380–381,
– septal, har vest of, 18–19, 19f, 62 – ret ract ion of, 100 –– dorsal augm en tat ion in , 129, 381f, 382f
cart ilage grafts, 6 – ret rusion of, 99 129f – preoperat ive evaluat ion , 177
– in rhinoplast y, 8 – sh or t , 9 –– elongat ion of fram ew ork in , cu cum ber face, 246
caruncle. See lacrim al carun cle – w ide base of, 99 127, 128f
Caucasians, as beau t y ideal, colum ellar base, too-w ide, –– graft car ving for, 126, 126f, D
historical perspect ive on , 5 correct ion of (n arrow ing of), 127f deep tem poralis fascia, 325, 325f,
Caucasoids, 3 103, 104f –– graft m aterial h ar vest ing for, 326f
ceph alom et r y Com fort Pulse Tech n ology 125–126, 125f den t al m odel, 272
– eth n ic di erences and, (Th erm age), 344 –– key tech n ical point s in , 130 depigm en tat ion , after laser facial
270–272, 272f, 290f com pu ted tom ography –– m ovabilit y of costal cart ilage h air rem oval, 370
– for gen ioplast y, 287, 288t, 289, – con e beam , 272 graft after, 130–131 derm al hydrat ion , u sing
290f, 295, 297f, 298 – preoperat ive –– n asal obst ru ct ion after, 131 hyaluron ic acid, 402
– param et ric values, disparit y –– for gen ioplast y, 289 –– pat ien t evaluat ion , 122–123, derm atoch alasis, 174, 174f, 210,
am ong Asians an d Caucasians, –– for m an dibular reduct ion , 256 123f 328
270–272, 272f –– for secon dar y rh inoplast y, 136 –– pearls, 122 – versu s blep h aroptosis, 175,
– preoperat ive, in orth ogn athic conjoin t fascia, 326, 327f, 331 –– pneum oth orax du e to, 130 176f
surger y, 282f–284f conjoin t ten don , 331 –– skin dam age in, 130 – brow ptosis w ith , 176
– referen ce poin t s in , 270, 271f, conjunct ival ch em osis, after low er –– skin un derm in ing, 127 – evaluat ion , 175
272f, 273t blepharoplast y, 206 –– st rategies for, 123–125, 124f digital im aging
ch arm ing roll, 378, 383 conjunct ival prolapse, after ptosis –– techn iques for, 123–129 – m orphing w ith , 27
ch eek correct ion , 221 –– t ip graft s in , 127–128, 128f – in rh inoplast y plan n ing, 27, 40,
– ller inject ion in, 397–399, 398f conjunct ival tarsal Mü llerectom y, –– t ip problem s after, 131 40f, 43, 43f
– four crescen t aging lin es, 211 –– t ip reposit ion ing in , 127–128, diplopia, after low er
397–399, 398f conjunct ivo-Mü llerectom y. See 128f blepharoplast y, 206
ch eekbones Mü ller m u scle conjun ct iva –– w arping of costal cart ilage dist ract ion test (for w ard t ract ion
– Asian , 6, 7f resect ion (MMCR) graft after, 130, 131f test), for eyelid laxit y,
– prom in en t (high ), 243, 244 con t act len s–in du ced ptosis, – spreader graft in , 78–79, 79f 198–199
ch em ical peeling, in facial 214, 214f – surgical plann ing, 74 dorsal nasal arter y, ller inject ion
rejuvenat ion , 340 con t ract ion , nasal, postoperat ive, – tech n iques for, 75–80 in , prevent ion of, 403,
ch em osis, conjun ct ival, after 24, 25f corrugator supercilii m uscle, 408–409, 409f
low er bleph aroplast y, 206 corneal protect ion m ech an ism , 326–327 double eyelid, 151–152, 152f, 162,
ch in preoperat ive evaluat ion , 177 costal cart ilage 163, 174
– aesth et ics of, 286 corneal ulcer, 177 – advant ages of, 27–28 – form at ion
– alloplast ic im plan t for, 309 correct ive rh in oplast y, 72–86 – age and, 28 –– extern al-in cision techn ique,
– asym m et r y, and low er facial – approach for, select ion of, 75 – car ving 153
con touring, 257 – bleeding/hem atom a after, 81 –– for augm ent at ion rh in oplast y, –– n on in cision sut ure ligat ion
– augm ent at ion , 40–43, 42f – case st udies, 81–83, 82f–85f 31, 43, 44f for, 153
–– in facial rejuvenat ion , 309 – closure, 80 –– for dorsal on lay graft , 126, – h eigh t for, 165, 166f
–– ller inject ion for, 400–401, – com plicat ion s of, 81 126f, 127f – open ing ph ase, 153f
401f – dorsal irregularit y/deviat ion –– for at st raigh t piece, 126, 127f – rest ing ph ase, 153f
– cobblestone, bot ulin um toxin after, 81 – disadvan tages of, 13 – too-high , after aging-related
for, 385, 386f – dressing, 80 – graft splint ing techn ique, 31, 32f (upper) bleph aroplast y, 181
418 Index
double-eyelid surger y, 162 –– procedu res for, 156–157, – edem a after, 337 – m edial, 8, 165
– asym m et r y after, 233 156f–158f – exam in at ion for, 328–329 – m odi cat ion an d re nem ent for
– bleph aroptosis after, 236–237, –– an d relapse, 158–159 – xat ion m eth od, 332–336 Asian s, 8
237f –– an d scar, 159, 160f –– w ith cort ical bone t un nels, – m odi ed Uch ida m ethod, 187,
– com plicat ion s of, 158–160, 170, –– an d st itch abscess, 160 334, 335f 188f
225–239 –– an d st rangulat ion , 160 –– w ith En dot in e Forehead – palpebral m argin in cision
–– case st udies, 238, 238f –– sut u re m aterial, 155–156 device, 334–336, 336f m eth od, 8
–– key tech nical poin ts for, 237 – part ial in cision al tech nique, 163 –– w ith brin glue, 333 – Park’s Z-plast y m eth od, 187,
–– pat ient evaluat ion , 225 – pat ien t evaluat ion for, 154 –– w ith m onocort ical screw s, 188f
–– pearls, 225 – pret arsal fullness after, 333–334, 334f – pat ien t evaluat ion for, 185
–– surgical tech n iques for, 232–233, 233f – forehead an d brow xat ion in , – pearls, 184
226–237 – ptosis after, 238, 238f 332–333 – reconst ruct ive, 189, 189f, 190f
– deep fold after, 228 – an d pu y eyelid, 154 – gran ulom a form at ion after, 337 –– back-cut design in, 189, 189f
– ect ropion after, 228, 230f – rem oval of surgically created – h airlin e elevat ion after, 337 –– rotat ion ap in , 189, 190f
– an d epicanth oplast y, 185–186, eyelid fold after, 237 – h em atom a caused by, 337 –– V-Y advancem en t ap for, 189,
186f – revision case, 154–155 – h istorical perspect ive on , 324 189f, 190f
– an d exoph th alm os, 154 – scar after, 226, 226f, 227f – h istor y-taking for, 328–329 – reverse Fuente’s design , 186f,
– incision al, 162–172 – shallow fold after, 227–228, 228f – an d im plan t problem s, 337 187
–– an esth esia for, 166 – sim ple sut ure tech n ique, 163 – incision s for, 330–331, 331f – Roveda m ethod, 186
–– asym m et r y after, 170 – su nken eyelid after, 236, 236f – indicat ion s for, 328 – scar after, 187–189
–– case st udies, 170–171, 171f – t ran sconjunct ival Mü ller – an d infect ion, 337 – sim ple skin excision m ethod, 186
–– closu re, 169, 169f t ucking in, 158, 159f, 161, 161f – inst rum en t s for, 330, 330f – skin excision in, 185
–– com plicat ions of, 170 – t riple fold caused by, 166, 167, – an d int racran ial inju r y, 337 – skin redraping m ethod, 187, 188f
–– for correct ion of h igh crease to 168f, 232, 233–236, 234f, 235f, – key tech n ical poin t s in , 336–337 – surgical techn iques for,
low crease, 171, 171f 238, 238f – n er ve injur y in, 337 186–187
–– for correct ion of sh ort in side – an d w eak levator fun ct ion, 154 – n o xat ion in , 333 – V-Y advan cem en t m ethods,
crease to out side crease, 170, double jaw surger y, 274t, 279 – an d open tech n iques, 186–187, 187f
171f dr y eye syn drom e, 177, 181, 214 com parison of, 324, 329 – W-plast y m eth od, 186
–– crease design , 165–166, 166f – over- and un der-correct ion – Wu’s square- ap m eth od, 188f
–– crease disappearance after, E in , 337 – Yoon’s on e-arm ed ju m ping m an
170 East Asian s, 3 – pat ien t evaluat ion for, 328–330 m eth od, 188f
–– disadvan tages of, 163 – facial aesth et ic procedures used – pearls, 324 – Z-plast y ap m ethod, 186–187,
–– xat ion sut ure of eyelid crease in, 3, 4f – plan e of dissect ion for, 325, 188f
in , 168, 168f – ph en ot ypic feat ures of, 6 325f, 326f, 331 epicanth us inversus, 184, 185f
–– in dicat ion s for, 163, 163f ecchym osis, after en doscopic – postoperat ive care, 336 – iat rogen ic, 187–189
–– key tech nical poin ts in , 169 forehead an d brow lift , 337 – preparat ion for, 330 – preven t ion of, 189, 189f, 190f
–– an d levator advan cem en t , ect ropion , 8, 198 – relaps after, 337 epicanth us palpebralis, 184, 185f
169, 169f – after dou ble-eyelid surger y, – release of m uscular an d epicanth us supraciliaris, 184,
–– m ult iple folds caused by, 166, 228, 230f ligam en tous at tach m en t in, 185f
167, 168f – after low er bleph aroplast y, 331–332, 332f epicanth us tarsalis, 184, 185, 185f
–– orbicularis m uscle rem oval in , 205, 205f – serom a after, 337 E-plan e. See esth et ic plan e
166–167, 167f – after ptosis correct ion , 221 – sut u re ext rusion after, 337 (E-plane)
–– orbit al fat rem oval in, 167, eczem a, lateral can th al, 174 – techn iques for, 330–336 ePTFE. See Gore-Tex
167f edem a – tem poral xat ion in, 332, 333f er yth m a
–– pat ient evaluat ion for, – after en doscopic foreh ead an d – an d w oun d problem s, 337 – after ller inject ion, 407
163–164 brow lift , 337 En dot ine Foreh ead device, – after laser facial h air rem oval,
–– pearls, 162 – facial fat graft ing an d, 319 334–336, 336f 370
–– postoperat ive care, 170 – after ller inject ion , 403, 412 en t ropion , 162 esthet ic line (E-line), 272, 272f,
–– ROOF rem oval in , 167, 167f EFBL. See en doscopic foreh ead – correct ion of, 168 288, 289f
–– skin bulging after, 168, 169f an d brow lift – after ptosis correct ion , 221 esthet ic plane (E-plane), 392
–– skin excision in , 165, 166–167, E-lin e. See esth et ic lin e (E-lin e) epican th al fold(s), 164–165, exoph th alm os, dou ble-eyelid
166f, 167f en doscopic foreh ead and brow 173, 184 surger y and, 154
–– skin in cision in , 166, 167f lift , 324–338 – recon st ruct ion , 194, 194f expan ded
–– skin su t ure in, 169, 169f – advant ages an d disadvan tages – thirds of, 185 polytet ra uoroethylen e. See
–– tech n iques for, 165–169 of, 324, 330 – t ypes of, 184–185, 185f Gore-Tex
– inclusion cyst after, 226, 227f – alopecia caused by, 337 – un der-corrected, 188–189 exposure kerat it is, 177, 181
– m ult iple folds caused by, 166, – an atom ical con siderat ion s in, epican th oplast y, 184–189 external n asal valve
167, 168f, 233–236, 234f, 235 324–326, 325f–327f, 331–332, – an atom ical considerat ion s in , 6 – collapse, 100–101
– n onin cision al sut u re tech n iques 332f – com plicat ion s of, 187–189 – sten osis, after alar base surger y,
–– case st udies, 161, 161f – an esthesia for, 330 – an d dog-ear, 185–186 100
–– com plicat ions of, 158–160 – an d bot ulin um toxin , 336 – double-fold operat ion an d, eyebrow (s). See also brow lift;
–– an d irregular fold, 159 – closure, 336 185–186, 186f, 187f en doscopic foreh ead an d brow
–– key tech nical poin ts in , 158 – com bin ed approach , sequen ce – Fuen te’s t ran sposit ion ap for, lift; ptosis
–– an d knot exposu re, 160 of, 336 187, 188f – aesth et ics of, 327, 327f
–– an d lid m argin tension – com plicat ion s of, 337 – Jordan’s deep t issue approach – age-related ch anges in , 174,
eversion, 160, 160f – dissect ion , 331 m ethod, 188f 175–176, 327
–– n eedle ch oice, 156 – dressing, 336 – Mat sun aga’s m odi ed M-plast y – asym m et r y of, 328
–– pearls, 151 – ecchym osis after, 337 m ethod, 188f – depressor m uscles, 326, 332
Index 419
– elevat ion, in com pen sat ion for –– m iddle lam ella, 152 – in /out (n eut ral), 154, 155f, 156 – laser in , 10
bleph aroptosis, 174, 174f, 175, –– opening process of, 152–153, – in side, 154, 155f, 156 facial an alysis, 14, 14f, 74, 75f,
175f, 210, 211, 212f, 221, 222f 153f – irregular, n onin cision al dou ble- 244–246, 255–256, 270
– elevator m uscles, 326 –– orbital fat of, 164 eyelid surger y an d, 159 – for en doscopic forehead an d
– h air t ran splant for, 305, 305f –– posterior lam ella, 152–153 – m ult iple, caused by double- brow lift , 329
– ideal posit ion of, 327, 327f –– pu y, 177 eyelid surger y, 166, 167, 168f, – for fat graft ing, 311–312
– posit ion of, evaluat ion , dou ble-eyelid surger y an d, 154 233–236, 234f, 235 – for gen ioplast y, 288–290
175–176, 329 –– ret ractors, 210 – out side, 154, 155f, 156 facial arter y, an atom y of, 407,
– rejuvenat ion of, 307–308, 307f, –– st ruct ure-fun ct ion – sh allow, after double-eyelid 407f
308f relat ion ships, 151 surger y, 227–228, 228f facial asym m et r y
– sh ape, evaluat ion , 329 – w rin kles – surgically created, rem oval – causes of, 73
– sh aping, bot ulin um toxin for, –– correct ion , 177 of, 237 – an d fat graft ing, 311–312
336, 381–382 –– preoperat ive evaluat ion , 177 – t riple – after ller inject ion , 412
– sym m et r y, evaluat ion , 329 eyelid crease. See also eyelid –– after double-eyelid su rger y, – after genioplast y, 294
– t at tooing, 328 fold(s) 166, 167, 168f, 232, 233–236, – an d low er facial con touring,
– volum izat ion of, 308, 308f – aging an d, 307–308, 307f, 308f 234f, 235f, 238, 238f 257
eyelash (es) – deep, after double-eyelid –– p r im ar y, cor re ct ion , 236, – preoperat ive, 14, 73
– direct ion of, 215, 215f surger y, 228 236f – t ransverse correct ion
– upp er, dow nw ard angulat ion , – design eye surger y, aesth et ic. See also genioplast y for, 290, 291f
164 –– in aging-related (upper) bleph aroplast y facial bones
eyelash ptosis, 162, 215, 215f bleph aroplast y, 178 – an atom ical con siderat ion s in , 6 – age-related ch anges in , 174,
– correct ion of, 168, 218–219 –– in double-eyelid surger y, 178
– evaluat ion of, 164 165–166, 166f F – Asian , an atom y of, 6
eyelid(s). See also lid lag; lid – duplicated, 177 face(s) facial bone surger y. See
m argin – evaluat ion , 177 – Asian , 243, 244f also m an dible; m axilla;
– age-related ch anges in , 174, 328 – xat ion sut ure of, in double- –– aesth et ic ideals an d, 378, orth ognath ic surger y
–– m an agem ent of, 307–309, 307f eyelid surger y, 168, 168f 392–393 – com plicat ions of, 280–281
– Asian – form at ion , in aging-related –– aging, m an agem en t of, facial con touring
–– an atom y of, 6, 162–163, 163f, (u pper) blepharoplast y, 179, 303–310, 311 – llers for, 392–404
211 180f, 182, 182f, 183, 183f –– anatom ical con siderat ions, 6, –– pearls, 392
–– characterist ics of, 173, 196 – heigh t , 165, 166f, 177, 213 7f, 8f, 378 – surger y for, 243. See also
– asym m et r y –– ideal, 163 –– ch aracterist ics of, 272, 272f m an dible, reduct ion
–– after dou ble-eyelid surger y, –– preoperat ive sim ulat ion , 163 – brachyceph alic, 243, 244f, 254 (con touring)
233 – high – Caucasian, 243, 244f –– plann ing for, 256–257, 256f
–– preoperat ive, 233 –– correct ion of, 229–232, – cult ural beliefs about , 5 facial con tour lin e(s)
– Caucasian , an atom y of, 163f 231f–233f – dolich oceph alic, 243, 244f – an terior, 244f
– East Asian , an atom y of, –– after double-eyelid surger y, – fem ale, at t ract ive com posites, – posterior, 244f
162–163, 163f 170, 229–232, 230f 3, 4f facial h air
– low er – in side, 164, 164f – at , adding dim en sion to, 255, – in m en, 364–365
–– age-related changes in, – low , after dou ble-eyelid 255f, 311 – in w om en, 364–365
196–197, 197f su rger y, 170, 228–229, 228f, – fron tal plane, ver t ical division s facial h arm ony, evaluat ion , 246,
–– Asian, characterist ics of, 196 229f ( fth s), 270, 271f, 324 246f
–– asym m et r y, after low er – nasally t apered, 164 – fron tal view, aesthet ic divisions facial m idlin e, 72–73, 73f
bleph aroplast y, 205 – outside, 164, 164f in , 270, 271f facial n er ve
–– fat graft ing for, 322, 322f –– fan -parallel t ype, 164 – ideally sh aped, creat ion of, 255, – fron tal bran ch of, 325, 325f,
–– u id accu m u lat ion in , 198 –– fan t ype, 164, 164f 255f, 256f 326, 331
–– horizon tal laxit y correct ion –– h igh er, 164, 165f – low er –– inju r y in en doscopic foreh ead
procedures for, 204 –– parallel t ype, 164, 164f –– aging of, 309 and brow lift , 337
–– laxit y, 198–199 – parallel, 164 –– rejuven at ion of, 309 – palsy, an d un ilateral ptosis, 174,
–– loss of skin elast icit y, 198 – part ially high , after double- –– sh ape, classi cat ion of, 256, 175f, 176
–– ret ract ion, after low er eyelid surger y, 232 256f – zygom at ic bran ch , 326
bleph aroplast y, 205 – postoperat ive disappearan ce, –– w idth facial rejuvenat ion , 9. See also
– ptosis, 328 after double-eyelid surger y, classi cat ion of, 256, 256f endoscopic foreh ead an d
–– evaluat ion , 329 170, 226–227 narrow ing, 255 brow lift
– redu ndan t skin of, evaluat ion , – sem ilun ar, 164 – m esocephalic, 254 – hyaluron ic acid for, 393
329 – sh allow, after double-eyelid – sh ape – ligh t devices for, 340–344
– rejuvenat ion of, 307–308, 307f, surger y, 227–228, 228f –– cult ural factors a ect ing, 257 – n on surgical, 10
308f – sh ape of, 164 –– eth nicit y an d, 257 – u sing en ergy devices,
– skin of, 164 – su rgically created, 308 –– an d fat graft ing, 311 339–348
– sun ken, 236, 236f –– age-related ch anges an d, 177 – th irds of (rule of th irds), 270, –– devices com m on ly used in ,
– upp er. See also double eyelid; –– aging an d, 309 271f, 288, 289f, 324 340
single eyelid – too-h igh, after aging-related – volum e loss in , 304–305, 304f, –– pearls, 339
–– an atom y of, 152–153, 153f, 162 (upper) blepharoplast y, 181 311 – volum e restorat ion in , 304–305,
–– anterior lam ella, 152–153 – w ebbing of, 165, 165f – volum e restorat ion in , 304–305, 304f
–– eth n ic variat ions, 152 eyelid fold(s). See also eyelid 304f, 311–312 facial sw elling, after hair
–– fat pockets in, 177 crease facelift , 309 t ran splant at ion , 359
–– low er-posit ioned t ran sverse – deep, after double-eyelid – h igh -frequen cy focused facial sym m et r y, an alysis of, 270
ligam en t in , 167, 168f surger y, 228, 238, 238f ult rasoun d in , 10 Fasan ella-Ser vat procedure, 211
420 Index
fat graft ing, 9 –– vascu lar em bolizat ion of fat – in nasolabial folds, 400, 400f – sling, 211, 215, 219–220, 220f
– facial, 304–305, 304f, 311–323 after, 320–321, 320f – pain after, 407 FUE. See follicular un it ext ract ion
–– an d abscess form at ion , 320, –– volum e used, 313–317, – self-pistol tech niqu e, 395 FUT. See follicular unit t ran splant
320f 314t–315t – serial pun ct ure (“kisses”)
–– an d acn eiform eru pt ion , 320 –– w h ole face, 321, 321f tech niqu e, 395, 395f, 406 G
–– addit ion al procedures, 318 – for su nken eyelid, 236, 236f – skin n ecrosis after, 403, 403f, galeal fat pad, 332, 332f
–– an esth esia for, 312, 313 – in upper-eyelid/brow com plex, 406, 406f, 409, 410f, 411, 412f gen ioplast y, 274, 274t, 282–283,
–– areas, 313–317, 313f, 308, 308f – skin th ickn ess an d, 405 282f–284f, 286–300
314t–315t ller inject ion , 10 – for sun ken eyelid, 236, 236f – advan cem en t sliding via
–– asym m et r y after, 319 – aesthet ic uses of, 392 – super cial, ller visibilit y after, int raoral approach , historical
–– baton grip tech nique, 317, – bruising after, 407 412, 413f perspect ive on , 287, 287f
318f – bum ps caused by, 413 – in tear t rough, 399 – anesthesia for, 290
–– bruising after, 319 – in ch in , 400–401, 401f – for tear t rough depression, 197 – anterior sliding advan cem en t ,
–– can nulas for, 312, 312f – com plicat ion s of, 10 – techn iques for, 395 h istorical perspect ive on ,
–– case st udies, 321–322, 321f, –– delayed onset , 412–413 – in upper-eyelid/brow com plex, 287, 287f
322f –– early on set , 407–411 308, 308f – asym m et r y after, 294
–– com plicat ions of, 319–321 –– pat ien t evaluat ion , 406 – ven ous congest ion cau sed by, – bleeding and, 293
–– direct ion of inject ion , 314, – danger zon es, 407 411, 412f – and bony m alun ion /n onu nion,
316f – depth of, 405 nasteride, 351 293
–– donor-site com plicat ions, 321 – edem a after, 412 follicular un it ext ract ion , for h air – bony m arking for, 290, 291f
–– edem a after, 319 – er ythm a after, 407 restorat ion , 306, 354–355, – case st udies, 295, 296f–297f,
–– en t r y sites for, 314, 316f – facial con tou ring using, 355f 298, 299f
–– fat preparat ion for, 312–313, 392–404 follicular un it t ransplan t , for h air – cephalom et r y for, 287, 288t,
313f –– an esth esia for, 394 restorat ion , 306, 350, 354, 355 289, 290f, 295, 297f, 298
–– fat resorpt ion in , 319 –– can n ulas for, 407, 407f folliculit is – chin ptosis after, 294
–– in foreh ead region , 315–317, –– in ch eek, 397–399, 398f – facial, im provem en t , laser h air – closure, 292
317f, 317t, 322, 322f –– com plicat ion s of, 403–404, rem oval and, 369, 369f – com plicat ion s of, 293–295
–– graft gravitat ional descen t 403f, 405–414 – in hair t ran splan tat ion , 355, –– allograft-related, 294–295,
in , 319 –– in foreh ead, 396, 397f 356f, 359–360 295f
–– graft h ar vest for, 312–313 –– key techn ical point s in , – after laser facial h air rem oval, – dressing for, 292
–– graft m igrat ion in , 319 402–403 370 – xat ion in, 292, 292f
–– h em atom a caused by, 319 –– m aterials for, 393–394, 393t foreh ead. See also en doscopic – historical perspect ive on, 287,
–– h istor y-t aking for, 312 –– n eedles for, 394, 394f, 407, foreh ead an d brow lift 287f
–– hyperpigm en tat ion after, 319 407f – age-related ch anges in , 327 – histor y-taking for, 287
–– hypo- an d hyper-correct ion –– pat ien t assessm ent for, 393 – an atom y of, 324–326, – in cision for, 290, 291f
in , 319 –– pat ien t con su ltat ion for, 393 325f–327f, 331–332, 332f – in dicat ion s for, 286
–– an d in am m at ion , 320 –– pearls, 392 – augm en tat ion, 15 – in fect ion after, 293
–– inject ion tech n iques, 313–317 –– Reteen age m eth od, 397–399, – ller inject ion in , 396, 397f – in t raoral approach for, 290, 291f
–– in st rum en ts for, 312, 312f 398f – h air rem oval from , 9, 365, 369, – key tech n ical poin t s in , 293
–– irregularit y after, 319 –– techn iques for, 394–402 369f, 371–372, 371f, 372f – labial m ucosal in cision for,
–– key tech nical poin ts in , –– in tem ple, 396–397, 397f – h eigh t , evaluat ion, 329 290, 291f
318–319 – in facial volu m e restorat ion , – h orizon t al lin es in , bot ulin um – lip drooping after, 294
–– in low er face, 313–315, 313f, 304–305, 393t, 405 toxin for, 379, 379f, 380f – m an dibular bony irregu larit y
314t – fan n ing tech n ique, 395, 396f, – layers of, 325, 396, 396f after, 294, 294f
–– for low er lid rejuvenat ion , 406 – preoperat ive exam in at ion of, – m arginal gingival in cision for,
322, 322f – ller m igrat ion after, 413 14–15, 14f 290, 291f
–– lum p/bum p cau sed by, 319 – llers for, 10, 393t – resh aping, by h air reduct ion , – m en t al n er ve injur y in , 293
–– in m idface, 313–315, 313f, – for foreh ead and glabellar 9, 365, 369, 369f, 371–372, – narrow ing, 255, 255f, 256f
314t rhyt idosis, 328 371f, 372f –– com bin ed w ith m an dible
–– pat ien t evaluat ion for, – gran ulom a after, 413 – rhyt idosis, 328 reduct ion (con touring), 260,
311–312 – high -risk areas, 405–406 –– evaluat ion, 329 260f
–– pearls, 311 – hypersen sit ivit y react ion to, – sh ape, evalu at ion , 329 – pain after, 293
–– placem en t , 313–317, 407 – size, cu lt u ral beliefs about , 365 – pat ien t evaluat ion for, 287–288
314t–315t – in fect ion after, 413 – w iden ing, laser hair rem oval – pearls, 286
–– postoperat ive care, 318 – in am m at ion after, 412 for, 365, 369, 369f, 371–372, – preoperat ive assessm en t for,
–– preparation for, 312 – in t ra-arterial, 403, 409, 410f 371f, 372f 288–290
–– scar after, 319–320 –– m anagem en t of, 409 four crescent aging lines, – sagit tal augm en tat ion (an terior
–– sequen t ial autologous fat –– prevent ion of, 407–408, 408f 397–399, 398f advan cem ent) tech nique,
inject ion (SAFI) techn ique for, – for jaw line resh aping, 401, 402f Fox’s m eth od, for aesthet ic lateral 290, 291f
313, 313f, 314t–315t, 316f, – for jow l con touring, 401, 402f can th oplast y, 191, 191f – sagit tal reduct ion (posterior
317t – linear threading (t un n eling) Frankfort h orizon tal line, reduction) technique, 290, 291f
–– sequen t ial depth of inject ion , techn ique, 395, 395f, 406 288–289, 289f – skin dim pling after, 294
314, 316f – in lips, 400 fron t alis m uscle, 210, 326 – tech n iques for, 290–292, 291f
–– sequen t ial inject ion in – for low er face contouring, – in t raderm al bot ulin um toxin – t ran sverse correct ion tech n ique,
abut t ing areas, 314–315, 316f 400–401, 401f, 402f inject ion and, 388–389, 389f 290, 291f
–– an d skin n ecrosis, 320, 320f – lum piness after, 412, 413 – overact ivit y of, 328 – ult rason ic bone cu t ter for, 292,
–– tech n iques for, 312–318 – for m arion et te lin es, 401–402 –– un ilateral, 328 292f, 293
–– in tem poral region , 313–315, – for nasal augm ent at ion , 395, – ptosis surger y an d, 210, 211, – vert ical augm en tat ion
313f, 314t 395f, 399–400, 399f 215, 219–220, 220f techn ique, 290, 291f
Index 421
– vert ical reduct ion tech n ique, h air t ran splan t at ion , 349–363. See – w ith m an dible reduct ion – orth ogn ath ic surger y and, 280
290, 291f also h air restorat ion (con touring), 261 – rh inoplast y an d, 143
glabella – an d arterioven ous st ula, 360 – in m andibular sagit t al split – an d saddle n ose, 89
– an atom y of, 324–326, – in Asian s, 349 ram us osteotom y, 280 – septoplast y and, 143
325f–327f, 331–332, 332f – case st udies, 360–361, 361f Hering’s law, 214–215 – septorh inoplast y an d, 141, 143
– augm en tat ion , 39 – com plicat ion s of, 358–360 h iccu ps, h air t ran splan t at ion in ferior alveolar ner ve inju r y,
– preoperat ive evaluat ion , 15 – and deh iscen ce, 358 and, 360 in m an dible redu ct ion
glabellar frow n lin es, bot ulin um – den sit y gradien t an d layering HIFU. See ult rasoun d, h igh - (con touring), 261
toxin for, 379–380, 380f, 381f e ect in , 357, 357f, 358 in tensit y focused in am m at ion
glabellar rhyt idosis, 328 – depth -con t rolled tech n ique for, high-frequency focused ultrasound – facial fat graft ing and, 320
– evaluat ion , 329 355–356, 356f, 358 (HIFU), in face lift, 10 – ller inject ion an d, 412
glycopyrrolate, 16 – don or h ar vest ing for, 353–355. h igh sagit t al supraforam in al – w ith m an dible reduct ion
gon ial angle, ideal, 256 See also follicular un it osteotom y, m an dibu lar, 274, (con touring), 261
Gore-Tex, 13, 113 ext ract ion 276, 276f, 281 – w ith n asal alloplast ic im plan ts,
– advant ages of, 14 –– st rip su rger y m eth od, Hinderer an alysis, of m axim al 140
– chin im plan t , com plicat ion s of, 353–354, 354f m alar project ion , 245, 245f infraorbital eye opening, botulinum
294, 295f – facial sw elling after, 359 horizontal line, in lower eyelid, 198 toxin for, 382–383, 383f
– disadvan tages of, 14 – folliculit is w ith , 355, 356f, HSSO. See h igh sagit t al in fraorbital n er ve, injur y
– dorsal n asal graft , 43, 43f 359–360 supraforam in al osteotom y – in orth ognath ic surger y, 281
– preform ed n asal dorsal im plan t , – graft dissect ion , 355–356, 355f, h um pectom y. See n asal h um p – in zygom a reduct ion , 249
114, 114f, 115f 356f surger y in fraorbital w rinkles, bot ulin um
– rem oval rate for, 135 – graft preser vat ion, 356 h um p n ose(s). See also nasal toxin for, 382, 382f
– in rh in oplast y, 8, 135 – gray hair follicles an d, 355, h um p in tense pulsed ligh t
–– com plicat ion s of, 135 355f, 358 – Asian , 60–71 – in facial rejuvenat ion , 340,
– sh eet , n asal dorsal im plant , 116 – h airline design in, 352–353, –– ch aracterist ics of, 60–61, 341–342, 341f, 342f
gran ulom a 353f 87, 88f –– com plicat ion s of, 342, 342f
– after en doscopic foreh ead an d – and h iccups, 360 – p reoperat ive exam inat ion of, – for n on ablat ive rejuven at ion ,
brow lift , 337 – hyperesthesia after, 359 60–61 339–340
– after ller inject ion , 413 – hypoesth esia after, 358–359 hyaluron ic acid, 10, 393–394, 405 in tercanth al dist ance, 185f
gran ulom atous disease(s), an d – im planters for, 356, 356f – biph asic, 393–394 in terepican th al dist an ce, 184,
saddle n ose, 89 – key tech n ical point s in , 358 – d erm al hydrat ion using, 402 185, 185f, 189
gum m y sm ile, bot ulin um toxin – and loss of t ransplan t , 360 – em bolizat ion , treat m en t of, in tern al n asal valve
for, 384, 384f – and n ecrosis, 358 409–410, 411f – an atom y of, 87
– n eu ralgia after, 359 – for facial rejuven at ion, 393 – collapse of, 87–88
H – n um bn ess after, 358–359 – m on ophasic, 394 in terpalpebral ssure, 212, 213f
h air, Asian , 6, 9, 350 – opt im al densit y for, 358 – p ropert ies of, 393t in t racran ial injur y, in endoscopic
h air densit y, in Asian s, 350 – pain after, 358 hyaluron idase, t reat m en t of ller foreh ead and brow lift , 337
h airline – pat ien t evaluat ion for, 351–352 em bolizat ion, 409–410, 411f intraoral vertical ram us osteotom y,
– Asian , 349–350, 350f – pearls, 349 hyperbaric oxygen t reat m en t , for m andibular, 276, 277f
– correct ion , laser h air rem oval – pit t ing after, 360 ller em bolizat ion, 410f, 411 IPL. See inten se pulsed light
for, 365 – poor graft su r vival after, 360 hyperesth esia, after h air IVRO. See in t raoral vert ical ram us
– design – postoperat ive care, 358 t ran splant at ion , 359 osteotom y
– – in h a ir t ra n sp la n t at ion , – preparat ion for, on day of hyperpigm en t at ion
3 5 2 – 3 5 3 , 3 5 3 f, 3 6 0 – 3 6 1 , surger y, 352 – facial, reduct ion , laser hair J
361f – recipien t site, 356–358, 357f rem oval an d, 368, 368f jaw line, resh aping, ller inject ion
–– laser h air rem oval an d, 369, – scalp prurit us after, 359 – facial fat graft ing and, 319 for, 401, 402f
369f – and scars, 351, 352, 358, 359 – after laser facial hair rem oval, jow l con touring, ller inject ion
– elevat ion , after en doscopic – and syn cope, 360 370 for, 401, 402f
foreh ead an d brow lift , 337 – tech n iques for, 352–358 – p ost-in am m ator y, 100, 196 Juvederm . See hyaluronic acid
– evaluat ion of, 329 – tem porar y hair loss after, 359 hypoch lorous acid, 16–17
– unn at ural, after hair – un n at ural h airlin e due to, 359 hypoesthesia, after hair K
t ran splant at ion, 359 – and W-plast y for scar revision, t ran splant at ion , 358–359 keloids, 9, 100
h air loss, 305–307, 305f, 306f. See 358, 359, 359f – h air t ran splant at ion an d, 351,
also alopecia Han Ryu , 5 I 359
– m ale pat tern , 349 h em atom a in clusion cyst , after eyelid keratitis, after ptosis correction, 221
– preven t ion , m edicat ion s for, – after en doscopic forehead an d surger y, 226, 227f Korea, plast ic surger y in, 5
351 brow lift , 337 in fect ion
– tem porar y, after h air – facial fat graft ing an d, 319 – alloplast ic im plant s and, 23, 24, L
t ran splant at ion, 359 – after ller inject ion , 403 25f, 141 lacrim al carun cle
h air rem oval/reduct ion, 9 – w ith m an dible reduct ion – augm en tat ion rhin oplast y – bilateral size discrepan cy, 185
– facial, using laser, 364–374. See (contouring), 261 and, 13 – exposu re
also laser h air rem oval – preseptal, low er bleph aroplast y – en doscopic forehead an d brow –– epican thal fold an d, 184, 185
h air restorat ion , 9, 305–307, an d, 206 lift an d, 337 –– excessive, 189
305f, 306f. See also hair – ret robulbar, low er – ller inject ion an d, 413 – h ook-sh aped, 184, 185f
t ran splant at ion blepharoplast y an d, 206 – gen ioplast y an d, 293 – rou nd, 184, 185f
– follicu lar un it ext ract ion for, h em orrhage. See also orbit al – m an dible reduct ion – sh ape of, 184, 185f
306, 354–355, 355f h em orrhage (con touring) an d, 261 – t riangular, 184, 185f
– follicu lar un it t ransplan t for, – gen ioplast y an d, 293 – n asal alloplast ic im plan ts an d, – visible size of, after
306, 354, 355 – in Le Fort I osteotom y, 280 141 epican thoplast y, 184
422 Index
lacrim al glan d –– techn ique for, 368 lid m argin –– t ypes of, 258, 258f
– injur y, in bleph aroplast y, 181 – m ech anism s of, 365, 365f – closed, 154, 155f – prot rusion , orthogn ath ic
– posit ion , preoperat ive – pat ien t evaluat ion for, 366 – de n it ion of, 154 surger y for, 274t
evaluat ion, 177 – pearls, 364 – dou ble-eyelid su rger y an d, – reduct ion (con tou ring),
lagoph th alm os – targets for, 365, 365f 154, 155f 254–267
– w ith congen it al ptosis, 214 – tech n iques for, 366–369 – in/out (neut ral) fold, 154, 155f, –– asym m et r y and, 257
– evalu at ion , 177, 329 lateral canth al rhyt ids. See 156 –– case st u dies, 261, 262f, 263,
– iat rogenic postoperat ive, 176, crow ’s-feet – inside fold, 154, 155f, 156 263f–264f, 265, 265f–267f
181 lateral canth oplast y, 6 – open, 154, 155f –– ch in an d, 257
– after ptosis correct ion , 214, 221 – aesthet ic, 189–192 – out side fold, 154, 155f, 156 –– com plicat ion s of, 261
laser(s) –– Blaskovics’ m ethod for, – sh apes of, 154, 155f –– con dylar fract ure in, 261
– for ablat ive rejuven at ion, 340, 190–191, 191f – ten sion eversion, 160, 160f –– eth n icit y an d, 257
343, 344f –– can didates for, 190 lip(s) –– fract ure in, 261
– Accusculpt , 344 –– case st udies, 194, 194f – Asian , ch aracterist ics of, 270 –– fron tal plan e an alysis for,
– Aram is, in facial rejuven at ion, –– Fox’s m ethod for, 191, 191f – drooping, after gen ioplast y, 294 256, 256f
342–343, 343f –– patient evaluation for, 189–190 – ller inject ion in , 400 –– gen eral procedure for,
– carbon dioxide (CO<sub>2</ –– pearls, 184 – posit ion of, evaluat ion , 272, 258–260, 259f
sub>), in facial rejuven at ion , –– principles of, 189 272f, 288, 289f –– h em orrh age w ith , 261
340, 343 –– Sh in’s m eth od for, 191, 192f – project ion of, 270 –– infect ion w ith , 261
– ch rom oph ores for, 339–340, –– surgical tech niques for, liposuct ion , for fat graft h ar vest , –– in am m at ion w ith , 261
342, 342f 190–192 312–313 –– int raoral versus extern al
– CoolTou ch , in facial –– Von Am m on’s m ethod for, – com plicat ion s of, 321 approach for, 258
rejuvenat ion , 342–343 190, 190f low er eyelid, sagging, 8 –– key techn ical poin ts in, 260
– dye, in facial rejuven at ion, – clin ical applicat ion s of, 189 low er-posit ion ed t ran sverse –– m an dible-m axilla relat ion ship
339, 340 – com bin ed w ith Mongolian ligam ent (LPTL), in upper an d, 257
– Edge, in facial rejuven at ion, 344f slan t low ering, 191–192, 193f, eyelid, 167, 168f –– an d n arrow ing gen ioplast y,
– in face lift , 10 194, 194f com bin ed, 260, 260f
– for facial hair rem oval, 364–374 – cont rain dicat ion s to, 190 M –– n er ve injur y in, 261
–– pearls, 364 – m in im ally invasive, 204 m alarplast y, an d gen ioplast y, 286 –– patien t evaluat ion for, 255–256
– in facial rejuven at ion, 340–344 – m odi cat ion an d re n em ent for m alar prom in ence, 6 –– pearls, 254
– fract ion al, in facial rejuven at ion, Asian s, 8 m alar reduct ion , 9 –– postoperat ive care, 260
340, 343–344, 344f – postoperat ive care, 192 m ale pat tern h air loss, 349 –– preoperat ive im aging for, 256,
–– ablat ive, 343, 344f lateral crural graft m align ancy, an d saddle n ose, 89 256f
–– n on ablat ive, 343 – in correct ive rh in oplast y m alocclusion , 9 –– sagit t al plan e an alysis for, 256
– Fraxel, in facial rejuven at ion, for sh or t con t racted n ose, – classi cat ion of, 269, 270f –– soft t issue and, 257
343 123–125, 124f – in ter-arch problem s an d, 269 –– surgical plan n ing, 256
– interst it ial, in facial – for nasal t ip contouring, 53–54, – in t ra-arch problem s an d, 269 –– surgical tech niqu es for,
rejuvenat ion , 344, 344f, 345f 53f, 54f – after orth ognath ic surger y, 281 258–260, 259f
– m idin frared, in facial – onlay, 53–54, 53f m an dible. See also or th ogn ath ic –– t ran sverse plan e analysis for,
rejuvenat ion , 339, 342–343, – st rut , 53–54, 54f su rger y 256, 256f
342f, 343f lateral n asal arter y – asym m et r y, an d low er facial –– an d un favorable aesth et ic
– Nd:YAG, in facial rejuvenat ion , – an atom y of, 404f contouring, 257 outcom e, 261
339, 340, 342 – ller inject ion in , preven t ion of, – bilateral ver t ical sagit tal ram us –– an d zygom a reduct ion ,
– for n onablat ive rejuvenat ion , 404, 406 osteotom y, 274t com bin ed, 246, 252, 252f,
339–340 lateral t arsal st rip procedure, 204 – fract ure, int raoperat ive, 261 253f, 263–265, 263f–267f
– Q-sw itch ed, in facial Le Fort I osteotom y. See also – h igh sagit tal supraforam in al – ret rusion, orth ogn ath ic surger y
rejuvenat ion , 340 double jaw surger y osteotom y, 274, 276, 276f, 281 for, 274t
– Sm ar tlipo, 344 – m axillar y, 274t, 276–277, 278f – hypoplasia, psych osocial e ects – sagit tal split ram us osteotom y,
– Sm ooth beam , in facial –– bleeding in, 280 of, 286 274–275, 274t
rejuvenat ion , 342–343 leprosy, an d saddle n ose, 89 – in st abilit y, after orth ogn ath ic –– bleeding during, 280
– thu liu m , in facial rejuven at ion , levator palpebralis, 210 su rger y, 281 –– case st u dies, 282–283,
343–344 – age-related changes in, 174 – in t raoral vert ical ram u s 282f–284f
laser hair rem oval, 9, 364–374 – apon eurosis osteotom y, 276, 277f –– an d gen ioplast y, 286
– case st udies, 370–372, 371f, –– advan cem ent , 169, 169f, 177 – an d m axilla, abn orm al skeletal –– infect ion after, 280
372f –– deh iscen ce, 175, 212–213, 328 relat ionsh ip bet w een , 257 – vert ical de cien cy, or th ogn ath ic
– com plicat ion s of, 370, 370f –– plicat ion , in double-eyelid – orth ogn athic surger y of, surger y for, 274t
– e cacy of, factors a ect ing, surger y, 169 274–275, 274t – vert ical excess, orthogn ath ic
365–366 –– ptosis surger y an d, 210, 211 –– case st udies, 282–283, surger y for, 274t
– for fem ale East Asian s, 366–367, –– st retch ing or disin sert ion , 177, 282f–284f m an dibular angle
367f 212–213, 213f –– com plicat ion s of, 281, 282f – Asian, 6, 7f, 254
– h airlin e design for, 369, 369f – an d congenital ptosis, 211, 212f –– fract ure in , 281 – prom in ent , 254
– h istorical perspect ive on , 364 – fun ct ion, evaluat ion , 175, 176f, –– in com plete osteotom y in , 281 – reduct ion , 9
– key techn ical point s in , 370 212, 213f – ostectom y –– an d gen ioplast y, 286
– lasers used for, 364 – m alfun ct ion, in aponeurot ic –– cur ved, w ith oscillat ing saw, – resect ion of, 255
– for m ale East Asian s, 367–369 ptosis, 213, 213f 258, 258f, 259, 259f – secon dar y (postoperat ive),
–– aesth et ic e ect s of, 368, 368f – ptosis surger y an d, 210, 211 –– tangent ial, w ith reciprocat ing 259, 260
–– goals of, 367 – resection, in ptosis correction, 219 saw (lateral cortex ostectom y), m an dibular plan e–sellar nasion
–– m ot ivat ions for, 364–365 lid lag, after ptosis correct ion , 221 258, 258f (MP-SN) angle, 256
Index 423
m andibular prognath ism , w ith m idface – m an agem en t of n asal base in , – dissect ion , in aesth et ic
long face, case st udies, – age-related ch anges in , 174 34, 34f rhin oplast y for South east
282–283, 282f–284f – four crescen t aging lin es, – osteotom y in, 32 Asians, 111, 112f
m andibular ram u s osteotom y, 397–399, 398f – p at ient evaluat ion for, 26–28, – ischem ia, an d saddle n ose,
tech n ique for, developm ent m idpupillar y h orizon tal lin e, 27f, 27f 89–90
of, 269f 60, 61f – p ostoperat ive care, 39–40 – L-st rut , fabricat ion of, 92–93,
m andibular redu ct ion / m inoxidil, 351 – p reoperat ive cou nseling for, 93f
advan cem en t , 9 MMCR. See Mü ller m uscle 27–28 – perforat ion
m argin -re ex distan ce conju nct iva resect ion (MMCR) – silicone im plan ts for, 13–25 –– Medpor im plant an d, 137, 138f
– clin ical signi can ce of, 175, Mongolian slant , low ering, – spreader graft placem en t in, –– and saddle n ose, 89–90
176f, 212 191–192, 193f, 194, 194f 32–33, 33f, 40, 41f – subtot al recon st ruct ion , for
– m easurem en t of, 175, 175f, Mongoloids, 3 – surgical tech n iques for, 28–37 class 3 saddling, 92–93, 93f
212, 213f – phen ot ypic feat ures of, 6 n asal dorsu m n asal skin , 6, 15, 26, 27f, 61, 62f,
m argin -re ex distan ce 1, 164, m outh corn er elevat ion , – an d appearan ce of n asal base, 100
210, 212, 213f bot ulin um toxin for, 385, 386f 100, 105 – exam inat ion of, 74
m argin -re ex distan ce 2, 198, MP-SN angle. See m an dibu lar – Asian , 26, 27f n asal t ip, 6, 7f, 8f, 26, 27f
212, 213f plan e–sellar n asion (MP-SN) – bony an d cart ilaginous, – an d appearan ce of n asal base,
m arion et te lin es angle relat ion sh ip of, 61–62, 62f 100, 105
– bot ulinum toxin for, 385, 386f MRD. See m argin -re ex dist ance – p reoperat ive evaluat ion, 15 – asym m et r y, 55
– ller inject ion for, 401–402 m ucocele, w ith n asal alloplast ic n asal h um p – augm en tat ion , 13
m asseter m uscle, hypert rophy im plan t , 138, 139f, 140, 141f – ch aracterist ics of, 60–61, 87, 88f –– case st udies, 56–57, 56f–58f
– bot ulinum toxin for, 386–388, Mü ller m uscle, 210 – gen eralized, 61 –– w ith en don asal on lay graft , 56,
387f, 388f – ptosis su rger y an d, 210, 211, – localized, 61 56f–57f
– an d low er facial contouring, 257 214 – versus pseudo hu m p, 61, 61f – boxy, ceph alic resect ion of
Mat riStem , in h air t ran splant Mü ller m uscle conjunct iva n asal h um p surger y, 60–71 low er lateral cart ilage lateral
procedures, 306 resect ion (MMCR), 211, 214, – an atom ical con siderat ion s in , cru s for, 52–53, 53f
m axilla. See also bim axillar y 215, 219 61–62, 62f – bulbous, ceph alic resect ion of
prot rusion ; orthogn ath ic m yasth en ia gravis, 164 – case st udies, 68, 68f–69f, 70, low er lateral cart ilage lateral
surger y 70f–71f cru s for, 52–53, 53f
– dow n -fract ure, in orthogn ath ic N – com plicat ions of, 67, 138, 139f, – cap graft via en don asal
surger y, 281 NAR. See n on ablat ive rejuven at ion 140, 141f approach , 48–49, 49f
– in st abilit y, after orthognath ic n asal ala (pl., alae). See ala (pl., – com pon en t h um p reduct ion , – colum ellar st rut , in terdom al
surger y, 281 alae) 63, 64f sut ure, an d on lay graft via
– Le Fort I osteotom y, 274t, n asal base, reduct ion, 39 – con ser vat ive h um pectom y, endonasal approach , 49, 50f
276–277, 278f n asal bon es, 6 65, 66f – con touring, 37–39, 38f
–– bleeding in , 280 n asal bridge, low, 6, 7f, 8f – d issect ion an d septal cart ilage –– case st udies, 40–43, 40f–45f,
– an d m an dible, abn orm al n asal dorsal augm en tat ion, 8–9, h ar vest in , 62 56–57, 56f–58f
skelet al relat ion ship bet w een, 21, 135, 136f – d orsal augm en t at ion an d t ip –– graft sh ow ing after, 55
257 – w ith alloplast ic im plant , and re nem ent w ith, 65–67, 66f –– key tech n ical poin t s, 40, 55
– or th ogn ath ic surger y for, 274t, sh ort n ose deform it y, 122 – funct ion al problem s after, 67 –– lateral crural st rut grafts for,
276–277 – alloplast ic im plan ts for, 135. See – an d in ternal valve collapse, 67 37–38, 38f
–– com plicat ion s of, 281, 282f also alloplast ic im plant s – inverted-V deform it y after, 67 –– and n asal obst ru ct ion , 55
–– in com plete osteotom y in , 281 –– pearls, 135 – key tech nical poin ts in , 67 –– pain /discom for t after, 55
– preoperat ive evaluat ion, 15 – an d base reduct ion , 39 – in large-h um p n ose, 63, 64f –– pat ien t evaluat ion for, 48, 48f
– prot ru sion, orth ognath ic – case st udies, 40–43, 40f–45f – n asal dorsal irregularit y after, –– shield graft versus h orizon tal
surger y for, 274t – closure for, 39 67 onlay graft for, 38, 38f, 40, 41f,
– vert ical excess, orth ognath ic – in correct ive rh in oplast y for – open versus closed approach 43, 44f
surger y for, 274t sh ort con t racted nose, 129, for, 62 – cost al cart ilage graft for, 26–46,
m axillar y ret rusion , 9 129f – pearls, 60 30f, 41f
m axim al m alar project ion , 245, – costal cart ilage for, 8, 26–46, – an d residu al convexit y, 67 –– pearls, 26
245f 30f, 41f, 43, 44f – sequ en ce of surger y and t ip - – deviat ion , 55
m edial epican th oplast y, 8, 165, –– pearls, 26 plast y in, 62–63, 63f – evaluat ion of, 48, 48f
194, 194f – dorsal graft placem en t an d – in sm all-h um p n ose, 65, 66f – lateral crural graft for, 53–54,
– w ith ptosis su rger y, 212 xat ion in , 35–37, 35f, 36f, 37f – spreader grafts in , 65, 65f 53f, 54f
m edical skin care, in facial – ller inject ion for, 395, 395f, – tech niqu es for, 61–67 – lift ing, bot ulin um toxin for,
rejuven at ion, 340 399–400, 399f n asal obst ruct ion 383, 383f
Medpor, 13, 113 –– com plicat ion s of, 408–409, – after alar base surger y, 105 – m odi cat ion
– advant ages of, 14 410f – assessm en t for, 73–74 –– in correct ive rh in oplast y
– rem oval rate for, 135 – and glabellar augm en tat ion , 39 – after correct ive rhin oplast y for for short con t racted n ose,
– in rh in oplast y, 135 – graft , w ithout osteotom y, short con t racted n ose, 131 123–125, 124f, 127–128,
–– com plicat ion s of, 135 31–32, 32f – after n asal t ip surger y, 55 128f, 131
m elan in index, 366, 367f – w ith h um p resect ion , 65–67, n asal pro le, 6, 7f –– using open approach , 57,
m ent al n er ve injur y, in 66f n asal pyram id, 6 57f–58f
genioplast y, 293 – key tech n ical point s, 40 n asal root , preoperat ive – over-rot at ion, 55
m icrognath ia, psych osocial e ect s – m anagem en t of bony vault in, evaluat ion , 15 – pain in , after correct ive
of, 286 31–32, 32f n asal sept um , 6 rhin oplast y for short
m icrojet inject ion , in skin – m anagem en t of m iddle th ird in, – d eviated, st raigh ten ing, 77–78, con t racted nose, 131
rejuven at ion, 340, 347, 347f 32–33, 33f 78f – preoperat ive evaluat ion, 15
424 Index
n asal t ip (cont inued) n euralgia, after hair –– correct ion , 122–134 orbital hem orrh age
– projection and counter-rotation, t ran splan tat ion, 359 –– path ogen esis of, 122 – aging-related (upper)
in aesthetic rhinoplast y for n eurotoxin inject ion . See also –– postoperat ive, 122, 123f bleph aroplast y an d, 181
Southeast Asians, 112–113, 113f bot ulin um toxin – skin -soft t issue envelope, – low er bleph aroplast y an d, 206
– project ion of, 47–48, 48f, 60 – for brow depressors, 332 exam in at ion of, 74 orbital ret ain ing ligam en t , 326,
–– augm en tat ion via en don asal – for plat ysm al bands, 309 – South east Asian, characterist ics 327f, 331
approach, 48–49, 49f, 50f n onablat ive rejuvenat ion of, 108 orth ogn athic surger y, 9
–– loss of, 55 – physiologic e ect s of, 340 – start ing point of, in Asian s, – aesth et ic, 268–285
–– sept al exten sion graft for, – prin ciples of, 339–340 60, 61f –– pat ien t evaluat ion for,
49–51, 51f n onsurgical in ter ven t ion , 10 – t w isted 269–272
– re n em en t n ose. See also nasal ent ries; –– physical exam in at ion of, –– pearls, 268
–– w ith h um p resect ion , 65–67, saddle n ose 72–73, 73f, 74f –– psych ological con siderat ion s
66f – alar base, 99 –– surgical correct ion of, 72–86. in, 269–270
–– preoperat ive cou nseling for, –– m odi cat ion of, 99–107 See also correct ive rh in oplast y – case st udies, 282–283,
27–28 – ar terial su pply to, an d ller – upper lateral cart ilages, 87–88 282f–284f
–– surgical tech n iques for, 37–39 inject ion , 403, 404, 406, –– dest ruct ion, w ith alloplast ic – classi cat ion of, by diagn osis,
– revision surger y, 136, 138, 138f 408–409, 409f im plan t com plicat ion s, 136 274, 274t
– rigid, w ith AlloDerm im plan t , – Asian, anatom y of, 6, 26, 27f, nost ril(s) – com plicat ion s of, 280–281
secon dar y rh inoplast y for, 140 61–62 – asym m et r y of, 99 – con dylar resorpt ion after, 281
– rot at ion , 9, 60 – basal view of, 100, 100f –– after alar base surgery, 105, 105f – de n it ion of, 268
–– septal exten sion graft for, – bird’s-eye view of, 73, 73f, –– after correct ive rhin oplast y for – developm en t of, 268, 269f
49–51, 51f 82f, 84f sh ort con t racted nose, 131 – fun ct ional relapse after, 281
– rot at ion of, 47–48, 48f – bony asym m et r y, 14 – large, 99 – and fun ct ion al restorat ion , 268
– septal exten sion graft for, – bony pyram id – teardrop, after alar base – in com plete osteotom ies in , 281
49–51, 51f –– late deviat ion after correct ive surger y, 105, 105f – in fect ion after, 280
–– en d-to-en d, 50, 52f rh in oplast y, 81 num bness, after h air – key tech n ical poin t s in , 280
–– overlapping, 50, 51f –– an d saddle nose, 87, 88f t ran splan t at ion , 358 – m an dibu lar, 274–275, 274t
–– tech n ique for, 50–51, 51f, 52f – cleft , 103, 104f –– case st u dies, 282–283,
–– t ypes of, 50, 51f – cont racted, postsurgical, 122 O 282f–284f
– sh ape, evaluat ion of, 48, 48f – crooked oblique lin e, in low er eyelid, –– com plicat ion s of, 281, 282f
– sh ield graft for, 51, 53f –– physical exam in at ion of, 197f, 198 – m axillar y, 274t, 276–277
– silicon e im plant an d, 13–25 72–73, 73f, 74f Obw egeser-Dal Pon t m ethod. See –– com plicat ion s of, 281, 282f
– skin thin ning on, augm ent at ion –– surgical correct ion of, 72–86. sagit tal split ram us osteotom y – n er ve injur y in , 281
rh inoplast y w ith silicon e See also correct ive rhin oplast y (SSRO) – pain after, 280
im plan t an d, 23 – deform it y. See also saddle n ose occlusion – part ial necrosis of bon e
– stacked on lay graft for, 13 –– oblique ligh t ing of, 74f – ideal, 269 segm en t an d m ucosa after,
– support , evaluat ion of, 48, 48f –– surgical correct ion of, 72–86. – n orm al, 268–269 281, 282f
– surger y See also correct ive rhin oplast y – preoperat ive evaluat ion , in – postoperat ive care, 279–280
–– in Asian s, 47 – deviat ion gen ioplast y, 288 – psych osocial ben e t s of, 268
–– com plicat ions of, 55 –– low er th ird, 79–80, 80f ocular m ot ilit y, preoperat ive – tech n iques for, 274–279
–– in h um p resect ion, 62–63, 63f –– m iddle th ird, 78–79, 79f evaluat ion , 177 – tech n ological advan ces an d, 268
–– key tech nical poin ts, 55 –– m idvault , 77 open bite, orth ogn ath ic surger y – un favorable osteotom ies in , 281
–– m odi cat ion an d re n em en t –– physical exam in at ion of, for, 274t osteotom y
for Asian s, 8–9 72–73, 73f, 74f orbicu laris oculi, 326–327 – in aesth et ic rh inoplast y for
–– pearls, 47 –– surgical correct ion of, 72–86. – prom inen ce of, 197f, 198 South east Asians, 113
–– prin ciples of, 47 See also correct ive rhin oplast y – suspension procedure, 198, 199, – anterior segm en tal, for
–– tech n iques for, 47, 48–55 –– t ip, 77 204, 206, 207f bim axillar y prot rusion , 274t,
– volum e of, 47 –– upper-th ird, 75–77 – t igh ten ing procedure, 199 277–279, 279f
–– reduct ion , ceph alic resect ion – extern al, physical exam in at ion orbicu lus oculi m uscle, 6 –– an d gen ioplast y, 286, 295,
of low er lateral cart ilage of, 72–73, 73f, 74f orbit , 6 296f–297f, 298, 299f
lateral crus for, 52–53, 53f – in tern al, exam in at ion of, 73–74 – age-related ch anges in , 174 – in augm en tat ion rhin oplast y, 19
– w idth of, 47 – inverted-V deform it y, 67, 87, orbit al fat – bilateral vert ical sagit t al ram u s,
– w ing graft for, 13 88f – age-related ch anges in , 198 m an dibular, 274t
n asion , level of, in Asian s, 60, 61f – keyston e area, 87, 88f – cen t ral, 164, 177, 198 – in correct ive rh in oplast y, 76–77
n asion (N)–an terior nasal sp in e – lateral cru ra, m alposit ion ed, 54 – h ern iat ion , 164 – h igh sagit t al supraforam in al,
(ANS)/an terior n asal spin e – low er lateral car t ilages, 88 – lateral, 198 m an dibular, 274, 276, 276f,
(ANS)–m en ton (Me) rat io, 272, –– dest ruct ion , w ith alloplast ic – m edial, 164, 177, 198 281
272f, 287, 288t, 289, 290f im plant com plicat ion s, 136 – prolapse, 177, 197f, 198 – in t raoral vert ical ram us,
n asofron t al angle, 60 – physical exam inat ion of, 72–74 – prot rusion , an d low er eyelid m an dibular, 276, 277f
n asofron t al t ran sit ion , 14f, 15 – preoperat ive exam in at ion of, appearan ce, 196 – Le Fort I. See also double jaw
n asolabial angle, 60, 272, 272f 14–15, 14f, 26–28, 27f, 60–61 – pseudoh erniat ion of, 197f surger y
– acute, 15 – preoperat ive X-ray of, 15, 15f – rem oval –– m axillar y, 274t, 276–277, 278f
– in Asian s, 15 – quadrangular cart ilage, and –– aesthet ic e ects of, 197 ––– bleeding in , 280
– obt use, 122, 123f saddle nose, 87, 88f –– in aging-related (upper) – m an dibu lar ram us, tech nique
n asolabial fold(s), ller inject ion – short . See also correct ive bleph aroplast y, 179, 179f for, developm ent of, 269f
in , 400, 400f rh in oplast y, for sh ort –– in dou ble-eyelid surger y, 167, – in n asal dorsal augm ent at ion ,
n eck. See also plat ysm al ban ds con t racted n ose 167f 32
– adiposit y, m an agem ent of, 309 –– congen ital, 122 –– in dicat ion s for, 198 – in rh in oplast y, 76–77
Index 425
–– lateral, 76–77, 76f, 77f polyacr ylam ide gel, proper t ies –– h istorical perspect ive on, – aesth et ic, for South east Asians,
–– m edial, 76f, 77 of, 393t 210–211 108–121
–– t ips for perform ing, 77 poly-caprolacton e, 394 –– in cision for, 216, 217f –– alar lift via sail excision in ,
–– t ypes of, 76, 76f poly-L-lact ic acid, 394, 405 –– in st ru m en ts for, 215, 216f 109–110, 110f–111f
– sagit tal split ram us, m andibular, – proper t ies of, 393t –– kerat it is after, 221 –– case st udies, 117, 118f, 119,
274–275, 274t polym ethyl m eth acr ylate, –– key tech n ical poin t s in , 220 119f–121f
–– bleeding du ring, 280 propert ies of, 393t –– lagoph th alm os after, 221 –– closure, 116
–– case st udies, 282–283, pore size, int raderm al bot ulin um –– and levator resect ion , 219 –– com plicat ion s of, 117
282f–284f toxin inject ion an d, 388–389, –– levator su rger y for, 215 –– con ch al cart ilage h ar vest for,
–– an d gen ioplast y, 286 389f –– lid lag after, 221 109
–– infect ion after, 280 porous h igh -den sit y polyethylen e. –– m eth od, select ion of, 215 –– dorsal im plan t for, 113–116
– in zygom a reduct ion See Medpor –– Mü ller m uscle conjun ct iva –– key tech n ical poin t s in , 116
–– an terior, 247, 247f prem axilla, preoperat ive resect ion (MMCR) for, 211, –– m em bran ous sept um
–– I-sh aped, 248 evaluat ion, 14f, 15 214, 215, 219 dissect ion in , 111, 112f
–– L-sh aped, 246–247, 247f, 248 prem axillar y augm en tat ion , 15 –– pat ien t evaluat ion for, –– osteotom y in , 113
–– ostectom y versus, 248 prem axillar y graft , 54 211–214 –– pat ien t coun seling before, 109
–– posterior, 247, 247f pretarsal area –– pearls, 210 –– pat ien t evaluat ion for,
– fulln ess, after double-eyelid –– photographs in sit t ing posit ion 108–109
P surger y, 232–233, 233f during, 218, 219f –– pearls, 108
p ain – h eigh t-volum e relat ionsh ip in , –– postoperat ive care, 220 –– sept al extension graft in, 112,
– after ller inject ion , 403, 407 232–233, 233f –– preoperat ive con siderat ion s, 112f, 113f
– after gen ioplast y, 293 pretarsal bulge, 378, 383 214–215 –– tech n iques for, 109–116
– after h air t ran splan t at ion , 358 pretarsal sh ow, 165, 166f –– preparat ion for, 215–216, 216f –– t ip project ion an d coun ter-
– after n asal t ip surger y, 55 procerus m uscle, 326–327 –– tech n iques for, 215–220 rot at ion in, 112–113, 113f
– after orthogn ath ic su rger y, 280 pro loplast y, 60–71 –– un ilateral versu s bilateral, 215 – alloplast ic im plant s in . See also
Pain ter, Neil, 5 – pearls, 60 –– visual eld test before, 214 alloplast ic im plan ts
p alpebral apert ure, w idening PRP. See platelet-rich plasm a – d iagnosis of, 212–214 –– com plicat ion s of, 135–148
of, 378 pseudo h um p, 61, 61f – after double-eyelid surger y, –– pearls, 135
p alpebrom alar groove, 197f, pseudolift , in t raderm al 238, 238f – augm en tat ion . See
198, 199 bot u lin um toxin inject ion an d, – evaluat ion of, 164, 210 augm en t at ion rh in oplast y
p aranasal augm ent at ion , 15 388–389, 389f – funct ion al e ect s of, 174 – correct ive. See correct ive
p aranasal im plant , 9 pseudoptosis, 162 – Hering’s test and, 214–215 rhin oplast y
p aresth esia, after zygom a – cau ses of, 210 – h istor y-t aking for, 211–212 – for deviated/t w isted n ose,
reduct ion , 249 ptosis, 162, 176, 307, 307f. See – latent , 214–215 72–86. See also correct ive
p arot id glan d, reduct ion, also ch in, ptosis; eyelash ptosis – m asked, 211 rhin oplast y
bot ulin um toxin for, 388, 389f – aesth et ic e ects of, 174, 327 – over-correct ion of, 220 –– pearls, 72
p eau d’orange, on ch in , after – aging-related, 212–213, 327, – physical exam ination for, 211–212 – edem a after
genioplast y, 294–295 328 – u nder-correct ion of, 220, 221f –– late (persisten t), 81
p eriorbital fat , 164 – apon eurot ic, 211, 212–213, – u nilateral, 174, 175f, 176, 210, –– m an agem en t of, 81, 140
p henyleph rin e test , 214, 215 212f, 213f 215 – in fect ion s in , 143
p hotodocu m en tat ion – asym m et ric, 214–215 pug n ose, 87 – inject ion, asym m et r y caused
– for facial fat graft ing, 312 – versus blepharoptosis, 174, 175f pulm on ar y em bolism , fat graft by, 412
– postoperat ive, w ith ptosis – congenital, 211, 212f, 213–214, and, 321 – m odi cat ion an d re n em en t for
correct ion , 212 222, 222f Asians, 8
– preoperat ive, 27, 74, 101 – con tact lens–in duced, R – osteotom y in, 76–77
–– for bleph aroplast y, 164 214– 214f Radiesse. See calcium –– lateral, 76–77, 76f, 77f
–– for endoscopic foreh ead and – correct ion of, 169, 169f, hydroxylapat ite –– m edial, 76f, 77
brow lift , 330 210–224 radiofrequency devices, in facial –– t ips for perform ing, 77
–– for h air t ransplan tat ion , 352 –– an esth esia for, 216, 216f rejuven at ion , 340, 344–346 –– t ypes of, 76, 76f
–– for low er blepharoplast y, 199 –– case st udies, 221–222, 222f – bipolar, 344, 345 – pat ient evaluat ion for, 14–15,
–– for m andibular redu ct ion, 256 –– com plicat ions of, 220–221 –– w ith ligh t , 345 14f, 15f, 72–75
–– for ptosis correct ion, 212 –– conjunct ival prolapse after, – in lt rat ive fract ional, 345–346, – plan n ing for, 27
– during ptosis correct ion , 218, 221 346f – preoperat ive cou nseling for,
219f –– con tour deform it y after, 221 – m on opolar, 344, 345 27–28
p iriform ligam ent s, release of, in –– dissect ion in, 216–217, 217f, reduct ion rh in oplast y, 60 – preoperat ive evaluat ion for, 27,
augm ent at ion rh in oplast y, 18 218f – pearls, 60 60–61
Pit anguy line, 325, 325f –– an d early postoperat ive relapsing polych on drit is, and – secon dar y
p latelet-rich plasm a revision, 221, 221f saddle n ose, 89 –– for alloplast-related
– in fat graft ing, 318 –– ect ropion after, 221 Rest ylan e. See hyaluron ic acid com plicat ion s, 135–148
– in hair transplant procedures, 306 –– en t ropion after, 221 ret rogn athia, 9 –– case st udies, 143, 144f, 145,
p lat ysm al ban ds –– eyelid crease design for, ret ro-orbicularis orbit al fat 145f–147f
– bot u linum toxin for, 386, 386f 215–216, 216f (ROOF), 164 –– and capsule aroun d silicone
– neurotoxin inject ion for, 309 –– and eye protective function, 214 – rem oval, in double-eyelid im plan t , 136, 137f
PLLA. See poly-L-lact ic acid –– xat ion of levator-Mü ller surger y, 167, 167f –– for deviated im plant , 138–139
p neum at ic com pression , in skin m uscle ap in , 217–218, 218f, revision rhin oplast y, 24, 25f –– for dorsal skin redn ess, 139
rejuven at ion, 340, 347, 347f 219f rhin oplast y, 7f –– and Gore-Tex im plan t
p neum oth orax, cost al car t ilage –– fron talis sling for, 210, 211, – adjun ct ive surgeries and com plicat ion s, 137
h ar vest and, 130 215, 219–220, 220f procedures w ith, 9 –– for h ard n asal t ip, 140
426 Index
rh in oplast y (cont inued) SAFI. See sequen t ial autologous fat – advan tages of, 13–14 skin rejuvenat ion
– secon dar y (cont inued) inject ion (SAFI) tech n ique – for augm en tat ion rh inoplast y, – ablat ive, 339–340. See also
–– for im plan t calci cat ion , 139, sagit tal split ram us osteotom y 13–25 ablat ive rejuven at ion
140f (SSRO), m an dibular, 274–275, –– capsu le aroun d, 136, 137f – n on ablat ive, 339. See also
–– for im plan t prot ru sion, 139 274t –– pearls, 13 n on ablat ive rejuven at ion
–– for in fect ious con dit ion s, – bleeding during, 280 – ch in , com plicat ions of, 294 – t ype I, 339, 340
140–141 – case st udies, 282–283, – com plicat ion s of, 22–23, 28, –– w ith in ten se pulsed ligh t ,
–– key tech nical poin ts in, 282f–284f 28f, 135 341–342, 341f
142–143, 142f – an d genioplast y, 286 – derm al fat graft w ith, 22, 23f – t ype II, 339, 340
–– an d Medpor im plan t – in fect ion after, 280 – popularit y of, 13–14 –– w ith in ten se pulsed ligh t , 342
com plicat ion s, 137, 138f Sam urai eyebrow, 382 – rem oval rate for, 135 skull, Asian, ch aracterist ics of,
–– for m obile im plan t , 139 sarcoidosis, an d saddle n ose, 89 – in rhin oplast y, 135 349–350, 350f
–– for n on in fect ious con dit ion s, sausage eyelid, 232 –– com plicat ions of, 135, 136, sn ap -back test , for eyelid laxit y,
138–140 scalp, prurit us, after h air 137f 198–199
–– pat ient evalu at ion for, t ran splan tat ion, 359 –– an d m ucocele form at ion, 138, sn ub n ose, postoperat ive, 122,
136–138 SCALP m n em onic, 396, 396f 139f, 140, 141f 123f
–– for sh ort nose deform it y, scar(s), 8. See also keloids –– pearls, 135 soft t issue, lift ing, in low er facial
141–142, 142f – after alar base surger y, Silskin . See silicon e, liquid con tou ring, 257
–– tech niqu es for, 138–142 104–105, 105f single eyelid, 152, 152f, 162–163, SOOF. See suborbicularis orbit al
–– for visible im plan t , 139 – w ith epican th oplast y, 187–189 173 fat (SOOF)
rhyt idectom y, 309 – after eyelid surger y, 226, 226f, – an atom y of, 153 South east Asians, 3, 8f
rhyt ids 227f – opening ph ase, 153f – aesth et ic rh in oplast y for,
– foreh ead, 327 – facial fat graft ing an d, 319–320 – rest ing ph ase, 153f 108–121
– glabellar, 327 – after ller inject ion , 411 skeletal reduct ion surger y, 9 –– pearls, 108
– lateral can th al. See crow ’s-feet – hair t ran splan tat ion and, 351, skin, Asian, 6 squ are jaw, bot ulin um toxin for,
– perioral, bot ulin um toxin for, 352, 358, 359 – age-related ch anges in , 174, 386–388, 387f, 388f
384–385, 385f – hypert roph ic, 100, 185, 196 178, 310 SSRO. See sagit t al split ram u s
Ricket t s line. See esthet ic line –– w ith epican th oplast y, 189 –– sun exposu re an d, 303–304 osteotom y (SSRO)
(E-line) –– after eyelid surger y, 226 – of alar base, 101 stereoph otogram m et r y,
ROOF. See ret ro-orbicularis orbital –– h air t ran splan t at ion an d, – ch aracterist ics of, 196 preoperat ive, 27
fat (ROOF) 351, 359 – ch in steroid inject ion , after correct ive
rule of fth s, 270, 271f, 324 –– t reat m en t of, 189 –– dim pling, after genioplast y, rh in oplast y, 81
rule of th irds, 270, 271f, 288, – w ith n onin cision al sut u re 294 st im ulator(s) ( ller), propert ies
289f, 324 techn ique for dou ble-eyelid –– peau d’orange appearance, of, 393t
surger y, 159, 160f after gen ioplast y, 294–295 subn asale–labialis in ferior:labialis
S – resurfacing, 10 – in epican th al area, 185 inferior–soft t issue m en ton
saddle n ose (deform it y) Sculpt ra. See poly-L-lact ic acid – of eyelid, 164 (Sn –Li:Li–Me´) rat io, 272f,
– aesth et ic e ects of, 87, 88f, 89f seborrh eic derm at it is, after laser – facial, laser h air rem oval and, 288, 289f
– an atom ic con siderat ion s, 87–88, facial hair rem oval, 370, 370f 368, 368f subn asale–stom ion :stom ion –soft
88f, 89f sent inel vein, in forehead, 325, – lift ing, in low er facial t issue m en ton (Sn–St:St–Me´)
– case st udies, 94, 95f, 96, 96f–98f 326f, 331–332 contouring, 257 rat io, 272f, 288, 289f
– ch aracterist ics of, 87, 88f Sephyl. See blood, as ller – low er eyelid, loss of elast icit y, suborbicularis orbital fat (SOOF)
– class 1, 90–91, 91f septal extension graft , 135, 136f 198 – elevat ion (lift), 198, 199, 203,
– class 2, 90, 91–92, 91f, 92f – in aesth et ic rh inoplast y for – n asal, 15, 26, 27f, 61, 62f, 100 207, 207f
– class 3, 90, 91f, 92–93, 93f Sou th east Asian s, 112, 112f, –– dam age in correct ive – in fat reposit ion ing
– class 4, 90, 91f, 93, 94f 113f rh inoplast y for sh ort bleph aroplast y, 203, 203f
– classi cat ion of, 90, 91f – in correct ive rh in oplast y cont racted n ose, 130 sun exposure
– correct ion of, 87–98 for sh or t con t racted n ose, –– dorsal redn ess, secondar y – avoidan ce, after laser facial h air
–– pearls, 87 123–125, 124f rh inoplast y for, 139 rem oval, 370
– disease an d, 89 septoplast y, in fect ion s in , 143 –– exam in at ion of, 74 – and skin aging, 303–304
– et iology of, 88–90 septorh in oplast y, 135 –– m obilit y, evalu at ion , 123, superior palpebral fold, 6, 7f
– exten ded spreader graft for, – com plicated, 135, 143 123f superior su lcus
92, 92f –– alloplast ic im plan ts for, 135 – n ecrosis – deepen ing
– fun ct ion al e ects of, 87 –– pearls, 135 –– w ith fat graft em bolizat ion , –– age-related, 175, 175f
– iat rogenic cau ses, 89 – in fect ion s in , 143 320, 320f –– w ith ptosis, 211, 212f
– m alignan cy an d, 89 sequen t ial autologous fat –– after ller inject ion , 403, 403f, – m an agem en t in aging-related
– pat ien t evaluat ion , 90 inject ion (SAFI) tech n ique, 406, 406f, 409, 410f, 411, 412f (u pper) blepharoplast y, 181
– versus pseudo saddle, 87, 88f 313, 313f, 314t–315t, 316f, –– after h air t ran splan t at ion , 358 supraorbital ner ve, injur y, in ller
– septal exten sion graft for, 92, 317t – palpebral, 6 inject ion , 403
92f serom a, after en doscopic – rejuvenat ion , 310 supraorbital neurovascular
– spreader graft for, 92, 92f, 93 foreh ead an d brow lift , 337 – resist ance to aging, 303–304, bundle, 325, 326f
– surgical tech niqu es for, 90–93, shield graft , in aesthet ic 378 suprat roch lear n eurovascular
91f–94f rh in oplast y for South east – resurfacing, 310 bundle, 325–326, 326f
–– key tech nical poin ts, 93 Asian s, 113 – topical therapy for, 310 supt rat rochlear arter y, ller
– system ic disease an d, 89 Sh in’s m eth od, for aesth et ic skin color inject ion in , prevent ion of,
– total dorsal recon st ruct ion for, lateral can th oplast y, 191, 192f – cu lt u ral beliefs about , 5, 404, 406
93, 94f silicon e, liquid, propert ies of, 393t 303–304 surgical tech niqu es, m odi cat ion
– t raum a-related, 89 silicon e im plan t s, 8, 113 – an d h air t ran splant at ion, 350 an d re n em en t for Asians, 8–9
Index 427
syn cope, hair t ran splan tat ion th um bprint sign , 32 vit am in c ion toph oresis, in facial – com plicat ions of, 249–250
an d, 360 TMJ. See tem porom an dibular rejuven at ion , 340 – xat ion in , 247, 248f, 249
syph ilis, and saddle n ose, 89 join t (TMJ) V-lin e surger y, 255, 255f – goals of, 243–244
Tran ilast , 188 volum izer(s), propert ies of, 393t, – in fraorbit al n er ve injur y an d
T t ransconjun ct ival Mü ller t ucking, 405 paresth esia after, 249
tear breakup t im e, 177, 181 158, 159f, 161, 161f Von Am m on’s m eth od, for – in t raoral approach for, 246–247
tear secret ion , preoperat ive t raum a, an d saddle n ose aesthet ic lateral can thoplast y, – I-sh aped osteotom y in, 248
evaluat ion , 177, 181 deform it y, 89 190, 190f – key tech n ical poin ts in , 248–249
tear t rough , ller inject ion in , 399 t riam cinolon e acetate, inject ion – L-sh aped osteotom y in ,
tear t rough depression, 197–198, – after correct ive rh in oplast y, 81 W 246–247, 247f, 248
197f, 199 – for hyper t roph ic scar, 189 Wegen er’s gran ulom atosis, an d – an d m an dible reduct ion
– fat graft ing for, 322, 322f t riangular m alar m oun d, 198 saddle n ose, 89 (con touring), com bin ed, 246,
teeth , exposure, an d facial t rism us, after zygom a reduct ion , West Asians, 3 252, 252f, 253f, 263–265,
aesth et ics, 270 249 W h it nall’s ligam en t , 167 263f–267f
tem p le, ller inject ion in, t w o-jaw su rger y, 268. See also Wilkin son an alysis, of m axim al – n on un ion after, 249
396–397, 397f double jaw surger y m alar project ion , 245, 245f – ostectom y versus osteotom y
tem p oral fossa in , 248
– ller inject ion in , 396–397, 397f U X – pat ient evalu at ion for, 244–246
– layers of, 396, 397f u lt rasoun d X-ray, preoperat ive – pearls, 243
tem p oral region , an atom y of, – in facial rejuven at ion, 340 – for gen ioplast y, 287, 289 – posterior osteotom y in, 247,
324–326, 325f–327f – h igh -in ten sit y focused, in facial – for m an dibular reduct ion , 256 247f
tem p orom an dibular join t (TMJ) rejuvenat ion , 340, 346, 346t – of n ose, 15, 15f – soft t issue sagging after, 249
– dysfunct ion , preoperat ive u pper eyelid crease, 6, 7f, 162 – for secon dar y rh inoplast y, 136 – surgical tech n iques for, 246–247
docum en tat ion of, 270 – low, 163 – t rism us after, 249
– in st abilit y, after orthognath ic Z – an d u nder-correct ion , 250
surger y, 281 V zero-m eridian, 288–289, 289f – vector of t ran sposition in , 248
– pain, after orth ogn athic surger y, visual eld(s) zygom a reduct ion , 243–253 zygom at ic arch, 6
280 – im provem ent, after aging-related – an esth esia for, 247 zygom at ic body, 6
tem p oropariet al fascia, 325, 325f, (upper) blepharoplast y, 180 – an terior osteotom y in , 247, 247f – posit ion of, 244–245
326f – ptosis and, 174 – approach for, 246–247 – volum e of, 244
Th erm age, 344 – test ing, w ith ptosis correct ion , – asym m et r y after, 249 zygom at ico-tem poral vein ,
thread lift ing, 10 214 – case st udy, 250, 250f, 251f m edial, 325, 326f